Hartford Hospital Discharge Forms by apg13300

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									Project BOOST
Reducing Readmissions
Mark V. Williams, MD, FACP, FHM
Professor & Chief, Division of Hospital Medicine
Northwestern U. Feinberg School of Medicine
Principal Investigator, Project BOOST
A Problem for a long time
 Rosenthal, J. M. and D. B. Miller
  "Providers have failed to work for
  continuity." Hospitals 53(10): 79-83.   1979
   Continuity of patient care between different
   health care settings has been advocated for
   nearly 20 years, but little has been done to
   effect it. The study described here emphasizes
   the current lack of effort by health care
   providers in hospitals and nursing homes to
   find a workable solution.
June 2007 MedPAC Report
 Medicare pays for ALL admissions regardless
      Initial stay or readmission for same condition
 17.6% of admissions result in
  re-admissions within 30 days (6% in 7 days)
      = $15 billion in spending
 Future
      “CMS proposes to require that all general acute
       hospitals conduct a CARE assessment on every
       Medicare beneficiary being discharged.”
           Continuity Assessment Record and Evaluation
      Public Disclosure of readmission rates
      Lower case payments for readmissions
• 1 in 5 Medicare patients rehospitalized in 30 days
• Half never saw outpatient doc
• 70% of surgical readmissions–chronic medical
  conditions
• Costs $17.4 billion
         Rates of Rehospitalization within 30 Days after Hospital Discharge




Jencks S, Williams MV, Coleman EA. et al. N Engl J Med 2009;360:1418-
1428
Health Affairs 2010; 29:57-64
Average LOS: US Hospitals

                                > 65 = 12.6 to 5.5 days




     DeFrances et al, Adv data, 2007 Jul 12;(385):1-19
              Harlan M. Krumholz, MD, SM research group



 Observational study of 6,955,461 Medicare FFS
  hospitalizations for HF; 1993 and 2006, with 30-day f/u.
       Mean age = 80
       52% Htn, 38% DM, 37% COPD
   LOS 8.8 days down to 6.3
   In-hospital mortality declined from 8.5% to 4.3%
   30-day mortality declined from 12.8% to 10.7%
   Discharges to SNF increased from 13% to 20%
       Discharge to home decreased from 74% to 67%
 30 day readmission increased from 17.2% to 20.1%
       Post-discharge mortality increased from 4.3% to 6.4%
Preventable Admissions
   Hospital inpatient care is the most expensive
    type of health care
   > 4 million Preventable Admissions
   Cost nearly $31 Billion

   Heart Failure and Pneumonia
       Half of the $ problem
   COPD – 16%
   Diabetes – 13%
   Elderly – 2/3 of these hospitalizations
    - 1 in 5 Medicare admissions
Care Coordination Failure?



  5 commercial disease management companies,
   3 community hospitals, 3 AMCs, 1 integrated
   delivery system, 1 hospice, 1 long term care
   facility, 1 retirement community across U.S.
  No cost savings
  2 reduced hospitalizations
  Sickest patients benefited
HospitalCompare.gov
Readmission Reduction
CBO - $7.1B savings over 10 yrs

Hospital Quality & Performance Based
 Payments
All DRG payment amounts in hospitals with
 excess readmission are reduced by a
 factor determined by the level of “excess,
 preventable readmissions”
   Effective 2013
   Excess = ratio of actual to expected (risk-adj)

   Reduction of 1%, 2%, and 3% first 3 years
Readmission Reduction
Program
 NQF endorsed measures
     Initially AMI, HF, pneumonia
     Expand in 2015 to 4 more conditions
          COPD, CABG, PTCA, Other Vascular
     Measures must have exclusions for readmissions
      unrelated to prior discharge
          e.g. transfers, planned readmissions
     Readmission time window specified by Secretary
          30 days in NQF measures
 Report all-payer readmission rates publicly
Measures – AMA PCPI
Care Transitions
   Work Group
   Performance Measure Set

Reconciled medication list
Transition record
Timely transmission
 Discharge Planning/Post-Discharge Support
  for Heart Failure Patients
Hospital Discharge
- currently
“Random events connected to highly
  variable actions with only a remote
  possibility of meeting implied
  expectations.”
      Roger Resar, MD
      Agent of Tremendous Change and Global Innovation Seeker
      Luther Midelfort – Mayo Health System
      Senior Fellow, IHI
Dangers of Discharge



 •19% of patients had a post discharge AE   Ann Intern Med 2003;

    - 1/3 preventable and 1/3 ameliorable   Vol. 138




 •23% of patients had a post discharge AE     CMAJ 2004;170(3)

    - 28% preventable and 22% ameliorable
Dangers of Discharge




                                                      Ann Intern Med
                                                    2005;143(2):121-8

     1095 of 2644 (41%) inpatients discharged with test
      result pending
          - 191 (9.4%) potentially required action
          - Survey of MDs involved: almost 2/3 unaware of results
          - Of these: 37% actionable and 13% urgent
Dangers of Discharge
                       Arch Intern Med. 2007;167:1305-1311




 ¼ of discharged patients require additional
  outpatient work-ups
 > 1/3 not completed
 Increased time to post-discharge f/u
  associated with lack of work-up completion
 Availability of discharge summary increased
  likelihood of work-up being done
Hospitalist to PCP
Info transfer and communication deficits at
 hospital discharge are common
   Direct communication 3-20%
   Discharge summary availability at 1st post-
    discharge appt 12-34%; 51-77% at 4 weeks
   Discharge summaries often lack info
       Dx test results (33-63%), hospital course (7-22%),
        discharge meds (2-40%), pending test results (65%)
       Follow-up plans (2-43%), Counseling (90-92%)

   Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW
   JAMA 2007;297:831-41.
Discharge Summary



            J Gen Intern Med 2009;24:1002-6




  “Discharge summaries are grossly inadequate at
   documenting both tests with pending results and
   appropriate f/u providers.”
Northwestern Solution




                      Journal of Hospital Medicine 2009;4:219

 Significantly improved the quality and timeliness.
 Better documentation of f/u issues, pending tests, and
  info provided to patients and/or family.
 PCPs more satisfied with timeliness and quality
 >95% of discharge summaries completed in < 1 week
Discharge Planning
 - is it THE answer?



 21 RCTs: 4509 medical, 2285 med-surg; 440 Ψ
      LOS: mean decrease -0.91 (95% CI: -1.55 to -0.27)
      Readmission rates: RR 0.85 (0.74 to 0.97)
      Elderly medical pts: mortality RR 1.04 (0.74 to 1.46)
      Discharged to home: RR 1.03 (0.93 to 1.14)
      Improved patient satisfaction
      Subset analysis: improved functional status


                                       Cochrane Database of Systematic Reviews 2010;1
 Randomized 363 patients age > 65
 “Comprehensive discharge planning” and home
  follow-up with APNs
 ~70% completion rate
 Readmissions at 24 weeks 20% vs 37%
     Reduced multiple readmissions 6.2% vs 14.5%
     Prolonged time to first readmission
     Medicare reimbursements cut in half
                                       Arch Intern Med 2006;166:1822-1828


 Elderly patients transitioning to SNF/home
 Randomized: Intervention group paired with
  “Transition Coach” vs. standard care
 Empowerment and education: 4 pillars
      Facilitate self management/adherence
      Maintain a personal health record
      Timely follow-up
      Knowledge and management of complications
 Education during hospitalization
      including meds and med reconciliation
 Phone calls and personal visits by TC post discharge
 Reduced rehospitalization and costs
Arch Intern Med 2006;166:1822-1828




                                              Results
     Rehospitalization               Interv   Cont   P(adj) OR (95%CI)
      Within 30d                       8.3    11.9   0.048 0.59 (0.35-1.00)
      Within 90d*                     16.7    22.5   0.04   0.64 (0.42-0.99)
      Within 180d*                    25.6    30.7   0.28   0.80 (0.54-1.19)
                            *Also significantly improved for
              “Rehospitalization for same diagnosis as index admission.”
     Costs($)                        Interv   Cont   Unadj Log Transformed
      At 30d                          784     918    0.048 0.06
      At 90d                         1519     2016   0.02   0.02
      At 180d                        2058     2546   0.04   0.049
Or should it be a Pharmacist?



                                        Am J Med 2001;111(9B):26S-30S


 N=221 randomized at UCSF
 All receive pharmacist facilitated discharge
 110 got 2 day phone call by pharmacist:
     Check on clinical status
     Remind about follow-up
     Check on medications (did they obtain them; any
      problems taking them; any side effects; did they know
      which to take and how; etc…)
                        Results
 Contacted 79 or 110
     25% had questions about their meds
     11% had questions about their care
     11% had questions about follow-up
     19% had been unable to get their meds
     15% reported new problems
     Greater satisfaction in intervention group:
      86% vs. 61% very satisfied (p=0.007)
     10% vs. 24% patients came to ED at UCSF at 30d
      (p=0.005)
     15% vs. 25% rehospitalized at 30d (p=0.07)
Pharmacy Literature

 Schnipper et al:
     N = 178 medical patients randomized
     Intervention:
          Med reconciliation done at d/c by Pharmacist
          Pharmacist counseling at d/c and 3day follow-up call
          At d/c, pharmacist recommended med changes in 60%
          At 3d call, unexplainable discrepancies between d/c meds
           and reported home meds in 29%
     At 30d
          Fewer preventable ADEs: 1% vs. 11% (p=0.01)
          Fewer preventable med related ED visits: 1% vs. 8% (p=0.03)
          49% had med discrepancies!
          No difference in total ADEs, health care utilization, patient
           satisfaction, or med adherence
                                               Arch Intern Med 2006;166:565-71
Pharmacists Work!
                 Arch Intern Med. 2009;169(9):894-900




Swedish ward-based pharmacists
 16% reduction in hospital visits
 47% reduction in ER visits
 Drug-related readmissions reduced 80%
 Intervention group cost < control
Project RED
RCT of 749 hospitalized adults
Intervention
     Nurse Discharge Advocate
        F/U appt, Medication Reconciliation
        Patient education

   Individualized instruction booklet
   Pharmacist call 2-4 days post-discharge
          Review medications
Limitations
     Urban, academic, safety net hospital
Project RED Outcomes

                          Intervention   Control
                            (n = 370)    (n = 368)
ER Visits*                  16.5%        24.5%
Rehospitalization**          15%          21%
PCP f/u in 30 days*          62%          44%
Prepared for Discharge*      65%          55%

   *p < 0.05

   **p = 0.09
Low-cost Intervention


                   JGIM 2008

 “user-friendly” Patient Discharge Form
 Telephone outreach from a nurse post-
  discharge
 Improved outpatient follow-up
 Reduced ER visits and rehospitalizations
  from historical controls
1.   Med Rec by PharmD
2.   RN Care Coordinator D/C Planning
3.   Phone Follow-up
4.   PHR, Supplemental Discharge Form
    Reduced ER visits, Reduced Readmission
SHM Initiatives
Discharge Checklist
 Halasyamani L et al. Transition of care for hospitalized elderly patients
 --development of a discharge checklist for hospitalists. J of Hosp Med 2006:354.

Resource Room
Safe STEPs

Project BOOST
   Better Outcomes for Older adults through
    Safe Transitions
   John A. Hartford Foundation $1.4 million
Safe STEPs
Safe and Successful Transitions for
 Elderly Patients
John A. Hartford Foundation Grant
Safe STEP Interventions

Medication reconciliation
   Pharmacy reviews: admission and d/c
   Geriatric friendly medication forms

Education
   Patients: pre-d/c appointment
   Providers: geriatric h&p

PCP communications
     “Fast facts”
Safe STEPs
 237 elderly patients at three hospitals
     Academic, community
 5 component intervention
     Admission form with geriatric cues
     Fax to PCP
     Interdisciplinary worksheet
     Pharmacist-physician medication reconciliation
     Pre-discharge planning appointments
 Reduced ED visits and readmissions
  by 1/3
Project BOOST Team
• Tina Budnitz, MPH         • Janet Nagamine, MD
• Eric Coleman, MD, MPH     • Dan Dressler, MD, MS
• Jeff Greenwald, MD        • Kathleen Kerr
• Eric Howell, MD           • Greg Maynard, MD
• Lakshmi Halasyamani, MD   • Arpana Vidyarthi, MD
• Mark V. Williams, MD
Advisory Board
      Chair: Eric Coleman, MD, MPH
      Co-Chair: Mark V. Williams, MD
 with organizational representatives from:
    Social work               Health systems
    Case management           NQF
    Clinical pharmacy         AHRQ
    Geriatric medicine        TJC
    Geriatric nursing         CMS
    Health IT                 National Consumer’s
    Blue Cross/Blue Shield     League
    United Health             Other content experts
www.hospitalmedicine.org/BOOST
What is BOOST Today?
 Intervention
     Tailored clinical Tools:
         Comprehensive Risk Assessment
         Team-based care
         Patient centered discharge process
         72 Hour follow-up call for “high-risk” patients
         Scheduled outpatient follow-up visits
         Standardized PCP Communication

     Tailored processes, work-flow
     Project management tools
BOOST components (cont)
    Technical Support
        Mentors calls, email, resources
        Teleconferencing across sites
        Education (webinars, newsletters)
        Enduring Materials (Teachback DVD)
    Peer Support
        Listserv
        Document sharing
        Moral support
    Infrastructure Development
        Train the trainer curricula
        Mentor Guides
        Mentor University
NEW CONCEPT: Health
   information, advice,
                                            Teach Back
 instructions, or change
     in management                           Assess patient
                                            comprehension /
                                             Ask patient to
                                              demonstrate



              Explain new concept /
              Demonstrate new skill
                                                                        Clarify and tailor
               Patient recalls and                                        explanation
                comprehends /
            Demonstrates skill mastery

                                          Re-assess recall and
                                         comprehension / Ask
 Adherence /                                   patient to
Error reduction                               demonstrate

                               Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90
Life-Cycle Project BOOST
Training & Preparation              Individualized Mentoring
                                            Implement       Analyze data
                                            intervention
                                                            Adjust
                                            Keep            intervention
                                            stakeholders    components
                                            informed
                                                            Report to
                                            Monitor core    stakeholders
                                            elements
                                                            Spread
                                                            gains




                         Training-6months   6-9 months     9-12 months
BOOST Network
BOOST eNewsletter
   Key milestones
   BOOST updates

   Site status reports, aggregate outcomes

   Forum for sharing ideas, challenges, mini
    studies
BOOST Network
   E-mail, call between sites
   BOOST listserv
End-Result

 Network of Institutions using the
  guide and interventions
 Understanding Impact of
  Interventions
 Understanding Implementation
  facilitating factors and barriers
BOOST Mentor Sites
Projected Growth
Cohort 1: 9/08          6 sites
Cohort 2: 3/09          24 sites
MI Collaborative 5/10   14 sites
Tuition pilot 5/10      2 sites

CA Collaborative       20 sites
Fall 10 Tuition Cohort 15 sites
     Online in 2010 =    81 sites
   So what happens to readmission rates?
 12/08           6/09         12/09                12/10

Cohort 1                                    Hierarchical time
                           Implementation   series analysis of
(n=6) kickoff              Survey           readmission rates
                Cohort 2                    (one year prior to
                (n=24)                      kick-off through one
                kickoff                     year post kick-off)
                                            12/10
Prelim Results
 Across all sites overall readmission rates
  decreased from 13% to 11%.
    BOOST Intervention Units
    6 months post “go live”

 Readmission rates rose in non-BOOST
  units by 2%
 Marked increased patient satisfaction
  at some sites.
A Hospital Nurse


“Project BOOST brings me back to what I
  thought nursing was really about.
  BOOST helps patients and families
  understand what they need to do to go
  home. This is why I went into nursing.”
THANKS!!!

 The John A. Hartford Foundation

								
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