Reducing Readmissions through The R e- E ngineered D ischarge – (Project RED)

1. Reducing Readmissions through The Re-Engineered Discharge –(Project RED) Suzanne Mitchell, MD MS Assistant Professor, Family Medicine Department of Family Medicine / Boston University School of Medicine March 25, 2014 Participants:1-866-639-0744, no code needed

2. The Re-Engineered Discharge (Project RED) March 25, 2014 Suzanne Mitchell, MD MS Assistant Professor, Family Medicine Department of Family Medicine / Boston University School of Medicine

3. Agenda • The Transition Problem • How We Got Started • The RED Process • Brief Mention of Health IT? • Lessons Learned from Dissemination

4. “Perfect Storm" of Patient Safety “Perfect Storm" of Patient Safety • 39.5 million hospital discharges/year = Costs totaling $329.2b! • 20% readmitted within 30 days • Hospital discharge is not-standardized: • Loose Ends - pending and post-dc tests • Communication – with PCP, ESL, Health lit • Poor Information - dc summary quality and availability • Poor Preparation – knowledge of dx, meds, appts • Great Variability – day of the week • Fragmentation – who is in charge? • Hospital Discharge is not safe! • 19% of patients have a post-discharge AE

5. A Real Discharge Instruction Sheet

6. ResearchQuestions We asked: • Can improving the discharge process reduce adverse events and unplanned hospital utilization? Grant reviewer asked: • What is the “discharge process”?

7. Question for you…… • Do you know what your hospital’s discharge process is? • Do you know the parts of the process where problems are occurring for patients or hospital personnel? • ie, occurring before or following discharge? • How are you identifying the problem spots?

8. Principles of the RED:Creating the Toolkit Patient Readmitted Within 3 Months Readmission Within 6 Months Hospital Discharge Probabilistic Risk Assessment Process Mapping Failure Mode and Effects Analysis Qualitative Analysis Root Cause Analysis

9. THE RED INTERVENTIONTwo key components • In Hospital –> Preparation & Education of written plan • AHCP • After Discharge – Reinforcement of the plan • Phone call within 72 hours after discharge • Assess clinical status • Review medications and appointments

10. RED Checklist Twelve mutually reinforcing components: • Medication reconciliation • Reconcile dc plan with National Guidelines • Follow-up appointments • Outstanding tests • Post-discharge services • Written discharge plan • What to do if problem arises • Patient education • Assess patient understanding • Dc summary to PCP • Telephone Reinforcement • Provide Language Services Adopted by National Quality Forum as one of 30 "Safe Practices" (SP-11)

11. RCT Methods- RED Intervention N=375 • 30-day • Outcome Data • Telephone Call • EMR Review Enrollment N=750 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)

12. Personalized cover page

13. MEDICATION PAGE (2 of 3)

14. APPOINTMENTS PAGE

15. PRIMARY DIAGNOSIS PAGE

16. Question for you…… • Does your institution have a patient-centered discharge document? • If no, what are the barriers to providing such a document? • If yes, • What are the design elements that facilitate communication? • What design elements support patient self-management?

17. FINDINGS from Project RED RCT

18. How well did we deliver intervention

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

20. Secondary Outcomes *

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

22. Medication Errors at 2 Day Call (n=197) Overall, 51% experienced error within 2 days!

23. Question for you….. • Have you tried any strategies to communicate with patients following discharge? • Are you able to make PCP appointments at the time of discharge? • What strategies are you using for medication reconciliation at the time of discharge?

24. Implications Should all patients get RED?

25. Question for you….. • Is your institution doing risk stratification at the time of admission?

26. Who is at risk of Rehospitalization? • CHF, COPD, Dementia • High risk Meds • Elderly • LOS • Co-morbidity • Men • Substance Abuse • Health Literacy (REALM) • Depression (PHQ-9) • Patient Activation (PAM) • Frequent Fliers (>2 in 6 months)

27. Can Health IT assist with providing a comprehensive discharge?

28. Characters: Louise (L) and Elizabeth (R) Health IT to Save Time • Virtual Patient Advocates • Emulate face-to-face communication • Develop therapeutic alliance-empathy, gaze, posture, gesture • Teach AHCP • Tailored • Do “Teach Back” • Can drill down • Print Reports • High Risk Meds • Lovenox • Insulin

29. Overall Usability Ease of Use Overall Satisfaction

31. Who Would You Rather Receive Discharge Instructions From? 36% prefer Louise 48% neutral 16% prefer doc or nurse “I prefer Louise, she’s better than a doctor, she explains more, and doctors are always in a hurry.” “It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and says ‘Here you go.’ Elizabeth explains everything.” 1=definitely prefer doc, 4=neutral, 7=definitely prefer agent

32. Question for you….. • Is your institution using health IT to streamline the hospital discharge process? • What processes are you automating? • What are the benefits/challenges of using health IT for discharge process?

33. Barriers to RED Can appointments be made? Will RED delay discharge time? Who serves as the Discharge Educator? Who does the 2 day phone call? Who Produces the AHCP? Can we Re-Engineer the Hospital Ward?

34. Success storiesBoston HealthNet plan • Period -> calendar year 2011 • Patients given RED -> 500 • Discharge educator = dedicated RN • Post discharge phone call = plan’s care manager • Results -> 30 day all cause readmission rate • Cost savings -> well over 400k

35. RED for Boston HealthNet

36. Formal risk screening Process for patient education Discharge educator Developing and teaching ACHP Pharmacist Standardized communication Primary care providers Other providers Home care Nursing Home RED Implementation – Strategies During hospitalization

37. Discharge Nurse Educator Uses checklist Assesses patient understanding of discharge plan (Teach back process used) Care Team Discusses discharge plan daily at team huddle Patient Receives individual written discharge plan RED Implementation – Strategies Prior to Discharge

38. Discharge is not rushed or late in the day AHCP and discharge summary are sent to PCP office Patient reminded about post discharge phone call phone number for follow-up call confirmed RED Implementation – Strategies at time of discharge

39. RED TEAM-based CARE

40. Barriers to High Quality Transitions • “Heads on Beds” • Med reconciliation • Discharge summary • Hospital-PCP communication • Language and health literacy • Cognitive Issues • Plan delegated to interns

41. Role of Senior Leadership • Set the vision and the goal • Communicate Commitment • Newsletter, grand rounds, M+M, RCA, emails • Provide resources & staff • Create implementation team • Set policies to integrate across organizational boundaries • Get IT on board • Hold people accountable • Recognize and reward success 41

42. Role of Implementation Team • Recruit a collaborative, interdisciplinary team • Identify process owners and change champions • Staff Engagement • Energize staff • Get buy-in • Implement a Plan that will work • Build skills to support and sustain improvement • Trouble shoot as RED is rolled out • Monitor progress to provide feedback 42

43. Question for you….. • What barriers or facilitators have you faced in helping to manage your hospital discharge process better?

44. Conclusions • Hospital DC is low hanging fruit • Changing the Culture of Hospitals is Hard • RED • Can decreased hospital use • 30% overall reduction, NNT = 7.3 • Saves $412 per patient • Health IT has great potential • Team-based Efficiency key to implementation • Determining who benefits is important

45. QUESTIONS FOR ME??

46. Thank you! brian.jack@bmc.orghttp://www.bu.edu/fammed/projectred/

47. Thank You! Questions suzanne.mitchell@bmc.org brian.jack@bmc.org Project RED Website http://www.bu.edu/fammed/projectred/

48. Upcoming RARE Events…. Stay tuned for the next RARE Mental Health Webinar’s: April 21, 2014 Care Transitions Interventions in Mental Health Harold Pincus, Columbia University May 19, 2014 In-REACH Program Elizabeth Keck, Allina Health June 26, 2014 New York Office of Mental Health Dr. Molly Finnerty

49. Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact: Kathy Cummings, kcummings@icsi.org Jill Kemper, jkemper@icsi.org