Transcript Presentation - Patient Safety

Module 2
The Re-Designed Discharge Process:
Patient Admission and
Care and Treatment Education
Accomplishments to Date
 Process map of current discharge
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process completed
Primary care practitioner (PCP) referral
base defined
Patient Care Plan structure finalized
Project charter initiated
Dates for training frontline staff set
Module 2 Objectives
 Review discharge planning activities that
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begin on admission
Develop plan for identifying targeted
patients on admission
Review Discharge Advocate (DA) initial
contact with patient
Define roles of multidisciplinary team
members in discharge planning
Confirm process for creating Patient
Care Plan
Module 2 Outline
 Project RED principles and
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components
Current discharge process and
suggested project metrics
Patient admission
Care and treatment education
Structure and process for
completing Patient Care Plan
Principles of the Re-Engineered
Hospital Discharge
1. Explicit delineation of roles and
responsibilities
2. Discharge process initiation upon admission
3. Patient education throughout hospitalization
4. Timely accurate information flow:
From PCP ► Among hospital team ► Back to
PCP
5. Complete patient discharge summary prior to
discharge
Principles of the Re-Engineered
Hospital Discharge
6. Comprehensive written discharge plan
provided to patient prior to discharge
7. Discharge information in patient’s language
and literacy level
8. Reinforcement of plan with patient after
discharge
9. Availability of case management staff outside
of limited daytime hours
10. Continuous quality improvement of discharge
processes
Patient and Family Centered Safe Care
Pre Patient
Admission
Discharge
Order
Written
H&P; Assessments; Rx Plan
Discharge
Event
Discharge Process
Discharge
Folder
Passport for
Home
White Board, Rounding & Bedside
Report
PATIENT EDUCATION/
Community providers:
• Nursing Home
• Home Health &
Hospice
• Home Care
• Physicians
• Accountable Care
Organizations
FINAL DISCHARGE INSTRUCTIONS
Prepare for Home
MEDICATION MANAGEMENT
Post-D/C
FOLLOW-UP
Admission and
Care and Treatment Education
1. Ascertain need for and obtain language assistance
2. Medication Reconciliation
3. Reconcile discharge plan with national guidelines
4. Follow-up appointments
5. Outstanding/pending lab & diagnostic tests follow-up
6. Post-discharge services
7. Written discharge plan
8. What to do if problem arises
9. Patient education
10. Assess patient understanding
11. Discharge summary sent to PCP
12. Telephone reinforcement
t
sample
Outcome Metrics for Target
Population
 Average length of stay
 30-day unplanned all-cause
readmission rate
 Pre/post data: Patient experience
related to discharge preparation
 Pre/post data: Frontline staff survey
related to discharge preparation
 Pre/post data – PCP survey related to
discharge preparation
Financial Metrics
 The cost of second length of stay
(readmission)
 Project costs
 Discharge process costs (current and
redesigned)
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’ PCPs notified within
24 hours discharge
 Percent of follow-up phone calls made
within 48 hours
Process Metrics
 Percent of follow-up calls requiring
second call by pharmacist (if nonpharmacist makes first call)
 Percent of patients completing postdischarge survey (30 days after
discharge)
Process Metrics
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Completion of care plan details
– Percent of care plans with medication list
included
– Percent of care plans with care needs included
(e.g., exercise, diet, main problem, when to call
doctor)
– Percent of care plans with follow-up
appointments listed
– Percent of care plans with pre-arranged
discharge resources identified (e.g., home health,
durable medical equipment)
– Percent of care plans with pending tests listed
Answer the Following Questions
as a Team
 What metrics do the project team want to use
to assess the impact of the re-engineered
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discharge process?
If you decide to collect the process measure
associated 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?
Project RED Components
The 11 components enable DAs 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
Identify the Patient
 By admission unit
 By admitting diagnosis
– Heart failure: How do you identify
these patients for core measure
processes?
 By physician
Identify the Patient
 Who will notify the DA of the patient’s
admission?
 How is the DA notified?
– Pager
– Phone
 DA should be notified within 12 hours to
be able to see patient within 24 hours of
admission
DA Secondary Screening
 DA reviews patient’s admission notes
 Considers:
– Working diagnosis
– Language
– Likely disposition
– Availability of home or cell phone number
 Determines if patient is a candidate for
Project RED intervention
Sample Log to Track
Key Dates and Times
Joe Smith
Date/Time of
Admission
Date/Time DA
Notified
Date/Time of Initial
DA Visit With Patient
Date/Time of Daily
DA Visits With
Patient (Note All)
Date/Time of
Discharge
Date/Time Care
Plan Faxed to PCP
Date/Time of PostDischarge Call
05-05; 1300
05-05; 1700
05-06; 1100
05-07; 0800
05-08; 1000
05-09; 1200
05-09; 1400
05-09; 1500
05-11; 1600
Patient Name
Patient Name
Answer the Following Questions
as a Team
 How will you first identify that a newly admitted
patient is in the target population for this
project?
 How will the DA be notified that a potential
Project RED patient has been admitted?
 What secondary screening criteria will the DA
use to confirm use of the Project RED
intervention with the patient?
 How will the DA track activities with new
patients?
Meeting the Patient
 Review the patient’s admission notes
– History and physical
– Medication reconciliation
– Preliminary plan of care
 Meet the patient and family
– Describe DA’s role
– Assess concerns, including potential post-
discharge needs
 Initiate Patient Care Plan and checklist
Daily Work of the DA
 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,
medications)
– Discuss patient’s concerns re: discharge
 Continue development of care plan
Discharge Planning Rounds
Multidisciplinary Team
 Consider daily discharge rounds
– Medical staff, nursing staff, pharmacy,
case management, and DA
– Who will be supportive?
– Where might resistance come from?
 When is discharge order written?
– Was it expected?
– Weekend discharge?
– Is there a timing expectation (e.g., time
from order to out the door)?
Patient’s Physician
 Initiates patient plan of care based on critical
pathway
 Leads and participates in discharge planning
rounds
 Communicates potential date of discharge
 Supports the performance improvement process
Nursing Staff
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Provide nursing care as planned
Educate patient and family
Communicate with each other
Communicate with other members of the health
care team, including DA
 Participate in multidisciplinary rounds, including
those that may be specifically focused on
discharge planning
Pharmacist
 Verify physician orders
 Reconcile admission medications with
medications from home
 Collaborate with care team specific to discharge
needs
 Reconcile medications upon discharge
 Assist with patient medication questions
Case Managers
 Post-discharge services
 Social work
 Utilization review
 Financial support
Other Key Staff
 Therapists
 Disease management
Answer the Following Questions
as a Team
 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?
Teaching the Patient
 Assess understanding of:
– Reason for admission
– Condition or diagnosis
– Current medications
 Begin teaching medications and
condition
 Use teach-back methods (discussed in
Module 3)
– Health literacy
– Language
– Culture
Ask Me 3*
 Created by the Partnership for Clear
Health Communication (National Patient
Safety Foundation)
 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/
Teaching Tips*
 Elicit symptoms and understanding from
the patient
 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
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
 “I forgot my glasses. Can you read it to me?”
 “I will read it at home.”
* Graham and Brookey
Health Literacy Tips*
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Avoid medical jargon
Speak slowly
Provide simple pictures when helpful
Emphasize what the patient should do
Avoid unnecessary information
Welcome questions
Ensure written materials use simple words,
short sentences in bulleted format, and lots of
white space
* Graham and Brookey
Additional Teaching Tips*
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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
Developing the
Patient Care Plan
 Accessing the care plan
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template
Accessing information for
the care plan
Saving individual Patient
Care Plan
Printing the care plan
Storing the care plan
– Permanent part of the
patient record?
Accessing the
Patient Care Plan Template
 IT department involvement
– Build interfaces?
 Written instructions for how to access
the care plan template
 Written description of care 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 Care Plan
Gathering Care Plan Content
 Start the Patient Care Plan on admission
and add to it daily
– Secure education material about the
patient’s primary condition
– Begin medication section, based on daily
discussions with medical team
– Begin post-discharge services section
– Identify PCP and add name to care plan
Module 2: Summary
Expected Outcomes
 Identify patients who are members of the
project’s targeted population
 Alert the DA about new patients
 Screen for final acceptance into project
 Initiate discharge planning on admission
 Meet the patient (through the care team,
admission notes, and in person)
 Initiate care plan and maintain activities log
 Participate in daily rounds with health care team
to plan patient education and post-discharge
services
 Visit patient daily and educate during each visit
 Continue to add to Patient Care Plan
Progression to Module 3
Checklist
Before going to Module 3, determine the:
___ Metrics you will use to assess impact
___ Process for identifying candidate
patients and notifying DA
___ Secondary screening criteria for
including patient
___ Process for multidisciplinary rounds
and/or updates on targeted patients
___ Process for accessing Patient Care
Plan