Transitions with a BOOST

1. Transitions with a BOOST Matthew Schreiber MD Medical Director Piedmont Hospitalist Physicians

2. Special Thanks • Sixty Plus Older Adult Services • Transitions Team • Nancy Morrison • Tim Young • Dee Tucker • Michelle Nelson…and many others • Vandy Vail-Dickson Admin Director Hospitalists • Society of Hospital Medicine • BOOST Mentors • Dr Mark Williams • Arpana R. Vidyarthi

3. www.hospitalmedicine.org/BOOST

4. Project BOOST Team www.hospitalmedicine.org/BOOST Mark Williams, MDPrincipal Investigator Professor of MedicineChief, Division of Hospital MedicineNorthwestern University Feinberg School of Medicine Eric Coleman, MD, MPHAdvisory Board Chair Associate ProfessorDivision of Health Care Policy & ResearchUniversity of Colorado at Denver, Health Sciences CenterDenver, CO Jeffrey L. Greenwald, MDCo-InvestigatorDirector, Hospital Medicine UnitBoston Medical Center Lakshmi Halasyamani, MD Co-InvestigatorVice President for Quality and Systems Improvement St Joseph Mercy Medical Center Eric Howell, MDCo-InvestigatorDirector, Hospitalist ServiceJohns Hopkins Bayview Medical Center Greg Maynard, MDClinical Professor of MedicineChief, Division of Hospital MedicineUCSD Medical Center Arpana R. Vidyarthi, MDAssistant Professor of MedicineDirector of Quality, Division of Hospital MedicineDirector of Quality and Safety Programs, GMEUniversity of California San Francisco Senior Advisor, Quality InitiativesTina Budnitz, MPH Senior Advisor, ResearchKathleen Kerr Senior Project ManagerJoy Wittnebert

5. Magnitude of the Problem Forster & Bates - Prospective cohort study 1 Objective: to describe the incidence, severity, preventability, and “ameliorability” of adverse events affecting patients after discharge Tertiary care academic hospital 400 medicine patients discharged home At 3 weeks - Medical record review and Telephone call (structured interview by internist)

6. Orders of Magnitude • One in five general medicine patients experiences an adverse event (resulting from medical management) within two weeks of hospital discharge 1 • 66% of these events are adverse drug events, 17% are related to procedures • 33% of these events lead to disability • Two-thirds of these events are preventable or ameliorable

7. Orders of Magnitude II • Types of discharge errors: 2 • 42% of patients had medication continuity errorsDC Plan.doc • 12 % had work-up errors • 8% test follow-up errors • Patients with work-up errors were more likely to be rehospitalized • Pending test results:3 • Many patients (41%) are discharged with test results still pending. • Many of these results (10%) can change management • Physicians are often (61%) unaware of test results returning after discharge that may change management

8. Orders of Magnitude III • Unsafe discharges are an under recognized yet significant issue that has received almost no attention in health care 5 • Discharges can be urgent and unplanned 5 • No longer does one practitioner typically take responsibility for the discharge 5 • Communication breakdown between multiple providers and between providers and patients 5, 6, 7 • Less than half of patients discharged from academic general medicine know their diagnoses, treatment plan or side effects of prescribed medications 8, 9

9. Bibliography • The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Forster AJ. Ann Intern Med. 2003;138:161-167 • Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Moore C. JGIM. Aug 2003, 18(8):646-51 • Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge. Roy CL. Ann Intern Med. 2005;143:121-128. • The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Baker GR. CMAJ.MAY 25, 2004; 70 (11) 5. Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care. Coleman EA. Ann Intern Med. 2004;140:533 • Low health literacy called a major problem. Vastag B. JAMA. May 12 2004;291(18):2181-82 • Resident recognition of low literacy as a risk factor in hospital readmission. Powell CK. JGIM 20(11):1042-4, 2005 Nov. • Patients’ Understanding of Their Treatment Plans and diagnosis at discharge. Makaryus AN. Mayo Clin Proc. August 2005;80(8):991-994

10. It’s All About the Meds Coleman et al found that hospital readmission rates for patients with identified medication discrepancies were 14.3% among the 375 study patients. This contrasted with a 6.1% readmission rate among patients with no identified medication discrepancy. Forster et al found that antibiotics were the most common drugs causing adverse events defined as injury resulting from medical management rather than the underlying disease. Antibiotics accounted for 38% of adverse events, while corticosteroids accounted for 16%, cardiovascular drugs 14%, analgesics including opiates 10%, and anticoagulants 8%.

11. It’s All About the Meds Schnipper et al showed in a randomized trial of 178 patients being discharged home from the general medicine service that pharmacist counseling reduced the number of preventable adverse drug events from 11% in the control group to 1% in the intervention group.

12. It’s All About the Meds Forster et al., using a survey of patient recollection of the discharge preparations among 400 discharged patients showed that discussion of potential side effects was associated with a reduction in frequency of adverse drug events (adjusted OR 0.4 [95% CI 0.2 to 0.7]). There was no evidence that these discussions increased the likelihood of reported side effects. Unfortunately, only 62% of patients could recall having been told about potential medication side effects at time of discharge.

13. References Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. Sep 12 2005;165(16):1842-1847. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. Feb 4 2003;138(3):161-167. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. Mar 13 2006;166(5):565-571. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. Apr 2005;20(4):317-323. Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system. Ann Emerg Med. Feb 2005;45(2):197-206.

14. Not In My Backyard? The initial med rec lists in PHC were only 45% accurate for medications listed (344/773) 209 medications were missing from these initial list Of patients that were taking medications prior to admit, 89% of initial med recs were incomplete and/or contained at least 1 error Only 11% of patients taking medications prior to admit had an initial MRR that was 100% correct/complete. It took an average of 27 minutes per patient to complete pharmacist reconciliation

15. The New Guard Hospitalist activities may include patient care, teaching, research, and leadership related to hospital care. Hospital medicine, like emergency medicine, is a specialty organized around a site of care (the hospital), rather than an organ (like cardiology), a disease (like oncology), or a patient’s age (like pediatrics). However, unlike medical specialists in the emergency department or critical care units, most hospitalists help manage patients throughout the continuum of hospital care, often seeing patients in the ER, admitting them to inpatient wards, following them as necessary into the critical care unit, and organizing post-acute care. The term was coined by Drs. Robert Wachter and Lee Goldman in a New England Journal of Medicine article in August of 1996 (Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med 1996;335:514-7).

16. Hospitalist Medicine Hospital medicine is the fastest growing field in the history of medicine Currently, no formal certification or board recognition, although this is in the works More than 22,000 hospitalists currently, projected to have more than 30,000 in 2010 There are more than 5 jobs awaiting each new hospitalist entrant Hospitalists “represent/staff” about 70% of all hospital beds nationwide

17. Mission Motivation The goal of Project BOOST (Better Outcomes for Older adults through Safe Transitions) is to improve the care of patients as they transition from the hospital to home.

18. BOOST[er] Power Create a national consensus for best practices. Create resources to implement best practices. Provide technical support.

19. Aiming High With A Value Proposition By improving discharge processes, Project BOOST aims to: Reduce 30 day readmission rates for general medicine patients (with particular focus on older adults) Improve facility patient satisfaction scores Improve the institution’s H-CAHPS scores related to discharge Improve flow of information between hospital and outpatient physicians Ensure high-risk patients are identified and specific interventions are offered to mitigate their risk Improve patient and family education practices to encourage use of the teach-back process around risk specific issues.

20. Join the BOOST Brigade • Any site can access the BOOST toolkit via the resource room free of charge at www.hospitalmedicine.org/BOOST. Over 265 sites have downloaded the complete Implementation Guide. • Six hospitals were selected to participate in Project BOOST’s pilot cohort in 9/08: • Hospital of the University of Pennsylvania • Queens Medical Center – Honolulu, Hawaii • Southwestern Vermont Medical Center • Piedmont Hospital – Atlanta, Georgia • University of New Mexico Health Science Center School of Medicine • ThedaCare: Appleton Medical Center, Appleton, WI; & ThedaClark Medical Center, Neenah WI). • Cohort 2 has 24 additional sites

21. The Basic Process Identify and Risk Stratify For Discharge Failure Intervene with focused care Educate/Inform the Patient AND Key Contact Written Discharge Action Plan that Patient/Caregiver can “Teach Back” Follow up with 72 hr call, home health, provider visit

22. Teach Back Step 1: Using simple language, explain the concept/process to the pt/caregiver. Step 2: Ask the pt/caregiver to repeat in his or her own words how s/he understands the concept. Step 3: Identify and correct misunderstandings Step 4: Ask the pt/caregiver to demonstrate understanding again to ensure the misunderstandings are corrected. Step 5: Repeat Steps 4 and 5 until the clinician is convinced of Comprehension. Dean Schillinger, MD Associate Professor of Clinical Medicine University of California, San Francisco

23. The Forms TARGET—Risk Assessment/Intervention Guide GAP—General Assessment of Discharge Preparedness Universal Discharge Check List

24. 7P Risk AssessmentAnd Triggered Interventions

25. 7P Risk AssessmentAnd Triggered Interventions

26. General Assessment of Preparedness (GAP)Logistical Issues Prior to discharge, evaluate the following areas with the patient/caregiver(s) and ambulatory medical care providers: 1. Functional status assessment 2. Access (e.g. keys) to home ensured 3. Home prepared for patient’s arrival? 4. Advanced care planning documented 5. Ability to obtain medications confirmed 6. Responsible party for med adherence ID’d? 7. Transportation to initial follow-up arranged 8. Transportation home arranged

27. General Assessment of PreparednessPsychosocial 1. Substance abuse/dependence identified/addressed 2. Abuse/neglect presence assessed/addressed 3. Cognitive status assessed/addressed 4. Financial resources assessed/appropriate programs applied for 5. Support circle for patient ID’d for patient, caregiver, homehealth, PCP 6. Contact info for caregivers provided for above?

28. Universal Discharge Checklist 1. GAP assessment (see below) completed with issues addressed……..……….YES NO 2. Medications reconciled with pre-admission list…………………… YES NO 3. Medication use/side effects reviewed using Teach-Back ………. YES NO 4. Teach-Back for understanding of dz, prog, and self-care requirements.……….…YES NO 5. Action plan for sx/s-e/cx requiring attn w/teach-back ………….... YES NO 6. D/c plan (edu mtls; med rec list; f/u plans) provided/taught back………………….…YES NO 7. D/c communication to principal care provider(s)……….………… YES NO 8. Documented receipt of discharge information …………………….YES NO 9. Arrangements made for outpt f/u with principal care provider(s)……………. YES NO

29. Universal D/C ChecklistFor increased risk patients, consider 1. Face-to-face multidisc rounds prior to discharge 2. Direct comm with main care provider before discharge 3. Phone contact arranged w/in 72 hours of d/c 4. F/u appoint with main care provider w/in7 days 5. Contact info for hospital MD/RN familiar w/pt provided to for use if unable to reach principal care provider prior to first follow-up

30. Patient Pass I I Was In the Hospital Because: If I have the following problems… 1. ______________________ 2. ______________________ 3. ______________________ I should … 1. ______________________ 2. ______________________ 3. ______________________

31. Patient PASS II My appointments: 1. ________________________ On: __/__/___ at __:__ am/pm For: _____________________ 2. ________________________ On: __/__/___ at __:__ am/pm For: _____________________ My appointments: 3. _________________________ On: __/__/___ at __:__ am/pm For: _____________________ 4. ________________________ On: __/__/___ at __:__ am/pm For:_______________________

32. Patient PASS III Tests and issues I need to talk with my doctor(s) about at my clinic visit: 1. __________________________ 2. __________________________ 3. __________________________ 4. __________________________ Important contact information: 1. My primary doctor: _________________ (____) ___________ 2. My hospital doctor: _________________ (____) ___________ 3. My visiting nurse: _________________ (____) ___________ 4. My pharmacy: _________________ (____) ___________ 5. Other: _____________________ (____) ___________

33. Patient PASS IV Other instructions: 1._______________________________________________ 2._______________________________________________ 3._______________________________________________ 4._______________________________________________ I understand my treatment plan. I feel able and willing to participate actively in my care: _______________________ Patient/Caregiver Signature _______________________ Provider Signature ____/____/_____ Date

34. The Forms Are Good, But the Process It Requires is Better Ever Feel like a hospital admission and discharge is like renting a car? Sign here, initial here, etc. It all sounds like everything is covered—until you have a problem. Ever find out the hard way that the underside of the car isn’t insured—even with the “total coverage?”

35. “Unique Mechanics” Geographically designated personnel including IMS MD—LEAN Advantage Ward organized around attending MD instead of disease state Name in the Box* Right person, right job***(eg pharmacy) Centralized Communication—d/c criteria, what’s next, patient out of room on “public” whiteboard Automation/Standardization—data retrieval results in predictable responses Detailed Risk Assessments translate into proactive care—medications, functional assessments “Specialized testing triage” Create “the Pull” Charge RN in Charge of being in charge

36. The Results An Astounding 45% decline in Avoidable Days (Excess LOS) from 9/08 – 1/09 vs same Period on the same unit the year prior (670 vs 366 avd days) During this Period, the MDs on the Unit discharged 260 pts/MD vs 116 pts/MD with traditional process (17% of workforce was responsible for 31% of the work) Each of the 2 Unit MDs had 183 Avoidable days for their 260 cases (0.7 avd days/case) vs. 141 avoidable days for each of the 10 MDs with 116 Cases each (1.2 avd days/case)

37. The Results II Readmission Rate significantly lower vs peers Patient Satisfaction has improved Markedly Staff Satisfaction is at an all-time high “Float RNs” asking to rotate there One Unit Making a Noticeable impact on whole house throughput PCPs LOVE the PASS Significant percentage of patients can still “teach back” at follow-up call Home Health Much Better informed and can verify that d/c MRR is same as what is actually being taken in home

38. Summary Statements • Adverse events resulting from medical (mis)management at discharge are: • Common in our patients • Often involve Medications and Tests • Dangerous and result in significant morbidity and increased healthcare utilization • Preventable

39. Classic Problems with Creating Safe Discharges • Discharges are unsafe for a number of reasons: • complex process • time constraints • low priority • poor planning • lack of ‘ownership’, • poor communication • not ‘patient=centered’

40. Creating Safe Discharges is Like Being an American In the Stock Market We all know the job—Save for retirement We’re offered some excellent tools (401K) There is a ton of information out there It confuses the experts No one and everyone “owns it” Success depends on getting the basics right and on doing the maintenance work between decision points

41. Pearls of Wisdom Take Ownership Every Visit Every Time Assume Anything that Can Go Wrong Will Go Wrong and Act Accordingly Managing “the Space Between” is the right thing to do Do you Have a daughter? Can I speak with Her? If no, automatic high risk. It’s all about the Meds If It’s confusing for you, it’s confusing for everyone

42. Wisdoms Continued Communication between providers is a key deficit. How tightly connected is your feedback loop? Is the patient included? Home care/community resources? Is the plan written, does the pt understand? Who’s the manager, the key assistants? Have you followed up to ensure things are going well and/or to redirect to care? Use Home Health Unless you Have a Good Reason Not To. Less than 1/3 of our patients with more than 4 Admissions in a year had home health at last discharge.

43. Eminent Domain Medicine Has Focused on Episodes and Domains of Care and Responsibility We Need to Focus not on how well we did “our job” rather on patient outcome We are all responsible for the whole shebang, though we choose to subdivide responsibility for our own convenience Make the Most of the “Inpatient Moment”

44. Parting Wisdom No Margin, No Mission; but without staying true to your mission, you’ll never have sustainable margin Don’t Collect Data you don’t use, Use the Data You Collect Do Something Different Wrong Always Do the Right Thing No Matter How Difficult Never accept of yourself an effort dependent failure We have all the help we need—it’s sitting in this room