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Heart Failure Improvement Across the Continuum. Hospital to Home: Optimizing the Transition January 2009 Florida Hospital Assoc. Peg M. Bradke, RN, MA Director, Heart Care Services St. Luke’s Hospital, Cedar Rapids, Iowa. February 2006.

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heart failure improvement across the continuum

Heart Failure Improvement Across the Continuum

Hospital to Home: Optimizing the Transition

January 2009 Florida Hospital Assoc.

Peg M. Bradke, RN, MA

Director, Heart Care Services

St. Luke’s Hospital, Cedar Rapids, Iowa

slide2

February 2006

  • St. Luke’s joined the Institute for Health Improvement Innovation Project for Transitions to Home.
  • Work concentrated on the Heart Failure patient.
slide3

Strategies in Place

  • Heart Failure work team in place
  • Congestive Heart Failure class
  • Utilizing BNP to identify HF patients
  • Follow-up phone calls
  • Setting up discharge appointments
  • Pad/pencil at bedside for patient
  • A lot of work on CMS indicators
slide4

First Steps

  • Heart Failure Work Group reorganized to include:
    • Home Care representative
    • Family member of a HF patient
    • Long-Term Care representative
    • Physician Clinic representative

These views added new context to our efforts.

slide5

MeasurementHow will we know a change is improvement?

HF 30-day readmission rate: (Unit of focus or hospital-wide)

  • HF is primary, secondary or lower level diagnosis
  • Patient with HF had a readmission for HF within 30 days of a readmission for HF
  • Use your own definition or CHF Toolkit measures at www.IHI.org

http://www.ihi.org/NR/rdonlyres/708DEB58-6082-453A-B26A-3391290EC0AD/0/MIFCHFPercentofCongestiveHeartFailurePatientDischargeswithReadmissionWithin30Days.doc

Hospital 30-day (all) readmission rate:

  • Patient with HF was readmitted for any reason

For both measures:

  • Exclude chemo day patients treated on the unit
  • If focusing your work on a single unit, the HF readmission or all readmission rates for that unit will be needed
  • Display monthly on a line (run) chart for last twelve months. 
slide6

AIM Statement(From February 2006 Initial Transition to Home IHI Kick-off Meeting)

  • By January 1, 2007, St. Luke’s Hospital’s Telemetry Unit and Medical Unit will reduce unplanned readmissions by 50% (from 12 to 6%) by improving the transition home process for all Heart Failure patients.
  • Our methodology will include the patient and caregiver - ensuring that they fully understand their diagnosis, plan of care and follow-up care with physician.
slide7

What Changes Can We MakeThat Will Result in Improvement?

  • Four Key Changes to Achieve an Ideal Care Transition from Hospital to Home:
      • Enhanced Assessment of Patients
      • Enhanced Teaching and Learning
      • Patient-Centered Communication Hand-offs
      • Post Hospital Follow-up
slide8

Result of the IHI Collaborative Work on Transitions

  • Transforming Care at the Bedside How-to Guide

http://www.ihi.org/NR/rdonlyres/8F0551D1-DCD7-4EE7-BEE0-7C0DFBB5F6AB/5867/TransitionsHome_HowtoGuide_Final102207.pdf

enhanced admission assessment for post discharge needs
Enhanced Admission Assessment for Post Discharge Needs
  • Identify the appropriate family caregivers
  • Partner with home care agencies, primary care offices and clinics, and long-term care facilities
  • Communicate to all members of the care team the discharge plan and what needs to happen
  • Estimate the home-going date on admission and anticipate needs
  • Estimate standard discharge criteria
heart failure work group reorganized to include
Heart Failure Work Group Reorganized to Include:
  • Home Care representative
  • Family member of a HF patient
  • Long-Term Care representative
  • Physician Clinic representative

These views added new context to our efforts.

communication
Communication
  • Daily discharge huddle at 10:00 AM
  • Bedside reporting
  • Both opportunities to review plan for day and anticipate discharge needs
reconcile medications upon admission
Reconcile Medications Upon Admission
  • Involve the patient and family caregivers, care providers, physicians, pharmacy
  • Reconcile on admission (suitably trained professional)
  • Include record of the reconciliation in the medical record
  • Ensure drug changes during the admission are reconciled, updated, accurate and timely
  • Consider using a personalized medication
slide16

Chart Review Tool

  • Known reason(s) for readmission.
  • What did the patient or family think contributed to the readmission?
  • Any self-care instructions misunderstood?
  • Evidence of teach back documented?
  • What did the physician or office staff think contributed?
  • Was a follow-up physician visit scheduled? Attended?
  • Number of days between the discharge and physician’s office visit. Number of days between discharge and readmission
  • Any urgent clinic/ED visits before readmission?
  • Functional status of the patient on discharge?
  • Clear discharge plan documented?
interview questions asked to patients caregiver readmitted with heart failure
Interview Questions Asked to Patients/ Caregiver Readmitted With Heart Failure
  • Can you tell me in your own words why you think you ended up sick enough to be readmitted again?
  • Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night?
  • Where are your scale and calendar located?
  • Have you seen your doctor since you were discharged from the hospital?
  • Do you have all of your medications? How do you set your pills up every day?
  • Were there any appointments that kept you from taking any of your pills?
enhanced understanding in the patient education process
Redesign the patient education process to improve patient/family or caregiver understanding of self care:

Identify the appropriate family or caregivers

Involve right learners in all critical education

Identify how the patient and family or caregiver learn best

Redesign written material

Redesign teaching methods

Enhanced Understanding in the Patient Education Process
slide20

Enhanced Teaching andLearning

Redesign patient teaching material:

  • During acute care hospitalizations for HF, only essential education is recommended
    • Reinforce within 1-2 weeks after discharge
    • Continue for 3-6 months

Adams, KF et al: HFSA 2006 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure Vol. 12, No. 1, pg 61 February 2006

intervention patient education material
Intervention:Patient Education Material

Key “small tests of change””

  • Reviewed content of educational materials utilizing health literacy concepts.
  • Outpatient Heart Failure class utilized as focus group for content.
  • Family member on team, along with her siblings, reviewed content for understanding Health Literacy.
slide22

Keys to Success Utilizing Health Care Literacy Concepts

  • On all written materials, matched terminology to what we said in class.
  • Used term Heart Failure as opposed to Congestive Heart Failure or Chronic HF
  • Removed ranges
  • Increased font size
  • Added more white space
keys to success with health literacy
Keys to Success with Health Literacy
  • Use universal health literacy communications principles to redesign written teaching materials:

User-friendly written materials use:

      • Simple words (1-2 syllables)
      • Short sentences (4-6 words)
      • Short paragraphs (2-3 sentences)
      • No medical jargon
      • Headings and bullets
      • Highlighted or circled key information
slide29

Evaluation of New Patient Education Material

Results from 15 follow-up phone calls:

  • “Information very helpful.”
  • Able to state where information was and reported that they were referring to it.
  • Understood content.
  • Successfully answered teach back questions related to “water pill,” diet and weight.
  • Improvement opportunity – patients were often unclear when they had multiple physicians which one to call for the symptoms (magnet revised).
enhanced teaching and learning
Enhanced Teaching and Learning

Redesign patient teaching:

  • Stop and check for understanding using Teach Back after teaching each segment of the information
  • If there is a gap, review again
  • Another way to close the loop
redesign patient teaching
Redesign Patient Teaching
  • Slow down when speaking to the patient and family and break messages into short statements
  • Use plain language, breaking content into short statements
  • Segment education to allow for mastery
slide32

Enhanced Teaching and Learning

Utilizing “Teach Back”

  • Explain needed information to the patient or family caregiver.
  • Ask in a non-shaming way for the individual to explain in his or her own words what was understood.
  • Example: “I want to be sure that I did a good job of teaching you today about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the doctor?”
  • Return demonstration or show back
teach back questions
Teach Back Questions
  • What is the name of your water pill?
  • What weight gain should you report to your doctor?
  • What foods should you avoid?
  • Do you know what symptoms to report to your doctor?
slide34

Enhanced Teaching and Learning

  • Use Teach Back daily
    • In the hospital
    • During home visits and follow-up phone calls
    • To assess the patients’ and family caregivers’ understanding of discharge instructions and ability to do self-care
    • To close understanding gaps between:
      • Caregivers and patients
      • Professional caregivers and family caregivers
teach back success
Teach Back Success
  • Percent of time patients can teach back 90% or more of content taught related to the transition to home utilizing the four questions related to self management of heart failure
  • Stop and check for understanding using Teach Back after teaching each segment of information
  • Assess patient’s, family’s or caregiver’s ability and confidence
staff competency validation for teachback
Staff Competency Validation for Teachback
  • Methodology
    • The learning station will use discussion, role playing and patient teaching scenarios to help RN’s communicate effectively to patient/family.
staff competency validation for teachback38
Staff Competency Validation for Teachback
  • Objectives – Each participant will be able to:
    • Define health literacy
    • Learn clear communication strategies
    • Define plain language
    • Learn and utilize the “teach back” method in a shame-free way
staff competency validation for teachback39
Staff Competency Validation for Teachback
  • Each participant will participate in a role-play providing education to a patient. The following will be assessed:
      • Ability to do teach back in a shame-free way; tone is positive
      • Utilizes plain language for explanations
      • Does not ask patient, “Do you understand?”
      • Uses statements such as “I want to make sure I explained everything clearly to you.” “Can you please explain it back to me in your own words?” Or, as an example, “I want to make sure I did a good job explaining this to you because it can be very confusing. Can you tell me what changes we decided to make and how you will take your medicine now?”
      • If needed, participant will clarify and reinforce the explanation to improve patient understanding.
patient centered transition communication
Patient-Centered Transition Communication
  • Provide next caregiver customized real-time information:
    • What to expect at home
    • Easy to read self-care instructions
    • Reasons to call for help
    • Number to call for emergent and non-emergent needs and questions
  • Share patient education materials and education processes across all care settings
  • Physicians, home care and other involved clinicians transmit information at time of discharge
  • Include anticipated, important next steps in the transition, including concerns about the patients
  • Ask receiving care teams for their preferred format, mode of communication and specific information needs about the patient’s functional status
  • Ask receiving care teams for their preferred format, mode of communication and specific information needs about the patient’s functional status
  • Continually improve by aggregating the experience of patients, families, and caregivers and designing improvements
st luke s heart failure continuum
St. Luke’s Heart Failure Continuum
  • Teach back in hospital using new teaching material
  • Standardized HF on-line discharge instructions
  • Home Care complimentary visit 24 to 48 hours post discharge – use teach back again
  • Physician office visit within three to five days
  • Advance Practice Nurse follow-up phone call on seventh day post discharge – teach back repeated
  • Outpatient Heart Failure class – seeing increased participation
  • Collaboration with cardiology office Heart Failure Clinic
slide46

Post Acute Care Follow-Up

  • High risk patients: prior to discharge, schedule a face-to-face follow-up visit (home care visit, care coordination visit, or physician office visit) to occur within 48 hours after discharge
  • Moderate risk patients: prior to discharge, schedule follow-up phone call within 48 hours and schedule a physician office visit within five days
slide47

Post Acute Care Follow-Up

High-risk patients:

  • Patient has been admitted two or more times in the past year
  • Patient failed “Teach Back” or the patient or family caregiver has low degree of confidence to carry out self-care at home
    • Patient and family caregiver have the phone number for questions and concerns
    • Consider home care or discharge coach
slide48

Post Acute Care Follow-Up

Moderate risk patients:

  • Patient has been admitted once in the past year
  • Patient or family caregiver has moderate degree of confidence to carry out self-care at home
    • Prior to discharge, schedule follow-up phone call within 48 hours
    • Schedule a physician office visit within five days
slide49

Intervention: Home Care Visit24-48 Hours Post Discharge

  • Small test of change October 2006
  • Education to all Home Care staff
  • Visit 48 hours after discharge
  • Visit outline
    • Medication Reconciliation
    • Review of diet and foods in-house
    • Teach back on water pill, diet and weight
    • Vital signs

Hardwired process in January 2007

cost for heart failure program
Cost for Heart Failure Program
  • Home Care visit: $110.00
    • St. Luke’s covers $58.00; the remainder of $52.00 is absorbed
    • Follow-up phone calls: $10,000
    • Education material
      • Magnet: $1.00
      • Total with handouts: $1,200
slide51

Intervention: Nursing Home

  • Patient education sent with all nursing home patients at discharge.
  • Educational offerings for the staff conducted in the nursing homes.
  • Nursing home representative added to our HF Team.
intervention follow up phone call
Intervention: Follow-Up Phone Call
  • Advance Practice Nurse makes follow-up phone call at seven days post-discharge
  • Standardize questions
  • Results monitored and changes made as needed based on feedback
  • Results monitored globally and per individual unit
slide54

Intervention: Primary CareFollow-Up Appointment

  • Worked with Primary Care to assure follow-up visits scheduled 3 to 5 days post discharge
  • Particularly on high-risk patient for readmission
slide55

Intervention: Dietitian Visits

  • Now mandatory on all HF patients
slide59

Good

Heart Failure Readmission Rates*

Aug 06 = Implemented use of new patient education materials

Jan 07 = Initiated complimentary visits

*Percent of heart failure patients readmitted for exacerbation of their heart failure.

hf continuum
HF Continuum
  • Teach back in hospital using new teaching material
  • Standardized HF on-line discharge instructions
  • Home Care complimentary visit 24 to 48 hours post discharge – use teach back again
  • Physician office visit within three to five days
  • Advance Practice Nurse follow-up phone call on seventh day post discharge – teach back repeated
  • Outpatient Heart Failure class – seeing increased participation
  • Collaboration with cardiology office Heart Failure Clinic
slide62

Lessons Learned

  • Engaged leadership
  • Worked in tandem with our CMS core measures for HF
  • Took advantage of existing workflows
  • Stories are as important as the data
  • Health literacy: “If they don’t do what we want, we haven’t given them the right information.” (Vice Admiral Richard Carmona, Former Surgeon General)
slide63

Our Work Continues

  • Working on HF LOS
  • Working in conjunction with Cardiologists, PC HF Clinic
  • HF Certification from JCAHO
  • Working with Wellmark to get Home Visit as a covered visit
our impact
Our Impact

By:

  • Enhancing the patient assessment process on admission
  • Enhancing patient and family understanding of complex self-care processes
  • Improving the hand-off of critical information to caregivers in the next care setting
  • Providing continuity in post acute care follow-up

We can reduce unnecessary readmissions for patients with Heart Failure.