By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting
On Call Magazine, December 31, 2008

Brian Jack, MD, is a practicing physician and professor of family medicine at Boston University. Several years ago, a patient came to see him for a follow-up appointment after being discharged from the hospital. Jack had not treated this man before, and he knew little about him, which would not necessarily be a problem except the patient’s discharge summary hadn’t arrived yet. Eventually Jack found out that all the right things had been done and the patient had a good medical plan in place. But when Jack first saw the patient, he had no idea what the plans were.

Problems at transitions of care — times when one group of providers stops treating a patient and another group starts — are not uncommon. The most frequent type of transition occurs when patients go from hospital to home, happening nearly 40 million times each year. Studies show that about 20% of discharged patients have an adverse event – a preventable emergency department visit or readmission — within 30 days following hospitalization. We don’t do a good job of preparing people to go home,” Jack says. This isn’t particularly anyone’s fault. It’s related to the fact that patients going home are relatively healthy and so get less medical attention than those being admitted to or who are already in the hospital.

Identifying key components

Jack and colleagues have spent close to five years researching what constitutes a “good” hospital discharge and how to achieve it. Working with funding from the Agency for Healthcare Research and Quality (AHRQ), he began a randomized control trial that was followed by an in-depth analysis of the hospital discharge process. The researchers used process mapping (drawing all the steps involved), failure mode effect analysis (looking for bottlenecks where the process breaks down), and qualitative analysis (interviewing patients and staff) to find consistent themes.

These are the key actions that must take place for a good hospital discharge:

• Educate the patient about diagnosis throughout the hospital stay.
• Make appointments for follow-up and post discharge testing, with input from the patient about times and dates.
• Discuss with the patient any tests or studies that were completed in the hospital.
• Organize post-discharge services.
• Confirm the medication plan.
• Reconcile the discharge plan with national guidelines and critical pathways.
• Review with the patient appropriate steps for what to do if a problem arises.
• Expedite transmission of the discharge summary to clinicians accepting post discharge care of the patient.
• Give the patient a written discharge plan.
• Assess the patient’s understanding of the plan.
• Call the patient two to three days after discharge to reinforce the discharge plan and help with problem-solving.

These key steps then were incorporated into a project called the Reengineered Hospital Discharge Program, also known as Project RED. The primary tool in Project RED is a booklet that’s personalized for patients called After Hospital Care Plan (or AHCP). The booklet has 5 key components:

• Cover. Discharge information is tailored for every patient. The booklet’s cover includes the patient’s name, discharge date, and phone numbers for the discharge advocate and treating physician.
• Medicines. This section lists both generic and trade names for each drug the patient will be taking along with simple text and icons that make clear what the drug is for, how much to take, and when to take it.
• Appointments. Each booklet has a 30-day calendar with scheduled appointments written in. There is space for patients to write down their questions along with notes to providers about any pending tests.
• My Medical Problem. This section has information about the patient’s diagnosis. It uses clear pictures and simple text to answer AskMe3 questions: What is my main problem? What do I need to do? Why is it important for me to do it?
• Closing. The final section includes a map showing where to go for follow-up appointments.

Technology both streamlines and personalized the process

Admittedly, it takes time for discharge advocates to review AHCP with patients. Jack and his team have also been looking at ways technology can help. Working with Tim Bickmore, professor of computer science at Northeastern University, they developed avatars (computer characters) that personify the booklet. Jack thinks of these avatars as “relational agents” that can emulate face-to-face communication and develop an empathetic alliance with patients.

Louise and Elizabeth are the two avatars, designed and named by audience testing. The avatars can be programmed to show empathy, or not. They also engage patients in social chit-chat, talking about everyday topics such as the Boston Red Sox. The avatars not only teach what’s in the booklet, but also test understanding. After key points are presented, Louise will say, “I’m going to ask you a few questions.” Patients then give their answers via touch screen. The intent of the testing is to confirm that patients know where to find needed information. One advantage of using avatars is that patients can take as much time as they need to review and repeat information.

Sarah Waite is the research assistant for Project RED. She says that one effect of the personalized nature of AHCP is that it shows patients that “we really care.” She adds that they seem glad to have this booklet to take home. Waite explains how the booklet uses key principles of health literacy. It was developed by listening to and learning from the intended audience. It is written in a direct manner, uses an engaging tone, and has simple wording and graphics to help patients more easily understand its messages. The booklet is currently available only in English but soon will be translated into Cantonese and Spanish.

The effectiveness of Project RED is currently being examined, but Jack and others feel the benefits are likely to far exceed the costs in terms of healthcare savings and increased patient safety. In a study at Boston Medical Center (BMC), discharge advocates who are research nurses create personalized copies of the booklet by entering each patient’s information into special software developed by the RED team. The booklet is then automatically printed and bound. Other organizations are welcome to reprint and use the booklet, available for free at http://www.bu.edu/fammed/projectred/toolkit.html. To learn more about how to acquire the software to create books automatically, contact Jack directly at Brian.Jack@bmc.org.

How to Find Out More

Web sites:

• Project RED. Available online at http://www.bu.edu/fammed/projectred/index.html
• AskMe3. Available online at http://www.npsf.org/askme3

Articles:

• “A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial.” 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. Annals of Internal Medicine – in press, scheduled for February 2009 publication.
• Greenwald JL, Denham CR, Jack BW, “The Hospital Discharge: A Review of High Risk Care Transition With Highlights of a Reengineered Discharge Process.” Journal of Patient Safety, Vol. 3, No. 2, June 2007, 97-106.

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. Her column appeared regularly in On Call. Helen speaks, writes, consults and podcasts about health literacy. To learn more, you can subscribe to her free “What’s New in Health Literacy Consulting” e-newsletter or contact her by e-mail at Helen@healthliteracy.com.