SEPONL April 4th, 2014

A Patient & Family Discharge Planning Model that Works

Or, Goodbyes Matter

• How can we ensure a “Good Fit” when we say Good-bye?

Objectives..& a thought

• The Larger Context• One Community Hospital’s Story

– Implementing a Model– Highlighting the Tools that are its Glue

• Consider Webster:– “..Discharge-to relieve of a burden, to

release from confinement…”– “..Transition-a passage or movement

from one stage to another..”

video

The Context & the Patient-a Fit?

“…collection of readmission data reflects Medicare’s view that hospitals should be responsible for patients’ well-being even after they go home…” (2013)

“The last place patients want to end up after a hospital stay is right back in the hospital….on average 8 minutes of conversation occurs about how to care for oneself at home, so no surprise that patients may have trouble” (2011)

“…not our parents’ medicine…” (2012)

The Quality of the Good-byes

• How many readmissions are “preventable” with standardization? No one knows

• Evidence: Re-hospitalizations & poor routines:– Lack of coordinated hand-offs

• Hospital resources: How to Maximize?– High Risk approach vs. Dx specific focus– Understand patients: who/why come back– Our nursing teams: how to shift from

Discharge to a Transition in Care paradigm

The Quality of the Good-byes

• Hospitals’ responsibility does not end at discharge– Recognize dangers of transition– Set patients/families up for success (2013)

• Positive associations between the patient experience and:– Adherence to prevention/treatment– Health care resource use (2013)

• Bundled Intervention Models:– Naylor’s Transitional Care Model– Coleman’s Care Transitions Interventions– Jack’s Project RED

The Context/VBP & the Patient

• “Transitions”-largest slice HCAHPS pie• Transition questions added (2013)

– During hospital stay ,staff took my preferences & my family’s into account

– When I left, I had a good understanding of the things I was responsible for

– When I left, I clearly understood the purpose of taking my medications

• Discharge centered on patient=Success– Domains: RN Communication, the 5

“Discharge” items,Responsiveness,Medications

• “…HCAHPS is not about Happiness..”

Penn Medicine Chester County Hospital

• CCH 263 bed community hospital

• Rich history, 120 years• Penn Medicine:

– September, 2013

– HUP-1st teaching hospital, 1874

– Pennsylvania Hospital, the nation’s first, 1751

– Penn Presbyterian Hospital

• CCH & Project RED

My home away from home

CCH & Project RED-our Story

• Project “RED” (Re-Engineered Discharge) Background– Safe Discharge is best when clinical team integrates efforts– Communication deficits at Discharge are common; the “Perfect

Storm” of patient safety– RED research, Dr. Brian Jack (Annals Internal Medicine , 2009)

• Dr. B. Jack/AHRQ/CCH-the national RED Roll-Out Contract– Does the Project RED 11 Element Checklist work in the real

world?– Can the Project RED 11 Element Checklist be used more

efficiently?– June 2011 site visit; Dr. Jack, Boston Implementation team,

AHRQ – Participants: Senior Team, physician & nursing leaders, front

line nursing staff, Case Mgt., Nursing Informatics, IT,HIM– CHF patients on Telemetry = pilot population– Our Core RED interdisciplinary team was formed, and still

meets!

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

2. Plan for the follow-up of results from lab tests or studies that are pending at discharge.

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

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

5. Reconcile discharge plan with national guidelines.6. Teach a written discharge plan (AHCP) the patient can

understand. 7. Educate the patient about his/her diagnosis. 8. Assess the degree of the patient’s understanding of this plan. 9. Review with the patient what to do if a problem arises.10. Expedite transmission of the discharge summary to clinicians

accepting care of the patient.11. Provide telephone reinforcement of the Discharge Plan. 12. (new!) Obtain language assistance for patients/families

Project RED Checklist – From Admission!

11

Re-Engineered Discharge

Nurse Commun-

ication

MD Commun-

ication

Medication TeachingDischarge

Hospital Rating

Integrated HCAHPS Benefits

12

• Discharge Planning Begins on Day 1

– RED = Guide to building relationships– RED = Promotes self-management skills– RED = Patient education throughout the stay– RED = Patients & clinical team; common

goals– RED = Family engagement – RED = Patient learning as the closing

message– RED = Tools for you to link patient safety &

the patient experience

RED Benefits HCAHPS? Absolutely!

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• AHCP recreated in word (available as a PDF/AHRQ website)• RED’s Discharge Educator role = our Telemetry nurses

– Telemetry RNs taught the AHCP to patients; what a moment!– All trained on the use of “Teach-Back”—now a RN Competency

• Unit Coordinators making F/Up apts: Patient & family satisfier

• Clinical Pharmacist inclusion with the CHF pilot patients• Physician Office Practice outreach—utilization of the AHCP• Volunteers & Transport staff: Discharge reminder at curb-

side• 48 hour post discharge F/Up phone calls

– Project RED script– Medication clarification, review F/Up apts, transition support

• Our patients, families, staff & physicians loved Project RED!

CCH Project RED Pilot Year: 2011-2012

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CCH’s AHCP “it’s like an award for discharge”

15

CCH’s List of Medicines & Why/How

16

CCH Clinical Pharmacists: Medication Teaching

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Brand Name

Why am I taking this med?

What do I need to look for?

Tylenol pain, fevertoo much can cause liver damage (read OTC labels), higher doses for long periods can increase warfarin effects

Ventolin, ProAir, Proventil

breathing problems, asthma "rescue" inhaler, fast heart beat, chest pain/pressure

Uroxatral enlarged prostate, kidney stones

Dizziness ,HA, avoid grapefruit juice, alcohol, changes in sex ability

Zyloprim gout/high uric acid upset stomach, rash/skin irritation

Xanax anxiety, "nerves" drowsiness, dry mouth

Cordarone, Pacerone abnormal heart rhythm constipation, sensitivity to sunlight (wear

sunscreen)

Elavil mood, migraine, nerve pain sedation, dry mouth, avoid grapefruit juice

CCH Appointment Calendar

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Readmission Rate- FY11 vs. FY12

• All Telemetry Patients with a Primary Diagnosis of CHF at Discharge

• 30 Day Readmissions

CCH: 2012-2013

• Were we getting to a Better Fit?

• Clinical & IT experts worked as 1 team - “priceless”– Replication of the AHCP into an electronic version

• Stories of the patient experience shaped the goals of this enlarged team

• RED’s Checklist worked; expansion for all CCH • CCH Re-Engineered Discharge: 5 Core Principles

– Discharge planning begins Day 1 all CCH patients– “My Discharge Plan” all CCH

patients– Teach-back methodology all CCH patients– Follow-up appts. High Risk patients– Follow-up phone calls High Risk

patients

Enlarging our CCH Team! 2012-2013

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My Discharge Plan example

My Discharge Plan example: Yield and Stop signs

Text block library for templated “last licks” instructions

High Risk for Readmission Patients

• Automated work flow processes to identify patients at risk • High Risk criteria include: polypharmacy, recent admission, key

CMS diagnoses, lack of support at home• Identification of High Risk in real time for staff• Creates High Risk for readmission “order” in chart

• Unit Coordinators making F/Up Appts : PCP & specialists• 48 hour F/Up phone calls-High Risk patients

• Automated work flow produces call list daily• Clinical Pharmacists, Paramedics, CV Nurse Navigator

High Risk Patients

• Populates a report showing all high risk patients on the unit/hospital and reason for inclusion

• Populates a report for after discharge phone calls:

Pre and Post Measures: Re-Engineered Discharge

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Oct-Dec 2011 Jan-Mar 2012 Oct-Dec 2012 Jan-Mar 20130.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

19.0%

24.7%

16.7%

11.7%

Indicator: COPD - % Readmit within 30 DaysComparison FY12Q2&3 vs. FY13Q2&3

CCH : HCAHPS Discharge Domain

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CCH : HCAHPS Care Transitions

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HCAHPS Trending - Domains related to Project RED Implementation

2011 Q3

2011 Q4

2012 Q1

2012 Q2

2012 Q3

2012 Q4

2013 Q1

2013 Q2

2013 Q3

2013 Q4

80.0

82.0

84.0

86.0

88.0

90.0

92.0

86.086.6

84.0

83.8

85.9

89.489.7

87.1

90.4

91.4

CCH FY12-FY14Q2 Performance: Informa-tion at Discharge

"During the hospital stay, did you get in-formation in writing about what symp-toms or health problems to look for?"

Percent "Always" Answers

Project RED Implementation Dates: Telemetry – Sept 2011 House-wide – Sept 2012

I clearly understood the purpose for taking each of my medications.

When I left, I had a good understanding of the things I was responsible for in managing my health.

Staff took the preferences and those of my family/caregiver into account in deciding what my health care needs would be.

CARE TRANSITIONS

74 76 78 80 82 84 86 88 90

84.7

82.4

79.1

81.8

84.7

85.7

82.7

84.6

83.5

83.5

79.1

82

86.2

84.6

79.6

83.1

87.4

84

79.8

83.6

88

85.4

81.7

84.9

84.6

82.8

81.4

82.8

CCH Care Transition Data: CCH FY13-FY14Q2 vs. Press Ganey Database

2012 Q3 CCH 2012 Q4 CCH 2013 Q1 CCH2013 Q2 CCH 2013 Q3 CCH 2013 Q4 CCH2012 Q3 - 2013 Q4 PG Database

Enhancing our Model • Patient’s White Board: planning information• Rapid Daily Rounds

– “Plan for the Day, Plan for the Stay”– Interdisciplinary group meets at set time daily– All stand & are prepared, one-two minutes per patient

• Teach-back becoming part of culture– Patient/family feel “safe” to ask questions

• Bedside Handoff between shifts• Open Visitation

– Summer 2013; a Nursing Council initiative

• Bedside Delivery of Medications – Telemetry Pilot in 2011; house-wide in 2012 – Enables patients to receive new medications prior to D/C– Walgreens’ Pharmacy Tech integrated into nursing

teams

Are we there yet?

• “..higher patient satisfaction with inpatient care & discharge planning is associated with lower 30 day readmission rates…” (2011)

A Model & the Patient: Good Fit?• Motivation/partnership with patients/families

– Never been healthy; “what does healthy look like”?– How to set up small “wins” in just a few days– Are we truly assessing Self-Management skills?– Applicability to Transitions in Care

• Patient Experience—understanding the whole – Care Transition results appear to show less than

50% take patient/family preferences into account upon discharge

– People in top 5% of spending--11x more likely to report fair to poor physical health

– Patients who report excellent health overall-their HCAHPS ratings 1.5 x higher than poor health

Do we know their expectations at D/C?

COLLECTED

PATIENT STORIES OVER A PERIOD OF TIME

SATISFACTION

DATA

The Patient’s Voice 2013-2014

• Bedside Survey Pilot 2011-2012: – Consistently: “I have heard little about D/C”

• Bedside Surveys: electronic solution– Charge RNs/Day 2—Mini iPads– Real time service recovery – Real time data sharing/reports available– Kick-off Fall 2013

• Revised: January 2014– Revised D/C question: “Have you heard about”– “Do you have any concerns about going back to

your home environment?” & Explain

• Winter 2014: Readmission Survey– Day 2, identified from our High Risk workflow

Current Data Overview# 611 Survey Question % Yes % No Don’t

KnowNo Answer

1 Is your call bell being answered promptly? 90.7% 2.3% 0.0% 7%

2 Has our Hourly Rounding helped address your needs? 85.3% 2.8 5 4.9% 7%

3 If you have pain, how well do you feel the staff is managing your pain? 4.81 average score (on a 1-5 scale) % was not available

4 Has the nursing staff addressed your questions/concerns about your medications?

84.3% 2.5% 5.6% none 7.6%

5 Are the doctors being attentive to your needs? 86.3% 5.2% 0.0% 8.5%

6

If NO can you tell me about your concerns?

Feel Rushed Don’t understand their answers

Other 92.0%

7 Planning for your transition back to your home is important to us. Has your nurse or other members of your team started talking with you about your discharge?

62.0% 30.1% 0.0% 7.9%

8 How would you say we are doing at keeping your room quiet? 4.71 average score (on a 1-5 scale) % was not available

9 Is there a staff member who has been especially helpful during your stay?

64.2% 22.7% 0.0% 8.6%

10 If you or your family member were sick today, would you choose to return to Chester County Hospital?

90.7% 0.7% 0.0% 8.6%

Chester County Hospital Readmission Survey

Chester County Hospital Readmission Survey

Next Steps/Concluding Remarks

• Reinforce: Bundled interventions vs series of tasks• Discharge Model-Yes; Transition Model-not quite Yet!

– Spotlight on community hand-off & feedback– Immediate follow-up care for the most vulnerable– Palliative Care referrals as part of our culture

• Senior Team Core Group formed; partner with original team

• Our understanding of why patients come back– Review All-Cause, but understand Potentially Preventable– Re-evaluate opportunities with High Risk list/F/Up phone calls

• Meaningful analysis of successes and returns (SNF/NVNA)– Unplanned 7 day Readmissions

• Bedside Survey expansion: insights for the entire clinical team– Conduct Case Reviews on patients who return/succeed

Re-Engineered Discharge

Nurse Commun-

ication

MD Commun-

ication

Medication TeachingDischarge

Hospital Rating

You Can Do It Too!

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A Good Fit-we’re getting there

• “..the way we communicate with patients/families about their health substantially influences their motivation for action & behavior change..” (2011)

Thank you!

Carli MeisterDirector, Customer Relations & Risk

Penn Medicine Chester County Hospitalcmeister@cchosp.com