Project Gives BOOST to Discharge Planning

NATIONAL HARBOR, MD. — The Society of Hospital Medicine wants to give hospitals a boost when it comes to discharge planning and preventing hospital readmissions.

“The field of hospital medicine has been characterized by some as the worst thing to ever happen to continuity of care,” Dr. Winthrop F. Whitcomb, cofounder and past president of the SHM, said at the World Health Care Congress Leadership Summit on Hospital Readmissions. “We really want to be part of the solution, not just part of the problem.”

To that end, in 2008 the society started Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), a quality improvement initiative aimed at increasing coordination between inpatient and outpatient care and solving problems with the discharge process. “It's a team intervention to bring together hospitalists, other providers, and the hospital itself,” Dr. Whitcomb explained. (See

The project has been implemented in 30 sites nationwide in two phases, with 6 hospitals coming on board in the first phase and the remaining 24 joining in the second phase. Each phase began with a kickoff meeting for all of the new sites, with experts delivering lectures and eliciting discussion on best practices; each site then received a visit from a hospitalist mentor assigned to that particular facility. “The mentor has regular phone calls with the project team to review barriers and [talk about] how things might be done better,” said Dr. Whitcomb, an internist at Mercy Medical Center, Springfield, Mass.

In addition to the mentoring component, the project identifies a hospitalist on staff at each site who will be part of the team, he said. “We want to help hospitalists realize their potential as change agents.”

One of the project's goals is to reduce the rate of readmissions to the hospital, he continued, noting that a recent study found that one in five Medicare patients who were admitted to the hospital were rehospitalized within 30 days at a cost to Medicare of $17.4 billion. Half of the readmitted patients never saw their outpatient physician before they were readmitted.

The Project BOOST toolkit includes Web-based tools and a listserv. In addition to those resources, the medical literature gives several clues as to what methods work well for coordinating the transition from inpatient to outpatient, Dr. Whitcomb said. These include multidisciplinary rounds, assessing and enhancing patients' understanding of their condition and treatment, a proactive approach to assessing patients' problems, patient-friendly discharge information including a reconciled medication list, and good communication. “BOOST gets everybody talking to each other, which doesn't necessarily happen if you don't go out of your way to make that happen,” he said.

To make sure patients understand their discharge instructions, project teams use the “teach back” method, in which patients teach back to providers what the discharge instructions are. There is also a discharge form that patients must fill out, which explains the reason for their hospital stay and their discharge instructions, including what to do and who to call if certain medical problems arise.

The team also calls high-risk patients within 72 hours of discharge to assess how they're doing, and makes sure they have defined appointments with their primary care physicians. Figuring out which patients are at high risk of readmission can be tricky, so the program team uses the “7 Ps” test:

▸ Principal diagnosis.

▸ Problem medications.

▸ Polypharmacy.

▸ Poor health literacy.

▸ Patient support lacking in the community.

▸ Psychiatric issues.

▸ Prior hospitalizations.

The “7 Ps” are “a way for the site to prioritize which patients get more intensive application of the BOOST toolkit,” Dr. Whitcomb said.

Hospitals participating in the project thus far say that some parts of Project BOOST are easier to implement than others, said Dr. Luke O. Hansen, an analyst for the project. Among the parts they find easy: improving communication, standardizing discharge information, and tracking length of stay, readmission rates, and satisfaction with the program.

Some of the more difficult issues include bridging silos between different parts of the hospital, dealing with the required changes in workflow and culture, arranging expedited follow-up appointments, and finding resources to make follow-up phone calls. “There is no 'one-size-fits-all' approach” to the program, said Dr. Hansen, of Northwestern University, Chicago. “Each hospital is a unique climate that will facilitate change [for] some elements and create barriers around others.”

One difficulty that can crop up is getting nonmedicine specialists, such as surgeons, to go along with the program. “Physician extenders tend to help the surgeon a lot,” Dr. Whitcomb said. “If a surgeon is in [an] operating room all day, is that surgeon really going to come out and spend 45 minutes on a good discharge? That is much more likely to happen if the surgeon uses a physician extender.”

Another option for helping surgeons participate in the project is to “talk to a hospitalist about comanaging more of the nonmedicine cases—not just doing the discharge paperwork, but also [helping with medical issues such as] glycemic control and delirium prevention,” he continued.

Next steps for the project include collecting and analyzing data, incorporating lessons learned, and expanding the number of sites, Dr. Hansen said, noting that project analysts hope to have preliminary results on hospital readmissions by the end of 2010. The project is currently adding another 15 sites in Michigan in partnership with that state's Blue Cross Blue Shield carrier, he added.

Disclosures: Funding for Project BOOST is being provided in part by the John A. Hartford Foundation. Dr. Whitcomb and Dr. Hansen did not disclose any conflicts of interest related to their presentations.

NATIONAL HARBOR, MD. — The Society of Hospital Medicine wants to give hospitals a boost when it comes to discharge planning and preventing hospital readmissions.

“The field of hospital medicine has been characterized by some as the worst thing to ever happen to continuity of care,” Dr. Winthrop F. Whitcomb, cofounder and past president of the SHM, said at the World Health Care Congress Leadership Summit on Hospital Readmissions. “We really want to be part of the solution, not just part of the problem.”

To that end, in 2008 the society started Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), a quality improvement initiative aimed at increasing coordination between inpatient and outpatient care and solving problems with the discharge process. “It's a team intervention to bring together hospitalists, other providers, and the hospital itself,” Dr. Whitcomb explained. (See

The project has been implemented in 30 sites nationwide in two phases, with 6 hospitals coming on board in the first phase and the remaining 24 joining in the second phase. Each phase began with a kickoff meeting for all of the new sites, with experts delivering lectures and eliciting discussion on best practices; each site then received a visit from a hospitalist mentor assigned to that particular facility. “The mentor has regular phone calls with the project team to review barriers and [talk about] how things might be done better,” said Dr. Whitcomb, an internist at Mercy Medical Center, Springfield, Mass.

In addition to the mentoring component, the project identifies a hospitalist on staff at each site who will be part of the team, he said. “We want to help hospitalists realize their potential as change agents.”

One of the project's goals is to reduce the rate of readmissions to the hospital, he continued, noting that a recent study found that one in five Medicare patients who were admitted to the hospital were rehospitalized within 30 days at a cost to Medicare of $17.4 billion. Half of the readmitted patients never saw their outpatient physician before they were readmitted.

The Project BOOST toolkit includes Web-based tools and a listserv. In addition to those resources, the medical literature gives several clues as to what methods work well for coordinating the transition from inpatient to outpatient, Dr. Whitcomb said. These include multidisciplinary rounds, assessing and enhancing patients' understanding of their condition and treatment, a proactive approach to assessing patients' problems, patient-friendly discharge information including a reconciled medication list, and good communication. “BOOST gets everybody talking to each other, which doesn't necessarily happen if you don't go out of your way to make that happen,” he said.

To make sure patients understand their discharge instructions, project teams use the “teach back” method, in which patients teach back to providers what the discharge instructions are. There is also a discharge form that patients must fill out, which explains the reason for their hospital stay and their discharge instructions, including what to do and who to call if certain medical problems arise.

The team also calls high-risk patients within 72 hours of discharge to assess how they're doing, and makes sure they have defined appointments with their primary care physicians. Figuring out which patients are at high risk of readmission can be tricky, so the program team uses the “7 Ps” test:

▸ Principal diagnosis.

▸ Problem medications.

▸ Polypharmacy.

▸ Poor health literacy.

▸ Patient support lacking in the community.

▸ Psychiatric issues.

▸ Prior hospitalizations.

The “7 Ps” are “a way for the site to prioritize which patients get more intensive application of the BOOST toolkit,” Dr. Whitcomb said.

Hospitals participating in the project thus far say that some parts of Project BOOST are easier to implement than others, said Dr. Luke O. Hansen, an analyst for the project. Among the parts they find easy: improving communication, standardizing discharge information, and tracking length of stay, readmission rates, and satisfaction with the program.

Some of the more difficult issues include bridging silos between different parts of the hospital, dealing with the required changes in workflow and culture, arranging expedited follow-up appointments, and finding resources to make follow-up phone calls. “There is no 'one-size-fits-all' approach” to the program, said Dr. Hansen, of Northwestern University, Chicago. “Each hospital is a unique climate that will facilitate change [for] some elements and create barriers around others.”

One difficulty that can crop up is getting nonmedicine specialists, such as surgeons, to go along with the program. “Physician extenders tend to help the surgeon a lot,” Dr. Whitcomb said. “If a surgeon is in [an] operating room all day, is that surgeon really going to come out and spend 45 minutes on a good discharge? That is much more likely to happen if the surgeon uses a physician extender.”

Another option for helping surgeons participate in the project is to “talk to a hospitalist about comanaging more of the nonmedicine cases—not just doing the discharge paperwork, but also [helping with medical issues such as] glycemic control and delirium prevention,” he continued.

Next steps for the project include collecting and analyzing data, incorporating lessons learned, and expanding the number of sites, Dr. Hansen said, noting that project analysts hope to have preliminary results on hospital readmissions by the end of 2010. The project is currently adding another 15 sites in Michigan in partnership with that state's Blue Cross Blue Shield carrier, he added.

Disclosures: Funding for Project BOOST is being provided in part by the John A. Hartford Foundation. Dr. Whitcomb and Dr. Hansen did not disclose any conflicts of interest related to their presentations.

NATIONAL HARBOR, MD. — The Society of Hospital Medicine wants to give hospitals a boost when it comes to discharge planning and preventing hospital readmissions.

“The field of hospital medicine has been characterized by some as the worst thing to ever happen to continuity of care,” Dr. Winthrop F. Whitcomb, cofounder and past president of the SHM, said at the World Health Care Congress Leadership Summit on Hospital Readmissions. “We really want to be part of the solution, not just part of the problem.”

To that end, in 2008 the society started Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), a quality improvement initiative aimed at increasing coordination between inpatient and outpatient care and solving problems with the discharge process. “It's a team intervention to bring together hospitalists, other providers, and the hospital itself,” Dr. Whitcomb explained. (See

The project has been implemented in 30 sites nationwide in two phases, with 6 hospitals coming on board in the first phase and the remaining 24 joining in the second phase. Each phase began with a kickoff meeting for all of the new sites, with experts delivering lectures and eliciting discussion on best practices; each site then received a visit from a hospitalist mentor assigned to that particular facility. “The mentor has regular phone calls with the project team to review barriers and [talk about] how things might be done better,” said Dr. Whitcomb, an internist at Mercy Medical Center, Springfield, Mass.

In addition to the mentoring component, the project identifies a hospitalist on staff at each site who will be part of the team, he said. “We want to help hospitalists realize their potential as change agents.”

One of the project's goals is to reduce the rate of readmissions to the hospital, he continued, noting that a recent study found that one in five Medicare patients who were admitted to the hospital were rehospitalized within 30 days at a cost to Medicare of $17.4 billion. Half of the readmitted patients never saw their outpatient physician before they were readmitted.

The Project BOOST toolkit includes Web-based tools and a listserv. In addition to those resources, the medical literature gives several clues as to what methods work well for coordinating the transition from inpatient to outpatient, Dr. Whitcomb said. These include multidisciplinary rounds, assessing and enhancing patients' understanding of their condition and treatment, a proactive approach to assessing patients' problems, patient-friendly discharge information including a reconciled medication list, and good communication. “BOOST gets everybody talking to each other, which doesn't necessarily happen if you don't go out of your way to make that happen,” he said.

To make sure patients understand their discharge instructions, project teams use the “teach back” method, in which patients teach back to providers what the discharge instructions are. There is also a discharge form that patients must fill out, which explains the reason for their hospital stay and their discharge instructions, including what to do and who to call if certain medical problems arise.

The team also calls high-risk patients within 72 hours of discharge to assess how they're doing, and makes sure they have defined appointments with their primary care physicians. Figuring out which patients are at high risk of readmission can be tricky, so the program team uses the “7 Ps” test:

▸ Principal diagnosis.

▸ Problem medications.

▸ Polypharmacy.

▸ Poor health literacy.

▸ Patient support lacking in the community.

▸ Psychiatric issues.

▸ Prior hospitalizations.

The “7 Ps” are “a way for the site to prioritize which patients get more intensive application of the BOOST toolkit,” Dr. Whitcomb said.

Hospitals participating in the project thus far say that some parts of Project BOOST are easier to implement than others, said Dr. Luke O. Hansen, an analyst for the project. Among the parts they find easy: improving communication, standardizing discharge information, and tracking length of stay, readmission rates, and satisfaction with the program.

Some of the more difficult issues include bridging silos between different parts of the hospital, dealing with the required changes in workflow and culture, arranging expedited follow-up appointments, and finding resources to make follow-up phone calls. “There is no 'one-size-fits-all' approach” to the program, said Dr. Hansen, of Northwestern University, Chicago. “Each hospital is a unique climate that will facilitate change [for] some elements and create barriers around others.”

One difficulty that can crop up is getting nonmedicine specialists, such as surgeons, to go along with the program. “Physician extenders tend to help the surgeon a lot,” Dr. Whitcomb said. “If a surgeon is in [an] operating room all day, is that surgeon really going to come out and spend 45 minutes on a good discharge? That is much more likely to happen if the surgeon uses a physician extender.”

Another option for helping surgeons participate in the project is to “talk to a hospitalist about comanaging more of the nonmedicine cases—not just doing the discharge paperwork, but also [helping with medical issues such as] glycemic control and delirium prevention,” he continued.

Next steps for the project include collecting and analyzing data, incorporating lessons learned, and expanding the number of sites, Dr. Hansen said, noting that project analysts hope to have preliminary results on hospital readmissions by the end of 2010. The project is currently adding another 15 sites in Michigan in partnership with that state's Blue Cross Blue Shield carrier, he added.

Disclosures: Funding for Project BOOST is being provided in part by the John A. Hartford Foundation. Dr. Whitcomb and Dr. Hansen did not disclose any conflicts of interest related to their presentations.