Patient safety in the Transition from the Hospital to the PCP Re-Engineering the Hospital Discharge Patient safety in the Transition from the Hospital to the PCP Brian Jack MD Dept of Family Medicine Boston Medical Center 4/25/2019

Errors + Hospital Discharge High rates of medical errors at discharge now well documented Readmission by 90-days: 20% of hospitalized patients Can improving the discharge process reduce errors and reduce unplanned rehospitalization? 4/25/2019

An Etiologic Classification of Errors at Hospital discharge 4/25/2019

What happens? 60 yo women with Congestive Heart Failure takes the same medicines after discharge as before, plus her new ones; she is readmitted with renal failure requiring long term dialysis. 50 yo Spanish speaking women doesn’t understand how to get to outpatient Stress test, she misses it and next presents with sudden death. 4/25/2019

Kaplan-Maier Survival Rehospitalization by Discharge Day Days to Rehospitalization 20 40 60 80 0.4 0.6 0.8 1.0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 4/25/2019

Errors at Discharge - Process Evaluation 4/25/2019

Example of Root Cause Analysis 42 year old man with Abdominal pain with nausea, vomiting, diarrhea Chest pain - sometimes exertional, sometimes at rest 30 admissions in 42 months Can’t something be done? 4/25/2019

Top 300 account for 25.8% of all charges Cumulative Percent of Charges for the 300 Most Frequent Users – Boston CareNET 2003 Total Charges 2003 = $186,136,650 Total Members = 56,535 Top 300 account for 25.8% of all charges Cumulative Percent of Charges for 300 most Frequent Users 25 20 15 % of total charges 10 5 50 100 150 200 250 300 Number of Patients 4/25/2019

Factors influencing re-hospitalization 4/25/2019

Errors at Discharge - Process Evaluation 4/25/2019

Process mapping of Hospital Discharge Step 1 - Collective Assessment 4/25/2019

Process mapping of current discharge process Step 2 - Communication and Coordination 4/25/2019

Process mapping of current discharge process Step 3 - Completion 4/25/2019

Errors at Discharge - Process Evaluation 4/25/2019

Re-engineering the Discharge Iterative Group Process Identification of Potential Failures Prioritization 4/25/2019

Principles of the Newly Re-Engineered Hospital Discharge Re-engineered Discharge must contain: Explicit delineation of roles and responsibilities Patient education throughout the hospitalization Easy Information flow from the PCP among the hospital team back to the PCP Written Discharge Plan 4/25/2019

Principles of the Newly Re-Engineered Hospital Discharge Written discharge plan: addresses medications dietary and other lifestyle modifications follow-up care patient education instructions about what to do if their condition changes completed before discharge Those at-risk should have the discharge plan reinforced after discharge. All information must be organized and delivered to the PCP. 4/25/2019

Principles of the Newly Re-Engineered Hospital Discharge Waiting until the discharge order is written before beginning the discharge process is error-prone. Efficient and safe hospital discharge is significantly more challenging if the case management staff works only the 7AM to 3 PM shift. All patients should have access to his/her discharge information in their language and at their literacy level. Discharge processes must be benchmarked, measured and subject to continuous quality improvement programs. 4/25/2019

Errors at Discharge - Process Evaluation 4/25/2019

Probabilistic Risk Assessment Predictors of Re-hospitalizations Secondary analysis of a retrospective cohort of 2,500 CHC patients admitted < 6 mo. Primary outcome variable – 90 day readmission 4/25/2019

Prediction Model for Re-hospitalization 4/25/2019

Probabilistic Risk Assessment using Standardized Screening Tools Sensitivity: 63-91% Specificity: 97% 22 items yes/no and Likert scale; use scoring algorithm 2.5 Anxiety Patient Health Questionnaire Sensitivity: 88% Specificity: 88% 9 item 4-point Likert scale Depression Internal consistency: 86-88% Extensively validated PCS: 0-100 MCS: 0-100 5 Health Related Quality of Life SF-12 Compare to Optimal Benchmark Scores 24 item 5-point Likert scale 10 Patient Satisfaction Patient Satisfaction survey Sensitivity: 50-80% Specificity: 90% 0-30 Mental Status Mini-Mental Status Exam Validation / Psychometrics Range of Response Time min Domain Measured Screening Tool 4/25/2019

Probabilistic Risk Assessment using Standardized Screening Tools Internal consistency: 86-95% Overall accuracy: 85% 0-10 2 Substance Abuse Drug Abuse Screening Test Harmful drinking: Sensitivity: 57-97% Specificity: 78-96% Abuse or dependence:Sensitivity: 61-96% Specificity: 85-96% 3 Alcoholism Alcohol Use Disorder Identification Test Internal consistency: .69-98% Test-retest reliability: .86-92% 3 separate scores 10 Social Support Norbeck Social Support Questionnaire Sensitivity: 36-56% Specificity: 61-84% 0-21 5 Nutrition Nutrition Screening checklist Validation / Psychometrics Range of Response Time (min) Domain Measured Screening Tool 4/25/2019

Three Tier Approach Who will Fund the Top Tier 4/25/2019

The TRANSFER Trial Flowsheet of Research methods 4/25/2019

Review of 5 most recent hospitalizations 4/25/2019

Psychosocial and Functional Risk factors for 90-day Re-hospitalization Adjusted Odds Ratio (95% CI) P-value SF-12 Physical function 0.95 (0.90-1.01) 0.07 PHQ-Depression 2.08 (1.03-4.19) 0.02 Norbeck Social support 1.00 (0.99-1.01) 0.47 4/25/2019

Thank You David Anthony Chris Manasseh Jeff Greenwald Anand Kartha VK Chetty Maria Rizzo Depaoli Cornelia Walsh Kathleen McKenna Lee Strunin Larry Culpepper Brian Jack 4/25/2019