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Re-Engineered Discharge Program covers all the details for safe discharge
Patients discharged with no doubt about the steps they need to take for recovery
It is vital for patients to receive complete information at discharge. Yet studies have shown the average discharge instruction is eight minutes, and there is no discharge checklist that covers what needs to be completed before a patient goes home, says Brian Jack, MD, associate professor and vice chair with the Department of Family Medicine at Boston University School of Medicine/Boston Medical Center.
To remedy this problem, Jack and a team of researchers developed a multifaceted program to educate patients about their post-hospital care plans. It is called the Re-Engineered Hospital Discharge Program, or RED, and was tested through a randomized controlled trial funded by the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD.
The study found that the cost of care for patients who received complete information was $412 less on average than those who did not. Fewer hospital readmissions and emergency department visits were the reason for the lower costs.
Although the study results were published in 2009, work on a complete discharge program began about five years earlier when Jack and his team of researchers submitted a grant application for improving patient safety by intervening at the discharge process.
"One of the big elements in safety is transitions in care, or going from one part of the health system to another - for example, from the emergency department to the hospital floor. One of the biggest transitions in care is being discharged from the hospital," explains Jack.
The grant review team wrote back that while the researcher's idea was interesting, no one had ever characterized what the hospital discharge is exactly. Therefore, a year and a half was spent characterizing the discharge process in detail. A process map was created, and a group of key leadership from throughout the medical center was asked to think about how to redesign it. They were asked what hospitals should be able to deliver to people before discharge.
From that process, the team came up with the principles of the re-engineered discharge and assembled a list of 11 components. The components include such steps as "make appointments for clinician follow-up and post-discharge testing with input from the patient regarding the best time and date of the appointment" and "confirm the medication plan." (The complete list also can be accessed and printed at www.bu.edu/fammed/projectred).
The education that takes place is more than details on the diagnosis or medication regimen; it includes details on the follow-up care that must be completed, such as medical tests needed once the patient returns home. In addition, information is organized in such a way that it is easy for patients to follow.
"In the hospital, we need to organize the information for patients and put it into a format that they can understand. Then, we need to reinforce that information when they go home, and that combination of activities was very effective in the outcome measure," says Jack.
Providing complete information
During the study, one group of patients underwent a standardized discharge intervention, and the other group did not. This intervention included patient education, comprehensive discharge planning, and post-discharge telephone reinforcement. (For more details on the study visit www.bu.edu/familymed/projectred.)
Nurse discharge advocates were trained to deliver the in-hospital intervention. A training manual was developed to teach nurse discharge advocates all aspects of RED. The manual has detailed scripts and simulated practice sessions. (Details on the training manual can be found at www.bu.edu/fammed/projectred/index.html).
Adhering to the elements of RED, the nurse collected all necessary information from the hospital care team and the patient and entered it into a software program to create the after-hospital care plan.
Each individualized plan contained contact information on the medical provider, dates for appointments and tests, an appointment calendar, a color-coded medication schedule, a list of tests with pending results at discharge, an illustrated description of the discharge diagnosis, and information on what to do should a problem arise. This care plan was printed and spiral-bound for each patient. (To obtain a sample copy of the after-hospital care plan, click on the toolbox icon on the web site.)
During the trial, the nurse discharge advocate taught the after-hospital care plan to the patient. Patients didn't have to memorize the information. They just had to know where it was located in the care plan. To test competency following education, the nurses asked the patients when an appointment was scheduled with a particular doctor or how many times a day they must take a particular medication. All the information was in the care plan, and they could answer the question by flipping to the correct page.
"The idea is that a lot of complex care happens in the hospital, and when patients go home, they are expected to take care of themselves. But we don't really do a good enough job teaching them what it is they are supposed to do, and there is lots of data to show that is the case," says Jack.
The final step in the care plan was a follow-up call from a clinical pharmacist two to four days after discharge to reinforce the information and answer any questions patients had. The interview process was scripted.
One important element of the care plan was its design. The format was created with good health literacy principles in mind. For example, the name of the medication was written in large type, and the daily regimen was divided into sections -- morning, noon, evening and bedtime - so it was easier to follow. A page that listed doctor appointments was then color-coded to a calendar.
Why would hospitals want to adopt the Re-Engineered Discharge program? There are many reasons, says Jack. It surpasses the standards set by The Joint Commission in Oakbrook Terrace, IL. It decreases the need for re-hospitalization and visits to the emergency department; it greatly improves patient and family satisfaction; and it documents all the information people are given.
For more information about the implementation of RED, contact:
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. Telephone: (617) 414-4465. E-mail: email@example.com.