L19 Presentation Greenwald - Institute for Healthcare Improvement

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IHI Learning Forum 2013
It Takes a System to Do Successful
Care Transitions:
Introducing Project BOOST
Jeff Greenwald, MD, SFHM
Associate Professor, Harvard Medical School
Inpatient Clinician Educator Service, Massachusetts General Hospital
Chair of Readmissions Committee, Partners Healthcare System
Co-investigator, Project BOOST
Drs. G’s
Financial Disclosures
Bupkus!
Nada! Zip!
Zero! Nuttin!
…except salary support
for Project BOOST from
SHM and PHS for
committee work, and
speaker’s fees.
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Outline for Today
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The Background of BOOST
Our Tools and Resources
The Data
Lessons Learned and Conclusions
A Brief Primer on BOOST
• Started in 2006 with a grant from the John A. Hartford
Foundation.
• Better Outcomes for Older Adults Through Safe
Transitions
• Development of discharge transitions toolkit, workbook,
and online resource room
• Identifies risk factors for failed transitions, standardizes
interventions, improves patient preparation for discharge,
and ensures access to aftercare.
• Initial 6 sites enrolled 2008
• Now over 190 sites
• Better Outcomes by Optimizing Safe Transitions
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A Brief Primer on BOOST
Purpose and Motivation:
• Help hospital teams improve the safety and
effectiveness of the care they provide around
hospital discharge.
• Help train hospitalists to become leaders in
local QI efforts.
A Brief Primer on BOOST
Official BOOST Sites get:
• Kickoff training (2-day)
• Workbook, tools, webinars, other web-based
resources, and BOOST community listserv.
• 12 months of mentorship
• 2 year access to our data center
• A site visit
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The Origin of Our Insights
If I have seen further
it is by standing on the
shoulders of giants.
- Sir Isaac Newton
A Small Village of Smart People
BOOST’s Advisory Board
Chair: Eric Coleman, MD, MPH
(MacArthur Fellow – Genius Award)
Co-Chair & PI: Mark Williams, MD
with organizational representatives from:
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Social work
Case management
Clinical pharmacy
Geriatric medicine
Geriatric nursing
Health IT
Blue Cross/Blue Shield
United Health
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Health systems
NQF
AHRQ
TJC
CMS
National Consumer’s
League
• Other content experts
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Our Village Grows
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BOOST Tools/Resources
Tools
• Risk assessment tool
• Discharge preparedness
assessment
• Patient-centered
discharge education
tools
• Teach Back
Resources
• Workbook
• Data collection tools
• Webinars
• Listserv access
• Online community
• Web-based resources
• ROI calculator
• Newsletters
• Teach Back Curriculum
• Mentors
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The BOOST Workbook
Contents:
1. Essential first steps in quality improvement
2. Analysis of current processes & opportunities for
improvement
3. BOOST interventions, the evidence behind them,
and tips for implementation
4. Evaluation: how will you know if you are making a
difference?
5. Continuing to improve
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The 8P Risk Scale
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Prior hospitalization
Problems with medications
Psychological
Principal diagnosis
Physical limitations
Poor health literacy
Patient support
Palliative care
Each associated
with risk specific
interventions
assigned to a
specific provider.
Identify, Mitigate, Communicate
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The General Assessment of
Preparedness: The GAP
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Caregivers and
social support circle
for patient
Functional status
evaluation
completed
Cognitive status
assessed
Abuse/neglect
Substance abuse
Advanced care
planning addressed
and documented
On
Admission
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Functional status
Cognitive status
Access to meds
Responsible party for
ensuring med
adherence prepared
Home preparation for
patient’s arrival
Financial resources
for care needs
Transportation home
Access (e.g. keys) to
home
• Understanding of
dx, treatment,
prognosis, followup and postdischarge warning
S/S (using Teach
Back)
• Transportation to
initial follow-up
At Discharge
Nearing
Discharge
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NEW CONCEPT / SKILL
The Teach Back Method
Health information, advice,
instructions, or change in
management
Assess patient
comprehension /
Ask patient to
demonstrate
Explain new concept /
Demonstrate new skill
Clarify and tailor
explanation
Patient recalls and
comprehends /
Demonstrates skill mastery
Adherence /
Error reduction
Re-assess recall and
comprehension /
Ask patient to
demonstrate
•Modified from Schillinger, D. et al. Arch Intern Med 2003;163:83-90
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Other Suggested Processes
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Interprofessional Rounds
Follow-up Telephone Calls
Medication Reconciliation
Expedited Follow-up Appointments
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•BOOST tools are not
intended to worn right
“off the rack.”
•They are to be tailored
to your own
institutional needs and
resources.
•Work with your
mentor on this.
A BOOST Mentor
1. Knowledgeable about
BOOST, QI, and care
transitions.
2. Will help you through the
process (but can’t do it for
you).
3. Can help you identify
resources when questions
arise.
4. Will hold regular mentor
calls with your BOOST
team.
5. Will perform a site visit at
your hospital.
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Data Tracking
•Stay tuned! We’ll discuss data soon!
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• Volunteer sample of 11 out of 30 hospitals
– Vary in geography, size and academic affiliation
• Pre-post changes in same hospital readmission
rates
– BOOST vs. Control Units
• Readmission rate declined 14.7% to 12.7%
in 12 months
– Relative reduction of 13.6%
– No change in control units (14.0 vs 14.1%)
Readmission Rate
* 7th hospital’s control unit had less than 10 monthly discharges and not included in the
analysis. All units included in analysis had 60 or more monthly discharges.
Preliminary
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Readmission Rate
25% Decrease
* 7th hospital’s control unit had less than 10 monthly discharges and not included in the
analysis. All units included in analysis had 60 or more monthly discharges.
Preliminary
Themes
• Change is hard… Changing care transitions is
REALLY hard (…and slow).
– Corollary: Mentors can help.
• There’s leadership support and then there’s
LEADERSHIP SUPPORT.
• Teamwork is critical. Break those silos!
– Corollary: Don’t be hospital-centric.
• Respect workflow…but EMRs are not the solution.
• The prepared and educated patient and caregiver
are your best allies.
• Pilots sites not pilot services.
• Small organizations are more nimble!
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Jeff Greenwald jlgreenwald@partners.org
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