iCARE 2014 DISCHARGE & MED REC

1. iCARE2014 DISCHARGE & MED REC Presented by: Ashley Marostica RN Created by: Sedgwick County Health Center’s iCARE Team Machelle Newth, Janet Coyne, Deb Nail, Mary Kantor, Billie Carlson, Ashley Marostica

2. Sedgwick County Health Center • MOTTO: • “Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.” – William A. Foster

3. THANK YOU iCARE/CRHA • THANK YOU FOR HAVING US PRESENT OUR ONGOING PROJECT!!!!! • ~SEDGWICK COUNTY HEALTH CENTER--- iCARE Team

4. SEDGWICK COUNTY HEALTH CENTER Joint effort between hospital & clinic • iCARE FOCUS • Struggles • Med Reconciliation • Discharge Education • Continuity of Care

5. HISTORY OF MED REC • 2005: Started as a result of part of 100,000 Lives Champaign • It was an initiative to be part of IHI • Rolled into 5 Million Lives ----------------------------------------------- • 2006: Pyxis Machine was added • 100,000 Money went toward Pyxis Rental

6. HISTORY OF MED REC • 2007: Article in the paper was written by Machelle Newth- RN/Director of Nursing • “Do you take responsibility for your health?” • Article addressed the need for patients to take responsibility for their health and know what medication they take, and to help us when the present to our facility • ( See attached – Do you take responsibility)

7. HISTORY OF MED REC Do you take responsibility for your health? Let me start by taking you; the reader through an all too common scenario that we see in the hospital all too often: A patient is brought in to the ER per a family member or friend with chest pain, or some other urgent complaint. The nurse checks the patient into ER and attends to the most urgent matters, then begins questioning the patient so that we can deliver the best care. These questions always involve things like symptoms, duration of the symptoms, and always a list of medications and an allergy list. A common response to this question is: “Well let’s see, I take a yellow pill for my heart, I take a white pill that makes me pee a lot. Don’t you have a list of all this? My doctor is here.” Please don’t get me wrong, I am not criticizing anyone here, but does this sound like you or someone you know? This scenario I have laid out for you is just one of many similar scenarios that actually may be putting your health and the care that is provided for you in jeopardy. We at Sedgwick County Health Center are embarking on a quest that is taking hold all over the nation. It is called Medication Reconciliation. What this means is that we have made a commitment to you; our patients to deliver the most accurate and timely care possible in part by making sure that we have an accurate list of your current meds from which to work when you enter the ER or are seen at the clinic. It is our responsibility to make sure that your medications do not interact, that you are not given a med that you are allergic to, and that your meds are not duplicated or omitted because we were unaware that you should be taking something prescribed by a doctor in another facility. You have an important role in this process as well. You should keep an updated list of your medications on your person at all times, or at least have a list readily available. As you complete a med; for instance, an antibiotic, you should make sure this is taken off of the list. If you have a known allergy to certain drugs, or if you have experienced an adverse reaction to a drug, this should be listed as well. You should make a point of asking your doctor or pharmacist why he has prescribed certain medications for you. You should know what the pill is called, why you take it, and the dosage and time of day you usually take this med. You should also list meds that you take, as you need if not on a routine basis. This will help the entire process flow more smoothly.   We are planning to put a more stable process in place at a later date which may include using a stick that you would carry that could be plugged into the USB port on a computer that would allow us to quickly update your med list for you when you are seen in the Dr’s office or are a patient in the hospital. This would help us to quickly access a list of your meds more quickly when you are brought into the hospital as well. We are making a commitment to your health; won’t you do the same?

8. HISTORY OF MED REC • 2007: Medication Wallet Cards • Failed: • Patients not accountable • Multiple Providers • Lack of Clinic Nurse Champion to Initiate

9. HISTORY OF MED REC • 2008: Lunch Box with List • Lunch Boxes so that all pill bottles could be placed inside and a list was kept along with • Failed: • Patient’s didn’t bring back in

10. HISTORY OF MED REC • 2009: • Refrigerator Magnetic Med Lists • Dry Erase Lists kept on patients’ refrigerator’s • Thought was that EMS could easily grab • Had Meds and Allergies • Easy to update changes • Failed: • Ems didn’t grab • Patient’s didn’t bring in with them • They would get bumped and marker would come off

11. HISTORY OF MED REC • 2007- Current • Failure has occurred • MULTIPLE REASONS!!!! • Multiple names for Medications (Trade, Brand, Generic) • Patient's not accountable • No Great Continuity of Care paperwork created • Multiple providers involved in care (Primary, Specialist) • Some physician’s nurses in the clinic aren’t licensed nurses and therefore PMH/PSH/DX aren’t trended with Med use • Nurses are now having to use computer systems which haven’t made med rec easy to correct

12. HISTORY OF MED REC • 2006 Pyxis Debut • Helped to prevent Medication Errors occurring in the ER and on the hospital Floor • 2007 Starting faxing MAR’S to NCMC’s 24/7 pharmacy for review of medications/interactions • 2008 Started faxing MAR’S to MCR’s 24/7 pharmacy for review of medications/interactions • 2012: EMR went live and now MCR has online access to review our patients and their “EMAR”

13. HISTORY OF MED REC • 2007-2012 • Hospital Med Rec Form • Machelle’s husband Gayle created a one page Medication Reconciliation form that was to be used for hospital admissions • The focus was to address Home Medications • There was a section for “In Hospital Usage” • There was a section for “At Discharge Usage” • This form was the start of our Medication Reconciliation path to success • (See attached: Med Rec page 1)

14. HISTORY OF MED REC • 2007-2012 • Hospital Med Rec Form • Initial form great • PROBLEMS • No section for “Meds ordered after Admission” and their status • So Gayle created a second page • This proved to work very well up until the time our facility with live with EMR • Keep in mind these pages are what we faxed to our 24/7 pharmacies • (See attached: Med Rec page 2)

15. HISTORY OF MED REC • 2007-2012 • Hospital Med Rec (Pg 1&2) • Over the 5 year period form was tweaked • Confusion between a Doctor’s order and Nursing form • Papers filed in chart under “Meds”

16. HISTORY OF MED REC • 2006-2010 Discharge Paper • “Continuum of Care Record” • This one piece of paper front to back was the one piece of paper given at time of discharge (See Attached: 2006 discharge and med list)

17. HISTORY OF MED REC • 2006-2010 Discharge Paper • “Continuum of Care Record” (see attached) • Issues with Discharge (front side) • No Education Given • Wasn’t ever filled out 100% by Staff • Very Small Areas To See • No Follow-up Appointments were made during weekend discharge due to clinic not being open • Very seldom were clinic appointments being made during the week day prior to discharge • Lack of Hospital/Clinic Nurse Champion

18. HISTORY OF MED REC • 2006-2010 Discharge Paper • “Continuum of Care Record” • ISSUES WITH MED LIST AT TIME OF DC • HOSPITAL NURSING STAFF----- • Not sure if other meds were omitted • Not always sure on dosage • Not sure on frequency • Not sure on DX for taking • Did not get transferred or compared with clinic chart during follow-up • Patients not responsible for knowing their own meds • Multiple Pharmacy usage • Concept of “Let their normal doc figure it out”

19. HISTORY OF MED REC • 2012 Discharge Paper *CHANGE* (2010-2012) • “AHRQ”- Taking Care of Myself: A guide for When I Leave the Hospital • (see attached: 2010 AHRQ discharge)

20. HISTORY OF MED REC • 2010-2012 Discharge Paper • “AHRQ”- Taking Care of Myself: A guide for When I Leave the Hospital • 6 page discharge packet in color • Phone numbers • Emergency Numbers • Reason for admission • Allergies • Reasons to return or call • Pharmacy • Diet • Activity Status • Equipment • Smoking • Immunizations • Advanced Directives • Discharge Clinical Data • Excel Med List Document • Follow-up Appointments • Questions for your return • Medical Records Signature Page

21. 2011- CURRENT: PROJECT RED • Tracked Readmissions • Goal is to prevent 30 day Readmissions • Started providing better education and more elaborate discharge interventions • Used an excel sheet in doing so • Reported Data to CHA • Issued Patient Evaluations • Provided Phone Calls within 24-72 hours of discharge • *See Attached*

22. 2014: PROJECT RED Addition • Transitional Care Model (TMC) • GOAL • Evaluate Inpatients on Day of Admission and give them a score in regards to risk for readmission: • Factors include: • Age • Fall Risk • Other DX • Support • Living Alone • Cognitive Impairments • Non-Compliance • Education Level • Recent ER or OBS admissions • (See attached TCM)

23. 2014: PROJECT RED *Addition* • Transitional Care Model (TMC) • GOAL • Score • Any Score Above 2 requires a plan of action within 1-2 days of admission • This might entail care conference • Extra time with discharge • Making sure things are “in place upon discharge” • Not leaving it up to them to get things accomplished • Fast/Multiple Follow-up calls

24. EMR Live- June 2012 • We thought with this new great EMR program that all of our discharge/med rec issues would be solved just like…..THAT • Boy were we WRONG!!!!!

25. EMR Live- June 2012 • Issues with EMR– (TONS)!! • We felt like we were the guinea pigs for this program • The nurses and doctors couldn’t figure out the computer program, especially the discharge/med rec form. If this was the case, how could patient’s understand???

26. EMR Live- June 2012 • Issues with EMR– (TONS)!! • Wrong Dosages • Special Instructions • Alerts Galore • Discharge Med Print out– confusing

27. EMR Live- June 2012 • Issues with EMR– (TONS)!! • Worked and Worked with EMR Company • Highlighted/Snipped all the ISSUES

28. EMR Live- June 2012 • ER Blue-Med List Project- 6/2012 • Started Tracking to see if patients • Had a list of Meds with them • Didn’t have a Med List with them • Didn’t Take meds at all • ------------------------------------------------- • This was a QI project • Outcome: if you take responsibility for your health you bring in your meds or have list

29. EMR Live- June 2012 • ER Blue Med List Project- 6/2012 • QI: • Issue • There was a huge discrepancy in the list that patient’s provided and what the clinic list showed • ?? Who is right • ?? Who is wrong • ?? What is the patient actually taking • ?? What did the doctor actually prescribe

30. CHART CHECKLISTS • Created----Due to the confusion of EMR’s VS. Old School Paper chart • For each Type of Admission we have a checklist created • This ensures all proper documents get done • Lets the oncoming shift know where the admitting shift left off • Ensures all assessments and questions get asked • Emphases home med collection and other important issues • Also address the “meaningful use stage 1 and 2 criteria” • (See attached: Checklists--- ER, Trauma, Outpatient, OBS, Inpatient, Swing Bed, Swing bed Transfer In, OB and nursery)

31. “YELLOW DC PACKETS” • Formally Known as “ Comprehensive Personal Health Packet” • Piloted November 2013 • February 2014- Full Blown • (Sample Packets will be available- also if you would like templates of any of this please let Caleb know and I can make them available to you all!!) * I will attach templates if I can*

32. “YELLOW DC PACKETS” • Project Start • Initial packets developed November 2013 • Pilot Test done thru end of year • Initial kick off for new packet roll out January 27th, 2014 • Packets located on a shared network folder all deserving staff has access to---Can be started by one nurse and finished by another. • See Attachment ( How to locate for set up) • Continued improvement usage and results since implementation • Engagement of patient, family, and key care givers has greatly improved • Due to a small patient denominator, our results may not correctly reflect our success with this project. However, as an entire inter-disciplinary team we are seeing the fruits of our labor pay off. • Patient Education and Family Education has helped in adoption

33. “YELLOW DC PACKETS” • DISCRIPTION • Have provided a complete patient profile including: • Date of admission and discharge • Admission Location and Discharge Location • Admitting DX • PMH (obtained from patient, clinic chart, old H&Ps, current H&P) • PSH (obtained from patient, clinic chart, old H&Ps, current H&P) • Allergies • Code Status • Vital Signs (note weight at admission and discharge for CHF patients) • Pharmacy • Medical Equipment • Therapies • Plan of Care Follow-up • Contact Information for other interdisciplinary outlets • Immunization Status for Flu and Pneumococcal • Smoking History • Advanced Directives • Medication Reconciliation • Teach back • Front of Chart has a sticker that is applied for the patients name and date of admit • Inside of the Chart has a sticker that is applied for a final checklist prior to giving them the packet upon discharge • Evidence: Patients have been bringing back this information in the yellow discharge packet that was sent home with them. We are noting an improved continuity of care. • (See attached: Discharge Label Inside and Outside for Yellow Folder)

34. “YELLOW DC PACKETS” • Difficulties noted along the way • Staff engagement • Adaptation to change • Starting the discharge process at the time of admission

35. “YELLOW DC PACKETS” DISCHARGE PAPERWORK TO GO ALONG WITH THIS-------- • Daily Discharge Note • Daily Utilization and Review Note • TCM started for all patients • Daily checklist • Daily update of discharge packet • Mail out-Eval(enclosed is a preaddressed envelope with postage- labels attached showing) • Follow-up Phone Call • Excel tracking form • (all of these forms are attached)

36. YELLOW PACKET- CLINIC • We have now been taking the Mediation Reconciliation page from the hospital and creating a new clinic med list that matches the hospital one • This is all kept under the same folder on a shared network drive that all doctors and nurses have access to • Both the hospital discharge packet & Clinic Med list

37. YELLOW PACKET- CLINIC • We are a making f/u appointments prior to discharge • Also including lab work prior, radiology testing, etc…. • We are noting this on the packet sent home with patient • We are going into our clinic scheduler and changing the color of the patient once the clinic med list has been given to Deb Nail- Clinic Manager • The color is now “Orange- meaning VIP”- must be seen!!!! • We are also noting in the comment section anything important--- please give flu shot, please check pneumo status- patient unsure, make sure they get PT/INR drawn ahead of time… • From there Deb notes that she gave the new med list to the nurse who will be taking care of patient • This med list also include: PMH, PSH, Height, Weight, Allergies, DOB, Pharmacy, Flu, Pneumo, Code/AD and smoking Status • * See attached: Clinic Med List- Excel

38. YELLOW PACKET- CLINIC • We have been noting great success!!! • We feel like we are now closing the loop • This has been the best medication reconciliation process we have had yet….. • We will continue to look, evaluate and make necessary changes

39. QUESTIONS

40. CONTACT INFORMATION • Ashley Marostica • Sedgwick County Health Center • 900 Cedar Street • Julesburg, CO 80737 • Phone: 970-474-3323 EXT 363 • Email: amarostica@schealth.org