Project BOOST - Better Outcomes by Optimizing Safe Transitions

Risk Assessment - 8P
Project BOOST® Implementation Toolkit

Touch Points: Admission, During Hospitalization, and Discharge

Background:

It is important to identify and understand a patient's risk for adverse events after discharge so that the hospital team can work to begin to mitigate those risks while the patient is hospitalized.  Several patient assessment tools exist, and sites use these tools in various ways to assess readmission risk and stratify patients by the severity of those risk factors. Given that resources are limited, stratifying patients by severity of risk assessment score would ideally allow a team to offer interventions only to those who are likely to benefit from them.  Unfortunately, none of the risk stratification scoring systems works with a high degree of accuracy (c-statistics ranging from 0.53 to 0.83) and, moreover, fail to yield information about what you should do with the risk score you have obtained for a given patient1. Published risk scores such as LACE, HOSPITAL, and PRA2-4 use factors which you likely cannot affect and primarily reflect patients’ severity of illness. Additionally, many of the more accurate risk scoring systems are cumbersome and require complex calculations to complete. Click to expand

For BOOST®, we took a different approach. Given that numerous risk factors have been identified in the literature as being associated with increased risk for adverse events after discharge, including unplanned readmissions, we aim to “risk identify” rather than “risk stratify.” That is, we advocate determining if the patient has a risk factor and then try to target an intervention to mitigate that risk.  The 8Ps Risk Assessment is not intended to be a score, but a checklist of risks that should be identified and addressed. The process has three steps:

  1. Identify: Screen the patient for specific risk factors known to be associated with adverse post-discharge events.

  2. Mitigate: Put in place risk-specific interventions that you believe will lessen the impact of the risk factor, and be sure you are clear who on the care team is responsible for carrying out the intervention.

  3. Communicate: We recognize that most interventions cannot eliminate the risk completely, and certainly not in the amount of time most hospitalizations offer. Therefore, it is important to communicate the risk and the intervention to the next providers of care so efforts may continue to reduce the impact of the risk on the patient’s health.

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The Tool: The 8Ps

Described below are eight risk factors (the 8Ps) we believe should be identified and addressed for all hospitalized patients. While many of the factors have been defined in different ways in the literature, we provide a sample definition.

  1. Problems with medications:  Patients with polypharmacy — i.e. >10 routine medications — or who are on high-risk medications including anticoagulants (e.g. warfarin, heparin, Factor Xa or thrombin inhibitors), antiplatelet agents in combination (e.g. aspirin and clopidogrel), insulin, oral hypoglycemic agents, digoxin, and narcotics.

  2. Psychological:  Patients who screen positive for depression or who have a history of depression. You may also choose to include anxiety and substance abuse in this screening.

  3. Principal diagnosis:  Patients with a principal diagnosis or reason for hospitalization related to cancer, stroke, diabetic complications, COPD, or heart failure.

  4. Physical limitations:  Patients with frailty, deconditioning, or other physical limitations that impair or limit their ability to significantly participate in their own care (e.g. perform activities of daily living, medication administration, and participation in post-hospital care).

  5. Poor health literacy:  Patients who are unable to demonstrate adequate understanding of their care plan as demonstrated by their inability to complete “Teach Back” successfully (See “Teach Back Process”).

  6. Poor social support:  The absence of a reliable caregiver to assist with the discharge process and to assist with care after the patient is discharged.  This P also captures the concept of social isolation.

  7. Prior hospitalization: Unplanned hospitalization in the six months prior to this hospitalization.

  8. Palliative care: When thinking about this patient, would you be surprised if the patient died within a year? Does this patient have an advanced or progressive serious illness? This risk factor would be triggered if you answered no to the first or yes to the second question.

Risk Specific Interventions

As noted, each identified risk should trigger a specific intervention or group of interventions to begin efforts to mitigate the associated risk.  The provided 8P form offers examples of the types of interventions your BOOST® program may want to include in this section.  To develop your site’s risk-specific interventions list, begin by looking at what internal resources you have already (e.g. do you have a diabetes team or diabetes specialists who can work with your patients starting insulin; do you have a mental health group who can work with your patients who screen positive for depression; do you have a clinical pharmacist who can educate patients on high-risk medications). Also consider protocols, order sets, and other high-reliability structures to support your interventions (e.g. do you utilize a heart failure or anticoagulation care pathway or issue-specific patient education materials.

It is important to recognize that each site will need to work in an interprofessional fashion to determine the best approach for addressing these factors considering your available resources. You must also remember that few of the identified risks can be eliminated prior to discharge so involving the ambulatory providers in the interventions is crucial if you hope to realize their full potential impact. For example, to address problem medications, you will likely need input from pharmacy, nursing, nutrition, case management, and primary care providers to address issues of medication monitoring and interactions, patient education, drug cost/access, and outpatient follow-up.

Accountability:

One of the key lessons of quality improvement is that “everybody” cannot be responsible for a task. Such an approach effectively yields no one taking responsibility and a needed task rarely gets handled satisfactorily. Assigning each intervention to a specific person — or at the very least, to a role (e.g. physical therapy) or small group (e.g. Mary and Sam) — is important to ensure that every necessary action is completed. Similarly, structuring follow-up to ensure completion of the task will increase the reliability that the tasks are, in fact, completed. Checklists have a highly functional role in accountability, especially if clear assignment and acceptance of responsibility for every task on a checklist is achieved.

Engagement and Goals of Care:

As with any therapeutic intervention, patients should understand your concerns about the risks identified, and providers should engage patients so they want to participate in any strategy to mitigate the risk. Developing a plan to address risks for which the patient and family/caregiver have no interest in participating will likely lead to little tangible improvement, frustrated patients, and wasted resources.  Working with patients and families/caregivers around issues of risk reduction requires engaging them in discussions about the goals for their care (not just regarding end-of-life issues, though this is obviously critical), and will give you insights into the best strategies to employ. Additionally, patients and families/caregivers often have their own ideas of ways to reduce risk that may in fact be more useful to them than any plan the hospital could develop. Indeed, engaging post-hospital providers (i.e. primary care providers or other relevant outpatient specialists) also may be fruitful as they may have a better sense of strategies that either have been tried and failed previously or understand what that particular patient is more likely to follow outside the hospital.

Implementation Tips:

Most successful BOOST® sites have implemented the 8Ps through structured interprofessional rounds (a.k.a. multidisciplinary rounds). This forum gives the care team an opportunity to review the risk factors — keeping risk identification on the minds of the care team – and assign interventions to the appropriate individuals who are likely present for the rounds. It also creates the obvious place for follow-up on the status of interventions on subsequent days.

Ideally, the 8P form (either paper or electronic) is available to all members of the care team for periodic review throughout the hospitalization, and should be reviewed if the patient’s condition or situation changes. Also, the form should eventually be entered into the patient’s chart so future care teams can see your efforts.

Finally, since the final phase of using the 8Ps is communication to the next provider, developing a process for reliably transmitting information to post-hospital providers (e.g. in the discharge summary) about what risk factors the inpatient care team identified and what interventions were initiated will be important.

 

BOOSTing Care Transitions 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.