BETHESDA, MD 02 February 2009—A comprehensive patient-discharge plan that included follow-up from a pharmacist cut subsequent hospital visits by about 30% at a Boston hospital, according to a report in the February 3 Annals of Internal Medicine.
The study found that patients in the intervention group were significantly more likely than other patients to identify their discharge diagnosis, feel prepared to leave the hospital, name their primary care provider, and schedule follow-up care with that person.
Other benefits of the intervention included an estimated $150,000 in savings on emergency department, hospital, and primary care visits, or $412 per patient.
The report describes a study involving 749 English-speaking adults who were admitted to the general medical service at Boston Medical Center in 2006 and 2007. Half of the patients received usual care, and half were enrolled in the intervention, dubbed the reengineered hospital discharge (RED) program. The main study goal was to compare 30-day hospital readmissions and emergency department visits between the intervention and usual-care groups.
The RED intervention was performed mostly by discharge advocates—specially trained nurses who worked with patients during their hospital stay. The advocates` duties included educating patients about their diagnoses, coordinating their care within the hospital, and confirming their medication and postdischarge plans.
Each patient in the intervention group received a written discharge plan, including a personalized booklet with a calendar of scheduled postdischarge appointments and tests. The booklet also contained a discharge medication list describing how and when to take each drug and where to obtain it. Discharge advocates were responsible for counseling the patients about the written plan.
Two to four days after discharge, a clinical pharmacist contacted each patient in the intervention group to review and reinforce the discharge plan. According to the report, the pharmacist followed a script that included asking the patients to bring their medications to the telephone so that they could be reviewed. Any problems identified by the pharmacist were communicated to the discharge advocate or the patient`s physician.
The study design specified that the pharmacist should make at least three attempts to contact each patient. According to the report, the pharmacist was able to reach 228 of the patients in the intervention group and complete the medication review for 195 patients. In all, 126 patients in the intervention group had one or more medication problems that the pharmacist found during the review, and 103 of those problems required corrective action by the pharmacist.
The researchers reviewed the hospital`s electronic medical record data and also contacted study participants by telephone 30 days after discharge. Data on secondary outcomes—patients` knowledge of their discharge diagnosis, preparedness for discharge, and use of follow-up primary care— were self-reported by the study participants.
In all, 116 hospitalizations or emergency department visits were recorded within 30 days after the initial discharge in the RED group, compared with 166 in the usual-care group. This translated to a statistically significant 30% decrease in the likelihood of intervention patients using hospital services in the first month after discharge.
Within 30 days after discharge, a total of 55 readmissions occurred in the intervention group and 76 in the usual-care group, but this difference was not statistically significant.
On average, the pharmacist`s portion of the RED intervention took about 30 minutes per patient, and the nurses` time required about 90 minutes per patient.
The report notes that the intervention was "bundled" so that it was not possible to determine how much each component of the intervention contributed to the study`s overall outcomes.
According to the report, the principles of the RED intervention form the basis of the National Quality Forum`s 2006 recommendations (PDF) for improving discharge practices at hospitals.
