Project RED

Project REDRe-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

Project Steering Committee

List team members Designate project team leader,

executive sponsor, and physician champion

Targeted Patient Population

To pilot Project RED, we have identified the following target patient population:– Provide diagnosis, unit, etc.

Baseline readmission rate = Average length of stay = Add stats from patient phone survey, if

available

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?

Patient and Family Centered Safe Care

Pre Patient Admission

H&P; Assessments; Rx Plan

PATIENT EDUCATION/Prepare for Home

Discharge Order

Written

Discharge Process Discharge Event

FINAL DISCHARGE INSTRUCTIONS

Post-D/C FOLLOW-UPMEDICATION MANAGEMENT

Discharge Folder

Passport for Home

White Board, Rounding & Bedside Report

Community providers: • Nursing Home• Home Health &

Hospice• Home Care• Physicians

• Accountable Care Organizations

Project RED Principles

Re-Engineered DischargePrinciples

1. Explicit delineation of roles and responsibilities2. Discharge process initiation upon admission3. Patient education throughout hospitalization4. Timely accurate information flow:

From PCP ► Among hospital team ► Back to PCP

5. Complete patient discharge summary prior to discharge

6. Comprehensive written discharge plan provided to patient prior to discharge

7. Discharge information in patient’s language and literacy level

8. Reinforcement of plan with patient after discharge

9. Availability of case management staff outside of limited daytime hours

10. Continuous quality improvement of discharge processes

Re-Engineered DischargePrinciples

RED Checklist12 mutually reinforcing components:1. Ascertain need for and obtain language assistance2. Medication Reconciliation 3. Reconcile discharge plan with national guidelines4. Follow-up appointments5. Outstanding/pending lab & diagnostic tests follow-up6. Post-discharge services7. Written discharge plan8. What to do if problem arises9. Patient education10. Assess patient understanding11. Discharge summary sent to PCP12. Telephone reinforcement

Adopted by National Quality Forumas 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 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

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

Questions