Testing the ReEngineered Discharge

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Testing the Re-Engineered Discharge
Hands-On Health Literacy September 9, 2008
Principal Investigator Brian Jack MD Associate
Professor and Vice Chair Department of Family
Medicine Boston Medical Center / Boston
University School of Medicine
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Perfect Stormof Patient Safety
Loose Ends - workups NOT completed Communication
- DC summary not available Poor Quality Info -
DC summary lack results Poor Preparation - few
pts know meds/dx Fragmentation - who is in
charge?
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Principles of the REDCreating the Toolkit
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RED Checklist

• Eleven mutually reinforcing
  components
• ? Medication Reconciliation
• ? Reconcile Plan with National Guidelines
• ? Follow-up Appointments
• ? Outstanding Tests and Studies
• ? Post-discharge Services
• ? Written discharge plan
• ? What to do if a problem arises
• ? Patient Education
• ? Assess patient understanding
• ? Dc summary to PCP
• Telephone Reinforcement

Adopted by National Quality Forum as one of 30
"Safe Practices" (SP-11)
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Intervention to Administer RED

• In Hospital - Discharge Advocate (DA)
• Nurse
• Interact with care team med rec and guidelines
• Prepare the After Hospital Discharge Plan (AHCP)
• Teach the AHCP
• After Discharge Clinical Pharmacist
• Follow-up call _at_ 2-3 days
• The DA and Pharm manual
• Scripts for each task

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Testing the RED Schematic
RED Intervention
30 day Outcome Data Telephone Call Chart Review
Enrollment N750
Randomization
Usual Care
Informed Consent
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AHCP Evaluation30 days post-discharge
How useful was the booklet to you?
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39
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AHCP Evaluation30 days post-discharge
What was the most helpful part of the booklet?
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25
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AHCP Evaluation30 days post-discharge
How helpful was the RED medication calendar?
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9
26
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45
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Self-PerceivedReadiness for Discharge 30 days
post-discharge
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Primary Outcome
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Cumulative Hazard of Patients Experiencing an
Hospital Utilization in 30d After Index Discharge
---- RED ---- Usual Care Chi-square p0.005
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Conclusions from the RCT

• RED
• Successfully delivered using
• RED protocols
• AHCP
• Improves Readiness for Discharge
• Decreases hospital use
• 32 reduction
• NNT 7.9
• Helps high hospital utilizers
• 40 reduction
• Is Cost-Effective
• 329 / patient
• 38 million discharges _at_ 753 billion x 32
  eligible 4 billion

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Major Problem RN TimeCan Health IT Help?

• Embodied Conversational Agent
• Teaches the AHCP
• Emulates face to face communication
• Develops therapeutic alliance
• Empathy
• Gaze, posture, gesture
• Competency Questions
• Can drill down in med education
• Maps of test sites and CHCs
• Instructions e.g., Lovenox, Glucometer
• Workstation database
• Connects to hospital IT
• Prints AHCP
• Feeds Louise
• Concordancy Studies
• Kiosk for patient access

Louise
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Social Chat
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Cover
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Medications
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Appointments
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Diagnosis
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Closing
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Thank You AHRQ!

• PI Brian Jack, MD
• Michael Paasche-Orlow MD, MPH
• Caroline Hesko, MPH
• Irina Kushnir
• Fiana Gershengorina
• Kim Visconti, RN
• Jared Kutzin, RN, MPH
• Alison Simas, RN
• Mary Goodwin, RN
• Lynn Schipelliti, RN
• Lindsey Hollister
• Maggie Jack
• Kacie Fyrberg, RN
• Vimal Jhaveri
• Laura Pfeifer

• Juan Fernandez
• David Anthony, MD, MSc
• Tim Bickmore PhD
• Gail Burniske, PharmD
• Kevin Casey, MPH
• VK Chetty, PhD
• Allyson Correia, RN
• Larry Culpepper, MD, MPH
• Shaula Forsythe, MPH, MS
• Rob Friedman, MD
• Jeffrey Greenwald, MD
• Anna Johnson
• Anand Kartha, MD
• Christopher Manasseh, MD
• Julie ODonnell