Patient Discharge Information

							        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.
           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
         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
        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
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
 7. What to do if problem arises     "Safe Practices" (SP-15)
 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 post-
discharge 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 re-
hospitalizations"
       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
   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
  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
    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
      dnadzam@jcrinc.com
          630-261-5048