Improving hospital discharge process is project tackled through variety of plans
Improving hospital discharge process is project tackled through variety of plans
After-hospital care plan is one method
National agencies have committed millions in federal funding to studies of how to improve the hospital discharge process, and as study results come in, certain best practices are emerging.
Also, there is growing evidence that the transition from hospital to home should be a priority target for improvement in the nation's health care policies, both to reduce unnecessary health care costs and to improve care quality for patients.
One recent study in The New England Journal of Medicine showed that nearly one-fifth of the more than 11 million Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days. More than one-third were rehospitalized within 90 days.1
Even more striking, the study showed that 67.1% of patients who were discharged with medical conditions were rehospitalized or died within the first year after discharge.1
"The transition from hospital to home is an extraordinarily high-risk time for patients and their families," says Jeff Critchfield, MD, an associate professor of medicine in the department of medicine at the University of California - San Francisco. Critchfield also is chief of the division of hospital medicine at San Francisco General Hospital.
Patients often are transferred from an area of intense acute care surrounded by doctors, nurses, nutritionists, and other providers to their homes, where support and follow-up are minimal, he explains.
"We're realizing there are several areas of significant challenges for patients being discharged home, and one of these involves their medications," Critchfield adds. "There is a lot of confusion around people taking their meds, understanding their meds, having enough money for meds."
Another problem area involves getting patients to primary care visits after they are discharged from the hospital, Critchfield says.
The NEJM study also found that 50.1% of patients who were rehospitalized within 30 days after discharge had not seen a community physician after their initial hospitalization and discharge.1
With all the confusion the hospital discharge process and medication changes can cause patients, it is important for a primary care provider to see them and assist them with follow-up care, Critchfield says.
"The data we're learning about discharges and transitions are an example of what I think is true: our care is not patient-centered care," he adds. "The hospital discharge is an intensely vulnerable time, and we as a society haven't put anything in place for that."
However, a number of physician researchers have worked in the past decade on models for improving the discharge process.
For example, the reengineered hospital discharge program (Project RED) showed in a recent study that a number of discharge services can reduce hospital utilization by 30% within 30 days of discharge.2
Project RED received more than $7.5 million in funding from the Agency for Healthcare Research and Quality (AHRQ) and the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH).
"We have now designed the reengineered discharge, and that had never happened before," says Brian Jack, MD, an associate professor and vice chair of the department of family medicine at Boston University School of Medicine and Boston Medical Center in Boston.
"We're looking at how to implement and disseminate this improvement, whether through hiring additional personnel or through staff already in hospitals," Jack adds. "This is where we are now in terms of hospitals deciding what's possible."
Jack and co-investigators have been working on the reengineering discharge project for most of the past decade. Jack's involvement stemmed from a personal interest in improving patients' experiences during care transitions.
"While working in the hospital, I noticed how we were sending people home who were not adequately prepared to take care of themselves once they got home," Jack says. "Once they left the hospital, the chances of their returning back to the hospital was much greater, and it was clear to me that we could do a whole lot better than that."
He clearly remembers one case in particular: "I was in a patient's room once without my white coat on, and I was just sitting in a chair beside an elderly man who was there to have his pacemaker adjusted," Jack recalls. "He was on Coumadin (warfarin), and he had been instructed to stop the blood thinner for a couple of days to have his pacemaker adjusted."
The patient was told to go back on warfarin when he returned home. But right before he was set to leave the hospital and as his elderly wife was warming up the car, the hospital medical team decided to give him a prescription for a three or four-day bridge dose of injectable blood thinner to help the warfarin build up again, Jack explains.
"The nurse walked in just as he was leaving and said, 'I don't have time to teach you how to do this, so take this,' and she handed him a cellophane-wrapped box," Jack says.
She had handed him a DVD with instructions for injecting himself with the drug, and it was clear to Jack that the man was bewildered and would not be able to handle this on his own, even if he had a DVD player, which the nurse had never inquired about.
"The nurse could have said, 'I'm going to take 15 minutes and show you how to do this,' and then she could have had him practice on an orange or something," Jack says.
There are many discharge cases like this, and that's why Jack and other physicians and researchers have been working on reengineering the discharge process.
For example, another project is the STAAR program (State Action on Avoidable Rehospitalizations), which is a four-year initiative, sponsored by the Institute for Health care Improvement (IHI), says Elizabeth C. Gundersen, MD, an associate chief of hospital medicine for UMass Memorial Medical Center in Worcester, MA. Gundersen also is the physician quality officer at UMass.
Hospitals in Massachusetts, Michigan, and Washington state are involved in STAAR, which has a goal to reduce readmission rates by 30%.
"Our goal is to reduce readmissions on a statewide basis and increase patient satisfaction scores with regard to discharge planning," Gundersen says.
STAAR has just begun, and UMass has formed a steering committee of hospital leaders among physicians, nurses, case managers, as well as health providers in the community, she explains.
"We want everyone to work together as a team, including not just those sending patients out of the hospital, but those receiving patients in the community," Gundersen says.
The project will identify hospital needs starting with the day of admission and focus on effective teaching, including use of the teachback method, she adds.
"Also, there will be more emphasis on scheduling appointments with patients to increase compliance," Gundersen says.
Too often, hospitals leave it to chance that patients will follow up on instructions to visit their primary care physician (PCP) or take their medications according to instructions or that the PCP will understand all that happened in the hospital, she notes.
"Our care needs to be more patient-centered, and the process of discharge or transition out of the hospital needs to happen earlier in the hospitalization," Gundersen says. "One thing that frustrates families most is on the morning of discharge being told that they are going home that day at 1 p.m."
This is an anxiety-provoking situation for patients and their families.
"We sometimes do health care in a vacuum, where I do my piece and send the patient out the door, and then the primary care physician does his or her piece to help the patient, and we do this without any coordination or communication with each other," Gundersen says. "So improving coordination and communication between providers is the big thrust of what all of these discharge improvement initiatives are trying to do."
UMass has become involved in several projects to improve the discharge process, including Project BOOST, Project RED, and INTERACT (Intervention To Reduce Acute Care Transfers), Gundersen says.
"One of our goals in terms of taking different initiatives is to explore them and tweak them into something particular to UMass," she explains. "Our obvious goals are to reduce readmissions and increase patient satisfaction, and our priority is to bring better, patient-centered care to patients and also to unify health care delivery systems across the community."
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. NEJM. 2009;360(14):1418-1428.
2. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Int Med. 2009;150(3):178-187.
For more information, contact:
Jeff Critchfield, MD, Associate Professor of Medicine, University of California - San Francisco; Chief, Division of Hospital Medicine, San Francisco General Hospital, San Francisco. Telephone: (415) 206-6078.
Elizabeth C. Gundersen, MD, Associate Chief, Hospital Medicine, UMass Memorial Medical Center; Physician Quality Officer, UMass, 119 Belmont St., Jaquith 2, Worcester, MA 01605. Telephone: (508) 334-8515.
Brian Jack, MD, Associate Professor and Vice Chair, Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Dowling 5309, IBMC Place, Boston, MA 02118. Telephone: (617) 414-5956. Email: [email protected]. Web site: http://www.bu.edu/fammed/projectred/.National agencies have committed millions in federal funding to studies of how to improve the hospital discharge process, and as study results come in, certain best practices are emerging.
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