Transcript Slide 1

Project RED
The Re-Engineered Discharge
JCR’s AHRQ-funded Project
April 2010
Disclaimer
This presentation and slide set do not
represent the policy of either the Agency
for Healthcare Research and Quality
(AHRQ) or the U.S. Department of
Health and Human Services (DHHS).
The views expressed herein are those of
the presenter, and no official
endorsement by AHRQ or DHHS is
intended or should be inferred.
Current information about the Patient
Safety Program should be obtained from
AHRQ, and not from these slides.
Speakers
Deborah M. Nadzam, PhD
Project Director, AHRQ KT/I Contract
Joint Commission Resources
Kim Visconti, RN
Discharge Advocate
Boston Medical Center
Today’s Web Conference
 Objectives of AHRQ-funded Knowledge Transfer
project - Deborah Nadzam
 Project RED – 11 steps to an improved patient
discharge process
Kim Visconti
 The value proposition of Project RED
Deborah Nadzam
 How to participate in this project
Deborah Nadzam
AHRQ-funded Knowledge
Transfer Project
 Background
– Knowledge Transfer/Implementation
contract
 Task assignment: Project RED
intervention
 Secure and support participation by 50
hospitals
Project Expectations
 Secure executive sponsorship
 Assign project team and project leader
 Identify targeted population of patients*
 Determine approach for generating After
Hospital Care Plan (ACHP)*
 Identify discharge advocate(s) and staff
to make post-discharge phone calls
 Participate in focus group conference call
Project Expectations cont’d
 Participate in web conference training
 Schedule bi-weekly consulting calls with
assigned JCR consultant
 Provide data to JCR re: readmission,
ALOS, patient satisfaction, resource
investments
 Participate in all-site web conference
discussions
 Participate in case-study interviews
“Perfect Storm" of Patient Safety
• 39.5 million hospital discharges per year
• $329.2 billion in total annual costs!
• Hospital discharge is not-standardized and marked with poor
quality.
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Loose Ends
Communication
Poor Quality Info
Poor Preparation
Fragmentation
Great Variability
• 19% of patients have a post-discharge AE
• 20% of Medicare patients readmitted within 30 days
• Only half had a visit in the 30 days after discharge1
More than Just Patient Safety
 "Hospitals with high rates of readmission will be paid
less if patients are readmitted to the hospital within the
same 30-day period saving $26 billion over 10 years"
Obama Administration Budget Document
 MedPAC recommends reducing payments to hospitals
with high readmission rates
MEDPAC Testimony before Congress March ‘09
 CMS: 14 Quality Improvement Organizations “Safe
Transitions” demonstration projects
 CMS to release new payment scheme
 http://www.hospitalcompare.hhs.gov/
Most Common Reasons for
Avoidable Readmission are not
Diagnosis-specific
 Poor discharge instruction:
Poor patient understanding of how to use
medications
 Patient doesn’t learn warning signs to report
to their physician
 Poor transfer of information to ambulatory
caregivers:
 Hospital to nursing home staff
 Hospital to primary care physician
 Lack of clarity on end of life care preferences
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Most Common Reasons for
Avoidable Readmission cont’d
 Lack of timely post-discharge physician visit:
 Physician unaware of hospitalization
 Patient has no primary care physician
 Patient has no transportation to see primary
care physician
 Poor medication reconciliation yields duplication
or interaction
Diagnosis-specific Reasons for
Avoidable Readmissions
 COPD, pneumonia—
Patients not getting home health benefits
 Pneumonia readmissions may reflect need
for end of life care
 Cardiac care—
 Cardiologists not arranging follow up for heart
failure patients
 Readmissions higher for heart failure patients
with behavioral problems
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Diagnosis-specific Reasons for
Avoidable Readmissions cont’d
 Post surgery—
Surgeons not arranging for post-surgical
primary care.
 Post-CABG patients, expecting to be pain
free, seek readmission for angina
 Inadequate teaching of the patient in caring
for their body after surgery (e.g., incision
care)
 Dialysis patients very vulnerable to drug therapy
changes
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The ReEngineered Discharge
Implementation Overview
Kimberly Visconti, RN
Discharge Advocate
Department of Family Medicine
Boston University Medical Center
Principles of the Newly
Re-Engineered Hospital Discharge
1) Explicit delineation of roles and responsibilities
2) Discharge process initiation upon admission
3) Patient education throughout hospitalization
4) Timely accurate information flow:
From PCP ► Among Hospital team ► Back to PCP
5) Complete patient discharge summary prior to discharge
6) Comprehensive written discharge plan provided to patient
prior to discharge
7) Discharge information in patient’s language and literacy
level
8) Reinforcement of plan with patient after discharge
9) Availability of case management staff outside of limited
daytime hours
10) Continuous quality improvement of discharge processes
RED Checklist
Eleven mutually reinforcing components:
1. Medication reconciliation
2. Reconcile discharge plan with national guidelines
3. Follow-up appointments
Adopted by
4. Outstanding tests
National Quality Forum
5. Post-discharge services
as one of 30 US
6. Written discharge plan
"Safe Practices" (SP-15)
7. What to do if problem arises
8. Patient education
9. Assess patient understanding
10. Discharge summary sent to PCP
11. Telephone reinforcement
RED Component #1
Educate patient about their diagnosis
throughout the hospital stay
o The RED intervention starts within 24 hours
of the patient’s admission to the hospital
and continues daily until discharge
SP-15: “preparation for discharge occurring with
documentation, throughout the hospitalization”
RED Component #2
Make appointments for clinician follow-up
and post-discharge testing
o Schedule PCP appointment within 2 weeks
after discharge
o Review the provider’s location,
transportation and plan to get to
appointment
o Consult with patient regarding best day and
time for appointments
o Discuss reason for and importance of all
follow-up appointments and testing
SP-15: “explicit delineation of roles and responsibilities in the discharge process”
RED Component #3
Discuss tests/studies completed
and who will follow-up on results
o Explain tests and studies done while in the
hospital and tell the patient which clinician is
responsible for reviewing the results
o Encourage the patient to discuss tests
his/her PCP; let the patient know that this
information will be listed on the AHCP
SP-15 “coordination and planning for follow-up
appointments that the patient can keep and
follow-up of tests and studies for which
confirmed results are not available at time of
discharge”
Red Component #4
Organize Post-discharge Services
o Collaborate with case manager and social
worker about patient needs and postdischarge services
o Provide patient with contact information for
these services (phone number, name of
company, etc.)
RED Component #5
Confirm the Medication Plan
o Reconcile the patient’s home medication list
upon admission to the hospital
o Review each medication; make sure that the
patient knows why they take it
o Discuss new medications each day with
medical team and with patient
SP-15 “completion of discharge plan and discharge summaries before
discharge”
RED Component #6
Reconcile discharge plan with
National Guidelines
o Communicate with medical team each day
about the discharge plan
o Recommend actions that should be taken for
each patient under a given diagnosis
RED Component #7
Review appropriate steps for what to do
if a problem arises
o What constitutes an emergency
o What to do if a non-emergent problem arises
o Where to find contact information for the
discharge advocate and PCP on the After
Hospital Care Plan
SP-15 “The time from discharge to the first appointment with the accepting
physician represents a period of high risk. All patients discharged from
hospitals should be told what to do if a question or problem arises,
including whom to contact and how to contact them. Guidance should also
be provided about resources for patients’ questions once they are
discharged.”
RED Component #8
Expedite transmission of the discharge
summary to the PCP
o Fax the discharge summary and AHCP to
PCP within 24 hours after discharge
SP-15 “reliable information from the primary care physician (PCP) or
caregiver on admission, to the hospital caregivers, and back to the PCP, after
discharge, using standardized communication methods”
“A discharge summary must be provided to the ambulatory clinical provider
who accepts the patient’s care after hospital discharge.”
RED Component #9
Assess degree of understanding by asking patient
to explain the details of the plan
o Deliver information to reach those with low
health literacy level
o Include caregivers when appropriate
o Utilize professional interpreters as needed
SP-15 "Before discharge, present a clear explanation that the patient understands
that addresses post-discharge medications, how to take them and how and where
prescription can be filled. This information must also be communicated to the
accepting physician.”
RED Component #10
Give the patient a written discharge plan
at time of discharge
o The AHCP should include:
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
SP-15 “coordination and planning for follow-up appointments that the patient can
keep and follow-up of tests and studies for which confirmed results are not
available at time of discharge”
After Hospital Care Plan
RED Component # 11
Provide telephone reinforcement
of the discharge plan after discharge
o Call patient within 72 hours after discharge
o Assess patient status
o Review medication plan
o Review follow-up appointments
o Take appropriate actions to resolve problems
SP-15 “Prospectively identify and provide a mechanism to contact patients with incomplete
or complex discharge plans after discharge to assess the success of the discharge plan,
address questions or issues that have arisen surrounding it, and reinforce its key
components, in order to avoid post discharge adverse events and unnecessary rehospitalizations"
11 RED Components Enable
Discharge Advocates to:
 Prepare patients for hospital discharge
 Help patients safely transition from
hospital to home
 Promote patient self-health management
 Support patients after discharge through
follow-up phone call
Challenges to Implementation:
Medical Team Related
 Busy medical team; discharge receives low priority in the
work schedule of inpatient clinicians
 Discharge is relegated to least experienced team member
 Last minute test / consultations resulting in delay of final
discharge plan and medication list
 Inaccurate medication reconciliation
 Discharge medication reconciliation started on the day of
discharge
Challenges to Implementation:
Hospital Related
 Lack of resources and financial incentives
to sustain discharge programs
 Standardized discharge papers; not
personalized or in language of patient
 Resistance to change by clinicians
 Financial pressure to fill beds as soon as
they are empty
Challenges to Implementation:
Patient Related
 Patient with no PCP
 Limited or no insurance coverage
 Inability to pay for medication co-pays
 Long wait times calling health centers
 Late discharge; less effective teaching to
patients who are anxious to leave
Using Health IT to Overcome
Challenge of RN Time
 Potential in future to link to patient EMR
so that information can flow into
workstation
 Assist in transferring clinical information
between health care settings
 Enhance patient education before
discharge
 Develop therapeutic alliance with patients
 Help determine patient competency
Automated Discharge Workflow
SP-15 “the development of IT systems to collect discharge information and create discharge
plans from existing hospital databases could enable components of the plan to be easily
collected”
Conclusions
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RED is NQF Safe Practice
RED:
– Can be delivered following the 11 components
and using the ACHP tool
– Can decrease hospital use
 30% overall reduction
 Savings of $412 per patient
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Success through elimination of barriers
-- Coordination and change are challenging
-- Providers must collaborate and work together
 Health IT could help
– Improve delivery
– Further improve cost savings and build the
business case
Value Proposition
 Hospitals
– Improved HCAHPS scores
 Potential reduction in malpractice claims
– Prepared for changes to CMS reimbursement
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penalties for high readmission rates
Improved relationship with private insurers
looking to contain costs
Improved nurse/provider time utilization
Demonstrated “Meaningful Use” under the
HITECH Act, eligibility for Medicare bonuses
Improved relationship with PCPs
Value Proposition cont’d
 Insurers
– Direct cost savings from reduced hospital
utilization ($412 per patient discharged)
– Patient satisfaction
– Improved long-term patient outcomes
Value Proposition cont’d
 Providers
– Improved nurse/provider time utilization
– Demonstrated “Meaningful Use” under the
HITECH Act
– Additional revenue from Current Procedural
Terminology (CPT) codes
– Improved patient satisfaction
Value Proposition cont’d
 Patients/Caregivers
– Improved outcomes
– Co-pays and premiums applied to more
effective services
– Enhanced autonomy and ability to direct
care
– Enhanced portability of personal health
records
Value Proposition cont’d
 Primary Care Physicians/Other Specialists
– Improved utilization and show rates by
patients
– Improved transmission of information to
better care for patient
 Increased patient satisfaction
Ready for Project RED?
 Next Steps
– Secure leadership commitment
– Identify targeted populations to begin
– Determine approach for developing After
Hospital Care Plan
– Identify staff: Project Leader, Project
Team, Discharge Advocate(s)
Identify Targeted Patient
Population
 Start small!
 Approaches to consider
– Specific patient care unit
– Diagnostic group
– Physician’s patient group
– Combination of above
 Also
– English-speaking patients
– Discharged home
– Access to telephone
Generating the AHCP
 “Manual” – use of template for discharge
advocate (DA) to enter all required data
 Provide template to your IT department
and request that they integrate with
existing systems
 Purchase software and integrate it with
your existing systems
To participate in JCR’s
AHRQ-funded project focused on
Project RED
Contact Deborah Nadzam
[email protected]
630-261-5048