Transcript Module II - Texas Center for Quality & Patient Safety

Module 2
The Re-designed Discharge Process:
Faculty from Joint Commission Resources
Deborah M. Nadzam, PhD, FAAN
Project Director
And
Kathleen Lauwers, RN, MSN
Consultant
© Joint Commission Resources
Patient Admission and Care/Treatment Education
Accomplishments to Date
 Project Charter initiated
 Primary Care Practitioner referral base defined
 Process map of current discharge process
completed
 Dates for training frontline staff set
© Joint Commission Resources
 Care plan structure is finalized: template,
location, how Discharge Advocate (D.A.) will
access it
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
 Confirm process for creating patient care plan
© Joint Commission Resources
 Define role of multidisciplinary team members
in discharge planning
Module 2 Outline
 Principles and Components of Project RED
 Current Discharge Process and Suggested
Project Metrics
 Patient Admission
 Care and Treatment Education
© Joint Commission Resources
 Patient Care Plan: Structure and Process for
Completing
© Joint Commission Resources
Let’s Review the Principles of
Project RED . . .
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
© Joint Commission Resources
5. Complete patient discharge summary prior
to 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
© Joint Commission Resources
Principles of the Re-Engineered Hospital
Discharge (continued)
© Joint Commission Resources
Module 2
Discharge Planning
Rx Plan
Patient
Admission
Discharge
Order
Written
Discharge Process
PATIENT EDUCATION
Dischar
ge Event
DISCHARGE INSTRUCTIONS
Post-D/C
Followup
© Joint Commission Resources
H&P
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
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)
© Joint Commission Resources
4. Outstanding tests
© Joint Commission Resources
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 – PCP survey related to
discharge preparation
© Joint Commission Resources
 Pre and Post data -Front line staff survey
related to discharge preparation
Financial Metrics
 The cost of second LOS (readmission)
 Project costs
© Joint Commission Resources
 Discharge process costs (current and
redesigned)

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
© Joint Commission Resources
Process Metrics

Percent of Follow-up calls requiring second
call by pharmacist (if non-pharmacist makes
first call).

Percent of patients completing postdischarge survey (30 days after discharge)
© Joint Commission Resources
Process Metrics
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
© Joint Commission Resources

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 timerelated 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?
 Who will be responsible for overseeing the measurement
activities?
© Joint Commission Resources
 Will you measure the completeness of the patient care plan?
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
© Joint Commission Resources
 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?
© Joint Commission Resources
 By physician
Identify the Patient (2)
 Who will notify the D.A. of the patient’s
admission?
 How is the D.A. notified?
– Pager?
– Phone?
© Joint Commission Resources
 D.A. should be notified within 12 hours, to be
able to see patient within 24 hrs of admission
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?
© Joint Commission Resources
–
–
–
–
Sample Log for Tracking Key Dates and
Times
Red Skeldoni Patient Name Patient
Name
Date/Time of
Admission
Date/Time D.A.
notified
Date/Time of
initial D.A. visit
with patient
05-05;1300
Date/Time of
daily D.A. visits
with patient
(note all)
05-07;0800
05-08; 1000
05-09; 1200
Date/time of
discharge
Date/time care
plan faxed to
PCP
05-09;1400
Date/time of
post-D/C call
05-11; 1600
05-05; 1700
05-06; 1100
© Joint Commission Resources
05-09;1500
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?
© Joint Commission Resources
 How will the D.A. 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
 Initiate care plan and checklist
© Joint Commission Resources
– Describe D.A. role
– Assess concerns, including potential post-D/C
needs
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
© Joint Commission Resources
 Continue development of care plan
© Joint Commission Resources
Discharge Planning Rounds
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?
– Was it expected?
– Weekend discharge?
– Is there a timing expectation (i.e., time from order to
‘out-the-door’)?
© Joint Commission Resources
 When is discharge order written?
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
© Joint Commission Resources
 Supports the performance
improvement process
Nursing Staff
 Provide nursing care as planned
 Educate patient/family as usual
 Communicate with each other, per
usual
 Participate in multidisciplinary
rounds, including those that may be
specifically focused on discharge
planning
© Joint Commission Resources
 Communicate with other members
of the health care team, including
D.A.
 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
© Joint Commission Resources
Pharmacist
Case Managers
 Post-discharge services
 Social work
 Utilization review
© Joint Commission Resources
 Financial support
Other Key Staff
 Therapists
© Joint Commission Resources
 Disease management
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 are the roles and responsibilities of members of the
health care team, as related to discharge planning?
© Joint Commission Resources
– What will it take to implement such rounds?
– Who will be supportive?
– Where might resistance be encountered?
Teaching the Patient
 Assess understanding of reason for admission,
condition/diagnosis, and current medications
 Begin teaching medications and condition
– Health literacy
– Language
– Culture
© Joint Commission Resources
 Use teach-back methods (to be discussed in
Module III)
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.”
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.
© Joint Commission Resources
Public health nurse: “How did your doctor tell you to take
them?
Ask Me 3*
 Created by the Partnership for Clear Health
Communication (NPSF)
 Three essential questions for patients:
*National Patient Safety Foundation http://www.npsf.org/askme3/
© Joint Commission Resources
– What is my main problem?
– What do I need to do?
– Why is it important for me to do this?
Teaching – Tips*
 Elicit from patient their symptoms and
understanding
 Be aware of when teaching new concepts and
ensure understanding
 Eliminate jargon
– Provide more robust health education vehicles to
help the patient remember
– Be proactive during time between visits
* Schillinger interview
© Joint Commission Resources
 System level support using technology:
Literacy Issues*
 Clues that patient has general literacy issues:
–
–
–
–
• “Forgot my glasses- can you read it to me?”
• “ I will read it at home”
* Graham and Brookey
© Joint Commission Resources
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
Health Literacy – Tips*
 Avoid medical jargon
 Speak slowly
 Simple pictures when helpful
 Emphasize what the patient should do
 Avoid unnecessary information
 Written materials: simple words, short sentences in
bulleted format, lots of white space
* Graham and Brookey
© Joint Commission Resources
 Welcome questions
1.
Use visual aids and illustrations
2.
Beware of words with multiple meanings
3.
Avoid acronyms and other new words
4.
Use idioms carefully
5.
Provide a health context for numbers and mathematical
concepts
6.
Take a pause
7.
Be an active listener
8.
Address quizzical looks
9.
Create a welcoming and supportive environment
*www.pfizerhealthliteracy.com/public-health-professional/tips
© Joint Commission Resources
Additional Teaching Tips*
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
© Joint Commission Resources
– Permanent part of the patient record?
Accessing the Care Plan Template
 IT department involvement
– Any interfaces built?
 Written instructions for how to
access the care plan template
 Written instructions for how and where to save
the patient’s care plan
© Joint Commission Resources
 Written description of template sections,
including what is entered manually, and what is
linked to other hospital systems
Gathering Care Plan Content
 Start the care plan on admission and add to it
daily
© Joint Commission Resources
– 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
Module 2: Summary

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 postdischarge services

Daily visits to patient

Educate throughout

Continue to add to care plan
© Joint Commission Resources
Expected Outcomes
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 ___
 Team evaluation of Module 2 ___
© Joint Commission Resources
 Process for accessing care plan ___