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Service Delivery Innovation Profile

Comprehensive Program To Improve Discharge Process Reduces Readmissions


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Snapshot

Summary

Developed by the Society of Hospital Medicine, Project BOOST (Better Outcomes by Optimizing Safe Transitions) offers hospitals a comprehensive program to improve care transitions for those being discharged. The program features a set of interventions to improve all major aspects of the process, including an assessment of each patient’s risks and level of preparedness to assume postdischarge responsibilities, teach-back education to ensure patient understanding, patient-centered discharge instructions, timely followup care, standardized communication with primary care and other postdischarge providers, and a followup call from hospital staff to high-risk patients. The program offers hospitals a free implementation guide and several fee-based services, including a learning network and mentoring from a physician. In a study involving 11 hospitals, the program significantly reduced readmissions within 30 days of discharge.

Evidence Rating (What is this?)

Moderate: The evidence consists of a controlled study that compared 30-day readmission rates and length of stay on units implementing Project BOOST with the help of a physician mentor to similar units in the same hospitals that used standard discharge planning and care processes.
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Developing Organizations

Society of Hospital Medicine
Philadelphia, PAend do

Use By Other Organizations

Although precise figures are not available, it appears that a significant number of hospitals have implemented some or all components of Project BOOST. Since October 2008, more than 6,400 have downloaded the BOOST toolkit, 54 have participated in BOOST eQUIPS, and more than 180 have received physician mentoring support.

Date First Implemented

2008

Problem Addressed

Patients discharged from the hospital often suffer adverse events that lead to readmission. Many of these readmissions are preventable, as they result from gaps in coordination and communication across settings, inadequate education of patients and family members, and lack of followup with primary care physicians (PCPs) and other providers.
  • Frequent, costly, and often preventable readmissions: Many recently discharged patients, particularly Medicare beneficiaries, are readmitted to the hospital not long after the initial discharge. For example, one study found that almost one-fifth of individuals with an initial preventable admission had at least one preventable readmission within 6 months, at an overall cost of approximately $730 million.1 The Medicare Payment Advisory Committee found that 11.5 percent of Medicare patients are readmitted within 15 days of initial discharge, and 17.6 percent are readmitted within 30 days; more than three-quarters (76 percent) of the readmissions within 30 days are considered preventable.2 Other studies have had similar findings, estimating that roughly 20 percent of Medicare beneficiaries are readmitted within 30 days.3
  • Little coordination, communication, and information sharing across settings: Providers in different settings often do not communicate effectively with each other or with patients and their caregivers. Communication problems lead to general inefficiency and ineffectiveness in the transition process and to specific transition-related problems such as medical errors, equipment-related issues, and transfers to inappropriate locations.4 For example, discharge summaries often lack important information, such as diagnostic test results, recommended treatment(s), accurate information on discharge medications, test results pending at discharge, patient or family counseling needs, and followup plans. One study estimated that 80 percent of serious medical errors involve miscommunication during handoffs between medical providers.5 Another found that even though 40 percent of patients have pending test results at the time of discharge and 10 percent of these require some action, outpatient physicians and patients often remain unaware of these results.6
  • Inadequate patient/caregiver education: After discharge, patients and caregivers are often expected to assume new self-care responsibilities, including adhering to new dietary and physical activity restrictions, taking new medications appropriately, and monitoring and responding to new and evolving symptoms. Yet patients often leave the hospital without adequately understanding their medical condition and their self-care plan.7 In fact, the Institute of Medicine’s Crossing the Quality Chasm report found that patients making the transition from one setting to another generally receive little information on how to care for themselves, when to resume activities, what medication side effects might occur, and how to get answers to their questions.8 In some cases, patients and caregivers are completely excluded from the transition planning process. This lack of education and preparation often culminates in a decline in the patient's medical condition and in readmission to the hospital.
  • Lack of followup with PCPs and other providers: Recently discharged patients who follow up with their PCPs and other providers are less likely to be readmitted to the hospital.9,10 Yet studies show that patients often do not receive appropriate followup care or ongoing outpatient management after leaving the hospital. One in three adult patients discharged from a hospital to the community does not see a physician within 30 days of discharge.11 Half of Medicare beneficiaries readmitted to the hospital within 30 days of a discharge had no contact with a physician between the initial hospitalization and the readmission.3

What They Did

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Description of the Innovative Activity

Hospitals participating in Project BOOST implement some or all elements of a comprehensive program to improve care transitions. The program features standardized interventions to improve all major aspects of the discharge process, including an assessment of the patient’s risks and level of preparedness to assume postdischarge responsibilities, teach-back education, patient-centered discharge instructions, timely followup care, communication with PCPs and other postdischarge providers, and a followup call to high-risk patients. The program offers a free implementation guide for hospitals and several fee-based services, including a learning network and mentoring from a physician. Key components of Project BOOST include the following:
  • Comprehensive suite of interventions and tools: Based on an assessment of their existing processes and needs (see the Planning and Development Process section for more details), hospitals participating in Project BOOST implement some or all components of a suite of interventions and associated tools that collectively cover most aspects of the discharge planning and care transition process, as outlined below:
    • Risk assessment: Project Boost focuses on eight important factors that increase the risk of readmission, emergency department (ED) visits, and other adverse events after discharge. Participating hospitals administer a user-friendly assessment tool known as the “8P” scale, which covers the following risk factors: problems with medications, psychological (such as depression), principal diagnosis (e.g., heart failure, chronic obstructive pulmonary disease, cancer, diabetes), physical limitations (e.g., level of frailty), poor health literacy, patient social support, prior hospitalization, and palliative care. Hospitals generally administer the tool at admission to identify those at risk, and then perform the assessment again during the inpatient stay to gauge the success of efforts to address risk factors.
    • Level of preparedness assessment: Participating hospitals administer the General Assessment of Preparedness (more commonly known as GAP) tool, which reviews potential psychosocial and logistical barriers to patients' ability to understand and engage in the intended care plan during and after hospitalization. The checklist reminds the care team of issues to consider and address as they work with patients and their caregivers. Different elements covered by the GAP tool are typically addressed at different stages of the hospitalization. For example, arranging transportation to subsequent followup appointments may occur on the day of discharge, whereas issues related to functional and cognitive status are addressed daily.
    • Teach-back education: Staff at participating hospitals use the teach-back approach to patient education throughout the stay and at discharge. Whenever a member of the care team explains a concept or information to the patient (e.g., a change in dosing or medication type, which would be explained during administration of the medication), the provider asks the patient to “teach back” the information to gauge his or her level of comprehension.
    • Patient-centered discharge instructions: Participating hospitals provide patients with printed, easy-to-understand instructions and reminders about key aspects of their postdischarge care plan to use as a reference. These instructions tend to be briefer than those included in the more comprehensive discharge summary prepared for providers, although some overlap will exist. The instructions provide a concise review of the most vital information, including reason for the hospitalization; warning signs of potential postdischarge complications and a list of contacts in the event of complications; the date, time, and place of any scheduled followup appointments; and a list of all medications, with directions for taking them written in lay terminology. Project BOOST offers participating hospitals two different tools to assist in creating these instructions: the Discharge Patient Education Tool (more commonly referred to as DPET) and the Patient Preparation to Address Situations Successfully (PASS) tool.
    • Timely followup appointments: Hospital staff attempt to schedule a followup appointment with the patient’s PCP (or another provider, if appropriate) before discharge, with the goal of having the patient seen within a week of discharge. This visit provides a critical opportunity to address the conditions that precipitated the hospitalization and to prepare the patient and caregivers for self-care activities that can reduce the risk of readmission.
    • Standardized communication with PCPs and other providers: The provider who sees the patient after discharge may not have direct knowledge about the hospital stay. To address this issue, hospitals use information technology to generate discharge summaries that provide accurate information to these providers (e.g., a current list of medications and doses). This summary is completed and sent to the PCP and other relevant providers (e.g., a subacute care facility) by e-mail, fax, or regular mail within 24 hours of discharge. If a complete discharge summary cannot be sent within this timeframe, an interim report is sent instead. At a minimum, this report includes information on the patient’s diagnoses, discharge medications, procedure results, followup needs, and pending test results.
    • Followup call to high-risk patients: Members of the discharge planning staff place followup calls to high-risk patients or their caregivers within 72 hours of discharge to assess status and identify and address issues or problems that may have arisen. The period right after discharge is critically important to the ultimate success of the transition, given that many aspects of care change when patients no longer have the support mechanisms available in the hospital. 
  • Implementation support: Hospitals that participate in Project BOOST have access to an implementation guide and additional fee-based support related to implementing and executing the interventions described above. These include the following:
    • Implementation guide: Available at no cost, the Project BOOST implementation guide provides management tools to help interdisciplinary teams evaluate their current discharge process and plan and implement interventions to address identified problem areas. It also provides guidance on quality improvement (QI) processes and support in evaluating the impact of the program and maintaining any positive outcomes. (More information on this guide can be found in the Other Tools and Resources section.)
    • Collaborative learning network: For $4,000, participating hospitals gain access for 2 years to "BOOST eQUIPS," a support package that includes an online learning community and discussion forum, document-sharing capabilities, newsletters, webinars, and a data center.
    • Physician mentor to support implementation: For $24,000, participating hospitals receive a year of implementation support from a physician mentor with expertise in QI and care transitions. Following the “mentored implementation” model refined by the Society of Hospital Medicine (SHM),12 the physician leads a 2-day kickoff training session on Project BOOST tools and hosts regular conference calls (typically five to six during the year) to gauge progress and help troubleshoot barriers to implementation. As needed, the mentor makes site visits and communicates with hospital-based team members via e-mail and phone. Throughout the process, the mentor helps to engage hospital leaders in the program, win the support of local physicians, motivate the hospital-based team, and address any institution-specific barriers. While ensuring fidelity to the model, the mentor works with the team to identify needed adaptations to the local environment.

Context of the Innovation

SHM is a professional medical society representing more than 10,000 of the 30,000 practicing hospitalists in the United States. The roots of Project BOOST go back to 2005, when Mark V. Williams, MD, (then working at Emory Crawford Long Hospital in Atlanta) received one of 17 Partnerships in Implementing Patient Safety (more commonly referred to as PIPS) grants from AHRQ. This 2-year grant allowed him to pursue long-time interests in improving health literacy and care transitions through the development of tools to help hospitals improve the discharge process. Known as the Patient Safe-D research project (with the “D” standing for discharge), the success of this work captured the attention of leaders at SHM, who in 2007 applied for and received a $1.4 million grant from the John A. Hartford Foundation to support and expand Dr. Williams’s efforts under a newly launched program known as Project BOOST. Incorporating and building on key components of this earlier work, SHM created a multidisciplinary team that reviewed published, peer-reviewed studies to identify evidence-based practices for improving the discharge and care transition process. SHM also created an advisory board consisting of experts and advocates involved in the hospital discharge process. Made up of patients, caregivers, physicians, nurses, case managers, social workers, and representatives from insurance companies, regulatory agencies, and research organizations, this panel provided advice and guidance on program components and associated tools.

Did It Work?

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Results

In a study involving 11 hospitals that implemented Project BOOST with support from a physician mentor, the program significantly reduced readmissions within 30 days of discharge.
  • Fewer readmissions: In a controlled study involving 11 hospitals that implemented Project BOOST on one unit (using a physician mentor to assist), readmission rates on BOOST units fell by 13.6 percent in the year following implementation (from 14.7 percent to 12.7 percent). Over the same time period, readmission rates on similar units in the same hospitals that did not implement the program remained stable (14.0 percent at baseline, 14.1 percent a year later).13
  • No meaningful difference in length of stay: Average length of stay fell by 0.5 days on Project BOOST units and by 0.3 days on control group units. This difference did not meet the test of statistical significance.13

Evidence Rating (What is this?)

Moderate: The evidence consists of a controlled study that compared 30-day readmission rates and length of stay on units implementing Project BOOST with the help of a physician mentor to similar units in the same hospitals that used standard discharge planning and care processes.

How They Did It

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Planning and Development Process

As noted, Project BOOST has developed a detailed implementation guide that outlines the steps and tools necessary for hospitals to implement the program. A brief review of the key phases and steps detailed in the guide follows: 
  • Establishing organizational framework for QI: This phase includes several foundational steps, including winning the support of institutional leaders; creating a team made up of stakeholders from various disciplines involved in the transition process; and establishing rules for that team, general goals for the project, and specific, quantifiable goals with associated target dates for achieving them.
  • Estimating financial costs and benefits: This phase involves estimating the financial impact of the program based on various factors, including but not limited to payer mix and occupancy rate.
  • Analyzing existing process: During this phase, the project team analyzes the existing discharge planning process (including patient education) and key areas in need of improvement. Important areas to consider include the following: tools used to assess patient/family preparedness for discharge; the medication reconciliation process, including how polypharmacy issues are addressed; patient handoffs, including processes and tools for communicating with physicians and subsequent care sites; and evaluation methods for assessing the quality of the discharge process.
  • Implementing and evaluating new process: During this phase, the team designs a new process that incorporates relevant and appropriate Project BOOST resources and interventions, as described earlier. The team collects, analyzes, and presents data showing the impact of the new discharge process on key outcomes, such as length of stay, 30-day readmission rates, and patient/caregiver satisfaction. This assessment may also include evaluation of important process metrics, such as the degree to which patients and caregivers understand their treatment, followup care plan, potential warning signs, and appropriate responses should these warning signs arise.
  • Ongoing refinement: Based on findings from the evaluation, the team continues to improve the discharge process on an ongoing basis, paying particular attention to ensuring that important patient needs are consistently being addressed and that members of the hospital staff fully embrace the new process. Whenever possible, the team should look for changes that further simplify the process.

Resources Used and Skills Needed

  • Staffing: Project BOOST requires no additional hiring of staff, as existing discharge planning and/or nursing staff incorporate the program and associated tools into their daily activities.
  • Costs: The program can be implemented with little financial outlay, making use of existing staff. As noted, the implementation guide and associated toolkit are available free of charge (see the Tools and Other Resources section below), and hospitals interested in additional support beyond the toolkit can pay $4,000 for 2 years of access to the learning network and $24,000 to receive a year of mentoring from a physician with expertise in QI and care transitions. 
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Funding Sources

The John A Hartford Foundation, Inc.
The John A. Hartford Foundation provided a $1.4 million grant to SHM to support the initial development of Project BOOST.

The following organizations have provided funding to collaboratives that support hospitals interested in implementing Project BOOST.  
  • Blue Cross Blue Shield of Michigan
  • Health Plan of Michigan
  • California HealthCare Foundation
  • Blue Cross Blue Shield of Illinois
  • Hospital Association of Southern California
  • LA Care
  • Hawaii Beacon Communities 
  • Center for Medicare & Medicaid Innovation, Hospital Engagement Networks
  • Hospital Association of Pennsylvania
  • University Health Consortium
  • South Carolina Partnership for Health
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Tools and Other Resources

Organizations interested in learning more about Project BOOST or in applying for support from a physician mentor should contact program leaders at (800) 843-3360 or boost@hospitalmedicine.org.

The Project BOOST implementation guide and associated tools are available at: www.hospitalmedicine.org/BOOST. Links to specific BOOST resources are provided below:

Adoption Considerations

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Getting Started with This Innovation

  • Obtain senior administrator support: A direct line of communication to a senior administrative “champion” can be very helpful. To win such support, the project team should share data on the program's potential to reduce readmissions and improve physician and patient satisfaction.
  • Consider financial implications: For many institutions, current payment mechanisms do not create a financial incentive to support activities that reduce readmissions. Would-be adopters should analyze the potential financial impact of better discharge education and care transitions. As penalties for readmissions become more prevalent, the financial implications of implementing this type of program should become more favorable. In addition, overcrowded hospitals generally stand to benefit from this type of program, as reductions in readmissions free up capacity without the need for expensive facility expansion.
  • Create multidisciplinary team that includes frontline staff: Because the discharge process involves multiple disciplines, the project team should include representatives from the medical staff, nursing, pharmacy, discharge planning, care management, and social work, with an emphasis on those who work directly with patients. Former patients can also be valuable team members.
  • Use guide and toolkit as starting point, adapt as needed: While a very useful starting point, the guide and toolkit should be adjusted and tailored to the unique aspects of the local environment. To assist in this process, the multidisciplinary team should create a formal map of the current discharge process, with the goal of identifying opportunities for improving it.
  • Leverage QI support: Understanding the principles, strategies, and tools involved in successful QI projects is critical to the success of any program designed to improve discharge education and care transitions. Institutions often have in-house QI staff who can assist in redesigning these processes.
  • Set appropriate project goals: Goals should be "SMART"—i.e., specific, measurable, achievable, realistic, and time defined.

Sustaining This Innovation

  • Expect and prepare for patient questions: Engaging patients in the discharge process is likely to result in their asking more questions and requesting more information. Clinicians should be prepared to respond and recognize that doing so will likely add time to the discharge process. Consequently, program leaders should regularly remind clinicians that answering questions benefits patients by enhancing their understanding of their medical issues, treatments, and required followup care.
  • Monitor and refine discharge process: Ongoing, regularly scheduled assessments of the discharge process help in identifying and addressing problem areas and making sure that program-related improvements can be sustained.
  • Share information on program impact: Regularly sharing information that highlights the program’s positive impact on patient/caregiver satisfaction, readmissions, and other key metrics helps keep physicians and other hospital staff engaged in the program.

Use By Other Organizations

Although precise figures are not available, it appears that a significant number of hospitals have implemented some or all components of Project BOOST. Since October 2008, more than 6,400 have downloaded the BOOST toolkit, 54 have participated in BOOST eQUIPS, and more than 180 have received physician mentoring support.

Additional Considerations

In 2011, SHM’s mentored implementation model (the model used to support the 11 hospitals participating in the trial) won the John M. Eisenberg Patient Safety and Quality Award from the Joint Commission. More information on this award is available at: http://www.jointcommission.org/topics/eisenberg_award.aspx.

More Information

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Contact the Innovator

Mark V. Williams, MD, FACP, MHM
Director, Center for Health Services Research
Vice Chair, Department of Internal Medicine
University of Kentucky
E-mail: mark.will@uky.edu

Jeff Greenwald, MD, SFHM
Inpatient Clinician Educator Service
Massachusetts General Hospital
Associate Professor of Medicine
Harvard Medical School
Co-Investigator, Project BOOST
Boston, MA
E-mail: jlgreenwald@partners.org

Tina Budnitz, MPH
Chief Strategic Development Officer
Society of Hospital Medicine
1500 Spring Garden, Suite 501
Philadelphia, PA 19130
(678) 694-1022
E-mail: tbudnitz@hospitalmedicine.org

Jing Li, MD, MS
Director, Project BOOST—Illinois
211 East Ontario Street, Suite 700
Chicago, IL 60611
(312) 926-4511
E-mail: jli2@nmh.org

Innovator Disclosures

In addition to the funding relationships listed in the Funding Sources section, the innovators reported the following financial and business/professional relationships related to the work described in this profile:
  • Dr. Williams reported that Northwestern University Feinberg School of Medicine received grant funding from the Agency for Healthcare Research and Quality (AHRQ) and Blue Cross Blue Shield of Illinois. He also reported receiving honoraria and consulting fees from QuantiaMD, Kaplan Inc., VHA Southeast, Missouri Hospital Association, Society of Hospital Medicine, American College of Physicians, and several academic medical centers.
  • Dr. Greenwald reported receiving honoraria and travel expense reimbursement from multiple organizations.
  • Ms. Budnitz reported having no related financial interests or business/professional relationships related to the work described in this profile, other than her employment at the Society of Hospital Medicine. 
  • Dr. Li reported receiving consulting fees from QuantiaMD for the development of educational presentations.

References/Related Articles

Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-7. [PubMed]

Society of Hospital Medicine. Better Outcomes by Optimizing Safe Transitions: Project BOOST [Web site]. Available at: http://www.hospitalmedicine.org/BOOST.

Maynard GA, Budnitz TL, Nickel WK, et al. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Jt Comm J Qual Patient Saf. 2012;38(7):301-10. [PubMed]

Footnotes

1 Friedman B, Basu J. The rate and cost of hospital readmissions for preventable conditions. Med Care Res Rev. 2004;61(2):225-40. [PubMed]
2 Report to the Congress: promoting greater efficiency in Medicare. Washington, DC: Medicare Payment Advisory Committee (MedPAC). 2007 June:103-20. Available at: http://www.medpac.gov/documents/Jun07_EntireReport.pdf.
3 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28. [PubMed]
4 Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-41. [PubMed]
5 Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9. [PubMed]
6 Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-8. [PubMed]
7 Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement American College of Physicians–Society of General Internal Medicine–Society of Hospital Medicine–American Geriatrics Society–American College of Emergency Physicians–Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-6. [PubMed]
8 Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
9 Hernandez AF, Greiner MA, Fonarow GC, Et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716-22. [PubMed]
10 Sharma G, Kuo YF, Freeman JL, et al. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010;170(18):1664-70. [PubMed]
11 Sommers A, Cunningham PJ. Physician visits after hospital discharge: implications for reducing readmissions. Washington (DC): National Institute for Health Care Reform. 2011 Dec. Research Brief No. 6.
12 Maynard GA, Budnitz TL, Nickel WK, et al. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Jt Comm J Qual Patient Saf. 2012;38(7):301-10. [PubMed]
13 Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421-7. [PubMed]
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Original publication: February 12, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.