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SEPONL April 4 th, 2014 A Patient & Family Discharge Planning Model that Works.

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Presentation on theme: "SEPONL April 4 th, 2014 A Patient & Family Discharge Planning Model that Works."— Presentation transcript:

1 SEPONL April 4 th, 2014 A Patient & Family Discharge Planning Model that Works

2 Or, Goodbyes Matter How can we ensure a “Good Fit” when we say Good-bye?

3 Objectives..& a thought The Larger Context One Community Hospital’s Story –Implementing a Model –Highlighting the Tools that are its Glue Consider Webster: –“..Discharge-to relieve of a burden, to release from confinement…” –“..Transition-a passage or movement from one stage to another..”

4 video

5 The Context & the Patient-a Fit? “…collection of readmission data reflects Medicare’s view that hospitals should be responsible for patients’ well-being even after they go home…” (2013) “The last place patients want to end up after a hospital stay is right back in the hospital….on average 8 minutes of conversation occurs about how to care for oneself at home, so no surprise that patients may have trouble” (2011) “…not our parents’ medicine…” (2012)

6 The Quality of the Good-byes How many readmissions are “preventable” with standardization? No one knows Evidence: Re-hospitalizations & poor routines: –Lack of coordinated hand-offs Hospital resources: How to Maximize? –High Risk approach vs. Dx specific focus –Understand patients: who/why come back –Our nursing teams: how to shift from Discharge to a Transition in Care paradigm

7 The Quality of the Good-byes Hospitals’ responsibility does not end at discharge –Recognize dangers of transition –Set patients/families up for success (2013) Positive associations between the patient experience and: –Adherence to prevention/treatment –Health care resource use (2013) Bundled Intervention Models: –Naylor’s Transitional Care Model –Coleman’s Care Transitions Interventions –Jack’s Project RED

8 The Context/VBP & the Patient “Transitions”-largest slice HCAHPS pie Transition questions added (2013) –During hospital stay,staff took my preferences & my family’s into account –When I left, I had a good understanding of the things I was responsible for –When I left, I clearly understood the purpose of taking my medications Discharge centered on patient=Success –Domains: RN Communication, the 5 “Discharge” items,Responsiveness,Medications “…HCAHPS is not about Happiness..”

9 Penn Medicine Chester County Hospital CCH 263 bed community hospital Rich history, 120 years Penn Medicine: –September, 2013 –HUP-1st teaching hospital, 1874 –Pennsylvania Hospital, the nation’s first, 1751 –Penn Presbyterian Hospital CCH & Project RED My home away from home

10 CCH & Project RED-our Story Project “RED” (Re-Engineered Discharge) Background –Safe Discharge is best when clinical team integrates efforts –Communication deficits at Discharge are common; the “Perfect Storm” of patient safety –RED research, Dr. Brian Jack (Annals Internal Medicine, 2009) Dr. B. Jack/AHRQ/CCH-the national RED Roll-Out Contract –Does the Project RED 11 Element Checklist work in the real world? –Can the Project RED 11 Element Checklist be used more efficiently? –June 2011 site visit; Dr. Jack, Boston Implementation team, AHRQ –Participants: Senior Team, physician & nursing leaders, front line nursing staff, Case Mgt., Nursing Informatics, IT,HIM –CHF patients on Telemetry = pilot population –Our Core RED interdisciplinary team was formed, and still meets!

11  Make appointments for follow-up medical appointments and post discharge tests/labs.  Plan for the follow-up of results from lab tests or studies that are pending at discharge.  Organize post-discharge outpatient services and medical equipment.  Identify the correct medicines and a plan for the patient to obtain and take them.  Reconcile discharge plan with national guidelines.  Teach a written discharge plan (AHCP) the patient can understand.  Educate the patient about his/her diagnosis.  Assess the degree of the patient’s understanding of this plan.  Review with the patient what to do if a problem arises.  Expedite transmission of the discharge summary to clinicians accepting care of the patient.  Provide telephone reinforcement of the Discharge Plan.  (new!) Obtain language assistance for patients/families Project RED Checklist – From Admission! 11

12 Re- Engineered Discharge Nurse Commun- ication MD Commun- ication Medication Teaching Discharge Hospital Rating Integrated HCAHPS Benefits 12

13 Discharge Planning Begins on Day 1 – RED = Guide to building relationships – RED = Promotes self-management skills – RED = Patient education throughout the stay – RED = Patients & clinical team; common goals – RED = Family engagement – RED = Patient learning as the closing message – RED = Tools for you to link patient safety & the patient experience RED Benefits HCAHPS? Absolutely! 13

14 AHCP recreated in word (available as a PDF/AHRQ website) RED’s Discharge Educator role = our Telemetry nurses –Telemetry RNs taught the AHCP to patients; what a moment! –All trained on the use of “Teach-Back”—now a RN Competency Unit Coordinators making F/Up apts: Patient & family satisfier Clinical Pharmacist inclusion with the CHF pilot patients Physician Office Practice outreach—utilization of the AHCP Volunteers & Transport staff: Discharge reminder at curb-side 48 hour post discharge F/Up phone calls –Project RED script –Medication clarification, review F/Up apts, transition support Our patients, families, staff & physicians loved Project RED! CCH Project RED Pilot Year: 2011-2012 14

15 CCH’s AHCP “it’s like an award for discharge” 15

16 CCH’s List of Medicines & Why/How 16

17 CCH Clinical Pharmacists: Medication Teaching 17 Brand Name Why am I taking this med? What do I need to look for? Tylenolpain, fever too much can cause liver damage (read OTC labels), higher doses for long periods can increase warfarin effects Ventolin, ProAir, Proventil breathing problems, asthma "rescue" inhaler, fast heart beat, chest pain/pressure Uroxatral enlarged prostate, kidney stones Dizziness,HA, avoid grapefruit juice, alcohol, changes in sex ability Zyloprimgout/high uric acidupset stomach, rash/skin irritation Xanaxanxiety, "nerves"drowsiness, dry mouth Cordarone, Pacerone abnormal heart rhythm constipation, sensitivity to sunlight (wear sunscreen) Elavilmood, migraine, nerve painsedation, dry mouth, avoid grapefruit juice

18 CCH Appointment Calendar 18

19 Readmission Rate- FY11 vs. FY12 All Telemetry Patients with a Primary Diagnosis of CHF at Discharge 30 Day Readmissions

20 CCH: 2012-2013 Were we getting to a Better Fit?

21 Clinical & IT experts worked as 1 team - “priceless” –Replication of the AHCP into an electronic version Stories of the patient experience shaped the goals of this enlarged team RED’s Checklist worked; expansion for all CCH CCH Re-Engineered Discharge: 5 Core Principles –Discharge planning begins Day 1 all CCH patients –“My Discharge Plan” all CCH patients –Teach-back methodology all CCH patients –Follow-up appts. High Risk patients –Follow-up phone calls High Risk patients Enlarging our CCH Team! 2012-2013 21


23 My Discharge Plan example

24 My Discharge Plan example: Yield and Stop signs

25 Text block library for templated “last licks” instructions

26 High Risk for Readmission Patients Automated work flow processes to identify patients at risk High Risk criteria include: polypharmacy, recent admission, key CMS diagnoses, lack of support at home Identification of High Risk in real time for staff Creates High Risk for readmission “order” in chart Unit Coordinators making F/Up Appts : PCP & specialists 48 hour F/Up phone calls-High Risk patients Automated work flow produces call list daily Clinical Pharmacists, Paramedics, CV Nurse Navigator

27 High Risk Patients Populates a report showing all high risk patients on the unit/hospital and reason for inclusion Populates a report for after discharge phone calls:

28 Pre and Post Measures: Re-Engineered Discharge 28

29 CCH : HCAHPS Discharge Domain 29

30 CCH : HCAHPS Care Transitions 30

31 HCAHPS Trending - Domains related to Project RED Implementation Project RED Implementation Dates: Telemetry – Sept 2011 House-wide – Sept 2012

32 Enhancing our Model Patient’s White Board: planning information Rapid Daily Rounds –“Plan for the Day, Plan for the Stay” –Interdisciplinary group meets at set time daily –All stand & are prepared, one-two minutes per patient Teach-back becoming part of culture –Patient/family feel “safe” to ask questions Bedside Handoff between shifts Open Visitation –Summer 2013; a Nursing Council initiative Bedside Delivery of Medications –Telemetry Pilot in 2011; house-wide in 2012 –Enables patients to receive new medications prior to D/C –Walgreens’ Pharmacy Tech integrated into nursing teams

33 Are we there yet? “..higher patient satisfaction with inpatient care & discharge planning is associated with lower 30 day readmission rates…” (2011)

34 A Model & the Patient: Good Fit? Motivation/partnership with patients/families –Never been healthy; “what does healthy look like”? –How to set up small “wins” in just a few days –Are we truly assessing Self-Management skills? –Applicability to Transitions in Care Patient Experience—understanding the whole –Care Transition results appear to show less than 50% take patient/family preferences into account upon discharge –People in top 5% of spending--11x more likely to report fair to poor physical health –Patients who report excellent health overall-their HCAHPS ratings 1.5 x higher than poor health


36 The Patient’s Voice 2013-2014 Bedside Survey Pilot 2011-2012: –Consistently: “I have heard little about D/C” Bedside Surveys: electronic solution –Charge RNs/Day 2—Mini iPads –Real time service recovery –Real time data sharing/reports available –Kick-off Fall 2013 Revised: January 2014 –Revised D/C question: “Have you heard about” –“Do you have any concerns about going back to your home environment?” & Explain Winter 2014: Readmission Survey –Day 2, identified from our High Risk workflow

37 Current Data Overview # 611Survey Question% Yes% No Don’t Know No Answer 1Is your call bell being answered promptly?90.7%2.3%0.0%7% 2Has our Hourly Rounding helped address your needs?85.3%2.8 54.9%7% 3If you have pain, how well do you feel the staff is managing your pain? 4.81 average score (on a 1-5 scale) % was not available 4 Has the nursing staff addressed your questions/concerns about your medications? 84.3%2.5%5.6% none7.6% 5Are the doctors being attentive to your needs?86.3%5.2% 0.0%8.5% 6 If NO can you tell me about your concerns? Feel Rushed Don’t understand their answers Other92.0% 7 Planning for your transition back to your home is important to us. Has your nurse or other members of your team started talking with you about your discharge? 62.0%30.1% 0.0%7.9% 8How would you say we are doing at keeping your room quiet? 4.71 average score (on a 1-5 scale) % was not available 9 Is there a staff member who has been especially helpful during your stay? 64.2%22.7%0.0%8.6% 10If you or your family member were sick today, would you choose to return to Chester County Hospital? 90.7%0.7% 0.0%8.6%

38 Chester County Hospital Readmission Survey


40 Next Steps/Concluding Remarks Reinforce: Bundled interventions vs series of tasks Discharge Model-Yes; Transition Model-not quite Yet! –Spotlight on community hand-off & feedback –Immediate follow-up care for the most vulnerable –Palliative Care referrals as part of our culture Senior Team Core Group formed; partner with original team Our understanding of why patients come back –Review All-Cause, but understand Potentially Preventable –Re-evaluate opportunities with High Risk list/F/Up phone calls Meaningful analysis of successes and returns (SNF/NVNA) –Unplanned 7 day Readmissions Bedside Survey expansion: insights for the entire clinical team –Conduct Case Reviews on patients who return/succeed

41 Re- Engineered Discharge Nurse Commun- ication MD Commun- ication Medication Teaching Discharge Hospital Rating You Can Do It Too! 41

42 A Good Fit-we’re getting there “..the way we communicate with patients/families about their health substantially influences their motivation for action & behavior change..” (2011)

43 Thank you! Carli Meister Director, Customer Relations & Risk Penn Medicine Chester County Hospital

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