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Re-engineering the discharge process to reduce readmissions

By Barbara Kirchheimer

It has long been acknowledged that unplanned re-hospitalizations cost the U.S. health care system billions of dollars each year. Researchers at Boston University Medical Center have been working on a project to reduce readmission rates by improving and standardizing the hospital discharge process. Thanks in part to the intersection of national policy with their clinical goals, the researchers’ work has begun to attract widespread interest.

The initiative, called Project Re-Engineered Discharge (RED), is still in a randomized control trial phase, but initial results show that using the RED protocol may significantly reduce readmission rates, says Brian Jack, MD, the project’s principal investigator. Jack is an associate professor and vice chair for academic affairs in the department of family medicine at Boston University School of Medicine and Boston Medical Center.

Project RED offers healthcare providers tools to help them create a unique “after hospital care plan” for each patient being discharged. The care plan and other elements of the re-engineered discharge enhance patient education, help reconcile medications, confirm appointments and make sure the patient's physician receives the discharge summary in a timely manner.

“Over the past five years, there’s been a significant amount of scientific reports documenting the transition from the hospital to the community being an area for medical errors and patient safety concern,” Jack says. “This is a big concern because there are so many discharges – 38 million per year.”

With grants from the Agency for Healthcare Research and Quality, Project RED’s developers began several years ago by establishing a set of key requirements for an optimal discharge, from which they put together a detailed checklist for healthcare staff to follow during the discharge process. A toolkit was created to help so-called “discharge advocates” create the care plan patients would use to help them navigate the challenging time between leaving the hospital and their first follow-up physician visit.

In 2009, Jack and his team published the results of a randomized trial of 750 patients, in which half received the after hospital care plan, taught by a nurse, and then received a call from a pharmacist two days after their discharge. Among the half that went through the re-engineered discharge, hospital utilization rates – defined as re-hospitalization plus emergency department visits within 30 days – were 30% lower.

According to a study in the April 2, 2009, New England Journal of Medicine, almost 20% of Medicare patients discharged from the hospital are re-hospitalized within 30 days, and 34% are re-hospitalized within 90 days. The estimated cost of unplanned re-hospitalizations to the Medicare program in 2004 was $17.4 billion, according to the study. Lowering the re-hospitalization rate by 30% or even a more modest but achievable 15%, therefore, may translate into billions of dollars saved each year, Jack says.

“Usually, improvements in care cost money, but this is actually something that saves money and improves care,” he says.

Efforts such as Project RED to reduce unnecessary re-hospitalizations have taken on a new sense of urgency because under healthcare reform, federal policymakers hope to align hospitals’ reimbursement incentives with broad quality goals. “Our research, based on my interest in improving care for whom it was a problem, has become a big deal because it’s colliding with policy issues,” Jack says.

“We have had hundreds and hundreds of hospitals contacting us (about Project RED),” Jack says. “AHRQ has given us another grant to put together a toolkit, a series of six documents on how to do a re-engineered discharge. They want us to assist six hospitals as beta sites, and we hope to learn a lot about implementing Project RED at those six sites. We’re taking our research and using it in other places to see how it works.”

Under the health care reform law signed into law by President Obama in March, a new Medicare readmissions policy will begin penalizing hospitals for potentially preventable readmissions in 2012. The new provision would reduce hospital payments based on the potentially preventable Medicare readmissions for three conditions endorsed by the National Quality Forum – acute myocardial infarction, heart failure and pneumonia – and for another four measures yet to be identified.

“Before, the incentive for hospitals was to admit everybody, send them home as quickly as possible, and readmit them as quickly as possible; that was the financial incentive,” Jack says. “Only now, when the financial mechanisms are changing for the payment for readmissions, are hospitals extremely interested in looking at evidence-based ways they can reduce their readmissions.”

The re-engineered discharge developed at Boston Medical Center includes a set of 11 components, each of which is broken down into detailed directives for discharge advocates on how to interact with patients as they are getting ready to leave. Among them are instructions about educating the patient, making follow-up appointments, discussing tests and follow-up results, confirming medication plans, organizing post-discharge services, expediting transmission of the discharge summary to patients' physicians, reviewing steps for what to do if a problem arises and asking patients to explain the plan in their own words to make sure they understand it. A follow-up phone call within two to three days provides reinforcement of the plan.

Under the RED model, each patient receives a personalized care plan, a spiral-bound, color booklet that outlines the information the patient will need between discharge and the first follow-up visit with an outpatient physician. The easy-to-read plan includes a list of medications and upcoming appointments and tests. It also includes a color-coded calendar noting appointments.

Hospital staff members receive tools to facilitate the Project RED intervention. A training manual and workbook describe in detail how to conduct an effective patient discharge. The workbook includes a script and instructions on how to arrange follow-up appointments. Creation of the after-care plan can also be automated with a dedicated discharge planning computer workstation that allows a nurse to enter the patient’s key data into a database and create a draft plan that can then be reviewed and refined as necessary before being given to the patient. The ultimate goal is to integrate the workstation into a hospital's electronic health record system.

In a second phase of the program, the Project RED team at Boston Medical Center has developed an animated computer character who can teach the after hospital care plan to patients. Dubbed “Louise,” the character is a “virtual discharge advocate” able to engage with patients about their self-care plans through a touch screen interface that can be brought to a patient’s bedside. For those who scoff at the idea that a computer generated character can take the place of an educated and empathetic doctor or nurse when it comes to answering a patient's difficult questions, it is worth noting that patients who have had the opportunity to “meet Louise” more often than not prefer her to a live human for discharge education.

“Louise does it with empathy and remembers what people tell her,” Jack says. “It’s very specific for that person, in terms of their medicine, their appointments, their physician, their pharmacy, and she does it with aplomb.”

Without Louise, the reengineered discharge takes about 81 minutes of a nurse’s time, according to Jack. With Louise doing the teaching, 30 minutes of that time is automated, which translates into a savings of about $145 per patient. Multiplied by 38 million discharges, that’s a massive potential savings to the health care system.

Louise simulates the face-to-face conversation a nurse would have with the patient. She uses synthetic speech and synchronized animation, and patients respond by touching what they want to say on the touch screen. Louise’s language is tailored to each patient’s medical data and the questions asked. As the patient reviews the paper copy of the after hospital care packet, Louise has a copy displayed on the computer screen. Both the paper plan and Louise’s language are tailored for patients with low levels of health literacy – a group that includes roughly 36% of adults, according to Jack.

Stefan Gravenstein, MD, MPH, the clinical director of Quality Partners of Rhode Island – the state’s quality improvement  organization – and a professor of medicine at Brown University’s Division of Geriatrics, says his organization is just beginning to implement Louise as part of a contract it won from Medicare to test ways to improve patient care transitions.

“What I like about Louise is that it provides a uniform, consistent way of communicating the exact same information to the patient and family members, the caregivers, and if you discover there's something about how you communicated that's mistaken or wrong, you can fix it,” he says.

“Louise doesn’t mince words," Gravenstein says. “The computer says it the way it is meant to be said. Louise is also different from people in that she has no impatience programmed in. As a physician, I can tell you that when clinicians go into the patient's room, some of us will already have one foot out the door before we even start talking, and patients know that.”

Such impatience might make patients hesitant to ask a question, he explains. “The social graces we think we need to have as patients are irrelevant to Louise. If you want to ask the same question five different times, you can do it.”

Louise's patience and empathy are evident in patient responses. When asked who they would rather receive discharge instructions from, 74% of patients who had conversed with Louise said they would prefer an automated agent, while 10% said they would prefer a nurse and 16% said either would be fine.

“Louise wins out over doctors, nurses and others,” Gravenstein says. “Patients like Louis, and they ordain Louise with human-like qualities.”

While Project RED is still being tested, the new government emphasis on aligning reimbursement patterns with quality goals has spurred hospitals around the country to focus on the discharge process, Jack says. Gravenstein says he is not cynical enough to believe that their interest is solely driven by financial concerns. He concedes, however, that “it helps to align the incentives with what you want people to do. There are a thousand things that hospitals and others have as priorities, and certainly if there’s a business case it helps.”

Editor’s note: Barbara Kirchheimer is a former news editor of Modern Healthcare. magazine and is now a freelance writer in the Chicago area

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