Leaders: Taking a Systems-Based Approach to Discharge Planning
Dr. Jeffrey L. Greenwald has spent the last several years testing strategies to improve the way that hospitalists handle the discharge process. A hospitalist at Massachusetts General Hospital in Boston, Dr. Greenwald first looked at this issue as a coinvestigator for Project RED (Re-Engineered Discharge) while at Boston University Medical Center. Today, he continues that work as a coinvestigator for Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), a quality improvement project from the Society of Hospital Medicine, which is also aimed at improving the discharge process and reducing readmissions.
In an interview, Dr. Greenwald explained the paradigm shift that is going on in the way hospitalists plan for discharge.
HN: Is the Affordable Care Act likely to push hospitalists to think more about how to reduce readmissions?
Dr. Greenwald: It will push hospital administrators to place pressure on hospitalist programs to think about how care transitions occur, specifically discharges and handoffs. But it will also begin to put more emphasis on the relationship between hospitalists and after-care providers. My hope is that long before hospitalists feel their hospital administrators bearing down on them, they will have grabbed this issue by the horns and decided to take it on themselves.
HN: Is Project BOOST the right tool to help hospitalists tackle preventable readmissions?
Dr. Greenwald: I think it is one of the right tools, and it is evidence based. There are many tools. The data on Project BOOST are just beginning to roll in. Our data on readmissions are not as robust as those from the Care Transitions Program and Project RED, which were randomized controlled trials. We are different in that we are a quality improvement project, and that has made uniform data collection across sites more challenging. But we have a number of sites that have now demonstrated moderate to significant decreases in readmission rates using elements of Project BOOST.
HN: What else can an individual hospitalist do to lower readmissions at his or her institution?
Dr. Greenwald: We want to move away from the idea of what the individual does, and move toward what the individual can contribute to the team and to the system. We’ve built the medical model for decades on the hard work and good intentions of the individual, and realistically that’s gotten us about as far as we can go in terms of readmission rates and other adverse events after discharge. I think that we need to move toward thinking about how the hospitalist plays a role in the care continuum in a number of areas: facilitating communication to after-care providers; ensuring appropriate, adequate, and timely follow-up; making sure that care standards are at their highest; and providing some accessibility to a provider who can help patients during the postdischarge period.
HN: Before there was Project BOOST, you were part of Project RED. What lessons did you learn from that experience?
Dr. Greenwald: First, we learned that it is critical that the roles and responsibilities around the discharge process and the care transition be very clearly delineated. It shouldn’t be based on "what Jeff Greenwald does." It has to be based on the hospitalist’s role in this process, so that if I take a vacation, the system doesn’t fall apart. Second, the discharge process really needs to begin at admission. It must engage not only the care team in the hospital, but also the patient and the appropriate family members or other caregivers. Third, no matter how well you oil your system in the hospital, some events are unpredictable. There’s no substitute for connecting with the patient to make sure they get through those first 3 days after discharge.