Re-Engineered Discharge Project RED Re-Engineered Discharge Project RED Re-Engineered Discharge

Re-Engineering Discharge The goal of this performance improvement (PI) project is to improve our discharge program Project RED: Is patient centered Prepares patients to care for themselves at home Decreases readmissions and visits to the emergency department Re-Engineering Discharge The goal of this performance improvement (PI) project is to improve our discharge program Project RED: Is patient centered Prepares patients to care for themselves at home Decreases readmissions and visits to the emergency department

Presentation Outline Impetus for project Strategic priorities PI structure Project RED components Role clarification Process Presentation Outline Impetus for project Strategic priorities PI structure Project RED components Role clarification Process

“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 is marked with poor quality Loose ends Poor communication Poor quality information Poor preparation Fragmentation Great variability 19 percent of patients have a post-discharge adverse event 20 percent of Medicare patients are readmitted within 30 days; only half had a visit in the 30 days after discharge “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 is marked with poor quality Loose ends Poor communication Poor quality information Poor preparation Fragmentation Great variability 19 percent of patients have a post-discharge adverse event 20 percent of Medicare patients are readmitted within 30 days; only half had a visit in the 30 days after discharge 4

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 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

Common Reasons for Avoidable Readmission -- Not Diagnosis-Specific Poor discharge instructions Patient doesn’t understand how to use medications Patient doesn’t learn warning signs for when to report to their physician Poor information transfer From hospital to primary care physician (PCP) From hospital to nursing home staff Lack of clarity on end-of-life care preferences Common Reasons for Avoidable Readmission -- Not Diagnosis-Specific Poor discharge instructions Patient doesn’t understand how to use medications Patient doesn’t learn warning signs for when to report to their physician Poor information transfer From hospital to primary care physician (PCP) From hospital to nursing home staff Lack of clarity on end-of-life care preferences

Common Reasons for Avoidable Readmission Lack of timely post-discharge physician visit Physician unaware of hospitalization Patient has no PCP Patient lacks transportation Poor medication reconciliation yields duplication or interaction Common Reasons for Avoidable Readmission Lack of timely post-discharge physician visit Physician unaware of hospitalization Patient has no PCP Patient lacks transportation 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 followup for heart failure patients Readmissions higher for heart failure patients with behavioral problems 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 followup for heart failure patients Readmissions higher for heart failure patients with behavioral problems

Diagnosis-Specific Reasons for Avoidable Readmissions Post surgery Surgeons not arranging for post-surgical primary care Post-CABG patients, expecting to be pain free, seek readmission for angina Inadequate patient teaching on self care after surgery (e.g., incision care) Dialysis patients very vulnerable to drug therapy changes Diagnosis-Specific Reasons for Avoidable Readmissions Post surgery Surgeons not arranging for post-surgical primary care Post-CABG patients, expecting to be pain free, seek readmission for angina Inadequate patient teaching on self care after surgery (e.g., incision care) Dialysis patients very vulnerable to drug therapy changes

Strategic Priorities Improve patient outcomes and satisfaction Improve cost and revenue management Improve patient satisfaction scores Prepare for changes to CMS reimbursement penalties for high readmission rates Improve nurse and provider time utilization Enhance portability of personal health information across care continuum Improve relationship with PCPs Strategic Priorities Improve patient outcomes and satisfaction Improve cost and revenue management Improve patient satisfaction scores Prepare for changes to CMS reimbursement penalties for high readmission rates Improve nurse and provider time utilization Enhance portability of personal health information across care continuum Improve relationship with PCPs 10

Specific Project Objectives Enter your specific objectives here Improve patient satisfaction with discharge preparation by ## percent Improve staff satisfaction with discharge process by ## percent Reduce readmissions by ## percent Reduce post-discharge visits to the ED Specific Project Objectives Enter your specific objectives here Improve patient satisfaction with discharge preparation by ## percent Improve staff satisfaction with discharge process by ## percent Reduce readmissions by ## percent Reduce post-discharge visits to the ED

Project Steering Committee Six Sigma Forum, Post Conference Workshop May 30, 2008 Project Steering Committee Vision Mandate improvement Identify champions Receive and review updates Project Steering Committee Vision Mandate improvement Identify champions Receive and review updates www.ies.ncsu.edu/leanhealthcare 12

Project Steering Committee List team members Designate project team leader, executive sponsor, and physician champion Project Steering Committee List team members Designate project team leader, executive sponsor, and physician champion

Targeted Patient Population To pilot Project RED, we have identified the following target patient population: Provide diagnosis, unit, etc. Baseline readmission rate = Average length of stay = Add stats from patient phone survey, if available Targeted Patient Population To pilot Project RED, we have identified the following target patient population: Provide diagnosis, unit, etc. Baseline readmission rate = Average length of stay = Add stats from patient phone survey, if available

Identifying Targeted Patients on Admission How will you first identify that a newly admitted patient is in the targeted population for this project? How will the Discharge Advocate (DA) be notified that a potential patient for Project RED has been admitted? What secondary screening criteria for patient inclusion will the DA use to confirm the use of the Project RED intervention with the patient? How will the DA track activities with new patients? Identifying Targeted Patients on Admission How will you first identify that a newly admitted patient is in the targeted population for this project? How will the Discharge Advocate (DA) be notified that a potential patient for Project RED has been admitted? What secondary screening criteria for patient inclusion will the DA use to confirm the use of the Project RED intervention with the patient? How will the DA track activities with new patients?

Patient and Family Centered Safe Care Community providers: Nursing Home Home Health & Hospice Home Care Physicians Accountable Care Organizations Pre Patient Admission Discharge Order Written H&P; Assessments; Rx Plan Discharge Process Discharge Event Discharge Planning Image: Graphic of discharge planning with patient education and discharge instructions as the foundation. Discharge Folder White Board, Rounding & Bedside Report Passport for Home PATIENT EDUCATION/ Prepare for Home FINAL DISCHARGE INSTRUCTIONS Post-D/C FOLLOW-UP MEDICATION MANAGEMENT

Project RED Principles

Re-Engineered Discharge Principles Explicit delineation of roles and responsibilities Discharge process initiation upon admission Patient education throughout hospitalization Timely accurate information flow: From PCP ► Among hospital team ► Back to PCP Complete patient discharge summary prior to discharge Re-Engineered Discharge Principles Explicit delineation of roles and responsibilities Discharge process initiation upon admission Patient education throughout hospitalization Timely accurate information flow: From PCP ► Among hospital team ► Back to PCP Complete patient discharge summary prior to discharge 18 18

Re-Engineered Discharge Principles Comprehensive written discharge plan provided to patient prior to discharge Discharge information in patient’s language and literacy level Reinforcement of plan with patient after discharge Availability of case management staff outside of limited daytime hours Continuous quality improvement of discharge processes Re-Engineered Discharge Principles Comprehensive written discharge plan provided to patient prior to discharge Discharge information in patient’s language and literacy level Reinforcement of plan with patient after discharge Availability of case management staff outside of limited daytime hours Continuous quality improvement of discharge processes 19 19

RED Checklist 12 mutually reinforcing components: Ascertain need for and obtain language assistance Medication Reconciliation Reconcile discharge plan with national guidelines Follow-up appointments Outstanding/pending lab & diagnostic tests follow-up Post-discharge services Written discharge plan What to do if problem arises Patient education Assess patient understanding Discharge summary sent to PCP Telephone reinforcement RED Checklist 12 mutually reinforcing components: 1. Medication reconciliation 2. Reconcile discharge plan with national guidelines 3. Followup appointments 4. Outstanding tests 5. Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10. Discharge summary sent to PCP Telephone reinforcement Adopted by National Quality Forum as one of 30 U.S. "Safe Practices" Adopted by National Quality Forum as one of 30 U.S. "Safe Practices" 20 20

Keys to the Project RED Intervention DA Related multidisciplinary activities Care plan for patient use after discharge Post-discharge followup with patient Keys to the Project RED Intervention DA Related multidisciplinary activities Care plan for patient use after discharge Post-discharge followup with patient

Discharge Advocate Coordinates all discharge activities within patient population Facilitates team activities and discharge planning rounds with primary doctor Collects discharge-focused data Ensures Patient Care Plan is completed and patient understands the information and can comply with the instructions in the plan Discharge Advocate Coordinates all discharge activities within patient population Facilitates team activities and discharge planning rounds with primary doctor Collects discharge-focused data Ensures Patient Care Plan is completed and patient understands the information and can comply with the instructions in the plan

Discharge Advocate Is notified when patients in the target population are admitted or diagnosed Initiates action steps associated with Project RED Initiates the Patient Care Plan Educates patient and family about condition, medications, treatments, post-discharge plans, and followup ordered by the physician Reviews Patient Care Plan with patient and family Collects measurement data on project and patient population Discharge Advocate Is notified when patients in the target population are admitted or diagnosed Initiates action steps associated with Project RED Initiates the Patient Care Plan Educates patient and family about condition, medications, treatments, post-discharge plans, and followup ordered by the physician Reviews Patient Care Plan with patient and family Collects measurement data on project and patient population

Discharge Advocate Project RED’s 12 components let the DA: 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 Discharge Advocate Project RED’s 12 components let the DA: 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 24

Staff Member Roles Patient’s physician and medical team Nursing staff Case management Pharmacists Staff Member Roles Patient’s physician and medical team Nursing staff Case management Pharmacists

Patient’s Physician Initiates patient plan of care based on critical pathway Leads or participates in discharge planning rounds Communicates potential discharge date Supports the PI process Patient’s Physician Initiates patient plan of care based on critical pathway Leads or participates in discharge planning rounds Communicates potential discharge date Supports the PI process

Nursing Staff Provide nursing care Educate patient and family Communicate with each other Communicate with other members of the health care team, including DA Participate in multidisciplinary rounds, including those focused on discharge planning Nursing Staff Provide nursing care Educate patient and family Communicate with each other Communicate with other members of the health care team, including DA Participate in multidisciplinary rounds, including those focused on discharge planning

Pharmacist Verifies physician orders Reconciles admission medications with medications from home Collaborates with care team specific to discharge needs Reconciles medications upon discharge Assists with patient medication questions Pharmacist Verifies physician orders Reconciles admission medications with medications from home Collaborates with care team specific to discharge needs Reconciles medications upon discharge Assists with patient medication questions

Case Managers Arrange post-discharge services Educate the patient Perform social work duties Perform utilization review Case Managers Arrange post-discharge services Educate the patient Perform social work duties Perform utilization review

Other Key Staff Therapists Disease management Other Key Staff

Discharge Planning Rounds Consider daily discharge rounds Medical staff, nursing staff, pharmacy, case management, and DA When is discharge order written? Was it expected? Weekend discharge? Is there a timing expectation (e.g., time from when the order is written to when the patient is out the door)? Discharge Planning Rounds Consider daily discharge rounds Medical staff, nursing staff, pharmacy, case management, and DA When is discharge order written? Was it expected? Weekend discharge? Is there a timing expectation (e.g., time from when the order is written to when the patient is out the door)?

Patient Care Plan Date of discharge Name and contact information for physician and DA Medications Pending tests and results Follow-up appointments Calendar Other orders (diet, activity, etc.) Information about disease or condition When to call physician or seek emergency care Form for writing down questions Map for locating appointments (optional) Other information about your center (optional) Patient Care Plan Date of discharge Name and contact information for physician and DA Medications Pending tests and results Follow-up appointments Calendar Other orders (diet, activity, etc.) Information about disease or condition When to call physician or seek emergency care Form for writing down questions Map for locating appointments (optional) Other information about your center (optional)

Patient Care Plan Accessing the template Accessing information Saving Printing Storing Will completed Patient Care Plan become part of the patient record? Patient Care Plan Accessing the template Accessing information Saving Printing Storing Will completed Patient Care Plan become part of the patient record?

Complete the Patient Care Plan Medication reconciliation Pending tests and results Post-discharge services Primary care provider Follow-up appointments Information about condition Complete the Patient Care Plan Medication reconciliation Pending tests and results Post-discharge services Primary care provider Follow-up appointments Information about condition

Medication Reconciliation Hospital procedure for completing medication reconciliation at discharge DA participates and conducts final check on medications DA populates Patient Care Plan (e.g., medication purpose, time of day taken) DA uses final list to teach the patient Medication Reconciliation Hospital procedure for completing medication reconciliation at discharge DA participates and conducts final check on medications DA populates Patient Care Plan (e.g., medication purpose, time of day taken) DA uses final list to teach the patient

Pending Tests and Results Obtains information about tests and studies completed and still-pending results Adds pending test results to the designated spot on the Patient Care Plan, including which clinician is responsible for getting final results Points out where the information is on the Patient Care Plan Encourages patient to discuss tests with PCP Pending Tests and Results Obtains information about tests and studies completed and still-pending results Adds pending test results to the designated spot on the Patient Care Plan, including which clinician is responsible for getting final results Points out where the information is on the Patient Care Plan Encourages patient to discuss tests with PCP

Post-Discharge Services Confirms with case manager that all services have been arranged Adds names and contact information of service providers to Patient Care Plan Post-Discharge Services Confirms with case manager that all services have been arranged Adds names and contact information of service providers to Patient Care Plan

Primary Care Provider Confirms name of PCP with patient Adds name and contact number of PCP to Patient Care Plan Primary Care Provider Confirms name of PCP with patient Adds name and contact number of PCP to Patient Care Plan

Follow-up Appointments Discusses best days of week and times of day with patient Discusses transportation needs Calls clinicians’ offices to make appointments that meet patient’s time options For off-hour or weekend discharges, leaves message with clinician’s office to call patient Adds appointments to Patient Care Plan Follow-up Appointments Discusses best days of week and times of day with patient Discusses transportation needs Calls clinicians’ offices to make appointments that meet patient’s time options For off-hour or weekend discharges, leaves message with clinician’s office to call patient Adds appointments to Patient Care Plan

Information About Condition Obtains information about the patient’s condition to add to Patient Care Plan Includes Signs and symptoms that warrant followup with clinician Signs and symptoms that warrant emergency care Contact information for the DA and PCP (phone numbers, paging instructions) Information About Condition Obtains information about the patient’s condition to add to Patient Care Plan Includes Signs and symptoms that warrant followup with clinician Signs and symptoms that warrant emergency care Contact information for the DA and PCP (phone numbers, paging instructions)

Post-Discharge Activities Transmits discharge summary and Patient Care Plan to PCP By fax: Ensures it is received and legible By e-mail: Ensures it is received Makes follow-up phone call to patient Uses script that includes medications and follow-up appointments Determines need for second call by clinician Post-Discharge Activities Transmits discharge summary and Patient Care Plan to PCP By fax: Ensures it is received and legible By e-mail: Ensures it is received Makes follow-up phone call to patient Uses script that includes medications and follow-up appointments Determines need for second call by clinician

Communication and Coordination Hospital discharge process is often characterized by poor communication and a lack of coordination between the hospital and the PCP  Patients often do not know what medications their physicians prescribed, when follow-up appointments should take place, and, in some cases, why they were hospitalized Communication and Coordination Hospital discharge process is often characterized by poor communication and a lack of coordination between the hospital and the PCP  Patients often do not know what medications their physicians prescribed, when follow-up appointments should take place, and, in some cases, why they were hospitalized

Primary Care Physician Referral Base Leaders identify the PCP referral base Hospital assesses PCP satisfaction before project launch Physician champion communicates with PCPs about project PCPs advise how to handle off-shift and weekend patient needs Primary Care Physician Referral Base Leaders identify the PCP referral base Hospital assesses PCP satisfaction before project launch Physician champion communicates with PCPs about project PCPs advise how to handle off-shift and weekend patient needs

Post-Discharge Phone Call Decide who calls the patient after discharge Decide when the follow-up call will be made Develop the caller’s script Develop the process for off-shift and weekend discharges Post-Discharge Phone Call Decide who calls the patient after discharge Decide when the follow-up call will be made Develop the caller’s script Develop the process for off-shift and weekend discharges

Process Measurement Measure the project to determine impact Outcome measures Process measures Resource investment Results will determine if Project RED will be used in other areas of the hospital Process Measurement Measure the project to determine impact Outcome measures Process measures Resource investment Results will determine if Project RED will be used in other areas of the hospital

Process Metrics Average time to notify DA about new admission Average time from admission to first patient visit by DA (initiation of care plan) – only for patients who meet all criteria Percent of patients’ PCPs notified within 24 hours discharge Percent of follow-up phone calls made within 48 hours Percent of follow-up calls requiring second call by pharmacist (if non-pharmacist makes first call) Percent of patients completing post-discharge survey (30 days after discharge) Process Metrics Average time to notify DA about new admission Average time from admission to first patient visit by DA (initiation of care plan) – only for patients who meet all criteria Percent of patients’ PCPs notified within 24 hours discharge Percent of follow-up phone calls made within 48 hours Percent of follow-up calls requiring second call by pharmacist (if non-pharmacist makes first call) Percent of patients completing post-discharge survey (30 days after discharge) 46 46

Process Metrics Completion of care plan details Percent of care plans with medication list included Percent of care plans with care needs included (e.g., exercise, diet, main problem, when to call doctor) Percent of care plans with follow-up appointments listed Percent of care plans with pre-arranged discharge resources identified (e.g., home health, durable medical equipment) Percent of care plans with pending tests listed Process Metrics Completion of care plan details Percent of care plans with medication list included Percent of care plans with care needs included (e.g., exercise, diet, main problem, when to call doctor) Percent of care plans with follow-up appointments listed Percent of care plans with pre-arranged discharge resources identified (e.g., home health, durable medical equipment) Percent of care plans with pending tests listed 47 47

Outcome Metrics for Target Population Average length of stay (LOS) 30-day unplanned readmission rate Cost of second LOS (readmission) Pre/post data: Patient experience related to discharge preparation Pre/post data: Frontline staff survey related to discharge preparation Project costs Discharge process costs (current and redesigned) Outcome Metrics for Target Population Average length of stay (LOS) 30-day unplanned readmission rate Cost of second LOS (readmission) Pre/post data: Patient experience related to discharge preparation Pre/post data: Frontline staff survey related to discharge preparation Project costs Discharge process costs (current and redesigned)

Project Launch Expected start date Targeted population or unit DA’s name and contact information Project leader’s name and contact information Physician champion’s name and contact information Project Launch Expected start date Targeted population or unit DA’s name and contact information Project leader’s name and contact information Physician champion’s name and contact information

Questions Questions