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Quality: Using Available Data

Janice Simmons, for HealthLeaders Magazine, July 10, 2009
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Resources are available now to lower rehospitalization rates and costs.

Healthcare providers looking to reduce unnecessary hospitalizations don't have to wait for solutions—nor do they need to spend a lot of money to do so.

Several hospital-based programs have found that using their own data and improving communications among their staff members can make a difference in lowering readmissions for not only senior patients but for the general patient population as well.

At Boston Medical Center (BMC), a private, nonprofit, 547-licensed bed facility, Brian Jack, MD, and his associates initially looked at the hospital discharge as a patient safety opportunity about six years ago. During this time, a "perfect storm" was brewing, he said: Patients were being discharged quicker from the hospital—often without outside follow-up care being assigned.

"And no one had set up guidelines for the kinds of things that ought to happen in a hospital discharge," said Jack, who is associate professor and vice chair of the department of family medicine at BMC. "There are 30 million [discharges a year nationally], so even if there were just a few problems associated those discharges, then that would add up to a lot."

Preliminary studies showed that one in five patients was being readmitted at BMC. This was consistent with a New England Journal of Medicine study published this spring that found that one-fifth of 12 million Medicare patients hospitalized in 2004 were readmitted to the hospital within 30 days. The estimated cost to Medicare during that period for unplanned rehospitalizations was projected at $17.4 billion—an amount that has caught the attention of key federal lawmakers overseeing healthcare reform legislation to reduce costs.

To better understand the situation at BMC, a randomized control study of 749 adults was conducted from January 2006 to October 2007. Half of the group was assisted by a nurse discharge advocate who worked with them to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was also sent to each patient's primary care provider. A clinical pharmacist also would call patients two days after they were released to reinforce the discharge plan and review medications.

The result was that hospital reutilization (combined emergency room visits and readmissions) decreased by 30% in the intervention group. From this study came a list of 11 components that make up what Jack called the "Re-Engineered Discharge" or Project RED (see www.bu.edu/fammed/projectred).

"What we did basically was to collect information in the hospital that was relevant to people—that allowed them to take care of themselves when they went home," Jack said. On average, many patients had been getting eight minutes of discussion before they went home. "How then are they are expected to take care of themselves? How is that possible? We need to [reach out] to allow people who want to take care of themselves to be able to do that when they go home."

While the earlier studies used a nurse to provide the patient with information before discharge, BMC is looking at a way to automate that process—and save money. In 2007, it rolled out "Louise"—an interactive character on a computer screen that patients can use at discharge to review care plans. The software, developed with the help of Tim Bickmore, PhD, an associate professor at Northeastern University, is popular so far among patients, Jack said.

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