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Project REDRe-Engineered Discharge
Our Journey to ImplementationTift Regional Medical Center
Mindy McStott, RN, CCM
June 22, 2011
Objectives
Identify why reducing re-admission is important and why now.
Describe various models for reducing re-admissions.
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.
A Story to Break the Ice
Tift Regional Medical Center
VEGAS
TIFTON
Tift Regional Medical Center
Tift Regional Medical Center
Hospital Community based regional hospital governed by Hospital
Authority
Serves 12 surrounding counties in a combined service area population of approximately 250,400
191 Licensed Beds 176 acute care
15 skilled nursing
Average Occupancy - 74.15% (YTD 2011)
FY 2010 Volumes (YTD 2011 volumes tracking up 110%)
12,244 Total Patients Admitted 1,090 Deliveries
316 Transitional Care (Skilled Nursing)
48,833 ER visits
110,412 Referred Outpatient Visits
7,595 Surgical Cases
Tift Regional Medical Center
Other Services Hospice
Dialysis
Oncology Center
Industrial Health
Palliative Care
Physician Practices Rural Health Center
Indigent Care Clinic
Staff 120 physicians on staff representing 15 specialties
1,558 employees (largest employer in Tift County)
Tift Regional Medical Center
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
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
Decision to Participate
FY 2011 Administrative Goal: focus on re-admissions
Identify diagnosis at risk for readmission and root causes for re-admissions
Monitor CMS regulations
Evaluate programs available to reduce re-admissions
Decision to Participate
FY 2011 administrative goal to focus on
re-admissions
Identify diagnosis at risk for readmission
and root causes for re-admissions
Monitor CMS regulations
Evaluate programs available to reduce re-
admissions
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
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
Common Reasons for Avoidable
Re-admissions (DIAGNOSIS RELATED)
COPD / Pneumonia Patients not receiving home health care
End of life issues
Cardiac Care Lack of follow-up with cardiologist for CHF
CHF patients with behavioral problems
Post surgery Surgeons not arranging post surgery PCP visit
Inadequate teaching for post surgical care
Post CABG patients seeking re-admit for angina
Dialysis patients with medication issues
Decision to Participate
TRMC Top Re-admission Diagnosis
Respiratory – COPD / Pneumonia
Diabetes*
Cardiac – Chest pain / CHF*
*We found a few patients with multiple re-admissions can drive up rate.
Decision to Participate
FY 2011 administrative goal to focus on
re-admissions
Identify diagnosis at risk for readmission
and root causes for re-admissions
Monitor CMS regulations
Evaluate programs available to reduce re-
admissions
CMS Regulations
CMS reduction in payment for re-
admissions
Starts with discharges on or after October 1,
2012
Starts with a 1% reduction in payment and
raises each year thereafter
Starts with AMI, CHF, and PN diagnosis
Decision to Participate
FY 2011 administrative goal to focus on
re-admissions
Identify diagnosis at risk for readmission
and root causes for re-admissions
Monitor CMS regulations
Evaluate programs available to reduce re-
admissions
BOOST
“Better Outcomes for Older adults through Safe Transitions (Dr. Mark Williams, et al)
Started in 2008 by Society for Hospital Medicine in California to address 30% of patients being readmitted within 1 year
Initial focus: Improve D/C planning through Value Stream Mapping
Key Elements: Risk & Gap Assessments
D/C Education from Nursing and PCP
Transitional planning and education
Teach Back method
Direct communication with OP PCP at discharge
Telephone contact within 72 hours
Provide tool kit and other resources
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
Care Transitions
Care Transitions Intervention Model (Eric Coleman & University of Colorado Health & Sciences Center)
Trialed in 2002 – 2003 in Colorado with Medicare patients
Premise: patients are at risk for quality and safety issues during transition from one care setting to another
Encourages patient accountability
Elements Medication self management
Patient centered record
Follow-up – patient arranges follow up / help from Transition Coach who makes home visits
Red Flags
Transitional Care
Transitional Care Model (Mary Nalor, RN, and University of Pennsylvania)
Premise: Transitional Care Nurse (TCN) coordinates care across the continuum
Holistic approach to care for high-risk adults with two or more risk factors
Elements: Includes 10 key elements centered around multidisciplinary
collaboration
Protocols include: TCN visit in hospital
TCN visit at home
TCN visit with patient to first PCP visit
TCN accessible 24/7 x 2 months, then transitions
TCN recommended to be Advanced Practice Nurse
VHA Georgia – Reducing
Readmissions Collaborative (R2C2)
Uses a combination of approaches from the various models
Allows using what you need (simple or complex)
Provides practical application which addresses quality of care as well as financial considerations
Addresses 5 key elements Admission Assessment
Hand off Communication
Discharge Planning
Patient / Family Education
Connections with Community Resources
Decision to Participate
TRMC Re-admission concerns
Readmission Rate
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
Jan-
10
Feb Mar Apr May June July Aug Sept Oct Nov
TRMC Re-admission Data
Hospital Compare – Re-admission Data
TRMC National Rate
AMINo Different than U.S.
National Rate (18.4%)19.8%
CHFNo Different than U.S.
National Rate (23.8%)24.8%
PNNo Different than U.S.
National Rate (18.2%)18.4%
Additional Pressures
Overall dissatisfaction with discharge process
Physicians (scale 1 – 5)
Hospital discharge process is effective = 3.0
Hospital sends discharge information = 2.5
Staff (scale 1 – 5)
D/C is organized & efficient = 3.21
D/C is effective in preparing patients = 3.25
Patients
Given information about what to do at home = 53rd
percentile
Additional Pressures
P4P + HCAHPS =
Additional Pressures
TRMC Value Base Purchasing score
calculations
Process Measures Score 91%
HCAHPS Score 28%
Overall VBP Score 72%
Payment Percentage 93%
The RED Decision
From: Melinda McStottSent: Sunday, April 11, 2010 5:50 PMTo: Nancy CarrierSubject: FW: Project RED (Re-engineering Discharges) - April Web ConferenceI don’t know if I shared this one. Joint Commission support might be good with our project for next year. Think about it.
Mindy McStott, RN, CCM
Director Quality / Case Management
From: Teresa McGuire Sent: Wednesday, April 07, 2010 2:29 PMTo: Melinda McStott; Diane PatrickSubject: FW: Project RED (Re-engineering Discharges) - April Web Conference
fyi
Teresa McGuire,
Please see the following information regarding Project RED.
= = = = = = = = = = = = = = = = =
5 CSR HOSPITAL COMPASS NEWSLETTER March 2010 Save the Date for April Web Conference on Re-Engineering Hospital Discharges
JCR is working with the Agency for Healthcare Research and Quality (AHRQ), part of the U.S. Department of Health and Human Services, to implement various tools and products derived from research funded by the Agency. One of these tools is designed to help hospitals re-engineer their discharge processes to make care safer. The AHRQ-funded project, known as Project RED, was developed and implemented at Boston Medical Center by Dr. Brian Jack.
Project RED is designed to re-engineer the hospital discharge process and improve patient safety by following 11 steps that have been shown to decrease hospital readmissions by 30 percent.
JCR is currently recruiting hospitals to participate in this project. No participation fee will be assessed. JCR will hold a Web conference in early April to provide additional information about Project RED and to explain how your organization can take advantage of this opportunity to improve your discharge process and lower preventable readmission rates.
If you would like more information in advance of the Web conference on how you can participate in this project, please contact Debbie Nadzam at [email protected] or 630-261-5048.
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.
The RED Decision
Joint Commission and AHRQ support
Structured
Training Modules
Timelines / Guidelines
Enough flexibility to allow us to
determine population of focus
Could focus on improving satisfaction
with discharge process
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
Project RED Team
Project RED
Re-Engineering Patient Discharge
Team Participant Education
Re-Engineering Discharge
The goal of this performance improvement (PI)
project is to improve our discharge program
Patient centered
Patient better prepared to care for self at
home
Decrease readmissions and visit to the
emergency department
Let’s Review the Principles
of Project RED . . .
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
Principles of the Newly
Re-Engineered Hospital 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
Principles of the Newly
Re-Engineered Hospital Discharge
(continued)
RED ChecklistEleven mutually reinforcing components:
1. Medication reconciliation
2. Reconcile discharge plan with national guidelines
3. Follow-up 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 US
"Safe Practices" (SP-15)
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
Discharge Advocate (Coordinator @ 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
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
Discharge Coordinator
11 RED Components Enable advocates to:
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
Roles of Staff Members
Patient’s physician and medical team
Nursing staff
Case management
Pharmacists
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
Nursing Staff
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
Care/Rx Education
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
Case Managers
Post-discharge
services
Social work
Utilization review
Financial support
Care/Rx Education
Other Key Staff
Therapists
Disease management
Care/Rx Education
Sections of the Care Plan
Date of discharge; name and contact info for physician and Discharge Coordinator
Medications
Pending tests and results
Follow-up appointments
Calendar
Other orders (diet, activity, etc.)
Information about disease/condition
When and how to reach physician or go to ED
Form for writing own questions down
Map of campus for locating appointments
Other information about your center (optional)
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?
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)
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
Complete the Patient Care Plan
Pending Tests/Results
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
Complete the Patient Care Plan
Post-Discharge Services
Confirm with case manager that all
services have been arranged
Add names of services and contact
information to care plan
Complete the Patient Care Plan
Primary Care Provider
Confirm name of PCP with patient
Add name and contact number of
PCP to care plan
Complete the Patient Care Plan
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.
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!
Information About Condition(s)
Secure pre-printed information about
patient’s condition to add to care plan
Add to care plan:
Signs and symptoms that warrant
follow-up with clinician
When to seek emergency care
How to contact the Discharge
Advocate and PCP (phone numbers;
paging instructions)
Complete the Patient Care Plan
Follow-up Appointments
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
Discharge Order Written
Post-Discharge Activities
Transmit DC summary and patient care plan
to PCP
Fax: be sure it is received and legible
Electronic: scan/email 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
The Post-Discharge Phone Call
Define who will call your
patient after discharge
Define when the follow-
up call will be made
Develop script for caller
Remember to develop
the process for off shifts
and weekends
TRMC Implementation
Getting from here to there . . . . .
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
Goals Established
Outcome Measures Improve satisfaction with discharge process
Patient
Physician
Staff
Reduce readmission rates (required by JCR)
Process Measures Complete discharge packet
Discharge turn around time
Patient follow-up calls within 48 hours
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
Strategies for Implementation
Training / Webinars
Team meeting two to three times / month
Conference calls every other week
JCR consultant
Communication education
Individual support
Strategies for Implementation
Identified timeline and
assignment of
responsibilities
Strategies for Implementation
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
Identified admission to discharge barriers
Process Map
Strategies for Implementation
Mapping the
current process
Strategies for Implementation
Detail Flow chart of individual responsibilities
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
Discharge Coordinator Forms
Post-Discharge Care Plan
Patient Education Tools
Follow-up Tools
•Follow-up phone call script
•Data collection spreadsheet
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.
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
Timeline
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
Strategic Goal Planning
May 2010
Review Options
June 2010
Team Planning
August 2010
Application to Participate
August 2010
D/C Coordinators Identified
Sept 2010
Base Team Meeting
Oct 2010
Training Completed
Nov 2010
Pilot x 1 month
Dec 2010
Go LIVE!
Jan 2011
Develop Tools
Oct – Dec 2010
GHA Presentation
March 2011
Planning Meeting to roll out to other units
June 2011
JCR Call for participants
April 2010
Thinking about Projects
Feb – Mar 2010
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”
Success from a physician perspective
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
Success –Patient Satisfaction Data (Med East)
Jan - Apr
Question RED ALL
Discharge Overall 87.4 81.3
Ready for D/C 88.9 80.6
Speed of D/C 80.8 75.7
Instruction for care at home 92.0 88.2
Success –Readmission Data (Med East)
Readmission Rate
Date MIE – RED MIE
Dec 10 8.97% 10.94%
Jan 11 11.85% 13.91%
Feb 11 10.88% 12.6%
Mar 11 15.44% 17.97%
Apr 11 11.32% 13.85%
Success –Patient Satisfaction Data (Med West)
Jan - Apr
Question RED ALL
Discharge Overall 87.8 86.3
Ready for D/C 91.9 88.8
Speed of D/C 80.4 81.2
Instruction for care at home 91.9 90.6
Success –Readmission Data (Med West)
Readmission Rate
Date West – RED West
Dec 10 14.55% 17.03%
Jan 11 10.60% 12.30%
Feb 11 11.63% 13.81%
Mar 11 11.39% 12.5%
Apr 11 8.56% 9.84%
Questionable Success –Average Total Time for D/C Process
0:00
0:28
0:57
1:26
1:55
2:24
2:52
3:21
3:50
Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11
Ho
urs
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
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
Next Steps
Further revision of tools to meet patient needs (still too much paper work)
Further work on discharge flow process to reduce the time it takes to discharge patients
Collaboration with ED
Develop discharge coordinator job description
New staff participant education Educate new MDs
Ongoing nursing staff education
Implement refined process to other units within hospital
