1. Heart Failure Improvement Across the Continuum
Hospital to Home: Optimizing the Transition
January 2009 Florida Hospital Assoc.
Peg M. Bradke, RN, MA
Director, Heart Care Services
St. Luke’s Hospital, Cedar Rapids, Iowa

2. February 2006
St. Luke’s joined the Institute for Health Improvement Innovation Project for Transitions to Home.
Work concentrated on the Heart Failure patient.

3. Strategies in Place Heart Failure work team in place
Congestive Heart Failure class
Utilizing BNP to identify HF patients
Follow-up phone calls
Setting up discharge appointments
Pad/pencil at bedside for patient
A lot of work on CMS indicators

4. First Steps Heart Failure Work Group reorganized to include:
Home Care representative
Family member of a HF patient
Long-Term Care representative
Physician Clinic representative
These views added new context to our efforts.

5. Measurement How will we know a change is improvement?
HF 30-day readmission rate: (Unit of focus or hospital-wide)
HF is primary, secondary or lower level diagnosis
Patient with HF had a readmission for HF within 30 days of a readmission for HF
Use your own definition or CHF Toolkit measures at
Hospital 30-day (all) readmission rate:
Patient with HF was readmitted for any reason
For both measures:
Exclude chemo day patients treated on the unit
If focusing your work on a single unit, the HF readmission or all readmission rates for that unit will be needed
Display monthly on a line (run) chart for last twelve months. 

6. AIM Statement (From February 2006 Initial Transition to Home IHI Kick-off Meeting)
By January 1, 2007, St. Luke’s Hospital’s Telemetry Unit and Medical Unit will reduce unplanned readmissions by 50% (from 12 to 6%) by improving the transition home process for all Heart Failure patients.
Our methodology will include the patient and caregiver - ensuring that they fully understand their diagnosis, plan of care and follow-up care with physician.

7. What Changes Can We Make That Will Result in Improvement?
Four Key Changes to Achieve an Ideal Care Transition from Hospital to Home:
Enhanced Assessment of Patients
Enhanced Teaching and Learning
Patient-Centered Communication Hand-offs
Post Hospital Follow-up

8. Result of the IHI Collaborative Work on Transitions
Transforming Care at the Bedside How-to Guide

9. Enhancing the Admission Assessment for Post-Discharge Needs

10. Enhanced Admission Assessment for Post Discharge Needs
Identify the appropriate family caregivers
Partner with home care agencies, primary care offices and clinics, and long-term care facilities
Communicate to all members of the care team the discharge plan and what needs to happen
Estimate the home-going date on admission and anticipate needs
Estimate standard discharge criteria

11. Heart Failure Work Group Reorganized to Include:
Home Care representative
Family member of a HF patient
Long-Term Care representative
Physician Clinic representative
These views added new context to our efforts.

12. Sample of White Board

13. Sample of SBAR Kardex

14. Communication Daily discharge huddle at 10:00 AM Bedside reporting
Both opportunities to review plan for day and anticipate discharge needs

15. Reconcile Medications Upon Admission
Involve the patient and family caregivers, care providers, physicians, pharmacy
Reconcile on admission (suitably trained professional)
Include record of the reconciliation in the medical record
Ensure drug changes during the admission are reconciled, updated, accurate and timely
Consider using a personalized medication

16. Chart Review Tool Known reason(s) for readmission.
What did the patient or family think contributed to the readmission?
Any self-care instructions misunderstood?
Evidence of teach back documented?
What did the physician or office staff think contributed?
Was a follow-up physician visit scheduled? Attended?
Number of days between the discharge and physician’s office visit. Number of days between discharge and readmission
Any urgent clinic/ED visits before readmission?
Functional status of the patient on discharge?
Clear discharge plan documented?

17. Interview Questions Asked to Patients/ Caregiver Readmitted With Heart Failure
Can you tell me in your own words why you think you ended up sick enough to be readmitted again?
Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night?
Where are your scale and calendar located?
Have you seen your doctor since you were discharged from the hospital?
Do you have all of your medications? How do you set your pills up every day?
Were there any appointments that kept you from taking any of your pills?

18. Enhancing Understanding in the Patient Education Process

19. Enhanced Understanding in the Patient Education Process
Redesign the patient education process to improve patient/family or caregiver understanding of self care:
Identify the appropriate family or caregivers
Involve right learners in all critical education
Identify how the patient and family or caregiver learn best
Redesign written material
Redesign teaching methods

20. Enhanced Teaching and Learning
Redesign patient teaching material:
During acute care hospitalizations for HF, only essential education is recommended
Reinforce within 1-2 weeks after discharge
Continue for 3-6 months
Adams, KF et al: HFSA 2006 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure Vol. 12, No. 1, pg 61 February 2006

21. Intervention: Patient Education Material
Key “small tests of change””
Reviewed content of educational materials utilizing health literacy concepts.
Outpatient Heart Failure class utilized as focus group for content.
Family member on team, along with her siblings, reviewed content for understanding Health Literacy.

22. Keys to Success Utilizing Health Care Literacy Concepts
On all written materials, matched terminology to what we said in class.
Used term Heart Failure as opposed to Congestive Heart Failure or Chronic HF
Removed ranges
Increased font size
Added more white space

23. Keys to Success with Health Literacy
Use universal health literacy communications principles to redesign written teaching materials:
User-friendly written materials use:
Simple words (1-2 syllables)
Short sentences (4-6 words)
Short paragraphs (2-3 sentences)
No medical jargon
Headings and bullets
Highlighted or circled key information

24. Heart Failure Magnet

25. Warning Signs and Symptoms

26. Heart Failure Handout

27. Diet Information

28. On-Line Discharge Instruction

29. Evaluation of New Patient Education Material
Results from 15 follow-up phone calls:
“Information very helpful.”
Able to state where information was and reported that they were referring to it.
Understood content.
Successfully answered teach back questions related to “water pill,” diet and weight.
Improvement opportunity – patients were often unclear when they had multiple physicians which one to call for the symptoms (magnet revised).

30. Enhanced Teaching and Learning
Redesign patient teaching:
Stop and check for understanding using Teach Back after teaching each segment of the information
If there is a gap, review again
Another way to close the loop

31. Redesign Patient Teaching
Slow down when speaking to the patient and family and break messages into short statements
Use plain language, breaking content into short statements
Segment education to allow for mastery

32. Enhanced Teaching and Learning
Utilizing “Teach Back”
Explain needed information to the patient or family caregiver.
Ask in a non-shaming way for the individual to explain in his or her own words what was understood.
Example: “I want to be sure that I did a good job of teaching you today about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the doctor?”
Return demonstration or show back

33. Teach Back Questions What is the name of your water pill?
What weight gain should you report to your doctor?
What foods should you avoid?
Do you know what symptoms to report to your doctor?

34. Enhanced Teaching and Learning
Use Teach Back daily
In the hospital
During home visits and follow-up phone calls
To assess the patients’ and family caregivers’ understanding of discharge instructions and ability to do self-care
To close understanding gaps between:
Caregivers and patients
Professional caregivers and family caregivers

35. Teach Back Success
Percent of time patients can teach back 90% or more of content taught related to the transition to home utilizing the four questions related to self management of heart failure
Stop and check for understanding using Teach Back after teaching each segment of information
Assess patient’s, family’s or caregiver’s ability and confidence

36. Improving Teach Back Results

37. Staff Competency Validation for Teachback
Methodology
The learning station will use discussion, role playing and patient teaching scenarios to help RN’s communicate effectively to patient/family.

38. Staff Competency Validation for Teachback
Objectives – Each participant will be able to:
Define health literacy
Learn clear communication strategies
Define plain language
Learn and utilize the “teach back” method in a shame-free way

39. Staff Competency Validation for Teachback
Each participant will participate in a role-play providing education to a patient. The following will be assessed:
Ability to do teach back in a shame-free way; tone is positive
Utilizes plain language for explanations
Does not ask patient, “Do you understand?”
Uses statements such as “I want to make sure I explained everything clearly to you.” “Can you please explain it back to me in your own words?” Or, as an example, “I want to make sure I did a good job explaining this to you because it can be very confusing. Can you tell me what changes we decided to make and how you will take your medicine now?”
If needed, participant will clarify and reinforce the explanation to improve patient understanding.

40. Patient and Family Centered Transition Communication

41. Patient-Centered Transition Communication
Provide next caregiver customized real-time information:
What to expect at home
Easy to read self-care instructions
Reasons to call for help
Number to call for emergent and non-emergent needs and questions
Share patient education materials and education processes across all care settings
Physicians, home care and other involved clinicians transmit information at time of discharge
Include anticipated, important next steps in the transition, including concerns about the patients
Ask receiving care teams for their preferred format, mode of communication and specific information needs about the patient’s functional status
Continually improve by aggregating the experience of patients, families, and caregivers and designing improvements

43. Example of Class Calendar

44. St. Luke’s Heart Failure Continuum
Teach back in hospital using new teaching material
Standardized HF on-line discharge instructions
Home Care complimentary visit 24 to 48 hours post discharge – use teach back again
Physician office visit within three to five days
Advance Practice Nurse follow-up phone call on seventh day post discharge – teach back repeated
Outpatient Heart Failure class – seeing increased participation
Collaboration with cardiology office Heart Failure Clinic

45. Post Acute Care Follow-Up

46. Post Acute Care Follow-Up
High risk patients: prior to discharge, schedule a face-to-face follow-up visit (home care visit, care coordination visit, or physician office visit) to occur within 48 hours after discharge
Moderate risk patients: prior to discharge, schedule follow-up phone call within 48 hours and schedule a physician office visit within five days

47. Post Acute Care Follow-Up
High-risk patients:
Patient has been admitted two or more times in the past year
Patient failed “Teach Back” or the patient or family caregiver has low degree of confidence to carry out self-care at home
Patient and family caregiver have the phone number for questions and concerns
Consider home care or discharge coach

48. Post Acute Care Follow-Up
Moderate risk patients:
Patient has been admitted once in the past year
Patient or family caregiver has moderate degree of confidence to carry out self-care at home
Prior to discharge, schedule follow-up phone call within 48 hours
Schedule a physician office visit within five days

49. Intervention: Home Care Visit 24-48 Hours Post Discharge
Small test of change October 2006
Education to all Home Care staff
Visit 48 hours after discharge
Visit outline
Medication Reconciliation
Review of diet and foods in-house
Teach back on water pill, diet and weight
Vital signs
Hardwired process in January 2007

50. Cost for Heart Failure Program
Home Care visit: $110.00
St. Luke’s covers $58.00; the remainder of $52.00 is absorbed
Follow-up phone calls: $10,000
Education material
Magnet: $1.00
Total with handouts: $1,200

51. Intervention: Nursing Home
Patient education sent with all nursing home patients at discharge.
Educational offerings for the staff conducted in the nursing homes.
Nursing home representative added to our HF Team.

52. Intervention: Follow-Up Phone Call
Advance Practice Nurse makes follow-up phone call at seven days post-discharge
Standardize questions
Results monitored and changes made as needed based on feedback
Results monitored globally and per individual unit

54. Intervention: Primary Care Follow-Up Appointment
Worked with Primary Care to assure follow-up visits scheduled 3 to 5 days post discharge
Particularly on high-risk patient for readmission

55. Intervention: Dietitian Visits
Now mandatory on all HF patients

56. Discharge Status (Nov 07-Oct 08)

57. Attending MD During Hospitalization (Nov 07-Oct 08)

58. Patient Satisfaction on Discharge Hand-Off

59. Heart Failure Readmission Rates*
Good
Aug 06 = Implemented use of new patient education materials
Jan 07 = Initiated complimentary visits
*Percent of heart failure patients readmitted for exacerbation of their heart failure.

60. Example of Data Collection

61. HF Continuum Teach back in hospital using new teaching material
Standardized HF on-line discharge instructions
Home Care complimentary visit 24 to 48 hours post discharge – use teach back again
Physician office visit within three to five days
Advance Practice Nurse follow-up phone call on seventh day post discharge – teach back repeated
Outpatient Heart Failure class – seeing increased participation
Collaboration with cardiology office Heart Failure Clinic

62. Lessons Learned Engaged leadership
Worked in tandem with our CMS core measures for HF
Took advantage of existing workflows
Stories are as important as the data
Health literacy: “If they don’t do what we want, we haven’t given them the right information.” (Vice Admiral Richard Carmona, Former Surgeon General)

63. Our Work Continues Working on HF LOS
Working in conjunction with Cardiologists, PC HF Clinic
HF Certification from JCAHO
Working with Wellmark to get Home Visit as a covered visit

64. Our Impact By: Enhancing the patient assessment process on admission
Enhancing patient and family understanding of complex self-care processes
Improving the hand-off of critical information to caregivers in the next care setting
Providing continuity in post acute care follow-up
We can reduce unnecessary readmissions for patients with Heart Failure.