Critical Path Network: Study shows readmissions drop when patients understand discharge instructions
May 1, 2009
Critical Path Network
Study shows readmissions drop when patients understand discharge instructions
Study demonstrates value of transitions in care
Patients who have a clear understanding of their after-hospital care instructions are 30% less likely to be readmitted or visit the emergency department (ED) than patients who don't have that knowledge, according to a study at Boston University Medical Center.
The results of the study have implications for the quality of care and costs for the more than 38 million hospital discharges each year, says Brian W. Jack, MD, who led the study conducted by a research team at the medical center's department of family medicine.
"About 20% of patients have an adverse event within 30 days after discharge from the hospital, and some of these events lead to preventable emergency department visits or readmissions. Our study showed that preparing people for what they need to do when they leave the hospital has a tremendous potential for improving the patients' recovery and saving health care dollars," he explains.
The hospital discharge process requires communication among the inpatient care team, the patient's primary care provider, the patient and his or her family, and community services, Jack reports.
Patients often leave the hospital without fully understanding their follow-up care, such as how to take their medication or when to see their physician for a follow-up examination or testing, he says.
The problem is compounded when hospitalists care for patients in the hospital and the primary care provider is not fully informed of what happened during the hospital stay or, in some cases, that the patient has even been hospitalized, Jack adds.
"Now that more and more hospitalists are following patients while they are in the hospital, there are more gaps in transitions of care. There rarely is any direct communication between the hospital and the ongoing provider; and research has shown that in a third of the cases, the primary care physician had not received a discharge summary when patients made their first follow-up visit," he reports.
As a result, patients often do not receive recommended tests after hospitalization or, if the tests are done in the hospital and the results aren't back before the patient is discharged, no one follows up on the results, Jack adds.
Re-Engineered Hospital Discharge Program
Boston University Medical Center's research team developed a Re-Engineered Hospital Discharge Program (RED) over a five-year period with grants from the Agency for Health Research and Quality (AHRQ) and the National Heart, Lung, and Blood Institute.
The multifaceted program is designed to educate patients about their post-discharge care plans, ensure that patients receive the recommended follow-up care, and increase communication between the hospital and the patients' primary care physicians.
The team started by identifying the steps in the discharge process, determining where the process breaks down, and then developed a discharge checklist that details what should be completed to ensure that the patient can be safe at home. (For details of the checklist, see the chart.)
With the help of graphic artists and health literacy experts, the team developed a six-page spiral-bound color booklet called the "After Hospital Care Plan" that contains individual information for each patient, depending on his or her condition, medication, and discharge instructions.
The booklet includes the reason for hospitalizations; photographs of the patient's doctor and nurses; an illustrated description of the discharge diagnosis and information about what to do if a problem arises or the patient's condition changes; a list of their medications and a color-coded schedule for taking them; a list of tests with pending results at discharge; a list of follow-up appointments with directions for getting there; and a calendar of what the patient should do for the next 30 days.
The study participants were 749 hospital inpatients who were being discharged to the community. Patients who were admitted from a skilled nursing facility or another hospital or were admitted for a planned hospitalization were not included. About half of the participants received the RED checklist while the remainder were discharged in the typical manner.
During the initial study, RNs called "discharge advocates" were assigned to coordinate the discharge for patients in the intervention group. They worked with the treatment team to develop the discharge plan and educated the patients to prepare them for discharge. They arranged follow-up appointments, ensured that the patients understood their medication regimen, and conducted patient education using the individualized instruction booklet. The discharge advocates spent approximately 30 to 60 minutes speaking with each patient throughout his or her hospital stay.
On the day of discharge, a research assistant faxed the discharge summary and the After Hospital Care Plan to the patient's primary care physician.
A clinical pharmacist called patients after discharge to review medications and reinforce the discharge plan.
The study found that total costs (a combination of actual hospitalization costs and estimated outpatient costs) were an average of $412 lower for patients who received the complete intervention than for those who did not.
The 370 patients who received the RED process had 30% fewer subsequent ED visits and readmissions than the 368 patients who did not.
About 94% of patients who participated in the RED program left the hospital with a follow-up appointment with their primary care physician, compared to 35% of patients in the control group.
The pharmacist who contacted the patients after discharge found that 65% of them had at least one medication problem and 53% needed corrective action, such as the pharmacist contacting the subject's primary care physician.
The team is currently conducting a study with patients who receive individually tailored discharge instructions at their own pace from a virtual discharge advocate, or "Louise," an animated character who simulates face-to-face interaction between a patient and a nurse and runs on a touch-screen display mounted on an articulated arm attached to a mobile cart.
The patients receive the same individualized After Hospital Care Plan booklet, but the teaching is done by the virtual discharge advocate, which educates patients about their post-discharge self-care plans. The educational sessions include information on diagnoses, medications, follow-up appointments, special diets, and exercise regimens.
"Nurses are busy, and we couldn't ask the nurses to spend the time that is needed on discharge education. We are testing a health information technology system to determine if it works as well as a having a nurse teach a care plan," Jack says.
Patients like the virtual discharge advocate because they can go at their own pace and come back to areas they don't understand, he says. In a pilot study, 74% of patients said they preferred receiving the discharge instructions from the virtual discharge advocate.
After completing the discharge instructions from the virtual nurse, the patients take a test that determines how well they understand their post-hospitalization care plan. The floor nurse prints the test results and can go in and reinforce the teaching, if necessary, Jack says.
(For more information, contact: Brian W. Jack, MD, Boston University Medical Center Department of Family Medicine, e-mail: [email protected].)
Patients who have a clear understanding of their after-hospital care instructions are 30% less likely to be readmitted or visit the emergency department (ED) than patients who don't have that knowledge, according to a study at Boston University Medical Center.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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