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Module 2The Re-designed Discharge Process: Patient Admission and Care/Treatment Education
Faculty from Joint Commission Resources
Deborah M. Nadzam, PhD, FAAN
Project Director
And
Kathleen Lauwers, RN, MSN
Consultant
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Accomplishments to Date
Project Charter initiated
Primary Care Practitioner referral base defined
Process map of current discharge process completed
Care plan structure is finalized: template, location, how Discharge Advocate (D.A.) will access it
Dates for training frontline staff set
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Objectives of Module 2
Review discharge planning activities that begin on admission
Develop plan for identifying targeted patients on admission
Review D.A.’s initial contact with patient
Define role of multidisciplinary team members in discharge planning
Confirm process for creating patient care plan
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Module 2 Outline
Principles and Components of Project RED
Current Discharge Process and Suggested Project Metrics
Patient Admission
Care and Treatment Education
Patient Care Plan: Structure and Process for Completing
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Let’s Review the Principles of Project RED . . .
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Principles of the Re-Engineered Hospital Discharge
1. Explicit delineation of roles and responsibilities
2. Discharge process initiation upon admission3. Patient education throughout hospitalization4. Timely accurate information flow:
From PCP ► Among Hospital team ► Back to PCP
5. Complete patient discharge summary prior to discharge
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Principles of the Re-Engineered Hospital Discharge (continued)
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 discharge
9. Availability of case management staff outside of limited daytime hours
10. Continuous quality improvement of discharge processes
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Module 2
Patient Admission
Care and TreatmentEducation
Demonstrationof Learning Patient
DischargeProblemSolved!
Re-engineering Patient Discharge: Project RED
Critical pathwayReconcile admission medsEducate the patient aboutthe plan of careInitiate discharge planningrounds
Reinforce care planReinforce teachingProvide explanations fortests and studiesDiscuss family supportoptions at homeClarify primary care provider
Written dischargeplanInitiate teach backSchedule follow upappointmentsSchedule postdischarge phone call
Confirm medication planPending test resultsFollow up appointmentscheduleReinforce AHCPSend PCP written AHCPDischarge telephone call
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Discharge Planning
Patient Admission
H & P
Rx Plan
PATIENT EDUCATION
Discharge Order
Written
Discharge Process
Discharge Event
DISCHARGE INSTRUCTIONS
Post-D/C Follow-
up
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RED Checklist: Admission and Care/Treatment Education
Eleven 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
Adopted by
National Quality Forum
as one of 30 US
"Safe Practices" (SP-15)
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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 MARAssist withmedication
reconciliation
Assist withmedicationteaching
Participate inDC Rounds
Educate patientabout diagnosis,
tests, and studies
Initiate DCorders
ReinforceDischarge Plan
Provide careand treatment
CompleteAHCP
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Outcome metrics for target population
Average length of stay
30 day unplanned ‘all cause’ readmission rate
Pre and post data -Patient experience related to discharge preparation
Pre and Post data -Front line staff survey related to discharge preparation
Pre and Post data – PCP survey related to discharge preparation
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Financial Metrics
The cost of second LOS (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 PCP 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:– % of care plans with medication list included– % of care plans with care needs included (e.g.,
exercise, diet, main problem, when do I call doctor)– % of care plans with follow up appointments listed– % of care plans with pre-arranged discharge
resources identified (e.g., home care, DME)– % of care plans with pending tests listed
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Let us pause now…As a team, answer the following questions:
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 associate 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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11 RED Components Enable Discharge Advocates (D.A.) 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 (2)
Who will notify the D.A. of the patient’s admission?
How is the D.A. notified? – Pager?– Phone?
D.A. should be notified within 12 hours, to be able to see patient within 24 hrs of admission
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Secondary Screening by D.A.
D. A. reviews patient’s admission notes
Consider:– Working diagnosis– Language– Likely disposition– Is there a home or cell phone number?
Is patient a candidate for Project RED intervention?
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Sample Log for Tracking Key Dates and Times
Red Skeldoni Patient Name Patient Name
Date/Time of Admission
05-05;1300
Date/Time D.A. notified
05-05; 1700
Date/Time of initial D.A. visit with patient
05-06; 1100
Date/Time of daily D.A. 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-D/C call
05-11; 1600
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Let us pause now…As a team, answer the following questions:
How will you first identify that a newly admitted patient is in the targeted population for this project?
How will the D.A. be notified that a potential Project RED patient has been admitted?
What secondary screening criteria for patient inclusion will the D.A. use to confirm the use of the Project RED intervention with the patient?
How will the D.A. track activities with new patients?
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Meeting the Patient
Review the patient’s admission notes– History and Physical– Medication reconciliation– Preliminary plan of care
Meet the patient and family– Describe D.A. role– Assess concerns, including potential post-D/C
needs
Initiate care plan and checklist
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Daily Work of the D.A.
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, meds)– Discuss patient’s 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 mgmt
and D.A.– Who will be supportive?– Where might resistance come from?
When is discharge order written?– Was it expected?– Weekend discharge?– Is there a timing expectation (i.e., time from order to
‘out-the-door’)?
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Patient’s Physician
Initiates patient plan of care based on critical pathway
Leads and/or participates in discharge planning rounds
Communicates potential date of discharge
Supports the performance improvement process
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Provide nursing care as planned
Educate patient/family as usual
Communicate with each other, per usual
Communicate with other members of the health care team, including D.A.
Participate in multidisciplinary rounds, including those that may be specifically focused on discharge planning
Nursing Staff
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Pharmacist
Verify physician orders Reconcile admission meds
with meds from home Collaborate with care team
specific to discharge needs Reconcile meds 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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Let us pause now…As a team, answer the following questions:
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/diagnosis, and current medications
Begin teaching medications and condition
Use teach-back methods (to be discussed in Module III)– 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 don’t 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 (NPSF)
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 from patient their symptoms and understanding
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
• “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
Simple pictures when helpful
Emphasize what the patient should do
Avoid unnecessary information
Welcome questions
Written materials: simple words, short sentences in bulleted format, 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-professional/tips
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Accessing the care plan template
Accessing information for the care plan
Saving individual patient’s care plan
Printing the care plan
Storing the care plan– Permanent part of the patient record?
Developing the Patient’s Care Plan
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Accessing the Care Plan Template
IT department involvement– Any interfaces built?
Written instructions for how to access the care plan template
Written description of 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’s care plan
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Gathering Care Plan Content
Start the care plan on admission and add to it daily– Secure education material about patient’s primary
condition– Can begin medication section, based on daily
discussions with medical team– Can 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 project’s targeted population
Alert the D.A. about new patient
Screen for final acceptance into project
Initiate discharge planning on admission
Meet the patient (thru team, admission notes and in person!)
Initiate care plan and maintain log of activities
Daily rounds with health care team to plan patient education and post-discharge services
Daily visits to patient
Educate throughout
Continue to add to care plan
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Progression to Module 3 Checklist
Metrics you will use to assess impact ___
Process for identifying candidate patients and notifying D.A. ___
Secondary screening criteria for including patient are confirmed ___
Process for multidisciplinary ‘rounds’ and/or updates on targeted patients ___
Process for accessing care plan ___
Team evaluation of Module 2 ___
