Six pilot sites have been selected to put SHM’s new hospital discharge project to a real-world test.
The Better Outcomes for Older Adults through Safe Transitions (BOOST) project was developed in response to an abundance of research indicating the period of time around hospital discharge often is stressful and dangerous for older patients. Further, up to one in five patients suffers an adverse event, many of which could have been prevented or ameliorated, according to SHM.
The project is paid for by a $1.4 million grant from the John A. Hartford Foundation, which selected SHM to develop a toolkit to improve the discharge process. Project BOOST incorporates the best components of many previous approaches including those funded by the Agency for Healthcare Research and Quality through a Partnerships in Implementing Patient Safety grant.
“Project BOOST is a completely new look at the entire hospital discharge project, using the best evidence and experience to develop a discharge toolkit to optimize the discharge process,” asserts Mark V. Williams, MD, principal investigator on the project and professor and chief of the Division of Hospital Medicine at the Feinberg School of Medicine at Northwestern University in Chicago. “We are going to work with frontline hospitalists to refine the toolkit so we can then deliver a practical and usable approach that SHM will make available to hospitals throughout the United States. By providing practical quality improvement mentorship to hospitalists, this national initiative will test the BOOST discharge toolkit in a wide variety of hospitals and demonstrate its success in real-world situations.”
Tina Budnitz, MPH, project director for BOOST, said the six pilot sites were selected based on the demonstrated support from their institution and cultural readiness for change. Careful attention was also given to ensure diversity of facility locations and size.
- Hospital of the University of Pennsylvania, Philadelphia;
- Queens Medical Center, Honolulu, Hawaii;
- Southwestern Vermont Medical Center; Bennington, Vt.,
- Piedmont Hospital, Atlanta, Ga.;
- University of New Mexico Health Science Center School of Medicine, Albuquerque; and
- Appleton Medical Center in Appleton, Wis., and ThedaClark Medical Center in Neenah Wis. Both facilities are part of ThedaCare.
Project BOOST comprises two major elements. The first, recently completed, was the development of a discharge planning toolkit including an “implementation guide” for the proposed intervention, clinical tools, staff training materials, patient education materials and more.
The second element of BOOST is an array of training and technical support for sites aiming to implement the BOOST toolkit. SHM recently launched the Care Transitions Resource Room, an online resource that includes the toolkit, general guidance for implementation, and related training materials for staff and residents. The resource room also provides an overview of relevant literature and a discussion forum.
Budnitz emphasizes the uniqueness of BOOST compared with other initiatives to improve discharge planning.
“BOOST goes beyond suggesting best practices,” she notes. “The toolkit’s primary focus is how to successfully implement those practices within a system resistant to change. The BOOST toolkit and mentoring program will help sites assess their resources and obstacles, pull together a team, train the team, gain the support of hospital administrators, and collect and utilize metrics to improve the program and build a case for continued institutional support.”
Sites looking for more guidance in implementing the BOOST toolkit can sign up for a daylong pre-course in conjunction with SHM’s 2009 annual meeting in Chicago in May.
BOOST also offers a comprehensive mentoring program. The yearlong assistance includes a daylong training session for the improvement team, regular calls between the participating hospital’s leader and project mentor, and individualized support using the BOOST toolkit. The intervention provides evidence and expert-based interventions for risk assessment, discharge education utilizing teach-back processes, and guidance for determining the need, timing and content of follow-up communications with receiving MDs and patients and families.
The program is offered at no charge to institutions because of the Hartford grant. Applications for the April 2009 training group of 24 sites will be accepted beginning in October.
The 7 P’s
A critical element in the intervention is a risk-assessment transition evaluation form known as a “7P Risk Scale.” The P’s stand for:
- Prior non-elective hospitalization in the past six months;
- Problem medications, including anticoagulants, insulin, aspirin plus clopidogrel (an anti-platelet agent) combination therapy, digoxin (digitalis), and narcotics;
- Punk (a positive depression screen or depression diagnosis);
- Principal diagnosis of cancer, stroke, diabetes mellitus, chronic obstructive pulmonary disease, or heart failure;
- Polypharmacy (taking five or more medications routinely);
- Poor health literacy; and
- Patient support (absence of a caregiver to assist with the discharge or home care).
This 7P risk assessment is completed when a patient is admitted to the hospital. It highlights the necessity of early identification of patients at risk of premature re-hospitalization or other adverse events during the post-discharge period.
The scale may be used throughout the hospitalization to improve risk identification and reduce adverse events. Linked to the assessment is a risk-specific intervention checklist that guides users in how to address the identified risk factor in a patient-centered fashion. The risk-specific checklist is coupled with a universal one with elements that apply more broadly to hospitalized patients. TH