Transitions with a BOOST

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Transitions with a BOOST

• Matthew Schreiber MD
• Medical Director
• Piedmont Hospitalist Physicians

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Special Thanks

• Sixty Plus Older Adult Services
• Transitions Team
• Nancy Morrison
• Tim Young
• Dee Tucker
• Michelle Nelsonand many others
• Vandy Vail-Dickson Admin Director Hospitalists
• Society of Hospital Medicine
• BOOST Mentors
• Dr Mark Williams
• Arpana R. Vidyarthi

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www.hospitalmedicine.org/BOOST
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Project BOOST Team

• Mark Williams, MDPrincipal Investigator
  Professor of MedicineChief, Division of
  Hospital MedicineNorthwestern University
  Feinberg School of Medicine
• Eric Coleman, MD, MPHAdvisory Board Chair
  Associate ProfessorDivision of Health Care
  Policy ResearchUniversity of Colorado at
  Denver, Health Sciences CenterDenver, CO
• Jeffrey L. Greenwald, MDCo-InvestigatorDirector,
  Hospital Medicine UnitBoston Medical Center
• Lakshmi Halasyamani, MD Co-InvestigatorVice
  President for Quality and Systems Improvement St
  Joseph Mercy Medical Center

• Eric Howell, MDCo-InvestigatorDirector,
  Hospitalist ServiceJohns Hopkins Bayview Medical
  Center
• Greg Maynard, MDClinical Professor of
  MedicineChief, Division of Hospital
  MedicineUCSD Medical Center
• Arpana R. Vidyarthi, MDAssistant Professor of
  MedicineDirector of Quality, Division of
  Hospital MedicineDirector of Quality and Safety
  Programs, GMEUniversity of California San
  Francisco
• Senior Advisor, Quality InitiativesTina Budnitz,
  MPH
• Senior Advisor, ResearchKathleen Kerr
• Senior Project ManagerJoy Wittnebert

www.hospitalmedicine.org/BOOST
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Magnitude of the Problem

• Forster Bates - Prospective cohort study 1
• Objective to describe the incidence, severity,
  preventability, and ameliorability of adverse
  events affecting patients after discharge
• Tertiary care academic hospital
• 400 medicine patients discharged home
• At 3 weeks - Medical record review and Telephone
  call (structured interview by internist)

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Orders of Magnitude

• One in five general medicine patients experiences
  an adverse event (resulting from
  medical management) within two weeks of hospital
  discharge 1
• 66 of these events are adverse drug events, 17
  are related to procedures
• 33 of these events lead to disability
• Two-thirds of these events are preventable or
  ameliorable

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Orders of Magnitude II

• Types of discharge errors 2
• 42 of patients had medication continuity errors
  DC Plan.doc
• 12 had work-up errors
• 8 test follow-up errors
• Patients with work-up errors were more likely to
  be rehospitalized
• Pending test results3
• Many patients (41) are discharged with test
  results still pending.
• Many of these results (10) can change management
• Physicians are often (61) unaware of test
  results returning after discharge that may change
  management

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Orders of Magnitude III

• Unsafe discharges are an under recognized yet
  significant issue that has received almost no
  attention in health care 5
• Discharges can be urgent and unplanned 5
• No longer does one practitioner typically take
  responsibility for the discharge 5
• Communication breakdown between multiple
  providers and between providers and patients 5,
  6, 7
• Less than half of patients discharged from
  academic general medicine know their diagnoses,
  treatment plan or side effects of prescribed
  medications 8, 9

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Bibliography

• The Incidence and Severity of Adverse Events
  Affecting Patients after Discharge from the
  Hospital. Forster AJ. Ann Intern Med.
  2003138161-167
• Medical errors related to discontinuity of care
  from an inpatient to an outpatient setting. Moore
  C. JGIM. Aug 2003, 18(8)646-51
• Patient Safety Concerns Arising from Test Results
  That Return after Hospital Discharge. Roy CL. Ann
  Intern Med. 2005143121-128.
• The Canadian Adverse Events Study the incidence
  of adverse events among hospital patients in
  Canada. Baker GR. CMAJ.MAY 25, 2004 70 (11)
• 5. Lost in Transition Challenges and
  Opportunities for Improving the Quality of
  Transitional Care. Coleman EA. Ann Intern Med.
  2004140533
• Low health literacy called a major problem.
  Vastag B. JAMA. May 12 2004291(18)2181-82
• Resident recognition of low literacy as a risk
  factor in hospital readmission. Powell CK. JGIM
  20(11)1042-4, 2005 Nov.
• Patients Understanding of Their Treatment Plans
  and diagnosis at discharge. Makaryus AN. Mayo
  Clin Proc. August 200580(8)991-994

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Its All About the Meds

• Coleman et al found that hospital readmission
  rates for patients with identified medication
  discrepancies were 14.3 among the 375 study
  patients. This contrasted with a 6.1 readmission
  rate among patients with no identified medication
  discrepancy.
• Forster et al found that antibiotics were the
  most common drugs causing adverse events defined
  as injury resulting from medical management
  rather than the underlying disease. Antibiotics
  accounted for 38 of adverse events, while
  corticosteroids accounted for 16, cardiovascular
  drugs 14, analgesics including opiates 10, and
  anticoagulants 8.

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Its All About the Meds

• Schnipper et al showed in a randomized trial
  of 178 patients being discharged home from the
  general medicine service that pharmacist
  counseling reduced the number of preventable
  adverse drug events from 11 in the control group
  to 1 in the intervention group.

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Its All About the Meds

• Forster et al., using a survey of patient
  recollection of the discharge preparations among
  400 discharged patients showed that discussion of
  potential side effects was associated with a
  reduction in frequency of adverse drug events
  (adjusted OR 0.4 95 CI 0.2 to 0.7). There was
  no evidence that these discussions increased the
  likelihood of reported side effects.
  Unfortunately, only 62 of patients could recall
  having been told about potential medication side
  effects at time of discharge.

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References

• Coleman EA, Smith JD, Raha D, Min SJ.
  Posthospital medication discrepancies
• prevalence and contributing factors. Arch Intern
  Med. Sep 12 2005165(16)1842-1847.
• Forster AJ, Murff HJ, Peterson JF, Gandhi TK,
  Bates DW. The incidence and severity of
• adverse events affecting patients after
  discharge from the hospital. Ann Intern Med. Feb
  4 2003138(3)161-167.
• Schnipper JL, Kirwin JL, Cotugno MC, et al. Role
  of pharmacist counseling in preventing adverse
  drug events after hospitalization. Arch Intern
  Med. Mar 13 2006166(5)565-571.
• Forster AJ, Murff HJ, Peterson JF, Gandhi TK,
  Bates DW. Adverse drug events occurring following
  hospital discharge. J Gen Intern Med. Apr
  200520(4)317-323.
• Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach
  KN, McDonald AK, Annest JL. Emergency department
  visits for outpatient adverse drug events
  demonstration for a national surveillance system.
  Ann Emerg Med. Feb 200545(2)197-206.

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Not In My Backyard?

• The initial med rec lists in PHC were only 45
  accurate for medications listed (344/773)
• 209 medications were missing from these initial
  list
• Of patients that were taking medications prior to
  admit, 89 of initial med recs were incomplete
  and/or contained at least 1 error
• Only 11 of patients taking medications prior to
  admit had an initial MRR that was 100
  correct/complete.
• It took an average of 27 minutes per patient to
  complete pharmacist reconciliation

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The New Guard

• Hospitalist activities may include patient care,
  teaching, research, and leadership related to
  hospital care. Hospital medicine, like emergency
  medicine, is a specialty organized around a site
  of care (the hospital), rather than an organ
  (like cardiology), a disease (like oncology), or
  a patients age (like pediatrics). However,
  unlike medical specialists in the emergency
  department or critical care units, most
  hospitalists help manage patients throughout the
  continuum of hospital care, often seeing patients
  in the ER, admitting them to inpatient wards,
  following them as necessary into the critical
  care unit, and organizing post-acute care.
• The term was coined by Drs. Robert Wachter and
  Lee Goldman in a New England Journal of Medicine
  article in August of 1996 (Wachter RM, Goldman L.
  The emerging role of "hospitalists" in the
  American health care system. N Engl J Med
  1996335514-7).

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Hospitalist Medicine

• Hospital medicine is the fastest growing field in
  the history of medicine
• Currently, no formal certification or board
  recognition, although this is in the works
• More than 22,000 hospitalists currently,
  projected to have more than 30,000 in 2010
• There are more than 5 jobs awaiting each new
  hospitalist entrant
• Hospitalists represent/staff about 70 of all
  hospital beds nationwide

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Mission Motivation

• The goal of Project BOOST (Better Outcomes for
  Older adults through Safe Transitions) is to
  improve the care of patients as they transition
  from the hospital to home.

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BOOSTer Power

• Create a national consensus for best practices.
• Create resources to implement best practices.
• Provide technical support.

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Aiming High With A Value Proposition

• By improving discharge processes, Project BOOST
  aims to
• Reduce 30 day readmission rates for general
  medicine patients (with particular focus on older
  adults)
• Improve facility patient satisfaction scores
• Improve the institutions H-CAHPS scores related
  to discharge
• Improve flow of information between hospital and
  outpatient physicians
• Ensure high-risk patients are identified and
  specific interventions are offered to mitigate
  their risk
• Improve patient and family education practices to
  encourage use of the teach-back process around
  risk specific issues.

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Join the BOOST Brigade

• Any site can access the BOOST toolkit via the
  resource room free of charge at
  www.hospitalmedicine.org/BOOST. Over 265 sites
  have downloaded the complete Implementation
  Guide.
• Six hospitals were selected to participate in
  Project BOOSTs pilot cohort in 9/08
• Hospital of the University of Pennsylvania
• Queens Medical Center Honolulu, Hawaii
• Southwestern Vermont Medical Center
• Piedmont Hospital Atlanta, Georgia
• University of New Mexico Health Science Center
  School of Medicine
• ThedaCare Appleton Medical Center, Appleton, WI
  ThedaClark Medical Center, Neenah WI).
• Cohort 2 has 24 additional sites

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The Basic Process

• Identify and Risk Stratify For Discharge Failure
• Intervene with focused care
• Educate/Inform the Patient AND Key Contact
• Written Discharge Action Plan that
  Patient/Caregiver can Teach Back
• Follow up with 72 hr call, home health, provider
  visit

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Teach Back

• Step 1 Using simple language, explain the
  concept/process to the pt/caregiver.
• Step 2 Ask the pt/caregiver to repeat in his or
  her own words how s/he understands the concept.
• Step 3 Identify and correct misunderstandings
• Step 4 Ask the pt/caregiver to demonstrate
  understanding again to ensure the
  misunderstandings are corrected.
• Step 5 Repeat Steps 4 and 5 until the clinician
  is convinced of Comprehension.
• Dean Schillinger, MD
• Associate Professor of Clinical Medicine
• University of California, San Francisco

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The Forms

• TARGETRisk Assessment/Intervention Guide
• GAPGeneral Assessment of Discharge Preparedness
• Universal Discharge Check List

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7P Risk AssessmentAnd Triggered Interventions
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7P Risk AssessmentAnd Triggered Interventions
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General Assessment of Preparedness
(GAP)Logistical Issues

• Prior to discharge, evaluate the following areas
  with the
• patient/caregiver(s) and ambulatory medical care
• providers
• 1. Functional status assessment
• 2. Access (e.g. keys) to home ensured
• 3. Home prepared for patients arrival?
• 4. Advanced care planning documented
• 5. Ability to obtain medications confirmed
• 6. Responsible party for med adherence IDd?
• 7. Transportation to initial follow-up arranged
• 8. Transportation home arranged

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General Assessment of PreparednessPsychosocial

• 1. Substance abuse/dependence identified/addressed
  
• 2. Abuse/neglect presence assessed/addressed
• 3. Cognitive status assessed/addressed
• 4. Financial resources assessed/appropriate
  programs applied for
• 5. Support circle for patient IDd for patient,
  caregiver, homehealth, PCP
• 6. Contact info for caregivers provided for
  above?

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Universal Discharge Checklist

• 1. GAP assessment (see below) completed with
  issues addressed...YES NO
• 2. Medications reconciled with pre-admission
  list YES NO
• 3. Medication use/side effects reviewed using
  Teach-Back . YES NO
• 4. Teach-Back for understanding of dz, prog, and
  self-care requirements..YES NO
• 5. Action plan for sx/s-e/cx requiring attn
  w/teach-back .... YES NO
• 6. D/c plan (edu mtls med rec list f/u plans)
  provided/taught back.YES NO
• 7. D/c communication to principal care
  provider(s). YES NO
• 8. Documented receipt of discharge information
  .YES NO
• 9. Arrangements made for outpt f/u with principal
  care provider(s). YES NO

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Universal D/C ChecklistFor increased risk
patients, consider

• 1. Face-to-face multidisc rounds prior to
  discharge
• 2. Direct comm with main care provider before
  discharge
• 3. Phone contact arranged w/in 72 hours of d/c
• 4. F/u appoint with main care provider w/in7 days
• 5. Contact info for hospital MD/RN familiar w/pt
  provided to for use if unable to reach principal
  care provider prior to first follow-up

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Patient Pass I

• I Was In the Hospital Because
• If I have the following problems
• 1. ______________________
• 2. ______________________
• 3. ______________________

• I should
• 1. ______________________
• 2. ______________________
• 3. ______________________

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Patient PASS II

• My appointments
• 1. ________________________
• On __/__/___ at ____ am/pm
• For _____________________
• 2. ________________________
• On __/__/___ at ____ am/pm
• For _____________________

• My appointments
• 3. _________________________
• On __/__/___ at ____ am/pm
• For _____________________
• 4. ________________________
• On __/__/___ at ____ am/pm
• For_______________________

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Patient PASS III

• Tests and issues I need to talk with my doctor(s)
  about at my clinic visit
• 1. __________________________
• 2. __________________________
• 3. __________________________
• 4. __________________________

• Important contact information
• 1. My primary doctor _________________
• (____) ___________
• 2. My hospital doctor _________________
• (____) ___________
• 3. My visiting nurse _________________
• (____) ___________
• 4. My pharmacy _________________
• (____) ___________

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Patient PASS IV

• Other instructions
• 1._______________________________________________
• 2._______________________________________________
• 3._______________________________________________
• 4._______________________________________________

• I understand my treatment plan. I feel able and
  willing to participate actively in my care
• _______________________
• Patient/Caregiver Signature
• _______________________
• Provider Signature
• ____/____/_____
• Date

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The Forms Are Good, But the Process It Requires
is Better

• Ever Feel like a hospital admission and discharge
  is like renting a car?
• Sign here, initial here, etc. It all sounds like
  everything is covereduntil you have a problem.
• Ever find out the hard way that the underside of
  the car isnt insuredeven with the total
  coverage?

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Unique Mechanics

• Geographically designated personnel including IMS
  MDLEAN Advantage
• Ward organized around attending MD instead of
  disease state
• Name in the Box
• Right person, right job(eg pharmacy)
• Centralized Communicationd/c criteria, whats
  next, patient out of room on public whiteboard
• Automation/Standardizationdata retrieval results
  in predictable responses
• Detailed Risk Assessments translate into
  proactive caremedications, functional
  assessments
• Specialized testing triage
• Create the Pull
• Charge RN in Charge of being in charge

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The Results

• An Astounding 45 decline in Avoidable Days
  (Excess LOS) from 9/08 1/09 vs same Period on
  the same unit the year prior (670 vs 366 avd
  days)
• During this Period, the MDs on the Unit
  discharged 260 pts/MD vs 116 pts/MD with
  traditional process (17 of workforce was
  responsible for 31 of the work)
• Each of the 2 Unit MDs had 183 Avoidable days for
  their 260 cases (0.7 avd days/case) vs. 141
  avoidable days for each of the 10 MDs with 116
  Cases each (1.2 avd days/case)

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The Results II

• Readmission Rate significantly lower vs peers
• Patient Satisfaction has improved Markedly
• Staff Satisfaction is at an all-time high
• Float RNs asking to rotate there
• One Unit Making a Noticeable impact on whole
  house throughput
• PCPs LOVE the PASS
• Significant percentage of patients can still
  teach back at follow-up call
• Home Health Much Better informed and can verify
  that d/c MRR is same as what is actually being
  taken in home

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Summary Statements

• Adverse events resulting from medical
  (mis)management at discharge are
• Common in our patients
• Often involve Medications and Tests
• Dangerous and result in significant morbidity and
  increased healthcare utilization
• Preventable

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Classic Problems with Creating Safe Discharges

• Discharges are unsafe for a number of reasons
• complex process
• time constraints
• low priority
• poor planning
• lack of ownership,
• poor communication
• not patientcentered

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Creating Safe Discharges is Like Being an
American In the Stock Market

• We all know the jobSave for retirement
• Were offered some excellent tools (401K)
• There is a ton of information out there
• It confuses the experts
• No one and everyone owns it
• Success depends on getting the basics right and
  on doing the maintenance work between decision
  points

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Pearls of Wisdom

• Take Ownership Every Visit Every Time
• Assume Anything that Can Go Wrong Will Go Wrong
  and Act Accordingly
• Managing the Space Between is the right thing
  to do
• Do you Have a daughter? Can I speak with Her?
  If no, automatic high risk.
• Its all about the Meds
• If Its confusing for you, its confusing for
  everyone

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Wisdoms Continued

• Communication between providers is a key deficit.
  How tightly connected is your feedback loop? Is
  the patient included? Home care/community
  resources?
• Is the plan written, does the pt understand?
  Whos the manager, the key assistants?
• Have you followed up to ensure things are going
  well and/or to redirect to care?
• Use Home Health Unless you Have a Good Reason Not
  To. Less than 1/3 of our patients with more than
  4 Admissions in a year had home health at last
  discharge.

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Eminent Domain

• Medicine Has Focused on Episodes and Domains of
  Care and Responsibility
• We Need to Focus not on how well we did our job
  rather on patient outcome
• We are all responsible for the whole shebang,
  though we choose to subdivide responsibility for
  our own convenience
• Make the Most of the Inpatient Moment

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Parting Wisdom

• No Margin, No Mission but without staying true
  to your mission, youll never have sustainable
  margin
• Dont Collect Data you dont use, Use the Data
  You Collect
• Do Something Different Wrong
• Always Do the Right Thing No Matter How Difficult
• Never accept of yourself an effort dependent
  failure
• We have all the help we needits sitting in this
  room

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