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Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
1
Provide Real-Time Handover CommunicationsPeg Bradke and Eric Coleman
These presenters have
nothing to disclose
April 23, 2014
Session Objectives
Participants will be able to:
• Identify failures in current practice from the
literature and their own experience
• Describe handover improvements and useful
ways to get started
• List tips and techniques for partnering across the
continuum of care to get results
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
“….effectively communicate post-
acute care plans to patients and
community-based providers of
care?”
How Might We….
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Recommended Changes
4. Provide Real-time Handover Communication
A. Give patient and family members a patient-friendly,
post-hospital care plan which includes a clear
medication list
B. Provide customized, real-time critical information to
the next clinical care provider(s)
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
Observe Current Discharge
Processes
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Communication Is a Two Way Street
Please share examples for when you reached out
to cross-setting partners to get their input.
Did you meet by phone or face-to-face?
Who did you meet with?
What surprised you?
Discharge Preparations
• Provide the patient and family caregivers with written information about what to expect when they return home and easy-to-read self-care and medication instructions
• Explore community support systems and resources to provide patient and family caregivers
• Plan ahead to keep patients comfortable on the trip home; consider pain medication administration and or filling prescriptions before patient goes home
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Post-hospital Follow-up Care
• Ensure that the patient and family caregivers
are present for discharge instructions
• Use Teach Back in your discharge instructions
• A single number to call for emergent needs and
non-emergent questions
• Current and baseline functional status of patient
not described, making it difficult to assess
progress and prognosis
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
Reconcile Medications
Review the patient’s pre-hospital and hospital medication regimens:
− Supplement with additional information about medications that was not evident at the time of admission
− Clarify whether medications that have been withheld should be restarted after discharge
− Convert hospital intravenous medications to oral medications
− Reconcile substitutions from the institution’s formulary and translate back to the original preparations to avoid duplication, medication errors, or unnecessary expense to the patient
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Reconcile Medications
• Can the patient:
- Read their medication labels?
- Afford the necessary medications and foods?
- Get to a pharmacy?
• Use highlighting on meds list to call attention to new
meds, dosage changes, or discontinued meds
• Encourage patients and families to use a tool or
document that does not require reliance on memory
Resources for Creating User-friendly
Medication Lists
How to Create a Pill Card
For more information, please visit the patient
safety and errors section at:
http://www.ahrq.gov/
Iowa Healthcare Collaborative (IHC)
Med Card
For more information, please visit:
http://www.ihconline.org/aspx/consumerresources.aspx#MedCard_Anchor
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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How to Create a Pill Card (AHRQ)
User-friendly Medication Card (IHC)
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Our Most Formidable Challenge
Year after year we try to improve med rec
However gains have been modest
Not due to lack of trying
Why do you think medications represent
our most formidable challenge?
If the patient is transitioning home and will be receiving
care in primary care office or specialty practice:
• Ensure the discharge summary arrives prior to the visit
• Arrange for access to patient discharge instructions in
the office practice
• Without this critical information, providers may duplicate,
overlook important aspects of the care plan, or convey
conflicting information
Handovers to Physician Offices
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Warm Handover to Community Partners
Written handover communication for high-risk
patients is insufficient : direct verbal
communication allows for inquiry and clarification
Transition to Home Health Care, Long-term Care,
Skilled Nursing or Other Community Settings
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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• Consider establishing HHC, SNF or LTC
liaisons that are based in the hospital (ex.
HHC liaison helps MDs determine
qualifications for HHC)
• Work with Liaisons and community partners
to standardize critical information to be
included in a handover communication tool
Transition to Home Health Care, Long-term Care,
Skilled Nursing Facility or Other Community Settings
Transition to Home Health Care, Long-term Care,
Skilled Nursing Facility or Other Community Settings
• Co-design handover communication
processes (i.e. preferred formats for
information)
• Create processes for bidirectional
communication for care coordination,
continual learning and ongoing
improvement efforts
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Handovers to Home Health Care, Skilled
Nursing Facilities or Community Services
• Share patient education materials and
educational processes across care settings
• Offer education for the staff in HHC, SNF, LTC
and community services
• Create processes for bidirectional communication
for care coordination, continual learning and
ongoing improvement efforts
INTERACT Transfer Tool
Available at: http://interact2.net/tools_v3.aspxnteract2.net
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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“Warm Handovers” for High-risk Patients
• For high-risk patients, a clinician should call the post-
acute provider listed as the individual the patient will
call for emergent needs:
– Alerts the next care provider of the discharge
status and plan of care
– Provides a mechanisms for bidirectional
communication
– Allows for inquiry and clarification of questions
Coordination of Care
Discuss • How many services are wrapped around the patient and
family caregiver?
• Are they all communicating? Do they all understand the Plan of
Care?
• If there are multiple services involved is a “lead person” identified
and communicated?
• How many phone call is that patient/family caregiver
receiving after they get home?
• What are each of the calls purposes?
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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Using Process Measures to
Guide Your Learning
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
Number of discharges in the sample where critical information is transmitted at the time of discharge to the next care site or person continuing care (e.g., home health care, long-term care facility, rehab care, physician office, or care at home)
Definition details on page 71 of the How-to Guide
What Are We Learning About Providing
Real-time Handover Communications?
• There are a “vital few” critical elements of patient
information that should be available at the time of
discharge for the community providers
– “Senders” and “receivers” agree upon the information
and design reliable processes to transfer information
effectively
• Written handover communication for high-risk
patients is insufficient; direct verbal
communication allows for inquiry and clarification
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/20/2014
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What Are We Learning About Providing
Real-time Handover Communications?
• Ensure that the discharge summary is available for office visits prior to the patients appointment
• Consider designing standardized handover forms for the community, region, or state
• Written care plans for patients and family caregivers should use clear, user-friendly formats for describing care at home
Table Exercise
• What is your experience with initiating follow-up care?
• What have you learned?
• What do you plan to test?