Axial in the News: Scaling Project RED and Project BOOST

Let’s face it: despite all kinds of incentives, financial and otherwise, statistics overwhelming indicate that the problem of readmissions isn’t improving. What other industries have a 20% return rate? While there are certainly issues that will and should land people back in the hospital, there are also many patients who shouldn’t go back.
Most experts believe 9-10% readmissions are really where we should be as a country.

  • Some 19% of all Medicare patients entering the hospital will be back within 30 days, and 34% within 90 days, costing America $19 billion per year.

Readmission costs on key diseases among the commercially insured, including congestive heart failure, heart attack, and pneumonia, total $6 billion; added to the above Medicare patient readmissions, this means we are spending $25 billion a year on readmissions.

Despite providers’ best efforts, huge communications gaps exist when patients transition from hospital to other care settings, or to home -- gaps that can drive up avoidable readmission rates and patient safety issues. The data is astounding, really:

  • Direct communication between hospital physicians and primary care physicians occurs in only 3 to 20 percent of cases. Journal of the American Medical Association, 2007
  • 78% of patients discharged from the ER do not understand their diagnosis, their ER treatment, home care instructions, or warning signs of when to return to the hospital. – Annals of Emergency Medicine, June 2000

Yet technology is already playing a powerful role in addressing readmissions at many leading institutions. The work of evidence-based programs such as Project RED and Project BOOST show meaningful reductions in readmissions -- up to 30% -- by addressing key issues such as better communications with follow-on medical professionals, caregiver involvement in the discharge process, patient engagement and education, and the scheduling of follow-on care before the patient is discharged.

Scalability, however, is another matter. With over 600 hospitals piloting these evidence-based programs, and getting impressive results in their pilots, most run smack into a brick wall. Providers can’t scale these initial manual efforts to educate, schedule, and stay in touch with patients -- intensive processes are needed to really move the needle at the hospital level. That’s where appropriate technology can change the equation, and allow these hospitals to do what’s right for every patient, not just a sample population.

Eight Steps to Using Technology

Eight of the eleven components of Project RED and Project BOOST can be optimized by software, and readily scaled to address many critical touch-points on the provider IT network. Specifically, technology helps RED and BOOST implementations deliver consistent patient engagement, increase the effectiveness and efficiency of the nursing staff without increasing headcount, and measure results via a real time dashboard. This leads to lower readmissions, improved PCP follow-through rates, and ultimately an improved patient experience.

Most of these changes aren’t rocket science, and they don’t require lengthy IT development efforts and costly extensions to the EHR. Rather they’re simple ways to use technology to deliver data the hospital already owns, but may needlessly lock into “silos” of information, instead of pushing it out toward the primary care physicians who can use it. These changes also may replace outdated approaches with less impact and efficiency.

  • Patient engagement via touch screen, instead of static brochures or paper handouts. Tablets with text-to-speech capability in particular can reach virtually every patient regardless of computer skill to learn about their condition and prepare for aftercare.
  • Real-time risk scoring, instead of failing to flag patients who have the potential to be readmitted – so clinicians can gauge readmission risks BEFORE the patient is discharged. Our motto is that discharge planning should start at the time of admissions, so appropriate interventions can be put into place from the start.
  • Automated delivery to clinical summaries provided in real time to community providers – not via faxes.

Here are eight ways that providers can follow Project RED’s lead and use technology to re-engineer the discharge process.

1. Expedite Transmission of the Discharge Summary.

Timely visits to an outpatient physician are an important part of the care plan. Yet only an estimated 12 to 34% of physicians receive discharge summaries by the time the patient makes his or her first post-discharge visit. Many hospitals resort to fax machines and remote access procedures, neither of which accommodates the busy reality of the outpatient physician. Modern Web technology solves this problem elegantly. Unwieldy hospital chart data can be automatically transformed into clean clinical summaries, and pushed in real-time to community care providers:

  • Securely transmit information to the physicians and nurses in simple, easy to use browser format – no Citrix clients, combing through lists of patients, or getting 20-page charts
  • Logically summarize and edit the key information and transmitting to the right place and time. Doctors should be able to access the information they need in thirty seconds on a single page
  • Make the customized summaries available to users via the device of their choice: smartphones, tablets, and/or PCs

2. Educate Patients throughout the Stay.

National statistics suggest that at discharge only 42% of patients are able to state their diagnosis, and only 37% able to state the purpose of their medications. In order to take control of their health and well-being, patients must have a baseline of health literacy. A visit to the hospital is an ideal time to begin the process by asking core questions such as these: Why have you been admitted? What is happening to your body? How can you recognize future symptoms? What should you do when complications arise?

Technology is ideally suited to:

  • Reviewing concepts
  • Presenting text with sound, video and interactivity that improve uptake
  • Providing pictures to facilitate greater understandin

3. Confirm the Medication Plan

Unlike scrawled prescription details on a discharge form, tablet and mobile displays can include actual photos of pills, along with doses, instructions on how and when to take the pills, and other information. Providing this in an easy to use graphical format makes certain those with different language or literacy levels can follow along.

4. Assess Understanding with Teach-back Processes.

Health care is one of the few industries that haven’t recognized that talking at a sick patient without give-and-take contributes to patients only retaining 15% of what they hear. Most education studies show that teach-back -- asking questions and assessing whether the patient ”got it” -- improves retention tremendously.
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5. Make Follow-up Appointments.

Patients who lack an outpatient appointment at the time of discharge represent 50% of readmitted cases nationwide. Relying on patients to make this initial appointment when they return home increases the risk that the appointment-setting will not happen. Instead, an easier and faster way is to automate both the appointment setting and the verification that the appointment is kept. Reminder systems can track date/time of medical appointments and equipment deliveries for the patient and their caregivers and family members.

6. Provide a Written Discharge Plan.

Discharge plans are communicated to patients orally as an eight-minute list of things they need to do. Can you remember eight or nine things that someone tells you, even if you’re not sick? We need to make written discharge plans that can be referred to by the patient, their physicians, family members, and caregivers as often as they need after discharge. With an estimated 1.4 billion smartphones on the market by 2015 – 500 million loaded with at least one health-related application – the time has come to consider smarter discharge plan delivery to patients as well. Electronic discharge plans can provide at-a-glance information for easier understanding and follow-through.

7. Organize Post-discharge Services.

Synthesizing aftercare appointments into a simplified one-page overview can facilitate understanding and compliance. It’s also a place where social worker support and payment considerations can be built into the provider-patient dialogue in a non-intrusive way.

8. Assess Patient Risk.

Technology can simultaneously streamline the discharge process for the clinician and identify risk factors.

  • When a discharge coordinator uses a mobile device, they can be guided through the many steps in the hospital’s discharge process.
  • Input gathered by the discharge coordinator can feed a real-time dashboard of risk factors such as whether the patient is leaving the hospital with their medication, with a primary care physician appointment, with transportation to their appointment, and whether the patient has questions on their care.
  • An early-warning dashboard can help clinicians to zero in on particular issues with each patient.

Businesses turn to technology to add efficiency and consistency where manual methods lack them. It’s time we follow the business world’s lead and add to what we have learned from evidence-based initiatives like Project RED and Project BOOST by selectively implementing technology where it can best assist the discharge process. Doing so is already engaging patients, lowering 30-day readmission scores, and improving patient satisfaction.

Readmissions News, July 2012