Problems at Discharge: Closing The Gap On “Self-Management” and Readmissions Bradi B. Granger, PhD, RN, FAHA, FAAN Duke Heart Center Nursing Research Program

Avoidable Readmissions Associated with Poor Discharge Readiness Problem –“Readiness” for discharge inadequate in 50-70% cases –Rate of readmission is high (20% in HF in 30 days) –Costs are high ($32 billion/year) Innovative Solution to Close the Gap –Communication at discharge – Medication reconciliation (AHRQ) –Skill-based education – The Joint Commission criteria –Communication at follow-up – EHR Meaningful Use, calls, visits, –Behavioral economics - Technology to reinforce beliefs, behaviors The Patient’s View –Shared goals and skill-based learning for medication management Future of Improving Care Transition – skills in context

National GAPS in Care Transition Resources Inpatient resources –Discharge preparedness checklist (AHRQ): APP, Care Nurse, PRM GAP- Medication-education (arrangements for payment - medications, f/u appointment transportation and cardiac rehab) –Follow up at 48 hr: Call center personnel, Call algorithm GAP- Medication access facilitator (both payment and transportation) GAP – Provider communication- common location for documentation Outpatient resources –Appointment attendance verification: Call center personnel, Maestro –SDA, specialty and PCP clinic care: good review/reinforcement GAP – Medication management skills, transportation for f/u GAP – Meaningful Use criteria: MyChart access , Bi-Directional communication  GAP – Post d/c patient access to literacy appropriate d/c instructions GAP – Provider communication- common location for documentation 3

4 We HAVE Care Delivery Innovations: Apple Healthkit

We DON’T HAVE - Pillbox Continuity Model

The Drag & Drop Pillbox: Patient-Centered, Skill-Based Medication Management Funded by The Duke Endowment

Skill-Based Learning Improves Outcomes Simulation improves: –Learner confidence –Learner knowledge –Learner performance –Learner critical thinking

The “Drag & Drop” Pillbox My Pill Box Medication List Click Here to download this list as a PDF document. NameFull Name Picture by Dosage(if available) AccuprilAccupril (quinapril) 5 mg 10 mg 20 mg 40 mg Acebutolol acebutolol (Sectral) 200 mg 400 mg Acetaminophen (Tylenol ER) 650 mg

The “Drag & Drop” Pillbox

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Drag and Drop: Skill-Based Learning Improves Outcomes Medication Literacy Patient Confidence and Performance Data Capture and Real-Time Feedback –Med Ed and Med Rec in “learning healthcare systems” –Real-time data and feedback to improve med outcomes Patient-Provider Engagement Shared Goal Setting Meaningful Use

20 Graphic courtesy of DIHI (Mark Dakkak and RJ Andrews)

What Works for Patient Adherence to Guidelines? Programs to Combine Proven, Scalable Interventions Communication at discharge –Teach-back improves shared goal setting and access Skill-based educational methods –Teach-back improves medication adherence Communication at follow up (phone or visit) –F/U calls (two-way interaction) provide reminders –Telephone technology (modules) improve engagement –F/U in community settings improve sustainability Feedback to reinforce beliefs –Behavioral economics + influence health behaviors –Home monitoring devices improve two-way engagement 21

Broad Implications for Drag & Drop Pillbox The Joint Commission Accreditation goals –National Patient Safety Goal revised elements –“maintain and communicate accurate patient med info” CMS Process of Care Core Measures – –Incorporation of med rec list in discharge instructions Consumer Assessment of Healthcare Providers/Systems (HCAHPS and CAHPS) Meaningful Use of Electronic Health Records –HITECH Act