1 Engaging Patients and Families to Improve Care Transitions

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Engaging Patients and Families to Improve Care Transitions

Objective for the Session

Discuss strategies for partnering with patients and families to improve their experience of discharge from the hospital and coordination of post-acute care.

Background: BIDMC’s Readmission Rates

Publically Available Medicare Data:

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How has BIDMC involved patients and families?

Patient and family involvement is vital to improving care transitions and, at BIDMC, the level of patient and family

involvement has evolved overtime.

2010 20122011

Patients & Families as

Advisors

Patients & Families as

Team Members

Patient Family Advisory Council

STAAR Cross-Continuum Team





With Increased Advisors With Increased Advisors

Patient Family Interviews

My Care Conference Pilot

DC Med List Focus Group

HF Pt Pathway Focus Group

HCA Care Transitions Pilot

How is BIDMC engaging patients and families in improving care transitions?

Macro Level Involvement

Mico Level Involvement

Cross Continuum Team

Patient Family Advisory Council Working at an individual level to

enable real-time patient- and family- centered handoff communication

Case Example

Case Example:Developing “My Care Conference” from

concept to implementation

Identified Need

Established Vision

Created Project Team

Pilot Implementation

Measured Progress

Adapted Strategy

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Step 1: Identifying the Need

Key Themes from Patients & Family Members in Interviews and Focus Groups

• Patients/families don’t feel like they can contribute to their plan; or when concerns are voiced may be ignored; afraid to push back and be labeled a “difficult” patient

• Discharge was too fast; no time to process what was happening & ask questions

• Discharge materials are an ineffective way to communicate

• PCP seemed unaware of hospitalizations

• Specialists appointments weren’t scheduled in a timely manner / not clear to pt why it was needed

• Too many silos for patients to manage/coordinate on their own (many want a “single point of contact”)

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Step 2: Establishing the Vision

Our patients’ needs are relatively simple… but hard to achieve

“OK, I have three requests…1. Please tell me what you're going to do before you do it to

me. It's kind of hard to deal with the surprises and if you could just make a plan with me, I can do a little better…

2. You know, there are a lot of you – doctors and nurses all around me – do you ever talk to each other? …It would be great if you talked to each other…

3. I’ve been here a lot, in fact, I’ve probably been in the hospital more than you have…if you ask me what I think, I can help you…”

Pt feedback from “Kevin,” retold by Dr. Donald M. BerwickAdministrator, Centers for Medicare and Medicaid Services (CMS); December 3, 2010

My Care ConferenceConnecting Patients with Their BIDMC Team

Our standard practice for ALL patients to:

1. Make a plan with them2. Ask them what they think3. Listen and answer their questions4. Talk to each other5. Coordinate their care

“My Care Conference” = Transformative Change

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Slowing down to speed up… Applying this Lean principle by meeting with the patient/family members and developing a plan together, as a team, prior to discharge, will enable faster implementation and less confusion.

Taking an extra 15 to 30 minutes upfront will help to align team, improve communication, and enhance the patient’s experience.

Current State Desired Future State

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Step 3: Building the Implementation Team

Membership

Scope of Work

Timeline

Patient PhysicianLeader

Project Manager

NurseManager

Social Worker

PatientRelations

• Define workflow for delivering care conference to patients• Develop communication materials for patients & families• Engage post-discharge providers • Train floor based staff• Create mechanisms for monitoring and review processes

Jan 2011Project team formed

Mar 2011Pilot Initiated

2-Months for Planning & Development

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Pre-Conference Process Details

Pt Admitted

CCF Checks in w/ Care Team After Rounds

Introduce My Care Conference to Patient

InterpreterNeeded?

Pt Interested?

FamilyNeeded?

Part of Screening;Other NeedsMay be Identified

Yes Share & Explain Materials

No

Understand Why

Other Issue?

Set-Up Meeting Time w/ Care Team

And Family, At Pt’s Request

CCF determines how much “prep” can happen during this initial visit

Post Time of Conference& Check-In w/ Pt

Conversation w/ Pt about questions / concerns– estimate approx amount of time for Conf and share w/ team

Have “My Care Conference”

At the end of the session, Team completes “Next Steps”together (Nurse acts as “scribe” to complete the worksheet).

Provide Intro Letter, Things to Think About and Sample Questions

= Activity w/ the Pt= Completed by Care Conference Facilitator (CCF)

Key

Prioritizes Pts based on estimated D/C

Add Note on Pt’s Whiteboard Re: Conf

So Team is aware it has been introduced

Scope of Work

• Define workflow for delivering care conference to patients


Making It Happen: Care Conference FacilitatorA new role to help bring all the key participants together

• Checks in with newly admitted patients to introduce “My Care Conference”

• Identifies potential times for the conference, and coordinates with the patient, family members and BIDMC Team

• Helps patient prepare questions and identify objectives for the conference

• Facilitates the conference session to help patient achieve his/her objectives

Care Conference Facilitator

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Key Participants

Patient & Family Member(s)

Nurse

Care Conference Facilitator

Physician

Pharmacist(As Available)

Case Manager(As Available)

Interpreters will also be included, as needed

Additional PerspectivesAs Needed / Available

Consultants PCP or Primary NP

Home Care Nurse LTAC or SNF

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Conference Components: Care Team Members


Conference Components: Environment of Care

Location

Ideally, the conference would occur outside the patient’s room in a dedicated family meeting space.

To foster dignity and respect

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Conference Components: Post Meeting Follow-Up

• All participants will leave the conference with a copy of the plan

• Care Conference Facilitator will use a template to document the meeting and include a copy of the plan in OMR

Develop a standard planning document for the Patient and the Care Team to complete during the conference

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Scope of Work

• Develop communication materials for patients and families


Dear _______________;

We understand that being ill and in the hospital can be a difficult experience.

Often, it’s hard to know when and where to ask questions or share your thoughts and concerns.

We want to make it easier– with “My Care Conference.”

At this conference, you and your family can meet with your care team to ask questions and make a plan together, without distractions or interruptions.

Your Care Conference Facilitator: ____________ will tell you more about the Conference and help coordinate the details.

Sincerely,Your BIDMC Care Team

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Step 3: Building the Implementation TeamMy Care ConferenceConnecting Patients with Their BIDMC Team

Things to Think About…This is not a test… everyone gets an A! If you find it helpful, you can use

the space provided to prepare for your Care Conference.

The health related problem that brought me to the Hospital was…

I am most concerned or worried about…

I’d like to know more about…

Next Steps:My Care Team is currently….

____ Investigating why I feel this way (my diagnosis)____ Determining how to make me feel better (my treatment plan)

Over the next two days, My Team will…

My health related goal is…

I can help My Care Team by…

My Nurse will update this plan daily on the whiteboard in my room.


Pilot: Outcome Measures to Monitor (Quarterly)

Primary Metrics: Patient Satisfaction Scores:

• The hypothesis is that this drastically different intervention will enable us to better meet inpatients’ needs, and show a consistent improvement in H-CAHPS scores for the floor (when compared to Farr 2 or CC7).

Secondary Metrics:Operational Efficiencies:

• Increased coordination will potentially decrease wasted or duplicated effort (measured through work sampling)

• Planning with the patient from the first day of their visit will help the Team better understand the goals of care and decrease length of stay or improve discharge times

• Ultimately, over the long term, this strategy may improve transitions in care and reduce readmissions.

Staff Satisfaction:• Although this intervention will require a time commitment from the Care Team, it will

enable staff to more effectively connect with their patients,potentially increasing staff satisfaction.

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Step 4: Pilot Implementation & Learning / Adaptation

Challenges Observed at 3-Months- Staff still perceive Care Conferences as only for the most complex patients

- Because conferences have been held primarily for highly complex patients, they typically last longer than the estimated 20 minutes

- Time staff is available doesn’t correlate with when family members can easily attend

- Patients sometimes decline– they don’t want to disrupt their busy doctors

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Step 4: Pilot Implementation & Learning / Adaptation

Questions Presented to PFAC

1) Timing: Based on your perspective, when during a patient’s stay would this type of conference be most beneficial?

2) Participation: Some patients have expressed a reluctance to participate in the conferences, how can we better present this option to them?

3) Triggers: Are there any factors that should automatically "trigger" a Care Conference?

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Step 5: Measuring Progress

Care Conferences are currently being piloted on Farr 7, with an average of four to five conferences per week (max=8; min=0).

Impact on 30-Day Readmissions (March – August 2011)

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Farr 7 Readmission Rate Readmission Rate for Pts who Participated in CareConferences

Although the population may not be large enough to fully assess the impact, the changes on a case by case basis are staggering. For example, 8 patients who in total represented 34 admissions in the past 6 months were discharged without a 30-day readmission.

Further analysis is underway to evaluate the impact of Care Conferences on H-CAHPS scores.

Ave CMI = 1.8 Ave CMI

= 1.2

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Step 5: Measuring Progress

56% of Farr 7’s Discharges Occur Before 4:00 PM

Inpatient Discharges by Hour as a Percent of Total Discharges on General Medicine Floors Between March 1, 2011 and February 29, 2012

44% of Discharges Occur Before 4:00 PM on CC7 and Farr 2

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PFAC and STAAR Advisors Have Offered Valuable Insight to These Changes

Hospital-Based Interventions

• Admission Checklist• Teach Back Method for

Patient Education• Readmission Huddles• Revised DC Instructions• Condition-focused

Inpatient Education• Automated Fax to PCP (on

admission & discharge)• Care Connection

Appointment Scheduling Service

• Pharmacist Assisted Medication Reconciliation

• Discharge Checklist• Discharge Summary

Curriculum • Enhanced Sharing of

Electronic Records• Anticoagulation Mgmt

Initiative

Post-Hospital Interventions• Post-discharge Telephone

Outreach• Transitions Coach

Intervention (Home Visit)

Transition Back to Primary Care• Hospitalist-staffed Post-

discharge Clinic• Enhanced VNA-PCP

Coordination• Enhanced ECF-PCP

Communication

Contingency Management• Cardiology “Heart Line”

for patients after discharge

• Improved Access to Urgent Care Visits

• Outpatient Diuresis Clinic

Preventing Unnecessary Hospitalization• ED-based Cardiologist During Peak

Admitting Hours• Case Management “Leveling” Patients in

the ED

Hospital Primary Care

Emergency Department

Patient & Family

VNA & Home Care

Extended Care Facility

Recovery Return to Primary

Care

Contingency Management

Appropriate Hospitalizations

Challenges to Date

Our Main Challenges in Involving Patients and Families in this Work

• Time Commitment• Sometimes hard to identify the “line” between engaging a patient or

family member in a project and asking too much of a volunteer. • The best times for patients and families to meet are not always the most

convenient time for staff.

• Committee Readiness• Newly developed committees / teams are often hesitant to involve

patients and families until they feel the group is more organized.

• “Representative” Population• The patient and family members who volunteer their time to these

initiatives may not be fully representative of our entire hospital population.

Documents

1 Engaging Patients and Families to Improve Care Transitions