Testing the Re-Engineered

Discharge

Principal Investigator: Brian Jack MD Associate Professor and Vice Chair

Department of Family MedicineBoston Medical Center /

Boston University School of Medicine

Hands-On Health LiteracySeptember 9, 2008

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?

“Perfect Storm”of Patient Safety“

Principles of the RED:Creating the Toolkit

Adopted by National Quality Forumas one of 30 "Safe Practices" (SP-11)

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

RED Checklist

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 @ 2-3 days

The DA and Pharm manual Scripts for each task

Intervention to Administer RED

EnrollmentN=750

Randomization

RED Intervention

Usual Care

30 day Outcome DataTelephone CallChart Review

Informed Consent

Testing the RED Schematic

ExtremelyVeryModeratelyA little bitNot at all

How useful was the booklet to you?

AHCP Evaluation:30 days post-discharge

19%

39%21%

17%

4%

What was the most helpful part of the booklet?

AHCP Evaluation:30 days post-discharge

Medical Provider Information

RED Medication Schedule

Appointment Page

Appointment Calendar

Diagnosis Information

Other

25%

20%

15%

13%

12%

15%

How helpful was the RED medication calendar?

AHCP Evaluation:30 days post-discharge

ExtremelyQuite a bitModeratelyA little bitNot at all

4%

26%

45%

9%

15%

Self-PerceivedReadiness for Discharge 30 days post-discharge

Control (n=376) Intervention (n=373)

P-value

Hospital UtilizationTotal # of visits Rate

16744/100 subjects

11631/100 subjects <0.00

1

ED Total # of visitsRate

9024/100 subjects

6116/100 subjects 0.01

RehospitalizationTotal # of visits Rate

7721/100 subjects

55

15/100 subjects 0.05

Primary Outcome

Cumulative Hazard of Patients Experiencing an Hospital Utilization in 30d After Index Discharge

0 5 10 15 20 25 30

Days after Discharge

0.5

0.6

0.8

1.0

Pro

bab

ilit

y o

f su

rviv

al

---- RED---- Usual Care Chi-square p=0.005

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 @ $753 billion x 32% eligible = 4 billion

Conclusions from the RCT

• 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

Major Problem: RN TimeCan Health IT Help?

Louise

Social Chat

Cover

Medications

Appointments

Diagnosis

Closing

• 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 O’Donnell

• 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

Thank You AHRQ!