Transcript HCAPS and Case Management Process Changes

The Finley Hospital
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Describe “best practice” methodologies
associated with patient perception of readiness
for discharge
Examine areas of “excellence” that potentially
strengthen and/or tie into patient perception of
readiness for discharge
Discuss individual roles of the interdisciplinary
team that impact patient perception of
care/readiness for discharge
Describe three interventions that you can trial in
your facility to improve HCAHPs discharge
scores
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Finley Hospital Discharge Domain scores have
been consistently above the 90th percentile
The scores are in the top 10% nationwide
IHS Affinity groups such as the Patient
Experience Team and the Case Management
Team started asking us about what we do.
Finley
IHS
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We know that people are really interested in
what we are doing
We cannot name just one or two things that
we have worked on that make are scores what
they are
We have many things that we are doing that
are working well
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The discharge domain has two questions in
the domain scoring
◦ During this hospital stay, did doctors, nurses or
other hospital staff talk with you about whether you
would have the help you needed when you left the
hospital?
◦ During this hospital stay, did you get information in
writing about what symptoms or health problems to
look out for after you left the hospital?
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Both questions are Yes or No
◦ In other words: Pass/Fail
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There is no way for the person to rate the
quality of the discussion or the written
instructions.
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Press Ganey Solution Starters
For standard questions the solution starter
gives the question definition and
improvement solutions.
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Some of the ideas on the Solution Starters
include:
Include the right people with the patient for
both the discussion on the help needed at
home and the review of the written discharge
instructions
Address questions and concerns they have
about the plan and the instructions before
they leave
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Use white boards, note pads for questions
and take-home packets for communication
during the stay
Discharge instructions need to be simple and
easy to read – health literate
Use the discharge phone calls to answer
questions and reinforce information
Let them know who to call if they have
questions
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Project RED (Re-Engineered Discharge)
◦ Developed by researchers at Boston University
Medical Center (BUMC)
◦ The Agency for Healthcare Research and Quality
(AHRQ) funded the development of the Project RED
tool kit
 Effective at reducing readmissions and post-hospital
emergency visits
Eleven activities that should be completed for
every patient
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Medication Reconciliation
The plan matches with national guidelines
◦ Doing the right thing at the right time
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Follow-up appointments are set
Communicate outstanding tests
Arrange post-discharge services
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Written discharge instructions
What to do if problems arise
Patient education throughout stay
Assess patient understanding
Discharge summary sent to PCP
Telephone reinforcement
Communication Among
Staff and Providers
Readmissions
Patient
Experience
Communication with
Patient/Family
Throughput
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We know that improvement has been
consistent over the past three years
We have reduced variation in scoring, so we
are more consistent in maintaining a
narrower range of scores
Mean 92.87
Mean 87.83
Mean 95.38
Significant reduction in variation and increase in
mean score per year demonstrated over 3 years
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2009 and Prior
Right people at the
interdisciplinary team
meetings for
communication
Focus on patient
satisfaction
◦ Scripting for case
managers and social
workers
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Focus on reducing length
of stay
2010
 Move to new med-surg
units
 Focus on updating new
custom white boards
◦ Goals
◦ Anticipated DC date
◦ Anticipated DC plan
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Focus on CM leading
daily care conference
Focus on CM seeing
patients daily
Discharge phone calls –
Fall 2010
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2011 and Forward Focus
Focus on preventing readmissions by:
◦ Daily readmission report to Case
Managers
◦ Readmission data collection on
specific data elements
◦ Communication to Physician
Champion of any readmission from
primary admitting physician
◦ Special Case Management /Social
Work process trialed with one
“Frequent flyer” patient to see if we
can better meet needs including
 Reviewed patient admission history
and costs in multi-disciplinary care
committee
 Assigned physician (did not have
primary care at first)
 Assigned unit to be admitted to
 Assigned Case Manager and Social
Work Professional to see patient
whenever readmitted
1/5/2010
Opened 4MS and 5MS
1/5/2010 - 4/2/2010
Focus on updating
white board
with patient goal daily
4/1/2010
6/30/2010 - 10/2/2010
Case Manager sees every patient
daily to discuss readiness
for discharge
7/1/2010
10/1/2010
1/1/2011 - 8/8/2011
Focus on readmission population
COPD/CHF/Pneumonia and begin to
look at chronic disease management
1/1/2011
4/1/2011
1/5/2010
7/1/2011
8/1/2011
4/2/2010 - 10/2/2010
Focus on Case Manager
driving interdisciplinary
patient team meetings
10/1/2010 - 6/30/2011
Case Managers focus on
collaborative improvement in
Core Measure Compliance
I Chart of Global Rating of Nurses 5MS by Quarter 2009-2011
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90
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I Chart of Global Rating of Physicians 5MS by Quarter 2009-2011
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UCL=87.34
90
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X=80.25
85
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UCL=90.89
80
75
LCL=73.16
70
65
Individual Value
Individual Value
85
LCL=69.61
65
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I Chart of Staff Discuss Help 5MS Quarter 2009-2011
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100
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I Chart of Info on Sypmtoms/Problems 5MS by Quarter 2009-2011
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105
UCL=97.50
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X=87.75
85
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Individual Value
90
UCL=98.73
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X=90.75
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LCL=82.77
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LCL=78.00
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X=80.25
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r -0
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Both Nursing and Physician global scores have risen annually along
with information on symptoms/problems to report to the physician
I Chart of Global Rating of Nurses OB by Quarter 2009-2011
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110
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X=86.75
80
LCL=71.68
70
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UCL=103.07
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X=88
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LCL=72.93
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I Chart of Info on Sypmtoms/Problems OB by Quarter 2009-2011
110
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Individual Value
90
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UCL=101.82
100
Individual Value
I Chart of Global Rating of Physicians OB by Quarter 2009-2011
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I Chart of Staff Discuss Help by Quarter 2009-2011
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130
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UCL=103.82
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X=98.5
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LCL=93.18
UCL=111.37
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Individual Value
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X=92.75
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LCL=74.13
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OB scores are holding consistent and fairly high
across all three years.
100
90
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70
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OB
Overflow Unit
4MS
5MS
ICU
% = unit survey response/overall response
40
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10
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4MS
5MS
OB
ICU
Overflow Unit
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Case Managers (RNs) Round on All Inpatients
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Daily rounding by Case Managers
Scripting for Case Managers:
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What can we do to help you get ready for
discharge?
What are your goals for discharge?
What problems do you anticipate may occur at
discharge?
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Social Workers are assigned to patients
based on need.
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Examples: Over 65 years, Major surgery,
Nursing Home Placement, Need for Home IV
Therapy
Social Work Scripting: How do you feel about
going home? Any concerns or worries?
Communication Between Disciplines
 Case Managers and Social Workers are
assigned to units and work well together
 Case Managers and Social Workers report to
same Director
 Daily Care Conference on Med Surg units that
includes: Charge Nurse, Case Manager, Social
Worker, Pharmacy, Physical Therapy and
other disciplines when requested
◦ Targeted conversations on re-admitted patients
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Large white boards in prominent place in
Med-Surg areas
Include names of nurse, tech, case manager
and social worker
Include anticipated discharge date and plan
for discharge such as home or nursing home
Patients and Families may write questions and
notes on the white board
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Disease management education is primarily a
nursing function, but also provided as needed
by case management, when appropriate ex
therapy, dietary
A case manager is one of the presenters at
the Joint Camp a class for patients preparing
for their new joint replacement
◦ Joint Camp presentation includes typical plan for
discharge
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Written discharge instructions are a mix
between home grown mainly for surgical
patients and Micromedex instructions
Booklets for specific groups such as the total
joint population and the new moms/parents
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Core Measure patients are identified on
admission or as soon as possible after
admission
Core Measure patients (CHF, Pneumonia and
AMI) receive specially made folders that
include several types of patient education
material as soon as they are identified as
having a core measure diagnosis.
When possible they are made prior to
discharge
 Staff check with patient regarding what time
of day is best for the patient for follow up
appointment
 Appointment is made by unit secretary
 Return appointment is written on an
appointment card with specific instructions if
lab or x-ray is needed prior
 Orders for lab or x-rays are faxed to the
office where the tests are to be performed
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If patient is discharged with home-care or to
a nursing facility information is faxed prior to
discharge to agency
Nursing staff call nurse to nurse report to
home care agency or the nursing facility
Medication list and copy of discharge
instructions are faxed to My Nurse for follow
up phone calls.
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Medication list reviewed with patient and
family
New medications or changes in medication
dosages are reviewed in detail
Prescriptions are faxed to pharmacy of
patient’s choice if requested
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Equipment needed for ambulation is ordered
and delivered to room by physical therapy
Home supplies such as commode, hospital
bed, or any other large item is ordered by
social worker and delivered to the patient’s
home prior to discharge if possible
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After instructed by nurse, patient or family
will do a return demonstration of care such as
dressing changes, trach cares, catheter cares,
emptying drains, etc.
Nurse will assess readiness or re-educate if
needed
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Home care instructions specific to diagnosis
are reviewed with patient and family member.
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Medication list reviewed
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Follow up appointment reviewed
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Nurse or nursing tech take patient to the
hospital exit and assist into vehicle
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Med- Surg patients receive a phone call from
My Nurse within 48 hours of going home
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My Nurse reviews medications and discharge
instructions prior to making the phone call
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Scripted questions are asked to patient
(teach-back)
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Patient has opportunity to ask nurse
questions
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Suite Beginnings
◦ All new mothers and babies have a one time home
visit by an obstetric nurse
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Work on reducing readmissions
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Monthly reporting/posting of patient satisfaction
data
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Affiliated with The Studor Group
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Leader rounding on patients
Leader rounding on staff
Hardwiring intentional rounding
Thank-you notes to staff
Monthly meeting model
Employee selection
WOW orientation ideas
Next up – hardwiring AIDET
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Using the best practice guidelines assess the
discharge process at your facility using
observations, feedback from your patients
and families and your staff
Start with something small and work up to
the bigger things to change
Solicit leadership support
Align goals of hospital and unit leaders
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Please consider sharing specific things that
are working in your facility
Questions?
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For more information about the discharge or
case management process at Finley Hospital
please contact either:
Teresa Neal, Director Of Performance Improvement,
563-589-2553 or [email protected]
Cindy Weidemann, Risk, Safety and Survey Readiness
Coordinator 563-589-2607 or
[email protected]
Chris Wilson, Director 4MS and Rehabilitation,
563-557-2788 or [email protected]