Module 3

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Module 3

• The Re-Designed Discharge Process Patient
  Discharge and Follow-up Care

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Accomplishments to Date (Module 1)

• Process map of current discharge process
  completed
• Primary care practitioner (PCP) referral base
  defined
• Patient Care Plan structure finalized
• Project charter initiated
• Dates for training frontline staff set

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Accomplishments to Date(Module 2)

• Project metrics identified and planned
• Patient inclusion criteria defined
• Process for identifying patients and notifying
  Discharge Advocate (DA) defined
• Multidisciplinary involvement and communication
  plan determined
• Patient Care Plan process finalized (what data to
  include and how to gather it)

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Module 3 Objectives

• Finalize process for identifying a PCP for
  patients who do not have one
• Identify resources to provide patient information
• Review completion of discharge preparation
• Medication reconciliation
• Pending test results
• Follow-up appointments
• Sending plan to PCP
• Finalize care plan completion and printing
• Review how to conduct teach-back with patient and
  family
• Finalize process for making post-discharge calls

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Module 3 Outline

• Completing the Patient Care Plan
• Teaching and teach-back
• Conducting post-discharge activities
• Measuring the process
• Training frontline staff

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Discharge Planning
Discharge Order Written
H P Rx Plan
Patient Admission
Discharge Event
Discharge Process
PATIENT EDUCATION
DISCHARGE INSTRUCTIONS
Post-D/C Follow-up
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RED Checklist Discharge and Followup

• 11 mutually reinforcing components
• 1. Medication reconciliation
• 2. Reconcile discharge plan with national
  guidelines
• 3. Follow-up appointments
• 4. Outstanding tests
• 5. Post-discharge services
• 6. Written discharge plan
• 7. What to do if problem arises
• 8. Patient education
• 9. Assess patient understanding
• 10. Discharge summary sent to PCP
• 11. Telephone reinforcement

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(No Transcript)
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Completing the Patient Care Plan

• Medication reconciliation
• Pending tests and results
• Post-discharge services
• PCP
• Follow-up appointments
• Information about condition

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Medication Reconciliation

• Hospital procedure for completing medication
  reconciliation at discharge
• DA may participate and conduct final check on
  medications
• Using final list, populate Patient Care Plan
  and complete additional columns (e.g., purpose,
  time of day)
• Final list used to instruct the patient

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Pending Tests and Results

• Obtain information about tests and studies
  completed in hospital but have results pending
• Add pending tests and results to the Patient Care
  Plan, including which clinician is responsible
  for getting final results
• Encourage patient to discuss tests with PCP,
  point out where the information is on the Patient
  Care Plan

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Post-Discharge Services

• Confirm with case manager that all services have
  been arranged
• List services and contact information in Patient
  Care Plan

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Primary Care Provider

• Confirm name of PCP with patient
• Add PCP name and contact number to Patient Care
  Plan

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Follow-up Appointments

• Discuss best days of week and times of day with
  patient
• Discuss transportation needs
• Call clinicians offices to make appointments
  that meet patients time options
• Leave message with clinicians office to call
  patient if calling outside of normal hours or on
  a weekend
• Add appointments to Patient Care Plan

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Information About Condition

• Get pre-printed information about patients
  condition to add to Patient Care Plan
• Add to Patient Care Plan
• Signs and symptoms that warrant followup with
  clinician
• When to seek emergency care
• How to contact the DA and PCP (phone numbers and
  paging instructions)

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Patient Care Plan Sections

• Date of discharge
• Name and contact information for physician and DA
• How to reach physician and when to seek emergency
  care
• Medications
• Pending tests and results
• Follow-up appointments
• Calendar
• Other orders (diet, activity, etc.)
• Information about disease or condition
• Form for writing down questions
• Map for locating appointments (optional)
• Other information about your center (optional)

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Answer the Following Questions as a Team

• Have all the content areas been included in the
  final Patient Care Plan template?
• Can the DA access all the content to add to the
  Patient Care Plan?
• From where?
• How reliably?
• How timely?
• What gaps still exist that need to be addressed?

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Teaching and Teach-Back

• All education material
• Care plan completed
• Two printed copies
• Copy to quality department
• Meet in quiet place
• Review all parts of the Patient Care Plan
• Confirm understanding using teach-back methods

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Health Literacy Tips

• Avoid medical jargon
• Speak slowly
• Provide simple pictures when helpful
• Emphasize what the patient should do
• Avoid unnecessary information
• Welcome questions
• Ensure written materials use simple words, short
  sentences in bulleted format, and lots of white
  space
• Graham and Brookey

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Teaching Tips

• Elicit symptoms and understanding from the
  patient
• Be aware of when teaching new concepts and ensure
  understanding
• Eliminate jargon
• System-level support using technology
• Provide more robust health education vehicles to
  help the patient remember
• Be proactive during time between visits
• Schillinger interview

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Teach-Back

• Way to confirm that you have explained what the
  patient needs to know
• Not a test of the patient but rather a test of
  how well you explained a concept
• Should be used with every patient never assume
  literacy or health literacy
• All staff should know how to do it

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Teach-Back Place Responsibility on Yourself

• I want to be sure I didnt leave anything out
  that I should have told you. Would you tell me
  what you are to do so that I can be sure you know
  what is important? (Doak et al.)
• I want to be sure that I did a good job
  explaining your blood pressure medications
  because this can be confusing. Can you tell me
  what changes we decided to make and how you will
  now take the medication? (Pfizer Web site)
• When you go home and your grandchild asks you
  what the doctor said about your heart, how are
  you going to explain this to your grandchild?
  (Schillinger interview on AHRQ Web site)

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Teach-Back Technique

• Do not ask a patient, Do you understand?
• Do not ask yes/no questions
• Ask patients to explain or demonstrate how they
  will undertake a recommended treatment or
  intervention
• Ask open-ended questions
• Assume that you have not provided adequate
  teaching if the patient does not explain
  correctly. Re-teach in a different way.

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Teach-Back Show Me Method
From the U.S. Health Resources and Services
Administration
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Teach-Back Steps

1. Use simple lay language explain the concept or
   demonstrate the process avoiding technical terms
   use a professional translator if a language
   barrier exists
2. Ask the patient or caregiver to repeat the
   concept in his or her own words or to demonstrate
   the process
3. Identify and correct misunderstandings or an
   incorrect procedure
4. Ask the patient or caregiver to repeat the
   concept or repeat the process to demonstrate
   understanding
5. Repeat steps 3 and 4 until clinician is convinced
   comprehension and ability to perform process is
   adequate and safe

Society of Hospital Medicine
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Beyond Comprehension

• Do you see yourself as able to follow these
  instructions?
• Is there anything you can think of that will
  keep you from following these instructions?
• Functional barriers (e.g., memory)
• Environmental barriers (e.g., lack of support
  person at home)
• Attitudinal barriers (e.g., lack of trust)
• Please demonstrate the activity Ive just
  explained to you or shown you.

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Conducting Post-Discharge Activities

• Transmit discharge summary and Patient Care Plan
  to PCP
• By fax Ensure it is received and legible
• By e-mail Ensure it is received
• Follow-up phone call to patient 48 to 72 hours
  after discharge
• Caller uses script that assess understanding of
  medication and follow-up appointments
• Need for second call by clinician determined

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Measuring the Process

• Timeliness of RED activities
• DA log data
• Review Patient Care Plans after discharge
• Percent with medication list
• Percent with care needs listed
• Percent with post-discharge services and contacts
  listed
• Percent with follow-up appointments made
• Percent with pending tests and results listed (or
  none)

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Teaching Frontline Staff

• Why?
• Gain understanding, buy-in, participation, role
  clarification
• Who?
• Nursing and medical staff on participating units,
  pharmacists, case managers
• When?
• Prior to launch of RED implementation
• Set date for live or recorded session
• How?
• Customize slide deck as necessary

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Module 3 SummaryExpected Outcomes

• DA aware of discharge order and completes Patient
  Care Plan
• Medication list
• Pending tests and results
• Post-discharge services
• PCP identified
• Follow-up appointments made
• DA conducts final teaching and teach-back with
  patient and family
• Post-discharge followup occurs
• Transmit summary and Patient Care Plan to PCP
• Phone patient within 48 to 72 hours
• Measurement of discharge process complete
• Plans for teaching frontline staff finalized

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Progression to Module 4 Checklist

• ___ Processes to finalize Patient Care Plan
  after discharge order is written in place
• ___ Teach-back methods outlined
• ___ Quality and performance improvement staff
  understand project measurement requirements and
  are prepared to gather data
• ___ Process for transmitting discharge summary
  and Patient Care Plan to PCP finalized
• ___ Plans for teaching frontline staff finalized