Implementing Re-Engineered Hospital Discharges (Project RED)

The Re-Engineered Hospital Discharge project, known as Project RED, was developed by Brian Jack, M.D., Associate Professor of Family Medicine at Boston University and Timothy Bickmore, Ph.D., Assistant Professor in the College of Computer and Information Science at Northeastern University, through a Partnerships in Implementing Patient Safety grant from the Agency for Healthcare Research and Quality. The project is designed to re-engineer the hospital workflow process and improve patient safety by using a nurse discharge advocate who follows 11 discrete, mutually reinforcing action steps shown to improve the discharge process and decrease hospital readmissions. Patients who have a clear understanding of their after-hospital care instructions, including how to take their medicines and when to make follow-up appointments with their doctors, are 30 percent less likely to be readmitted or visit the emergency department than patients who lack this information, according to a study by Dr. Jack that appeared in the February 3, 2009, Annals of Internal Medicine.

The Project RED toolkit includes the following:

• Training Manual—This workbook for health professionals details how to deliver a safe and effective hospital discharge.
• After Hospital Care Plan Sample Form—The After Hospital Care Plan is designed to clearly present the information needed by patients to prepare them for the days between discharge and the first visit with their ambulatory care physician.
• Computerized Workstation to Print the After Hospital Care Plan—This document describes the computerized workstation and the process used to create and print the After Hospital Care Plan.

The following are some frequently asked questions—and answers—about Project RED.

 

Contents

Instructions for Follow-up Medical Appointments Post-Discharge
Discharge Advocate
Discharging Patients to Nursing Homes and Assisted Living Facilities
Evaluation of Project RED
Cost and Implementation of Project RED

 

Instructions for Follow-up Medical Appointments Post-Discharge

1. A component of Project RED is that the primary care physician (PCP) appointment is scheduled. Who is responsible for scheduling the appointment?

   In the Project RED study, the nurse was responsible for speaking to the patient to identify times that they were available for an appointment and to note the PCP name and location. The nurse would also consult with the patient's medical team to find out if there were specific requests about the timeframe for the appointment. The nurse would schedule the appointment if she or he had time. Otherwise, the nurse would ask the research assistant to schedule the appointment.

2. When is the appointment scheduled?

   The appointment is scheduled prior to discharge. Staff tried to make every appointment within two weeks after discharge. The patient would be informed of this appointment before discharge by writing it on his or her After Hospital Care Plan. The only exception was that patients discharged on Saturday or Sunday would have to wait until Monday for an appointment to be scheduled. Subsequently, staff called the patient to inform them of the appointment time and make sure they would be able to go.

3. Did you have a target timeframe for scheduling PCP or specialist follow-up appointments, and if so, what was it and why?

   The target timeframe for scheduling PCP or specialist follow-up appointments was within two weeks post-discharge. Nurses in the Project RED study were able to schedule follow-up appointments for more than 80 percent of patients within that timeframe at health centers or with their primary care physicians. Researchers chose two weeks as the timeframe based on suggestions from the medical team that this was the appropriate timeframe in order to foster continuity of care.

4. Are the phone calls from the pharmacy and other post-discharge phone calls normally made by a nurse?

   The phone calls from the pharmacist to the patient to discuss medications occur independently from any other post-discharge phone calls.

 

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Discharge Advocate

5. What type of commitment is required from providers, nurses, and other hospital staff to make implementation successful?

   The research study found that it is not only important for a majority of the providers, nurses, and other hospital staff to support the new process, but also that they commit to making the process successful. The type of commitment required by providers, nurses, and other hospital staff depends on several factors such as the hospital's patient population and patient needs, as well as the number of hospital personnel allocated to carry out the Project RED intervention.

6. What is the ratio of the discharge advocate to discharge patient, and how many patients can a discharge advocate discharge per shift, on average?

   In the Project RED study, the ratio of the discharge advocate to discharge patient was 1:2, and on average, one patient was discharged per day. However, because it was a research study, there were several factors that limited the ability of the discharge advocate to care for more patients:

   • Lack of staff: The discharge advocate typically worked six hours on the weekdays and five hours on the weekends (e.g., Monday through Friday from 8:00 a.m. to 2:00 p.m., weekends from 10:00 a.m. to 3:00 p.m.) which is less than a typical eight-hour shift.
   • Time to generate After Hospital Care Plan: It took a considerable amount of time to generate the After Hospital Care Plan because the discharge advocate had to populate it manually (the electronic software to generate the After Hospital Care Plan was not available at the time).
   • Lack of integration with medical team: The discharge advocates were not integrated with the medical team. Therefore, they did not have access to the medical team's data on the patients and had to ask patients more questions than they would have otherwise.

   Researchers anticipate that discharge advocates would be able to care for more patients in the normal hospital setting given that these research limitations would either not exist or they would be minimized.

7. Does the discharge education associated with Project RED allow physicians to bill at a higher level?

   Physicians can bill for two different levels of discharge education. In general, physicians who perform discharge education using Project RED can bill at the higher level (CPT Code 99239), which would allow them to bill approximately $32 more per discharge.

8. How have providers, nurses, and other hospital staff responded to the use of the virtual discharge advocate?

   Project RED has been well received so far. To understand nurse reaction, a brief test was conducted during an in-service for nurses. Half of the nurses received a briefing on Project RED, and the other half had a one-on-one interaction with one of the virtual nurses and performed some trust-building exercises. They had a personalized 10-minute chat with the virtual nurse. The test found that nurses with the opportunity for a one-on-one interaction were significantly more accepting of the system, more likely to recommend it to their patients, and felt significantly less threatened by it.

9. Is the virtual discharge advocate technology only available as a stand-alone application or can it be built into other existing discharge planning programs a hospital may have?

   The virtual discharge advocate technology is available as a stand-alone application and can also be built into other existing technology. The system can be integrated directly into the hospital information technology environment. In addition, staff training is available on how to deliver the discharge materials and information.

10. Was it necessary to enter all patient data at the nurses' workstation, or did the program interface with the hospital's electronic medical record (EMR) and pull in some information?

    Currently, it is necessary to manually enter all data in the workstation. Project RED is working on integrating the software with the hospital electronic medical record, but that project has not been completed.

 

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Discharging Patients to Nursing Homes and Assisted Living Facilities

11. What do nursing homes and assisted living facilities think of the discharge tools?

    In some cases, Project RED study subjects were discharged to a nursing home. In such cases, nursing home personnel provided positive feedback, saying, "This After Hospital Care Plan is terrific. We used to only get the discharge summary, and it is very unclear from a discharge summary what we are supposed to do." The staff and the nursing homes benefited from a clearer presentation of what the patient needs to do, when the appointments are, what tests are pending, what the diagnosis is, how to follow up on any problems, and how to reach the clinician that is covering for them.

    It should be noted that the Project RED study did not enroll patients that were admitted from nursing homes, skilled nursing facilities, and rehabilitation centers for research purposes. However, the Project RED intervention could be adapted to meet the needs of these patients and their care facilities.

12. How do you best educate family members about discharge instructions when patients are being discharged to a nursing home or assisted living facility?

    The Project RED research study found that the best way to educate family members about discharge instructions was through both the paper-based and electronic version of the After Hospital Care Plan. Often a nurse does not have time to provide education to a family member separately after he or she has already provided education to the patient. With the After Hospital Care Plan, an organization can provide family members the necessary information they need to take care of their elderly relative. Using the electronic version of Project RED, a nursing home can simply invite family members to sit and meet Louise, the virtual discharge nurse, and go through everything that they need to know to take care of their elderly family member.

 

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Evaluation of Project RED

13. Have there been any post-discharge followup studies to determine if improvement has been sustained and gains maintained?

    Project RED has collected hospital readmission data up to 90 days post-discharge. These data will be analyzed in the near future in order to answer this question. However, it has been observed that the vast majority of the readmissions occurred within the first 30 days after discharge. Therefore, this is a specific area in which Project RED investigators are interested given that no further intervention is provided after the pharmacist phone call, which occurs two to four days post-discharge.

14. What software, electronic forms, and process ideas can be shared to test Project RED at other organizations?

    Researchers tested Project RED by tracking various process and patient outcome measures. In order to better understand how well staff were using Project RED to discharge patients, researchers examined a variety of process measures, including the number of patients who received the After Hospital Care Plan, instruction from the discharge advocate, follow-up telephone calls, as well as the number of patients who had their medications reconciled. Researchers also reviewed various patient outcome measures, including patient satisfaction measures and hospital readmission rates.

    For additional information on the types of measures used to test Project RED, please review the following article: "A Reengineered Hospital Discharge Program to Decrease Rehospitalization. A Randomized Trial," by Brian W. Jack, MD, et al., in the February 3, 2009, Annals of Internal Medicine, 150(3), pp. 178-187.

 

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Cost and Implementation of Project RED

15. Is the After Hospital Care Plan a retail software product? How much does it cost to purchase and implement?

    The software to create the After Hospital Care Plan is available for purchase and implementation at your organization.* The cost of the software varies based on multiple factors including, but not limited to, the size of your organization, the extent of training and support required, if your organization wants to integrate the After Hospital Care Plan into an existing electronic medical record, and if your organization wants to purchase the Virtual Discharge Advocate technology (i.e., the electronic version of Project RED). With the electronic version of Project RED, the amount of time the nurses need to teach the After Hospital Care Plan is greatly reduced.

    For more information or if you are interested in implementing Project RED in your organization, please visit the Project RED Web site at http://www.bu.edu/fammed/projectred/.

*Boston Medical Center/Boston University School of Medicine has developed this product using professional and scientific methods, sources, and up-to-date clinical standards at the time of publication to confirm that the information contained in it is both reliable and valid. However, Boston Medical Center/Boston University School of Medicine and AHRQ caution that the product is to be utilized using the professional judgment of authorized physicians or nurses and staff directed and supervised by them. Each health care professional who decides to use this product or its content should understand that such use would be on the basis of that provider's professional judgment with respect to the needs and characteristics of the particular patients they are caring for. Boston Medical Center/Boston University School of Medicine and AHRQ disclaim any and all liability for adverse consequences or for damages that may arise out of or be related to the professional use or application by practitioners of the product or its content, including but not limited to, indirect, special, incidental, exemplary, or consequential damages. Furthermore, practitioners should be cautioned that professional and scientific methods and standards evolve over time. Therefore, attention should be given to possible progress in medical standards, techniques, and technology occurring after the production of this material.

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