1 engaging patients and families to improve care transitions
TRANSCRIPT
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Engaging Patients and Families to Improve Care Transitions
Objective for the Session
Discuss strategies for partnering with patients and families to improve their experience of discharge from the hospital and coordination of post-acute care.
Background: BIDMC’s Readmission Rates
Publically Available Medicare Data:
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How has BIDMC involved patients and families?
Patient and family involvement is vital to improving care transitions and, at BIDMC, the level of patient and family
involvement has evolved overtime.
2010 20122011
Patients & Families as
Advisors
Patients & Families as
Team Members
Patient Family Advisory Council
STAAR Cross-Continuum Team
Patient Family Advisory Council
STAAR Cross-Continuum Team
Patient Family Advisory Council
STAAR Cross-Continuum Team
With Increased Advisors With Increased Advisors
Patient Family Interviews
My Care Conference Pilot
DC Med List Focus Group
HF Pt Pathway Focus Group
HCA Care Transitions Pilot
How is BIDMC engaging patients and families in improving care transitions?
Macro Level Involvement
Mico Level Involvement
Cross Continuum Team
Patient Family Advisory Council Working at an individual level to
enable real-time patient- and family- centered handoff communication
Case Example
Case Example:Developing “My Care Conference” from
concept to implementation
Identified Need
Established Vision
Created Project Team
Pilot Implementation
Measured Progress
Adapted Strategy
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Step 1: Identifying the Need
Key Themes from Patients & Family Members in Interviews and Focus Groups
• Patients/families don’t feel like they can contribute to their plan; or when concerns are voiced may be ignored; afraid to push back and be labeled a “difficult” patient
• Discharge was too fast; no time to process what was happening & ask questions
• Discharge materials are an ineffective way to communicate
• PCP seemed unaware of hospitalizations
• Specialists appointments weren’t scheduled in a timely manner / not clear to pt why it was needed
• Too many silos for patients to manage/coordinate on their own (many want a “single point of contact”)
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Step 2: Establishing the Vision
Our patients’ needs are relatively simple… but hard to achieve
“OK, I have three requests…1. Please tell me what you're going to do before you do it to
me. It's kind of hard to deal with the surprises and if you could just make a plan with me, I can do a little better…
2. You know, there are a lot of you – doctors and nurses all around me – do you ever talk to each other? …It would be great if you talked to each other…
3. I’ve been here a lot, in fact, I’ve probably been in the hospital more than you have…if you ask me what I think, I can help you…”
Pt feedback from “Kevin,” retold by Dr. Donald M. BerwickAdministrator, Centers for Medicare and Medicaid Services (CMS); December 3, 2010
My Care ConferenceConnecting Patients with Their BIDMC Team
Our standard practice for ALL patients to:
1. Make a plan with them2. Ask them what they think3. Listen and answer their questions4. Talk to each other5. Coordinate their care
“My Care Conference” = Transformative Change
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My Care ConferenceConnecting Patients with Their BIDMC Team
Slowing down to speed up… Applying this Lean principle by meeting with the patient/family members and developing a plan together, as a team, prior to discharge, will enable faster implementation and less confusion.
Taking an extra 15 to 30 minutes upfront will help to align team, improve communication, and enhance the patient’s experience.
Current State Desired Future State
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Step 3: Building the Implementation Team
Membership
Scope of Work
Timeline
Patient PhysicianLeader
Project Manager
NurseManager
Social Worker
PatientRelations
• Define workflow for delivering care conference to patients• Develop communication materials for patients & families• Engage post-discharge providers • Train floor based staff• Create mechanisms for monitoring and review processes
Jan 2011Project team formed
Mar 2011Pilot Initiated
2-Months for Planning & Development
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Step 3: Building the Implementation Team
My Care ConferenceConnecting Patients with Their BIDMC Team
Pre-Conference Process Details
Pt Admitted
CCF Checks in w/ Care Team After Rounds
Introduce My Care Conference to Patient
InterpreterNeeded?
Pt Interested?
FamilyNeeded?
Part of Screening;Other NeedsMay be Identified
Yes Share & Explain Materials
No
Understand Why
Other Issue?
Set-Up Meeting Time w/ Care Team
And Family, At Pt’s Request
CCF determines how much “prep” can happen during this initial visit
Post Time of Conference& Check-In w/ Pt
Conversation w/ Pt about questions / concerns– estimate approx amount of time for Conf and share w/ team
Have “My Care Conference”
At the end of the session, Team completes “Next Steps”together (Nurse acts as “scribe” to complete the worksheet).
Provide Intro Letter, Things to Think About and Sample Questions
= Activity w/ the Pt= Completed by Care Conference Facilitator (CCF)
Key
Prioritizes Pts based on estimated D/C
Add Note on Pt’s Whiteboard Re: Conf
So Team is aware it has been introduced
Scope of Work
• Define workflow for delivering care conference to patients
My Care ConferenceConnecting Patients with Their BIDMC Team
Making It Happen: Care Conference FacilitatorA new role to help bring all the key participants together
• Checks in with newly admitted patients to introduce “My Care Conference”
• Identifies potential times for the conference, and coordinates with the patient, family members and BIDMC Team
• Helps patient prepare questions and identify objectives for the conference
• Facilitates the conference session to help patient achieve his/her objectives
Care Conference Facilitator
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My Care ConferenceConnecting Patients with Their BIDMC Team
Key Participants
Patient & Family Member(s)
Nurse
Care Conference Facilitator
Physician
Pharmacist(As Available)
Case Manager(As Available)
Interpreters will also be included, as needed
Additional PerspectivesAs Needed / Available
Consultants PCP or Primary NP
Home Care Nurse LTAC or SNF
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Conference Components: Care Team Members
My Care ConferenceConnecting Patients with Their BIDMC Team
Conference Components: Environment of Care
Location
Ideally, the conference would occur outside the patient’s room in a dedicated family meeting space.
To foster dignity and respect
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My Care ConferenceConnecting Patients with Their BIDMC Team
Conference Components: Post Meeting Follow-Up
• All participants will leave the conference with a copy of the plan
• Care Conference Facilitator will use a template to document the meeting and include a copy of the plan in OMR
Develop a standard planning document for the Patient and the Care Team to complete during the conference
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Step 3: Building the Implementation Team
Scope of Work
• Develop communication materials for patients and families
My Care ConferenceConnecting Patients with Their BIDMC Team
Dear _______________;
We understand that being ill and in the hospital can be a difficult experience.
Often, it’s hard to know when and where to ask questions or share your thoughts and concerns.
We want to make it easier– with “My Care Conference.”
At this conference, you and your family can meet with your care team to ask questions and make a plan together, without distractions or interruptions.
Your Care Conference Facilitator: ____________ will tell you more about the Conference and help coordinate the details.
Sincerely,Your BIDMC Care Team
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Step 3: Building the Implementation TeamMy Care ConferenceConnecting Patients with Their BIDMC Team
Things to Think About…This is not a test… everyone gets an A! If you find it helpful, you can use
the space provided to prepare for your Care Conference.
The health related problem that brought me to the Hospital was…
I am most concerned or worried about…
I’d like to know more about…
Next Steps:My Care Team is currently….
____ Investigating why I feel this way (my diagnosis)____ Determining how to make me feel better (my treatment plan)
Over the next two days, My Team will…
My health related goal is…
I can help My Care Team by…
My Nurse will update this plan daily on the whiteboard in my room.
My Care ConferenceConnecting Patients with Their BIDMC Team
Pilot: Outcome Measures to Monitor (Quarterly)
Primary Metrics: Patient Satisfaction Scores:
• The hypothesis is that this drastically different intervention will enable us to better meet inpatients’ needs, and show a consistent improvement in H-CAHPS scores for the floor (when compared to Farr 2 or CC7).
Secondary Metrics:Operational Efficiencies:
• Increased coordination will potentially decrease wasted or duplicated effort (measured through work sampling)
• Planning with the patient from the first day of their visit will help the Team better understand the goals of care and decrease length of stay or improve discharge times
• Ultimately, over the long term, this strategy may improve transitions in care and reduce readmissions.
Staff Satisfaction:• Although this intervention will require a time commitment from the Care Team, it will
enable staff to more effectively connect with their patients,potentially increasing staff satisfaction.
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Step 4: Pilot Implementation & Learning / Adaptation
Challenges Observed at 3-Months- Staff still perceive Care Conferences as only for the most complex patients
- Because conferences have been held primarily for highly complex patients, they typically last longer than the estimated 20 minutes
- Time staff is available doesn’t correlate with when family members can easily attend
- Patients sometimes decline– they don’t want to disrupt their busy doctors
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Step 4: Pilot Implementation & Learning / Adaptation
Questions Presented to PFAC
1) Timing: Based on your perspective, when during a patient’s stay would this type of conference be most beneficial?
2) Participation: Some patients have expressed a reluctance to participate in the conferences, how can we better present this option to them?
3) Triggers: Are there any factors that should automatically "trigger" a Care Conference?
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Step 5: Measuring Progress
Care Conferences are currently being piloted on Farr 7, with an average of four to five conferences per week (max=8; min=0).
Impact on 30-Day Readmissions (March – August 2011)
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Farr 7 Readmission Rate Readmission Rate for Pts who Participated in CareConferences
Although the population may not be large enough to fully assess the impact, the changes on a case by case basis are staggering. For example, 8 patients who in total represented 34 admissions in the past 6 months were discharged without a 30-day readmission.
Further analysis is underway to evaluate the impact of Care Conferences on H-CAHPS scores.
Ave CMI = 1.8 Ave CMI
= 1.2
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Step 5: Measuring Progress
56% of Farr 7’s Discharges Occur Before 4:00 PM
Inpatient Discharges by Hour as a Percent of Total Discharges on General Medicine Floors Between March 1, 2011 and February 29, 2012
44% of Discharges Occur Before 4:00 PM on CC7 and Farr 2
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PFAC and STAAR Advisors Have Offered Valuable Insight to These Changes
Hospital-Based Interventions
• Admission Checklist• Teach Back Method for
Patient Education• Readmission Huddles• Revised DC Instructions• Condition-focused
Inpatient Education• Automated Fax to PCP (on
admission & discharge)• Care Connection
Appointment Scheduling Service
• Pharmacist Assisted Medication Reconciliation
• Discharge Checklist• Discharge Summary
Curriculum • Enhanced Sharing of
Electronic Records• Anticoagulation Mgmt
Initiative
Post-Hospital Interventions• Post-discharge Telephone
Outreach• Transitions Coach
Intervention (Home Visit)
Transition Back to Primary Care• Hospitalist-staffed Post-
discharge Clinic• Enhanced VNA-PCP
Coordination• Enhanced ECF-PCP
Communication
Contingency Management• Cardiology “Heart Line”
for patients after discharge
• Improved Access to Urgent Care Visits
• Outpatient Diuresis Clinic
Preventing Unnecessary Hospitalization• ED-based Cardiologist During Peak
Admitting Hours• Case Management “Leveling” Patients in
the ED
Hospital Primary Care
Emergency Department
Patient & Family
VNA & Home Care
Extended Care Facility
Recovery Return to Primary
Care
Contingency Management
Appropriate Hospitalizations
Challenges to Date
Our Main Challenges in Involving Patients and Families in this Work
• Time Commitment• Sometimes hard to identify the “line” between engaging a patient or
family member in a project and asking too much of a volunteer. • The best times for patients and families to meet are not always the most
convenient time for staff.
• Committee Readiness• Newly developed committees / teams are often hesitant to involve
patients and families until they feel the group is more organized.
• “Representative” Population• The patient and family members who volunteer their time to these
initiatives may not be fully representative of our entire hospital population.