How to Use
Better Outcomes for Older adults through Safe Transitions (BOOST)
Hospital discharge is often a stressful and hazardous venture for older adults. Discontinuity and fragmentation of care yields tangible risks of harm to the patient. Recent research documents that up to 49% of patients experience at least one medical error (Moore, Wisnivesky et al. 2003), and 1 in 5 patients discharged from the hospital suffer an adverse event (Forster, Murff et al. 2003; Forster, Clark et al. 2004). Importantly, more than half of these adverse events are preventable or ameliorable. Inadequate communication was identified as a major etiology for such adverse events. We should not be surprised that things do not necessarily go smoothly after discharge from the hospital, especially given the lack of understanding by many patients of their hospitalization diagnosis and treatment plans (Makaryus and Friedman 2005). Additionally, many patients are discharged with test results pending (Roy, Poon et al. 2005), and we often fail to tie up such loose ends (Moore, McGinn et al. 2007). Unfortunately, information transfer and communication deficits at the time of hospital discharge are common with direct communication between physicians occurring less than 20% of the time, and discharge summaries often lack important information are unavailable when patients present for post-hospitalization follow-up with their primary physicians (Kripalani, LeFevre et al. 2007). The discharge process significantly impacts patient satisfaction, potentially impacts health outcomes, and lacks a consistent, coordinated and safe approach.
A common result of a “failed” hospital discharge is subsequent rehospitalization. Reflecting the costs of such a failure, MedPAC (Medicare Payment Advisory Commission) recommended to Congress in its June 2007 report that hospitals should publicly disclose their own risk-adjusted readmission rates (MedPAC June 2007). MedPAC’s report documented a readmission rate among Medicare recipients in 2005 of 17.6% at 30 days, and 6.2% and 11.5% at 7 and 15 days, respectively. Utilizing 3M® technology, 76% (or 13.3% total) of all readmissions at 30 days were considered potentially preventable. The price tag of these readmissions, $12 billion, drives the desire to enact penalties aimed at reducing their frequency. Not surprisingly, MedPAC suggested that “after a year or two, public disclosure could be complemented by a change in payment rates, so that hospitals with high risk-adjusted rates of readmission receive lower average per case payments”(MedPAC June 2007).
Based on such concerns and worrisome findings from research, we initiated project BOOST© (Better Outcomes for Older adults through Safe Transitions) to provide resources to optimize the hospital discharge process and mitigate many of the problems described above. In this resource room you will find expert- and evidence-based interventions advocated by The Joint Commission, the National Quality Forum (NQF), the Institute for Healthcare Improvement (IHI), and the Agency for Healthcare Research and Quality (AHRQ). We believe that use of this proposed toolkit will promote a safe and high quality hospital discharge as patients transition out of the hospital setting. Our resource room, implementation guide, and toolkit embraces the recent movement toward “patient-centered care”(Stewart 2001) suggesting that patients play a more active role in their care, including engagement in medical decision making (Kravitz and Melnikow 2001). Complementing its ethical basis, expanded patient involvement in care yields improved health outcomes (Greenfield, Kaplan et al. 1985).
The Society of Hospital Medicine and The John A Hartford Foundation hope you will find this resource room and the included tools useful as you aim to improve the discharge process at your hospital.
How to Use the Resource Room
Congratulations on your commitment to improving the care of your patients!
This resource room is designed to facilitate the implementation, evaluation and maintenance of the BOOST toolkit and its adaptations. We recognize that each institution is unique in terms of their experience conducting quality improvement programs, available resources, and existing discharge procedures and processes. Therefore, we have designed interventions with the expectation that they will be adapted to facilitate their integration into daily practices at your institution.
The interventions presented include using a teach-back process during discharge education, identifying specific patient readmission risks to better tailor communications and providing outpatient providers and receiving sites with a discharge record. For high-risk patients, scheduling an outpatient follow-up visit and or conducting a 72-hour follow-up call with the patient and/or caregivers is also recommended.
This resource room assumes that each reader will have unique informational needs. Therefore, it has been designed to allow readers to follow a clear linear path through the content, or skip around to meet specific needs. If you proceed through the resource room as presented, in the First Steps section, it will review key principles applicable to any quality improvement initiative such as gaining support for an intervention and creating a team, and defining key outcomes. Next, in Best Practices, it will review key literature presented as an annotative bibliography. In Analyze Care Delivery you will learn how to perform an institutional assessment of your institutions current care delivery. Then it provides an evaluation plan and methods / approaches to maintain your improvements. It will also review the BOOST Intervention key components and suggest methods to adapt and the launch the intervention at your institution. Following planning your intervention, you will learn to manage the overall process. The room also provides clinical tools, an overview of the Teach Back process, educational resources such as the core competencies and an area to exchange information with your peers or ask an Expert in Care Transitions for the Older Adult a question.