Use evidence-based tools to improve discharge
Expert points to Project BOOST
One strategy hospitals can employ to improve their readmission rate is to use evidence-based tools and processes at discharge.
Project BOOST tools are one place to start, says Mark V. Williams, MD, FACP, FHM, chief of the division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago. Williams was one of the researchers who worked on a project that evolved into Project BOOST.
"Not only does BOOST present an evidence-based tool kit that hospitals can use, it also engages the hospital through mentored implementation," Williams says. "We have an experienced hospitalist who is knowledgeable in transitions of care to guide a team at the hospital to implement the BOOST tool."
One tool Williams helped to develop is a patient discharge tool that is designed with language that is very accessible to the layperson.
"Instead of writing the diagnosis of heart failure, the tool has you write, 'I have the following medical problems,' and 'While in the hospital I had these tests performed, which showed this,'" he explains.
Here are other features on the discharge patient education tool:
It lists patient's admission date, discharge date, and days in the hospital.
The patient's doctors' names are listed, along with their specialties; the hospitalist's number is listed, as well.
Under the section of "Diagnosis," there are notes written after these three statements: "I had to stay in the hospital because," "The medical word for this condition is," and "I also have these medical conditions."
Under the "Test" and "Treatment" sections, there are tables for writing multiple tests and conditions.
The treatment section states, "While I was in the hospital I was treated with ____"; "The purpose of this treatment was: ____".
The top of the second page lists information about follow-up appointments, and there's a place for the patient to put his or her initials before the statement, "After leaving the hospital, I will follow up with my doctors."
The follow-up appointment section includes places to list the primary care physician's and the specialist physician's names, phone numbers, and dates and times of appointments.
Under "Follow-Up Tests," the patient again places initials before the statement, "After leaving the hospital, I will show up for my tests"; This is followed by a brief table listing tests, location, date, and time.
A final section, called "Life Style Changes," asks the patient to initial this statement: "After leaving the hospital, I will make these changes in my activity, and diet"; It leaves one line for activity and one for diet, and each are followed by an answer to the question "because."
There also is a subsection for smoking that has the patient check if he or she is a nonsmoker or list a plan for quitting if the patient is a smoker.
Then there is space for a date and time when the patient will receive a follow-up phone call, followed by the patient's signature and doctor or nurse case manager's signature, along with a date.
The bottom of the second page of the patient education tool also lists phone numbers for the patient to call if he or she has any problems or questions after leaving the hospital.
The third page has one brief section on medications, stating, "When I leave the hospital and go home, I will be taking the medicines on my prescription form." This is followed by these four statements which the patient must initial:
I understand which medicines I took before I came to the hospital and will now STOP.
I understand the medicines I will continue taking and new medicines I will take.
I understand why and when I need to take each medicine.
I understand which side effects to watch for.
Finally, the tool states: "Please bring all of your medicines to your follow-up appointments."
The tool provides a pathway that presents only essential information for the patient.
"Instead of 25-30 pages of materials, which find their ways to wastebaskets or to folders that are never opened, it gives patients the information they need to manage their care," Williams says.
For instance, the three-page tool does not include a number of items that should be included in the discharge summary, including these:
key findings and test results;
condition at discharge, including functional status and cognitive status, if relevant;
discharge destination and rationale;
all pending labs or tests, responsible person who will receive the results;
recommendations of any sub-specialty consultants;
documentation of patient education and understanding;
resuscitation status and any other pertinent end-of-life issues.1
In addition to using a patient discharge instruction tool, discharge planners should use the teach-back strategy with every patient.
"What's critical is if you're teaching a patient about a procedure they must do themselves, like administering insulin . . . that you have them demonstrate that procedure to you," Williams says.
Or discharge planners should ask the heart failure patients to explain why they should weigh themselves daily, he adds.
So, the discharge nurse or social worker might say, "I want to make sure I've done a good job of educating you about this, so I'm going to check," he says.
Then ask them who they are supposed to call for follow-up care, he says.
"As we demonstrated in earlier research, standardized appointment slips are hard to understand for some patients," Williams says.
Also, hospital discharge teams should call patients within 48 to 72 hours after discharge with appointments scheduled within one week of discharge, he adds.
"Get the discharge summaries completed within 24 hours of discharge, and make sure all medications are reconciled," Williams says. "You need to make sure the patient knows how to recognize all signs and symptoms and exacerbation of disease."
1. Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients – development of a discharge checklist for hospitalists. J Hosp Med. 2006;1(6):354-360.