Agency for Healthcare Research and Quality Advancing Excellence in Health Care Discharge Information f Register for this teleconference at: April 24, 2013 Carrie Brady, JD, MA Ashka Dave David Schulke

Advancing Excellence in Health Care AHRQ/HRET Patient Safety Learning Network (PSLN) Project  This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET).  HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education.  AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. 2

Advancing Excellence in Health Care The Patient Experience of Care is Fundamental to Clinical Improvement  Understanding the patient experience of care is not an add-on activity: it should be used as a fundamental element in your other improvement efforts.  For those working on the HRET Partnership for Patients Hospital Engagement Network (HEN) or another HEN, your work will benefit directly from your efforts to improve the patient experience of care (e.g., readmissions, ADEs).  Lessons you learn in this HCAHPS Learning Network will help you succeed in the HEN project because— Patient-centered care is a driver of clinical outcomes Patient-centered care is a driver of clinical outcomes Employee and patient engagement are 2 sides of one coin Employee and patient engagement are 2 sides of one coin HCAHPS assesses key factors in ADEs and readmissions HCAHPS assesses key factors in ADEs and readmissions 3

Advancing Excellence in Health Care HCAHPS Technical Assistance Faculty  Carrie Brady, MA, JD  HRET’s primary HCAHPS faculty  Former senior Connecticut Hospital Association staffer  Previously a vice president at Planetree  Exemplary hospital peers  The Chester County Hospital  Recent successful interventions to improve the discharge experience 4

Advancing Excellence in Health Care HCAHPS Discharge Information Domain During this hospital stay: Did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? Did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Source: CMS Summary of HCAHPS Survey Results and HCAHPS Percentiles December 2012 Public Report (April 2011 – March 2012 Discharges) 84% “Always” is the national average 84% “Always” is the national average Highest scoring HCAHPS domain Highest scoring HCAHPS domain – But also high percentage of “bottom box” because they are yes/no questions Best performing hospitals in the country (95 th percentile) get 90% or more “Always” Best performing hospitals in the country (95 th percentile) get 90% or more “Always” 5

Advancing Excellence in Health Care Patients Given Information About Recovery At Home: National Benchmarks

Advancing Excellence in Health Care Scale: Strongly Disagree, Disagree, Agree, Strongly Agree During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications. When I left the hospital, I clearly understood the purpose for taking each of my medications. New HCAHPS Questions: Care Transitions (effective 1/1/13) 7

Advancing Excellence in Health Care “Higher patient satisfaction with inpatient care and discharge planning is associated with lower 30-day readmission rates even after controlling for hospital adherence to evidence-based practice guidelines.” “Higher patient satisfaction with inpatient care and discharge planning is associated with lower 30-day readmission rates even after controlling for hospital adherence to evidence-based practice guidelines.” For some conditions, HCAHPS performance is more predictive of readmission rates than clinical performance measures For some conditions, HCAHPS performance is more predictive of readmission rates than clinical performance measures Source: Am J Manag Care. 2011; 17(1):

Advancing Excellence in Health Care Although the location of the patient changes at discharge, the patient does not change Although the location of the patient changes at discharge, the patient does not change Hospitals’ responsibility does not end at discharge Hospitals’ responsibility does not end at discharge – Recognize the dangers of transition – Set patients up for success – Be aware of “post-hospital syndrome” Krumholz, HM “Post-Hospital Syndrome – An Acquired, Transient Condition of Generalized Risk”, New England Journal of Medicine 368;2 (January 10, 2013) Redefining “Discharge” 9

Advancing Excellence in Health Care 50+ pages of written materials provided at discharge Instructions to obtain appointments with five different providers No identified point of contact No one knowledgeable about the comprehensive care plan No follow-up or coordination Beth Ann Swan, Dean of Jefferson School of Nursing, Thomas Jefferson University, PA Health Affairs, 31, no.11 (2012): Don’t Overwhelm Patients

Advancing Excellence in Health Care Promote consistent communication Promote consistent communication – e.g. Anne Arundel SMART discharge process (symptoms, medication, talk to me) Engage and educate caregivers, not just patients Engage and educate caregivers, not just patients Expand the team Expand the team Partner Throughout the Hospital Stay 11

Advancing Excellence in Health Care Start with the Basics Source: Olson DP and Windish DM, “Communication Discrepancies Between Physicians and Hospitalized Patients” Arch Intern Med 2010; 170 (15):

Advancing Excellence in Health Care AHRQ Resource: Re-Engineered hospital Discharge (RED) Key Components Discharge Advocate educates patient in hospital Discharge Advocate educates patient in hospital Give After Hospital Care Plan (AHCP) to patient and PCP Give After Hospital Care Plan (AHCP) to patient and PCP Pharmacist calls patients 2-4 days post-discharge Pharmacist calls patients 2-4 days post-discharge New RED Toolkit addresses language barriers, cross-cultural issues, and disparities in health care communication and trust, with step- by-step instructions New RED Toolkit addresses language barriers, cross-cultural issues, and disparities in health care communication and trust, with step- by-step instructions For new RED toolkit, see: systems/hospital/toolkit/index.html 13

Advancing Excellence in Health Care Use Plain Language  Who Is the Responsible Clinician  What Is the Next Step  Who Should Be Contacted with Questions  What Should the Patient Watch Out For  What Is The Medication/Procedure Schedule “NO ETOH” 14

Advancing Excellence in Health Care Assess Understanding: Example: Teach Back Training toolkit available at Always Use Teach-Back! Iowa Health System Facilitates communication through use of the teach-back method Extensive training toolkit developed, including: Videos Evaluation Tools Coaching Tips 15

Advancing Excellence in Health Care PSLN Participant Discharge Innovations Red Envelope Red Envelope Three Most Important Things List Three Most Important Things List Next Dose of Medications Next Dose of Medications 16

Advancing Excellence in Health Care Discharge Information Case Study The Chester County Hospital and Health System “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” (AHRQ 2011)

Advancing Excellence in Health Care The Chester County Hospital & Health System (TCCH) West Chester, PA 220 bed community hospital 220 bed community hospital Rich history, 120 years Rich history, 120 years Affiliations include: Affiliations include: – Cleveland Clinic’s- Division of CT Surgery – University of Pennsylvania- Oncology & Radiology – Children’s Hospital of Philadelphia-Pediatric & Neonatal Services 18

Advancing Excellence in Health Care Patient Safety & Service Excellence; aiming for High Reliability Patient Safety & Service Excellence; aiming for High Reliability CMS mandates; opportunities for integration CMS mandates; opportunities for integration Alignment of resources & Senior Team support Alignment of resources & Senior Team support Project RED Boston team/AHRQ invitation Summer 2011 Project RED Boston team/AHRQ invitation Summer 2011 – Participation-the national RED Roll-Out Contract – Telemetry pilot unit: CHF patients Project RED & HCAHPS at TCCH Project RED & HCAHPS at TCCH 19

Advancing Excellence in Health Care Re- Engineered Discharge Nurse Commun- ication MD Commun- ication Medication Teaching Discharge Hospital Rating INTEGRATED HCAHPS BENEFITS 20

Advancing Excellence in Health Care Discharge Planning Begins on Day 1 Discharge Planning Begins on Day 1 – RED = Guide to building relationships – RED = Patient safety & service excellence go hand in hand – RED = Patients & clinical team; common goals – RED = Family engagement – RED = Patient learning as the closing message – RED = Opportunity for hospital & community team to shine Benefits, really? Absolutely! 21

Advancing Excellence in Health Care Our After Hospital Care Plan (AHCP)—”heart and soul” of our success Our After Hospital Care Plan (AHCP)—”heart and soul” of our success RED’s Discharge Educator role = our Telemetry nurses RED’s Discharge Educator role = our Telemetry nurses – Telemetry RNs delivered the AHCP to patients, using Teach-Back Unit Coordinators making F/Up apts. Unit Coordinators making F/Up apts. RED Roadmap for 4 day admission RED Roadmap for 4 day admission Clinical Pharmacist inclusion Clinical Pharmacist inclusion Physician Office Practice outreach—AHCP sharing Physician Office Practice outreach—AHCP sharing 48 hour post discharge F/Up phone calls 48 hour post discharge F/Up phone calls – Project RED script Our patients, families, staff & physicians loved Project RED! Our patients, families, staff & physicians loved Project RED! TCCH RED Integration

Advancing Excellence in Health Care Personalized Plan- “it’s like an award for discharge” 23

Advancing Excellence in Health Care List of Medicines & Why/How 24

Advancing Excellence in Health Care TCCH Clinical Pharmacists Medication Teaching TCCH Clinical Pharmacists Medication Teaching 25 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

Advancing Excellence in Health Care Personalized Instructions 26

Advancing Excellence in Health Care Appointment Calendar 27

Advancing Excellence in Health Care Our clinical & IT experts collaborated as 1 team - “priceless” Our clinical & IT experts collaborated as 1 team - “priceless” – Replication of the AHCP electronically in Soarian (Siemens) Over 50% reduction in the Telemetry CHF readmission rates Over 50% reduction in the Telemetry CHF readmission rates RED’s Checklist worked; expansion for all TCCH RED’s Checklist worked; expansion for all TCCH TCCH Re-Engineered Discharge: 5 Core Principles TCCH Re-Engineered Discharge: 5 Core Principles – Discharge planning begins Day 1 all TCCH patients – “My Discharge Plan” all TCCH patients – Teach-back methodology all TCCH patients – Follow-up appts. High Risk patients – Follow-up phone calls High Risk patients TCCH Integration:

Advancing Excellence in Health Care Sample: “My Discharge Plan” 29

Advancing Excellence in Health Care Identification of our High Risk patients Identification of our High Risk patients – Unit based electronic work list of High Risk patients available daily – Criteria include: polypharmacy, recent admissions, key CMS diagnoses Interventions with our High Risk patients Interventions with our High Risk patients – Unit Coordinators throughout the hospital make the F/Up appointments – Focus for the Rapid Daily Rounds “Plan for the Day, Plan for the Stay” Volunteers & transport staff: discharge at curb-side Volunteers & transport staff: discharge at curb-side – Reinforce value of “My Discharge Plan” as TCCH says “good-bye” 48 hour F/Up phone calls-High Risk patients 48 hour F/Up phone calls-High Risk patients – Paramedics & Clinical Pharmacists; scripted interview – Medication clarification, F/Up appointment reminders, overall Transition support TCCH Integration

Advancing Excellence in Health Care The Chester County Hospital: HF Readmission Rates

Advancing Excellence in Health Care TCCH : HCAHPS Discharge Domain 32

Advancing Excellence in Health Care TCCH : HCAHPS Care Transitions 33

Advancing Excellence in Health Care “Roadmap” for better alignment of HCAHPS opportunities with Re-Engineered Discharge “Roadmap” for better alignment of HCAHPS opportunities with Re-Engineered Discharge IT support-wealth of process/outcome reports IT support-wealth of process/outcome reports – Live interviews with High Risk readmitted patients NVNA support: new High Risk patients found NVNA support: new High Risk patients found Office practice visits/CMS 2013 incentives Office practice visits/CMS 2013 incentives – Explore office practice/hospital connections for improved patient transitions Don’t forget the Celebration! Don’t forget the Celebration! Our Next Steps! 34

Agency for Healthcare Research and Quality Advancing Excellence in Health Care Questions and Discussion Ways to Get Involved in the Discussion 1. Follow operator’s instructions to ask a question 2. Type your question in chat 3. Use the HRET listserv or discussion board to ask questions or share your experiences

Advancing Excellence in Health Care HCAHPS Curriculum All Web conferences are scheduled for 12-1pm Eastern All are archived at:  December 7, 2012: Fundamentals of HCAHPS  December 18/19, 2012: Using HCAHPS Data Effectively  January 16, 2013: Nurse Communication  February 13, 2013: Responsiveness  March 13, 2013: Medication Communication  April 24, 2013: Discharge Information  May 15, 2013: Physician Communication and Engagement  June 5, 2013: Pain Management  July 17, 2013: Clean  August 14, 2013: Quiet 36