Healthleaders Magazine Features Brian Jack in ’20 People Who Make Healthcare Better’
One cost and safety issue that has caught the attention of Capitol Hill lawmakers discussing healthcare reform issues deals with patients returning to hospitals within 30 days of their discharges. Those looking to improve the discharge process—and stem high costs associated with readmissions—have been looking closely at the ongoing work of Brian Jack, MD.
“There are a lot of stories that I could tell you about people who have been discharged without adequate plans who are set up to failure.”
—Brian Jack, MD
About six years ago, Jack and his associates at Boston Medical Center (BMC), a nonprofit, 547 licensed bed facility, began studying the hospital discharge process as a patient safety issue. The reason wasn’t so much that errors were happening to patients during discharge: It was concern that errors were occurring following the discharge—when patients were making the transition to other types of care outside of the hospital.
At the same time, two trends were converging to create “even more problems in an already stressed healthcare system,” says Jack, who is an associate professor and vice chair of the department of family medicine at BMC.
First, lengths of stay in hospitals were getting shorter, meaning patients were leaving quicker—and sometimes in less stable condition compared with the longer LOS, Jack says. And second, primary care providers “were not seeing their patients in the hospital as much as they used to” because hospitalist care was being expanded.
“No one had ever looked at the [discharge] process carefully before,” he says. “And no one had set up guidelines for the kinds of things that ought to happen in hospital discharge.” With 30 million hospital discharges occurring annually nationwide, the impact could be huge.
“It really bothered me because I knew that a certain number of [patients] were going to be coming back because we just weren’t spending the time to take care of all the details necessary for them to go home,” Jack says. A 2009 study that Jack worked on showed the rate was close to 20%.
A grant from the Agency for Healthcare Research and Quality in 2003 got them on their way to “re-engineering the hospital discharge process” with a focus on patient safety. An ironic term, Jack contends, because the process had never been “engineered” in the first place. But, now, Jack and his team would borrow engineering principles—ideas such as process mapping or root-cause analysis—and apply them to hospital processes.
The result of their research was development of 11 components called the Re-engineered Discharge (RED) that could be used when patients were ready to leave the hospital. The components were incorporated into a checklist—similar to that used by airline pilots before takeoff—noting areas such as educating about discharge plans or providing timely telephone follow-up.
They began to test the RED process, and including an intervention at the time of discharge with a specially trained nurse, called a discharge advocate, who would teach elements in an after-hospital care plan that they had developed.
“What we did basically was to collect information in the hospital that was relevant to people that allowed them to take care of themselves when they went home,” Jack says. On average, many patients had been getting eight minutes of discussion before they went home. “How then are they are expected to take care of themselves?”
In one study using the RED intervention program, 94% in the intervention group were discharged with a primary care appointment within 24 hours after discharge; in the usual care group, 35% were discharged with a primary care appointment. Hospital utilization with RED within 30 days of discharge decreased by 30% among patients receiving general medical services. Overall, avoiding unnecessary hospitalizations was found save the healthcare system about $412 per person.
While their studies used a nurse to provide the patient with information before discharge, BMC began looking for a way to automate that process. In 2007, it rolled out “Louise,” an interactive character on a computer screen that patients could use at discharge to review care plans.
So is the message getting through? On grand rounds, Jack likes to tell the story of how his father—after having his pacemaker battery replaced—was discharged. Following an overnight stay, he was handed a box with a cellophane-wrapped CD on how to “bridge” his blood-thinner medication, or bring it up to the necessary coagulation level.
The nurse said she didn’t have time to talk with him, and that he should go home and watch this CD because “it will explain to you how to draw up your medicine and inject yourself, and why you need to do that.”
“It was totally ridiculous,” Jack says. “There are a lot of stories that I could tell you about people who have been discharged without adequate plans who are set up to failure.”