Project BOOST - Better Outcomes by Optimizing Safe Transitions

Developing Interventions
Project BOOST® Implementation Toolkit

This step cannot be undertaken without all the essential preparatory work in the previous steps. This is the time for your team to take the opportunity to brainstorm ideas about how to fix the root causes of the problems you have identified in the Analyze Care Delivery, Track Performance and Understanding Deficiencies sections.

In analyzing interventions to improve transitions, there are five core principles central to the Project BOOST® interventions described in this toolkit. They include:

Patient CenterednessClick to expand

This concept implies that the intervention focuses on identifying the needs, abilities and desires of patients and their families/caregivers with respect to ensuring a safe care transition. Also embodied in this principle is the idea that all materials and educational efforts are targeted at the language and literacy levels of patients and their families/caregivers.

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Patient and Family/Caregiver EmpowermentClick to expand

While preparing the patient and family/caregiver for discharge, the hospital care team should address patients’ after-discharge needs, and empower patients and their families/caregivers to address them and to advocate for themselves in the event that further needs arise that they cannot address. Patients and families/caregivers should be provided information about, and access to, available resources that can assist patients after leaving the hospital. Patients and families/caregivers should be alerted to predictable adversities and their warning signs and symptoms, along with a plan to respond to such events. Additionally, patients and families/caregivers should be given tools for coping with unexpected adverse events, including access to medical personnel who can assist patients in dealing with such adverse events.

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Reduce Risk for Harm After DischargeClick to expand

Here, risk implies the chance that a patient will suffer an undesirable experience after discharge (e.g., medication error, missed therapy, unplanned rehospitalization, etc.). The literature has identified several risk factors that portend increased risk of harm after discharge. While many of those risk factors are not modifiable, some may be amenable to targeted interventions (e.g., consultation from a clinical pharmacist for patients new to warfarin or disease management programs for patients with heart failure), while others will be more general (e.g., a follow-up phone call after discharge, a transition coach or an expedited follow-up appointment.) In addition, formally assessing an individual patient’s risk (e.g., using a risk assessment tool such as the 8Ps) should help teams adjust resource utilization around the care transition process for patients at higher versus lower risk.

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Team OrientedClick to expand

The successful transition of a patient out of the hospital typically requires the coordinated efforts of nurses, case managers, social workers, therapists, physicians, patients and their families/caregivers. To coordinate this care transition, clear communication about the patient’s care is paramount. The hospital-based provider should communicate with the patient’s primary care provider on a routine basis during the hospital stay, including upon admission to the hospital, throughout the stay for significant events and during the planning and execution of the transition out of the hospital. In addition, the hospital provider should communicate with aftercare providers (e.g., extended care facility physicians and ambulatory providers) on discharge as well. Using interdisciplinary tools that delineate roles for team members helps to ensure timely, efficient communication between providers, team members and their patients. Because interprofessional teams can be large and unwieldy at times, it is important that there is one team member who oversees and takes ownership of the care transition process. The care transition leader need not be a process/content expert in all elements of the discharge process, but rather should serve as a coordinator to ensure that all parts of the process are completed.

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Bridging the Care Transition GapClick to expand

The care transition does not end at the time of hospital discharge. Indeed, medical research clearly indicates that patients are at high risk of complications during the time between hospital discharge and before being seen by an outpatient provider. Consequently, to bridge this gap in care, hospital care teams must work closely with aftercare providers and patients and their families/caregivers to ensure access and follow-up to help patients address issues and questions that arise after discharge. For some patients, additional resources such as visiting nurses, transition coaches or other community resources will be needed to ensure a safe post-discharge period.

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These principles should be central to the interventions your team develops and deploys. In addition to these larger principles, your improvement ideas should be consistent with four more granular principles.

First, your interventions should address the root causes identified in the Understanding Deficiencies section.

Second, your interventions should be focused on revising or improving the existing process, not just adding another process to existing work. No member of your care team has time to do more work; instead, look for ways to remove low-value, redundant or wasteful aspects of the existing workflow, and replace them with more meaningful work related to care transitions.

Third, your interventions should use the concepts of the Project BOOST® tools, if not the actual tools themselves. For example, it is vital that your team assess each patient for the risk of harm that may occur after the patient is discharged. The Society of Hospital Medicine Project BOOST team believes the 8Ps tool is an effective way to achieve this task. Your team, however, should feel comfortable modifying the tool to meet your needs so long as the patient is screened for risk factors that may cause harm after discharge and a plan is developed to address the risks identified.

Last, your interventions should align with the strategic objectives and concerns of the hospital so as to ensure adequate resource allocation for intervention deployment. Work with your senior executive sponsor and BOOST mentor to ensure harmony between the intended intervention and the hospital.


Project BOOST® implementation toolkit Project Team
This first edition of the BOOST implementation toolkit was sponsored in part by an unrestricted educational grant from the John A. Hartford Foundation, Inc. SHM updated the second edition workbook in 2014.
Disclaimer
The implementation toolkit is an online resource for visitors to the Society of Hospital Medicine's website. All content and links have been reviewed by the BOOST Project Team, however the Society of Hospital Medicine does not exercise any editorial control over content associated with the external links that have been made available via this website.