May / June 2009
Re-engineered Hospital Discharge Process Lowers Re-admissions, Reduces Costs
As the number of days
that patients spend in the hospital continues to drop, the need for
thoroughly planned and clearly explained post-hospital care has risen
In 2006, the average hospital stay for patients of
all ages was 4.8 days, compared with 7.5 days in 1980, according to
government statistics (National Center for Health Statistics, 2007).
The drop in hospital days has been even more dramatic for patients 65
years and older; visits for these patients have fallen from 10.7 days
to 5.5 days during the same time period.
For many patients, especially older patients or
those with complex medical needs, shorter hospital stays demand well
coordinated follow-up care. Priorities include making sure patients and
their clinicians find out about pending lab test results, understand
their new or revised medication protocols, and can arrange for
appropriate follow-up appointments.
In many cases, however, patients don't have or
fully understand their hospital discharge information, causing their
follow-up care to suffer.
In fact, a 2007 study (Moore) sponsored by the
Agency for Healthcare Research and Quality (AHRQ) found that more than
one-third (36%) of patients discharged from the geriatric or medicine
service at a large teaching hospital and in need of outpatient workups
failed to get that care. Post-discharge follow-up included lab tests,
diagnostic procedures, or sub-specialty referrals.
One reason why patients and their primary care
doctors don't follow through on such care is the incomplete information
contained in the hospital discharge summary, the study found. Slightly
more than half (54%) of all discharge summaries failed to document the
recommended outpatient workups that were documented in the patients'
hospital charts. The lack of complete and timely information impairs
the continuity of care and increases the likelihood of
The Re-engineered Discharge
Clinicians are beginning to appreciate why they
must work to close the information gaps that accompany many hospital
discharges. One project at Boston Medical Center in Massachusetts is
showing excellent results toward meeting this goal.
Called Project RED (short for Re-engineered
Discharge) and led by family medicine doctor Brian Jack, MD, it has
transformed the way patients are discharged from the hospital and seen
for follow-up care at nearby community health centers. His work is
funded by AHRQ.
Simple principles are at the heart of Project RED (Jack, 2009):
- Well-defined roles and responsibilities for everyone on the health care team.
- Patient education throughout the hospital stay.
- Easy flow of information from the patient's doctor to the hospital team and back to the doctor.
- A written discharge plan.
Dr. Jack's team uses 11 steps to put these principles into action (Project RED, 2009):
- Educating the patient about his or her diagnosis throughout the hospital stay.
- Making appointments for clinician follow-up
and post-discharge testing, including making and coordinating
appointments, discussing their importance with the patient, and
confirming transportation arrangements.
- Discussing any tests or studies that have been completed in the hospital and deciding who is responsible for follow-up.
- Organizing post-discharge services, including making appointments and discussing how to receive each service.
- Confirming the medication plan and making
sure the patient understands changes in the routine and which side
effects to watch for.
- Reconciling the discharge plan with national guidelines and critical pathways.
- Reviewing steps to take if a problem arises, such as whom to call and what constitutes an emergency.
- Expediting the discharge summary to the physicians and other services responsible for the patient's care after discharge.
- Asking the patient to explain in their own words the details of the discharge plan.
- Giving the patient a written discharge plan
at the time of discharge that explains the reason for hospitalization
and information on medications and what to do if their condition
- Phoning the patient 2 to 3 days after discharge to identify and resolve any problems.
Fewer Readmissions, Cost Savings
Patients who participated in Project RED are
one-third less likely to be readmitted to the hospital or to visit the
emergency department than patients who received the usual care hospital
discharge, a new study in the Annals of Internal Medicine found (Jack, 2009).
Thirty days after their hospital discharge, the
370 patients who participated in the RED program had 30% fewer
subsequent emergency visits and readmissions than the 368 patients who
did not. Nearly all (94%) of the patients who participated in the RED
program left the hospital with a follow-up appointment with their
primary care physician, compared to 35% for patients who did not
participate. And nearly all (91%) participants had their discharge
information sent to their primary care physician within 24 hours of
leaving the hospital.
Fewer hospital readmissions and emergency
department visits also translated to lower total costs. Total costs (a
combination of actual hospitalization costs and estimated outpatient
costs) were an average of $412 lower for the patients who received
complete information than for those who did not, according to the study.
Making medication review available to patients did
not prevent problems from occurring after discharge, but a
post-discharge telephone call by a clinical pharmacist did allow early
detection and corrective actions. According to the study, nearly
two-thirds (62%) of the RED program participants completed the
medication review. In over half of those cases (54%), at least one
medication-related problem was identified that required clinician
Dr. Jack and his study co-authors (Joint
Commission, 2008) acknowledged that a current lack of financial
incentives to implement a discharge program such as this poses a
barrier to widespread adoption. However, they note, the growing
importance to hospitals of demonstrating their quality performance,
such as patient safety goals identified by the Joint Commission, could
spur added interest in this type of program.
The emphasis on moving patients from acute
inpatient settings to outpatient settings or back to their homes as
soon as they no longer require inpatient care remains a sound policy
objective. However, this trend failed to fully appreciate the need for
protocols to ensure that post-hospital care is understood by the
patient and communicated to outpatient clinicians in a timely and
complete manner. Project RED and other efforts to bridge these gaps
demonstrate the improvements in quality that are possible when
continuity of care is a common goal for providers, and a goal that can
be achieved through an organized and structured plan.
Carolyn Clancy is director of the Agency for
Healthcare Research and Quality, Rockville, Maryland. She is a general
internist and holds an academic appointment at George Washington
University School of Medicine in Washington, DC. She may be contacted
Jack, B. W., Chetty, V. K., Anthony, D. et al.
(2009, February 3) A reengineered hospital discharge program to
decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187.
Joint Commission. (2008). 2008 Hospital National Patient Safety Goals. Accessed March 4, 2009, at: http://www.jointcommission.org/NR/rdonlyres/91DCAAB8-D84D-4AD3-B9C5-1308A803F60C/0/08_NPSG_HAP_gp.pdf.
Moore, C., McGinn, T., Halm, E. (2007, June 25). Tying up loose ends: Discharging patients with unresolved medical issues. Archives of Internal Medicine, 167(12), 1305-1311.
National Center for Health Statistics. (2007). Health, United States, 2007. Hyattsville, MD. Accessed March 4, 2009, at: http://www.cdc.gov/nchs/data/hus/hus07.pdf.
Project RED, Boston Medical Center. (2009). Components of Re-Engineered Discharge (RED). Accessed March 4, 2009, at: http://www.bu.edu/fammed/projectred/components.html.