Published in the October 2006 issue of Today’s Hospitalist
Ask a group of hospitalists who they think is officially in charge of managing the discharge process at their institution, and most will take a tentative stab at naming an individual or department “usually nursing, case management or social work.
A few might actually say it’s the hospitalist’s job. But according to Jeffrey Greenwald, MD, director of Boston Medical Center’s hospital medicine unit, most hospitalists aren’t likely to assume that level of accountability.
“Whose job is it? It’s ‘everybody’s’ job, which means that it’s nobody’s,” Dr. Greenwald told hospitalists at a recent Society of Hospital Medicine (SHM) session on discharge innovations. He was one of three panelists who detailed the problems they’d found in their own institutions that were clear signs that the discharge process needed to be overhauled.
While steep re-admission rates were the red flag at Boston Medical, other facilities struggled with lingering lengths of stay for complex patients and the all-too-familiar “voltage drop” that leaves patients vulnerable “and physicians liable “to medication errors after discharge.
In fact, discharges are so complicated that forgetting a single detail can derail the whole process, according to panel moderator and hospitalist Lakshmi Halasyamani, MD. At St. Joseph Hospital in Ann Arbor, Mich., where she is associate chair of medicine, elaborate discharge plans have completely fallen through when an “officially discharged” patient is still in the hospital at 5 p.m. “because no one made sure the patient had a ride home.
To turn such costly problems around, panelists detailed innovations that make creative use of discharge advocates, interdisciplinary rounds, and even contracts that spell out both hospitalists’ and patients’ discharge responsibilities. One theme was constant throughout their narratives: A successful discharge must be a team effort, with clearly delineated responsibilities for every member of the team.
Boston Medical realized it had a real problem: 19.7 percent of the medical center’s discharged patients were being re-hospitalized within 30 days, while 17 percent hit the emergency room at some point in the month after discharge. Not surprisingly, investigators discovered that patients were more likely to be re-admitted if they’d been discharged on weekend days or if they lacked family or social support.
Those statistics were the starting point for Boston Medical’s “Project RED” (ReEngineering the Discharge) initiative, which was funded by the Agency for Healthcare Research and Quality. Dr. Greenwald was the project’s co-investigator.
“We wanted to find out if we could decrease those unplanned re-hospitalizations by improving the discharge process,” he said. But when it deconstructed that process, the hospital found it was tremendously complex “and that physicians, nurses and case managers all operated effectively “in silos” that weren’t coordinated with each other.
The project included several innovations. First, team members appointed a dedicated discharge advocate to each patient. That advocate not only coordinates some activities during admission and immediately prior to discharge, but also becomes the key contact person post-discharge.
“This gets to the idea that somebody’s got to own the process,” Dr. Greenwald said. While the discharge advocate doesn’t have to personally arrange every discharge detail, “it does mean that she makes sure everything gets done.”
The advocate’s responsibilities include coordinating care-team members, preparing patient education, arranging “after care,” and dealing with medication education and reconciliation. The discharge advocate also arranges medication pickups and durable medical equipment delivery as needed, and makes sure patients have scheduled transportation.
Addressing after-hospital care
Another re-engineered component was the creation of a highly-detailed, comprehensive and illustrated after-hospital care plan. The document, which includes a title page with photos of both the primary treating physician and the discharge advocate, gives explicit instructions for the first days and weeks after discharge.
It also includes the following elements:
“¢ follow-up appointment details, including a color-coded calendar that highlights appointments;
“¢ mention of pending test results;
“¢ a list of medications, with brand and generic names, medical indications and diagnoses, and doses and schedule, as well as photos of each pill;
“¢ diet, exercise and lifestyle recommendations; and
“¢ a copy of one of Boston Medical’s patient-focused clinical pathways if the patient has a diagnosis like heart failure.
A third component was also re-engineered: a scripted phone call from the hospital pharmacist to the patient or caregiver within two to three days after discharge. The phone call accomplishes several goals: It helps identify medication issues or concerns before they lead to re-admission or, worse, a serious adverse event. It also allows the pharmacist to touch base with patients about their clinical condition, and it serves as a reminder to patients about follow-up appointments.
In addition, Project RED has redesigned other care components to improve discharges: delivering patient education throughout the hospital stay, not just at discharge; using case management services on a full-time basis; and providing discharge information in the patient’s primary language and at the patient’s literacy level.
While data from the project are still coming in, Dr. Greenwald is confident they will show improvement. The painstaking process of mapping out the maze of discharge procedures has already identified “the clear roles and responsibilities of physicians, nursing and others involved in the discharge process” to improve coordination, he said. It’s also raised everyone’s appreciation of what goes into “a good discharge.”
Cutting LOS for complex patients
Hospitalist Adrienne Green, MD, associate clinical professor of medicine at University of California, San Francisco (UCSF),cited another real-life discharge dilemma: patients with complex medical needs and/or social situations, or unusually long lengths of stay.
She presented the case of a 57-year-old woman with multiple co-morbidities and multiple admissions over a six-month period. The patient had diabetes, end-stage renal disease, obstructive sleep apnea and COPD, as well as anoxic brain injury, cardiac arrest and two hospital-acquired infections. To make matters worse, she had poor family support and no social network.
“Transferring this patient out of the hospital was extremely complex,” said Dr. Green. “She had a trach and was on dialysis and BIPAP, so she required attendant care.”
It was cases like this “which aren’t that unusual for an urban academic center “that prompted UCSF, as part o fan SHM demonstration project, to look for a better approach to complex discharges. The result, which Dr. Green described as “a work in progress,” was the evolution over the past five years of what became known as complex discharge planning rounds for patients with complex medical, psychosocial or financial needs; extended length of stay of more than seven days; or financial issues, including lack of insurance.
The rounds program has evolved into a weekly gathering where the core attendees are social workers and case managers, who directly enter discussion details into an automated case-management system.
In addition to social workers and case managers, attendees include the chief medical officer and physician advisor to care coordination, nurse managers and a patient-care director, the rehabilitation services supervisor, and admissions personnel.
“We’ve also added insurance and contract folks recently,” Dr. Green said, “and we’ve learned that physicians need to serve as the care-coordination champions” to produce the desired result: a well-planned discharge where patients don’t bounce back as re-admissions.
The rounds “which typically review up to 25 patients “combine both highly structured and informal elements. First, the case manager or social worker gives a brief presentation. Then the entire group brainstorms during a targeted discussion of anticipated discharge obstacles.
Harnessing information technology
According to Dr. Green, those discussions are particularly helpful to share information and expertise.
“One case manager knows absolutely everything about homecare services,” she said. Dr. Green has also learned a lot about insurance and financial issues, as well as ways to expedite transfer of patients both into and out of the UCSF system.
The fact that case managers enter real-time rounds data and decisions into the system has also paid off, she added. On-site data entry saves chart and system information entry later, for one. It also promotes much better follow-through, which was previously a sore point.
“We would have a discussion about action plans” one week, Dr. Green pointed out, “and then go through it the next week again.”
And having the case management system available during rounds gives attendees access to key discharge-related information, including how many patients are waiting for skilled nursing facility or long-term care placement.
“It’s enabled us to look at issues like ‘avoidable’ inpatient days,” said Dr. Green. “This is a good example of how IT can actually augment a discharge system.”
Dr. Green was not able to provide any cost or savings data. But “we now believe that many patients who have been in our hospital 45 to 55 days probably would have been there many more days without the rounds.”
Improving medication reconciliation
More than one-half of all inpatient medication errors occur at care transition points, such as discharge.
To close that gap, a project being conducted at Johns Hopkins Bayview Medical Center in Baltimore is designed to improve medication reconciliation and patient education at discharge. Part of a multicenter study funded by the Hartford Foundation through a grant to SHM, the Bayview project zeroes in on medication safety issues as patients transition from hospital to home.
The project is timely, noted panelist Eric Howell, MD, a hospitalist involved in the study. “It just so happened that when we decided to look at this, JCAHO had just mandated some form of medication reconciliation at care transitions,” he said of the accrediting organization’s 2006 patient-safety goals. “We focused on the discharge aspect because we thought it was the lowest-hanging fruit.”
The Bayview intervention is two-fold. First, it standardizes the medication review process on admission and again at discharge. Historically, physicians, not nurses, do the medication reconciliation, which a case manager then clarifies and confirms.
“We wanted to impact steps two and three by using an inpatient pharmacist with experience in geriatrics,” said Dr. Howell. The pharmacist now reviews and reconciles the medications “both at admission and discharge “with the help of the outpatient physician, reporting any concerning findings to the hospitalist. The goal of the intervention is to complete medication reconciliation within 24 hours of admission and within three business days of discharge. (The latter time frame was needed to accommodate weekend discharges.)
The second component being tested expands the patient education process at discharge. Before, “We basically went in with a list of medications and said ‘thank you,’ ” Dr. Howell said. “In fact, we have found that patients understand very little of what you are explaining about the discharge process “especially medication lists and test results.”
Now, hospitalists schedule an in-hospital “pre-discharge appointment “within the 24-hour period before discharge. These appointments last 30 minutes or less (as compared to 15-minute discharge meetings used prior to the intervention) and are done in partnership with a case manager.
Each appointment includes pictorials for patients with literacy issues, dedicated time to answer questions about discharge-related issues, and a medication “dry run” to assess patients’ understanding of what they will take and when. Ideally, Dr. Howell added, appointments also include a family member or patient “agent” at the bedside.
The discharge contract
The discharge appointment also introduces another feature: a discharge contract, which both the hospitalist and patient must sign, that spells out each of their responsibilities.
“That’s the part that’s novel “and perhaps controversial,” Dr. Howell said. By signing, the hospitalist agrees to make the hospitalist service available by phone post-discharge if questions arise. (The contract also states that the hospital pharmacy agrees to provide medications as needed to reconcile all medications between discharge and the first follow-up appointment.)
For their part, patients agree that they understand their medication list and schedule, and what symptoms to look and get help for.
While it is still too soon to assess the intervention’s impact, investigators plan to look at three- and 30-day results with regard to medication issues, re-admission rates and patient satisfaction with the discharge process.
To date, Dr. Howell said he and his colleagues have already learned two key lessons: First, interventions should be as simple as possible to start. And two, everyone who will be affected by or involved in a new process must buy in.
“If this is something that will require a special discharge form and process that will take more time for the hospitalist,” he said, “there needs to be a document that states that the physician agrees to participate.
Bonnie Darves is a freelance writer specializing in health care.She is based in Lake Oswego, Oregon