Module 2

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Module 2

• The Re-Designed Discharge Process Patient
  Admission and Care and Treatment Education

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Accomplishments to Date

• 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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Module 2 Objectives

• Review discharge planning activities that begin
  on admission
• Develop plan for identifying targeted patients on
  admission
• Review Discharge Advocate (DA) initial contact
  with patient
• Define roles of multidisciplinary team members in
  discharge planning
• Confirm process for creating Patient Care Plan

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Module 2 Outline

• Project RED principles and components
• Current discharge process and suggested project
  metrics
• Patient admission
• Care and treatment education
• Structure and process for completing Patient Care
  Plan

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Principles of the Re-Engineered Hospital Discharge

• Explicit delineation of roles and
  responsibilities
• Discharge process initiation upon admission
• Patient education throughout hospitalization
• Timely accurate information flow
• From PCP ? Among hospital team ? Back to
  PCP
• Complete patient discharge summary prior to
  discharge

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Principles of the Re-Engineered Hospital Discharge

1. Comprehensive written discharge plan provided to
   patient prior to discharge
2. Discharge information in patients language and
   literacy level
3. Reinforcement of plan with patient after
   discharge
4. Availability of case management staff outside of
   limited daytime hours
5. Continuous quality improvement of discharge
   processes

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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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Admission and Care and Treatment Education

• Project Reds 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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Outcome Metrics for Target Population

• Average length of stay
• 30-day unplanned all-cause readmission rate
• Pre/post data Patient experience related to
  discharge preparation
• Pre/post data Frontline staff survey related to
  discharge preparation
• Pre/post data PCP survey related to discharge
  preparation

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Financial Metrics

• The cost of second length of stay (readmission)
• Project costs
• Discharge process costs (current and redesigned)

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Process Metrics

• Average time to notify DA about new admission
• Average time from admission to first patient
  visit by DA (initiation of care plan) only for
  patients who meet all criteria
• Percent of patients PCPs notified within 24
  hours discharge
• Percent of follow-up phone calls made within 48
  hours

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Process Metrics

• Percent of follow-up calls requiring second call
  by pharmacist (if non-pharmacist makes first
  call)
• Percent of patients completing post-discharge
  survey (30 days after discharge)

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Process Metrics

• Completion of care plan details
• Percent of care plans with medication list
  included
• Percent of care plans with care needs included
  (e.g., exercise, diet, main problem, when to call
  doctor)
• Percent of care plans with follow-up appointments
  listed
• Percent of care plans with pre-arranged discharge
  resources identified (e.g., home health, durable
  medical equipment)
• Percent of care plans with pending tests listed

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Answer the Following Questions as a Team

• What metrics do the project team want to use to
  assess the impact of the re-engineered discharge
  process?
• If you decide to collect the process measure
  associated with time-related activities, how will
  that happen?
• Will you use the patient phone survey? How?
• Will you use the frontline staff survey? How?
• Will you use the PCP survey? How?
• Will you measure the completeness of the Patient
  Care Plan?
• Who will be responsible for overseeing the
  measurement activities?

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Project RED Components

• The 11 components enable DAs to
• Prepare patients for hospital discharge
• Help patients safely transition from hospital to
  home
• Promote patient self-health management
• Support patients after discharge through
  follow-up phone call

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Identify the Patient

• By admission unit
• By admitting diagnosis
• Heart failure How do you identify these patients
  for core measure processes?
• By physician

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Identify the Patient

• Who will notify the DA of the patients
  admission?
• How is the DA notified?
• Pager
• Phone
• DA should be notified within 12 hours to be able
  to see patient within 24 hours of admission

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DA Secondary Screening

• DA reviews patients admission notes
• Considers
• Working diagnosis
• Language
• Likely disposition
• Availability of home or cell phone number
• Determines if patient is a candidate for Project
  RED intervention

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Sample Log to Track Key Dates and Times
Joe Smith Patient Name Patient Name
Date/Time of Admission 05-05 1300
Date/Time DA Notified 05-05 1700
Date/Time of Initial DA Visit With Patient 05-06 1100
Date/Time of Daily DA Visits With Patient (Note All) 05-07 0800 05-08 1000 05-09 1200
Date/Time of Discharge 05-09 1400
Date/Time Care Plan Faxed to PCP 05-09 1500
Date/Time of Post-Discharge Call 05-11 1600
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Answer the Following Questions as a Team

• How will you first identify that a newly admitted
  patient is in the target population for this
  project?
• How will the DA be notified that a potential
  Project RED patient has been admitted?
• What secondary screening criteria will the DA use
  to confirm use of the Project RED intervention
  with the patient?
• How will the DA track activities with new
  patients?

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Meeting the Patient

• Review the patients admission notes
• History and physical
• Medication reconciliation
• Preliminary plan of care
• Meet the patient and family
• Describe DAs role
• Assess concerns, including potential
  post-discharge needs
• Initiate Patient Care Plan and checklist

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Daily Work of the DA

• Review progress and nursing notes
• Clarify any concerns with health care team
• Visit the patient
• Review treatment plan (as related to discharge)
• Begin educating as appropriate (condition,
  medications)
• Discuss patients concerns re discharge
• Continue development of care plan

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Discharge Planning Rounds
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Multidisciplinary Team

• Consider daily discharge rounds
• Medical staff, nursing staff, pharmacy, case
  management, and DA
• Who will be supportive?
• Where might resistance come from?
• When is discharge order written?
• Was it expected?
• Weekend discharge?
• Is there a timing expectation (e.g., time from
  order to out the door)?

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Patients Physician

• Initiates patient plan of care based on critical
  pathway
• Leads and participates in discharge planning
  rounds
• Communicates potential date of discharge
• Supports the performance improvement process

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Nursing Staff

• Provide nursing care as planned
• Educate patient and family
• Communicate with each other
• Communicate with other members of the health care
  team, including DA
• Participate in multidisciplinary rounds,
  including those that may be specifically focused
  on discharge planning

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Pharmacist

• Verify physician orders
• Reconcile admission medications with medications
  from home
• Collaborate with care team specific to discharge
  needs
• Reconcile medications upon discharge
• Assist with patient medication questions

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Case Managers

• Post-discharge services
• Social work
• Utilization review
• Financial support

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Other Key Staff

• Therapists
• Disease management

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Answer the Following Questions as a Team

• Do you currently address discharge planning in
  multidisciplinary rounds?
• What works well?
• What could be improved?
• Who participates?
• If you do not do the above, why not?
• What will it take to implement such rounds?
• Who will be supportive?
• Where might resistance be encountered?
• What are the roles and responsibilities of
  members of the health care team, as related to
  discharge planning?

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Teaching the Patient

• Assess understanding of
• Reason for admission
• Condition or diagnosis
• Current medications
• Begin teaching medications and condition
• Use teach-back methods (discussed in Module 3)
• Health literacy
• Language
• Culture

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A True Story

• Public health nurse Jill, I see you are taking
  birth control pills. Tell me how you are taking
  them.
• Jill Well, some days I take three some days I
  dont take any. On weekends, I usually take
  more.
• Public health nurse How did your doctor tell
  you to take them?
• Jill He said these pills were to keep me from
  getting pregnant when I have sex, so I take them
  anytime I have sex.
• Graham S and Brookey J. 2008.

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Ask Me 3

• Created by the Partnership for Clear Health
  Communication (National Patient Safety
  Foundation)
• Three essential questions for patients
• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?
• National Patient Safety Foundation
  http//www.npsf.org/askme3/

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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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Literacy Issues

• Clues that patient has general literacy issues
• Incompletely filled-out forms
• Frequently missed appointments
• Poor compliance
• Inability to identify the name, purpose, or
  timing of medication
• Not asking any questions
• Reaction to written materials
• I forgot my glasses. Can you read it to me?
• I will read it at home.
• Graham and Brookey

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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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Additional Teaching Tips

1. Use visual aids and illustrations
2. Beware of words with multiple meanings
3. Avoid acronyms and other new words
4. Use idioms carefully
5. Provide a health context for numbers and
   mathematical concepts
6. Take a pause
7. Be an active listener
8. Address quizzical looks
9. Create a welcoming and supportive environment

www.pfizerhealthliteracy.com/public-health-profes
sional/tips
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Developing the Patient Care Plan

• Accessing the care plan template
• Accessing information for the care plan
• Saving individual Patient Care Plan
• Printing the care plan
• Storing the care plan
• Permanent part of the patient record?

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Accessing the Patient Care Plan Template

• IT department involvement
• Build interfaces?
• Written instructions for how to access the care
  plan template
• Written description of care template sections,
  including what is entered manually and what is
  linked to other hospital systems
• Written instructions for how and where to save
  the Patient Care Plan

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Gathering Care Plan Content

• Start the Patient Care Plan on admission and add
  to it daily
• Secure education material about the patients
  primary condition
• Begin medication section, based on daily
  discussions with medical team
• Begin post-discharge services section
• Identify PCP and add name to care plan

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Module 2 SummaryExpected Outcomes

• Identify patients who are members of the
  projects targeted population
• Alert the DA about new patients
• Screen for final acceptance into project
• Initiate discharge planning on admission
• Meet the patient (through the care team,
  admission notes, and in person)
• Initiate care plan and maintain activities log
• Participate in daily rounds with health care team
  to plan patient education and post-discharge
  services
• Visit patient daily and educate during each visit
• Continue to add to Patient Care Plan

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Progression to Module 3 Checklist

• Before going to Module 3, determine the
• ___ Metrics you will use to assess impact
• ___ Process for identifying candidate patients
  and notifying DA
• ___ Secondary screening criteria for including
  patient
• ___ Process for multidisciplinary rounds and/or
  updates on targeted patients
• ___ Process for accessing Patient Care Plan