By Brian Jack, MD
I don’t think the medical community needs any more research that shows that there are many opportunities to improve the quality of the hospital discharge. It is also clear that new payment policies will greatly impact hospital reimbursement for those patients readmitted within 30 days of discharge. To address these issues, at Boston University Medical Center, we’ve created Project RED, the Re-Engineered Discharge program, to facilitate better transitions of care.
The result of five years of work, with support from the Agency for Research and Quality and the National Heart, Lung, and Blood Institute of NIH, Project RED emphasizes patient education, preplanning for post-discharge services and appointments, expediting the discharge summary to clinicians accepting care of the patient, and post-discharge follow-up. We developed a tool called the After Hospital Care Plan (AHCP) that clearly presents the components of the RED.
The results speak for themselves. In 2008, we completed a randomized controlled trial of 749 subjects that compared the impact of the RED/AHCP process to usual care. Results showed a 30 percent lower rate of hospital utilization 30 days after discharge in the RED/AHCP group; one readmission or emergency department visit was prevented for every 7.3 persons discharged with the new process. Avoided costs totaled $149,995, or $412 per person — a 34 percent lower observed cost than the control group.
So why hasn’t Re-Engineered Discharge been adopted by teaching hospitals and academic medical centers across the country? Although hospitals are now highly motivated to reduce readmission, culture change is difficult.
As we get ready to become accountable care organizations, everyone must start playing together. Yet, there is a long list of barriers. For example, Project RED requires that discharge summaries be sent to primary care physicians within 24 hours; the requirement, however, is 30 days. This is a huge disconnect that does not benefit the patient.
In teaching hospitals, the presence of residents can be another barrier; we often delegate the creation of the patient’s discharge plan to the most junior physicians on the team. Yet, we developed Project RED in a teaching hospital, which shows it can be done.
Close follow-up for many patients after discharge is a critical component in reducing readmissions, but many hospitals have trouble getting appointments after discharge. Project RED specifies that nurses make appointments for follow-up and post-discharge testing, with input from the patient about date and time. It’s critical that we work with patients to accept this follow-up as their responsibility.
Project RED is a best practice. It’s critical that academic medical centers and teaching hospitals understand the strategic importance of improving hospital discharge to prevent readmission. Soon there will be a change in reimbursement policies for patients who are readmitted within 30 days. It doesn’t really matter which program you adopt. They’re all very similar, and much of this is commonsense stuff. But implementation is where the rubber hits the road.
We expect patients magically to understand and remember their post-discharge instructions and medications; we present them with complex information, yet don’t give them the tools to remember how to care for themselves when they go home. Right now, we focus on fixing problems as presented, not caring for patients. We need to change that mentality to improve ways for caring for complex patients outside the hospital and transitioning to a plan that moves with patients through time.
—Brian Jack, MD is Professor and Vice Chair for Academic Affairs in the Department of Family Medicine at Boston University School of Medicine/Boston Medical Center. He can be reached at email@example.com.