Module 2 The Re-designed Discharge Process: Patient Admission and Care/Treatment Education

1. Module 2The Re-designed Discharge Process: Patient Admission and Care/Treatment Education Faculty from Joint Commission Resources Deborah M. Nadzam, PhD, FAAN Project Director And Kathleen Lauwers, RN, MSN Consultant

2. Accomplishments to Date • Project Charter initiated • Primary Care Practitioner referral base defined • Process map of current discharge process completed • Care plan structure is finalized: template, location, how Discharge Advocate (D.A.) will access it • Dates for training frontline staff set

3. Objectives of Module 2 • Review discharge planning activities that begin on admission • Develop plan for identifying targeted patients on admission • Review D.A.’s initial contact with patient • Define role of multidisciplinary team members in discharge planning • Confirm process for creating patient care plan

4. Module 2 Outline • Principles and Components of Project RED • Current Discharge Process and Suggested Project Metrics • Patient Admission • Care and Treatment Education • Patient Care Plan: Structure and Process for Completing

5. Let’s Review the Principles of Project RED . . .

6. Principles of the Re-Engineered Hospital Discharge • Explicit delineation of roles and responsibilities • Discharge process initiation upon admission • Patient education throughout hospitalization • Timely accurate information flow: From PCP ► Among Hospital team ► Back to PCP • Complete patient discharge summary prior to discharge

7. Principles of the Re-Engineered Hospital Discharge (continued) • Comprehensive written discharge plan provided to patient prior to discharge • Discharge information in patient’s language and literacy level • Reinforcement of plan with patient after discharge • Availability of case management staff outside of limited daytime hours • Continuous quality improvement of discharge processes

8. Module 2

9. Discharge Planning Discharge Order Written H & P Rx Plan Patient Admission Discharge Event Discharge Process PATIENT EDUCATION DISCHARGE INSTRUCTIONS Post-D/C Follow-up

10. RED Checklist: Admission and Care/Treatment Education Eleven mutually reinforcing components: 1.Medication reconciliation 2. Reconcile discharge plan with national guidelines 3. Follow-up appointments 4. Outstanding tests 5.Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8.Patient education 9. Assess patient understanding 10. Discharge summary sent to PCP 11.Telephone reinforcement Adopted by National Quality Forum as one of 30 US "Safe Practices" (SP-15)

12. Outcome metrics for target population • Average length of stay • 30 day unplanned ‘all cause’ readmission rate • Pre and post data -Patient experience related to discharge preparation • Pre and Post data -Front line staff survey related to discharge preparation • Pre and Post data – PCP survey related to discharge preparation

13. Financial Metrics • The cost of second LOS (readmission) • Project costs • Discharge process costs (current and redesigned)

14. Process Metrics • Average time to notify DA about new admission • Average time from admission to first patient visit by DA (initiation of care plan) – only for patients who meet all criteria • Percent of patients PCP notified within 24 hours discharge • Percent of Follow-Up phone calls made within 48 hours

15. Process Metrics • Percent of Follow-up calls requiring second call by pharmacist (if non-pharmacist makes first call). • Percent of patients completing post-discharge survey (30 days after discharge)

16. Process Metrics • Completion of care plan details: • % of care plans with medication list included • % of care plans with care needs included (e.g., exercise, diet, main problem, when do I call doctor) • % of care plans with follow up appointments listed • % of care plans with pre-arranged discharge resources identified (e.g., home care, DME) • % of care plans with pending tests listed

17. Let us pause now…As a team, answer the following questions: • What metrics do the project team want to use to assess the impact of the re-engineered discharge process? • If you decide to collect the process measure associate with time-related activities, how will that happen? • Will you use the patient phone survey? How? • Will you use the frontline staff survey? How? • Will you use the PCP survey? How? • Will you measure the completeness of the patient care plan? • Who will be responsible for overseeing the measurement activities?

18. 11 RED Components Enable Discharge Advocates (D.A.) to: • Prepare patients for hospital discharge • Help patients safely transition from hospital to home • Promote patient self-health management • Support patients after discharge through follow-up phone call

19. Identify the Patient • By admission unit • By admitting diagnosis • Heart Failure: How do you identify these patients for core measure processes? • By physician

20. Identify the Patient (2) • Who will notify the D.A. of the patient’s admission? • How is the D.A. notified? • Pager? • Phone? • D.A. should be notified within 12 hours, to be able to see patient within 24 hrs of admission

21. Secondary Screening by D.A. • D. A. reviews patient’s admission notes • Consider: • Working diagnosis • Language • Likely disposition • Is there a home or cell phone number? • Is patient a candidate for Project RED intervention?

22. Sample Log for Tracking Key Dates and Times

23. Let us pause now…As a team, answer the following questions: • How will you first identify that a newly admitted patient is in the targeted population for this project? • How will the D.A. be notified that a potential Project RED patient has been admitted? • What secondary screening criteria for patient inclusion will the D.A. use to confirm the use of the Project RED intervention with the patient? • How will the D.A. track activities with new patients?

24. Meeting the Patient • Review the patient’s admission notes • History and Physical • Medication reconciliation • Preliminary plan of care • Meet the patient and family • Describe D.A. role • Assess concerns, including potential post-D/C needs • Initiate care plan and checklist

25. Daily Work of the D.A. • Review progress and nursing notes • Clarify any concerns with health care team • Visit the patient • Review treatment plan (as related to discharge) • Begin educating as appropriate (condition, meds) • Discuss patient’s concerns re: discharge • Continue development of care plan

26. Discharge Planning Rounds

27. Multidisciplinary Team • Consider daily ‘discharge rounds’ • Medical staff, nursing staff, pharmacy, case mgmt and D.A. • Who will be supportive? • Where might resistance come from? • When is discharge order written? • Was it expected? • Weekend discharge? • Is there a timing expectation (i.e., time from order to ‘out-the-door’)?

28. Patient’s Physician • Initiates patient plan of care based on critical pathway • Leads and/or participates in discharge planning rounds • Communicates potential date of discharge • Supports the performance improvement process

29. Nursing Staff • Provide nursing care as planned • Educate patient/family as usual • Communicate with each other, per usual • Communicate with other members of the health care team, including D.A. • Participate in multidisciplinary rounds, including those that may be specifically focused on discharge planning

30. Verify physician orders Reconcile admission meds with meds from home Collaborate with care team specific to discharge needs Reconcile meds upon discharge Assist with patient medication questions Pharmacist

31. Case Managers • Post-discharge services • Social work • Utilization review • Financial support

32. Other Key Staff • Therapists • Disease management

33. Let us pause now…As a team, answer the following questions: • Do you currently address discharge planning in multidisciplinary rounds? • What works well? • What could be improved? • Who participates? • If you do not do the above, why not? • What will it take to implement such rounds? • Who will be supportive? • Where might resistance be encountered? • What are the roles and responsibilities of members of the health care team, as related to discharge planning?

34. Teaching the Patient • Assess understanding of reason for admission, condition/diagnosis, and current medications • Begin teaching medications and condition • Use teach-back methods (to be discussed in Module III) • Health literacy • Language • Culture

35. A True Story* Public health nurse: “Jill, I see you are taking birth control pills. Tell me how you are taking them” Jill: “Well, some days I take three; some days I don’t take any. On weekends I usually take more.” Public health nurse: “How did your doctor tell you to take them? Jill: “He said these pills were to keep me from getting pregnant when I have sex, so I take them anytime I have sex.” * Graham S and Brookey J. 2008.

36. Ask Me 3* • Created by the Partnership for Clear Health Communication (NPSF) • Three essential questions for patients: • What is my main problem? • What do I need to do? • Why is it important for me to do this? *National Patient Safety Foundation http://www.npsf.org/askme3/

37. Teaching – Tips* • Elicit from patient their symptoms and understanding • Be aware of when teaching new concepts and ensure understanding • Eliminate jargon • System level support using technology: • Provide more robust health education vehicles to help the patient remember • Be proactive during time between visits * Schillinger interview

38. Literacy Issues* • Clues that patient has general literacy issues: • Incompletely filled out forms • Frequently missed appointments • Poor compliance • Inability to identify the name, purpose or timing of medication • Not asking any questions • Reaction to written materials • “Forgot my glasses- can you read it to me?” • “ I will read it at home” * Graham and Brookey

39. Health Literacy – Tips* • Avoid medical jargon • Speak slowly • Simple pictures when helpful • Emphasize what the patient should do • Avoid unnecessary information • Welcome questions • Written materials: simple words, short sentences in bulleted format, lots of white space * Graham and Brookey

40. Additional Teaching Tips* • Use visual aids and illustrations • Beware of words with multiple meanings • Avoid acronyms and other new words • Use idioms carefully • Provide a health context for numbers and mathematical concepts • Take a pause • Be an active listener • Address quizzical looks • Create a welcoming and supportive environment *www.pfizerhealthliteracy.com/public-health-professional/tips

41. Developing the Patient’s Care Plan • Accessing the care plan template • Accessing information for the care plan • Saving individual patient’s care plan • Printing the care plan • Storing the care plan • Permanent part of the patient record?

42. Accessing the Care Plan Template • IT department involvement • Any interfaces built? • Written instructions for how to access the care plan template • Written description of template sections, including what is entered manually, and what is linked to other hospital systems • Written instructions for how and where to save the patient’s care plan

43. Gathering Care Plan Content • Start the care plan on admission and add to it daily • Secure education material about patient’s primary condition • Can begin medication section, based on daily discussions with medical team • Can begin post discharge services section • Identify PCP and add name to care plan

44. Module 2: SummaryExpected Outcomes • Identify patients who are members of the project’s targeted population • Alert the D.A. about new patient • Screen for final acceptance into project • Initiate discharge planning on admission • Meet the patient (thru team, admission notes and in person!) • Initiate care plan and maintain log of activities • Daily rounds with health care team to plan patient education and post-discharge services • Daily visits to patient • Educate throughout • Continue to add to care plan

45. Progression to Module 3 Checklist • Metrics you will use to assess impact ___ • Process for identifying candidate patients and notifying D.A. ___ • Secondary screening criteria for including patient are confirmed ___ • Process for multidisciplinary ‘rounds’ and/or updates on targeted patients ___ • Process for accessing care plan ___ • Team evaluation of Module 2 ___