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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
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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
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
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 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 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
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 Vision Mandate improvement Identify champions Receive and review updates
List team members Designate project team leader, executive sponsor, and physician champion Project Steering Committee
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 Patientson 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?
Discharge Planning Discharge Order Written H & P Rx Plan Patient Admission Discharge Event Discharge Process PATIENT EDUCATION DISCHARGE INSTRUCTIONS Post-D/C Follow-up
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
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
RED Checklist 11 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 11. Telephone reinforcement Adopted by National Quality Forum as one of 30 U.S. "Safe Practices"
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 • 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 11 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
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
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
Case Managers • Arrange post-discharge services • Educate the patient • Perform social work duties • Perform utilization review
Other Key Staff • Therapists • Disease management
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 • 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
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
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
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)
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
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
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 • 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
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
