1. Re-Engineered Discharge
Project RED
Re-Engineered Discharge
Project RED
Re-Engineered Discharge

2. 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

3. 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

4. “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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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 12

13. 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

14. 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

15. 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?

16. 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

17. Project RED Principles

18. 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

19. 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

20. 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

21. Keys to the Project RED InterventionDA
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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Other Key Staff Therapists Disease management Other Key Staff

31. 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)?

32. 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)

33. 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?

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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)

41. Post-Discharge Activities
Transmits discharge summary and Patient Care Plan to PCP
By fax: Ensures it is received and legible
By 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 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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)

49. 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

50. Questions
Questions