Discharge Planning VeHU Class 321

1. Discharge PlanningVeHU Class # 321 Hi-Ho, Hi-Ho, It’s Out the Door You Go! -Welcome to class # 321, Discharge Planning – Hi-Ho, Hi-Ho, It’s Out the Door You Go!-Welcome to class # 321, Discharge Planning – Hi-Ho, Hi-Ho, It’s Out the Door You Go!

2. 2 Presenters Nancy H. Prewitt, RN Nurse Manager Lexington VAMC Kathleen Wolner, MD CBOC Section Chief Dayton VAMC Kay Willis, R.Ph Chief, Pharmacy / SPD North Chicago VAMC -Briefly introduce self and other presenters.-Briefly introduce self and other presenters.

3. 3 HOUSE KEEPING Welcome This is a 1.5 hour class Please silence your cell phones and pagers. If you must answer a call, please leave the room. Thank you. Before we get started we need to take care of some Housekeeping issues. This is a 90 minute class. Please take time to turn off your cell phones, or set them to vibrate. If you must take a call, please leave the room to answer. Before we get started we need to take care of some Housekeeping issues. This is a 90 minute class. Please take time to turn off your cell phones, or set them to vibrate. If you must take a call, please leave the room to answer.

4. 4 Please, Hold your questions during the presentation. Questions written on the 3X5 cards provided will be answered at the conclusion of the presentation. For questions not answered, the question and the answer will be available on the web. If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.

5. 5 Objectives -To enable participants to explore the utilization of electronic media to expedite the Discharge Process -To expose multidisciplinary team members to alternative methods for improving access and coordination of care. -To highlight key processes along the way Transportation Placement Medication Reconciliation Outpatient Appointments Hand Off Communication -To discuss methods to improve the transition of care from the Inpatient to the Outpatient Provider Outline the class objectives.Outline the class objectives.

6. 6 And last, but not least… -To get it all planned and completed the day prior to the planned discharge date! And last, but not least… Get it all done the day prior to discharge.And last, but not least… Get it all done the day prior to discharge.

7. 7 Facility Complexities University Affiliation Residency Program Teaching Hospital -Discuss the complexities of our organizations which complicate discharge planning.-Discuss the complexities of our organizations which complicate discharge planning.

8. 8 Challenges -Continuity -Coordination -Potential for errors -Rapid Inpatient Turnover -Reduction in Patient Bed Days -Frequent Turnover of Resident Physicians Discuss the challenges these complexities create related to discharge planning.Discuss the challenges these complexities create related to discharge planning.

9. 9 Importance of Discharge Planning Benefits to Patient / Family -Outcomes -Safety -Satisfaction Benefit to Facility -Efficiency, Safety, Satisfaction -Utilization -Cost Discuss the benefits of discharge planning to patients, families, staff and the facility at large. Discuss the benefits of discharge planning to patients, families, staff and the facility at large.

10. 10 Link to National Patient Safety Goals Hand-off Communication Medication Reconciliation Discuss the relationship of discharge planning to two key National Patient Safety Goals: -Hand-off Communication -Medication ReconciliationDiscuss the relationship of discharge planning to two key National Patient Safety Goals: -Hand-off Communication -Medication Reconciliation

11. 11 Managing and Meeting the Challenge “It Takes a Village” Interdisciplinary Teamwork is necessary for successful discharge planning -”It takes a village”. Many disciplines and services must participate in the discharge planning process in order to pull it off efficiently and successfully. -”It takes a village”. Many disciplines and services must participate in the discharge planning process in order to pull it off efficiently and successfully.

12. 12 Interdisciplinary Team Physician Nurse Social Worker Dietician Pharm D. -Minimally, the required team players include the Physician, Nurse, Social Worker, Dietician and Pharm D.-Minimally, the required team players include the Physician, Nurse, Social Worker, Dietician and Pharm D.

13. 13 Other Roles -Discharge Planner ( RN, MSW, other ) -Utilization Case Manager -Specialty Specific Case Manager -Community Health Coordinator -Primary Care Case Manager -Inpatient Medical Team Administrator -You name it, you create it! -Some facilities have created and incorporated other roles to improve their process. Some variations include Discharge Planners Utilization Case Manager Specialty Specific Case Manager (ortho,vascular,cardiac,ENT,heme/onc,etc.) Community Health Coordinator Primary Care Case Manager Inpatient Medical Team Administrator Whatever your need may be, a role can be created to fit that need.-Some facilities have created and incorporated other roles to improve their process. Some variations include Discharge Planners Utilization Case Manager Specialty Specific Case Manager (ortho,vascular,cardiac,ENT,heme/onc,etc.) Community Health Coordinator Primary Care Case Manager Inpatient Medical Team Administrator Whatever your need may be, a role can be created to fit that need.

14. 14 Discharge Planning Starts When?! Discharge Planning Begins on Admission – or does it? In many instances, discharge planning begins PRIOR to admission. -We often know, within a pretty narrow degree of accuracy, what the expectation is for a hospitalization. This may be more accurate for surgical procedures than purely medical admissions, but we still have a pretty good idea of the hospital course which lies ahead. -Primary care can play a tremendous role in communicating patient needs and in anticipating home care needs. -Clinical pathways can guide care to the point of knowing exactly when the patient will be discharged, provided that all goes according to plan. -Share example of TAH/BSO/BURCH, pain control, diet, catheter, voiding trials, bowel awakening, discharge. -We often know, within a pretty narrow degree of accuracy, what the expectation is for a hospitalization. This may be more accurate for surgical procedures than purely medical admissions, but we still have a pretty good idea of the hospital course which lies ahead. -Primary care can play a tremendous role in communicating patient needs and in anticipating home care needs. -Clinical pathways can guide care to the point of knowing exactly when the patient will be discharged, provided that all goes according to plan. -Share example of TAH/BSO/BURCH, pain control, diet, catheter, voiding trials, bowel awakening, discharge.

15. 15 Tools to Assist in Successful Discharge Planning Impact of the Electronic Age Communication Documentation Tracking -The electronic age has improved our ability to communicate, document and track care and processes. Face to face communication among staff members is preferable, but many times, impossible. Electronic communication can be overwhelming, but effective if planned and carried out appropriately (the dreaded view alert)-The electronic age has improved our ability to communicate, document and track care and processes. Face to face communication among staff members is preferable, but many times, impossible. Electronic communication can be overwhelming, but effective if planned and carried out appropriately (the dreaded view alert)

16. 16 Sample Tools and Methods to Improve Discharge Planning Processes Initial RN Assessment Template, dialog box progress noteTemplate, dialog box progress note

17. 17 Learning Readiness AssessmentClinical Reminder Examples of electronic templates which improve processes and documentation.Examples of electronic templates which improve processes and documentation.

18. 18 Collaborative Care Note Template, dialog box progress note Template, dialog box progress note

19. 19 Day of Discharge Note – narrative, completed by Physician the day prior to discharge, appointment is made for planned discharge time, and all staff are accountable to meet that time as agreed upon by the patient / family. – narrative, completed by Physician the day prior to discharge, appointment is made for planned discharge time, and all staff are accountable to meet that time as agreed upon by the patient / family.

20. 20 Day of Discharge Note Continuation of Physician Day of Discharge Note.Continuation of Physician Day of Discharge Note.

21. 21 Discharge Appointment -non-count clinic in appointment management, appointment is made for planned discharge time, and all saff accountable to meet that time as agreed upon by the patient/family.-non-count clinic in appointment management, appointment is made for planned discharge time, and all saff accountable to meet that time as agreed upon by the patient/family.

22. 22 Expanded Entry Discharge Appt. Expanded Entry of the Discharge Appointment. Expanded Entry of the Discharge Appointment.

23. 23 CPRS Cover Sheet View Discharge Day Appointment Another view of the Discharge Day Appointment from the CPRS Cover Sheet.Another view of the Discharge Day Appointment from the CPRS Cover Sheet.

24. 24 Discharge Instruction Note Con’t Discharge Instruction note continuation.Discharge Instruction note continuation.

25. 25 Discharge Instruction Note -Template, dialog boxes, given to patient/ family at discharge for home reference.-Template, dialog boxes, given to patient/ family at discharge for home reference.

26. 26 Outpatient Medication List Share locally developed software which creates an Outpatient Medication List for patients to use as reference tool. Pulls from VISTA Pharmacy Package, and places medication orders in layman’s terminology, changes to large font, and landscapes the document.Share locally developed software which creates an Outpatient Medication List for patients to use as reference tool. Pulls from VISTA Pharmacy Package, and places medication orders in layman’s terminology, changes to large font, and landscapes the document.

27. 27 Tools Extended Care Consults Skilled Home Health Homemaker / Home Health Aide Respite Hospice Rehabilitation Long Term Care -Consult package, templates, dialogue boxes. GEC Referral -> interdisciplinary progress note.-Consult package, templates, dialogue boxes. GEC Referral -> interdisciplinary progress note.

28. 28 So, to Summarize… -Many avenues to enhancing discharge planning processes -Electronic Medical Record lends itself well to improvements in the process -The possibilities are endless! -We’ve talked about several ideas to enhance discharge planning and communications -Many of these ideas stem from our marvelous electronic medical record. -The possibilities are endless.-We’ve talked about several ideas to enhance discharge planning and communications -Many of these ideas stem from our marvelous electronic medical record. -The possibilities are endless.

29. 29 If you have a process which needs improvement ( and who doesn’t?) Implement an interdisciplinary team to work on solutions: -ACA Team (Advanced Clinic Access) -Goal Sharing Team So you find a process which needs improvement – implement an interdisciplinary team to work on solutions. So you find a process which needs improvement – implement an interdisciplinary team to work on solutions.

30. 30 The “Pay-off” for Your Work -Decrease Bed Days of Care -Decrease Nosocomial Infection Rate -Decrease Potential for Errors -Decrease in Recidivism -Decrease Call Volume back to Telephone Care Program from Recently Discharged Patients -Decrease Staff and Patient Frustration -Improve Utilization of Resources -Improve Staff and Patient Satisfaction -Reduce Cost of Care -Improve Third Party Payment / Cost Recovery -Meet Performance Measures -The pay-off for your work could be astounding! -The pay-off for your work could be astounding!

31. 31 So, Hi-Ho, Hi-Ho, We’re All Discharge Planners You Know! So, Hi-Ho, Hi-Ho, We’re All Discharge Planners, you know!So, Hi-Ho, Hi-Ho, We’re All Discharge Planners, you know!

32. 32 I’m a dog nut, I’m ending my section of the presentation with the photograph of a beautiful Golden Retriever as we move to our next presenter. I’m a dog nut, I’m ending my section of the presentation with the photograph of a beautiful Golden Retriever as we move to our next presenter.

33. 33 Formulary on Toolbar Kathleen Wolner, MD Chuck Knueve, Pharm D., created a consolidated formulary that has dramatically changed our practice in Dayton. Chuck Knueve, Pharm D., created a consolidated formulary that has dramatically changed our practice in Dayton.

34. 34 Formulary on Toolbar Go to the tools bar and drop down to the Pharmacy Formulary Guide. Go to the tools bar and drop down to the Pharmacy Formulary Guide.

35. This is the first page of the formulary. Drugs are grouped by class and if criteria exist for use. They are summarized.This is the first page of the formulary. Drugs are grouped by class and if criteria exist for use. They are summarized.

36. 36 Medication Reconciliation Clinical Reminder We created a clinical reminder for medication reconciliation. Dr Puja Khanna, currently a rheumatology fellow, made the suggestion as a resident. Here I am opening my note. We created a clinical reminder for medication reconciliation. Dr Puja Khanna, currently a rheumatology fellow, made the suggestion as a resident. Here I am opening my note.

37. 37 Here is my template. Here is my template.

38. 38 My cursor is at the bottom and this is where I do most of my reminders. My cursor is at the bottom and this is where I do most of my reminders.

39. 39 Here is the reminder alarm clock ringing away… medications must be reconciled now!! Here is the reminder alarm clock ringing away… medications must be reconciled now!!

40. 40 You review and correct the allergies first. You review and correct the allergies first.

41. 41 If there is an allergy, correct it! If there is an allergy, correct it!

42. 42 Document to whom you spoke and any additional information from the conversation. Document to whom you spoke and any additional information from the conversation.

43. 43 If no changes, click here and you are finished! If no changes, click here and you are finished!

44. 44 Annotate any changes very briefly. This is a good time to review with the patient and make sure you have done everything!Annotate any changes very briefly. This is a good time to review with the patient and make sure you have done everything!

45. 45 This reminds you to send it off to the correct person if this is not your personal patient. This reminds you to send it off to the correct person if this is not your personal patient.

46. 46 Always give enough medications to last until the next visit! This raises awareness. Always give enough medications to last until the next visit! This raises awareness.

47. 47 Click here to review the active medications. This simply allows you to review them.Click here to review the active medications. This simply allows you to review them.

48. 48 Click here if you want the medication list to be stuffed into the note rather than just for your viewing! Click here if you want the medication list to be stuffed into the note rather than just for your viewing!

49. 49 Here is the text you create for the reminder. Here is the text you create for the reminder.

50. 50 How to Add a Drug to the Drug File If a patient comes in with the latest drug from the private doctor, you must add it to the non va meds. If it is not in the file, we created this method to allow the pharmacy to help add it! And the pharmacy actually gets the alertl! I learned about this at VEHU last year and our CAC created this process. If a patient comes in with the latest drug from the private doctor, you must add it to the non va meds. If it is not in the file, we created this method to allow the pharmacy to help add it! And the pharmacy actually gets the alertl! I learned about this at VEHU last year and our CAC created this process.

51. 51 Start here to add the missing drug… Start here to add the missing drug…

52. 52 Fill in the name, dose and route.Fill in the name, dose and route.

53. 53 Here is the dialog it creates. Here is the dialog it creates.

54. 54 Alas, it creates a consult that goes to the pharmacy! Alas, it creates a consult that goes to the pharmacy!

55. 55

56. 56 Here is the consult. Sign and move on! Our hospital has a very nice way of managing resident hand offs. Go to the Dayton VA intranet and make your way to the Medical Service portal. Here is the consult. Sign and move on! Our hospital has a very nice way of managing resident hand offs. Go to the Dayton VA intranet and make your way to the Medical Service portal.

57. 57 Resident Patient Information Handoff

58. 58 In the lower left hand corner is the secure medical resident handoff site In the lower left hand corner is the secure medical resident handoff site

59. 59

60. 60 The four teams can put anything in their files. The main purpose is to manage the patient information but it is also a good place to stow away good articles or other pearls of wisdom pertinent to the team members and or their patients.The four teams can put anything in their files. The main purpose is to manage the patient information but it is also a good place to stow away good articles or other pearls of wisdom pertinent to the team members and or their patients.

61. 61 Here is the grid. When a patient is admitted, he or she is added. The residents update the list daily and remove the patient from the list upon discharge. Here is the grid. When a patient is admitted, he or she is added. The residents update the list daily and remove the patient from the list upon discharge.

62. 62 Dayton Discharge Note Here is our form of the discharge note. There are a few nice things here that may help you at your site.Here is our form of the discharge note. There are a few nice things here that may help you at your site.

63. 63 The CHF education was a deficiency for us so we added it to the discharge note. It has worked very well and we are now meeting our EPRP measures.The CHF education was a deficiency for us so we added it to the discharge note. It has worked very well and we are now meeting our EPRP measures.

64. 64 Here is the text Here is the text

65. 65 The smoking reminder The smoking reminder

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70. 70 Pharmacy, The Last Stop before Out the Door Or as we say at North Chicago, the cab’s meter is running….Or as we say at North Chicago, the cab’s meter is running….

71. 71 Get Started Early Pharmacist involvement in discharge planning should begin on admission and should include: Allergy Assessment Complete medication history, including NON-VA meds and Herbal/OTCs Medication Reconciliation Involvement of the pharmacist early in the process may prevent roadblocks from delaying the discharge and affecting patient satisfactionInvolvement of the pharmacist early in the process may prevent roadblocks from delaying the discharge and affecting patient satisfaction

72. 72 Have a Discharge Plan Many ideas to improve discharge system FIX (Flow Inpatient Improvement Initiative Discharge appointment I am sure you have heard of other solutions as we all try to maximize efficiency in our patient flow.I am sure you have heard of other solutions as we all try to maximize efficiency in our patient flow.

73. 73 Special Issues Specialized medications might require more intense education Home IV therapy New Patient Administered Medications like Enoxaparin Scriptalk (for vision impaired patients) Tube Feeding Warfarin Pharmacy is responsible for disposable medical supplies which a patient might need for certain therapies. Often specialized medical supplies must be ordered to be available on dischargePharmacy is responsible for disposable medical supplies which a patient might need for certain therapies. Often specialized medical supplies must be ordered to be available on discharge

74. 74 Be Proactive As soon as specialized medications are identified as going home with patient Obtain list of drugs and supplies Educate patient and family multiple time Education should include return demonstration Competency checklists may be needed for more complex home therapyCompetency checklists may be needed for more complex home therapy

75. 75 Roadblocks Stability of medications may be too short to support home infusion Patient unable to self-administer medications Short notice discharge announcement Medication Reconciliation Too often advanced planning does not occur, and the patient is delayed while medications are preparedToo often advanced planning does not occur, and the patient is delayed while medications are prepared

76. 76 Speaking of Medication Reconciliation VA struggles to meet the intent of National Patient Safety Goals for an complete and accurate medication profile Recommend you consider attending 212 Medication Reconciliation (The Good, The Bad, and The Ugly) Thursday, August 23, 200710:00 AM  -10:30:00 AM (EST) Note my shameless plug for the round table discussion on Medication Reconciliation at VEHUNote my shameless plug for the round table discussion on Medication Reconciliation at VEHU

77. 77 Hines Class III Medication Reconciliation Tool It is the best fit for our current situation, and that is why it will likely be released as class I during FY08 (pending the $$funding approval) Thanks to Rob Silverman for sharing this great example.It is the best fit for our current situation, and that is why it will likely be released as class I during FY08 (pending the $$funding approval) Thanks to Rob Silverman for sharing this great example.

78. 78 DISCHARGE PLANNING Know your medical center’s policy on discharge planning Understand that special need medications may need to be ordered Plan Ahead Try to avoid the last minute discharge…..Try to avoid the last minute discharge…..

79. 79 Actual Discharge RX Process Provider determines medications to go home with patient after conducting medication reconciliation Provider enters outpatient prescriptions in CPRS for medications and supplies to go home

80. 80 Pharmacy Actions Pharmacist reviews medication orders Seeks clarification concerning any problems Prepares medications to go home Medication teaching by pharmacist/nurse with actual prescriptions in hand Documentation of discharge medication teaching

81. 81 Components of Medication Teaching Documentation A complete list of medications is provided to the patient including NON-VA medications and Herbal/OTC Documentation that patient was educated on and was able to verbalize all new and old medications including use, dosage and side effects Documentation that patient medication instruction sheets were given to patient

82. 82 More Components Documentation of potential drug-nutrient and drug-drug interactions. Patient advised to contact provider with any questions or concerns Documentation that patient was/was not able to understand instructions If patient unable to understand medication instructions, spouse/family member was educated on medications.

83. 83 Discharge Counseling Note Example EDUCATION MEDICATION TEACHING [ ] A complete list of medications was provided to the patient upon discharge. [ ] Patient was educated on and was able to verbalize all new and old medications including use, dosage, and side effects. Topics also included potential drug-nutrient and drug-drug interactions. Patient was advised to call provider with any questions or concerns. [ ] Patient unable to understand instructions. [ ] If patient unable to understand medication instructions, spouse/family member was educated on medications.

84. 84 QUESTIONS?