Publications and Abstracts

The following publications are PDFs and can be downloaded by clicking the titles (excluding those that are currently in press). You will need Acrobat Reader to view.

Project ReEngineered Discharge (RED) Lowers Hospital Readmissions of Patients Discharged From a Skilled Nursing Facility.
Berkowitz R, Fang Z, Helfand B, Jones R, Schreiber R, Paasche-Orlow M. Journal of American Medical Directors Association 2013 Apr 22.

Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis.
Walley AY, Paasche-Orlow M, Lee E, BA, Forsythe S, Chetty VK, Mitchell S, MD, Jack BW. Journal of Addiction Medicine 2011 Oct 4. [Epub ahead of print]. PMID: 21979821

Gender as Risk Factor for 30 days Post-Discharge Hospital Utilisation: a secondary data analysis.
Woz S, Mitchell S, Hesko C, Paasche-Orlow M, Greenwald J, Chetty VK, O'Donnell J, Jack B. BMJ Open 2012;2:e000428. doi:10.1136/ bmjopen-2011-000428

Health Literacy and 30-day Post discharge Hospital Utilization.
Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Journal of Health Communications - International Perspectives, 2012:17(3);325-28 , DOI: 10.1080/10810730.2012.71523317:sup3, 325-338

Physician Practice Management, 2nd edition

The following is an excerpt from the book:

Innovative Sources of Competition

Competition sometimes comes from unexpected places. Disruptive innovations, often dismissed in their earliest stages because they represent something other than "business as usual," have the potential to change the market landscape and the market's behavior...

Many innovations address problems that the healthcare world had yet to successfully solve. Project RED, the shortened name for the Project Re-Engineered Hospital Discharge, targets preventable hospital readmissions. The Agency for Healthcare Research and Quality (AHRQ) cites 4.4 million hospital stays as resulting from preventable causes. The physician behind the innovation, Brian Jack, stated: "There are loose ends, there are communication problems, there is poor quality information, there is poor preparation, there is fragmentation of care, and there is great variability. . . . It is no surprise that there are many adverse events post discharge."¹² At the heart of many preventable readmissions lie poorly coordinated care, including unreconciled medications; still-pending test results and still-needed tests; poorly communicated discharge instructions; and rushed staff who don't have adequate time to spend with patients who are leaving the hospital. His innovative solution to this problem was to create a virtual discharge assistant named Louise, a software program that, relying on the input of information from a discharge advocate, generates a thorough posthospital care plan that includes information about medications (how much, how often, what the pills look like), follow-up appointments, and other instructions relative to caring for oneself after leaving the hospital. Although a discharge advocate, who may be one of the always extremely busy nurses, spends some amount of time with the patient discussing the discharge plan, Louise, presented on-screen as an animated face with a pleasant voice, can "talk" with patients, answering questions that are routinely asked by patients leaving the hospital, can show emotion, and can ask each patient questions that require the patient to respond to be certain that he or she is paying attention. This frees up the nurses to carry out their other duties for which there is no substitute innovative solution. Could one say that Project RED competes with nurses, in that it replaces the nurse for part of the discharge process? The answer is yes, but with hospitals keeping their nursing staff numbers low in order to control costs, this type of competition, which lessens the burden on hospital nurses, is a welcome form of competition. The AHRQ reported that the use of Project RED's virtual discharge assistant prevented one emergency room readmission for every 7.3 discharge patients, resulting in significant cost savings.¹²

Innovations in healthcare may evoke fear and concern in some due to their direct competitive nature, or they may bring about relief because they successfully tackle problems that have not previously been solved. Either way, the flow of healthcare innovations will continue.

Improving Disposition Outcomes for Patients in a Geriatric Skilled Nursing Facility
Berkowitz R, Jones R, Rieder R, Bryan M, Schreiber R, Verney S, and Paasche-Orlow M. J Am Geriatr Soc 2011.

Family Physicians Geographic Density is Associated with Lower Hospital Readmission Rates and Costs
Chetty VK, Culpepper L, Phillips R, Rankin J, Xierali I, Finnegan S and Jack B. Family Physician Geographic Density is Associated with Lower Hospital Readmission Rates and Costs. 2011.

Longitudinal Remote Follow-Up by Intelligent Conversational Agents for Post-Hospitalization Care
Pfeifer L and Bickmore T. Longitudinal Remote Follow-Up by Intelligent Conversational Agents for Post-Hospitalization Care. Association for the Advancement of Artificial Intelligence. 2011.

The Re-Engineered Hospital Discharge Program to Decrease Rehospitalization
Jack B and Bickmore T. The Re-Engineered Hospital Discharge Program to Decrease Rehospitalization. CareManagement. December 2010/January 2011.

Project RED: Improving Continuity of Care at BMC
Hussein K. Project RED: Improving Continuity of Care at BMC. The Future Physician. Volume 3, Issue 1, October 2010.

Usability of Conversational Agents by Patients with Inadequate Health Literacy: Evidence from Two Clinical Trials
Bickmore, Timothy W. , Pfeifer, Laura M. , Byron, Donna , Forsythe, Shaula , Henault, Lori E. , Jack,
Brian W. , Silliman, Rebecca and Paasche-Orlow, Michael K.(2010) 'Usability of Conversational Agents by Patients with Inadequate Health Literacy: Evidence from Two Clinical Trials', Journal of Health Communication, 15: 1, 197 — 210

Reducing Readmissions:  Establish a Transition Program that Works (PDF 170 KB)
April 3, 2010.

Post-Discharge Hospital Utilization Among Adult Medical Inpatients with Depressive Symptoms (216 KB)
Mitchell S, Jack B Et al. Post-Discharge Hospital Utilization Among Adult Medical Inpatients with Depressive Symptoms, Journal of Hospital Medicine. 2009. In press.

Response to a Relational Agent by Hospital Patients with Depressive Symptoms
Bickmore T, Mitchell S, Pfifer L, Paasche-Orlow M, Forsythe S, Jack B. Response to a Relational Agent by Hospital Patients with Depressive Symptoms, Interacting with Computers. 2010. In Press.

Reengineering Hospital Discharge: A Protocol to Improve Patient Safety, Reduce Costs, and Boost Patient Satisfaction. (PDF 86 KB)
Clancy, Carolyn M. American Journal of Medical Quality. 2009; 24: 344.

A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. (PDF 190 KB)
Jack BW, Chetty VK, Anthony D, Greenwald JL, Burniske GM, Johnson AE, Forsythe SR, O’Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine.

Taking the Time to Care: Empowering Low Literacy Hospital Patients with Virtual Nurse Agents (PDF 262 KB)
Bickmore T, Pfeifer L, Jack B.

Preventing the preventable: Reducing rehospitalizations through coordinated, patient-centered discharge processes.
Greenwald J, Jack B. Preventing the preventable:  Reducing rehospitalizations through coordinated, patient-centered discharge processes. Professional Case Management: The Leader in Evidence-Based Practice. In press.

Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program. (PDF 151 KB)
Brian Jack, MD; Jeffrey Greenwald, MD; Shaula Forsythe; Julie O'Donnell; Anna Johnson; Lynn Schipelliti, RN; Mary Goodwin, RN; Gail M. Burniske, PharmD, BCPS; Caroline Hesko; Michael Paasche-Orlow, MD, MPH; Christopher Manasseh, MD; David Anthony, MD, MSc; Stephen Martin, MD, MEd; Lindsey Hollister; Margaret Jack; Vimal Jhaveri; Kevin Casey MPH; V.K. Chetty PhD. In, Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches. Vol. 3. Performance and Tools. AHRQ Publication No. 08-0034-3. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.

Re-engineering the hospital discharge: an example of a multifaceted process evaluation (PDF 2.88 MB)
Anthony D, Chetty VK, Kartha A, McKenna K, Rizzo DePaoli M, Jack B. Re-engineering the hospital discharge: an example of a multifaceted process evaluation. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in patients safety: from research to implementation. Vol. 2, Concepts and methodology. AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005.

The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process (PDF 2.69 MB)
Greenwald JL, Denham, CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. Journal of Patient Safety. 2007;3(2):97-106.

Depression is a risk factor for rehospitalization in medical inpatients (PDF 367 KB)
Kartha A, Anthony D, Manasseh CS, Greenwald JL, Chetty VK, Burgess JF, Culpepper L, Jack BW. Depression is a risk factor for rehospitalization in medical inpatients. Primary Care Companion Journal of Clinical Psychiatry. 2007;9(4):256-262.

Understanding rehospitalization risk: can the hospital discharge be modified to impact recurrent hospitalization (PDF 2.13 MB)
Strunin L, Stone M, Jack B. Understanding rehospitalization risk: can the hospital discharge be modified to impact recurrent hospitalization. Journal of Hospital Medicine. In Press.

Posters

Higher acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis (PDF 264 KB)
Walley A, Paaschle-Orlow M, Lee, E, Forsythe S, Jack B. Higher acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis, poster accepted for presentation at the 2010 CPDD Scientific Meeting, June 14, 2010.

Higher acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis
Walley A, Paaschle-Orlow M, Lee, E, Forsythe S, Jack B. Higher acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis, poster accepted for presentation at the SGIM 33rd Annual Meeting, Minneapolis, MN, April 30, 2010.

Post-discharge Hospital Utilization Among Adult Medical Inpatients With Depressive Symptoms
Mitchell S, Paasche-orlow M, Chetty V, Forsythe S, O'donnell J, Greenwald J, Sanchez G, Anthony D, Manasseh C, Culpepper L, Jack B. Post-discharge Hospital Utilization Among Adult Medical Inpatients With Depressive Symptoms, poster presented at the 2009 NAPCRG Annual Meeting, Le Centre Sheraton Montreal Hotel, West Montreal, Quebec, Canada, Nov 14–18, 2009.

ReEngineered Discharge (RED)
Jenson J, Jack B. ReEngineered Discharge (RED), poster presented at the Massachusetts Life Sciences Innovation Day, Massachusetts Technology Transfer Center, Boston, MA, June 3, 2009.

Interactive patient – specific discharge method
Jack, B. Interactive patient – specific discharge method, poster presented at the Boston University Translational Research and Corporate Relations Entrepreneur’s Open House, Boston, MA, April 22, 2009.

Taking the time to care: empowering low health literacy hospital patients with virtual nurse agents
Bickmore T, Pfeifer L, Jack B. Taking the time to care: empowering low health literacy hospital patients with virtual nurse agents, poster presented at the Computer Human Interaction (CHI) 2009 Papers & Notes Program, Boston, MA, April 4-9, 2009.

Impact of pharmacist follow-up telephone calls after intensive nurse-based patient education upon hospital discharge
Burniske G, PharmD, BCPS, O’Donnell J, BA, Chetty VK, PhD, Schipelliti L, RN, Goodwin M, RN, Johnson A, BA, Anthony D, MD, MSc, Greenwald JL, MD, Manasseh C, MD, Martin S, MD, MEd, Paasche-Orlow M, MD, MPH, Casey K, MPH, Forsythe S, BS, Jack B, MD. Impact of pharmacist follow-up telephone calls after intensive nurse-based patient education upon hospital discharge, poster accepted for presentation at the American College of Clinical Pharmacy 2007 Annual Meeting, Denver, Colorado, October, 2007.

Effect of the Re-Engineered Discharge program on satisfaction after hospitalization for patients with limited health literacy
Paasche-Orlow MK, Chetty VK, O’Donnell J, Anthony D, Johnson A, Greenwald J, Manasseh C, Burniske G, Casey K, Jack B. Effect of the Re-Engineered Discharge program on satisfaction after hospitalization for patients with limited health literacy, poster presented at the Society of General Internal Medicine Conference, Toronto, ON, Canada, April, 2007.

A clinical prediction model for hospital readmissions
Chetty VK, O’Donnell J, Anthony D, Johnson A, Greenwald J, Paasche-Orlow M, Manasseh C, Burniske G, Casey K, Jack B. A clinical prediction model for hospital readmissions, poster presented at North American Primary Care Research Group (NAPCRG) Conference, Tucson, Arizona, October, 2006.

Risk score to predict readmission after discharge
Forsythe S , Chetty VK, Ph.D, Anthony D, M.D., Johnson A, Greenwald J, M.D., Paasche-Orlow M, M.D., Manasseh C, M.D., Burniske G, Pharm.D., Casey K, Jack B. Risk score to predict readmission after discharge, poster presented at North American Primary Care Research Group (NAPCRG) Conference, Tucson, Arizona, October, 2006.