1. Hospital to Home: Keeping our patients safe IHS Leadership Symposium Breakout Session I April 20, 2010 Peg M. Bradke, RN, MA St. Luke’s Hospital, Cedar Rapids, Iowa

2. Who Owns the Transition? Are we placing the burden on the patient? What is causing the readmissions? Do we know? Are we being proactive?

3. Reducing Re-Hospitalizations: Background If re-hospitalizations are prevalent, costly, and able to be reduced, why haven’t they been? Hospital-level barriers Financial disincentives (volume-revenue), no financial incentives, not part of P4P contracts, not high on priority list, limited disease- specific efforts Community-level barriers Not common to engage organizations across continuum to collaborate on improving care, frustration between inpatient and post-acute providers, lack of IT connectivity, no reimbursement for coordination State-level barriers Lack of population-based data, lack of understanding costs of poor quality on systems, effect of fragmented payer market and lack of CMS participation

4. Need for Paradigm Shift Traditional focus on discharging patients > facilitating transitions in care and a shift to handoffs (senders and receivers design the process) Hospital Problem to Continuum issue Focus on what clinicians are teaching > to focus on what the patient is learning Patient is the focus of the care team > patient and defined family are essential members of the care team Immediate focus on clinical needs > to a focus on the whole person and their social situation over time Focus on patient care needs in various settings > focus on the patient’s experience over time

5. Transition to Home Team Heart Failure team since 2001 St. Luke’s joined the Institute for Health Care Improvement (IHI) Innovation Project for Transitions to Home in February 2006 Work concentrated on the Heart Failure patient to provide the “ideal” transition to home Goal: To Improve the reliability of the care patients receive and resultant outcomes Worked in tandem with compliance to CMS Core Measures

6. St. Luke’s Heart Failure Continuum Standardized care through order sets Teaching Utilizing Universal Health Literacy Concepts Enhanced teaching materials Teach back Touchpoints Home Care - care coordination visit 24 to 48 hours post discharge Follow-up physician clinic visit appointment in three to five days APN - follow-up phone call on seventh day post discharge Outpatient Heart Failure class Collaboration with cardiology office Heart Failure Clinic

7. What Changes Can We Make That Will Result in Improvement? Key Changes to Achieve an Ideal Transition from Hospital to Home: 1.Perform an Enhanced Assessment of Post- Hospital Needs 2.Provide Effective Teaching and Facilitate Learning 3.Provide Real-time Patient and Family-Centered Handoff Communications 4.Ensure Post-Hospital Care Follow-Up

8. How-to Guide: Creating an Ideal Transition Home -- Page 6 Creating an Ideal Transition Home I. Perform Enhanced Admission Assessment for Post-Hospital Needs A.Include family caregivers and community providers as full partners in completing standardized assessments, planning discharge, and predicting home-going needs. B.Reconcile medications upon admission. C.Initiate a standard plan of care based on the results of the assessment. II. Provide Effective Teaching and Enhanced Learning A.Identify all learners on admission. B.Customize the patient education process for patients, family caregivers, and providers in community settings. C.Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care. III. Conduct Real-Time Patient and Family-Centered Handoff Communication A. Reconcile medications at discharge. B. Provide customized, real-time critical information to the next care provider(s). IV. Ensure Post-Hospital Care Follow-Up A.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. B.Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48 hours and schedule a physician office visit within five days.

9. Although the care that prevents rehospitalization occurs largely outside the hospital, it starts in the hospital. Steve Jencks, NEJM 2009 260:1417-28

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 Initiate a standard plan of care based on the results of the assessment Designate a person accountable for the effective discharge of each patient Estimate the home-going date on admission and anticipate needs Key learner may be different than Care Provider Who is managing medications? Who do you want to be included in your discharge instructions?

11. Emphasis on Cross Continuum Team/Interdisciplinary Team These views added new context to our efforts. Home Care representative Family member of a HF patient Long-Term Care representative Physician Clinic representative Patient

12. Facilitating Patient-Centered Care “Nothing about me without me” Patient and family needs and goals for the day associated with going home are listed on the white board Consider what it would be like to be a patient going home Care Plan Partner – if they are included, they will be engaged; include in rounds, shift handoffs, and all discharge preparation discussions

13. The richest source of information is under our nose… The Patient

15. Interventions to Enhance Assessment for Post-Discharge Needs Take 5 Daily discharge huddle Bedside reporting All opportunities to review plan for day and anticipate discharge needs

16. Identify Opportunities: 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? 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? Was discharge plan clear? Functional status of patient on discharge

17. Interview Questions For patients with HF that are readmitted within 30 days of last admission: 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? 17

18. How-to Guide: Creating an Ideal Transition Home -- Creating an Ideal Transition Home I. Perform Enhanced Admission Assessment for Post-Hospital Needs A.Include family caregivers and community providers as full partners in completing standardized assessments, planning discharge, and predicting home-going needs. B.Reconcile medications upon admission. C.Initiate a standard plan of care based on the results of the assessment. II. Provide Effective Teaching and Enhanced Learning A.Identify all learners on admission. B.Customize the patient education process for patients, family caregivers, and providers in community settings. C.Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care. III. Conduct Real-Time Patient and Family-Centered Handoff Communication A.Reconcile medications at discharge. B.Provide customized, real-time critical information to the next care provider(s). IV. Ensure Post-Hospital Care Follow-Up A.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. B.Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48 hours and schedule a physician office visit within five days.

19. 19 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

20. Paradigm Shift “The patient is noncompliant” vs. Asking: What is our responsibility as the sender of the information?

21. 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

22. 22 Redesign Patient Teaching Materials During acute care hospitalizations for HF, only essential education is recommended Reinforce within one to two weeks after discharge Continue for three to six months Adams, KF et al: HFSA 2006 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure Vol. 12, No. 1, pg 61 February 2006HFSA 2006 Comprehensive Heart Failure Practice Guideline

23. 23 Universal Communication Principles Focus on key points Need to know vs. nice to know Emphasize what patient should do Avoid duplicating paperwork Be careful with color

24. 24 Keys to Success with Health Literacy Use universal health literacy communication 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 Two-word explanations, e.g., “water pill/ blood pressure pill”

25. Add more white space Highlight or circle key information Headings and bullet points Increase font size Remove ranges On all written material, assure words/ terminology match Use visual aids Provide a health context for numbers or values Keys to Success with Health Literacy

26. Heart Failure Magnet

27. Heart Failure Zones

28. 28

31. 31 Online Discharge Instructions St Luke’s Hospital, Cedar Rapids, Iowa

32. 32 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. St Luke’s Hospital, Cedar Rapids, Iowa

33. 33 Evaluation of New Patient Education Material 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). St Luke’s Hospital, Cedar Rapids, Iowa

34. 34 Arch Intern Med, 2003;163:83-90 Copyright © 2003, American Medical Association. All Rights reserved

36. Closing the Loop Check points to evaluate how well transactions are going How well we are doing giving the information How often do we close the loop?

37. 37 Enhanced Teaching and Learning Utilizing “Teach Back” Explain needed information to the patient or family caregiver. You do not want your patient to view TeachBack as a test, but rather of how well you explained the concept. You can place the responsibility on yourself. Can be both a diagnostic and teaching tool

38. 38 Enhanced Teaching and Learning 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?”

39. 39 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 If your patient is not able to repeat the information accurately, try to re-phrase the information rather than just repeat it. Then, ask the patient to repeat again until you fee comfortable that the patient understood.

40. 40 Redesign Patient Teaching Slow down when speaking to the patient and family and break messages into short statements Take a pause Be an active listener Use plain language, breaking content into short statements Segment education to allow for mastery

41. 41 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? St Luke’s Hospital, Cedar Rapids, Iowa

42. 42 Enhance Teaching and Facilitate Learning Use Teach Back daily: In the hospital During home visits and follow-up phone calls To assess the patient’s 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

43. 43 Teach Back Competency Validation St Luke’s Hospital, Cedar Rapids, Iowa Nursing Competency Assessment Annual competency validation day Methodology The learning station will use discussion, role playing and patient teaching scenarios to help RN’s communicate effectively to patient/family.

44. How-to Guide: Creating an Ideal Transition Home Creating an Ideal Transition Home I. Perform Enhanced Admission Assessment for Post-Hospital Needs A.Include family caregivers and community providers as full partners in completing standardized assessments, planning discharge, and predicting home-going needs. B.Reconcile medications upon admission. C.Initiate a standard plan of care based on the results of the assessment. II. Provide Effective Teaching and Enhanced Learning A.Identify all learners on admission. B.Customize the patient education process for patients, family caregivers, and providers in community settings. C.Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care. III. Conduct Real-Time Patient and Family-Centered Handoff Communication A. Reconcile medications at discharge. B. Provide customized, real-time critical information to the next care provider(s). IV. Ensure Post-Hospital Care Follow-Up A.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. B.Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48 hours and schedule a physician office visit within five days.

45. Opportunities for Improvement  81% of patients requiring assistance with basic functional needs failed to have a home care referral  64% said no one at the hospital talked to them about managing their care at home Clark PA. Patient Satisfaction and Discharge Process: Evidence-Based Best Practice. Marblehead, MA: HCPro, Inc., 2006

46. Patients sometimes do not see readmissions as a failure

47. Reconcile Medications for Discharge Communicate clearly to the patient, family caregiver and next care team: Names of each medication, reason to take it New medications and pre-hospital medications the patient is to discontinue Whether there are any recommended changes in the dose or frequency from pre- hospital instructions 47

48. Pre-hospital medications to be continued with the same instructions Medications and over-the-counter medications that should not be taken The cost of the medication Can patients read their medication labels, afford the necessary medications and food, and get to the pharmacy? 48 Reconcile Medications for Discharge

49. Patients going home: Provide patient and family Easy-to-read self-care instructions What to expect at home Medication card with current medications Reasons to call for help Numbers for emergent needs and non- emergent questions 49 Real-Time Patient and Family- Centered Handoff Communication

50. Patients going home: Identify the appropriate care providers (physicians, home care, other providers) Transmit critical information at time of discharge Ideally precedes or accompanies patient to next care location Be sure the information adequately delineates patient status and recommendations for plan of care Speak with emergency contact listed in medical record before discharge and provide critical information on patient safety 50 Real-Time Patient and Family- Centered Handoff Communication

51. Example of Calendar 51

53. Real-Time Patient and Family- Centered Handoff Communication Patients going to community facility: Alert next care providers to patient’s discharge readiness and needs post discharge Nursing home or SNF liaison with hospital Ask receiving care teams for their preferred format, mode of communication and specific information needs about patient’s functional status. Share patient education materials and educational processes across all care settings

54. Long-Term Care/Skilled Nursing Facility Patient education is sent with all nursing home patients at discharge. Educational offerings for the staff conducted in the LTC/SNF Long-term care/Skilled Nursing Facility representative added to our HF Team. St Luke’s Hospital, Cedar Rapids, Iowa

55. Schade et al; Impact of a national campaign on hospital readmission in home care patient; Journal of Quality Health Care vol 21, no 3  Hospitalization rates appeared to improve in agencies participating in the National Campaign compared with those not participating.  Use of the material was significantly more common among agencies whose performance improved.

56. Home Health Quality Initiative National Campaign Intervention Used Hospitalization risk assessment Patient emergency plan Phone monitoring and loading visits Teletriage Medication management Telemonitoring Immunization Physician relationships Fall prevention Patient self-management/disease management Transitional care coordination

57. Mor et al; The Revolving Door of Rehospitalization from Skilled Nursing Facilities, Health Affairs Jan. 2010 29:1  Almost one-fourth of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within thirty days; this cost Medicare $4.34 billion in 2006.  The overall rate increased from 18.2% in 2000 to more that 23.5% in 2006.

58. Case Management Monthly Reducing Hospital-SNF 30-day Readmission (2007 Pfizer)  Finding from 931 hospitals and SNF interviews in 2009 indicated that 30-day hospital readmission could be reduced if: SNF had better access to hospital staff SNF had better access to hospital staff and documentation and documentation Medication changes for non-medical Medication changes for non-medical or formulary reasons were minimized as or formulary reasons were minimized as patients transition between settings patients transition between settings

59. Which Setting is Most Responsible for Readmission in 30 Days? Hospital View 1.Patient 2.SNF 3.Physician Practice 4.Hospitals 5.Government 6.All of above 7.None of above SNF View 1.Hospitals 2.Patients 3.Physician Practice 4.SNF 5.Government 6.All of above 7.None of above

60. Barriers to Efficient Transitions The two settings agree that better communication and better education management, including support for discharge planners, are highly likely to reduce readmissions Yet, less than 9% of Hospitals and 14% of SNF’s reported regular meetings or hold multiple facility transition of care meetings to discuss cases or processes.

61. Establish Cross-Venue or Continuum Collaboration Develop creative solutions for bi- directional communication and feedback processes, coordination and greater understanding of patient needs Continually improve by aggregating the experience of patients, families, and caregivers and designing improvements 61

63. How-to Guide: Creating an Ideal Transition Home -- Page 6 Creating an Ideal Transition Home I. Perform Enhanced Admission Assessment for Post-Hospital Needs A.Include family caregivers and community providers as full partners in completing standardized assessments, planning discharge, and predicting home-going needs. B.Reconcile medications upon admission. C.Initiate a standard plan of care based on the results of the assessment. II. Provide Effective Teaching and Enhanced Learning A.Identify all learners on admission. B.Customize the patient education process for patients, family caregivers, and providers in community settings. C.Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care. III. Conduct Real-Time Patient and Family-Centered Handoff Communication A. Reconcile medications at discharge. B. Provide customized, real-time critical information to the next care provider(s). IV. Ensure Post-Hospital Care Follow-Up A.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. B.Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48 hours and schedule a physician office visit within five days.

64. Post Acute 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 a 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

65. Identifying High Risk History of rehospitalization Failed teach back Longer stay than expected High-risk conditions Poor, disabled, or on dialysis But, the resources used in screening might be better spent on system changes

66. Post Acute 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

67. Controlled Trials  Clinic visit only is not enough  Nursing support alone is equivalent to telemonitoring  Early follow-up appointment important, but not clear if it is 3-5-7 days; some data show after seven days is too long  Multidisciplinary team most effective  Single home visit can make a difference

68. Intervention: Dietitian Visits Mandatory on all patients

69. Intervention: Home Care Visit 24-48 Hours Post Discharge Small test of change October 2006 Education to all Home Care staff Visit 24-48 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

70. 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.

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

72. 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

73. Data Speaks: Evaluating Progress in Reducing Heart Failure Readmissions

74. Facility Assessment Is reducing Readmission a strategic priority for Executive Leaders? What is you understanding of the problem? Have you established improvement goals? What will help you drive the Success in the Improvement process? What and how are you providing oversight? What investments are we willing to make What are you measuring?

75. Measurement How will we know change is an improvement?

76. Outcome Measures: Readmission

77. Harvard Public Health Literacy Finding that current efforts to collect and publicly reported data on discharge planning are unlikely to yield large reductions in unnecessary readmissions. Jha, NEJM 361:27 Dec. 2009

78. Attending MD During Hospitalization (Nov 07 – Dec 09)

79. Discharge Status (Nov 07- Dec 09)

81. Palliative Care Referral Year-to-date, 10% referred to Palliative Care In 2007, averaged less than 5%

82. Successful Teachback Rate

83. Patient Satisfaction on Discharge Handoff

84. “I had a great time tonight and I’d like to see you again in four to six weeks.”

85. 3-5 Day Follow-up

87. Percent of Heart Failure Patients Readmitted within 30 Days with Heart Failure Good (Numerator based on discharge date; denominator is number of discharges excluding deaths.)

88. Percent of Heart Failure Patients Readmitted within 30 Days for Any Cause Good (Numerator based on discharge date; denominator is number of discharges excluding deaths.)

89. Peg Bradke St. Luke’s Hospital Cedar Rapids Iowa Bradkemm@crstlukes.com

90. COPD/Pneumonia What would your teachback questions be? What are the vital few?