Transcript Module II

Module 3
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 Discharge and Follow-up Care
Accomplishments to Date (Module 1)
 Project Charter initiated
 Primary Care Practitioner referral base defined
 Process map of current discharge process
completed
 Care plan structure (template, location, how
D.A. will access it) finalized
© Joint Commission Resources
 Dates for training frontline staff set
Accomplishments to Date (Module 2)
 Project metrics identified and planned
 Patient inclusion criteria defined
 Process for identifying patients and notifying
D.A. defined
 Care plan process finalized (what and how to
gather data for inclusion)
© Joint Commission Resources
 Multidisciplinary involvement and
communication plan determined
Objectives of Module 3
 Finalize process for identifying a PCP for patients who do not
have one
 Identify resources to provide patient information
 Review completion of discharge preparation
–
–
–
–
medication reconciliation
pending test results
follow up appointments
Fax of plan to PCP
 Review how to conduct ‘teach-back’ with patient and family
 Finalize process for making post-D/C calls
© Joint Commission Resources
 Finalize care plan completion and printing
Module 3 Outline
 Complete the care plan when
discharge order is written
 Teaching and ‘teach-back’
 Post-discharge activities
 Training of frontline staff
© Joint Commission Resources
 Measurement of process
© Joint Commission Resources
Module 3
Discharge Planning
Rx Plan
Patient
Admission
Discharge
Order
Written
Discharge Process
PATIENT EDUCATION
Discharg
e Event
DISCHARGE INSTRUCTIONS
Post-D/C
Follow-up
© Joint Commission Resources
H&P
RED Checklist: Discharge and Follow Up
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" (SP15)
© Joint Commission Resources
Eleven mutually reinforcing components:
© Joint Commission Resources
Complete the Care Plan
 Medication reconciliation performed
 Pending tests and results
 Post-discharge services
 Primary Care Provider
 Follow up appointments
© Joint Commission Resources
 Information about condition(s)
Medication Reconciliation
 Hospital procedure for completing medication
reconciliation at discharge
 D.A. may participate and/or conduct final
check on medications
 The final list will be used to
instruct the patient
© Joint Commission Resources
 Using final list, populate patient care
plan, and complete additional columns
(e.g., purpose, time of day visual)



Obtain information about tests and
studies completed in hospital, but still
pending results
Add pending test/results to the
designated spot on the patient’s care
plan, including which clinician is
responsible for securing final results.
Encourage patient to discuss tests
PCP; point out where the information
is on the care plan
© Joint Commission Resources
Pending Tests/Results
Post Discharge Services
 Confirm with case manager that all services
have been arranged
© Joint Commission Resources
 Add names of services and contact information
to care plan
Primary Care Provider (PCP)
 Confirm name of PCP with patient
© Joint Commission Resources
 Add name and contact number of PCP to care
plan
Follow Up Appointments
 Discuss best days of week and
times of day with patient
 Discuss transportation needs
with patient (how will patient get to
appointment?)
 Place calls to clinicians’ offices to make appointments
that meet patient’s time options
 Add appointments to care plan
© Joint Commission Resources
– Leave message with clinician office to call patient (off hours
and weekend)
Information about Condition(s)
 Secure pre-printed information about patient’s
condition to add to care plan
– Signs and symptoms that warrant
follow up with clinician
– When to seek emergency care
– How to contact the Discharge
Advocate and PCP (phone numbers; paging
instructions)
© Joint Commission Resources
 Add to care plan:
Sections of the Care Plan

Date of D/C; name and contact info for physician and D.A.

Medications

Pending tests and results

Follow-up appointments

Calendar

Other orders (diet, activity, etc)

Information about disease/condition

Form for writing own questions down

Map of campus for locating appointments (optional)

Other information about your center (optional)
© Joint Commission Resources
– When and how to reach physician or go to E.D.
As a team, answer the following questions:
 Have all of these content areas been included
in the final care plan template?
 Can the D.A. access all of this content to add
to the care plan?
 What gaps still exist that need to be
addressed?
© Joint Commission Resources
– From where?
– How reliable?
– How timely?
Final Teaching and Teach-Back
 All education material
 Care plan completed
– 2 copies printed
– Copy to Quality?
 Meet in quiet place with patient/family
 Confirm patient/family understanding utilizing
‘teach-back’ methods
© Joint Commission Resources
 Review all parts of the care plan
Health Literacy – Tips*
 Avoid medical jargon
 Speak slowly
 Simple pictures when helpful
 Emphasize what 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
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:
Teach-Back
 A way to confirm that you have explained to
the patient what they need to know
 It is NOT a test of the patient, but rather a test
of how well YOU have explained the concept
 Use it with everyone; do not assume literacy or
health literacy
© Joint Commission Resources
 Teach all staff how to do it!
Teach Back: Place the responsibility on
yourself
 “I want to be sure I didn’t leave anything out that I should have
told you. Would you tell me what you are to do so that I can be
sure you know what is important.” (Doak et al)
 “I want to be sure that I did a good job explaining your blood
pressure medications, because this can be confusing. Can you
tell me what changes we decided to make and how you will now
take the medication.” (Pfizer web site)
© Joint Commission Resources
 “When you go home and your grandchild asks you what the
doctor said about your heart, how are you going to explain this to
your grandchild?” (Schillinger interview on AHRQ Web site)
The teach-back technique
 If the patient does not explain correctly,
assume that you have not provided adequate
teaching and re-teach in a different way
© Joint Commission Resources
 Do not ask a patient, “Do you understand?”
 Do not ask “yes/no” questions
 Instead, ask patients to explain or demonstrate
how they will undertake a recommended
treatment or intervention
 Ask open-ended questions
© Joint Commission Resources
1.
Use simple lay language; explain concept or demonstrate
process avoiding technical terms; use a professional translator
if language issue exists
2.
Ask patient/caregiver to repeat concept in own words and/or to
demonstrate process
3.
Identify/correct misunderstandings or incorrect procedure
4.
Ask patient/caregiver to repeat concept and/or repeat process
to demonstrate understanding
5.
Repeat Steps 3 and 4 until clinician is convinced
comprehension and ability to perform process is adequate and
safe.
* Society of Hospital Medicine
© Joint Commission Resources
Teach-Back Steps*
Beyond Comprehension
 “Do you see yourself as able to follow these
instructions?”
 “Is there anything you can think of that will keep you
from following these instructions?”
– Functional barriers (like memory)
– Environmental barriers (lack of support person at home)
– Attitudinal barriers (lack of trust)
© Joint Commission Resources
 “Please demonstrate the activity I’ve just
explained/shown to you.”
Post Discharge Activities
 Transmit D/C summary and care plan to PCP
– Fax: insure it is received and legible
– Electronic: scan/ email if possible; insure it is
received
– Caller uses script that assess understanding of
medication and follow-up appointments
– Need for second call by clinician determined
© Joint Commission Resources
 Follow-up phone call to patient: 48--72 hours
after discharge
Measurement of Process
 Timeliness of RED activities
– D.A. log data
–
–
–
–
–
% with medication list
% with care needs listed
% with post-discharge services and contacts listed
% with follow up appointments made
% with pending tests and results listed (or ‘none’)
© Joint Commission Resources
 Review patient care plans after discharge
Plan for Teaching Frontline Staff about
Project
 Why: understanding, buy-in, support, participation,
clarification of roles
 Who
– Nursing and medical staff on participating units; pharmacists,
case managers
 When
 Utilize provided slide deck and customize as
necessary
© Joint Commission Resources
– Set date for live session and/or record
– Prior to launch of RED intervention
Module 3: Summary
Expected Outcomes
 D.A. aware of discharge order and completes care plan
–
–
–
–
–
Medication list
Pending test and results
Post-discharge services
PCP identified
Follow up appointments made
 Final Teaching and Teach Back with Patient/Family
 Arrange post-discharge follow up
 Complete measurement of discharge process
 Finalize plans for teaching frontline staff
© Joint Commission Resources
– Transmit summary and care plan to PCP
– Phone patient within 48 hours
Progression to Module 4 Checklist
 Processes in place to finalize care plan once discharge
order is written ____
 Teach-back methods outlined ____
 Quality/P.I. staff understand project measurement
requirements and prepared to gather data ____
 Process for transmitting D/C summary and care plan to
PCP finalized ____
 Team evaluation of Module 3 ___
© Joint Commission Resources
 Plans for teaching frontline staff finalized ____