Project BOOST: Enhancing Care Transitions with Risk Stratification Tools

Hospital readmissions are a significant concern in healthcare, often stemming from inadequate post-discharge care planning. Many patients experience complications soon after discharge due to a lack of understanding and proper management of their healthcare needs, such as adherence to medication regimens. Addressing these challenges is crucial for improving patient outcomes and reducing preventable readmissions.

The Society of Hospital Medicine’s (SHM) Project BOOST (Better Outcomes for Older Adults through Safe Transitions) initiative offers a comprehensive solution to these issues. This innovative program is specifically designed to minimize preventable readmissions, streamline provider workflows, decrease medication-related errors, and empower patients and their families with enhanced discharge education. Project BOOST provides a structured framework that hospitals can adapt to fit their unique organizational environments, priorities, resources, and cultures. At the heart of this framework is the effective utilization of risk stratification tools, exemplified by the care transitions network’s risk stratification tool integrated within the BOOST model, which allows for targeted interventions and improved patient care.

Key components of the Project BOOST initiative include:

• Risk Assessment for Post-Discharge Adverse Events: Project BOOST utilizes the 8Ps Risk Assessment, a care transitions network’s risk stratification tool, to identify patients at high risk for adverse events following hospital discharge. This tool screens patients based on eight critical risk factors associated with readmissions: (1) Problems with medications, (2) Psychological factors, (3) Principal diagnosis, (4) Physical limitations, (5) Poor health literacy, (6) Poor social support, (7) Prior hospitalizations, and (8) Palliative care needs. By identifying these risks early, healthcare providers can implement specific interventions and communicate these risks and ongoing strategies to subsequent care providers, ensuring a smoother transition.

• Preparedness Assessment for Hospital Discharge: The General Assessment of Preparedness (GAP) checklist is another vital tool within Project BOOST. This checklist, acting as a care transitions network’s risk stratification tool in its broader application, evaluates a patient’s readiness to leave the hospital. It helps identify both logistical and psychological concerns patients may have about their discharge. The GAP checklist can be integrated into electronic health records or provided as a form for patients and caregivers to complete privately, allowing healthcare teams to proactively address any identified concerns and ensure patients feel prepared and confident about managing their health at home.

• Patient-Centered Discharge Instructions: Effective communication is paramount during care transitions. BOOST offers tools like Patient PASS (Patient Preparation to Address Situations Successfully) and DPET (Discharge Patient Education Tool). These resources are designed to concisely and clearly convey essential discharge information at an appropriate literacy level. By using patient-friendly language and formats, these tools ensure that patients understand their care plans and are equipped to manage their health effectively after leaving the hospital. These can be considered part of the broader care transitions network’s risk stratification tool strategy, as effective communication reduces risk of misunderstanding and errors.

• Teach-Back Method for Enhanced Understanding: To further ensure patient comprehension, Project BOOST promotes the Teach Back method. This patient-centered communication technique encourages healthcare providers to ask patients to explain, in their own words, their understanding of the information provided. This method verifies that patients have truly grasped their care instructions and can correctly demonstrate any necessary skills, such as medication administration. Involving families and caregivers in the Teach Back process extends this understanding to everyone supporting the patient’s recovery.

• Post-Discharge Follow-Up Telephone Calls: Proactive follow-up is a critical element of successful care transitions. Project BOOST recommends telephone follow-up calls to patients after discharge. These calls serve to check on the patient’s condition, reconcile medications, and reinforce follow-up plans. These interactions can identify potential problems early, such as new symptoms, medication issues, or difficulties accessing follow-up care, allowing for timely intervention and preventing potential readmissions. This follow up can be seen as an ongoing monitoring aspect of a care transitions network’s risk stratification tool approach.

• Scheduled Follow-Up Appointments: Ensuring patients attend necessary follow-up appointments is essential for continuity of care. Project BOOST emphasizes the importance of assisting patients and families in scheduling these appointments before discharge. This proactive approach addresses potential barriers to attendance, such as scheduling conflicts or transportation issues, and ensures that patients receive timely post-discharge medical attention.

• Interprofessional Rounds for Coordinated Care: Effective communication among the healthcare team is vital for seamless care transitions. Project BOOST advocates for interprofessional or interdisciplinary rounds. These rounds bring together various members of the care team, including physicians, nurses, case managers, therapists, and pharmacists, to discuss patient care plans. Ideally, these rounds also include representatives from post-acute care settings like hospice and ambulatory care. This collaborative approach enhances communication, coordination, and shared understanding of patient needs.

• Optimizing Post-Acute Care Transitions: Project BOOST recognizes the importance of smooth transitions to post-acute care facilities. Hospitals are encouraged to leverage existing partnerships with skilled nursing facilities (SNFs) to improve these transitions. Cross-continuum teams and collaborative improvement efforts can ensure continuity of care and optimize patient outcomes as they move between care settings.

• Medication Reconciliation for Safety: Medication errors are a common cause of readmissions. As part of its readmission prevention strategy, Project BOOST highlights the importance of medication reconciliation. For hospitals seeking to enhance their medication reconciliation processes, BOOST recommends the MARQUIS toolkit, another valuable resource from SHM, which provides tools and strategies to improve medication safety during care transitions.

Building upon its success with adult populations, the Society of Hospital Medicine introduced Pedi-BOOST in 2013. This adaptation of the BOOST toolkit incorporates specific elements tailored to the unique needs of pediatric patients, further extending the reach and impact of this innovative program.

Context and Development of Project BOOST

Project BOOST originated from the Patient Safe-D research project conducted at Emory Midtown Hospital. Dr. Mark V. Williams, driven by his interest in health literacy and improving care transitions, developed the program. The project gained significant momentum in 2005 when Dr. Williams received a Partnerships in Implementing Patient Safety (PIPS) grant from the Agency for Healthcare Research and Quality (AHRQ). These grants were designed to foster the development of practical tools and resources for implementing patient safety interventions. Project BOOST disseminates resources developed through Patient Safe-D, along with tools from Project RED (Re-Engineered Discharge), another PIPS project tested at Boston Medical Center, ensuring a wide availability of effective strategies for improving care transitions.

Proven Results and Benefits

Project BOOST has demonstrated significant positive outcomes in improving care transitions and reducing hospital readmissions.

• Effective Risk Identification: A retrospective study using manual case review confirmed the effectiveness of the BOOST risk assessment tool, a key care transitions network’s risk stratification tool, in accurately predicting over 90% of readmissions.11 This highlights the tool’s ability to identify high-risk patients who can benefit most from targeted interventions.

• Reduced Readmission Rates: A pre-post study across 11 hospitals participating in Project BOOST showed a clear decrease in 30-day readmission rates.12 This evidence underscores the tangible impact of the BOOST program on improving patient outcomes at a system level.

• Mentorship Benefits: Qualitative analysis from pilot hospitals revealed that the mentorship component of Project BOOST was crucial for overcoming implementation challenges and identifying factors for success.13 This suggests that expert guidance and support are vital for successful adoption and adaptation of care transition improvement programs.

Implementing Project BOOST: A Step-by-Step Approach

Project BOOST provides a detailed implementation guide, offering a structured pathway for hospitals to adopt and customize the program. Key steps in the planning and development process include:

• Establishing a Quality Improvement Framework: Initiating Project BOOST requires foundational steps such as securing support from hospital leadership, assembling a multidisciplinary team, and defining clear, measurable goals for improvement.

• Analyzing Current Care Transition Processes: Mapping the existing discharge process is essential to identify inefficiencies and areas for improvement. This detailed understanding of the current workflow is crucial for targeted intervention.

• Identifying Root Causes of Deficiencies: Hospitals are encouraged to conduct root cause analysis or failure modes effects analysis (FMEA) to understand the underlying reasons for shortcomings in their care transition processes.

• Tailoring Interventions: Interventions should be selected and adapted to address the identified root causes, leveraging the principles and tools of Project BOOST to align with hospital-specific strategic objectives and resource allocation.

• Data Collection and Reporting: Establishing a robust data collection and reporting plan, with support from administrative and IT departments, is vital for monitoring progress and measuring the impact of interventions. Key metrics include length of stay, readmission rates, and patient satisfaction, along with process measures like patient understanding and adherence to care plans.

• Implementing Solutions Using PDSA Cycles: Project BOOST recommends using the Plan-Do-Study-Act (PDSA) cycle for iterative implementation. This approach allows for rapid testing and refinement of interventions in a continuous improvement framework.

• Performance Tracking: Utilizing run charts to track key outcome, process, and balancing metrics provides visual feedback on progress and helps identify areas needing further attention.

• Continuous Refinement: Based on ongoing evaluation, the BOOST team should continuously refine the discharge process to ensure it meets the needs of all patients, is embraced by staff, and is as streamlined as possible.

Resources, Skills, and Costs

Implementing Project BOOST requires specific resources and skills, but is designed to be cost-effective.

• Staffing: The core BOOST team includes a leader (physician, nurse, care manager, or social worker), a QI facilitator, a project manager, process owners from relevant departments (pharmacy, nursing, case management), and IT experts. The program can often be implemented using existing staff, integrating BOOST tools into their daily workflows.

• Mentorship: External expertise in care transitions can significantly enhance implementation success by providing guidance, identifying barriers, and facilitating problem-solving.

• Costs: Project BOOST tools are freely available, minimizing financial barriers to implementation. The program can be implemented primarily using existing staff resources, making it a highly cost-effective approach to improving care transitions.

Funding and Getting Started

Patient Safe-D research was funded by an AHRQ PIPS grant, and Project BOOST was supported by The John A. Hartford Foundation, highlighting the importance of external funding in developing and disseminating such initiatives.

To initiate Project BOOST implementation:

• Secure Senior Leadership Support: Presenting data on the program’s potential to reduce readmissions and improve satisfaction can garner administrator buy-in. A senior administrative champion is invaluable for program success.

• Create an Interdisciplinary Team: Engage representatives from medical staff, nursing, pharmacy, discharge planning, care management, and social work to ensure a comprehensive approach. Including former patients can also provide valuable perspectives.

• Learn Quality Improvement Techniques: Understanding QI principles is essential. Hospital QI officers can provide valuable support in process design and implementation.

• Set SMART Goals: Establish project goals that are specific, measurable, achievable, realistic, and time-bound to guide implementation and measure success.

• Prepare for Increased Patient Engagement: Engaging patients in the discharge process may lead to more questions, which should be welcomed as opportunities to enhance patient understanding and improve care.

Sustaining Improvements

Sustaining the benefits of Project BOOST requires ongoing effort:

• Continuous Monitoring and Refinement: Regularly scheduled assessments of the discharge process are necessary to maintain improvements and adapt to evolving needs and challenges.

By implementing Project BOOST and leveraging care transitions network’s risk stratification tool principles, hospitals can significantly enhance their care transition processes, reduce preventable readmissions, and improve patient outcomes. This comprehensive, evidence-based approach offers a valuable framework for healthcare organizations committed to providing safer and more effective care transitions.

References/Related Articles

Society of Hospital Medicine. Care Transitions for Older Adults Resource Room: Project BOOST [Web site]. Available at: https://www.hospitalmedicine.org/clinical-topics/care-transitions/

SHM Project Boost Implementation Guide (2nd Edition): https://www.hospitalmedicine.org/globalassets/professional-development/professional-dev-pdf/boost-guide-second-edition.pdf

Footnotes

Date Verified by Innovator

May 14, 2021 FYI: You may notice that PSNet Innovations Exchange has recently been updated (July 2022) to remove the evidence rating section. For more information or questions, please email [email protected].

The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter or developer of the innovation.