ihi - triple aim fragmented, episodic care continues · mary henrikson, mn, bsn, cenp vice...

Nutrition, Discharge Planning and Care Coordination: The Impact on HCAHPS

Mary Henrikson, MN, BSN, CENP

Vice President of Patient Care, CNO/COO

St. Anthony Medical Center

Frisco, Colorado

Disclosure

The content of this program has met the continuing education criteria of being evidence-based, fair and balanced, and non-promotional.

This educational event is supported by Abbott Nutrition Health Institute, Abbott Laboratories.

No relevant financial relationships to disclose

Honorarium and travel supported by Abbott Nutrition

Objectives:

• Discuss the questions and related care practices that have the strongest impact on overall HCAHPS score.

• Describe how to incorporate best practices to enhance discharge and transition planning with nutrition-related approaches.

• Review the importance of discharge and transition planning in comprehensive care coordination.

Care Coordination, Discharge Planning, Transitions of Care

• Impact on HCAHPS Scores

• Best Practices

• Bedside Nurse’s Role

• Bedside Nurse’s Responsibility

“The System that Never Discharges the Patient” Advisory Board

IHI - Triple Aim

• Improve Health Outcomes• Increase satisfaction• Decrease costs

Care Coordination

Fragmented, Episodic Care Continues

• > 70% of ED visits are avoidable

• 4.4 million hospital trips preventable

• 20% of d/c’d pts. experience adverse event within 3 weeks

• 2.3 million ED visits from pts. d/c’d in previous 7 days• 18% of hospitalized pts. are readmitted within 30 days

• $25 - $45 Billion wasted because of inadequate care coordination

• Hospital Readmissions Program – 3% penalty

What is Care Coordination?

“The deliberate organization of individual care activities between two or more participants (including the patient) involved in an individual’s care (for the purpose of) facilitating appropriate delivery of health services.” AHRQ, Care Coordination Atlas, Chapter 2 1/2011

What is Care Coordination?

• For the health professional Care Coordination is:• A patient, family and team-based activity• Helping them navigate through the health care system• Involves determining:

• Where to send the patient• What information• Who is accountable & responsible

What does failure look like?

• For the patient = “unreasonable levels of effort required”

• For the health care professional:• Patient is directed to the wrong place in the health care

system• Has poor health outcomes • Unreasonable levels of effort

What is Discharge Planning?

Activities that facilitate a patient’s movement fromone health care setting to another, or to home. It is a multidisciplinary process involving physicians, nurses,social workers, and possibly other health care professionals.

Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Aim of Discharge Planning

• Reduce hospital length of stay• Reduce unplanned readmissions• Improve coordination of care

Failure of Discharge Planning

Only….•State their diagnosis – 41%•State purpose of medications – 37%•Knew common side effects – 14%

Maniaci.MJ. et.al., 2008, Functional Health History and Understanding of Medications at Discharge, Mayo Clin Proc., 83(5):554‐558

What is Care Transition?

• TJC: The movement of patients between health care practitioners, settings, and home as their condition and care needs change

• AHRQ: Transitions may occur between health care entities over time and are characterized by shifts in responsibility and information flow.

• More Complex

Care Transitions

DischargePreparation

Failure

MultidisciplinaryRounds

Discharge Teaching

Motivational Interviewing

ReED (AHCP)

PCP Connect

F/U Appointments

PostAcuteCareConnectio

n

Hospitalist

Care Coordinator

Case Management

Patient Activation

Care Transition Roles

Identify high risk pts.

Physician

Nursing

PT/OT/STNeeds Summary

Teach Back

MedicationReconciliation

Post D/C Phone Call

HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems)

•Purpose• Publically report patients perception• Value based purchasing program

• 30%

What Drives High Overall HCAHPS Scores?

• NOT Discharge Planning!• Most highly correlated:

• Those questions associated with patient’s interaction with hospital staff:

• Patient centered• Responsive

Discharge Information

• Two Questions• Did the 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?

• Yes or no answers

Impact of Discharge Planning

• Groups of pts. received d/c planning vs. not• Those who did were more satisfied (Shepperd, S. et al, Discharge

planning from hospital to home, The Cochrane Collaboration, 2013, Issue 1)

• Identifying promising practices for improving patient centeredness

• Major theme was a focus on discharge planning (Aboumatar, et al, Medical Care, 2015)

Impact of Discharge Planning

• Directly not a high correlation…..BUT• Relationship to those questions that are:

• Acute intentional interaction strong nurse communication

• Patient centered

• Patient satisfaction with discharge planning associated with lower 30 day readmission rates (p < .001) ( Boulding, W.,et. al., Am J Manag Care. 2011;17:1).

Care Transitions – 3 Questions

• 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.

• Rooted in communication• Assessed capacity & capability

• Patient & family to perform post discharge activities• Mutual decision about post discharge plan

Care Transitions

• 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

• Information on side effects is not enough

Best Practices (BP)

Clinicians in any setting need to feel responsible for a patient’s care across

the full continuum.

Best Practice Tools to Use: Phases of Hospitalization

A

Admission/Post Admission

B

During

C

Close to Discharge Other

Begin on admission Multidisciplinary Rounds Medication Reconciliation Care Transition Roles

Identify pt’s at high risk

for readmission

Teach Back Interfacility Summary Tool Programs

Assess level of patient

engagement

Discharge Instructions Schedule timely F/U visits Sharpening the Saw

Identify key learners After Hospital Care Plan Post D/C phone calls Measure

Effectiveness

Community Care

Partners

(Not) “an add-on to your current discharge process. It is a new way of

discharging patients that requires you to stop discharging patients the old way.”

(Project ReED, AHRQ)

Think differently…..

Case Study

Mr. D

Best Practice (BP): Begin on Admission

• Discharge questions added to admission form• Assess knowledge base

• Does Mr. D know anyone with diabetes?• How is that person’s health?

• Before hospitalization education for planned admission

BP: Identify patients at high risk for readmission

• Helps to focus time and energy• Deep dive into records to identify frequent flyers and their

diagnoses• Use clinical judgement:

• Diagnoses with high readmission rates • Multiple co-morbidities• Numerous medications • Psychosocial and emotional factors• Lack of other caregiver• Older age

(continued)

BP: Identify patients at high risk for readmission - continued

• Financial distress

• Deficient living environment • homeless

• Low health literacy

• Low levels of activation

• Substance abuse

• No primary care practitioner (PCP)

• Male

BP: Identify the key learner

• Who beside the patient should be present?

• Goal: to ensure patient education efforts include person most likely to carry out discharge instructions

• 3 Questions to identify key learner:• Who assists you with your medications at home?• Who accompanies you to your doctors appointments?• Who should be present to listen to your discharge instructions?

• Put their name on the white board

• Schedule education when key learner is present

• Have conversation and tailor approach

BP: Assess level of patient engagement and use it to individualize discharge planning and teaching

“It is much more important to know what sort of a patient has a disease than what sort of a disease the patient has.”Sir William Osler, Founder of Department of Medicine, John Hopkins Hospital


• Major focus in health care reform:• “Actions individuals must take to obtain the greatest benefit

from the health care services available.”Center for Advancing Health

http://www.cfah.org/file/CFAH_Engagement_Behavior_Framework_current.pdf

• Better outcomes

• More engaged patients makes the health care professional’s job easier

• Who’s engaged and who is not?


• Patient Activation Measure (PAM)• Metric to quantify patient engagement• More activated = more effective use of health

resources and engage in more positive behavior• Less activated = 2x more likely to be readmitted to

hospital within 30 days of discharge• Costs are 8% higher

• Baseline score predicts future clinical, behavioral and utilization outcomes.


•PAM – A vital sign?• More efficient use of resources• Tailor teaching and coaching

• Diet and Nutrition Goals

Level 1 Level 2


• Example: Regional Health System in Midwest• Incorporate PAM in to frontline care coordination

• Administered as soon as patient is scheduled for discharge

• Low Activated patients assigned a coordinator • Coaches for activation

• Results: 8-12% decrease in hospital readmission Hospitalized adult medical patients in an urban academic safety net hospital with

lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital

utilization. J Gen Intern Med. 2014 Feb;29(2):349-55. doi: 10.1007/s11606-013-2647-2. Epub 2013 Oct 4.


• Motivational Interviewing• Puts patients at ease• Stronger rapport develops• Addresses barriers to engagement• Evidence based• Helps to gain the patient perspective• Asks questions in a non judgmental way• Training available: “Motivational Interviewing 101”, Advisory

Board Company, 2015


• Motivational Interviewing Examples

Normal Motivational

Can you pay for your medication? Most people have trouble paying for medicines. Is this something you might struggle with as well?

Are you a smoker? How much do you smoke a day?

Would you mind if we talked about your smoking? How do you feel about it?

Your blood sugar is really high; you need to take insulin and change your diet.

What do you think you can do to cut down on high carbfoods in your diet?

BP: Multi (Inter) disciplinary Rounds (MDR)

• A key best practice to utilize in the hospital to improve care transitions

• Disciplines come together• Coordinate patient care• Determine care priorities• Establish daily goals• Plan for transfer or discharge• DONE WITH THE PATIENT!

• Case management, Nursing, Pharmacy

PT/OT, Dietary, RT, SW, Physicians

BP: Multidisciplinary Rounds (MDR)

• Occur frequently

• 4-6 minutes per patient

Structured Interdisciplinary Bedside Rounds PreparationSheetShapiro, S.E., “Accountable Care at Emory University”,Voice of Nursing Leadership, January, 2015

Discharge Education/Instructions

• 80% of medical info is immediately forgotten

• Only half of what is retained is correct

• 3 Common Pitfalls1. Key Learner often receives little or no education2. Often crammed into a brief session on day of discharge3. Focused solely on knowledge, not motivation or

behaviors

• Need to expand from education to buy-in

• Patient Centered: literacy, culture, primary language

BP: Teach Back

• Intervention that promotes adherence, quality and patient safety

• Not a test of the patient, but rather a test of how well YOU explained the concept

• Ask pt. to explain in own words• “So that I know I did a good job of teaching you how to choose the right foods for your

diet, can you show me from this group of foods what you would choose for breakfast tomorrow morning?”

BP: Teach Back

• Use the technique with ALL patients• Sequence the questions to determine knowledge,

attitude and behavior • Knowledge – Ask the Mr. D to tell you what foods he should avoid

now that he has been diagnosed with diabetes.• Attitude – Why is it important to substitute other foods for the

doughnuts?• Behavior – How will you make sure have those foods in the house

so you won’t be tempted to eat the food you should avoid?

• Helps to address barriers

BP: Teach Back – Does it Work?

• All levels of literacy skill prefer teach back method• Lehigh Valley Health Network Peter, D., et. al., 2015 Reducing Readmission Using

Teach Back, Enhancing Patient and Family Education, JONA, 45:1, 35-42.

• Heart Failure patients• 30 Day Readmission rates

• 9.97% without teach back• 7.61% with teach back

• ALOS• 6.61 days without teach back• 5.16 days with teach back

• Training Toolkit available at www.teachbacktraining.com

BP: Teach a discharge plan that is easy for patients to understand and follow correctly

• 78% of patients demonstrate poor comprehension of at least one discharge instruction element

• 77% are discharged with inaccurate or incomplete medication instructions

• Common pitfalls• Illegible handwriting• Blocks of small text• Multiple pages• Medical terminology• Medication abbreviations• Long sentences, sophisticated language• Intended for both PCP and patient

BP: Teach a discharge plan that is easy for patients to understand and follow correctly

• Review current instructions for 3 C’s• Patient Centered• Concise• Comprehensive

• Simplify & organize• Q & A format• Simple words and one sentence phrases• Use plain language• Color coded calendar of follow up apts.

• After Hospital Care Plan (Project ReED – Project ReEngineeredDischarge))

Does ReED Work?

• Boston Medical Center• 28% reduction in readmissions among patients in pilot

program• 51% of the patients in the pilot reported the program

being extremely or very useful

BP: Discharge Medication Reconciliation

• Confusion about medication PROBLEMS!• Fails to take medicine• Takes duplicate medicine• Experience adverse reactions• Natural Remedy interactions

• Do before patient leaves the hospital

• Identify problems patients may have with obtaining their medication

BP: Schedule F/U Visits/Referrals

• One of the most important components of care transitions

• PCP, Tests, Home Health visit, medical equipment delivery, clinics – diabetic clinic

• Explain the why

• Enter in to workbook

BP: Post Discharge Phone Calls

• Within 48 hours of discharge

• Purpose• Allay concerns• Review tests• Remind of F/U apts.• Opportunity to ask questions (medicines, pain)

• Personalize

• Pharmacist calls

• Document

Does it Work?

• Memorial Hospital• After 10 months, readmission rates for

• CHF pts. decreased from 15.4% to 9.1%; • COPD from 20.6 to 11.8%; • Pneumonia from 10% to 9.7%

• Patient satisfaction went up from 81.4 to 87.7 top box

Memorial Hospital Uses AHRQ Resource to Cut Readmission, Promote Patient Self Management, April 2015, AHRQ, Rockville, MD http:/ww.ahrq.gov/policymakers/case-studies/201507.html

BP: Interfacility Patient Summary Tool

• Electronic or written

• Jointly developed

• Goal is to ensure critical info is easily accessible to PAC providers

• Include• Active issues• Diagnoses• Medications• Required services• Warning signs• Who to contact in emergency

• Verbal report

BP: Project ReEd

• Individualize to culture/language needs• F/U apts.• Plan for F/U results• Organize post d/c outpatient services• Correct medicines & plan to obtain• Teach a written discharge plan• Education patient about diagnosis & meds• Review what to do if problems• Expedited discharge summary to PAC units& clinicians• Telephone reinforcement

Why should Hospitals Use ReED?

• Improve Clinical Outcomes

• Meets Safety Standards & Improves Documentation

• Improves Return on Investment

• Improves Patient Centeredness & Hospital’s Community Image

Internet Citation: Tool 1: Overview. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/redtool1.html

Project ReEd Results

• Care Transitions Scores• 79.6% 84.6% (top box)• Preferences 78.2% 81.2%• Good Understanding 81.7% 85.1%• Understanding of medications 84.2 87.4

http://www.ahrq.gov/professionals/systems/hospit

al/toolkit/index.html


• Two hospitals in Texas: (heart failure, AMI, pneumonia)

• Readmission decrease • Brownsville – 23.3 to 15%• Harlingen – 26% to 15%

• AHRQ’s RED Toolkit Leads to Lower Readmissions, Better Care Transitions in Two Texas Hospitals, November 2014, AHRQ, Rockville, MD http:/ww.ahrq.gov/policymakers/case-studies/201420.html


• SNF in Boston• Rate of hospitalization 30 days 18.9% 10.2%

p<.05.

• Attended outpatient apt. within 30 days of d/c52% 70.5% vs. ( p<.003).

Berkowitz, RE, et. al., 2013, “Project ReEngineered Discharge (RED) lowers hospital readmission of patients discharge from a skilled nursing facility. J Am Med Dir Assoc, 2013, Oct; 14(10) 736-40.

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ihi - triple aim fragmented, episodic care continues · mary henrikson, mn, bsn, cenp vice...

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