1. Module 3 The Re-designed Discharge Process: Patient Discharge and Follow-up Care
Faculty from Joint Commission Resources
Deborah M. Nadzam, PhD, FAAN
Project Director
and
Kathleen Lauwers, RN, MSN
Consultant
Welcome to Module 3 of the Project RED training course.

2. 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
Dates for training frontline staff set
By now you have listened to the first two modules of the Re-Engineered Discharge training program. From module 1, we suggested you complete these activities. We realize that you may not have yet had time to complete all of these, or those from module 2 on the next slide.

3. Accomplishments to Date (Module 2)
Project metrics identified and planned
Patient inclusion criteria defined
Process for identifying patients and notifying D.A. defined
Multidisciplinary involvement and communication plan determined
Care plan process finalized (what and how to gather data for inclusion)
And from Module 2, we hope that you have worked your way thru these activities, including the selection of metrics you will use to assess the impact of the re-engineered discharge program; of course it is also necessary to determine who and how they will be collected.
By now we hope that you have confirmed your patient inclusion criteria, including how frontline staff will identify candidate patients and notify the D.A. of the new admission.
You should conduct a careful review of your current multidisciplinary communication related to discharge plans – and define a strategy for enhancing it as necessary.
Confirming the patient care plan structure (template) and how the D.A. will access and use are important steps toward finalizing the document that will be ready for use at the point of implementation of the re-engineered discharge process.
Depending on how much time has passed since you listened to these first 2 modules, you may have completed these activities or are still working thru them.

4. 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
Finalize care plan completion and printing
Review how to conduct ‘teach-back’ with patient and family
Finalize process for making post-D/C calls
In Module 3 we will continue to discuss the specific activities of the re-engineered discharge program, focusing on what happens when the discharge order has been written (or is imminent). Objectives for this module focus on reviewing the necessary structure and processes to support your new discharge program, particularly for those activities that support post-discharge plans for the patient, for teaching and for completing the follow up call to the patient.

5. Module 3 Outline
Complete the care plan when discharge order is written
Teaching and ‘teach-back’
Post-discharge activities
Measurement of process
Training of frontline staff
This module will provide information and guidance on the topics displayed on this slide – all prompted when the discharge order is written.

6. Module 3
You have seen this slide in both modules 1 and 2. We include it again here to visualize the parts of the Project RED that we will discuss in this module: emphasis on patient understanding, and on the final items on the Project RED checklist.

7. Discharge Order Written DISCHARGE INSTRUCTIONS
Discharge Planning
Discharge Order Written
H & P
Rx Plan
Patient Admission
Discharge Event
Here is the Discharge Planning diagram also seen in the previous two modules. In this module, we focus here – at the end of the hospital stay and the beginning of the post-discharge period.
Discharge Process
PATIENT EDUCATION
DISCHARGE INSTRUCTIONS
Post-D/C Follow-up

8. RED Checklist: Discharge and Follow Up
Eleven mutually reinforcing components:
Medication reconciliation
Reconcile discharge plan with national guidelines
Follow-up appointments
Outstanding tests
Post-discharge services
Written discharge plan
What to do if problem arises
Patient education
Assess patient understanding
Discharge summary sent to PCP
Telephone reinforcement
Adopted by
National Quality Forum
as one of 30 US
"Safe Practices" (SP-15)
The 11 components of RED do overlap throughout the hospital stay – the highlighted ones on this slide focus more specifically on the end of the acute care stay- scheduling appts, reviewing pending tests, writing the final discharge plan, instructing and assessing patient understanding, and finally performing the post-discharge activities related to contacting the PCP and the patient. 8 8 8

9. In the swim lane diagram of the discharge process, we are concentrating on the physician’s writing of the order, nursing staff’s role with educating the patient and actually assisting with the discharge process and event (departure of the patient). The DA completes the care plan, instructs the patient on all aspects of the care plan, arranging for the post-discharge phone call; and the pharmacist’s role to assist with medication reconciliation, perhaps with teaching, and with follow up contact with patient as indicated. 9

10. Complete the Care Plan Medication reconciliation performed
Pending tests and results
Post-discharge services
Primary Care Provider
Follow up appointments
Information about condition(s)
Now that the discharge order has been written, it’s time to finalize the patient’s care plan and ensure that all sections are complete, accurate and phrased in ways the patient will understand. We’ll walk thru these areas one at a time.

11. Medication Reconciliation
Hospital procedure for completing medication reconciliation at discharge
D.A. may participate and/or conduct final check on medications
Using final list, populate patient care plan, and complete additional columns (e.g., purpose, time of day visual)
The final list will be used to instruct the patient
You probably already have a process for conducting medication reconciliation at discharge, likely involving the physician and nurse, perhaps the pharmacist. An important aspect of medication reconciliation at this time is the actual use of the list to instruct the patient about the prescribed medications. Talk to the patient and family about the list, asking about other medications at home that the patient may think are still okay to take. This is RECONCILING the list with the patient and family.

12. Pending Tests/Results
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
It is not uncommon for a patient to be discharged before all tests are completed or before test results are known. Of course these tests and results may bring to light new findings that will require a change in the patient’s treatment plan after discharge. Therefore, insure all incomplete tests and pending test results are included on the patient care plan. This is important information to bring to the patient’s attention, informing the patient that he/she should ask about these at follow up appointments.

13. Post Discharge Services
Confirm with case manager that all services have been arranged
Add names of services and contact information to care plan
Final arrangement of post-discharge services needs to be confirmed at this point. If discharge planning has been occurring throughout the length of stay, then these activities should be more of a ‘confirmation’ that everything has been planned, and matches the discharge order for disposition and services needed for the patient in the home. Giving the patient/family the names of companies providing these services will help the patient and family make contact with them if necessary.

14. Primary Care Provider (PCP)
Confirm name of PCP with patient
Add name and contact number of PCP to care plan
One reason patient’s return to the emergency department or get readmitted to the hospital is that they have not followed up with a physician after discharge, and that may be because the patient does not have a primary care provider. This component of Project RED promotes that hospitals confirm the name and contact information of the patient’s PCP – adding it to their care plan, OR try to find a PCP for the patient who does not have one.

15. 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
Leave message with clinician office to call patient (off hours and weekend)
Add appointments to care plan
Often at discharge a patient is given a list of follow up appointments to make. This component of Project RED focuses on making the appointments for the patient prior to departure. The D.A. (or designee) will discuss the patient’s availability on days and times of day, as well as learn about transportation needs. Armed with that information, calls are placed to the offices where follow up appointments are needed. Hopefully a good match can be made, scheduling the appointment at a time that the patient will be able to keep. On weekends a message can be left with the office to please phone the patient to make the follow up appointment.
All appointments should be added to the Patient Care Plan given to the patient.

16. Information about Condition(s)
Secure pre-printed information about patient’s condition to add to care plan
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)
The information about the patient’s condition may be most similar to what you have already been providing to your patients. While re-engineering your discharge program, review these materials to confirm that they are current and written in terms that are understandable to non-health care professionals. Use pictures, white space, short sentences, and avoid too much information that may be too detailed.
Be clear about the signs and symptoms that should alert the patient, differentiating between those that should prompt a phone call to the physician and those that are emergent.

17. 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
When and how to reach physician or go to E.D.
Form for writing own questions down
Map of campus for locating appointments (optional)
Other information about your center (optional)
The Patient Care Plan should now be inclusive of these sections, and as the patient is preparing to depart this information should be reviewed with the patient carefully, using teach back techniques (addressed later in this module).

18. 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?
From where?
How reliable?
How timely?
What gaps still exist that need to be addressed?
As a team, you may want to consider these questions about your progress with finalizing the Patient Care Plan structure and process for completing it.

19. Final Teaching and Teach-Back
All education material
Care plan completed
2 copies printed
Copy to Quality?
Meet in quiet place with patient/family
Review all parts of the care plan
Confirm patient/family understanding utilizing ‘teach-back’ methods
Now let’s review the important points of the final teaching session with the patient. With all education material completed and the care plan final, it can be printed for conducting the final teaching and for giving to the patient. A second copy might be given to your quality department if you are planning to review the completeness of it as one of your metrics.
Now the D.A. will meet with the patient and family in a quiet place to review the teachings that have been offered during the length of stay, teach any new information that is a result of final discharge orders. Cover all parts of the care plan and assess the patient’s understanding. The next several slides highlight important teaching and teach-back points.

20. Health Literacy – Tips*
Avoid medical jargon
Speak slowly
Simple pictures when helpful
Emphasize what patient should do
Avoid unnecessary information
Welcome questions
Written materials: simple words, short sentences in bulleted format, lots of white space
* Graham and Brookey
We first showed you this slide in Module 2 but believe it is important to emphasize again because as health care professionals we easily slip into medical jargon, and patients easily slip into saying they understand when perhaps they do not.

21. Teaching – Tips* Elicit from patient their symptoms and understanding
Be aware of when teaching new concepts and ensure understanding
Eliminate jargon
System level support using technology:
Provide more robust health education vehicles to help the patient remember
Be proactive during time between visits
* Schillinger interview
Here again is the same slide from module 2 – this time considering it during the FINAL teaching session with the complete care plan. Dr. Dean Schillinger suggests that we should first ELICIT from the patient his understanding of the symptoms and disease/condition. Rather than telling the patient – first seek to learn what the patient currently knows. When you recognize that the patient needs more or better information to understand, be cognizant that these concepts may be new, and seek to insure that the patient really understands.
In addition, Dr. S suggests that there are system-level interventions that could make health education a more robust and effective process. For example utilizing technology to visualize concepts being taught, and to reinforce teachings to promote patient understanding AND retention. Such technology might also be used in between live visits with the patient – particularly with patients who are computer literate and can access applications from home.

22. 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
Teach all staff how to do it!
Teach back techniques help to determine if the patient understands what you have taught him/her. By utilizing certain phrases and approaches you will learn if your teaching was effective – did you use terms the patient understands? Perhaps you will need to repeat the information again – in a different way to gain patient understanding. And we need to assume that all patients are vulnerable to not understanding, regardless of their education level or primary spoken language.
Dr. Dean Schillinger-prof of med at UCSF: ‘LET’S ASSUME THAT EVERYBODY HAS IT (LIMITED HEALTH LITERACY). THAT WAY, IT IS SORT OF A ‘UNIVERSAL PRECAUTIONS’ EQUIVALENT IN THE PT SAFETY MOVEMENT.”
Self management and health literacy of two sides of the same coin.

23. 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)
“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)
Do not embarrass the patient. Here are few phrases that you may consider using.

24. The teach-back technique
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
If the patient does not explain correctly, assume that you have not provided adequate teaching and re-teach in a different way
Some additional strategies for assessing the patient’s understanding focus on the use of open-ended questions and repetition or demonstration by the patient. You may learn that the patient did not fully understand your teaching, and so will need to repeat the teaching, perhaps with different words and using other techniques (drawing, demonstrations).

25. This diagram displays the teach –back method – in and of itself a ‘visual’ to help YOU understand the process of teaching and teach-back!

26. Teach-Back Steps*
Use simple lay language; explain concept or demonstrate process avoiding technical terms; use a professional translator if language issue exists
Ask patient/caregiver to repeat concept in own words and/or to demonstrate process
Identify/correct misunderstandings or incorrect procedure
Ask patient/caregiver to repeat concept and/or repeat process to demonstrate understanding
Repeat Steps 3 and 4 until clinician is convinced comprehension and ability to perform process is adequate and safe.
The Society for Hospital Medicine offers these 5 steps for teach-back, demonstrated in the previous visual as well – with the circling back to re-teach if the patient does not demonstrate understanding.
* Society of Hospital Medicine

27. 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)
“Please demonstrate the activity I’ve just explained/shown to you.”
Most discharge procedures check comprehension, but not efficacy (can patient actually DO this even though they understand). For example, “I know how a piano works, that doesn’t mean I can play it.” Here are some additional points to consider when you conduct final teaching and assess patient comprehension.

28. Post Discharge Activities
Transmit D/C summary and care plan to PCP
Fax: insure it is received and legible
Electronic: scan/ if possible; insure it is received
Follow-up phone call to patient: hours after discharge
Caller uses script that assess understanding of medication and follow-up appointments
Need for second call by clinician determined
Finally, the last components of the Re-engineered Discharge program focus specifically on the patient’s post-discharge follow up. First, be certain the discharge summary and perhaps even a copy of the Patient Care Plan are provided to the PCP in a timely fashion. Depending on your mechanism of transmission, you may need to confirm receipt and legibility.
Consider the phone call placed to the patient hours after discharge as a ‘clinical call’ of sorts. You are assessing the patient’s status now that they’ve been home a couple days. You will want to ask the patient how they are feeling; do they have questions about the information on the care plan that require teaching-reminders; have they filled their prescriptions and are they taking their medications; are they taking any medications that are NOT on the list they were given at discharge; do they have specific medication questions; will they keep their follow up appointments.
The caller may also need to arrange a second call by another person – a pharmacist, physician, case management.
Your hospital will also want to decide if this call should be documented and where that documentation will be stored.

29. Measurement of Process
Timeliness of RED activities
D.A. log data
Review patient care plans after discharge
% 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’)
Concurrent data collection can be occurring throughout the contact with the patient, concluding when the follow-up activities are completed. If you have decided to use these metrics, conclude the measurement for each patient at this time.

30. 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
Set date for live session and/or record
Prior to launch of RED intervention
Utilize provided slide deck and customize as necessary
Now that you are finalizing your plans for the 11 components and implementation of Project RED, it is time to education your hospital staff about this effort. If you are piloting Project RED on one patient care unit, you might limit your detailed teaching to the staff who work with patients on that unit (nurses, physicians, pharmacists, case workers). You may also decide to provide general information about the project to all staff, using newsletters, flyers, your intranet site.
On the AHRQ site you will also find a power point file of slides that you may select from for creating your presentation to staff.

31. 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
Transmit summary and care plan to PCP
Phone patient within 48 hours
Complete measurement of discharge process
Finalize plans for teaching frontline staff
In Module 3 we have reviewed the several activities that occur once the discharge order is written. You should complete structure and process-related issues that will facilitate the DA’s completion of the care plan and teaching with the patients. In addition, you should be finalizing post-discharge communication with the PCP and patient , and again, review how measurement will take place.
Once you have completed all the activities associated with modules 1-3, and have your final plans in place, it will be time to train the staff who will be working with the DA and the targeted patient group. A slide deck of a presentation for staff for your considered use is available on AHRQ’s website. Some slides will prompt you for specific information about your organization’s decisions (targeted population, approach to the care plan, etc.).
You may also want to hold a more general session with other hospital staff, and consider a brief article about this PI project in your hospital newsletter or intranet. Some hospitals may also want to let the community know that they are working on this project with AHRQ and JCR. We would be happy to work with you on a press release should you decide to announce your participation. 31

32. 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 ____
Plans for teaching frontline staff finalized ____
Team evaluation of Module 3 ___
Moving forward, we hope that you can complete most of your activities in the very near future and then complete Module 4.