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					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
   Mark Williams, MD                               Eric Howell, MD
    Principal Investigator                           Co-Investigator
    Professor of Medicine                            Director, Hospitalist Service
    Chief, Division of Hospital Medicine             Johns Hopkins Bayview Medical Center
    Northwestern University Feinberg School of      Greg Maynard, MD
    Medicine                                         Clinical Professor of Medicine
   Eric Coleman, MD, MPH                            Chief, Division of Hospital Medicine
    Advisory Board Chair                             UCSD Medical Center
    Associate Professor                             Arpana R. Vidyarthi, MD
    Division of Health Care Policy & Research        Assistant Professor of Medicine
    University of Colorado at Denver, Health         Director of Quality, Division of Hospital
    Sciences Center                                  Medicine
    Denver, CO                                       Director of Quality and Safety Programs,
   Jeffrey L. Greenwald, MD                         GME
    Co-Investigator                                  University of California San Francisco
    Director, Hospital Medicine Unit                Senior Advisor, Quality Initiatives
    Boston Medical Center                            Tina Budnitz, MPH
   Lakshmi Halasyamani, MD                         Senior Advisor, Research
    Co-Investigator                                  Kathleen Kerr
    Vice President for Quality and Systems          Senior Project Manager
    Improvement                                      Joy Wittnebert
    St Joseph Mercy Medical Center




              www.hospitalmedicine.org/BOOST
Magnitude of the Problem
 Forster & Bates - Prospective cohort study   1

 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
Orders of Magnitude II
 Types of discharge errors:    2

    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
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     5


 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
1.   The Incidence and Severity of Adverse Events Affecting Patients
     after Discharge from the Hospital. Forster AJ. Ann Intern Med.
     2003;138:161-167
2.   Medical errors related to discontinuity of care from an inpatient to an
     outpatient setting. Moore C. JGIM. Aug 2003, 18(8):646-51
3.   Patient Safety Concerns Arising from Test Results That Return after
     Hospital Discharge. Roy CL. Ann Intern Med. 2005;143:121-128.
4.   The Canadian Adverse Events Study: the incidence of adverse
     events among hospital patients in Canada. Baker GR. CMAJ.MAY
     25, 2004; 70 (11)
5.   Lost in Transition: Challenges and Opportunities for Improving the
     Quality of Transitional Care. Coleman EA. Ann Intern Med.
     2004;140:533
6.   Low health literacy called a major problem. Vastag B. JAMA. May 12
     2004;291(18):2181-82
7.   Resident recognition of low literacy as a risk factor in hospital
     readmission. Powell CK. JGIM 20(11):1042-4, 2005 Nov.
8.   Patients’ Understanding of Their Treatment Plans and diagnosis at
     discharge. Makaryus AN. Mayo Clin Proc. August 2005;80(8):991-
     994
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):1842-
   1847.

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):317-
   323.

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
    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;335:514-
   7).
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
    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      Med spec educ using Teach Back- pt and caregiver
(insulin, Coumadin,      Monitoring plan for patient and aftercare providers
Plavix, Narcs/BZDs,      Specific strategies for managing adverse drug events
Dig)                     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      Review of national discharge guidelines [Core Measures]
(cancer, stroke, DM,     Disease specific educ with Teach-Back for pt and caregiver
COPD, heart failure)     Action plan reviewed
                         How and When to contact if worsening/new symptoms
                         Discuss goals of care and chronic illness

Polypharmacy             Eliminate unnecessary medications
(>5 more routine meds)   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            Follow-up phone call at 72 hours
(absence of care giver     Follow-up appointment after every hospitalization. Get
to assist with             an MD if needed.
discharge and home         Engage home care providers with clear d/c
care)                      plans/expectations
Prior hospitalization      Review reasons for re-hospitalization. ID areas for
(non-elective; in last 6   early interventions
months)                    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           NO
3. Medication use/side effects reviewed using Teach-Back ………. YES       NO
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   NO
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          NO
8. Documented receipt of discharge information …………………….YES             NO
9. Arrangements made for outpt f/u with principal care
    provider(s)……………. YES 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   Important contact information:
   my doctor(s) about at my clinic     1. My primary doctor: _________________
   visit:
                                       (____) ___________
1. __________________________
                                       2. My hospital doctor: _________________

                                       (____) ___________
2. __________________________
                                       3. My visiting nurse: _________________

                                       (____) ___________
3. __________________________          4. My pharmacy: _________________

                                       (____) ___________
4. __________________________          5. Other: _____________________

                                       (____) ___________
Patient PASS IV

Other instructions:          I understand my treatment
                             plan. I feel able and willing to
1.________________________   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
    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
 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:
     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:
     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
    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

				
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