Transcript Title 54 pt Arial, Two Line Maximum

IHI STAAR Fall Learning Session 2011:
Breakout A – Early Assessment of PostDischarge Needs
Laura Carr, PharmD
Jane Murray, MBA
Jessica Smith, RN
Cross-Continuum Team
Executive Sponsors: Elizabeth Mort, MD, MPH & Andrew Karson, MD, MPH
Day-to-Day Leads: Jane Murray, MBA
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Chris Annese, RN, El16
Paul Arpino, Pharmacist, Clinical
Operations Director
Victoria Brower, Project Mgr,
HPM4
Laura Carr, IP Pharmacist
Jacqui Collins, RN, CNS, El16
Gwen Crevensten, MD, Faculty,
CQS
Joanne Doyle, OP Pharmacist
Joanne Empoliti, CNS, Wh6
Kathleen Finn, MD, Clin Educator
Theresa Gallivan, RN, Associate
Chief Nurse
Jeff Greenwald, MD, Medicine
Kathryn Hall, RN, Nurse Dir, El16
Bob Hallisey, Pharmacist, Clinical
Specialist
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Yanie Jackson, MS, CQS
Joanne Kauffman, RN, Team Mgr,
Case Mngt
Deb Kiely, PHS Home Care
Colleen Macauley, RN, Medicine
Mary Neagle, Project Mgr, CMP
Terry O’Malley, MD, Director,
Non-Acute Services
Kathleen Myers, RN, Nurse Dir,
El6 and Wh6
Karen Pickell, NP Patient Care
Services
David Ring, MD, Orthopedics
Nancy Sullivan, Director, Case
Mngt
Kristin Sybertz, RN, Team Mgr,
Case Mngt
Ryan Thompson, MD, Medicine
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Key Change – Perform an enhanced assessment of
post-hospital needs
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Discharge Nurse Role
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New role piloted through STAAR
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Unit decided to keep position even after pilot was completed
because team thought the role was extremely important
Pharmacist Role: pre-discharge visits to patients
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Patients referred to Pharmacist by the Discharge Nurse
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Discharge Nurse Role - manage high-risk patients based
on specific criteria
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Three RNs (adding up to 1 FTE) serve exclusively as Discharge Nurses and follow
patients from Admission to Discharge on Ellison 16 (Medicine)
– Approximately 40% of patients on floor are managed by Discharge Nurses
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Inclusion Criteria
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>=10 medications
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Any patient with diagnosis/reason for admission of:
• CHF
• Pneumonia
• Acute Renal Failure
• Afib
• Cancer Pain
• Dehydration
• UTI
• Change in mental status
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English-speaking
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Throughout the hospital stay, Discharge Nurses prepare the
patient and family members for post-discharge needs
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Advantages of Discharge Nurses for patients and family members
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Continuity with teaching - the same person is providing the patient with
disease education and medication reconciliation/education
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Improves MD-RN-CM communication
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Assist with post-discharge services such as arranging VNA visits,
educating patients on importance of follow-up appointments and
coordinating transportation with family members
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Patients receive a folder which is compiled throughout the hospital stay
with education materials, provider contact information, follow-up
instructions, and labs/tests appointments
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Review Patient Discharge Medication List with individualized
medication details which is given to patient at discharge
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Overall improvement in the quality of discharge information and
communication
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Discharge Nurse Role has continually evolved to streamline
workflow and brings focus to the discharge process early on
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Changes tested
– Patients taking more active role in their care;
• Sheet in patients’ folders to write down questions throughout
their stay and go over questions with nurse, physician,
pharmacist, etc.
– Identified communication barriers between physicians, case
managers and nurses;
• Special Discharge Nurse pager created so there is single point
person for discharge questions
• Discharge Nurse participates in 4pm rounds to help identify
patients who are ready for discharge
– Discharge dates were not communicated clearly to patient or care
team on a regular basis;
• anticipated discharge date added to white board at nursing
station to align the entire team and set expectations
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Pharmacist Role – work with Discharge Nurse to reconcile
medication and answer patients questions prior to discharge
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Discharge Nurses refer patients to the Pharmacist if there is any
confusion about medication while the patient is still in the hospital
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The goal is to provide medication reconciliation and counseling
services to complex patients prior to discharge
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Pharmacist coordinates dispensing of medication if necessary
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Pharmacist reviews final medication list with patient and/or
caregiver
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Pharmacist pre-discharge visits are important as evident in
recent patient stories
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60 year old woman admitted with PE going to rehab
– found that Atorvastatin was missed on her PAML, and not included on
discharge orders
– RPh was able to resolve issue prior to discharge and educate patient on
new Warfarin
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75 year old man admitted with PNA going to SNF
– patient on his second admission in two weeks
– patient was on 22 meds
– RPh found 6 errors in Discharge Orders including doubling of patient’s
new Metoprolol XL dose from 25mg QD to 25mg BID
– RPh was able to resolve issue prior to discharge
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74 year old man admitted with MRSA being discharged home
– complex medication regimen of antibiotics and renal transplant meds
which could not be taken together
– RPh created a med dose chart to accommodate 7 admin times
– RPh called patient post-discharge to follow up
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Patients benefit from having Pharmacist perform additional
review of medications prior to discharge
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Pharmacist provides direct patient counseling
– High-risk patients continue to benefit from additional teaching
and opportunities to ask medication related questions
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Common issues identified
– Medication instruction not clearly written out for patients
• Antibiotic end dates
• Taper instructions
• PRN vs. standing orders
– Incomplete medication reconciliation
– Differences between medical record and discharge
instructions/prescriptions to patients
– Errors with high-risk medications including Warfarin, Insulin,
and Opioids
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Ellison 16 all-cause 30-day readmissions data
Discharge RN
role
STAAR teams
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Pharmacy predischarge visits
RNs responsible
for simple VNA
Pharmacy postdischarge calls
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The overall readmission rate on the floor is trending
downward, possibly aided by the Discharge Nurse Role
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Ellison 16 Discharge Nurse Role Readmission Rate
– Between 12/1/2010 and 5/31/2011
Meets Criteria
No
Yes
Total
Discharges
448
275
723
Readmissions
80
47
127
Readmission
Rate
17.9%
17.1%
17.6%
– Between 7/1/2010 and 11/30/2010
Meets Criteria
No
Yes
Total
Discharges
397
236
633
Readmissions
80
53
133
Readmission
Rate
20.2%
22.5%
21.0%
Exclusions:
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Observation patients and patients transferred to another floor are excluded even if they met inclusion criteria. Bad
data was also excluded (e.g. double-entries, patients with no TSI record, etc)
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Discharges do not include rehab or hospice admissions, deceased, discharged against medical advice, or transfer to
another short-term facility or psych hospital or unit
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Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions
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More data required to determine the impact of predischarge Pharmacy visits on readmissions
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Pre-discharge Pharmacy visit readmission rate
– Between 1/1/2011 and 5/31/2011
Visits
30
Readmissions
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Readmission
Rate
23.3%
Exclusions:
1.
Observation patients and patients transferred to another floor are excluded even if they met inclusion criteria. Bad
data was also excluded (e.g. double-entries, patients with no TSI record, etc)
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Discharges do not include rehab or hospice admissions, deceased, discharged against medical advice, or transfer to
another short-term facility or psych hospital or unit
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Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions
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Lessons learned from Discharge Nurse and Pharmacist
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Discharge process can be disjointed which is why having a single
contact person (Discharge Nurse) coordinate the process increases
patient, physician, case manager and nurse satisfaction
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Discharge Nurse Role improved workflow and provided
standardized process; sets expectations for patients and providers as
to what patient should know prior to discharge
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Having anticipated date of discharge provides a timeline for all
providers and helps coordinate nursing assignments
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Pharmacist involvement is important both pre and post-discharge
– Pre-discharge collaboration between Discharge Nurse and
Pharmacist to reconcile medication helps reduce medication errors
– Another program where the Pharmacist conducts post-discharge
calls has shown a reduction in readmission rates (13% vs. 17%)
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Next steps
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Discharge Nurse Role is being presented to Nursing Leadership as a
best practice to expand to additional units
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Increase collaboration with outpatient nurses to improve transitions
in care
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Include an electronic copy of the Discharge Nurse note in the LMR
(outpatient electronic record)
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Increase number of referrals to Pharmacy for pre-discharge visits –
may require additional resources
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Appendix
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Patient Discharge Medication List (PDML) –
New Medication
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PDML – List of medications to stop
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Pharmacist post-discharge calls have shown a reduction in
readmission rates (13% vs. 17%)
Discharges* (1)
Patients discharged from Ellison 16
629
Patients who received a Pharmacy call #
101
% of patients who received a Pharmacy call
16.6%
Readmissions* (2)
Patients readmitted who received a call #
13 / 101 = 12.9%
Patients readmitted who did not receive a call
91 / 528 = 17.2%
Total Readmission rate
104 / 629 = 16.5%
*Includes only patients discharged Home from E16
# Excludes
patients who fit criteria but declined call or RPh was unable to reach
Time period: January 11 to June 30, 2010
(1) Discharges do not include rehab or hospice admissions, deceased,
discharged against medical advice, or transfer to another short-term facility or
psych hospital or unit
Source:
TSI Encounters
UHC Database
Pharmacy Worksheets
(2) Readmissions do not include rehab, hospice, chemotherapy, radiation, or
dialysis readmissions
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