1. A Patient & Family Discharge Planning Model that Works
SEPONL
April 4th, 2014

2. Or, Goodbyes Matter
How can we ensure a “Good Fit” when we say Good-bye?

3. Objectives..& a thought The Larger Context
One Community Hospital’s Story
Implementing a Model
Highlighting the Tools that are its Glue
Consider Webster:
“..Discharge-to relieve of a burden, to release from confinement…”
“..Transition-a passage or movement from one stage to another..”

4. video

5. The Context & the Patient-a Fit?
“…collection of readmission data reflects Medicare’s view that hospitals should be responsible for patients’ well-being even after they go home…” (2013) “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” (2011) “…not our parents’ medicine…” (2012)

6. The Quality of the Good-byes
How many readmissions are “preventable” with standardization? No one knows
Evidence: Re-hospitalizations & poor routines:
Lack of coordinated hand-offs
Hospital resources: How to Maximize?
High Risk approach vs. Dx specific focus
Understand patients: who/why come back
Our nursing teams: how to shift from Discharge to a Transition in Care paradigm

7. The Quality of the Good-byes
Hospitals’ responsibility does not end at discharge
Recognize dangers of transition
Set patients/families up for success (2013)
Positive associations between the patient experience and:
Adherence to prevention/treatment
Health care resource use (2013)
Bundled Intervention Models:
Naylor’s Transitional Care Model
Coleman’s Care Transitions Interventions
Jack’s Project RED

8. The Context/VBP & the Patient
“Transitions”-largest slice HCAHPS pie
Transition questions added (2013)
During hospital stay ,staff took my preferences & my family’s into account
When I left, I had a good understanding of the things I was responsible for
When I left, I clearly understood the purpose of taking my medications
Discharge centered on patient=Success
Domains: RN Communication, the 5 “Discharge” items,Responsiveness,Medications
“…HCAHPS is not about Happiness..”

9. Penn Medicine Chester County Hospital
CCH 263 bed community hospital
Rich history, 120 years
Penn Medicine:
September, 2013
HUP-1st teaching hospital, 1874
Pennsylvania Hospital, the nation’s first, 1751
Penn Presbyterian Hospital
CCH & Project RED
My home away from home

10. CCH & Project RED-our Story
Project “RED” (Re-Engineered Discharge) Background
Safe Discharge is best when clinical team integrates efforts
Communication deficits at Discharge are common; the “Perfect Storm” of patient safety
RED research, Dr. Brian Jack (Annals Internal Medicine , 2009)
Dr. B. Jack/AHRQ/CCH-the national RED Roll-Out Contract
Does the Project RED 11 Element Checklist work in the real world?
Can the Project RED 11 Element Checklist be used more efficiently?
June 2011 site visit; Dr. Jack, Boston Implementation team, AHRQ
Participants: Senior Team, physician & nursing leaders, front line nursing staff, Case Mgt., Nursing Informatics, IT,HIM
CHF patients on Telemetry = pilot population
Our Core RED interdisciplinary team was formed, and still meets!

11. Project RED Checklist – From Admission!
Make appointments for follow-up medical appointments and post discharge tests/labs.
Plan for the follow-up of results from lab tests or studies that are pending at discharge.
Organize post-discharge outpatient services and medical equipment.
Identify the correct medicines and a plan for the patient to obtain and take them.
Reconcile discharge plan with national guidelines.
Teach a written discharge plan (AHCP) the patient can understand.
Educate the patient about his/her diagnosis.
Assess the degree of the patient’s understanding of this plan.
Review with the patient what to do if a problem arises.
Expedite transmission of the discharge summary to clinicians accepting care of the patient.
Provide telephone reinforcement of the Discharge Plan.
(new!) Obtain language assistance for patients/families

12. Integrated HCAHPS Benefits
Re-Engineered Discharge
Nurse Commun-ication
MD Commun-ication
Medication Teaching
Discharge
Hospital Rating

13. RED Benefits HCAHPS? Absolutely!
Discharge Planning Begins on Day 1
RED = Guide to building relationships
RED = Promotes self-management skills
RED = Patient education throughout the stay
RED = Patients & clinical team; common goals
RED = Family engagement
RED = Patient learning as the closing message
RED = Tools for you to link patient safety & the patient experience

14. CCH Project RED Pilot Year: 2011-2012
AHCP recreated in word (available as a PDF/AHRQ website)
RED’s Discharge Educator role = our Telemetry nurses
Telemetry RNs taught the AHCP to patients; what a moment!
All trained on the use of “Teach-Back”—now a RN Competency
Unit Coordinators making F/Up apts: Patient & family satisfier
Clinical Pharmacist inclusion with the CHF pilot patients
Physician Office Practice outreach—utilization of the AHCP
Volunteers & Transport staff: Discharge reminder at curb-side
48 hour post discharge F/Up phone calls
Project RED script
Medication clarification, review F/Up apts, transition support
Our patients, families, staff & physicians loved Project RED!

15. CCH’s AHCP “it’s like an award for discharge”

16. CCH’s List of Medicines & Why/How

17. CCH Clinical Pharmacists: Medication Teaching
Brand Name
Why am I taking this med?
What do I need to look for?
Tylenol
pain, 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
Zyloprim
gout/high uric acid
upset stomach, rash/skin irritation
Xanax
anxiety, "nerves"
drowsiness, dry mouth
Cordarone, Pacerone
abnormal heart rhythm
constipation, sensitivity to sunlight (wear sunscreen)
Elavil
mood, migraine, nerve pain
sedation, dry mouth, avoid grapefruit juice

18. CCH Appointment Calendar

19. Readmission Rate- FY11 vs. FY12
All Telemetry Patients with a Primary Diagnosis of CHF at Discharge
30 Day Readmissions

20. CCH:
Were we getting to a Better Fit?

21. Enlarging our CCH Team! 2012-2013
Clinical & IT experts worked as 1 team - “priceless”
Replication of the AHCP into an electronic version
Stories of the patient experience shaped the goals of this enlarged team
RED’s Checklist worked; expansion for all CCH
CCH Re-Engineered Discharge: 5 Core Principles
Discharge planning begins Day all CCH patients
“My Discharge Plan” all CCH patients
Teach-back methodology all CCH patients
Follow-up appts High Risk patients
Follow-up phone calls High Risk patients

22. There are two version of the report- one for patient and one for SNF/Home Health Nurse/Rehab

23. My Discharge Plan example

24. My Discharge Plan example: Yield and Stop signs

25. Text block library for templated “last licks” instructions

26. High Risk for Readmission Patients
Automated work flow processes to identify patients at risk
High Risk criteria include: polypharmacy, recent admission, key CMS diagnoses, lack of support at home
Identification of High Risk in real time for staff
Creates High Risk for readmission “order” in chart
Unit Coordinators making F/Up Appts : PCP & specialists
48 hour F/Up phone calls-High Risk patients
Automated work flow produces call list daily
Clinical Pharmacists, Paramedics, CV Nurse Navigator

27. High Risk Patients
Populates a report showing all high risk patients on the unit/hospital and reason for inclusion
Populates a report for after discharge phone calls:

28. Pre and Post Measures: Re-Engineered Discharge

29. CCH : HCAHPS Discharge Domain

30. CCH : HCAHPS Care Transitions

31. HCAHPS Trending - Domains related to Project RED Implementation
Project RED Implementation Dates: Telemetry – Sept House-wide – Sept 2012

32. Enhancing our Model Patient’s White Board: planning information
Rapid Daily Rounds
“Plan for the Day, Plan for the Stay”
Interdisciplinary group meets at set time daily
All stand & are prepared, one-two minutes per patient
Teach-back becoming part of culture
Patient/family feel “safe” to ask questions
Bedside Handoff between shifts
Open Visitation
Summer 2013; a Nursing Council initiative
Bedside Delivery of Medications
Telemetry Pilot in 2011; house-wide in 2012
Enables patients to receive new medications prior to D/C
Walgreens’ Pharmacy Tech integrated into nursing teams

33. Are we there yet?
“..higher patient satisfaction with inpatient care & discharge planning is associated with lower 30 day readmission rates…” (2011)

34. A Model & the Patient: Good Fit?
Motivation/partnership with patients/families
Never been healthy; “what does healthy look like”?
How to set up small “wins” in just a few days
Are we truly assessing Self-Management skills?
Applicability to Transitions in Care
Patient Experience—understanding the whole
Care Transition results appear to show less than 50% take patient/family preferences into account upon discharge
People in top 5% of spending--11x more likely to report fair to poor physical health
Patients who report excellent health overall-their HCAHPS ratings 1.5 x higher than poor health

35. Do we know their expectations at D/C?
COLLECTED
PATIENT STORIES OVER A PERIOD OF TIME
SATISFACTION
DATA

36. The Patient’s Voice 2013-2014 Bedside Survey Pilot 2011-2012:
Consistently: “I have heard little about D/C”
Bedside Surveys: electronic solution
Charge RNs/Day 2—Mini iPads
Real time service recovery
Real time data sharing/reports available
Kick-off Fall 2013
Revised: January 2014
Revised D/C question: “Have you heard about”
“Do you have any concerns about going back to your home environment?” & Explain
Winter 2014: Readmission Survey
Day 2, identified from our High Risk workflow

37. Current Data Overview # 611 Survey Question % Yes % No Don’t Know
No Answer 1
Is your call bell being answered promptly?
90.7%
2.3%
0.0% 7% 2
Has our Hourly Rounding helped address your needs?
85.3%
2.8 5
4.9% 3
If you have pain, how well do you feel the staff is managing your pain?
4.81 average score (on a scale) % was not available 4
Has the nursing staff addressed your questions/concerns about your medications?
84.3%
2.5%
5.6% none
7.6% 5
Are the doctors being attentive to your needs?
86.3%
5.2%
 0.0%
8.5% 6
If NO can you tell me about your concerns?
Feel Rushed
Don’t understand their answers
Other
92.0% 7
Planning for your transition back to your home is important to us. Has your nurse or other members of your team started talking with you about your discharge?
62.0%
30.1%
7.9% 8
How would you say we are doing at keeping your room quiet?
4.71 average score
 (on a scale) % was not available  9
Is there a staff member who has been especially helpful during your stay?
64.2%
22.7%
8.6% 10
If you or your family member were sick today, would you choose to return to Chester County Hospital?
0.7%

38. Chester County Hospital Readmission Survey

39. Chester County Hospital Readmission Survey

40. Next Steps/Concluding Remarks
Reinforce: Bundled interventions vs series of tasks
Discharge Model-Yes; Transition Model-not quite Yet!
Spotlight on community hand-off & feedback
Immediate follow-up care for the most vulnerable
Palliative Care referrals as part of our culture
Senior Team Core Group formed; partner with original team
Our understanding of why patients come back
Review All-Cause, but understand Potentially Preventable
Re-evaluate opportunities with High Risk list/F/Up phone calls
Meaningful analysis of successes and returns (SNF/NVNA)
Unplanned 7 day Readmissions
Bedside Survey expansion: insights for the entire clinical team
Conduct Case Reviews on patients who return/succeed

41. Re-Engineered Discharge
You Can Do It Too!
Re-Engineered Discharge
Nurse Commun-ication
MD Commun-ication
Medication Teaching
Discharge
Hospital Rating

42. A Good Fit-we’re getting there
“..the way we communicate with patients/families about their health substantially influences their motivation for action & behavior change..” (2011)

43. Thank you!
Carli Meister Director, Customer Relations & Risk Penn Medicine Chester County Hospital