Jeff Greenwald_ MD Co-Investigator_ Project RED Boston Medical .ppt by lovemacromastia


									A Tale of Two Projects:
        Jeff Greenwald, MD
   Co-Investigator, Project RED
  Co-Investigator, Project BOOST
         December 8, 2008
• Project RED: Research in Progress
• Project BOOST: Furthering QI
  Education while Improving Transitions
  of Care
Factors influencing


Hospital Care System
   Health Care System                           Patient
                                                Patient                                 Clinician

    Lapse ofof communication
       Lapse Communication                      New Medical Problem
                                              New MedicalProblem                             Lab/Test Error
                                          Deteriorization of known medical problem
                                           Old Problem Gets Worse
          D/C SummaryPCP
          Discharge summary to PCP                                                              Not Ordered
                                                                                                 Not ordered

                                                   Late Post-discharge
                                                     Distant from discharge
          Inpatient TeamPCP
             Inpatient team to PCP                                                            Not Performed
                                                                                               Not performed

                                                  Early Post-discharge
                                                     Early Post-discharge
         Home ServicesPCP
         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
Principles of the Newly
Re-Engineered Hospital
 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

 • 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
 • Post-discharge plan reinforcement
 • Organized information delivered to the PCP

 • Process measures, benchmarks, and QC
The current study

                    30 Days
The Intervention
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
                  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
                                                      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***

   Chest Pain


 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)
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
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.

   Do your physical therapy exercises.
   1. walk for at least 20 minutes each day
   2. do your therapy exercises


   Eating food that is low in fat and low in cholesterol will help your heart.

 REMEMBER you are ALLERGIC to Penicillin.

   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
                                                                          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 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
    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
    PharmD call highlights
     (2-3d post-discharge)

   MEs due to system error:

Patient not given prescription for most current regimen on    5
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
                             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
• 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
• 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 –
  – QI skills building
• Mentorship for accepted sites free
 Thank You!
  For further information:
 And thanks to the Project
  RED & BOOST teams!

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