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Patient education program slashes ED readmissions
Patients taught about disease and meds, follow-ups
A new initiative at Boston University Medical Center called the Re-Engineered Hospital Discharge Program (RED) has significantly reduced additional ED visits and readmissions. Thirty days after their hospital discharge, the 370 patients who participated in the RED program had 30% fewer subsequent ED visits and readmissions than the 368 patients who did not.
In addition, 94% of the patients who participated in the program left the hospital with a follow-up appointment with their primary care physician, compared to 35% for patients who did not participate. Also, 91% of the participants had their discharge information sent to their primary care physician within 24 hours of leaving the hospital.
The program used specially trained nurses to help one group of patients arrange follow-up appointments, confirm medication routines, and understand their diagnoses using a personalized instruction booklet. A pharmacist contacted patients two to four days after hospital discharge to reinforce the medication plan and answer any questions.
"Everyone wants patients to be safe and prevent them from coming back to the ED when it may be unnecessary, and giving them the tools they need to take care of themselves when they are home is huge," says discharge nurse Lynn Schipelliti, RN, one of the "discharge advocates" on the project. "This [instruction booklet] is a great tool and reminds us as well to do things that sometimes we as clinicians forget to do," she says.
Brian Jack, MD, head of the project and associate professor and vice chair, clinical director, Lesotho Boston Health Alliance Department of Family Medicine, Boston University School of Medicine/Boston Medical Center, says, "The program is successful because, in a nutshell, we prepare people for discharge and teach them about their diagnosis. We review their meds and how to take them, when their follow-up visit is scheduled, what to do if there's a problem, and then we test their competency."
How is that testing done? "For example, if they have been taught about three or four different medications, we mention one of those drugs and ask them, using a customized booklet we created for them, to show us how many of those pills they take each day," Jack says. This "open-book test" lets the discharge nurse know whether additional education is needed, he explains. The same test can be used, for example, to confirm that the patient knows when, where, and with whom their follow-up appointments will be.
Teaching is customized for each ED patient
One of the keys to a successful discharge program at Boston University Medical Center's ED is the fact that patients get customized education, says discharge nurse, Lynn Schipelliti, RN, one of the "discharge advocates" on the project, known as the Re-Engineered Hospital Discharge Program (RED).
For example, during pre-discharge education, every patient receives a booklet that has "all the important pieces of information they need," says Schipelliti, adding that she and the other discharge advocates created the template. The size and content, she continues, depends on the patient's situation, the number of meds they're on, the number of follow-up appointments, and so forth. "It could be as simple as someone who comes in for pneumonia and has one follow-up visit and is on two meds, to someone who comes in with a diabetic problem, has heart problems, is on many meds, and sees a cardiologist and pulmonologist," says Schipelliti.
So, for example, if a patient is diabetic, the booklet will include a chart on which they can track their blood sugars. [Sample booklet pages is included.] The average booklet is about eight pages long, but some are as long as 14 pages.
Although they are customized, all of the booklets have common elements. For example, the cover includes the patient's name, main diagnosis/es, why they came to the hospital, important phone numbers (i.e., the pharmacy, primary care doctor), and the location, date, and time of their follow-up visit(s). "The patient receives a color-coded (for time of day) calendar, and a list of every med they take grouped by morning, noon, evening, bedtime, and 'as needed,'" says Schipelliti. There also is a picture page about their diagnosis and helpful hints for when they go home.
The other common thread running through the program is the list of 11 key components which comprise its checklist. (Editor's note: The components may be found at www.bu.edu/fammed/projectred/components.html.) The National Quality Form has adopted all of the project RED components as "safe practices," notes Brian Jack, MD, head of the project and associate professor, vice chair, and clinical director at the Lesotho Boston Health Alliance Department of Family Medicine, Boston University School of Medicine/Boston Medical Center.
'Virtual teacher' added to program
ED managers wishing to implement the successful discharge program used at Boston University (BU) Medical Center might soon be able to do so without having to use full-time "discharge advocates" such as those used by BU, according to the program's developer, Brian Jack, MD, associate professor and vice chair, clinical director, Lesotho Boston Health Alliance Department of Family Medicine, Boston University School of Medicine/Boston Medical Center.
"We've developed a software program so when nurses sit down and enter patient information, it prints out automatically to the hospital information system," Jack explains. "In the ED, you could push a button and, in a couple of minutes, receive a printed after-ED care plan." Nurses who use the system could be trained in a half-hour inservice, he says.
What's more, Jack adds, he has developed a "virtual" teacher named "Louise," who reviews the plan with the patient. "We just wheel in a kiosk, and the brochure is on the screen," he says. "Louise teaches them what to do."(Editor's note: You can "meet" Louise on the project home page: www.bu.edu/fammed/projectred/. Click on "Meet Louise.")
Jack says the software will be available for purchase in the future. Meanwhile, he adds, ED managers can go to the project home page and download project toolkits and the training manual free of charge. (Editor's note: Go to www.bu.edu/fammed/projectred and click on "toolkit.")