Rehospitalization is a problem our healthcare system must address in order to improve not only patient safety and quality outcomes but the economic viability of our entire healthcare system. This issue has now floated to the top of the priority charts for CMS and other third party payors. Even though high rehospitalization rates are an indictment of the fragmentation and inefficiency of the whole healthcare system, future changes in hospital reimbursement make it imperative that hospitals begin to take the lead in re-engineering and coordinating post-discharge care.
Last week’s New England Journal of Medicine (Jencks et al 2009) has a study on Medicare data that shows 19.6% of all patients discharged from an acute care hospital are rehospitalized within 30 days. Since this study excluded some patients, such as Medicare managed care patients, that figure is in keeping with the more widely used rate of 18% in the literature. 34% were rehospitalized within 90 days and almost two-thirds either died or were rehospitalized within a year. Probably less than 10% of the rehospitalizations were planned. And most of the rehospitalizations after surgical discharges were for primarily medical conditions. And the rehospitalizations had an average LOS longer than that for comparable first hospitalizations for the same diagnosis. The cost to Medicare is probably over $20 billion annually for rehospitalizations.
Significantly, over half of those patients rehospitalized after a discharge to the community for a non-surgical diagnosis were not seen by a physician between hospitalizations (based on physician billing data).
Though there are some predictors of rehospitalizations (certain DRG’s, presence of ESRD, long LOS, many prior hospitalizations), the data strongly support the need to re-engineer the process for all patients, not just targeted ones.
Our February 24, 2009 Patient Safety Tip of the Week “Discharge Planning: Finally Something That Works!” began to address the rehospitalization problem and focus on the hospital discharge process. In that column, we discussed the recent randomized study (Jack et al. 2009) from Project RED that documented considerable improvement in rehospitalization rates using a structured hospital discharge program. Recall that that study showed about a 30% reduction in rehospitalizations or ER visits after hospital discharge and saved about $412 per patient. Last week, many of you had the opportunity to learn about Project RED from a webinar sponsored by AHRQ featuring Brian Jack, M.D., the lead author of the above article. AHRQ has announced that webinar will be made available free on its website for a year. Believe us, this is one you don’t want to miss!
But even while you are waiting to view the webinar, go to the Project RED website and learn about the program. There you can download a detailed description about the project and the idealized discharge process. You can also download a training manual plus sample “after hospital care plans” (AHCP’s). And make sure you watch the video’s to meet “Louise” and their other animated “virtual” nurse discharge advocates! (More on that later.)
Some of the key components to the structured discharge planning process are not new. Everyone has heard “discharge planning begins on admission”! While the words are somewhat trite, you really do need to begin planning for discharge on admission (or prior to admission if the admission is not emergent). Discharge planning should be a truly interdisciplinary process, not one managed in traditional silos. Unfortunately, the discharge planning participants from the medical team are often the most inexperienced medical team members (interns and first year residents), who are also least familiar with the physicians and medical resources in the community outside the hospital. So a senior member of the medical team, preferably the attending, should be intimately involved in the process.
The nurse discharge advocate still remains the key player and coordinator of the process. Using a discharge planning checklist is a good idea (add another thing to our list of things we should all be using checklists for!). The Project RED team actually also uses a computerized database to help coordinate the discharge process. That is a good way to help ensure that you have all the necessary components in place. But it should be clear that a paper-based system can be as good as a computer-based one.
Scheduling followup visits and tests for the patient is critical. The discharge team needs to work with that patient and family to make sure they will be able to keep those appointments. A color-coded calendar is given to the patient with all key follow-ups and appointments highlighted in color. (Note also from the Jencks study in NEJM that most of the rehospitalizations after a surgical admission are for medical conditions. That stresses the importance of coordinating not just surgical followup but also medical followup after such admissions.)
Getting a pertinent and timely discharge summary to all who need it is critical. That summary, in addition to outlining the reason(s) for hospitalization, tests results, care provided, condition and diagnoses, needs also to emphasize what needs to be done after hospitalization. We’ve spoken often in the past about the need to highlight in the discharge summary test results that are pending so that the physician providing after-hospital care knows to follow up on them. Explaining to the patient (or family) about those pending tests is also important. Expediting transmission of that summary to the next provider in the care chain (whether it is a physician, SNF, home care organization, etc.) is very important. No longer can we tolerate waiting weeks to get discharge summaries dictated and signed. Just as importantly, you need to know who to send the discharge summary to. Most hospitals get a copy to the hospital attending but do a poor job at identifying the primary care physician or specialist who will be providing care to the patient after discharge. (See a recent timely article from ACP Hospitalist “Creating a Better Discharge Summary. Is Standardization the Answer?” for relevant insight and a good review of the literature on discharge summaries.)
Medication reconciliation at discharge is as important as during any phase of the hospitalization process. It needs to be explained to the patient what drugs he was on prior to hospitalization need to be continued and which should be discontinued. Any new drugs or changes in dosages of old drugs must be explained in detail. Care must be taken to avoid duplication of therapy. It is not uncommon for a patient to be given a prescription at discharge with, for example, the generic name of a drug and the patient knows the drug at home by its brandname and thus takes both the generic and the brandname drug. Make sure that drugs intended to be prophylactic only while hospitalized are not inadvertently continued after discharge. And it must be carefully explained to the patient what each drug is for and what side effects to watch for (and what to do if those side effects occur). And making sure the patient can easily get his medications is important.
Medication reconciliation is so important that the next key feature of the re-engineered discharge is added: the post-discharge phone call. In Project RED that phone call was done by a clinical pharmacist but theoretically it could be done by another type of clinician. We’ve stressed before that most patients on the day of discharge just want to “get out of the hospital” so discharge is not your optimal “teaching moment”. Reinforcing medication management a few days after discharge is very helpful and can raise unanticipated problems that would otherwise be missed.
In our February 24, 2009 Patient Safety Tip of the Week “Discharge Planning: Finally Something That Works!” we also mentioned a prior demonstration project by the Colorado Foundation for Medical Care (a Medicare QIO) had demonstrated that a coaching model was successful in reducing readmission rates by almost 50%. In that model, an RN “coach” visits the patient once in the hospital and once within 48 hours after discharge and also calls the patient by phone three additional times. They discuss medication management, followup visits with physicians, a patient-centered record, and knowledge of “red flags” the patient should be aware of. And we’ve also stressed that post-discharge phone calls to patients can do wonders for the public relations of your organization.
The written discharge plan given to the patient is useful both for the patient and for the hospital team to document what was done at discharge. Every effort should be made to establish that the patient understands all the elements in the discharge plan.
Making it clear to the patient who to call for emergencies or other questions is crucial. This should be clearly spelled out, providing not only the name of the physician to call but also the phone contact information. The sample Project RED after hospital care plans provide great examples of how to communicate such issues.
Lastly, communication…communication…communication. While written materials are a necessity, there is still no substitute for verbal or face-to-face communication. The old saw that 80-90% of communication is non-verbal holds true. The best hospitalist programs are successful because the hospitalist is in frequent communication with the outside physician(s).
That gets us to “Louise”. Louise is a virtual nurse discharge advocate in a pilot program being used by the Project RED team. Timothy Bickmore, PhD, explains her role in the AHRQ Project RED webinar. The virtual nurses are very realistic and the communication is two-way. The patient (or their family) can interact with the virtual nurse as often as they like. It is a good way of ensuring that the patient truly understands the elements and importance of the after-hospital care plan. Take a look at the video clips of the virtual nurse on the Project RED website. You’ll be impressed! And the Project RED team tells you that as many as 75% of the respondents actually prefer the virtual nurse to a real discharge nurse! They like her because they can ask all the questions they want, are not constrained by time, and often ask questions they are too embarrassed to ask a live nurse. Stay tuned to the wave of the future!
Update: See also our April 14, 2009 Patient Safety Tip of the Week “More on Rehospitalization After Discharge”.
Jencks SF, Williams MV, Coleman EA.. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. NEJM 2009; 360: 1418-1428
Jack BW, Chetty VK, Anthony D et al. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine 2009; 150(3): 178-187
AHRQ webcast. Improving Patient Safety: Implementing Re-Engineered Hospital Discharges Web Conference originally aired Tuesday, March 31, 2009 - 2:00 PM - 3:15PM (EDT)
AHRQ Project RED website
Louden K. Creating a Better Discharge Summary. Is standardization the answer? ACP Hospitalist March 2009
Atlantic Information Services. CMS Targets Readmission Through Payment, Audits; “Coaching” Model Reduces Rates. Report on Medicare Compliance 2008; 17(24): 1-2 (June 30, 2008)