Standardized Discharge Planning Focusing on Patient Education and Care Coordination Increases Understanding of Postdischarge Needs and Likelihood of Followup Care

Problem Addressed

• Inadequate attention to discharge planning: In many hospitals, first-year residents and/or other health professionals with many competing responsibilities are charged with overseeing the discharge planning process; their divided attention increases the risk of an incomplete and/or otherwise inadequate discharge process.¹
• Poor communication and a lack of coordination: The hospital discharge process is often characterized by poor communication and a lack of coordination between the hospital and the PCP. When patients are discharged, they often do not know what medications their physicians have prescribed, when their follow up appointments should take place, and, in some cases, why they were hospitalized in the first place.²
• Negative impact on quality: Poor discharge planning results in many patients failing to receive needed follow up care from their PCP within 30 days of discharge. This lack of follow up care, along with other problems caused by inadequate discharge planning, can lead to medical errors, adverse events, and high rates of rehospitalization.¹

Description of the Innovative Activity

• Re-engineered discharge process: The revamped process consists of the following 11 steps that should be completed by the hospital staff prior to discharge; for Project RED, these steps were carried out by the discharge advocate. The process consists of the following steps: 
  • Educate the patient about his or her diagnosis throughout the hospital stay.
  • Make appointments for clinician follow up care and postdischarge testing at times and locations that are convenient and practical for the patient.
  • Discuss with the patient any tests or studies that have been completed in the hospital, and discuss who will be responsible for following up with the results.
  • Organize postdischarge services.
  • Confirm the medication plan.
  • Reconcile the discharge plan with national guidelines and clinical pathways.
  • Review the appropriate steps if a problem arises.
  • Expedite transmission of the discharge plan to clinicians accepting responsibility for the patient’s care after discharge.
  • Give the patient a user-friendly discharge plan at the time of discharge.
  • Assess the patient’s degree of understanding by asking them to explain the details of the discharge plan in their own words.
  • Provide telephone reinforcement of the discharge plan and problem-solving assistance 2 to 4 days after discharge.
• Discharge advocate: Beginning within the first 24 hours of admission, a nurse serving as a discharge advocate spends an average of 50.1 minutes providing a number of services for the patient, which correspond to the 11 steps. These services include general patient education; medication reconciliation; communicating with hospital physicians; locating a primary care provider as needed; arranging follow up appointments at convenient times for the patient; connecting patients with pharmacies; explaining discharge information; creating and explaining the postdischarge care plan; and telling patients who to contact if they have any questions or if a problem arises. 
• After-Hospital Care Plan: The After-Hospital Care Plan is a spiral-bound, color booklet designed to clearly present the information patients need to prepare them for the days between discharge and the first visit with their PCP.
  • Discharge planning workstation: The discharge advocate enters relevant patient information into a dedicated, computerized workstation that serves as the nexus of all information regarding patient discharge and follow up care. The information is then used to create a draft of After Hospital Care Plan. The discharge advocate asks the patient’s physician to approve the draft; once finalized, the discharge advocate prints a final copy that is spiral-bound and used in patient education. 
  • After-Hospital Care Plan contents: The plan contains information about the discharge diagnosis; a list of discharge medications, including why and when the patient needs to take each medication; a daily medication schedule that indicates visually what time medications should be taken; instructions about what the patient should do if his or her condition changes, including phone numbers of outpatient providers; a calendar indicating scheduled appointments with outpatient providers and/or follow up tests; information on diet, exercise, and home equipment; and information to enable the patient to take an active role in follow up care. 
• Outreach by pharmacists: A pharmacist calls patients 2 to 4 days after discharge to review their medications, assess whether they are taking the medications as prescribed, determine whether they understand how and when to take them, verify the dosage and times of day the patient should take the medications, explain the potential for adverse events such as drug-drug or drug-food interactions, and intervene when necessary.

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Results

• Reduced rehospitalization rate: The rate at which patients were readmitted to the hospital in the 30 days after discharge was 30 percent lower for the intervention group compared to the control group (0.314 vs. 0.451 visits per person per month). Emergency department visits were 33 percent lower in the intervention group (0.165 vs. 0.245 visits per person per month).
• Improved patient understanding of condition and follow up care needs: The revised discharge planning process enhanced patients’ understanding of postdischarge roles and responsibilities. For example, 66 percent of the intervention patients understood their primary diagnosis when they left the hospital, compared to 57 percent of the control patients, and 89 percent of intervention patients understood how to take their medications after hospital discharge, compared to 83 percent of control patients.
• Better patient perception of preparedness for discharge: Sixty-five percent of patients receiving the intervention felt prepared to leave the hospital, compared to 55 percent of control patients. In addition, 77 percent of intervention patients believed their questions had been answered before they left the hospital, whereas only 62 percent of control patients felt that way.
• Increased likelihood of follow up care: Overall, 86 percent of the intervention patients understood what appointments they were supposed to have after leaving the hospital, compared to 79 percent of control patients. Sixty-two percent of those in the intervention group reported having seen their PCP in the 30 days after discharge, compared with 44 percent of the control group.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Upfront problem analysis: Researchers applied probabilistic risk assessment, process mapping, qualitative analyses, failure mode and effect analysis, and root cause analysis to determine the factors in the standard discharge process that contribute to high rates of rehospitalization; these analyses helped to inform the development of the re-engineered discharge planning process.
• Development of multidisciplinary teams: The researchers assembled two multidisciplinary teams to advise the project team, conduct various aspects of the project, ensure continuity of progress and diversity of ideas, and provide oversight and hospital-wide support.
  • Advisory group: An advisory group that met monthly comprised the chief medical officer, the directors of Developmental Center for Patient Safety Research, senior researchers and statisticians, and Boston Medical Center's directors of nursing, inpatient service, case management, and quality improvement.
  • Working group: A working group that met weekly consisted of a health services researcher, statistician, substance abuse counselor, a clinical pharmacist, directors of the inpatient teams, a research assistant, a discharge advocate, and a hospital administrator.
• Development of underlying principles: The researchers and members of the advisory groups developed a number of principles to guide the new process, including explicit delineation of roles and responsibilities; provision of patient education throughout hospitalization; expedited information flow between hospital team members and the patient’s PCP; ongoing information capture; the development of a comprehensive written discharge plan for each patient; reinforcement of the discharge plan after discharge; delivery of information to the PCP within 24 hours; readily available case management staff; and presentation of discharge information in the patient’s language and at his/her educational level.
• Development of program components: The teams developed the 11-step process, the After-Hospital Care Plan, and the provider training manual.
• Hiring and training of staff: Information provided in April 2009 indicates that Research nurses were hired to function as discharge advocates; their only responsibility was to carry out the 11-step process with intervention patients. The provider training manual was utilized in the training of the discharge advocates. Research assistants assisted the discharge advocates in the delivery of the intervention. The research team notified the medical teams and floor nurses about the conduct of the trial.
• Study design: Researchers designed a randomized controlled trial to test the re-engineered discharge process.

Resources Used and Skills Needed

• Staffing: In addition to the aforementioned advisory groups, project staffing includes a principle investigator (0.2 full-time equivalent, or FTE); data and adverse event analysts (1.5 FTE); postdischarge re-enforcement professionals (0.125 FTE); research assistants (2 FTE); discharge advocates (35 hours/week); a discharge intervention director (0.125 FTE); and a director of health literacy (0.2 FTE).
• Computer equipment and technical support: A dedicated discharge workstation with a computer, printer, and supplies was designated for the creation of After-Hospital Care Plans. Current work includes integrating the dedicated workstation into the hospital's electronic health record system.
• Costs: Cost analysis data provided in April 2009 showed that the total cost of hospital utilization in the 30 days after discharge was $149,995 higher in the control group than the intervention group. This accounted for hospital readmissions and emergency department visits, as well as outpatient followup with primary care providers, which was more expensive in the intervention group (because more patients followup). The cost reduction was thus 33.9 percent, with a savings of $412 per discharge (not including the cost of the intervention).

Funding Sources

Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute (U.S.)

• Project development (2004): The AHRQ Safe Practices Implementation Challenge Grant Program (HS-014289-01) provided funding for an indepth analysis and redesign of the current hospital discharge.
• Trial (2005): The AHRQ Partnerships in Implementing Patient Safety and the National Heart Lung and Blood Institute of the National Institutes of Health provided funding for the randomized controlled trial.
• Ambulatory care integration (2007): The AHRQ Ambulatory Safety and Quality provided funding for integration of Project RED into the ambulatory setting.

Tools and Other Resources

Getting Started with This Innovation

• Clearly delineate staff responsibilities: Staff members should understand their roles and responsibilities related to the revised discharge planning process.
• Implement individual components of the program if necessary: In some cases, implementing the entire 11-step process is impractical; however, implementing discrete steps can be valuable.
• Ensure patient understanding: Consider patients’ general and health literacy levels when designing patient education materials and tools to be used after discharge; present patients with discharge information they can understand by using simple language rather than medical terminology. In addition, confirm the postdischarge care plan with patients to ensure their understanding.
• Ensure adequate time for discharge education: Build in time to educate and explain to patients everything they need to know about their condition and required care during and after hospitalization.
• Ensure that follow up care is convenient for the patient: Make follow up appointments at times that are convenient for patients, and have patients verify that they will be able to come for these visits.
• Extend access to case management staff: Case managers should be readily available throughout the day. Efficient and safe discharge is significantly more difficult to achieve if staff work only the 7:00 a.m. to 3:00 p.m. shift.
• Create a checklist of discharge-related tasks for staff use: Use of this tool increases the likelihood that staff members follow all necessary discharge process steps.

Sustaining This Innovation

• Continually work to overcome ongoing challenges: Ongoing challenges may relate to ensuring patient understanding of discharge education, ensuring proper medication reconciliation, and ensuring timely follow up care for patients whose PCPs have long appointment wait times.

Use By Other Organizations

• Project RED has been chosen as a National Quality Forum (NQF)–Endorsed™ Safe Practice, one of 30 practices that the NQF recommends that all hospitals should adopt to be considered a “safe” organization.