A Tale of Two Projects: RED & BOOST Jeff Greenwald, MD Co-Investigator, Project RED Co-Investigator, Project BOOST ACGIM December 8, 2008 Overview: • Project RED: Research in Progress • Project BOOST: Furthering QI Education while Improving Transitions of Care Factors influencing re-hospitalization Discharge Discharge Hospital Care System Health Care System Patient Patient Clinician Clinician Lapse ofof communication Lapse Communication New Medical Problem New MedicalProblem Lab/Test Error Lab/Testerror Deteriorization of known medical problem Old Problem Gets Worse D/C SummaryPCP Discharge summary to PCP Not Ordered Not ordered Late Post-discharge Distant from discharge Inpatient TeamPCP Inpatient team to PCP Not Performed Not performed Early Post-discharge Early Post-discharge Home ServicesPCP Community services with PCP Not Seen Not seen Addiction Issues Drug/Alcohol use Inadequate Pt Education Indadequate Patient Education Not acted Upon Not Actedupon Language/Cultural Barriers Language/Cultural barrier Medication Errors Medication Error Inappropriate Discharge Inappropriate discharge Medication Adherence Medication non-adherence Lack of timely Follow-up Lack of Timelyfollow-up Inappropriate Medications Inappropriate medication Lapse in Home Services Lapse in community services Doesn't keep Does Not follow-up appointment Keep Follow-up Inadequate use Home Services Inadequateof community services Rehospitalization or Complication Rehospitalization Principles of the Newly Re-Engineered Hospital Discharge Re-engineered Discharge must contain: • Roles and responsibilities • Patient education throughout • Easy Information flow • Full time case management services • All discharge information in patient’s language and literacy level. Principles of the Newly Re-Engineered Hospital Discharge • Written discharge plan: – Medications, diet, and lifestyle modifications – follow-up care – patient education re their disease – what to do if their condition changes – completed before discharge NQF • Post-discharge plan reinforcement • Organized information delivered to the PCP • Process measures, benchmarks, and QC PIPS-RED: The current study 30 Days The Intervention Group The intervention: – The Discharge Advocate (D.A.) during admission – After Hospital Care Plan – A scripted follow-up phone call from a pharmacist 2-3 days after discharge – Access to the D.A. by phone, after discharge The Role of the DA • Coordination with • Arrangements for medical team, RNs, and medication pick-up, rides, Case Managers DMA • Educating patients • Preparing & reinforcing about their disease After Hospital Care Plan • Arranging aftercare with with patient & family patient & family • Data collection tools are • Reinforcing national scripted for consistency quality guidelines – REALM (literacy) • Medication education & – Depression Screen reconciliation (PHQ-9) After Hospital Care Plan for: Maria Johnson Discharge Date: October 25, 2005 Problem with anything in this packet? Call Mary Goodwin: (617) 414-6210 Serious health problem? Call your Doctor, Chris Manasseh: (617) 825-3400 EACH DAY follow this schedule: Medication Schedule for Maria Johnson Picture Medication What time of day do (the medication from name How do I take Why am I taking I take this the pharmacy may not Amount this medicine? this medication? medicine? look exactly like this) # of pills Motrin© (Ibuprofen) by mouth with pain 800mg 1 pill food Zestril© (Lisinopril) blood by mouth 10mg 1 pill pressure Apresazide© (HCTZ) blood Morning by mouth 25mg 1 pill pressure Nifedical XL© (Nifedipine) blood by mouth 30 mg 1 pill pressure Protonix© (Pantoprazole) by mouth indigestion 40 mg 1 pill After Hospital Care Plan Maria Johnson 10/11/05 ***Bring this Plan to each Appointment*** MAIN PROBLEM: Chest Pain APPOINTMENTS: Monday, October 31st Friday, November 4th Wednesday, November Tuesday, November at 1:30pm at 10:00am 9th at 9:30am 15th at 11:00am Dr. Chris Manasseh Dr. Sheilah Bernard Nutritionist Cardiac Stress Test Primary Care Physician Consultant (Cardiologist) (Doctor) at Harvard St. Community at Boston Medical Center; at Boston Medical Center at Boston Medical Center Health Center Doctor’s Office Building - Take #1 bus 850 Harrison Ave John will drive 642 4th floor – Cardiac Take cab, use cab Station voucher John will drive; take parking sticker For a Follow-up For a heart appointment To help with food plan To check your heart appointment Tests: Phone #: 617-825- Office Office Phone #: 617-638- Office Phone #: 617-555-1234 Office Phone #: 617-555- Waiting for results. Lab test/Studies done in hospital. 7490 3400 2345 Lab test/ study name Date done Name of clinician to Day/Date subject will see clinician to discuss review/location results? Stomach biopsy from October 24, Dr. Manasseh at Harvard Street Dr. Manasseh will talk to you about results at endoscopy (stomach 2005 CHC your appointment with him on October 31, 2005. test) EXERCISE: Do your physical therapy exercises. 1. walk for at least 20 minutes each day 2. do your therapy exercises WHAT TO EAT: Eating food that is low in fat and low in cholesterol will help your heart. ALLERGIES: REMEMBER you are ALLERGIC to Penicillin. PHARMACY: Walgreens Pharmacy 583 Washington St. Boston, MA 02135 (617) 825-2401 Problem with anything in this packet? Call Your Discharge Advocate, RN – Lynn, Michael, or Mary: (617) 414-6822 Serious health problem? Call your Doctor, Chris Manasseh: (617) 825-3400 November 2005 ***Bring this Plan to each Appointment*** Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1 2 3 4 5 Call cab at 9:15am Dr. Bernard at 10:00am at BMC 6 7 8 9 10 11 12 Cardiac Stress Nutritionist Test at 9:30am at 11:00 am at BMC at BMC Take #1 bus John will drive 13 14 15 16 17 18 19 20 21 22 23 24 25 26 BMC will call at 10am for study 27 28 29 30 Medical Problem: Angina Angina is a feeling of tightness, squeezing, or pain in the chest. •Take your medications as prescribed. •Take walks, get exercise. •Keep weight within healthy range. •Eat healthy, follow a nutrition plan. •Carry your medicine with you. •See your doctor and ask questions. PharmD call highlights (2-3d post-discharge) MEs due to failure to take medication: (n=169) Patient did not fill because of cost 18 Patient does not think s/he needs med 17 Patient did not pick up from pharmacy 14 Patient did not get prescription on discharge 14 Number of subjects with any ME due to failure to take 67 medication PharmD call highlights (2-3d post-discharge) MEs due to incorrect self-administration: (n=169) Medication not on discharge sheet or dc summary 75 Wrong frequency/interval 32 Wrong dose taken 29 Number of subjects with any ME due to incorrect self- 77 administration PharmD call highlights (2-3d post-discharge) MEs due to system error: Patient not given prescription for most current regimen on 5 discharge Duplication on medication list (same drug/class/indication) 2 Conflicting information 4 Number of subjects with any MEs due to system error 11 PharmD call highlights (2-3d post-discharge) Frequency (%) of PharmD Interventions Intervention* Sent information to PCP via EMR 51 (38%) RPh calls PCP, pharmacy, etc in order to solve problem 26 (19%) Instruct to take med after picking up from pharmacy 15 (11%) Number of subjects requiring at least 1 intervention 88 (52%) Primary Outcomes (Interim) Intervention Control P- Total (n=285) (n=281) Value (n=566) Total ED visits 45 (16%) 69 (25%) 0.013 114 (20%) Mean ED visits/subject 0.16 0.25 0.16 Total Rehospitalizations 44 (15%) 53 (19%) 0.33 97 (17%) Mean rehosp/subject 0.15 0.19 0.38 Total Hospital utilization 89 (31%) 122 (43%) 0.004 211 (37%) Mean utilization/subject 0.31 0.44 0.05 Conclusions RED: • Decreases ED use (by 35%) • Identifies a lot of medication errors • Improves ‘Readiness for Discharge’* • Helps limited health literacy patients* • Successfully delivered using AHCP* • Is Cost Effective* *Data not shown www.hospitalmedicine.org/BOOST • John A Hartford Foundation grant to SHM • Multidisciplinary advisory board • Components: – Workbook – Website – Toolkit – Yearlong mentorship • Tools: – TARGET: Tool for Addressing Risk – a Geriatric Evaluation for Transitions • Risk assessment (7Ps) • Risk specific intervention – Universal Patient Discharge Checklist • Raising the bar on all discharges – GAP (General Assessment of Preparedness) • Addresses psychosocial and logistical issues • Enrolled 6 pilot sites • Recruiting NOW 24 additional sites for mentored implementation program • Website: free to all – www.hospitalmedicine.org/BOOST – QI skills building • Mentorship for accepted sites free Thank You! For further information: Jeffrey.Greenwald@bmc.org 617-414-4373 And thanks to the Project RED & BOOST teams!
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