Project RED: Reengineering the Discharge Process

1. Project RED:Reengineering the Discharge Process The Patient Centered Discharge Process HCAHPS PSLN May 18, 2012 Michael Paasche-Orlow MD, MA, MPH Associate Professor of Medicine Boston University School of Medicine

2. Acknowledgements • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET). • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education. • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

3. Why a Project RED Webinar for HCAHPS PSLN Participants? Top four HCAHPS Priorities of over 430 hospitals participating in 18 HCAHPS PSLNs: • RN Communication • Responsiveness • Medication Communication* • Discharge Information* * Addressed by the patient-centered discharge process under Project RED

4. Staff Always Explained About Medicines • United States, 2008-2010

5. Patients Given InformationAbout Recovery At Home • United States, 2008-2010

7. New HCAHPS Care Transitions Questions Scale: Strongly Disagree, Disagree, Agree, Strongly Agree During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications.

8. Timing of HCAHPS Integration New care transitions questions available in HCAHPS on a voluntary basis beginning with July 1, 2012 discharges New care transitions questions proposed to become mandatory in HCAHPS beginning with January 1, 2013 discharges

9. You’re Invited:  Free Web Conferences for all PSLN Participants • June 25, 2012, 11:30-12:30pm EDT—Using the Medication Reconciliation Process for Medication Communication • Two expert authors of the new AHRQ Medication Reconciliation toolkit, Kristine Gleason, RPh, and Helga Brake, PharmD, of Northwestern Memorial Hospital, will teach how to use the new AHRQ toolkit for medication communication. • Registration URL: • http://event.on24.com/r.htm?e=462520&s=1&k=111F339A38B513C651360711DCA5E847 • Dial-In Information: 1-866-710-0179 / Passcode: 846 488

10. You’re Invited to the National AHRQ/HRET Patient Safety Learning Networks Meeting A national PSLN meeting will take place June 20 (in the same hotel as the national TeamSTEPPS conference on June 21-22): https://register.rcsreg.com/r2/tsnational2012/ga/top.html • Date: June 20, 2012 • Registration is free • Location: Sheraton Nashville Downtown – Nashville, TN • Contact for more information: Jennifer Shaw at jshaw@aha.org Meeting Objectives: • Identify and share PSLN effective peer-to-peer learnings • To connect patient experience of care to improvement work • To connect teamwork and culture to improvement work

11. Learning Network Faculty Michael Paasche-Orlow, M.D., M.A., M.P.H., Associate Professor, Boston University, Co-Investigator for Project RED Dr. Paasche-Orlow is a practicing general internist in the Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine. Health Literacy is the central focus of Dr. Paasche-Orlow’s research career.  Besides research relating to rehospitalization, Dr. Paasche-Orlow has examined the role of health literacy in a range of circumstances including medication adherence, mental health, informed consent, disparities, asthma, behavioral interventions, and end-of-life decision-making.

12. Declaration of COI • Dr. Paasche-Orlow is a consultant for Engineered Care, Inc., a firm that markets patient education software to hospitals. http://www.engineeredcare.com

13. Tremendous Attention on Rehospitalization • Efficiency • Decreasing readmissions allows for the alignment of improving quality and decreasing cost. • Plentiful • 2006: 39.5 million hospital discharges with costs totaling $329.2 billion!

14. Patient Protection and Affordable Care Act • Transitions of Care • Accountable Care Organizations  1/1/2012 • Community Care Transitions Program  ACA Sec. 3026 • Expanding Authority to Bundle Payments • Value-Based Purchasing • http://www.hospitalcompare.hhs.gov/ • MI, CHF, PNA “Starter Set” • Effective for payments for discharges occurring on or after October 1, 2012.

15. Characteristics of Hospital Discharge Not standardized and frequently poor quality • Loose Ends • Fragmentation • Poor Quality Information • Poor Preparation • 20% of Medicare patients readmitted within 30 days • Only half had a visit in the 30 days after discharge Source: N Engl J Med 2009 2;360(14):1418-28.

16. Patients Are Not Prepared at Discharge At Discharge: • 37% able to state purpose of all medications • 14% knew the common side effects • 42% able to state their diagnosis Source: Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Amgad N. Makaryus, MD, Eli A. Friedman, MD. Mayo Clinic Proceedings. August 2005; 80(8):991-994

17. Time Spent on Discharge • Audiotaped 97 discharge encounters • Nurse, Pharmacist, Physician, Nurse Case Manager • Averaged 8 minutes (range, 2 to 28.5 min) • No teach back 84% of the time • Patient is a passive participant (95/97) • Not comprehensive

18. Communication Barriers • Patients with communication problems: • 3 times more likely to have adverse event • 46% had multiple adverse events Source: Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Gillian Bartlett, PhD, RégisBlais, PhD, Robyn Tamblyn, PhD, Richard J. Clermont, MD and Brenda MacGibbon, PhD CMAJ. June 2008;178(12)

19. Errors Lead to Adverse Events • 19% of patients had a post-discharge AE • 1/3 preventable and 1/3 ameliorable • 23% of patients had a post-discharge AE • 28% preventable and 22% ameliorable

20. Principles of the RED:Creating the Toolkit

21. Process Mapping-1Ready for Discharge?

22. RED Checklist Eleven mutually reinforcing components:  Patient education  Follow-up appointments  Outstanding tests  Post-discharge services  Medication reconciliation  Reconcile dc plan with National Guidelines  What to do if problem arises  D/C summary to PCP  Assess patient understanding  Written discharge plan > Telephone Reinforcement Adopted by National Quality Forum as one of 30 "Safe Practices" (SP-15)

23. RED Component #1 Educate patient about their diagnosis throughout their stay RED intervention starts within 24 hours of the patient’s admission Continues daily until discharge How is this done in your organization? Who is involved? How do you know if you are succeeding?

24. RED Component #2 Make appointments for clinician follow-up and post-discharge testing Schedule PCP appt within 2 weeks after discharge Review the provider, location, transportation and plan to get to appointment Consult with patient regarding best day and time for appointments Discuss reason for and importance of all follow up appointments and testing How is this done in your organization? Who is involved? What % of patients who leave your facility get an appointment in 2 weeks?

25. RED Component #4 Organize post-discharge services Communicate with case manager and social worker about post-discharge services that they schedule Provide patient with contact information for these services (phone number, name of company, etc.) Are there any ways you feel this needs to be improved?

26. RED Component #5Confirm the Medication Plan Reconcile the patient’s home medication list as close to admission as possible Review each medication; make sure that the patient knows why they take it Discuss new medications each day with medical team and with patient What is your current plan to improve?

27. RED Component #7 Review appropriate steps for what to do if a problem arises • What constitutes an emergency? • What to do if a non-emergent problem arises? • Where is contact information found for the discharge advocate and PCP on the After Hospital Care Plan? What are you doing now and what is your current plan to improve?

28. RED Component #9Assess degree of patient understanding, ask patient to explain discharge plan Deliver information to reach those with low health literacy Include caregivers when appropriate Utilize professional interpreters as needed How are you doing now and what is your current plan to improve?

29. RED Component #10 Give the patient a written discharge plan at time of discharge After Hospital Care Plan includes: 1) Principal discharge diagnosis 2) Discharge medication instructions 3) Follow-up appointments with contact information 4) Pending test results 5) Tests that require follow-up How are you doing now and what is your current plan to improve?

30. RED Component # 11 Provide telephone reinforcement of the discharge plan after discharge Call patient within 72 hours after discharge Assess patient status Review medication plan Review follow-up appointments Take appropriate actions to resolve problems What are you doing now and what is your current plan to improve?

31. Operationalizing RED • After Hospital Care Plan • Discharge Advocate • Follow-up phone call

32. After Hospital Care Plan Patient-centered discharge instruction booklet Designed to reach pts w/ low health literacy Individualized for each patient and organization

33. COVER PAGE of AFTER HOSPITAL CARE PLAN

35. MEDICATION PAGE (2 of 3)

39. PATIENT ACTIVATION PAGE

42. Components of RED Intervention In acute care facility – Nurse Discharge Advocate (DA) Interacts with care team: medication reconciliation, appointments, and national guidelines Prepares and teaches After Hospital Care Plan (AHCP) Post Discharge – Clinical Pharmacist Calls for follow-up @ 72 hours post-dc Reinforces dc plan and review medications

43. Testing the RED Process:Randomized Controlled Trial

44. Randomized Controlled Trial RED Intervention N=374 • 30-day • Outcome Data • Telephone Call • EMR Review Enrollment N=749 Randomization Usual Care N=375 Enrollment Criteria: • English speaking • Have telephone • Able to independently consent • Not admitted from institutionalized setting • Adult medical patients admitted to Boston Medical Center (urban academic safety-net hospital)  48% Medicaid + 22% Free Care

45. Analysis Primary outcome: • Total hospital utilization (readmissions plus ED visits) • Intention-to-treat • Poisson tests for significance • Cumulative hazard curves generated for time to multiple events Secondary outcomes: • PCP follow-up rate, identified dc diagnosis, identified PCP name, self-reported preparedness for discharge, cost • Proportions tests for significance

46. Primary Outcome: Hospital Utilization within 30d after dc * Hospital utilization refers to ED + Readmissions

47. 0.3 0.2 Cumulative Hazard Rate 0.1 0.0 0 5 10 15 20 25 30 Time after Index Discharge (days) Cumulative Hazard Rate of Patients Experiencing Hospital Utilization 30 days After Index Discharge Usual care Intervention p = 0.004

48. Outcome Cost Analysis We saved $412 in outcome costs for each patient given RED

49. RED Workstation

50. Patient Centered Care Transitions • Significant Cultural Change • Shifting to service mentality • Culturally and Linguistically Appropriate • Across the care continuum