February 24, 2009 Discharge Planning: Finally Something That Works!
We spend a lot of time discussing the many dangerous things that can happen during a hospitalization. But the period following discharge is just as or even more dangerous. The most widely cited study on post-discharge adverse events (Forster et al 2003) found 19% of patients discharged from an academic tertiary care center suffered an adverse event within 3 weeks of discharge. And almost two-thirds of these events were considered either potentially preventable or ameliorable. Adverse drug events were the most common type seen.
A big problem in the past has involved transitioning patients cared for in tertiary hospitals back to their primary care providers. And now that many community hospitals have begun using the hospitalist model for inpatient care, the physicians providing the inpatient care may never see the patient again after discharge. Hence, the communication and coordination of care that occur at discharge have become even more important.
We’ve discussed on several occasions the problem of test results pending at the time of discharge that fail to be followed up on (see our May 1, 2007 Tip of the Week More on Tracking Test Results”). A study by Roy et al in two tertiery care hospitals (Roy et al 2005) found that 41% of patients had test results that returned after patients had been discharged. Almost 10% of those were potentially actionable and over 60% of physicians surveyed were unaware of those test results.and our February 12, 2008 Tip of the Week “
And, of course, one of the biggest reasons for the push to perform medication reconciliation has been the frequent occurrence of medication errors at the time of discharge. A recent study (Zhang et al 2009) found that comorbidities, but not advancing age, were associated with repeat admission for adverse drug events in older adults.
Nationally, almost 18% of Medicare patients get readmitted to the hospital within 30 days after discharge. We all spend a considerable amount of time on the discharge planning process but there is a surprising dearth of literature showing what specific interventions are successful in avoiding readmissions or avoiding other post-discharge adverse events. A recent review of the discharge planning process (Katikireddi and Cloud 2008) provided practical advice on performing discharge planning and outlined many of the key elements to incorporate in that process but pointed out that almost none of the recommendations are evidence-based.
However, this month a new randomized study (Jack et al. 2009) documented considerable improvement in rehospitalization rates using a structured hospital discharge program. In that program, a nurse discharge advocate interacted with a multidisciplinary team to develop a post-discharge plan, schedule and coordinate followup medical appointments and tests, provide a list of pending test results, a description of the discharge diagnosis and medications, and information about what to do if a problem occurred. A clinical pharmacist then called the patient by phone 2-4 days after discharge. The primary outcome measure was a composite of repeat hospitalizations or ER visits within 30 days. The intervention group had 21.6% of such events, compared to 26.9% in the usual care group. The average time spent by the discharge advocate (in contact with the patient or the medical team and preparing the discharge documents) was 87.5 minutes per patient and the pharmacist spent a median of 14 minutes talking to the patient plus 10 minutes preparation time. And the average net savings was $412 per person who received the intervention.
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.
So these two studies demonstrate that use of a nurse-managed model with well-designed plans for discharge successfully reduce the likelihood of readmission and more than pay for themselves.
More than that, we’ve found that post-discharge phone calls to patients can do wonders for the public relations of your organization. The patient’s perception that you care about them after discharge can significantly improve their satisfaction with the entire hospital experience.
Update: See also our April 7, 2009 Patient Safety Tip of the Week “Project RED”.
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. 2003; 138:161-167
Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005; 143:121-128
Zhang M, Holman CDJ, Price SD, et al. Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: retrospective cohort study. BMJ 2009; 338: a2752 (Published)
Katikireddi SV, Cloud GC. Planning a patient’s discharge from hospital. BMJ 2008; 337: a2694 (Published 12 December 2008, doi:10.1136/bmj.a2694)
Jack BW, Chetty VK, Anthony D et al. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine. 150(3):178-187, February 3, 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)