February 24, 2009 Discharge Planning: Finally Something That Works!
We spend a lot of time discussing the many dangerous things that can happen during a hospitalization. But the period following discharge is just as or even more dangerous. The most widely cited study on post-discharge adverse events (Forster et al 2003) found 19% of patients discharged from an academic tertiary care center suffered an adverse event within 3 weeks of discharge. And almost two-thirds of these events were considered either potentially preventable or ameliorable. Adverse drug events were the most common type seen.
A big problem in the past has
involved transitioning patients cared for in tertiary hospitals back to their
primary care providers. And now that many community hospitals have begun using
the hospitalist model for inpatient care, the physicians providing the
inpatient care may never see the patient again after discharge. Hence, the
communication and coordination of care that occur at discharge have become even
more important.
We’ve discussed on several occasions the problem of test
results pending at the time of discharge that fail to be followed up on (see
our May 1, 2007 Tip of the Week The
Missed Cancer and our February 12, 2008 Tip of the Week “More
on Tracking Test Results”). A
study by Roy et al in two tertiery care hospitals (Roy et al 2005)
found that 41% of patients had test results that returned after patients had
been discharged. Almost 10% of those were potentially actionable and over 60%
of physicians surveyed were unaware of those test results.
And, of course, one of the biggest
reasons for the push to perform medication reconciliation has been the frequent
occurrence of medication errors at the time of discharge. A recent study (Zhang et al 2009)
found that comorbidities, but not advancing age, were associated with repeat
admission for adverse drug events in older adults.
Nationally, almost 18% of Medicare
patients get readmitted to the hospital within 30 days after discharge. We all
spend a considerable amount of time on the discharge planning process but there
is a surprising dearth of literature showing what specific interventions are
successful in avoiding readmissions or avoiding other post-discharge adverse
events. A recent review of the discharge planning process (Katikireddi and
Cloud 2008) provided practical advice on performing discharge planning and
outlined many of the key elements to incorporate in that process but pointed
out that almost none of the recommendations are evidence-based.
However, this month a new randomized
study (Jack et
al. 2009) documented considerable improvement in rehospitalization rates
using a structured hospital discharge program. In that program, a nurse
discharge advocate interacted with a multidisciplinary team to develop a
post-discharge plan, schedule and coordinate followup medical appointments and
tests, provide a list of pending test results, a description of the discharge
diagnosis and medications, and information about what to do if a problem
occurred. A clinical pharmacist then called the patient by phone 2-4 days after
discharge. The primary outcome measure was a composite of repeat
hospitalizations or ER visits within 30 days. The intervention group had 21.6%
of such events, compared to 26.9% in the usual care group. The average time
spent by the discharge advocate (in contact with the patient or the medical
team and preparing the discharge documents) was 87.5 minutes per patient and
the pharmacist spent a median of 14 minutes talking to the patient plus 10
minutes preparation time. And the average net savings was $412 per person who
received the intervention.
A prior demonstration project by the Colorado
Foundation for Medical Care (a Medicare QIO) had demonstrated that a
coaching model was successful in reducing readmission rates by almost 50%. In
that model, an RN “coach” visits the patient once in the hospital and once
within 48 hours after discharge and also calls the patient by phone three
additional times. They discuss medication management, followup visits with
physicians, a patient-centered record, and knowledge of “red flags” the patient
should be aware of.
So these two studies demonstrate that
use of a nurse-managed model with well-designed plans for discharge
successfully reduce the likelihood of readmission and more than pay for
themselves.
More than that, we’ve found that
post-discharge phone calls to patients can do wonders for the public relations
of your organization. The patient’s perception that you care about them after
discharge can significantly improve their satisfaction with the entire hospital
experience.
Update: See also our April 7, 2009 Patient Safety Tip of the Week “Project RED”.
References:
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003; 138:161-167
http://www.annals.org/cgi/reprint/138/3/161.pdf
Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005; 143:121-128
http://www.annals.org/cgi/reprint/143/2/121.pdf
Zhang M, Holman CDJ, Price SD, et al. Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: retrospective cohort study. BMJ 2009; 338: a2752 (Published)
http://www.bmj.com/cgi/reprint/338/jan07_3/a2752
Katikireddi SV, Cloud GC. Planning a patient’s discharge from hospital. BMJ 2008; 337: a2694 (Published 12 December 2008, doi:10.1136/bmj.a2694)
http://www.bmj.com/cgi/content/extract/337/dec12_1/a2694
Jack BW, Chetty VK, Anthony D et al. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine. 150(3):178-187, February 3, 2009
http://www.annals.org/cgi/content/abstract/150/3/178
Atlantic Information Services. CMS Targets Readmission Through Payment, Audits; “Coaching” Model Reduces Rates. Report on Medicare Compliance 2008; 17(24): 1-2 (June 30, 2008)
http://www.cfmc.org/files/rmc063008.pdf
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