Reduce rehospitalizations with RED discharge plan
Three components to discharge intervention
Quality care doesn't end when a patient leaves the hospital. And with rehospitalization rates on the top of the list of concerns for the Centers for Medicare & Medicaid Services, managing the care of the patient after he or she is discharged from your facility is not a nicety, it's a necessity.
"This is really relevant now," says Brian Jack, MD, associate professor of family medicine, department of family medicine at Boston University Medical Center. He also is lead author of a study in the Annals of Internal Medicine — "A reengineered hospital discharge program to decrease hospitalization."1
"The Obama administration is saying that if we can cut down rehospitalization by 20% or 30%, we're going to save $14 billion... And our study shows you can decrease them by 30%," Jack says.
According to the study, the problems with discharge at present include lack of standardization with the discharge process, difficulty of ensuring patient data are transferred to the patient's primary care physician, discharge summaries lack crucial information, and patients often do not understand their medication instructions.
Citing the importance of follow-up care post-discharge, Jack says, "to send people out of the hospital when they're done with treatment or treatment hasn't even begun without a plan for ongoing care, I don't think that can be defended in any way. Nobody can say that's good care, but in fact that's what we do a large majority of the time."
The reengineered discharge (RED) intervention has three critical components: communication between the patient and the nurse discharge advocate (DA), use of an after-hospital care plan, and a follow-up phone call to patients from a hospital pharmacist to review medication use and to answer any questions.
Because it was a research study, Jack could not use the hospitals' nurses; DAs were hired. But he points out that this position can certainly be filled by existing hospital personnel and that no additional hires need be made. Ideally, he says the floor nurses would handle patient discharge, because they know the patient and his or her medications.
Jack says the discharge summary is key to the whole process of successful discharges. A recent study in the Journal of the American Medical Association, he says, showed that primary care physicians or the follow-up care provider had that summary less than half the time, maybe a third of the time upon the patient's first visit. And the summary often lacked crucial information.
In changing the terminology from discharge plan to after-hospital care plan, the study authors stressed what was essential to the program — making it patient-centered. Jack says many patients don't know what a discharge summary means, but an after-hospital care plan puts it in their language.
And this was a critical part of the intervention. Each patient was sent home with a "a booklet that is designed with health literacy in mind; with graphic design so that people who are older can read it." The booklets, which can be hung on patients' refrigerators, include color-coded calendars with follow-up appointment times. All follow-up appointments were scheduled by hospital staff before a patient left the hospital.
"I think a lot of our success," Jack says, "is that [patients] weren't just told about what to do; they were given this book and the book was taught to them. So it was very clear about what medicines were to be taken, why they need to take them, what to do if a problem arises, what appointments are coming up, and when those appointments are on the calendar. And it's designed so they understood it."
Staying clear of medical jargon in the after-hospital discharge plan is "a really, really important" piece of the process, Jack says. "We worked very hard at being sure that the words were words people could understand."
Using the teach-back method of education, the DA would ask a patient, for example, "Tell me when your cardiology appointment is." And the patient would have to articulate and answer the question addressed in his or her plan.
Also included in the booklet were maps showing how to get to the scheduled follow-up appointment and instructions if there were other appointments, such as a physical therapy session. Patients also were told if and when medical equipment was supposed to arrive.
Now what about the chronically ill and elderly? How much can one prevent rehospitalizations in this population with chronic illnesses and frequent exacerbations? "If 20% of elderly people get readmitted within 30 days, some percent of those are preventable. Is it 10%, 20%, 30%, or 50%? Our study shows it's 30%. Others have shown about that, too. So that's kind of the going number right now."
Components meet TJC requirements
If you follow the RED components, Jack says you will be following Joint Commission requirements. In fact, he says, you will be surpassing it. He says TJC's discharge requirements are actually "pretty vague." Project RED is a part of the National Quality Forum's safe practices of hospital discharge. "The Joint Commission was a follower of that, as well as Leapfrog Group, CMS, the Institute for Healthcare Improvement, all of those guys... Project RED is a level above what The Joint Commission requires. So if you do Project RED, then you certainly fulfill The Joint Commission requirements. No question about that," Jack says.
The financial impact
One element of the program he comes back to is the incremental cost associated with it. "I don't think you need a new cadre of health care workers to do this... There's a bill in Congress right now that's going to be passed that is a new benefit for Medicare beneficiaries that will provide for post-discharge transition coaching. Maybe that's a good thing, but it's going to be expensive," Jack says.
"But the fact is is that right now it's pretty intuitive and pretty straightforward and inexpensive and is nothing more than what everybody should get anyway, and to not do those things doesn't seem to make much sense. And the whole program doesn't cost money; it actually saves money. There's really not too many things that improve care and cost less. And this does."
Frankly, though, he says the current payment system incentivizes hospitals to fill up their beds and to discharge patients as quickly as possible. "That's the incentive. There is no incentive not to readmit them. And it won't be until the summer that there's going to be some beginning of legislation and payment reform about rehospitalization." But it is definitely coming, he says.
(Editor's note: For more information, visit http://www.bu.edu/fammed/projectred/index.html.)
Reference
- Jack BW, Chetty VK, Anthony D, et al. "A reengineered hospital discharge program to decrease rehospitalization: a randomized trial" Ann Intern Med. 2009 Feb 3;150(3):178-87.
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