A Reengineered Hospital Discharge Program to Decrease Rehospitalization

Context Emergency department visits and rehospitalizations are common after hospital discharge. Contribution This trial demonstrated that a nurse discharge advocate and clinical pharmacist working together to coordinate hospital discharge, educate patients, and reconcile medications led to fewer follow-up emergency visits and rehospitalizations than usual care alone. Caution The trial was conducted at a single center, and not all eligible patients were enrolled. Implication A systematic approach to hospital discharges can reduce unnecessary health service use. The Editors One in 5 hospitalizations is complicated by postdischarge adverse events (1, 2), some of which may lead to preventable emergency department visits or readmissions. Despite this finding, hospital discharge procedures have not been standardized (3). In addition, the declining presence of primary care providers (PCPs) in hospitals has not been adequately accompanied by systems to ensure that patient data are transferred to subsequent caregivers (4, 5). For example, discharge summaries frequently lack critical data and are not sent to the PCP in a timely fashion (6, 7), resulting in outpatient clinicians being unaware of test results that were pending at discharge (8) and evaluations that were scheduled to be done after discharge not being completed (9). Similarly, patients are often left unprepared at discharge; many do not understand their discharge medications and cannot recall their chief diagnoses (10). With more than 32 million adult discharges in the United States each year (11), these deficiencies in the transition of care increase illness, unnecessary hospital utilization, and cost. Some peridischarge interventions have shown a reduction in hospital readmission rates and cost (1214), emergency department visits (15), and postdischarge adverse events (16), whereas some have shown little or no effect (1720). Peridischarge interventions have also shown improved PCP follow-up and outpatient work-ups (21) and higher patient satisfaction (15). Most of these studies have focused on specific diagnoses (14, 22, 23) or highly selected populations, such as geriatric adults (12, 13, 19, 24). Some have focused on specific aspects of the discharge, such as increasing access to primary care follow-up (25), connecting with transitional nursing services (26), or improving patients' ability to advocate for themselves after discharge (12). To date, no study has evaluated a standardized discharge intervention that includes patient education, comprehensive discharge planning, and postdischarge telephone reinforcement in a general medical population. In 2004, we began an in-depth examination of hospital discharge, for which we designed a package of services to minimize discharge failuresa process called reengineered discharge (RED) (Table 1) (3, 27). We did a randomized, controlled trial to evaluate the clinical effect of implementing RED among patients admitted to a general medical service. Table 1. Components of Reengineered Hospital Discharge Methods Setting and Participants We conducted a 2-group, randomized, controlled trial of English-speaking patients 18 years of age or older who were admitted to the medical teaching service of Boston Medical Center, Boston, Massachusettsa large, urban, safety-net hospital with an ethnically diverse patient population. Patients had to have a telephone, be able to comprehend study details and the consent process in English, and have plans to be discharged to a U.S. community. We did not enroll patients if they were admitted from a skilled nursing facility or other hospital, transferred to a different hospital service before enrollment, admitted for a planned hospitalization, were on hospital precautions or suicide watch, or were deaf or blind. Boston University's institutional review board approved all study activities. Randomization Each morning, a list of admitted patients was reviewed for initial eligibility (hospital location, age, date and time of admission, and previous enrollment). Last names of potential participants were ranked by using a random-number sequence to determine the order in which to approach patients for enrollment. A trained research assistant then approached each patient and further determined eligibility according to inclusion and exclusion criteria (Figure 1). Figure 1. Study flow diagram. * Patients did not meet inclusion criteria if they were admitted from or planned discharge to an institutional setting (n= 74), planned hospitalization (n= 3) or discharge to a non-U.S. community (n= 5), were transferred to different hospital service (n= 8), did not speak English (n= 371) or have a telephone (n= 71), were on hospital precautions (n= 274) or suicide watch with a sitter (n= 10), were unable to consent (n= 181), had sickle cell disease as the admitting diagnosis (n= 38), had privacy status (n= 8), were deaf or blind (n= 2), or other (n= 4). Usual care participants did not meet eligibility criteria if they were discharged to a nursing facility (n= 28), were transferred to another hospital service (n= 1), were previously enrolled (n= 1), died during index admission (n= 2), requested to be removed (n= 5), or other (n= 3). Intervention participants did not meet eligibility criteria if they were discharged to a nursing facility (n= 21), were transferred to another hospital service (n= 6), died during index admission (n= 1), requested to be removed (n= 2), or other (n= 8). 107 intervention participants did not receive a reinforcement call because they could not be reached by telephone (n= 93), they were readmitted the same or next day (n= 2), there was no staffing coverage (n= 8), or other (n= 4). By using block randomization (28) with varying block sizes of 6 and 8, we randomly arranged index cards indicating either the usual care or intervention group. We placed the cards in opaque envelopes labeled consecutively with study numbers. We assigned eligible participants who consented to enrollment to a study group by revealing the concealed index card. This process continued until 2 participants were enrolled each day of the week (or 3 participants if the first 2 participants were randomly assigned to the usual care group). This protocol ensured that research assistants could not selectively choose potential participants for enrollment or predict assignment. Participants randomly assigned to usual care received no further intervention. There were 40 participants in the usual care group and 38 in the intervention group who were enrolled but no longer met inclusion criteria at discharge (most commonly because they were discharged to a nursing facility). Because the primary analysis was by intention to treat, we included these participants in the analysis, with the exception of those who died before index discharge, requested to be removed, or were previously enrolled (Figure 1). Interventions Nurse discharge advocates (DAs) carried out all aspects of the in-hospital intervention. We hired 6 part-time DAs to work with intervention participants to ensure coverage by 1 DA 7 days a week, 5 hours a day. We trained all DAs to deliver the RED intervention by using a manual containing detailed scripts, observation of relevant clinical interactions, and simulated practice sessions. The primary goals of the DA were to coordinate the discharge plan with the hospital team and educate and prepare the participant for discharge. At admission, the DA completed the RED intervention components outlined in Table 1. Additional information about the DA training manual is published elsewhere (3) and can be found on our Web site (www.bu.edu/fammed/projectred/index.html). With information collected from the hospital team and the participant, the DA created the after-hospital care plan (AHCP), which contained medical provider contact information, dates for appointments and tests, an appointment calendar, a color-coded medication schedule, a list of tests with pending results at discharge, an illustrated description of the discharge diagnosis, and information about what to do if a problem arises. Information for the AHCP was manually entered into a Microsoft Word (Microsoft, Redmond, Washington) template, printed, and spiral-bound to produce an individualized, color booklet designed to be accessible to individuals with limited health literacy. By using scripts from the training manual, the DA used a teach-back methodology (29) to review the contents of the AHCP with the participant. On the day of discharge, the AHCP and discharge summary were faxed to the PCP. A clinical pharmacist telephoned the participants 2 to 4 days after the index discharge to reinforce the discharge plan by using a scripted interview. The pharmacist had access to the AHCP and hospital discharge summary and, over several days, made at least 3 attempts to reach each participant. The pharmacist asked participants to bring their medications to the telephone to review them and address medication-related problems; the pharmacist communicated these issues to the PCP or DA. Outcomes Measures and Follow-up At the time of recruitment, research assistants collected baseline data, including sociodemographic characteristics; the Short Form-12 Health Survey, Version 2 (30); the depression subscale from the Patient Health Questionnaire-9 (31); and the Rapid Estimate of Adult Literacy in Medicine (32). We calculated the Charlson Comorbidity Index score by using primary and secondary diagnoses recorded on the index admission discharge summary (33). We determined the number of hospital admissions and emergency department visits in the 6 months before index admission through medical record review (Boston Medical Center hospital utilization) and participant report (all other hospital utilization). The primary end point was the rate of hospital utilizationthe total number of emergency department visits and readmissions per participant within 30 days of the index discharge. Any