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Readmission-reducing RED Protocol Adoption Lagging

 |  By John Commins  
   January 26, 2016

The creators of the 12-step Re-Engineered Discharge protocol say it saves money, but hasn't yet been widely or fully adopted. Follow-up studies have shown that problems arise when RED is diluted.

Five years after its launch, the Re-Engineered Discharge protocol is struggling to catch hold in the nation's hospitals.

The creators of the 12-step discharge protocol, which took seven years to compile, say it reduces readmissions and saves money, but hasn't yet been widely adopted.

 

Suzanne Mitchell, MD

"That's a good question," Suzanne Mitchell, MD, a RED co-creator, said when asked how many hospitals were using RED. "What we have seen mostly is hospitals adapting and cherry picking from a number of different programs. They might take a couple of items from RED and marry them with the Eric Coleman model, which uses a coach that works with patients and caregivers post discharge."

"Because hospitals have mixed and matched based on what they felt they had available and what was familiar to them, it is hard to know who implemented RED as an entire package," says Mitchell, who is also an assistant professor of Family Medicine at Boston University School of Medicine and a physician in Family Medicine at Boston Medical Center.

In fact, even though Mitchell and her BU colleagues developed RED, the protocol isn't widely used at Boston Medical Center.

"BMC has been using adapted versions of RED. It is not disseminated throughout the hospital, but we use it on our designated floor for family medicine, a team-based model," Mitchell says. "It's the same as in many places. A lot of it has to do with the way payments are still based on fee for service," she says.

"We are in a very rapid change in terms of being in alignment and accountable care. But it takes resources to change the way you do things and people don't always feel that RED is going to benefit their particular population."

'Overkill'
Mitchell says it's not uncommon to see three or four readmissions initiatives operating simultaneously at the same hospital. "Nobody knows about the other ones and they are all focusing on different patient problems," she says.

"There is overkill in terms of the patients' experience because many have multiple comorbidities. Cancer has their readmission initiative. The cardiology group has theirs, and family medicine has their own, and everybody is doing something slightly different based on how they see the world. There needs to be more work to strategize and streamline discharge and share transition programs so they actually meet patients' needs."

By design, Mitchell says, the 12 steps identified in the RED protocol are pragmatic and basic, with recommendations that include language assistance when needed, follow-up plans for pending lab results, and providing patients with written discharge plans.

"It's the same reason why airline pilots use checklists," Mitchell says. "They want to make sure everything gets done systematically. We feel that everything on the checklist is important and should be done systematically."

Follow-up studies have shown that problems arise when RED is diluted.

"It's like every process. When people are carrying it out, there is the potential for eliminating or overlooking or not doing something with a high level of fidelity," Mitchell says.

Implementation Lacks Rigor
"Unfortunately when some places around the country have adopted RED, they haven't in most cases kept he program in its entire original form. It is not so much being outside of a research condition as it is institutions making decisions in the planning process to eliminate or adopt certain roles from the original design to meet their needs or resources of the limited commitment from leadership to implement RED."

For example, RED protocol calls for a pharmacist to make the two-day, post-discharge call on a patient to check their medicines and to see if any problems have arisen.

"The reason we had a pharmacist was because we needed someone who had knowledge of medications and the ability to intervene with a problem was necessary to make that call effective," Mitchell says. "Other organizations have said 'we can use a social worker or a community health worker to see how they are doing,' which is sort of a nice-but-not-necessary approach. We've learned that those kinds of adaptations make those calls less effective."

Mitchell says the same thing happens when hospitals use social workers with no clinical background as discharge educators.

"The adaptations of RED don't always translate to an effective model," she says. "Hospitals will cherry pick. They might pick three or four things on the check list to implement. They don't implement the whole thing. That impacts the success of the program."

Mitchells says the best way to ensure the success of the program is go get firm buy-in from hospital leadership.

"It has to be real and visible and it can't be tied to a short-term goal such as readmission reduction in six months. It takes time to change the way organizations do things. It's like turning a ship. When there is loose commitment from leadership everyone knows it," she says.

"Leadership is demonstrated not just by announcements, but resources and a long-term trajectory. It has to be a three-to-five year plan. You also need a really innovative and energized implementation team that is multidisciplinary so that people feel represented in the implementation process. Those are the two most important drivers. It has to be part of the organization's mission. It has to be a decision to change the way the hospital does discharge process. Not a special project—something that is nice, but not necessary."

Although RED was designed years before Medicare's readmissions penalties kicked in, the threat of losing of revenues should further incentivize hospitals to adopt aggressive discharge planning. While RED is not the only way to plan discharges, Mitchell says, it is the only protocol that's designated from inside the hospital, which gives hospitals greater control of the process.

"RED makes sense. It is high-quality care. It prioritizes the discharge and helps people go home and it helps you recognize the patients who aren't prepared or don't know what to do when they go home," she says. "So yes, the RED way is the right way."

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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