Project BOOST's evolution has led to DP changes
Hospitals form teams, change processes
Hospitals and health care professionals want to provide patients with safe, effective, quality discharges but often lack the resources necessary to make this process optimal.
The Philadelphia-based Society of Hospital Medicine's Project BOOST, which stands for Better Outcomes for Older adults through Safe Transitions, is one national effort that seeks to remove all barriers to better discharge planning and transitions for adults.
When the project began, the society rounded up experts to discuss best practices in the discharge process, says Tina Budnitz, MPH, senior advisor of the Society of Hospital Medicine (SHM) and director for Project BOOST.
"We found our members really need the tools to change their system," Budnitz says.
SHM's initial project, called "Safe Steps," was intended to improve discharge safety, partly through the development of a comprehensive risk assessment.
"Our findings from Safe Steps were there were a lot of systems out there that were, in fact, broken in terms of a smooth discharge process," Budnitz says.
Comprehensive planning about the discharge process was started on admission, and Safe Steps focused on putting together a comprehensive team of all people who contact the patient, including pharmacists, nurses, case managers, physicians, etc., she explains.
"Doing a comprehensive risk assessment at the time of admission helped get the patient ready for discharge," she adds. "It really helps get them ready in terms of allowing complete staff to have time to work with the patient to understand self-care instructions, reconcile medications before they leave the hospital, and spend time with family members/caregivers before they go."
One byproduct of Safe Steps was an overall improvement in patient care, Budnitz notes.
Safe Steps had focused on adults ages 65 and older, but this mandate soon proved to be a barrier.
"We learned it would be more efficient to roll out an intervention for all patients," Budnitz says. "If you can solve a problem for your frailest patients, then you probably can solve it for all your patients."
So SHM officials discussed this with the Hartford Foundation, and the foundation granted SHM $1.5 million to evolve the intervention and roll it out on a grander scale for all adult patients, she adds.
"It became Project BOOST," Budnitz explains. "If you solve the issue for your frailest patients, you solve it for all of them, so in all of our hospitals the target is the general adult population."
Project BOOST was founded with a multidisciplinary team of advisors, including health care leaders, insurance companies, and accreditation, nursing, case worker, and pharmacy organizations.
"We brought them all to the table and said, 'Tell us the best elements of what you have to offer, and can we come up with something that has all the best elements?'" Budnitz says.
Two goals were met:
"One, we wanted to come up with a clinical intervention and create a toolkit to help people implement that intervention," Budnitz says. "That was a platform on which to layer on many other interventions."
Secondly, Project BOOST focused on a system-change intervention.
"Project BOOST has a comprehensive implementation guide with project-planning tools and form letters," Budnitz says.
The tools include a form letter discharge planning advocates can send to their hospital administrators, saying, "This is why we should participate in this project," she adds.
There also is a worksheet for the team, assisting members in narrowing down their goals into specific objectives, worksheets for meetings, data collection tools, sample project timeline, and others, Budnitz says.
"We included all the things you could create and do on your own, but we're giving you a huge leg-up and jump start," she explains. "The feedback we received was that people couldn't have gotten started on the project for two years without the tools."
The tools came from the literature, as well as some that were brought to the table by the project's advisory board, Budnitz says.
The advisory board painstakingly went through every form and critiqued them, helping with improvements and overseeing the forms being piloted at a few sites, she adds.
"Some of the feedback we received initially from the toolkit was, 'This is fabulous, but we're still overwhelmed,'" Budnitz says. "They said they could use someone to provide mentoring."
So Project BOOST formed a mentoring program, bringing participants together for a two-day training session, walking them through the toolkit, talking about the project's rationale, and discussing how to adapt tools to their particular institutions, she explains.
"We do a lot of work-around teamwork and discuss how it is they can function better as a team," Budnitz says. "They meet with a mentor and then get started on an action plan, identifying major milestones over the course of a year and what needs to be done in month one."
Participating sites meet with mentors by telephone every two months. They also share a listserv in which participants can have private conversations with each other about challenges in changing their discharge processes.
"The other thing we offer to our mentoring sites is we have a Web-based community area for them to share across sites," Budnitz says. "One site may say, 'I've developed a script for a 72-hour call,' and they'll post their script."
Each quarter, there's an all-site conference call for which sites can submit topics in advance.
Project BOOST has participating sites collect data for their own quality improvement or publication purposes, as well as for the project to collect aggregate information.
The data collection includes this information:
What are the 30-day readmission rates?
What are patient satisfaction scores?
Did someone send data to the receiving physicians?
How did communication and teach-back with patients/families go?
How often are patients getting a discharge appointment that's comprehensive and focused to their particular risk level?
What's happening in 72-hour follow-up calls post-discharge?
Were adverse events prevented and how?
"We encourage sites to share data as widely as possible, and some will do that in peer review journals, and others will do it in less formal mechanisms, like a local paper or societal newsletter," Budnitz says.
Project BOOST is still collecting aggregate data but will publish results when the first year's data are complete, she adds.
"We've interviewed all six sites and are conducting periodic interviews to see how the system change is working," Budnitz says.
"There are two outcomes we're going for," she adds. "One is that ultimately we want to improve patient outcomes, and the other thing is to build capacity at every site and have teams that could be front-line army for all patient issues."
The project appears to be a success, Budnitz notes.
"We're seeing changes in patient satisfaction, and, anecdotally, we've seen places where we've averted adverse outcomes in discharge," she says. "We do have data from comprehensive interviews from the first six sites, and our intention is to write that up for a journal."
Also, additional hospitals have contacted Project BOOST about becoming participants in the third cohort. Although the project's initial funding is scheduled to conclude in the spring of 2010, Budnitz says the project will continue and a third cohort will be initiated next year.
Hospitals and health care professionals want to provide patients with safe, effective, quality discharges but often lack the resources necessary to make this process optimal.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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