Transcript Transitions with a BOOST - Georgia`s Partnership for Health and

Transitions with a BOOST
Matthew Schreiber MD
Medical Director
Piedmont Hospitalist Physicians
Special Thanks
 Sixty Plus Older Adult Services
 Transitions Team
 Nancy Morrison
 Tim Young
 Dee Tucker
 Michelle Nelson…and many others
 Vandy Vail-Dickson Admin Director Hospitalists
 Society of Hospital Medicine
 BOOST Mentors
 Dr Mark Williams
 Arpana R. Vidyarthi
www.hospitalmedicine.org/BOOST
Project BOOST Team
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Mark Williams, MD
Principal Investigator
Professor of Medicine
Chief, Division of Hospital Medicine
Northwestern University Feinberg School of
Medicine
Eric Coleman, MD, MPH
Advisory Board Chair
Associate Professor
Division of Health Care Policy & Research
University of Colorado at Denver, Health
Sciences Center
Denver, CO
Jeffrey L. Greenwald, MD
Co-Investigator
Director, Hospital Medicine Unit
Boston Medical Center
Lakshmi Halasyamani, MD
Co-Investigator
Vice President for Quality and Systems
Improvement
St Joseph Mercy Medical Center
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Eric Howell, MD
Co-Investigator
Director, Hospitalist Service
Johns Hopkins Bayview Medical Center
Greg Maynard, MD
Clinical Professor of Medicine
Chief, Division of Hospital Medicine
UCSD Medical Center
Arpana R. Vidyarthi, MD
Assistant Professor of Medicine
Director of Quality, Division of Hospital
Medicine
Director of Quality and Safety Programs,
GME
University of California San Francisco
Senior Advisor, Quality Initiatives
Tina Budnitz, MPH
Senior Advisor, Research
Kathleen Kerr
Senior Project Manager
Joy Wittnebert
www.hospitalmedicine.org/BOOST
Magnitude of the Problem
 Forster & Bates - Prospective cohort study
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 Objective: to describe the incidence, severity,
preventability, and “ameliorability” of adverse
events affecting patients after discharge
 Tertiary care academic hospital
 400 medicine patients discharged home
 At 3 weeks - Medical record review and
Telephone call (structured interview by internist)
Orders of Magnitude
 One in five general medicine patients
experiences an adverse event (resulting
from medical management) within two weeks
of hospital discharge 1
66% of these events are adverse drug
events, 17% are related to procedures
 33% of these events lead to disability
 Two-thirds of these events are
preventable or ameliorable
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Orders of Magnitude II
 Types of discharge errors:
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42% of patients had medication continuity errors DC Plan.doc
 12 % had work-up errors
 8% test follow-up errors
 Patients with work-up errors were more likely to be
rehospitalized
 Pending test results:3
 Many patients (41%) are discharged with test results
still pending.
 Many of these results (10%) can change management
 Physicians are often (61%) unaware of test results
returning after discharge that may change
management
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Orders of Magnitude III
 Unsafe discharges are an under recognized yet significant
issue that has received almost no attention in health care 5
 Discharges can be urgent and unplanned
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 No longer does one practitioner typically take responsibility
for the discharge 5
 Communication breakdown between multiple providers and
between providers and patients 5, 6, 7
 Less than half of patients discharged from academic general
medicine know their diagnoses, treatment plan or side effects
of prescribed medications 8, 9
Bibliography
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The Incidence and Severity of Adverse Events Affecting Patients
after Discharge from the Hospital. Forster AJ. Ann Intern Med.
2003;138:161-167
Medical errors related to discontinuity of care from an inpatient to an
outpatient setting. Moore C. JGIM. Aug 2003, 18(8):646-51
Patient Safety Concerns Arising from Test Results That Return after
Hospital Discharge. Roy CL. Ann Intern Med. 2005;143:121-128.
The Canadian Adverse Events Study: the incidence of adverse
events among hospital patients in Canada. Baker GR. CMAJ.MAY
25, 2004; 70 (11)
Lost in Transition: Challenges and Opportunities for Improving the
Quality of Transitional Care. Coleman EA. Ann Intern Med.
2004;140:533
Low health literacy called a major problem. Vastag B. JAMA. May 12
2004;291(18):2181-82
Resident recognition of low literacy as a risk factor in hospital
readmission. Powell CK. JGIM 20(11):1042-4, 2005 Nov.
Patients’ Understanding of Their Treatment Plans and diagnosis at
discharge. Makaryus AN. Mayo Clin Proc. August 2005;80(8):991994
It’s All About the Meds
 Coleman et al found that hospital readmission rates
for patients with identified medication
discrepancies were 14.3% among the 375 study
patients. This contrasted with a 6.1% readmission
rate among patients with no identified medication
discrepancy.
 Forster et al found that antibiotics were the most
common drugs causing adverse events defined as
injury resulting from medical management rather than
the underlying disease. Antibiotics accounted for
38% of adverse events, while corticosteroids
accounted for 16%, cardiovascular drugs 14%,
analgesics including opiates 10%, and
anticoagulants 8%.
It’s All About the Meds
Schnipper et al showed in a randomized trial
of 178 patients being discharged home from
the general medicine service that pharmacist
counseling reduced the number of
preventable adverse drug events from
11% in the control group to 1% in the
intervention group.
It’s All About the Meds
 Forster et al., using a survey of patient
recollection of the discharge preparations among
400 discharged patients showed that discussion
of potential side effects was associated with a
reduction in frequency of adverse drug events
(adjusted OR 0.4 [95% CI 0.2 to 0.7]). There was
no evidence that these discussions increased the
likelihood of reported side effects.
Unfortunately, only 62% of patients could
recall having been told about potential
medication side effects at time of discharge.
References
Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies:
prevalence and contributing factors. Arch Intern Med. Sep 12 2005;165(16):18421847.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity
of
adverse events affecting patients after discharge from the hospital. Ann Intern
Med. Feb 4 2003;138(3):161-167.
Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in
preventing adverse drug events after hospitalization. Arch Intern Med. Mar 13
2006;166(5):565-571.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events
occurring following hospital discharge. J Gen Intern Med. Apr 2005;20(4):317323.
Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL.
Emergency department visits for outpatient adverse drug events: demonstration
for a national surveillance system. Ann Emerg Med. Feb 2005;45(2):197-206.
Not In My Backyard?
 The initial med rec lists in PHC were only 45% accurate
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for medications listed (344/773)
209 medications were missing from these initial list
Of patients that were taking medications prior to admit,
89% of initial med recs were incomplete and/or
contained at least 1 error
Only 11% of patients taking medications prior to admit
had an initial MRR that was 100% correct/complete.
It took an average of 27 minutes per patient to complete
pharmacist reconciliation
The New Guard
 Hospitalist activities may include patient care, teaching,
research, and leadership related to hospital care. Hospital
medicine, like emergency medicine, is a specialty organized
around a site of care (the hospital), rather than an organ (like
cardiology), a disease (like oncology), or a patient’s age (like
pediatrics). However, unlike medical specialists in the
emergency department or critical care units, most hospitalists
help manage patients throughout the continuum of hospital care,
often seeing patients in the ER, admitting them to inpatient
wards, following them as necessary into the critical care unit,
and organizing post-acute care.
 The term was coined by Drs. Robert Wachter and Lee Goldman
in a New England Journal of Medicine article in August of 1996
(Wachter RM, Goldman L. The emerging role of "hospitalists" in
the American health care system. N Engl J Med 1996;335:5147).
Hospitalist Medicine
 Hospital medicine is the fastest growing field
in the history of medicine
 Currently, no formal certification or board
recognition, although this is in the works
 More than 22,000 hospitalists currently,
projected to have more than 30,000 in 2010
 There are more than 5 jobs awaiting each
new hospitalist entrant
 Hospitalists “represent/staff” about 70% of all
hospital beds nationwide
Mission Motivation
The goal of Project BOOST (Better Outcomes
for Older adults through Safe Transitions) is
to improve the care of patients as they
transition from the hospital to home.
BOOST[er] Power
 Create a national consensus for best
practices.
 Create resources to implement best
practices.
 Provide technical support.
Aiming High With A Value Proposition
By improving discharge processes, Project BOOST aims to:
 Reduce 30 day readmission rates for general medicine
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patients (with particular focus on older adults)
Improve facility patient satisfaction scores
Improve the institution’s H-CAHPS scores related to
discharge
Improve flow of information between hospital and outpatient
physicians
Ensure high-risk patients are identified and specific
interventions are offered to mitigate their risk
Improve patient and family education practices to encourage
use of the teach-back process around risk specific issues.
Join the BOOST Brigade
 Any site can access the BOOST toolkit via the resource room
free of charge at www.hospitalmedicine.org/BOOST. Over 265
sites have downloaded the complete Implementation Guide.
 Six hospitals were selected to participate in Project BOOST’s
pilot cohort in 9/08:
 Hospital of the University of Pennsylvania
 Queens Medical Center – Honolulu, Hawaii
 Southwestern Vermont Medical Center
 Piedmont Hospital – Atlanta, Georgia
 University of New Mexico Health Science Center School of
Medicine
 ThedaCare: Appleton Medical Center, Appleton, WI; &
ThedaClark Medical Center, Neenah WI).
 Cohort 2 has 24 additional sites
The Basic Process
 Identify and Risk Stratify For Discharge
Failure
 Intervene with focused care
 Educate/Inform the Patient AND Key Contact
 Written Discharge Action Plan that
Patient/Caregiver can “Teach Back”
 Follow up with 72 hr call, home health,
provider visit
Teach Back
Step 1: Using simple language, explain the concept/process to the
pt/caregiver.
Step 2: Ask the pt/caregiver to repeat in his or her own words how
s/he understands the concept.
Step 3: Identify and correct misunderstandings
Step 4: Ask the pt/caregiver to demonstrate understanding again to
ensure the misunderstandings are corrected.
Step 5: Repeat Steps 4 and 5 until the clinician is convinced of
Comprehension.
Dean Schillinger, MD
Associate Professor of Clinical Medicine
University of California, San Francisco
The Forms
 TARGET—Risk Assessment/Intervention
Guide
 GAP—General Assessment of Discharge
Preparedness
 Universal Discharge Check List
7P Risk Assessment
And Triggered Interventions
Problem medications
(insulin, Coumadin,
Plavix, Narcs/BZDs,
Dig)
Med spec educ using Teach Back- pt and caregiver
Monitoring plan for patient and aftercare providers
Specific strategies for managing adverse drug events
Follow-up phone call at 72 hours re: med issues/educ
Punk (depression)
Psych Assessment for in/out pt needs
Comm w/aftercare providers for f/u on this issue
Involvement/awareness of support network arranged
Principal diagnosis
(cancer, stroke, DM,
COPD, heart failure)
Review of national discharge guidelines [Core Measures]
Disease specific educ with Teach-Back for pt and caregiver
Action plan reviewed
How and When to contact if worsening/new symptoms
Discuss goals of care and chronic illness
Polypharmacy
(>5 more routine meds)
Eliminate unnecessary medications
Simplify medication scheduling to improve adherence
Follow-up phone call at 72 hours
7P Risk Assessment
And Triggered Interventions
Poor health literacy
Committed caregiver involved in all plans
(inability to do Teach Specific, concrete interventions
Back)
Written Aftercare plan education using Teach-Back
Link to as many community resources as possible
Follow-up phone call at 72 hours
Patient support
(absence of care giver
to assist with
discharge and home
care)
Follow-up phone call at 72 hours
Follow-up appointment after every hospitalization. Get
an MD if needed.
Engage home care providers with clear d/c
plans/expectations
Prior hospitalization
(non-elective; in last 6
months)
Review reasons for re-hospitalization. ID areas for
early interventions
Follow-up phone call at 72 hours to
Follow-up appointment. Ensure has MD.
General Assessment of Preparedness (GAP)
Logistical Issues
Prior to discharge, evaluate the following areas with the
patient/caregiver(s) and ambulatory medical care
providers:
1. Functional status assessment
2. Access (e.g. keys) to home ensured
3. Home prepared for patient’s arrival?
4. Advanced care planning documented
5. Ability to obtain medications confirmed
6. Responsible party for med adherence ID’d?
7. Transportation to initial follow-up arranged
8. Transportation home arranged
General Assessment of Preparedness
Psychosocial
1. Substance abuse/dependence
identified/addressed
2. Abuse/neglect presence assessed/addressed
3. Cognitive status assessed/addressed
4. Financial resources assessed/appropriate
programs applied for
5. Support circle for patient ID’d for patient,
caregiver, homehealth, PCP
6. Contact info for caregivers provided for above?
Universal Discharge Checklist
1. GAP assessment (see below) completed with issues
addressed……..……….YES NO
2. Medications reconciled with pre-admission list…………………… YES
3. Medication use/side effects reviewed using Teach-Back ………. YES
4. Teach-Back for understanding of dz, prog, and self-care
requirements.……….…YES NO
5. Action plan for sx/s-e/cx requiring attn w/teach-back ………….... YES
6. D/c plan (edu mtls; med rec list; f/u plans) provided/taught
back………………….…YES NO
7. D/c communication to principal care provider(s)……….………… YES
8. Documented receipt of discharge information …………………….YES
9. Arrangements made for outpt f/u with principal care
provider(s)……………. YES NO
NO
NO
NO
NO
NO
Universal D/C Checklist
For increased risk patients, consider
1. Face-to-face multidisc rounds prior to discharge
2. Direct comm with main care provider before
discharge
3. Phone contact arranged w/in 72 hours of d/c
4. F/u appoint with main care provider w/in7 days
5. Contact info for hospital MD/RN familiar w/pt
provided to for use if unable to reach principal
care provider prior to first follow-up
Patient Pass I
 I Was In the Hospital Because:
If I have the following problems…
I should …
1. ______________________
1. ______________________
2. ______________________
2. ______________________
3. ______________________
3. ______________________
Patient PASS II
My appointments:
My appointments:
1. ________________________
3. _________________________
On: __/__/___ at __:__ am/pm
On: __/__/___ at __:__ am/pm
For: _____________________
For: _____________________
2. ________________________
4. ________________________
On: __/__/___ at __:__ am/pm
On: __/__/___ at __:__ am/pm
For: _____________________
For:_______________________
Patient PASS III
Tests and issues I need to talk with
my doctor(s) about at my clinic
visit:
Important contact information:
1. My primary doctor: _________________
(____) ___________
1. __________________________
2. My hospital doctor: _________________
(____) ___________
2. __________________________
3. My visiting nurse: _________________
(____) ___________
3. __________________________
4. My pharmacy: _________________
(____) ___________
4. __________________________
5. Other: _____________________
(____) ___________
Patient PASS IV
Other instructions:
1.________________________
_______________________
I understand my treatment
plan. I feel able and willing to
participate actively in my
care:
2.________________________
_______________________
_______________________
Patient/Caregiver Signature
3.________________________
_______________________
_______________________
Provider Signature
4.________________________
_______________________
____/____/_____
Date
The Forms Are Good, But the Process It
Requires is Better
 Ever Feel like a hospital admission and
discharge is like renting a car?
 Sign here, initial here, etc. It all sounds like
everything is covered—until you have a
problem.
 Ever find out the hard way that the underside
of the car isn’t insured—even with the “total
coverage?”
“Unique Mechanics”
 Geographically designated personnel including IMS MD—LEAN
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Advantage
Ward organized around attending MD instead of disease state
Name in the Box*
Right person, right job***(eg pharmacy)
Centralized Communication—d/c criteria, what’s next, patient out
of room on “public” whiteboard
Automation/Standardization—data retrieval results in predictable
responses
Detailed Risk Assessments translate into proactive care—
medications, functional assessments
“Specialized testing triage”
Create “the Pull”
Charge RN in Charge of being in charge
The Results
 An Astounding 45% decline in Avoidable Days (Excess
LOS) from 9/08 – 1/09 vs same Period on the same unit
the year prior (670 vs 366 avd days)
 During this Period, the MDs on the Unit discharged 260
pts/MD vs 116 pts/MD with traditional process (17% of
workforce was responsible for 31% of the work)
 Each of the 2 Unit MDs had 183 Avoidable days for
their 260 cases (0.7 avd days/case) vs. 141 avoidable
days for each of the 10 MDs with 116 Cases each (1.2
avd days/case)
The Results II
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Readmission Rate significantly lower vs peers
Patient Satisfaction has improved Markedly
Staff Satisfaction is at an all-time high
“Float RNs” asking to rotate there
One Unit Making a Noticeable impact on whole house
throughput
 PCPs LOVE the PASS
 Significant percentage of patients can still “teach back” at
follow-up call
 Home Health Much Better informed and can verify that d/c
MRR is same as what is actually being taken in home
Summary Statements
 Adverse events resulting from medical
(mis)management at discharge are:
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Common in our patients
Often involve Medications and Tests
Dangerous and result in significant morbidity
and increased healthcare utilization
Preventable
Classic Problems with Creating Safe
Discharges
 Discharges are unsafe for a number of
reasons:
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complex process
time constraints
low priority
poor planning
lack of ‘ownership’,
poor communication
not ‘patient=centered’
Creating Safe Discharges is Like
Being an American In the Stock Market
 We all know the job—Save for retirement
 We’re offered some excellent tools (401K)
 There is a ton of information out there
 It confuses the experts
 No one and everyone “owns it”
 Success depends on getting the basics right
and on doing the maintenance work between
decision points
Pearls of Wisdom
 Take Ownership Every Visit Every Time
 Assume Anything that Can Go Wrong Will Go
Wrong and Act Accordingly
 Managing “the Space Between” is the right thing
to do
 Do you Have a daughter? Can I speak with
Her? If no, automatic high risk.
 It’s all about the Meds
 If It’s confusing for you, it’s confusing for
everyone
Wisdoms Continued
 Communication between providers is a key
deficit. How tightly connected is your feedback
loop? Is the patient included? Home
care/community resources?
 Is the plan written, does the pt understand?
Who’s the manager, the key assistants?
 Have you followed up to ensure things are going
well and/or to redirect to care?
 Use Home Health Unless you Have a Good
Reason Not To. Less than 1/3 of our patients
with more than 4 Admissions in a year had home
health at last discharge.
Eminent Domain
 Medicine Has Focused on Episodes and
Domains of Care and Responsibility
 We Need to Focus not on how well we did
“our job” rather on patient outcome
 We are all responsible for the whole shebang,
though we choose to subdivide responsibility
for our own convenience
 Make the Most of the “Inpatient Moment”
Parting Wisdom
 No Margin, No Mission; but without staying true
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to your mission, you’ll never have sustainable
margin
Don’t Collect Data you don’t use, Use the Data
You Collect
Do Something Different Wrong
Always Do the Right Thing No Matter How
Difficult
Never accept of yourself an effort dependent
failure
We have all the help we need—it’s sitting in this
room