Quality Talk

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Brian Jack, M.D. is Professor of Family Medicine and Chair of the Department of Family Medicine at Boston Medical Center and Boston University School of Medicine. As the Principal Investigator for the "Re-Engineered Discharge" (Project RED) process, he leads a research team whose work to improve hospital discharge processes has been adapted by the National Quality Forum as a national "Safe Practice" used in 50 states and over 10 countries.

Jack graduated from the University of Massachusetts Medical School, completed his residency at Brown University and held a fellowship at the University of Washington. He then worked on the faculty of the Department of Family Medicine at Brown University before joining Boston University Family Medicine Department in 1997. He has authored over 100 peer-reviewed articles or book chapters, reviewed papers for major medical journals, served on grant review panels and received numerous awards including the Peter Drucker Award for non-profit innovation for the RED program. He was elected to the Institute of Medicine in 2013.

Explain the Re-Engineered Discharge” process or Project RED as it is more commonly referenced.

Project RED started out as a quality improvement project 10 years ago and later, when readmission reduction became an important public policy issue, became a model for hospital-based readmission reduction programs. Project RED was our attempt to address what we saw as an enormous patient safety issue in that patients simply were not prepared to take care of themselves after leaving the hospital. They did not know how to take their medications, how to follow-up, what tests they needed, etc. We studied the discharge process carefully and brought together experts from around our hospital to discuss the principles we desired and how to operationalize them. That led to the creation of Project RED, which has been recognized as a best practice by the National Quality Forum and serves as an evidence-based process for many hospital-based readmission programs. In 2009, we conducted a randomized control trial to show the effects of Project RED, and it successfully reduced 30-day readmission rates from 20 percent to 15 percent. More recently, Project RED has been used in the nursing home setting to reduce readmissions to hospitals. Over the years, we have learned a lot about how to reduce readmissions. People who are at higher risk need more home-based interventions. We need to activate primary care practices, so that they see a patient within seven days of discharge. End-of-life care is important in reducing readmissions, and the role of family caregivers cannot be overstated.

How did your background in family medicine lead to your involvement in improving hospital discharge processes?

Initially my interest came from my clinical work. I was working with residents caring for patients in a hospital setting, and I sensed that we probably were not doing an adequate job of preparing patients for discharge. When I was working in my office practice, I would regularly see people who had recently been discharged from the hospital; however, I did not have all of the information necessary to take care of them, such as updated lists of medications or a discharge summary. At that point, I realized we needed to do better by our patients.

Highlight some of the most significant results from the application of Project RED since its inception 10 years ago.

We are proud of the fact that a lot of hospitals are using Project RED. One specific component of our toolkit that I particularly like is the After-Hospital Care Plan” (AHCP), which describes what patients need to do to care for themselves. It is a patient-centered document that is designed so patients can understand it. It uses large font, icons and a calendar that summarizes what patients need to do in the next 30 days and is color coded to an appointment table. Patients typically will hang the ACHP on the refrigerator. Both patients and families really like it.

To what extent does Project RED address health literacy?

We paid a great deal of attention to health literacy from the very beginning. We tested Project RED with focus groups, collected data and learned that low health literacy is a risk factor for 30-day readmissions. Specifically, patients with low health literacy are 50 percent more likely to be readmitted to the hospital. Our toolkit is designed to help hospitals implement Project RED for all types of patients, including those with limited English proficiency and with diverse cultural backgrounds.

What resources are included in your toolkit and what is the best method to access it?

Our original toolkit was comprised of six tools, including an overview of Project RED, how to begin implementation, how to deliver it (including to diverse populations) how to conduct the post-discharge follow-up call and how to monitor implementation and outcomes. Recently, we added a new chapter on the role of family caregivers in readmissions. In the future, we might add chapters on end-of-life care; community-based organizations activating the primary care practice; and nursing homes. Our toolkit can be accessed on our website and on the Agency for Health Research & Quality’swebsite.

Anything else you’d like QIO News readers to know?

Right now we are working with the Patient Centered Outcomes Research Institute (PCORI) in interviewing clinicians, patients and families about what is important for patients regarding readmissions and care transitions. We are learning a lot of interesting things, including how our perceptions of what patients view as important often are incorrect. We also would like to expand our collaboration with other organizations focused on quality improvement, so please feel free to contact us via our website.