Slide Presentation from the AHRQ 2008 Annual Conference
On September 9, 2008, Brian Jack, M.D., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (2.1 MB).
Slide 1
Testing the Re-Engineered Discharge (RED)
Hands-on Health Literacy
September 9, 2008
Principal Investigator: Brian Jack, MD
Associate Professor and Vice Chair
Department of Family Medicine
Boston Medical Center /
Boston University School of Medicine
Slide 2
"Perfect Storm" of Patient Safety
- Loose Ends—workups NOT completed.
- Communication—DC [discharge] summary not available.
- Poor Quality Info—DC summary lack results.
- Poor Preparation—few pts know meds/dx.
- Fragmentation—who is in charge?
Slide 3
Principles of the RED: Creating the Toolkit
Screen shot of a chart that shows:
- Readmission Within 6 Months
- Between Readmission Within 6 Months and Hospital Discharge:
- Upward arrow with text box underneath stating Probabilistic Risk Assessment
- Hospital Discharge
- Upward arrow from the text box Process Mapping pointing to Hospital Discharge.
- Between Hospital Discharge and Patient Readmitted Within 3 Months:
- Failure Mode and Effects Analysis
- Patient Readmitted Within 3 Months
- Qualitative Analysis and upward arrow.
- Root Cause Analysis and upward arrow.
Slide 4
RED Checklist
Eleven mutually reinforcing components:
- Medication Reconciliation.
- Reconcile Plan with National Guidelines.
- Follow-up Appointments.
- Outstanding Tests and Studies.
- Post-discharge Services.
- Written discharge plan.
- What to do if a problem arises.
- Patient Education.
- Assess patient understanding.
- Dc summary to Primary Care Physician (PCP):
>Telephone Reinforcement.
Note: Adopted by National Quality Forum as one of 30 "Safe Practices" (SP-11)
Slide 5
The slide shows a sample cover of an "After Hospital Care Plan" for a discharged patient from Boston Medical Center.
Slide 6
The slide shows a sample page from the "After Hospital Care Plan" entitled "Medicines." It shows the name of the medicine, dosage, what it is for, and what time of day to take it.
Slide 7
The slide shows a continuation of the previous slide"s sample page, "Medicines."
Slide 8
The slide shows a sample calendar from the plan which highlights when the patient left the hospital, when the pharmacist will call, and when future appointments are scheduled.
Slide 9
The slide shows a sample page from the plan which gives information on "Noncardiac Chest Pain."
Slide 10
Intervention to Administer RED
- In Hospital—Discharge Advocate (DA):
- Nurse.
- Interact with care team—med rec and guidelines.
- Prepare the After Hospital Discharge Plan (AHCP).
- Teach the AHCP.
- After Discharge—Clinical Pharmacist:
- Follow-up call @ 2-3 days.
- The DA and Pharm manual:
Note: The slide shows a photograph of a woman.
Slide 11
Testing the RED Schematic
Screen show of a flowchart showing:
- Enrollment N=750
- Informed Consent
- Randomization
- RED Intervention and Usual Care
- 30 Day Outcome Data; Telephone Call; Chart Review
Slide 12
AHCP Evaluation: 30 days post-discharge
The pie chart presents the results to the question, "How useful was the booklet to you?"
- Extremely: 19%
- Very: 39%
- Moderately: 21%
- A little bit: 17%
- Not at all: 4%
Slide 13
AHCP Evaluation: 30 days post-discharge (continued)
The pie chart presents the results to the question, "What was the most helpful part of the booklet?"
- Medical Provider Information: 13%
- RED Medication Schedule: 25%
- Appointment Page: 20%
- Appointment Calendar: 12%
- Diagnosis Information: 15%
- Other: 15%
Slide 14
AHCP Evaluation: 30 days post-discharge (continued)
The pie chart presents the results to the question, "How helpful was the RED medication calendar?"
- Extremely: 26%
- Quite a bit: 45%
- Moderately: 15%
- A little bit: 9%
- Not at all: 4%
Slide 15
Self-Perceived Readiness for Discharge
30 days post-discharge
The bar graph shows RED had higher numbers than Usual Care in the following areas:
- Prepared
- Understand Appointments
- Understand Meds
- Understand Dx
- Questions answered
Slide 16
Primary Outcome
| Outcome |
Control
(n=376) |
Intervention
(n=373) |
P-value |
Hospital Utilization:
Total number of visits
Rate |
167
44/100 subjects |
116
31/100 subjects |
<0.001 |
Emergency Department (ED):
Total number of visits
Rate |
90
24/100 subjects |
61
16/100 subjects |
0.01 |
Rehospitalization:
Total number of visits
Rate |
77
21/100 subjects |
55
15/100 subjects |
0.05 |
Slide 17
Cumulative Hazard of Patients Experiencing a Hospital Utilization in 30d After Index Discharge
Screen shot of a line graph presenting the "Probability of Survival" for 0 to 30 days after discharge for RED and Usual Care. The results show the probability of survival declining for both RED and Usual Care as time elapses. However, at 10 days after discharge, RED's decline is not as rapid as Usual Care.
Slide 18
Conclusions from the Randomized Controlled Trial (RCT)
RED:
- Successfully delivered using:
- Improves "Readiness for Discharge".
- Decreases hospital use:
- 32% reduction.
- Number needed to treat (NNT) = 7.9.
- Helps high hospital utilizers:
- Is Cost-Effective:
- $329/patient.
- 38 million discharges @ $753 billion x 32% eligible = 4 billion.
Slide 19
Major Problem: RN Time Can Health Information Technology (IT) Help?
- Embodied Conversational Agent to Teach the AHCP:
- Emulate face to face communication.
- Develop therapeutic alliance:
- Empathy.
- Gaze, posture, gesture.
- Workstation database to automatically print AHCP and "feed" Louise.
- Connect hospital IT to workstation.
- Kiosk for patient access.
Note: The slide shows an image of a woman named "Louise".
Slide 20
The slide shows a photograph of a woman in a hospital bed adjusting a telemedicine screen.
Slide 21
Social Chat
Slide 22
Cover
Slide 23
Medications
Slide 24
Appointments
Slide 25
Diagnosis
Slide 26
Closing
Slide 27
Thank You AHRQ!
- PI: Brian Jack, MD
- Michael Paasche-Orlow MD, MPH
- Caroline Hesko, MPH
- Irina Kushnir
- Fiana Gershengorina
- Kim Visconti, RN
- Jared Kutzin, RN, MPH
- Alison Simas, RN
- Mary Goodwin, RN
- Lynn Schipelliti, RN
- Lindsey Hollister
- Maggie Jack
- Kacie Fyrberg, RN
- Vimal Jhaveri
- Laura Pfeifer
- Juan Fernandez
- David Anthony, MD, MSc
- Tim Bickmore PhD
- Gail Burniske, PharmD
- Kevin Casey, MPH
- VK Chetty, PhD
- Allyson Correia, RN
- Larry Culpepper, MD, MPH
- Shaula Forsythe, MPH, MS
- Rob Friedman, MD
- Jeffrey Greenwald, MD
- Anna Johnson
- Anand Kartha, MD
- Christopher Manasseh, MD
- Julie O'Donnell
Current as of January 2009
Internet Citation:
Testing the Re-Engineered Discharge: Hands-on Health Literacy. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090908slides/Jack2.htm
540 Gaither Road Rockville, MD 20850