Project RED: The ReEngineed Discharge Reducing 30 Day All Cause Rehospitalization Rates: A CQI Adventure Heart Failure and Readmission Reduction Summit August Maine, March 30, 2010 Charles Telfer Williams, MD Vice Chair for Clinical Affairs and Quality Division of Family Medicine – Boston Medical Center Assistant Professor Department of Family Medicine - Boston University School of Medicine

Basic quality improvement Select an area for improvement. Establish goal. Describe current system (Process Map) Select Measures Standardize the process Rapid Cycle improvement (PDSA) AND then Spread it. (Today is that)

Plan for Today The Challenge How We Got Started - CQI NQF ‘Safe Practice’ Is ‘Safe Practice’ Safer? Risk Factors for Rehospitalization Barriers to Implementation Roll-out Can Health IT Deliver? This is what we will discuss today.

Case 1—Gloria 61 yo female admitted to hospital with cellulitis. She has a history of hypertension for which she takes Lisinopril at home. While in the hospital she was treated with antibiotics for her cellulitis. She was noted to have persistently high blood pressure and the decision was made to increase her blood pressure medicine. Her blood pressure responded appropriately to the new dose. On the day of discharge she was given a prescription for clindamycin, motrin and a new prescription for lisinopril with a new dose. She went home, got her new prescriptions filled and took them as instructed on her discharge papers and as well as what was written on the medication bottles. But also continued to take her old dose of Lisinopril as well. Patient started to have problems of feeling light headed, family brought her back to ED and she was readmitted to the hospital with acute renal failure. 5 5

Case 2– Alex 80 yo male admitted to hospital to have his pacemaker adjusted. Was found to have new onset of atrial fibrillation and started on coumadin. On the day of dc he was given prescription for coumadin and follow up appts to his PCP, cardiologist and Coumadin clinic. Teaching was done and he was given reading material on Coumadin. Patient’s 79 yo wife was waiting in the car outside while their son came up to get his father. They were in the hospital room getting patient’s shoes on when the nurse came in and said, “the doctors decided you should be bridged with Lovenox while at home. Here is a box with all your information and there is a CD inside for you to watch on how to give yourself the medicine.” 6 6

Poor Quality & High Cost The Challenges: Poor Quality & High Cost The ability of hospitals to safely discharge a patient in a reliable way is low (very low) and it costs a lot (too much!). In 2006, there were 39.5 million hospital discharges with costs totaling $329.2 billion! Hospital discharge is a time of high risk for adverse events and there a lot of discharges.

Major Changes in Hospital Payments "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

Current Developments All cause hospital readmission rates released this summer http://www.hospitalcompare.hhs.gov/ CMS: 14 Quality Improvement Organizations “Safe Transitions” demonstration projects AHA H2H - goal to reduce readmissions by 20% by 2012

Patients Are Not Prepared at Discharge 37% able to state the purpose of all their medications 42% able to state their diagnosis Many patients are not ready for discahrge. Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Amgad N. Makaryus, MD, Eli A. Friedman, MD. Mayo Clinic Proceedings. August 2005; 80(8):991-994.

Little Time Spent on Discharge Audiotaped 97 discharge encounters 8 Elements - Roter Interactional Analysis Nurse, Pharmacist, Physician, Nurse Case Manager Averaged 8 minutes (range, 2 to 28.5 min) No teachback 84% of the time Patient is a passive participant Two initiated questions Not comprehensive 4 or fewer elements covered 50% of time The discharge is not currently a priority for providers.

Documentation of Pending Tests in Discharge Summaries 668 pts DC summaries mentioned only 16% of pending tests (482 of 2,927) All pts had at least 1 pending result, but only 25% of dc summaries mentioned a pending result Were, MC et al. J Gen Internal Med 24(9):1002-6

Pending Tests Not Followed Annals of Internal Medicine. 2005; 143(2):121-8. 41% of inpatients discharged with a pending test result 37% actionable and 13% urgent 2/3 of physicians unaware of results Tests done in the hospital the results of which are not back are often not tracked which could lead to many errors.

Work-ups Not Completed Archives of Internal Medicine. 2007;167:1305-11. 25% of discharged patients require additional outpatient work-ups More than 1/3 not completed

Communication Deficits at Hospital Discharge Are Common Discharge summary not readily available: 12-34% at first post-discharge appt 51-77% at 4 weeks Discharge summary lacking key components: Hospital course (7-22%) Discharge medications (2-40%) Completed test results (33-63%) Pending test results (65%) Follow-up plans (2-43%) Direct communication, 3-20% Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-41.

Discharges are Variable by Day of the Week Days to Rehospitalization 20 40 60 80 0.4 0.6 0.8 1.0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Errors Lead to Adverse Events Arch Intern Med 2003;138:pp. 19% of patients had a post-discharge AE 1/3 preventable and 1/3 ameliorable CMAJ 2004;170(3):pp. 23% of patients had a post-discharge AE 28% preventable and 22% ameliorable

A Real Discharge Instruction Sheet This is an example of an actual instructin sheet for a patient being discharges – how couudl anybody nderstand this. 18

“Perfect Storm" of Patient Safety The hospital discharge is non-standardized and frequently marked with poor quality. Loose Ends Communication Poor Quality Info Poor Preparation Fragmentation Great Variability N summary – there is great room for improvement in the hospital discharge. 20% of Medicare patients readmitted within 30 days1 Only half had a visit in the 30 days after discharge1 Jenks NEJM 2009.

Quality goals Do the right thing (evidence-based care) For this patient (individualized) and every patient (equal care) Every time (consistency)

Basic quality improvement Select an area for improvement. Establish goal. Describe current system (Process Map) Select Measures Standardize the process Rapid Cycle improvement (PDSA)

Two Questions We asked: Can improving the discharge process reduce adverse events and unplanned hospital utilization? Grant reviewer asked: What is the “discharge process”?

Approaches to improving reliability Definition: Failure free performance over time. Approaches to improving reliability Method 1 -- Prevent errors Method 2 -- Catch and correct errors

Method 1 Preventing Errors Goal: Prevent system failure from occurring in the first place. Method: Standardization of the system. There is good evidence that quality improves with standardization. Simple test: Ask 5 people. Roger Resar suggests that one ask 5 people to describe the process or standard work of a system. If you do not get the same answer the process is not standardized.

Method 2 Catch and correct errors Goal: To identify failures and minimize further harm. Method: Redundancy in the process Measure: Track adherence to standard process AND Number of failures identified and mitigated by redundancy in the process

Poka Yoke Error - proofing Fit the system to the human not the other way around

Principles of the RED: Creating the Toolkit Readmission Within 6 Months Hospital Discharge Patient Readmitted Within 3 Months Probabilistic Risk Assessment Process Mapping Failure Mode and Effects Analysis Qualitative Root Cause So we used theses methods to carefully look at the process 27

RED Component #1 Educate patient about their diagnosis throughout the hospital stay RED intervention starts within 24 hours of the patient’s admission to the hospital Continues daily until discharge Before meeting the patient we view their EmR; Talk to their team of doctors; (so you can be as knowledgeable as possible) Important to meet with the patient every day to reinforce previous teaching, update them on new information and answer any questions that may have arisen. Discharge planning should start as close to admission as possible. Discharge planning on the day of discharge is very ineffective. Like cramming for an exam on the day of the test. NQF Safe Practice-15: “preparation for discharge occurring with documentation, throughout the hospitalization” 28 28

RED Component #2 Make appointments for clinician follow-up and post-discharge testing Schedule PCP appt within 2 weeks after discharge Review the provider, location, transportation and plan to get to appointment Consult with patient regarding best day and time for appointments Discuss reason for and importance of all follow up appointments and testing From RED: -Make appointments with input from the patient regarding the best time and date of the appointment. -Coordinate appointments with physicians, testing, and other services. -Discuss reason for and importance of physician appointments. -Confirm that the patient knows where to go, has a plan about how to get to the appointment; review transportation options and other barriers to keeping these appointments. (1) “explicit delineation of roles and responsibilities in the discharge process” If its not one person responsibility then its no ones responsibility SP-15: “explicit delineation of roles and responsibilities in the discharge process” 29 29

RED Component #3 Discuss tests/studies completed and who will follow up on results Information listed in After Hospital Care Plan (AHCP), which is transmitted to PCP Patient knows to discuss this with PCP at follow-up appointment and where to find it on their AHCP (7) “coordination and planning for follow-up appointments that the patient can keep “follow-up of tests and studies for which confirmed results are not available at time of discharge” From RED: Be sure patient understands the importance of such services. Make appointments that the patient can keep. Discuss the details about how to receive each service. SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge” 30 30

RED Component #4 Organize post-discharge services Communicate with case manager and social worker about post-discharge services that they schedule Provide patient with contact information for these services (phone number, name of company, etc.) SP-15: “explicit delineation of roles and responsibilities in the discharge process”

RED Component #5 Confirm the Medication Plan Reconcile the patient’s home medication list as close to admission as possible Review each medication; make sure that the patient knows why they take it Discuss new medications each day with medical team and with patient “completion of discharge plan and discharge summaries before discharge” This is definitely a challenge but is a current JACHO requirement It is important to talk to the medical team early on in the admission to “fix or clean up med rec as soon as descrepancies are found Don’t save it until discharge SP-15 “completion of discharge plan and discharge summaries before discharge” 32 32

RED Component #6 Reconcile discharge plan with national guidelines and critical pathways Communicate with medical team each day about the discharge plan Recommend actions that should be taken for each patient under a given diagnosis The DA looks at these to see that they are done and if not discusses them with the medical team. Provides a starting point for conversation 33

RED Component #7 Review appropriate steps for what to do if a problem arises What constitutes an emergency What to do if a non-emergent problem arises Where to find contact information for the discharge advocate and PCP on the After Hospital Care Plan From RED: Instruct on a specific plan of how to contact the PCP (or coverage) by providing contact numbers for evenings and weekends. Instruct on what constitutes an emergency and what to do in cases of emergency. (14) “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.” SP-15 “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.” 34 34

RED Component #8 Expedite transmission of the discharge summary to the PCP Fax the discharge summary and After Hospital Care Plan to PCP within 24 hours after discharge SP-15 “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods” “A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.” From RED: Reason for hospitalization with specific principal diagnosis. Significant findings. (When creating this document, the original source documents – e.g. laboratory, radiology, operative reports, and medication administration records – should be in the transcriber’s immediate possession and be visible when it is necessary to transcribe information from one document to another.) Procedures performed and care, treatment, and services provided to the patient. The patient’s condition at discharge. A comprehensive and reconciled medication list (including allergies). A list of acute medical issues, tests, and studies for which confirmed results are pending at the time of discharge and require follow-up. Information regarding input from consultative services, including rehabilitation therapy. (3) “reliable information from the primary care physician (PCP) or referring primary care physician PCP or referring caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods” (8) “A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge. At a minimum, the discharge summary should include the following: reason for hospitalization; significant findings; procedures performed and care, treatment, and services provided to the patient; the patient’s condition at discharge; information provided to the patient and family; a comprehensive and reconciled medication list; a list of acute medical issues, tests, and studies for which confirmed results are unavailable at the time of discharge and require follow-up” (italicized text is part of the Safe Practice recommendation but not presented in the slide) Calling the PCP, faxing PCP med list, faxing DC summary Keeping DA in the loop of developments 35 35

RED Component #9 Assess degree of patient understanding, ask patient to explain discharge plan Deliver information to reach those with low health literacy level Include caregivers when appropriate Utilize professional interpreters as needed From RED: May require removal of language and literacy barriers by utilizing professional interpreters. May require contacting family members who will share in the care-giving responsibilities. (11) "Before discharge, present a clear explanation that the patient understands that addresses postdischarge medications, how to take them and how and where prescription can be filled.  This information must also be communicated to the accepting physician.” (21) “Use the ‘teach back process’ to ensure pt understands transition-of-care planning.” SP-15 "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled.  This information must also be communicated to the accepting physician.” "Use the 'teach back process' to ensure pt understands transition-of-care planning." 36 36

RED Component #10 Give the patient a written discharge plan at time of discharge After Hospital Care Plan includes: 1) Principal discharge diagnosis 2) Discharge medication instructions 3) Follow-up appointments with contact information 4) Pending test results 5) Tests that require follow-up From RED: Reason for hospitalization. Discharge medications including what medications to take, how to take them, and how to obtain the medication. Instructions on what to do if their condition changes. Coordination and planning for follow-up appointments that the patient can keep. Coordination and planning for follow-up of tests and studies for which confirmed results are not available at the time of discharge.  (7) “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge” SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge” 37 37

After Hospital Care Plan Patient-centered discharge instruction booklet Designed to reach patients with low health literacy Individualized to each patient and hospital

COVER PAGE

MEDICATION PAGE (1 of 3)

MEDICATION PAGE (2 of 3)

MEDICATION PAGE (3 of 3)

APPOINTMENT PAGE

APPOINTMENT CALENDAR

PATIENT ACTIVATION PAGE

PRIMARY DIAGNOSIS PAGE

RED Component # 11 Provide telephone reinforcement of the discharge plan after discharge Call patient within 72 hours after discharge Assess patient status Review medication plan Review follow-up appointments Take appropriate actions to resolve problems (15) “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid postdischarge adverse events and unnecessary rehospitalizations" SP-15 “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post discharge adverse events and unnecessary re-hospitalizations"  47 47

Components of RED Intervention In Hospital – Nurse Discharge Advocate (DA) Interacts with care team: medication reconciliation, appointments, and national guidelines Prepares and teaches After Hospital Care Plan (AHCP) After Discharge – Clinical Pharmacist Calls for follow-up @ 72 hours post-dc Reinforces dc plan and review medications “Discharge” preparation begins at admission… and continues post discharge with a phone call. 48 48

Rapid Cycle Improvement The random controlled trial

Testing the RED Process Randomized Controlled Trial RED Intervention N=375 30-day Outcome Data Enrollment N=750 Randomization Usual Care N=375 Enrollment Criteria: English speaking Have telephone Able to independently consent Not admitted from institutionalized setting Adult medical patients admitted to Boston Medical Center (urban academic safety-net hospital) Usual care at BMC No policy to make PCP appt for patients Provided with dc summary, typed out sheet with dc info written Little instruction, few minutes with nurse/doctor 50

How well did we deliver intervention RED Component Intervention Group (No,%) (N=370) * PCP appointment scheduled 346 (94%) AHCP given to patient 306 (83%) AHCP/DC Summary faxed to PCP 336 (91%) PharmD telephone call completed 228 (62%) * 3 subjects excluded from outcome analysis: subject request (n=2), died before index discharge (n=1)

What did we find?

Primary Outcome: Hospital Utilization within 30d after Discharge Usual Care (n=368) Intervention (n=370) NNT P-value Hospital Utilizations * Total # of visits Rate (visits/patient/month) 166 0.451 116 0.314 7.3 0.009 ED Visits 90 0.245 61 0.165 12.5 0.014 Readmissions 76 0.207 55 0.149 17.2 0.090 * Hospital utilization refers to ED + Readmissions

Cumulative Hazard Rate Time after Index Discharge (days) Cumulative Hazard Rate of Patients Experiencing Hospital Utilization 30 days After Index Discharge 5 10 15 20 25 30 0.0 0.1 0.2 0.3 Cumulative Hazard Rate Time after Index Discharge (days) Cumulative hazard curve – shows the cumulative hazard of hospital utilization over the 30 days after discharge from the index admission. For subjects with more than one event in that time period, all events were counted, with time-to-event measured from the date of index discharge for each one. The p-value, significant at 0.004, comes from a log-rank test, comparing the intervention subjects to control subjects. Usual care Intervention p = 0.004

Hospital utilizations among people with acute MI, CHF, or pneumonia Primary outcomes within 30 days after index hospitalization Control group (n=49) Intervention group (n=45) P value No. of hospital utilizations,* (No.visits/patient/month) 36 (0.73) 14 (0.31) 0.004 Incidence rate ratio of hospital utilizations, IRR (95%CI) REF 0.42 (0.23 , 0.79) - 55 55

Outcome Cost Analysis We saved $412 for each patient given RED Cost (dollars) Usual Care (n=368) Intervention (n=370) Difference Hospital visits 412,544 268,942 +143,602 ED visits 21,389 11,285 +10,104 PCP visits 8,906 12,617 -3,711 Total cost/group 442,839 292,844 +149,995 Total cost/subject 1,203 791 +412 We saved $412 for each patient given RED

Elderly: Outcomes For Ages >=65yrs (121/738 Total Participants) Primary outcomes ≤30 days after index hospitalization Control n=60 Intervention n=61 P value Hospital utilizations, n (visits/patient/mo) 32 (0.53) 14 (0.23) 0.001 Emergency department visits, n (visits/patient/mo) 12 (0.20) 2 (0.03) 0.01 Readmissions, n (visits/patient/mo) 20 (0.33) 0.13 Secondary Outcomes How well were your questions answered before you left the hospital? 15 (47%) 19 (76%) 0.03 How well did you understand your appointments after you left the hospital? 35 (73%) 44 (88%) 0.06

Self-Perceived Readiness for Discharge: 30 days post-discharge %

Median Clinical Time Required DA: 90 minutes/subject * Collect information from patient, teach AHCP Communicate with medical team, enter data into AHCP** * Some information collection redundant with existing hospital staff ** Can be expedited using workstation software and ECA character PharmD: 30 minutes/subject Prepare for call Call patients Conduct interventions post-call

Medication Errors (MEs) Frequency, number (%) Patient did not fill did not need prescription money/financial barrier intentional non-adherence non-intentional non-adherence did not fill, insurance issue 16 (3.5) 1 (0.2) 19 (4.1) 170 (36.7) 57 (12.3) 18 (3.9) System Rx given w/ known allergies conflicting info from different sources d/c instructions incomplete/inaccurate duplication incorrect dosage incorrect quantity pt needed to fill at special pharmacy pt does not know how to use no Rx given at d/c 3 (0.6) 111 (24.0) 13 (2.8) 14 (3.0) 8 (1.7) 2 (0.4) 28 (6.0) Total errors 463 (100.0) Numbers are how many times that particular error came up, not the number of people with that type of error (i.e. one person could have 4 of one type and they are all counted). 60

Should the NQF/RED be Done for Discharge at Every Hospital? Hypotheses A comprehensive discharge will: Lower hospital utilization Improve readiness for discharge Increase PCP follow-up

Implications The components of the RED should be provided to all patients as recommended by the National Quality Forum, Safe Practice.

Who is at risk of Rehospitalizations? Frequent Fliers Health Literacy Depression Men Substance Abuse Elderly LOS Co-morbidity

HEALTH LITERACY: Risk of hospital re-utilization 60 Usual Care Intervention 50 40 30 Risk of re-utilization 20 p=0.06 p=0.59 p=0.38 p=0.04 10 Grade 3 and below Grade 4-6 Grade 7-8 Grade 9+ REALM category

IRR = Incident Rate Ratio Depression: # Hospital Utilizations, Hospital Utilization Rate, and IRR at 30, 60 and 90 days Hospital Utilization Depression Screen* Negative Positive n=500 (68%) n=238 (32%) p-value IRR* (CI) No. of Hospital Utilizations† 30-day Hospital utilization rate 140 0.296 134 0.563 <0.001 1.90 (1.51,2.40) 60-day Hospital utilization rate 231 0.463 205 0.868 1.87 (1.55,2.26) 90-day Hospital utilization rate 324 0.648 275 1.165 1.79 (1.53,2.10) *Depression screen determined by scoring of Patient Health Questionnaire-9 (PHQ9). Depressive symptom score of 5 points or higher is designated as positive. (17) † Number of hospital utilizations include all emergency department (ED) visits and hospital readmissions following discharge from Project RED index admission. ED visits leading to hospital admission are counted as one event. Sum reflects cumulative number of events over 30, 60 and 90 days. IRR = Incident Rate Ratio

GENDER: Primary outcomes ≤30 days after index hospitalization Males Females P value Patients, n 367 370 Hospital utilizations, n (visits/patient/mo) * 174 (0.474) 108 (0.292) <0.001 IRR (95% CI) 1.62 (1.28, 2.06) REF Emergency department visits, n (visits/patient/mo) 101 (0.275) 50 (0.135) 2.04 (1.45, 2.86) Readmissions, 73 (0.199) 58 (0.157) 0.09 1.27 (0.90, 1.79)

GENDER: Outcome data collected at 30-day follow-up call by gender Males Females P value Able to identify PCP name 77% 88% <0.001 How well did you understand your appointments? 78% 87% 0.005 Visited PCP 49% 57% 0.04 Able to identify discharge diagnosis 73% 0.24 How well did you understand how to take your medications after leaving the hospital? 84% 0.12

RED Effectiveness by Risk Stratified Groups 1. This graph shows that at the extremes (Risk Group 20 or lower or 70 and above) the intervention does not work. For groups 20 to 70 (mid-level risk), the intervention is very effective with the exception of a small significantly insignificant point. 2. The y axis is hospital reutilization rate, defined as TOTAL number of hospital readmissions + ER visits/person/30 days. This counts multiple admissions/ER visits per index discharge. 3. Risk factors included in the analysis are: gender, marital status, depression status, hypertension/diabetes/asthma status, “frequent flier” status, and homelessness Risk factors included in the analysis are: gender, marital status, depression status, hypertension/diabetes/asthma status, high hospital utilization, and homelessness 68

Conclusions Hospital Discharge is low hanging fruit for improvement RED is NQF Safe Practice RED: Can be delivered using AHCP tool Can decreased hospital use 30% overall reduction NNT = 7.3 Saves $412 per patient Health IT Could Help could improve delivery further improve cost savings and build the business case

Using Health IT to implement RED

Can Health IT assist with providing a comprehensive discharge?

Software to print AHCP

Using Health IT to Overcome Challenge of RN Time Embodied Conversational Agents Emulate face-to-face communication Therapeutic alliance using empathy, gaze, posture, gesture Teaches RED AHCP Determine Competency Can drill down Maps of CHCs Characters: Louise (L) and Elizabeth (R)

Studies of Nurse-Patient Interaction 74

Patient Interacting with Louise

Automated Discharge Workflow 76

Who Would You Rather Receive Discharge Instructions From? “I prefer Louise, she’s better than a doctor, she explains more, and doctors are always in a hurry.” “It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and says ‘Here you go.’ Elizabeth explains everything.” 77

Embodied Conversational Agent http://relationalagents.com/red.wmv 78

Current Work: Online Louise Post-discharge web-based system designed to emulate the post-hospital phone call Multiple interactions in the days between discharge and first PCP appointment Designed to Enhance adherence Monitor for adverse events Prevent adverse events Identifying post-dc “confusion” and rectify Screening system for who needs 2 day phone call Beginning a trial of this system

A moment for reflection

RED Implementation

Why Hospitals Should Use RED Volume Opens beds by decreasing 30 day hospital utilization Reduces diversion and creates greater capacity for higher revenue patients Improves PCP follow-up Satisfaction Improves satisfaction of patients and their families Improves community image Brands the hospital with high quality Safety National Quality Forum Safe Practice (endorsed by IHI, Leapfrog, CMS) Exceeds Joint Commission standards Improves patient “readiness for discharge” Documents the discharge teaching and preparation Documents patient understanding of the plan Cost - the business case Saves $412 per subject enrolled Allows physicians to bill higher discharge level Improves relationships with ambulatory providers Improves market share as “preferred provider” Prepares for change in CMS rules regarding readmission reimbursement How about dissemination – why should hospitals use RED 82 82

Dissemination Website diagnostics - Thousands of worldwide contacts PR - AHRQ webinar - 2,200 hospitals signed up AHRQ Roll –out 6 hospital beta sites across country Studying the process of implementation Joint Commission, AMA, State Hospital Assns, KP etc. Office of Tech Transfer at BU 132 hospitals now actively engaged AHA - H2H CMS: 14 QIO - “Safe Transitions” IHI Commonwealth Fund - STARS Society Hospital Medicine - BOOST

RED TOOLBOX After Hospital Care Plan (AHCP) How to create it (paper or IT) How to teach it Discharge Advocate Training Manual How to provide RED in other languages In English to non-English speakers In Spanish and Chinese language AHCPs How to conduct post-discharge telephone call How to implement Project RED How to evaluate/benchmark progress

Discharge Advocate Training Principles of RED Roles and division of responsibilities Hire as new role or use existing staff Use of workstation to enter patient data and print AHCP Medication reconciliation review Patient teaching and activation Cultural and linguistic competency

DA Workbook Used to collect patient information: Allergies Appointments and Transportation Substance Use Medications Medical Equipment Diet Exercise

Post-dc call manual Review with patient: Medical condition Any new or existing medical issues Medications Acquisition, Adherence, Side Effects Appointments Communication with patient and with medical providers

How to implement RED Process mapping to understand discharge process at your hospital Choose appropriate staff for each task Use IT capabilities Pilot Evaluate

Process Mapping-1 Ready for Discharge? 1 measure of discharge Complex communication that happens 89 89

Process Mapping - 2 Discharge Summaries 90 90

Process Mapping-3 Appointments 91 91

Process Mapping – 4 Patient Education If its not anyones responsibility then its no ones responsibility 92 92

Delineation of Roles Where does usual hospital care end and Project RED begin? What is usual care? Getting the word out: Inservice the floor nurses Inservice the pharmacists Inservice the medical teams Send letters to attendings each month 93 93

Understanding the risk factors for rehospitalization High hospital use Limited health literacy Depression Male Substance Abuse Elderly Longer LOS Co-morbidities

How to evaluate RED Staff feedback Process outcomes: success of delivery Patient outcomes: satisfaction, 30-day rehospitalization

Barriers to Providing a Comprehensive Discharge Discharge receives low priority for inpatient clinicians Financial pressure to fill beds as soon as possible  Often unclear about who is responsible for discharge Medical team too busy Many errors in the discharge summary If done, it is often rushed and incomplete Relegated to least experienced team members Discharge papers are standardized and not personalized RE Bullet #6-One problem we have encountered here at BMC is that the intern (ie least experienced) is frequently the clinician to do the discharge med rec. Often they are stressed, in a hurry, work overloaded & sleep deprived. Many discrepancies are noted by the DA. It has been suggested that the supervising resident oversee ALL med recs. It may be worthwhile to note the average # of d/c’s in a typical weekday and weekend day to see if this is feasible. 96 96

Barriers to Implementation Discharges often occur in the late afternoon and evening Patients are anxious to leave after waiting all day for final word; teaching is less effective Lack of communication between hospital physicians and PCPs No designation about who will follow up on pending tests from hospital and post hospital tests

Barriers to Implementation: Medication Reconciliation Medication plan is regularly changed late in the hospitalization and not always complete/reconciled Frequent inaccuracies in medication reconciliation (between admission and discharge) Medication list not reconciled with ambulatory EMR Team not sure if medication will be added/changed…need to wait for a decision by someone else Team trained to do med reconciliation at time of discharge or after 98 98

Barriers to Implementation: Appointments Difficult to obtain PCP appointments within two weeks Patient has no PCP PCP not accepting new pts Insurance Long time to wait on phone Team not sure of follow up/consults 99 99

Health Outcomes – the bottom line “The ultimate test of the quality of a health care system is whether is helps the people it intends to help.” “Crossing the Quality Chasm: A New Health System for the 21st Century”. Committee on Quality of Health Care in America –Institute of Medicine. 2001. National Academy Press. p44

What have we learned Getting quality right in healthcare is a GREAT challenge. Healthcare systems are very complex and the improvement work is hard. The honesty and humility necessary require significant courage. Yet I feel it is a worthy and even noble challenge and to shy away from it is immoral.

Conclusions Project RED: Can be delivered using AHCP tool Can decrease all-cause 30 day rehospitalization 30% overall reduction NNT = 7.3 Saves $412 per patient Hospital Discharge is low hanging fruit for improvement RED should be provided to all patients as recommended by the National Quality Forum, Safe Practice #15 (2009).

Thank you Thank you for being here. Charles T. Williams, MD charles.williams@bmc.org

For more information: Project RED Toolkit: Research questions: http://www.bu.edu/fammed/projectred/ Research questions: Brian.jack@bmc.org (Dr. Brian Jack, PI) Commercial software and implementation support: info@engineeredcare.com

BREAK! Please take a few minutes to stretch and refresh yourselves 

An diversion 5 min.

Guiding principles for quality efforts Must be: sustainable evidence based focus on high impact items feedback must be timely systems focus measures should derive from core values

Guidelines for implementation of changes Must be time neutral or saving for each individual user. Must be cost neutral or saving to the system Should be piloted first No new staff added unless mandatory for … Insist on standard work and data Enter information once and only once Automate where ever possible.

Muda -- Waste Inventory: documents, forms, supplies, storage space, waiting Overproduction: space, care (churning), over-prescribing Correction: apologizing for delays, retaking vitals or H&P, reentry, duplicate entry Material & Info Movement: charts, labs slips & samples Processing: Turning an encounter in to a viable bill for HCFA Waiting: waiting, waiting waiting… Motion: leaving the exam room, looking for charts

Review of key points Use Improvement science Keep it simple Must address people’s concerns Look for “Triple aim”; WIN – WIN – WIN items

Resources IHI – www.ihi.org Measurement – www.qualityhealthcare.org Lean Enterprise Institute – www.lean.org AAFP Quality Site – www.aafp.org/quality Future of Family Medicine -- www.annfammed.org/cgi/content/abstract/2/suppl_1/s3

--Sidebar-- How good is your system Assume that you audit these 20 and find 1 who did not get appropriate follow up. How big is your problem?

Estimation of error rate for rare events. It is difficult to calculate error rates for rare events in most systems. The rule of 3 can give an estimate of error rates in such cases.

Observed event (errors) = y Rule of 3/n If “y” is the number of error (events) in “n” patients, then the upper limit of the 95% confidence interval (CI) can be estimated by the formula x/n. Observed event (errors) = y x = Numerator for calculating the approximate upper limit of the 95% CI 3 1 5 2 7 9 4 10

Our example. 1 in 20 defect/error rate For a numerator of 1 the table says use a numerator of 5 5/n, n=20: 5/20 = 0.25 You found a 5% defect rate (1 in 20) but it may be as high as 25%. For a high risk issue is this good enough?

Rule of 3 example If you find no errors in an audit of 100 charts, then upper limit of 95% CI is 3/100 (0.03 or 3%). You are fairly sure that your error rate is < 3%. However if you do a random sample of 10 charts and find 1 error, then the error rate may be as high as 50%. (numerator = 1; then use 5/n  5/10 = 0.5 or 50%).

--Sidebar-- SMART Goals A SMART objective is one that is specific, measurable, achievable, relevant and time-bound. George T. Doran, There's a S. M. A. R. T. Way to Write Management Goals and Objectives, Management Review (AMA Forum), November 1981, pps. 35-36. For additional information in this area search “SMART goals” and you will get much information. E.g., http://www4.asq.org/blogs/edu/2006/04/how_smart_are_your_goals.html