Presentation on theme: "Readmission Race: Checkpoint Call Improving the Discharge Planning Process October 22, 2012 12:00 to 12:45 pm CST."— Presentation transcript:
1 Readmission Race: Checkpoint Call Improving the Discharge Planning Process October 22, 201212:00 to 12:45 pm CST
2 Welcome and Overview Welcome, thank you for joining us today! HousekeepingThis webinar is being recorded and will be archived.You will receive a PDF of today’s presentation, as well as a link to fill-out the evaluation and a summary of Q&A.For questions: please reach out to your state lead or us:AgendaImproving the Discharge Planning ProcessHospital Sharing and CoachingQ&A
3 IntroductionsTasha Gill, MPH, HRETDenise Remus, PhD, RN, Cynosure HealthAmy E. Boutwell, MD, MPP, Collaborative Healthcare StrategiesMisti Wedding, RN, Medical/Surgical/ICU Nurse Manager, Harrison Memorial Hospital
4 Readmissions Race: Improve the Discharge Planning Process Amy E. Boutwell, MD, MPPCollaborative Healthcare Strategies
5 Terminology Matters Discharge planning process…. Implies we in the hospital make the plansDischarge is rather unilateral in natureTransition to the next setting of care….Reminds us there is a next setting with needsTransition is more bilateral in nature
6 Improving Transition Process Matters A lot of focus on NEW work and NEW toolsTransitional care coachesTransitional care Nurse PractitionersDisease-specific clinicsMedical home care managersTele-monitoringWe have a lot of opportunity to improve our DAILY work:81% of patients requiring assistance with basic functional needs failed to have a home-care referral64% said no one at the hospital talked to them about managing their care at homeClark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006.
7 42 million family caregivers 46% perform nursing tasks 75% of them manage medicines33% of them do wound care66% of the patients had no VNAAvailable at:
8 SVP & Director, AARP Public Policy Institute “We ask caregivers to do things that would make evennursing students tremble…….As hospitals discharge patients quicker and sicker…..family caregivers are responsible for medical and nursing care including medication management and wound care.”~ Susan ReinhardSVP & Director, AARP Public Policy Institute
9 Director of Families and Health Care Project “Despite frequent encounters with the acute care system, family caregivers were not prepared for the medical and nursing tasks they were expected to provide at home…“We asked family caregivers how they learned to manage their family members’ medications and 61 percent said, ‘I learned on my own.’ Clearly, professionals need to do a better job of training family caregivers.”~ Carol LevineDirector of Families and Health Care ProjectUnited Hospital Fund
10 Step 1: Study your existing process * WARNING: Do not get stuck in process mapping quicksand!This does not need to take monthsI have seen hospitals take over 18 monthsAim for basic blueprint in 2-3 meetingsThis does not need to be done perfectly with complete review and consensus prior to starting improvementsMany teams do not start on clear tests for too longAim for first test of change “by Tuesday”
11 Step 1: Study your existing process Describe the existing steps and tasks involved in the discharge planning process currentlyInvolve multiple stakeholders inputAdmitting RNFloor RNFloor CM/discharge plannerFloor Nurse ManagerResident MD (they do most “teaching” discharges)NP/PA if part of floor team (they do most discharges)Attending MD (especially those that discharge “non-teaching” patients)PT/OT/SLP/RT/nutrition/SW/clergyDon’t forget the “receivers” on your cross-continuum team!Patients/families/caregiversHome health, hospiceSNF/LTACOutpatient providers, when available (don’t always need MD; practice manager/RN)
12 Step 2: Compare to Best Practice Role Definition, Responsibility & StandardizationDischarge AdvocateChecklist or “bundle”Enhanced Assessment of RiskPatient/caregiver/provider interview for readmitted patientsExpanded view of risk, and assessment techniquesEnhanced Teaching & LearningTeach-back/ personal health recordIdentify the appropriate learner/ engage caregiverTimely CommunicationCommunication with PCP at admission and d/c; same-day summaryWarm handoffs to clinicians for complex/high riskTimely Follow-Up24-48h contact for complex/high risk ; availability for contactFollow up 3-5 days
13 Step 3: Implement Tests of Change Examples of tests you could implement today:Enhanced assessmentUse your data systems: daily readmission reports; high utilizer reportsRisk screens include: BOOST 8P or STAAR readmission interviewIdentify LearnerAs the patient/family “who will help you with your care/medications…?It is NOT always the visitor at the bedside, NOT always the spouseUse Teach-BackUse the entirety of the hospital stay to engage in educationAsk the patient/learner to describe medications, care plan, follow up when & whyTimely communicationWarm handoffs with SNFsClinical synopsis sent to receiving MD at time of discharge (real-time)Follow-upMake follow up appointment(s) for the patient prior to dischargeCoordinate follow up phone call <72h to review medications, plan, questions
14 Three recent excellent transitional process improvements
16 “SNF Circle Back” Multi-hospital system in North Carolina Pilot in one hospital; commitment to spread system-wide if effectiveProblem: early readmissions from SNFTest:warm handoffs to SNFCall back to SNF 3-24 hours after transfer to answer questionsDetails:RCA revealed SNF-readmission pattersHospital readmission champion met with SNFs to discuss shared goalsHospital (with some leadership effort) asked SNF to participate in this communicationRN calls nurse at SNFSW or care coordinator calls for follow up clarification 3-24 hours after transferDaily workflow (with some modifications for weekends, done next business day)Follow up calls are scripted and documented in Allscripts systemPilot on paper with 1 RN and 1 SWPilot expanded to RN call report to SNFPilot expanded to add follow up callsPilot expanded to build questions into AllscriptsExpand to all; new standard of practiceSource: Emily Skinner, Carolinas Healthcare System
17 SNF Circle Back -2 SNF Circle Back Questions Did the patient arrive safely?Did you find admission packet in order?Were the medication orders correct?Does the patient’s presentation reflect the information you received?Is patient and/or family satisfied with the transition from the hospital to your facility?Have we provided you everything you need to provide excellent care to the patient?InsightsTransitions are a PROCESS (forms are useful, but only a tool to achieve intent)Best done ITERATIVELY with COMMUNICATIONSource: Emily Skinner, Carolinas Healthcare System
18 Transition to SNF Medication Safety 2007, medication events, patient complaints re: d/c processEvaluated medication ordersFound that only 8% of their patients had NO errorsMedication reconciliation was complete >90% of the time!Common medication errors:Formulation errorsDuplicatesIncorrect doseMissing medicationsInsulin dosing errorsSource: Bruce Thompson, AHRQ Innovations Exchange
19 Transition to SNF Medication Safety-2 New Process: Enhanced medication reviewMD orders Pharm D and CCSNFIdentify patients being d/c to SNFWhen bed available, MD, Pharm D and CC pagedMD has 4 h to enter d/c ordersCC scans orders hourly; paged Pharm D when enteredPharm D & CC have 2 hours to review; clarify with MDWhen errors are noted, resident AND attending are pagedOutcomes: enhanced review group had 5.7% readmissions v. 10.2%High patient satisfaction, high physician satisfactionSource: Bruce Thompson, AHRQ Innovations Exchange
21 Readmission Race: Checkpoint Call Improving the Discharge Planning Process Misti Wedding, RN, Medical/Surgical/ICU Nurse Manager, Harrison Memorial Hospital
22 Harrison Memorial Hospital Who We Are… Speaking; Misti Wedding, RN, Harrison Memorial Hospital Medical/Surgical/ICU Nurse ManagerCynthiana, Kentucky, 61 beds, private not-for-profit hospitalA full-service regional medical center meeting the needs of residents of sevencentral Kentucky countiesHMH and its employees are accredited members of the following organizations, showing that we meet or exceed strict guidelines for healthcare quality:The Joint CommissionCollege of American PathologistsAmerican College of Radiology for– CT,Mammography, Nuclear Medicine, MRIFifty-eight percent of hospital staff areclinical staff members who have multiplecertifications and licensures
23 Reducing Readmissions Our readmission rate for Congestive Heart Failure (CHF) is higher than the state and the nation.Medicare Readmission Rate ( 10/1/08-6/30/10)HMH rate for CHF – 26.2 %KY rate for CHF – 25.3%U.S. rate for CHF – 24.8%Goal: Reduce CHF Readmissions by 20% by December 2013
24 Reducing Readmissions Improve discharge processMultidisciplinary team participationCommunity Collaborative against readmissionsImprove patient complianceStandardize discharge processProvide CHF patients with the Heart Healthy HandbookIncrease patient safety and improve patient outcomes2424
25 Improving the Discharge Planning Process Multidisciplinary team approachCEONursesPhysiciansPharmacistsInformation TechnologistsDieticiansCase ManagersEveryone contributes to the discharge process25
26 Improving the Discharge Planning Process Community CollaborativeQuarterly meeting with Nursing Homes, Hospice, Home Health, Physicians, Nurse Practitioners, and our readmission team members.Improve communication.Standardize discharge process decreasing preventable readmissions.26
27 Improving the Discharge Planning Process Discharge teaching and planning begins on admissionUtilize the teach-back methodFollow-up phone calls to patients and nursing homes after discharge. Bedside nurse verifies phone number with patient at discharge.Ensuring patients have the means to be compliantCan they afford the prescribed medications?Do they have a scale to weigh on daily?Are they able to obtain transportation to their follow-up appointments?
28 Improving the Discharge Planning Process Heart Healthy HandbookCHF discharge instructionsLow sodium diet with sample menuMedication list (Pharmacist review)Calendar of appointmentsAfter hospital care planWeight logScale provided if unable to obtain oneCHF magnet with heart healthy remindersTeach-back method utilizedChecklist for discharging nurse to complete28
36 Improving the Discharge Planning Process CHF discharge process changes effective October 1stCHF patients are contacted after discharge by a nurseCan they verbalize the instructions they were given?Example: Mrs. Jones can you tell me when your appointment is with Dr. Besson?
37 Lessons Learned Hard to receive and maintain physician participation Interim team meetings are beneficial to keeping the interest and process flowingTeam approach requires the division of labor and the relinquishing of control thereby encouraging ownership and buy-in.
38 ResourcesMeister, C., “Re-engineered discharge” A conversation about Barriers & Opportunities K-HEN Kickoff Conference. Retrieved from