Implementing Teach-Back Throughout HCMC

November 8, 2012RARE Action Learning DayJennifer Rudolph, HCMC

Structure

• Performance Excellence Department

• Manage Organizational Initiatives

• Advise on the Projects to Implement

• Facilitate & Manage the Project

Future Process

HIG

H R

ISK

ME

DIU

M R

ISK

LOW

RIS

K DIS

CH

AR

GE

D

Patient Admitted

Review criteria to categoriz

e into H, M, L

Follow-up appointment

made

Follow-up appointment

made

Medication Education & Discharge

Instruction using teach back

Discharge summary

sent to PCP

Follow-up phone call

Discharge summary

sent to PCP

Follow-up phone call

(24-48 hours)

Home care visit

Follow-up appointment

occurs

Home care visit

Follow-up appointment

occurs

Follow-up appointment occurs

MEDIUM

Medication Reconcillation

Medication Reconcillation

Medication Reconcillation

Medication education and discharge instruction

using teach back

Prim

ary C

are

Specia

lty Care

Home Health Care

Skille d Nurs ing Fac ilit y

Hospice

HCMC Hospital Transitions of Care Program2012

Teachback: Operationalize a process, using best practices,

that supports nurses, pharmacists, and providers with applying teachback to

education patients on medications and discharge

instructions.

Epic AVS: Develop standard work for

completion of AVS that meets regulatory

requirements, is patient friendly, bases for teach-

back, & contains pertinent information.

Redesign of Case Management: Redesign case management to incorporate workflow changes that align their work with the goals of the organization, and that creates a more patient and

family centric model.

Follow-Up Appointments: Follow-up appointment

occurs within 3 days (high risk) and 5 days (medium

risk) of discharge.

Medication Reconciliation: TBD

Discharge Follow-Up Phone Calls: Implement a

process based on best practices that provides patients in the high and

medium risk categories a follow-up phone call within

24 hours (high) and 48 hours (medium).

Criteria Review: Use best practices and HCMC

experience, to develop and implement a process, to

assess inpatients for their admission risk.

Discharge Summary: Within 24 hours of discharge ensure

discharge summaries are available to PCP for

all patients. Program Objective: Improve clinical processes and tools to communicate and optimize the patient’s

health after hospitalization to decrease avoidable hospital

readmissions.

Every Project Has A Charter

Timeline

Fall 2012 Continued

Organizational Training (Ambulatory, Pharmacy,

etc.)

By December 2012

Training for New Employees

Implemented

August 2012

Started Provider Education &

Plan

June 2012 Approved for all

of HCMC

July 2012Teach-back at

ReNEW

May 20122 day workgroup to

develop training- initial focus

inpatient

March 2012

Teachback chosen as a

project

April 2012 Teach-back

project started, planning phase

Defined Training Objectives• Define teach-back

• Know the benefits of using teach-back

• State expectations of using teach-back at HCMC

• Demonstrate use of teach-back

Training Plan

Benefits

• Organization: Standard Teaching Method• Operational leaders: Dedicated Project Management• Patient care units: Team Environment• Patients: Increased Understanding and Compliance• C-Suite: Fewer Avoidable Readmissions

Sustainment

• Hardwiring

• New Employee Education

• Integrated into other education & programs

• Becoming the culture at HCMC