1. Module 3 The Re-Designed Discharge Process: Patient Discharge and Follow-up Care

2. Accomplishments to Date (Module 1) Process map of current discharge process completed Primary care practitioner (PCP) referral base defined Patient Care Plan structure finalized Project charter initiated Dates for training frontline staff set

3. Accomplishments to Date (Module 2) Project metrics identified and planned Patient inclusion criteria defined Process for identifying patients and notifying Discharge Advocate (DA) defined Multidisciplinary involvement and communication plan determined Patient Care Plan process finalized (what data to include and how to gather it)

4. Module 3 Objectives 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 Sending plan to PCP Finalize care plan completion and printing Review how to conduct teach-back with patient and family Finalize process for making post-discharge calls

5. Module 3 Outline Completing the Patient Care Plan Teaching and teach-back Conducting post-discharge activities Measuring the process Training frontline staff

6. Patient and Family Centered Safe Care Pre Patient Admission H&P; Assessments; Rx Plan PATIENT EDUCATION/ Prepare for Home Discharge Order Written Discharge Process Discharge Event FINAL DISCHARGE INSTRUCTIONS Post-D/CFOLLOW-UP MEDICATION MANAGEMENT Discharge Folder Passport for Home White Board, Rounding & Bedside Report Community providers: Nursing HomeNursing Home Home Health & HospiceHome Health & Hospice Home CareHome Care PhysiciansPhysicians Accountable Care OrganizationsAccountable Care Organizations

7. Admission and Care and Treatment Education 1. Ascertain need for and obtain language assistance 2. Medication Reconciliation 3. Reconcile discharge plan with national guidelines 4. Follow-up appointments 5. Outstanding/pending lab & diagnostic tests follow-up 6. Post-discharge services 7. Written discharge plan 8. What to do if problem arises 9. Patient education 10. Assess patient understanding 11. Discharge summary sent to PCP 12. Telephone reinforcement t

8. Sample Process Map: Patient Discharge

9. Completing the Patient Care Plan Medication reconciliation Pending tests and results Post-discharge services PCP Follow-up appointments Information about condition

10. Medication Reconciliation Hospital procedure for completing medication reconciliation at discharge DA may participate and conduct final check on medications Using final list, populate Patient Care Plan and complete additional columns (e.g., purpose, time of day) Final list used to instruct the patient

11. Pending Tests and Results Obtain information about tests and studies completed in hospital but have results pending Add pending tests and results to the Patient Care Plan, including which clinician is responsible for getting final results Encourage patient to discuss tests with PCP, point out where the information is on the Patient Care Plan

12. Post-Discharge Services Confirm with case manager that all services have been arranged List services and contact information in Patient Care Plan

13. Primary Care Provider Confirm name of PCP with patient Add PCP name and contact number to Patient Care Plan

14. Follow-up Appointments Discuss best days of week and times of day with patient Discuss transportation needs Call clinicians’ offices to make appointments that meet patient’s time options – Leave message with clinician’s office to call patient if calling outside of normal hours or on a weekend Add appointments to Patient Care Plan

15. Information About Condition Get pre-printed information about patient’s condition to add to Patient Care Plan Add to Patient Care Plan: – Signs and symptoms that warrant followup with clinician – When to seek emergency care – How to contact the DA and PCP (phone numbers and paging instructions)

16. Patient Care Plan Sections Date of discharge Name and contact information for physician and DA How to reach physician and when to seek emergency care Medications Pending tests and results Follow-up appointments Calendar Other orders (diet, activity, etc.) Information about disease or condition Form for writing down questions Map for locating appointments (optional) Other information about your center (optional)

17. Answer the Following Questions as a Team Have all the content areas been included in the final Patient Care Plan template? Can the DA access all the content to add to the Patient Care Plan? – From where? – How reliably? – How timely? What gaps still exist that need to be addressed?

18. Teaching and Teach-Back All education material Care plan completed – Two printed copies – Copy to quality department Meet in quiet place Review all parts of the Patient Care Plan Confirm understanding using teach-back methods

19. Health Literacy Tips* Avoid medical jargon Speak slowly Provide simple pictures when helpful Emphasize what the patient should do Avoid unnecessary information Welcome questions Ensure written materials use simple words, short sentences in bulleted format, and lots of white space * Graham and Brookey

20. Teaching Tips* Elicit symptoms and understanding from the patient 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

21. Teach-Back Way to confirm that you have explained what the patient needs to know Not a test of the patient but rather a test of how well you explained a concept Should be used with every patient; never assume literacy or health literacy All staff should know how to do it

22. Teach-Back: Place Responsibility on Yourself “I want to be sure I didn’t leave anything out that I should have told you. Please, in your own words, tell me what you will be doing when you get home so that I can be sure I have explained it correctly.” “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)

23. Teach-Back Technique Do not ask a patient, “Do you understand?” Do not ask yes/no questions Ask patients to explain or demonstrate how they will undertake a recommended treatment or intervention Ask open-ended questions Assume that you have not provided adequate teaching if the patient does not explain correctly. Re-teach in a different way.

24. From the U.S. Health Resources and Services Administration Teach-Back – Show Me Method

25. Teach-Back Steps* 1. Use simple lay language; explain the concept or demonstrate the process avoiding technical terms; use a professional translator if a language barrier exists 2. Ask the patient or caregiver to repeat the concept in his or her own words or to demonstrate the process 3. Identify and correct misunderstandings or an incorrect procedure 4. Ask the patient or caregiver to repeat the concept or repeat the process to demonstrate understanding 5. Repeat steps 3 and 4 until clinician is convinced comprehension and ability to perform process is adequate and safe * Society of Hospital Medicine

26. 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 (e.g., memory) – Environmental barriers (e.g., lack of support person at home) – Attitudinal barriers (e.g., lack of trust) “Please demonstrate the activity I’ve just explained to you or shown you.”

27. Resources for Teach Back Coaching Teach-Back Self-Evaluation Tool Conviction Confidence Scale Discharge Instructions - Teach-Back Completion Rate Discharge Instructions - Teach-Back Completion Rate Observation Tool

28. Conducting Post-Discharge Activities Transmit discharge summary and Patient Care Plan to PCP – By fax: Ensure it is received and legible – By e-mail: Ensure it is received Follow-up phone call to patient 48 to 72 hours after discharge – Caller uses script that assess understanding of medication and follow-up appointments – Need for second call by clinician determined

29. Measuring the Process Timeliness of RED activities – DA log data Review Patient Care Plans after discharge – Percent with medication list – Percent with care needs listed – Percent with post-discharge services and contacts listed – Percent with follow-up appointments made – Percent with pending tests and results listed (or “none”)

30. Teaching Frontline Staff Why? – Gain understanding, buy-in, participation, role clarification Who? – Nursing and medical staff on participating units, pharmacists, case managers When? – Prior to launch of RED implementation – Set date for live or recorded session How? – Customize slide deck as necessary

31. Module 3: Summary Expected Outcomes DA aware of discharge order and completes Patient Care Plan – Medication list – Pending tests and results – Post-discharge services – PCP identified – Follow-up appointments made DA conducts final teaching and teach-back with patient and family Post-discharge followup occurs – Transmit summary and Patient Care Plan to PCP – Phone patient within 48 to 72 hours Measurement of discharge process complete Plans for teaching frontline staff finalized

32. Progression to Module 4 Checklist ___Processes to finalize Patient Care Plan after discharge order is written in place ___Teach-back methods outlined ___Quality and performance improvement staff understand project measurement requirements and are prepared to gather data ___Process for transmitting discharge summary and Patient Care Plan to PCP finalized ___Plans for teaching frontline staff finalized