Project BOOST Be'er Outcomes by Op2mizing Safe Transi2ons Mark V. Williams, MD, FACP, MHM Professor & Chief, Division of Hospital Medicine Northwestern University Feinberg School of Medicine Principal Inves2gator, Project BOOST 1 in 5 Medicare patients rehospitalized in 30 days Half never saw outpatient doc 70% of surgical readmissions chronic medical conditions Costs $17.4 billion 1
Rates of Rehospitalization within 30 Days after Hospital Discharge Jencks S, Williams MV, Coleman EA. N Engl J Med 2009;360:1418-1428 Illinois #49 2
Lessons Learned in 5 Years (and still learning) 1) Difficulty 4) Patient Education 2) Teamwork 5) Beyond Hospital 3) Workflow 6) Mentoring #1: It ain t easy 3
Harlan M. Krumholz, MD, SM research group n Observational study of 6,955,461 Medicare FFS hospitalizations for HF; 1993 and 2006, with 30-day f/u. n Mean age = 80 n 52% Htn, 38% DM, 37% COPD n LOS 8.8 days down to 6.3 n Discharges to SNF increased from 13% to 20% n Discharge to home decreased from 74% to 67% n 30 day readmission increased from 17.2% to 20.1% n Post-discharge mortality increased from 4.3% to 6.4% n In-hospital mortality declined from 8.5% to 4.3% n 30-day mortality declined from 12.8% to 10.7% 46% reported challenges 12% felt unprepared for discharge 11% difficulty ADLs 6% trouble adhering to discharge meds 5% difficulty accessing discharge meds 5% lack of social support Low SES had more difficulty 4
#2: It requires a Team Project BOOST www.hospitalmedicine.org/boost Project BOOST was developed by the Society of Hospital Medicine through generous grant support from The John A. Har\ord Founda2on www.hospitalmedicine.org 5
Advisory Board Chair: Eric Coleman, MD, MPH MacArthur Fellow Genius Award Co-Chair & PI: Mark Williams, MD with organizational representatives from: Social work Case management Clinical pharmacy Geriatric medicine Geriatric nursing Health IT Blue Cross/Blue Shield United Health Health systems NQF AHRQ TJC CMS National Consumer s League Other content experts #3: You need to integrate into Workflow 6
Key Components Project Management Tools Clinical Tools Comprehensive risk assessment on admission 8Ps Risk specific interven2ons during stay & at discharge Pa2ent centered discharge process Teachback, F/U appt scheduled prior to discharge (and within 7 days) Standardized PCP communica2on 72 hour follow- up call for high risk pa2ents Mentored ImplementaDon Longitudinal coaching throughout implementa2on Ongoing educa2onal opportuni2es BOOST Community/Collabora2ve Checklists Michael Scriven Western Michigan U The humble checklist the process of validating an evaluative checklist is a task calling for considerable sophistication. 7
TARGET Assessment Tool The 8Ps TARGET Assessment Tool - The 8Ps Tool for Addressing Risk: a Geriatric Evaluation for Transitions Prior hospitalization Problem medications / Polypharmacy Psychological Principal diagnosis Poor health literacy Patient support Palliative care Poor physical function Risk Specific Checklist GAP: General Assessment of Preparedness 4 Drug groups account for 2/3 Warfarin 33% Insulin 14% Anti-platelet agents 13% Oral Hypoglycemics 11% 8
The General Assessment of Preparedness: The GAP Caregivers and social support circle for pa2ent Func2onal status evalua2on completed Cogni2ve status assessed Abuse/neglect Substance abuse Advanced care planning addressed and documented On Admission Functional status Cognitive status Access to meds Responsible party for ensuring med adherence prepared Home preparation for patient s arrival Financial resources for care needs Transportation home Access (e.g. keys) to home Nearing Discharge l Understanding of dx, treatment, prognosis, followup and postdischarge warning S/S (using Teach Back) l Transportation to initial follow-up At Discharge 9
Discharge Patient Education Tool DIAGNOSIS I had to stay in the hospital because: The medical word for this condition is: I also have these medical conditions: TESTS DPET While I was in the hospital I had these tests: which showed: TREATMENT While I was in the hospital I was treated with: The purpose of this treatment was: FOLLOW-UP APPOINTMENTS After leaving the hospital, I will follow up with my doctors. (initials) Primary Care Doctor: Phone Number: DATE:,, 200 TIME: : m Specialist Doctor: Phone Number: DATE:,, 200 TIME: : m FOLLOW-UP TESTS After leaving the hospital, I will show up for my tests. (initials) TESTS LOCATION DATE TIME,, 200 : m Call your Primary Care Doctor for the following: Warning signs 1) 4) LIFE STYLE CHANGES After leaving the hospital, I will make these changes in my activity and diet. (initials) Activity:, because Diet:, because 10
#4: Teach Back is a Winner NEW CONCEPT: Health information, advice, instructions, or change in management The Teach Back Method Assess patient comprehension / Ask patient to demonstrate Explain new concept / Demonstrate new skill Patient recalls and comprehends / Demonstrates skill mastery Clarify and tailor explanation Adherence / Error reduction Re-assess recall and comprehension / Ask patient to demonstrate Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90 11
#5: You need to Reach Out Involve the Community Primary Care Providers Community Services AAA AoA Pharmacies Home Health Agencies Skilled Nursing Facilities 12
Early follow-up can make a difference Associated with a higher rate of comple2on of recommended outpa2ent work- ups Moore et al. Arch Intern Med 2007 HF readmissions were lower among pa2ents who had follow- up within 7- days Hernandez et al. JAMA 2010;303(17):1716-22 Primary Care RNs making outreach phone calls within 1-2 days are improving follow- up and reducing readmissions Balaban et al. J Gen Intern Med. 2008 New systems to ensure early follow-up Aker hospitaliza2on, outpa2ent services need to proac2vely connect with their pa2ents Scheduling an appointment is not enough confirm; Day, 2me, and place (Graff et al. 2010) Access to transporta2on Provider name, specialty and why appointment is important New standards of care o Geisinger strives for 7- day follow- ups for all discharged pa2ents o Metro Health Hospital has 7- day follow- ups for all HF discharges: readmits have decreased by 50% 13
#6: Mentors Help Understanding YOUR Culture You can t have one uniform set of materials on XXXXX that works everywhere You cannot work in China without a deep understanding of how Chinese business works and that means listening to the Chinese it s not about telling them what should work there just because that s how it works here. 14
Mentored Implementation Secret Sauce for Project BOOST 2011 John M. Eisenberg PaDent Safety and Quality Award Recipient Innova&on in Pa&ent Safety and Quality at the Na&onal Level Target hospitalists at sites QI effector arm Mentor conference calls with QI team Mentor experienced physician with QI expertise #7: It works! 15
BOOST Program Introductory Webinar Establish BOOST Teams Process Mapping and Ac2on Plans Kick- off Session Mentored Implementa2on Conference calls Site visits Periodic Webinars Web- Based BOOST Collabora2ve E- community Toolkit Progress Repor2ng Tangible Deliverables Reunion Mee2ng Case Study Presenta2ons A Hospital Nurse Project BOOST brings me back to what I thought nursing was really about. BOOST helps pa2ents and families understand what they need to do to go home. This is why I went into nursing. 16
BOOST@hospitalmedicine.org www.hospitalmedicine.org/boost 17