Project RED

Re-Engineered Discharge

Re-Engineering Discharge
The goal of this performance improvement (PI)
project is to improve our discharge program
Project RED:
Is patient centered
Prepares patients to care for themselves at
home
Decreases readmissions and visits to the
emergency department

Presentation Outline

Impetus for project

Strategic priorities
PI structure
Project RED components
Role clarification
Process

Perfect Storm" of Patient Safety

39.5 million hospital discharges per year
$329.2 billion in total annual costs
Hospital discharge is not standardized and is marked with
poor quality
- Loose ends
- Poor communication
- Poor quality information
- Poor preparation
- Fragmentation
- Great variability
19 percent of patients have a post-discharge adverse event
20 percent of Medicare patients are readmitted within 30 days;
only half had a visit in the 30 days after discharge

More than Just Patient Safety

"Hospitals with high rates of readmission will be paid

less if patients are readmitted to the hospital within the

same 30-day period, saving $26 billion over 10 years."
-- Obama Administration Budget Document
MedPAC recommends reducing payments to hospitals
with high readmission rates.
-- MEDPAC Testimony before Congress March 09
CMS: 14 Quality Improvement Organizations Safe
Transitions demonstration projects
CMS to release new payment scheme

Common Reasons for Avoidable

Readmission -- Not DiagnosisSpecific
Poor discharge instructions

Patient doesnt understand how to use

medications
Patient doesnt learn warning signs for when
to report to their physician
Poor information transfer
From hospital to primary care physician
(PCP)
From hospital to nursing home staff
Lack of clarity on end-of-life care preferences

Common Reasons for

Avoidable Readmission
Lack of timely post-discharge physician visit
Physician unaware of hospitalization
Patient has no PCP
Patient lacks transportation
Poor medication reconciliation yields duplication

or interaction

Diagnosis-Specific Reasons for

Avoidable Readmissions
COPD, pneumonia

Patients not getting home health benefits

Pneumonia readmissions may reflect need
for end-of-life care
Cardiac care
Cardiologists not arranging followup for heart
failure patients
Readmissions higher for heart failure patients
with behavioral problems

Diagnosis-Specific Reasons for

Avoidable Readmissions
Post surgery

Surgeons not arranging for post-surgical

primary care
Post-CABG patients, expecting to be pain
free, seek readmission for angina
Inadequate patient teaching on self care after
surgery (e.g., incision care)
Dialysis patients very vulnerable to drug therapy
changes

Strategic Priorities
Improve patient outcomes and satisfaction
Improve cost and revenue management
Improve patient satisfaction scores
Prepare for changes to CMS reimbursement
penalties for high readmission rates
Improve nurse and provider time utilization
Enhance portability of personal health information
across care continuum
Improve relationship with PCPs

Specific Project Objectives

Enter your specific objectives here
Improve patient satisfaction with discharge

preparation by ## percent
Improve staff satisfaction with discharge
process by ## percent
Reduce readmissions by ## percent
Reduce post-discharge visits to the ED

Project Steering Committee

Vision
Mandate improvement
Identify champions
Receive and review updates

Project Steering Committee

List team members
Designate project team leader, executive

sponsor, and physician champion

Targeted Patient Population

To pilot Project RED, we have identified

the following target patient population:

Provide diagnosis, unit, etc.

Baseline readmission rate =

Average length of stay =
Add stats from patient phone survey, if

available

Identifying Targeted Patients

on Admission
How will you first identify that a newly admitted

patient is in the targeted population for this

project?
How will the Discharge Advocate (DA) be notified
that a potential patient for Project RED has been
admitted?
What secondary screening criteria for patient
inclusion will the DA use to confirm the use of the
Project RED intervention with the patient?
How will the DA track activities with new patients?

Discharge Planning

H&P
Rx Plan
Patient
Admission

Discharge
Order
Written

Discharge Process

PATIENT EDUCATION

Discharge
Event

DISCHARGE INSTRUCTIONS
Post-D/C
Follow-up

Project RED Principles

Re-Engineered Discharge
Principles
Explicit delineation of roles and responsibilities
Discharge process initiation upon admission
Patient education throughout hospitalization
Timely accurate information flow:
From PCP Among hospital team Back to
PCP
5. Complete patient discharge summary prior to
discharge
1.
2.
3.
4.

Re-Engineered Discharge
Principles
6. Comprehensive written discharge plan
7.
8.
9.
10.

provided to patient prior to discharge

Discharge information in patients language
and literacy level
Reinforcement of plan with patient after
discharge
Availability of case management staff outside
of limited daytime hours
Continuous quality improvement of discharge
processes

RED Checklist
11 mutually reinforcing components:
1. Medication reconciliation
2. Reconcile discharge plan with national guidelines
3. Followup appointments
4. Outstanding tests
Adopted by
5. Post-discharge services
National Quality Forum
6. Written discharge plan
as one of 30 U.S.
7. What to do if problem arises
"Safe Practices"
8. Patient education
9. Assess patient understanding
10. Discharge summary sent to PCP
11. Telephone reinforcement

Keys to the Project RED

Intervention
DA
Related multidisciplinary activities

Care plan for patient use after discharge

Post-discharge followup with patient

Discharge Advocate
Coordinates all discharge activities within patient

population
Facilitates team activities and discharge planning rounds
with primary doctor
Collects discharge-focused data
Ensures Patient Care Plan is completed and patient
understands the information and can comply with the
instructions in the plan

Discharge Advocate
Is notified when patients in the target population

are admitted or diagnosed

Initiates action steps associated with Project RED
Initiates the Patient Care Plan
Educates patient and family about condition,
medications, treatments, post-discharge plans,
and followup ordered by the physician
Reviews Patient Care Plan with patient and family
Collects measurement data on project and patient
population

Discharge Advocate
Project REDs 11 components let the

DA:

Prepare patients for hospital discharge

Help patients safely transition from hospital to

home
Promote patient self-health management
Support patients after discharge through followup phone call

Staff Member Roles

Patients physician and medical team
Nursing staff
Case management
Pharmacists

Patients Physician
Initiates patient plan of care based on critical

pathway
Leads or participates in discharge planning
rounds
Communicates potential discharge date
Supports the PI process

Nursing Staff
Provide nursing care
Educate patient and family
Communicate with each other
Communicate with other members of the health
care team, including DA
Participate in multidisciplinary rounds, including
those focused on discharge planning

Pharmacist
Verifies physician orders
Reconciles admission medications with

medications from home

Collaborates with care team specific to
discharge needs
Reconciles medications upon discharge
Assists with patient medication questions

Case Managers
Arrange post-discharge services
Educate the patient
Perform social work duties
Perform utilization review

Other Key Staff

Therapists
Disease management

Discharge Planning Rounds

Consider daily discharge rounds
Medical staff, nursing staff, pharmacy, case

management, and DA

When is discharge order written?

Was it expected?
Weekend discharge?
Is there a timing expectation (e.g., time

from when the order is written to when the

patient is out the door)?

Patient Care Plan

Date of discharge
Name and contact information for physician and DA
Medications
Pending tests and results
Follow-up appointments
Calendar
Other orders (diet, activity, etc.)
Information about disease or condition
When to call physician or seek emergency care
Form for writing down questions
Map for locating appointments (optional)
Other information about your center (optional)

Patient Care Plan

Accessing the template

Accessing information
Saving
Printing
Storing
Will completed Patient Care Plan become part of the

patient record?

Complete the Patient

Care Plan
Medication reconciliation
Pending tests and results
Post-discharge services
Primary care provider
Follow-up appointments
Information about condition

Medication Reconciliation
Hospital procedure for completing

medication reconciliation at discharge

DA participates and conducts final
check on medications
DA populates Patient Care Plan (e.g.,
medication purpose, time of day
taken)
DA uses final list to teach the patient

Pending Tests and Results

Obtains information about tests and

studies completed and still-pending

results
Adds pending test results to the
designated spot on the Patient Care Plan,
including which clinician is responsible for
getting final results
Points out where the information is on the
Patient Care Plan
Encourages patient to discuss tests with
PCP

Post-Discharge Services
Confirms with case manager that all

services have been arranged

Adds names and contact information
of service providers to Patient Care
Plan

Primary Care Provider

Confirms name of PCP with patient
Adds name and contact number of

PCP to Patient Care Plan

Follow-up Appointments
Discusses best days of week and times of

day with patient

Discusses transportation needs
Calls clinicians offices to make
appointments that meet patients time
options
For off-hour or weekend discharges,
leaves message with clinicians office to
call patient
Adds appointments to Patient Care Plan

Information About Condition

Obtains information about the patients

condition to add to Patient Care Plan

Includes

Signs and symptoms that warrant followup

with clinician
Signs and symptoms that warrant
emergency care
Contact information for the DA and PCP
(phone numbers, paging instructions)

Post-Discharge Activities
Transmits discharge summary and

Patient Care Plan to PCP

By fax: Ensures it is received and legible

By e-mail: Ensures it is received

Makes follow-up phone call to patient

Uses script that includes medications and

follow-up appointments
Determines need for second call by clinician

Communication and
Coordination
Hospital discharge process is often characterized

by poor communication and a lack of

coordination between the hospital and the PCP
Patients often do not know what medications
their physicians prescribed, when follow-up
appointments should take place, and, in some
cases, why they were hospitalized

Primary Care Physician

Referral Base
Leaders identify the PCP referral

base
Hospital assesses PCP satisfaction
before project launch
Physician champion communicates
with PCPs about project
PCPs advise how to handle off-shift
and weekend patient needs

Post-Discharge Phone Call

Decide who calls the patient after discharge
Decide when the follow-up call will be made
Develop the callers script
Develop the process for off-shift and weekend

discharges

Process Measurement
Measure the project to determine impact
Outcome measures
Process measures
Resource investment

Results will determine if Project RED will be

used in other areas of the hospital

Process Metrics

Average time to notify DA about new admission

Average time from admission to first patient visit by DA (initiation of
care plan) only for patients who meet all criteria
Percent of patients PCPs notified within 24 hours discharge
Percent of follow-up phone calls made within 48 hours
Percent of follow-up calls requiring second call by pharmacist (if nonpharmacist makes first call)
Percent of patients completing post-discharge survey (30 days after
discharge)

Process Metrics

Completion of care plan details

Percent of care plans with medication list included
Percent of care plans with care needs included (e.g., exercise,
diet, main problem, when to call doctor)
Percent of care plans with follow-up appointments listed
Percent of care plans with pre-arranged discharge resources
identified (e.g., home health, durable medical equipment)
Percent of care plans with pending tests listed

Outcome Metrics for

Target Population
Average length of stay (LOS)
30-day unplanned readmission rate
Cost of second LOS (readmission)
Pre/post data: Patient experience related to

discharge preparation
Pre/post data: Frontline staff survey related
to discharge preparation
Project costs
Discharge process costs (current and
redesigned)

Project Launch
Expected start date
Targeted population or unit
DAs name and contact information
Project leaders name and contact

information
Physician champions name and contact
information

Questions