Project RED Re-Engineered Discharge

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1 Project RED Re-Engineered Discharge Our Journey to Implementation Tift Regional Medical Center Mindy McStott, RN, CCM June 22, 2011

2 Objectives Identify why reducing re-admission is important and why now. Identify the principles of a Re-engineered Discharge process (Project RED). Describe the steps utilized by Tift Regional Medical Center to implement Project RED. Describe the lessons learned in project implementation. Present data to support success of project implementation.

3 Why address re-admissions? 39.5 million hospital discharges per year $329.2 billion in total annual costs 20% (1 out of every 5) hospital admissions stem from a re-admission Medicare Data indicates that 20% 40% of these re-admissions are probably avoidable 1 2 million unnecessary re-hospitalizations Costs tax payers between $10 - $20 billion annually

4 Why address re-admissions? Perfect Storm of patient safety Hospital discharge is not standardized and is marked with poor quality Loose ends Poor communication Poor quality information Poor preparation Fragmentation Great variability 19% of patients have a post-discharge adverse event Only half of Medicare patients had a physician visit in 30 days after discharge

5 Common Reasons for Avoidable Re-admissions (NOT DIAGNOSIS RELATED) Poor discharge instructions to patient / caregivers Poor understanding of medications Poor understanding of when to notify MD Poor transfer of information to post-discharge caregivers SNF PCP Lack of clarity on end of life preferences Lack of timely MD follow-up visit No PCP MD not aware of hospitalization Patient has no transportation Poor medication reconciliation results in duplication or interaction

6 Decision to Participate TRMC top re-admission reasons Social Issues PCP follow-up No PCP available Timing of PCP appointment Medication issues Care Coordination / Caregiver knowledge of home care plan

7 Project RED Re-Engineered Discharge (Brian Jack; Boston Medical) Pilot funded in 2006 by the Agency for Healthcare Research & Quality (AHRQ) Initial focus: fragmentation on discharge Elements: Well defined roles & responsibilities of team Easy flow of information from hospital to PCP Patient education throughout stay A printed, easy to understand discharge plan for the patient A discharge checklist

8 The RED Decision Participation Requirements In addition to complying with the project timeline and intervention strategies, participating hospitals will be expected to: Adhere to the project timeline and intervention strategies Establish a project team to guide the implementation process Select an approach to participation Identify a discharge advocate(s) Identify pharmacist(s) who will make post-discharge follow-up calls to patients when medication questions exist Identify staff who will participate in webinar-training on Project RED Participate in focus groups to learn more about current discharge planning processes at the participating hospitals Participate in webinars offered during the project time period Participate in interviews during the project time period to share experience and learnings related to use of the Project RED intervention, for purposes of generating case studies Provide data pre and post-intervention on the following measures for patients in the targeted population: 30-day readmission, ED visits, length of stay, patient experience/satisfaction Inform AHRQ contractor if public announcement of participation is made.

9 Team Recruitment Quality Management Department to facilitate project HR Administrator (responsible for patient satisfaction) - Executive Champion Hospitalist Medical Director - Physician Champion Other team members Nursing Administration Pilot unit Nursing managers / staff Case Management manager / discharge planning staff ER social services staff Palliative Care social worker Patient Representative Pharmacy Employee Education Service Excellence Coordinator

10 Project RED Team

11 Principles of the Newly Re-Engineered Hospital Discharge 1. Explicit delineation of roles and responsibilities 2. Discharge process initiation upon admission 3. Patient education throughout hospitalization 4. Timely accurate information flow: From PCP Among Hospital Team Back to PCP 5. Complete patient discharge summary prior to discharge

12 Principles of the Newly Re-Engineered Hospital Discharge (continued) 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

13 RED Checklist Eleven mutually reinforcing components: 1. Medication reconciliation 2. Reconcile discharge plan with national guidelines 3. Follow-up appointments 4. Outstanding tests 5. Post-discharge services Adopted by 6. Written discharge plan as one of 30 US 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10. Discharge summary sent to PCP 11. Telephone reinforcement National Quality Forum "Safe Practices" (SP-15)

14 Keys to the Project RED Intervention Discharge advocate TRMC calls them Discharge Coordinator Related multidisciplinary activities Care plan for patient use after discharge Post-discharge follow-up with patient

15 Discharge Advocate TRMC) Coordinates all discharge activities within patient population Facilitates team activities and discharge planning rounds with primary MD Collects discharge focused data Assures completion of Patient Care Plan and demonstrated learning by the patient

16 Discharge Coordinator Is notified when patients in target population are admitted/diagnosed Initiates action steps associated with Project RED Initiates the Patient Care Plan Educates patient and family about condition, medications, other treatments, post discharge plans, and follow-up ordered by the physician Reviews Patient Care Plan with patient and family Collects measurement data specific to project and patient population

17 Roles of Staff Members Patient s physician and medical team Nursing staff Case management Pharmacists

18 Patient s Physician Initiates patient plan of care based on critical pathway Leads and/or participates in discharge planning rounds Communicates potential date of discharge Supports the performance improvement process

19 Nursing Staff Care/Rx Education Provide nursing care as planned Educate patient/family as usual Communicate with each other as usual Communicate with other members of the health care team, including DA Participate in multidisciplinary rounds, including those that may be specifically focused on discharge planning

20 Care/Rx Education Case Managers Post-discharge services Social work Utilization review Financial support

21 Pharmacist Verify physician orders Reconcile admission meds with meds from home Collaborate with care team specific to discharge needs Reconcile meds upon discharge Assist with patient medication questions

22 Developing the Patient Care Plan Accessing the patient care plan template Accessing information for the patient care plan Saving individual patient s care plan Printing the patient care plan Storing the patient care plan Permanent part of the patient record?

23 Completing the Patient Care Plan Medication reconciliation performed Pending tests and results identified Post-discharge services Primary care provider Follow-up appointments Information about condition(s)

24 Complete the Patient Care Plan Medication Reconciliation Hospital procedure for completing medication reconciliation at discharge DA may participate and/or conduct final check on medications Using final list, populate patient care plan and complete additional columns (e.g., purpose, time of day visual) The final list will be used to instruct the patient

25 Pending Tests/Results Complete the Patient Care Plan Obtain information about tests and studies completed in hospital and still-pending results Add pending test results to the designated spot on the patient s care plan, including which clinician is responsible for securing final results Encourage patient to discuss tests with PCP; point out where the information is on the care plan

26 Post-Discharge Services Complete the Patient Care Plan Confirm with case manager that all services have been arranged Add names of services and contact information to care plan

27 Primary Care Provider Complete the Patient Care Plan Confirm name of PCP with patient Add name and contact number of PCP to care plan

28 Poor Communication with PCP and Lack of Coordination The hospital discharge process is often characterized by poor communication and a lack of coordination between the hospital and the PCP. When patients are discharged, they often do not know what medications their physicians have prescribed, when their follow-up appointments should take place, and, in some cases, why they were hospitalized in the first place.

29 Primary Care Physician Referral Base Leaders will identify the PCP referral base PCP satisfaction will be assessed prior to project launch Physician champion will communicate with PCPs about project PCPs will advise how to handle their off shift and weekend patient needs LEADERSHIP PRIORITY!

30 Follow-up Appointments Discharge Order Written Discuss best days of week and times of day with patient Discuss transportation needs with patient (how will patient get to appointment?) Place calls to clinicians offices to make appointments that meet patient s time options Leave message with clinician office to call patient (off hours and weekend) Add appointments to care plan

31 Post-Discharge Activities Transmit DC summary and patient care plan to PCP Fax: be sure it is received and legible Electronic: scan/ if possible; be sure it is received Follow-up phone call to patient - 72 hours Caller uses script inclusive of medication and follow-up appointment understanding Need for second call by clinician determined

32 The Post-Discharge Phone Call Define who will call your patient after discharge Define when the followup call will be made Develop script for caller Remember to develop the process for off shifts and weekends

33 TRMC Implementation Getting from here to there.....

34 Strategies for Implementation Identification of pilot units / physicians Chose two medical units to pilot Hospitalist patients Identified excluded populations Nursing Home patients Palliative care / Hospice Non-English speaking Patients below the age of 30 Identification of Discharge Coordinators (Discharge Advocates) Did not get new FTE s for position Restructured responsibilities Selected nurse from each pilot unit based on enthusiasm and interest

35 Project RED - Metrics Review of discharge packet to be sure it is complete % care plans completed % follow up appointments made % of care plans with pre-arranged discharge resources identified % plans with med list included Discharge turn around time Patient satisfaction Readmission rates (required for JCR) Will also track readmission rates for those patients seen by DC % phone calls made in 48 hours % phone calls needing a 2nd call by Pharmacist Follow up surveys to staff and physicians DC will be tracking their overall time with patient during stay % discharge summary to PCP within 48 hours

36 Strategies for Implementation Training / Webinars Team meeting two to three times / month Conference calls every other week JCR consultant Communication education Individual support

37 Strategies for Implementation Identified admission to discharge barriers Rushed discharge d/c planning at the last minute Limited teach back to access understanding Caregiver education needed Medication reconciliation Too many yes/no questions vs open ended questions MD availability for follow up appointments Family availability MD communication with families MD time constraints Money/insurance issues Transportation issues Lack of support systems Noncompliance Consults at last minute ie: SS Communication Language barriers Cultural competence Delay in test results

38 Strategies for Implementation Development of TRMC specific tools Project explanation brochures for physicians & staff After hospital care plan for patients Development of discharge check list Revision of discharge Instruction sheet Revision of patient education tools Follow-up phone call assessment tool Discharge Coordinator interview tool Data Collection Tools 30 day readmission root cause interview tool Readmission reports Satisfaction reports Physician / Staff satisfaction survey tools

39 Post-Discharge Care Plan

40 Patient Education Tools

41 Follow-up Tools Follow-up phone call script Data collection spreadsheet

42 Challenges Discharge Coordinator (DC) Position Development Role and Responsibilities Identification of patient needs and referral to appropriate resources Education planning Follow-up phone calls Team meetings Everyone had to learn D/Cs did not eliminate any job functions from another group Assumed new / expanded duties to foster discharge process for the patient Serve to provide consistency to patient and coordinate group communication.

43 Other Identified Issues Medication Reconciliation issues and challenges Timely follow-up appointments Issues with Medicaid / Self Pay Issues with availability of appointments Compliance with medications / affordability Follow-up calls with negative feedback / voiced complaints & concerns Duplication Multiple staff addressing the same issues Documentation / instructions provided to patient Team Building Opportunity

44 Timeline Application to Participate August 2010 Strategic Goal Planning May 2010 Team Planning August 2010 Develop Tools Pilot x 1 month Oct Dec 2010 Dec 2010 Training Completed Nov 2010 GHA Presentation March 2011 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Review Options June 2010 Base Team Meeting Oct 2010 Go LIVE! Jan 2011 JCR Call for participants April 2010 D/C Coordinators Identified Sept 2010 Planning Meeting to roll out to other units June 2011 Thinking about Projects Feb Mar 2010

45 Success from the Patient Perspective DC took time to come in and talk with us and explain things... DC took the time to find the doctor and have him come in and take time to talk with us Very thankful for the follow-up call! I got all the information I needed to take care of myself at home

46 Successes Team Building Identification and understanding of roles Ensures all needs met with elimination of repetition Saves time and effort with reduced duplication of efforts Improved communication among team members Other physician groups asking when they can participate Consistency for patients through Discharge Coordinator

47 Success Patient Satisfaction Data (Med East) Jan - Apr Question RED ALL Discharge Overall Ready for D/C Speed of D/C Instruction for care at home

48 Success Readmission Data (Med East) Readmission Rate Date MIE RED MIE Dec % 10.94% Jan % 13.91% Feb % 12.6% Mar % 17.97% Apr % 13.85%

49 What we gained Opportunity to look at discharge process from patient point of view Opportunity for standardization of processes Improves communication / coordination Knowledge and understanding of roles to decrease duplication Consider implication of issues identified post discharge Physicians appreciate attention to identifying issues related to medication compliance Physicians appreciate nurse to round with them Improved patient teaching Staff education on adult learning / literacy issues for patients Focus on teach back techniques

50 Lessons Learned Be sure ALL physicians involved have been educated Knowledge and understanding of roles to decrease duplication Administrative support is necessary Guard against activity creep Data is important but don t let it distract from patient care Need to continue to monitor all re-admissions to determine cause

51 Questions