preventing avoidable readmission together using project re-engineering discharge project red

Learn. Act. Improve. Spread. Keep the Drum Beat Going.1

Preventing Avoidable Readmission Together

Using Project Re-engineering Discharge

PROJECT RED

Discharge Planning

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/C

FOLLOW-UPMEDICATION MANAGEMENT

Discharge Folder Passport for HomeWhite Board, Rounding & Bedside Report

Community providers


Modules

• Module 1 - Getting started.• Module 2 - Patient admission care and treatment.• Module 3 - Patient discharge and follow-up care.• Module 4 - Preparing to launch.


Module 1: Getting Started

• Identify organizational strategic priorities that will align with local, regional, and national requirements

• Develop a systematic performance improvement process to facilitate knowledge transfer and sustainable change

• Review the roles of executive sponsor, project team leader, discharge advocate, physician champion, and pharmacist in the redesigned discharge process

• Develop an understanding of Project RED’s 12 elements


Where are we?

• All Cause, All Payor– Baseline 11.56%– 2012 11.50%– 3Quarter 2013 11.03%

• 30 day Medicare All Cause– Baseline 18.75%– 2Quarter 2013 17.36%

Goal = 9.2%

GA HEN Goal = 15.24%CMS Average = 14.2%


Why?

Keeping our Aim in sight!14,300 individuals

What is your Aim?


HHS Project RED

ALL12 elements

Learn. Act. Improve. Spread. Keep the Drum Beat Going.

1. Explicit delineation of roles and responsibilities2. Discharge process initiation upon admission3. Patient education throughout hospitalization4. Timely accurate information flow: 5. From PCP ► Among hospital team ► Back

to PCP 6. Complete patient discharge summary prior to

discharge

Principles of the Re-Engineered Hospital Discharge


6. Comprehensive written discharge plan provided to patient prior to discharge

7. Discharge information in patient’s language and literacy level

8. Reinforcement of plan with patient after discharge9. Availability of case management staff outside of

limited daytime hours10. Continuous quality improvement of discharge

processes

Principles of the Re-Engineered Hospital Discharge (continued)


12 Elements

1. Ascertain need for and obtain language Assistance2. Medication reconciliation 3. Reconcile discharge plan with national guidelines4. Follow-up appointments5. Outstanding tests 6. Post-discharge services7. Written discharge plan8. What to do if problem arises9. Patient education10. Assess patient understanding11. Discharge summary sent to PCP12. Telephone reinforcement


Performance ImprovementStructure

Deming, Shewhart, Lean

• Plan• Do• Check (Study)• Act

Lean Six Sigma

• Define• Measure• Analyze• Improve• Control


Getting Started

• Leadership Support• Determine Your

Infrastructure– Oversight committee– Champion– Project Team

• Team formation• Team Charter

• Process Flow – current state• Swim Lane – Delineates

roles and responsibilities• Gap Analysis – measure

current process with the 12 elements – What’s missing?

• Gallery Walk – SWOB– Prioritize


Questions to run on

• What really matters to the organization? Achieve bottom-line results• Can we measure the impact of the project?• How much has the project contributed this year and will contribute

in future years?• Is our project scope manageable?• Do we have PI structure including oversight steering committee;

project champion; DA; pharmacist; team members; team leader; scheduled dates, times, and resources needed for the meetings?

• Have we alerted ad hoc resources such as finance, medical records, IT, education dept, etc., as needed?

• What is missing and who will be responsible?


Define the Current State – finding the root cause(s)

• Initiate a high-level process map• Multidisciplinary participation• Patient admission is the starting point• Start with the ending point - After hospital care provision is the

ending point• Ask each discipline what steps it takes to prepare the patient

for discharge

Physician

Nursing

DischargeAdvocate

Pharmacy

Sample Process Map: Patient Discharge

Patient AdmissionOrders

Initiate postdischarge phone

call

EstablishClinical

Pathway

AdmissionAssessment

MedicationReconciliation

Educate patientabout diagnosis,

tests, and studies

Identifytarget patient

Initiate dailydischarge

huddle

Initiate AfterHospital Plan

Collect data reProcess and

Outcome metrics

Schedule Postdischarge f/uappointment

Verify MDorders Create MAR

Assist withmedication

reconciliation

Assist withmedicationteaching

Participate inDC Rounds

Educate patientabout diagnosis,

tests, and studies

Initiate DCorders

ReinforceDischarge Plan

Provide careand treatment

CompleteAHCP


Once the Process Map is Completed

• Analyze the work flow – get the patients input• What defects exist? Where are communication breakdowns, failure

to hand off information?• Where do delays occur?• What are your Project RED gaps? • Do we have omission , selection, documentation, communication,

administration failures?• What steps in this process would the patient be willing to “pay

for”? Value Added?


Compare Discharge Information

List current state

• What are we missing?

RED Discharge Plan Components

• Individual hard copy care plan (language specific)

• Medication calendars in lay terms• Daily morning, afternoon, and

evening meds identified• Patient questions list• Scheduled follow-up

appointments• Pending tests and results• Location of appointments

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Process MetricsRED Component DE Responsibilities Process Measures 1. Ascertain need for and obtain language assistance.

Find out about preferred languages for oral communication and written materials.

Determine patient and caregivers’ English proficiency Arrange for language assistance as needed, including

translation of written materials.

Is the spot on the nursing assessment for language filled in?

Is the plan for how to communicate filled in if there is a language problem identified?

Is discharge info in pts/ learner’s preferred language?

2. Make appointments for follow-up medical appointments and post discharge tests/ labs.

Determine primary care and specialty followup needs. Find a primary care provider (if patient does not have one)

based on patient preferences: gender, location, specialty, health plan participation, etc.

Determine need for scheduling future tests. Make appointments with input from the patient regarding

the best time and date for the appointments. Instruct patient in any preparation required for future tests

and confirm understanding. Discuss importance of clinician appointments and

labs/tests. Inquire about traditional healers and assure that traditional

healing and conventional medicine are complementary. Confirm that the patient knows where to go and has a plan

about how to get to appointments; review transportation options and address other barriers to keeping appointments (e.g., lack of day care for children).

Are needs clearly documented in medical record and on D?C paperwork?

Does unassigned pt have a plan for f/u?

Do apt setting procedures involve pts?

Did pt receive education about f/u needed? Labs needed p d/c? Is this documented?

Is there documentation of traditional medicine/ complementary medicine discussion?

Is transportation discussed and documented in the d/c notes? Are barriers addressed?

3. Plan for the followup of results from lab tests or studies that are pending at discharge.

Identify the lab work and tests with pending results. Discuss who will be reviewing the results, and when and

how the patient will receive this information.

Is lab work that is pending documented? How will the pt get these results? Is this documented? Does the patient know (is this documented as well?

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4. Organize post-discharge outpatient services and medical equipment.

Collaborate with the case manager to ensure that durable medical equipment is obtained.

Document all contact information for medical equipment companies and at-home services in the AHCP.

Assess social support available at home. Collaborate with the medical team and case managers to

arrange necessary at-home services.

Is need for DME identified and specifically addressed? Is all info for getting this on D/C paperwork so pt can F/U if needed

Does CM assessment address the social support situation/ transportation situation?

What at home services can be made available to this pt? Have they been requested? Outcome?

5. Identify the correct medicines and a plan for the patient to obtain and take them.

Review all medicine lists with patient, including, when possible, the inpatient medicine list, the outpatient medicine list, the outpatient pharmacy list, and what the patient reports taking.

Ascertain what vitamins, herbal medicines, or other dietary supplements the patient takes.

Explain what medicines to take, emphasizing any changes in the regimen.

Review each medicine’s purpose, how to take each medicine correctly, and important side effects.

Ensure a realistic plan for obtaining medicines is in place. Assess patient’s concerns about medicine plan.

Is there documentation of medication list? Are all lists in the medical record the same or is there conflict? If conflict- has this been addressed? Is there documentation of medication teaching for each medication the patient is to be taking?

How will the pt get these medications? Does the pt have concerns about the plan? If so, how are these addressed?

6. Reconcile the discharge plan with national guidelines.

Compare the treatment plan with National Guidelines Clearinghouse recommendations for patient’s diagnosis and alert the medical team of discrepancies.

Does the treatment plan meet all guidelines and if not, why not? Is this discrepancy explained in the medical record?

7. Teach a written discharge plan the patient can understand.

Create an AHCP, the easy-to-understand discharge plan sent home with patient.

Review and orient patient to all aspects of AHCP. Encourage patients to ask.

Does the discharge plan reflect what the patient needs to know and do to continue to improve?

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8. Educate the patient about his or her diagnosis.

Research the patient’s medical history and current condition.

Communicate with the inpatient team regarding ongoing plans for discharge.

Meet with the patient, family, and/or other caregivers to provide education and to begin discharge preparation.

Is there documentation of pts understanding of why they are in the hospital?

Are key learners identified and did they receive education?

9. Assess the degree of the patient’s understanding of the discharge plan.

Ask patients to explain in their own words the details of the plan (the teach-back technique).

May require contacting family members and/or other caregivers who will share in the care-giving responsibilities.

Is teach back being used (must assess during live d/c teaching)

Are key learners included in education?

10. Review with the patient what to do if a problem arises.

Instruct on a specific plan of how to contact the primary care provider (PCP) by providing contact numbers, including evenings and weekends.

Instruct on what constitutes an emergency and what to do in cases of emergency.

Do d/c papers identify who to call if the pt has a question?

Do d/c papers have key conditions that would be impt to notify MD regarding/ to return to the hospital (specific for the patient being d/c’d)

11. Expedite transmission of the discharge summary to clinicians accepting care of the patient.

Deliver discharge summary and AHCP to clinicians (e.g., PCP, visiting nurses) within 24 hours of discharge.

How long does it take other providers to receive the d/c summary?

12. Provide telephone reinforcement of the Discharge Plan.

Call the patient within 3 days of discharge to reinforce the discharge plan and help with problem-solving.

Staff DE Help Line. Answer phone calls from patients, family, and/or other caregivers with questions about the AHCP, hospitalization, and followup plan in order to help patient transition from hospital care to outpatient care setting.

F/U phone call data is used to change or drive care delivery?

Does the d/c paperwork offer a live human to help with questions from family and care givers?


Rounding, Communication Board, Huddles

• Do discharge planning rounds exist on your unit or for your designated patient population?

• Who attends discharge planning rounds?• How often do they occur?• Do your physicians participate in rounds?• How accurate is the information that is discussed in rounds?• How is the knowledge that is obtained during discharge rounds

shared with the rest of the team?• How are you using the communication board?


Tools

What do I do when I go home?


Does your plan include:

• Medications in a clear format?


Does your plan include:

• Follow up appointments ? – How are they going to get there? – Who is going to take them to the appointment?– Location map?


Eliminate Documentation Time and Re-Writes

Ideally, • Information should flow from the medical record to the care

provider who needs it• Information should flow from one practice setting to another• Information that is documented can be time stamped and

assessed for accuracy• The discharge care plan could be automated and flow to the

hands of the care team and patient


Primary Care Physician Referral Base

• Leaders will identify the PCP referral base • PCP satisfaction will be assessed prior to

project launch• Physician champion will communicate with

PCPs about project• PCPs will advise how to handle their off-

shift and weekend patient needs


Post-Discharge Phone Call

• Define who will call your patient after discharge• Define when the follow-up call will be made• Develop script for caller• Develop a process for off shifts and weekends


Module 1: SummaryExpected Outcomes

• Align your strategic priorities

• Develop an infrastructure that will promote communication, understanding of team progress, and documentation of the patient care plan

• Review roles of executive sponsor, project team leader, DA, physician champion and pharmacist in the redesigned discharge process

• Develop a systematic performance improvement process that will facilitate knowledge transfer and sustainable change

• Embed Project RED key principles, including application of the Discharge Care Plan, communication with PCPs and implementing post DC phone calls


Progression to Module 2 Checklist

Before moving to Module 2: • Create your current state process map• Establish the primary physician referral base• Determine the Patient Care Plan structure• Initiate the project charter• Set dates for training frontline staff


Everything you heard today is from:

• Internet Citation: Re-Engineering Discharge Project Charter: Project RED (Re-Engineered Discharge) Training Program. August 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/charter.html


Project RED mini-series: Dates to remember

• In-person– February 6, 2014 – Ramping up Readmissions: Getting to Target – 2

p.m. – 4 p.m. Cobb Galleria Waverly• Teleconference/Webinars

– February 19, 2014 10:00 – 11:30– March 13, 2014 10:00 – 11:30 – March 27, 2014 10:00 – 11:30


Renew Your Sense of Purpose

When we do what’s right for the patient the numbers will follow…..

preventing avoidable readmission together using project re-engineering discharge project red

Documents

patient discharge

drum beat

discharge advocate

pi project

discharge planning process

graphic of discharge

discharge planning image

project reds components