My Heart Failure Knowledge Passport

2. Greater Lansing AreaCare Transitions Heart Failure Work Group Almost one in five Medicare beneficiaries who are discharged from a hospital will be readmitted within one month Though some readmissions are planned, almost nine out of ten are not The readmission cost to Medicare in 2004 was $17.4 Billion 2 A study was conducted by Dr. Jencks, Williams, and Coleman of almost 12 million Medicare beneficiaries. They analyzed Medicare claims data from 2003-2004 to describe the patterns of rehospitalization and the relation of rehospitalization to demographic characteristics of the patients and of the hospitals. One fifth (19.6%) were rehospitalized within 30 days of an index hospitalization according to the study. It�s estimated that about 10% of rehospitalizations are planned, but the cost of unplanned rehospitalizations was approximately $17.4 Billion in 2004. A study was conducted by Dr. Jencks, Williams, and Coleman of almost 12 million Medicare beneficiaries. They analyzed Medicare claims data from 2003-2004 to describe the patterns of rehospitalization and the relation of rehospitalization to demographic characteristics of the patients and of the hospitals. One fifth (19.6%) were rehospitalized within 30 days of an index hospitalization according to the study. It�s estimated that about 10% of rehospitalizations are planned, but the cost of unplanned rehospitalizations was approximately $17.4 Billion in 2004.

3. 3 From those records analyzed, almost one fifth (19.6%) were rehospitalized within 30 days of an index hospitalization. 34% were rehospitalized after 90 days, and 56.1% after 365 days. From those records analyzed, almost one fifth (19.6%) were rehospitalized within 30 days of an index hospitalization. 34% were rehospitalized after 90 days, and 56.1% after 365 days.

4. Most Common Medical Readmissions Heart failure Pneumonia Chronic obstructive pulmonary disease Psychoses Gastrointestinal problems 4 The five most common medical conditions for the index hospitalization that were associated with rehospitalization are heart failure, pneumonia, COPD, psychoses, and gastointestinal problems.The five most common medical conditions for the index hospitalization that were associated with rehospitalization are heart failure, pneumonia, COPD, psychoses, and gastointestinal problems.

5. Most Common Surgical Readmissions Cardiac stent placement Major hip or knee surgery Vascular surgery Major bowel surgery Other hip or femur surgery 5 The five most common surgical procedures for the index hospitalization that were associated with rehospitalization are cardiac stent placement, major hip or knee surgery, vascurlar surgery, major bowel surgery, an other hip or femur surgery.The five most common surgical procedures for the index hospitalization that were associated with rehospitalization are cardiac stent placement, major hip or knee surgery, vascurlar surgery, major bowel surgery, an other hip or femur surgery.

6. Patients that are readmitted Half of patients readmitted within 30 days, were found to have no bill for a physician office visit. 70% of surgical patients readmitted, were admitted for a medical condition such as pneumonia or urinary tract infection. 6 The study conducted by Jencks, Williams, and Coleman found there was no associated bill for an outpatient physician visit between the index hospitalization and the 30 day readmission in 50% of patients. Most rehospitalizations among patients who were discharged after surgical procedures were readmitted for a medical diagnosis such as pneumonia, post op infection, or urinary tract infection.The study conducted by Jencks, Williams, and Coleman found there was no associated bill for an outpatient physician visit between the index hospitalization and the 30 day readmission in 50% of patients. Most rehospitalizations among patients who were discharged after surgical procedures were readmitted for a medical diagnosis such as pneumonia, post op infection, or urinary tract infection.

7. The Care Transitions Project: Three year CMS Initiative ending July 31, 2011 Focused in the Greater Lansing Area Goals of project: Reduce hospital readmissions Improve collaboration across care settings 7 MPRO is the Michigan QIO and Care Transitions is a sub-national project of the 9th scope of work , a 3 year CMS contracted project from 8/1/2008 through 7/31/2011. It was awarded to only 14 states in the nation. Lansing was submitted as the target community for its patient penetration rate. Greater than 70% of patients in Lansing, stay in the Lansing area. CMS is evaluating the success of the project to then spread the best practices developed by the participants nationwide probably in the next scope of work which will begin August 1, 2011. The Care Transitions project was designed to reduce all-cause hospital readmissions and improve collaboration across all setting.MPRO is the Michigan QIO and Care Transitions is a sub-national project of the 9th scope of work , a 3 year CMS contracted project from 8/1/2008 through 7/31/2011. It was awarded to only 14 states in the nation. Lansing was submitted as the target community for its patient penetration rate. Greater than 70% of patients in Lansing, stay in the Lansing area. CMS is evaluating the success of the project to then spread the best practices developed by the participants nationwide probably in the next scope of work which will begin August 1, 2011. The Care Transitions project was designed to reduce all-cause hospital readmissions and improve collaboration across all setting.

8. Greater Lansing AreaCare Transitions Heart Failure Work Group Community Collaborative formed in September of 2009. Comprised of area Hospitals, Skilled Nursing Facilities, Home Health Agencies, Hospice, LTAC, and Physician Practices. Established an open line of communication between the different facilities 8 What is the workgroup? Who makes up the workgroup. The purpose of the workgroup� Dialog is also ongoing with providers on communication needs at each care setting and identifying barriers to obtaining this information. Collaborative meetings are held to facilitate discussion and identify potential solutions to identified issues between each setting.What is the workgroup? Who makes up the workgroup. The purpose of the workgroup� Dialog is also ongoing with providers on communication needs at each care setting and identifying barriers to obtaining this information. Collaborative meetings are held to facilitate discussion and identify potential solutions to identified issues between each setting.

9. Greater Lansing AreaCare Transitions Heart Failure Work Group Brought knowledge and awareness of the needs of each facility All facilities working toward a common goal of best practices Continue their efforts to identify joint ventures for improvement 9 What has happened as a result of the workgroup? Collaborative meetings are held to facilitate discussion and identify the communication needs at each care setting and the barriers to obtaining information. Potential solutions to transition barriers between each setting are worked on by evaluating re-admission data, root cause analysis of potential drivers of readmissions and development of interventions to address potential drivers as a collaborative. Dialog is ongoing with providers on communication needs and best practices.What has happened as a result of the workgroup? Collaborative meetings are held to facilitate discussion and identify the communication needs at each care setting and the barriers to obtaining information. Potential solutions to transition barriers between each setting are worked on by evaluating re-admission data, root cause analysis of potential drivers of readmissions and development of interventions to address potential drivers as a collaborative. Dialog is ongoing with providers on communication needs and best practices.

10. Greater Lansing AreaCare Transitions Heart Failure Work Group Seamless transition of Heart Failure patients across settings Improving communication between settings Discharge Information Guidelines Use of SBAR to communicate Review of Medication Reconciliation 10 Main goal is the seamless transition of HF patients. The first steps to that goal was improving the communications between the settings. The group came up with the Discharge Information Guidelines. It�s a minimum clinical data set of information needed by down stream providers. All providers looked at using the SBAR method of reporting when notifying other providers. Each facility is working on med reconciliation. Main goal is the seamless transition of HF patients. The first steps to that goal was improving the communications between the settings. The group came up with the Discharge Information Guidelines. It�s a minimum clinical data set of information needed by down stream providers. All providers looked at using the SBAR method of reporting when notifying other providers. Each facility is working on med reconciliation.

11. Greater Lansing AreaCare Transitions Heart Failure Work Group Identified Educational needs for Heart Failure Diagnosis For patients and care givers For downstream providers Birth of the �Patient Passport� and �Magnet� in April 2010 11 The HF Workgroup identified the lack of consistent education of patients across settings. Down stream providers didn�t have materials for the patients to continue the learning process of the patient. The development of the passport and magnet began in April 2010.The HF Workgroup identified the lack of consistent education of patients across settings. Down stream providers didn�t have materials for the patients to continue the learning process of the patient. The development of the passport and magnet began in April 2010.

12. Greater Lansing AreaCare Transitions Heart Failure Work Group The Passport is designed to: Provide consistent HF education guidelines for all users across care settings Empower patients through education Be given to the patient diagnosed with heart failure on admission/arrival by any healthcare provider 12 The passport is a tool for patients/caregivers and providers across all setting. It has become important for the patient to take responsibility for their disease. Discharge planning and care needs to start on the day of admission and be continued throughout their stay in a facility. The passport is a tool for patients/caregivers and providers across all setting. It has become important for the patient to take responsibility for their disease. Discharge planning and care needs to start on the day of admission and be continued throughout their stay in a facility.

13. Greater Lansing AreaCare Transitions Heart Failure Work Group Role of the Provider: Verbally guide the patient through the pages Have the patient write in the Passport Use teach-back questions to evaluate patient understanding Supplement the Passport with other teaching materials 13 The role of the healthcare worker is to support the patient and guide them through their disease management. Heart failure is a life style self help disease. We need to give the patient the tools to work with. Encourage the patient to participate in the use of the passport by having them write in it. Do not write in it for them. Use open ended teach-back questions when working with patients. The passport is not designed to be all encompassing; supplement the passport with other materials and other referrals, i.e., dietary, physical therapy, cardiac rehab.The role of the healthcare worker is to support the patient and guide them through their disease management. Heart failure is a life style self help disease. We need to give the patient the tools to work with. Encourage the patient to participate in the use of the passport by having them write in it. Do not write in it for them. Use open ended teach-back questions when working with patients. The passport is not designed to be all encompassing; supplement the passport with other materials and other referrals, i.e., dietary, physical therapy, cardiac rehab.

14. Greater Lansing AreaCare Transitions Heart Failure Work Group What is Teach-Back? Tool to help evaluate Health Literacy Verbal communication technique Helps to ensure a patient�s understanding of what you teach them Involves asking patients to explain or demonstrate what they have been told 14 Teach-back was originally designed as a verbal communication technique to evaluate health literacy. It does not mean patients can not read but, they may not understand the sometimes complex medical language the healthcare industry uses. It helps the healthcare worker ensure the patient understands what you teach them by asking the patient to explain or demonstrate what they have been told. It involves using open ended questions to avoid �yes� and �no� answers by the patients.Teach-back was originally designed as a verbal communication technique to evaluate health literacy. It does not mean patients can not read but, they may not understand the sometimes complex medical language the healthcare industry uses. It helps the healthcare worker ensure the patient understands what you teach them by asking the patient to explain or demonstrate what they have been told. It involves using open ended questions to avoid �yes� and �no� answers by the patients.

15. Greater Lansing AreaCare Transitions Heart Failure Work Group Teach-Back Don�t ask �Do you understand?� Instead, ask patients to explain or demonstrate what they understand. If the patient does not explain correctly, assume that you have not provided adequate teaching. 15 Avoid asking the patient if they understand. This leaves the patient open to answer �yes� even if they do not. Ask patients to explain or demonstrate what they understand. If a patient cannot explain instructions or demonstrate correctly, teach-back technique assumes the teacher did not provided adequate teaching. Avoid asking the patient if they understand. This leaves the patient open to answer �yes� even if they do not. Ask patients to explain or demonstrate what they understand. If a patient cannot explain instructions or demonstrate correctly, teach-back technique assumes the teacher did not provided adequate teaching.

16. Greater Lansing AreaCare Transitions Heart Failure Work Group Teach-Back Use open ended questions. Don�t make questions a test for the patient. Rather, ask how well you explained the topic. 16 Use open ended questions to encourage dialog with patients. Don�t quiz the patient, this can make the patient uncomfortable and less willing to learn. As a healthcare provider, take responsibility for adequately teaching the patient. Use sentences like: �So I can be sure I have explained everything to you correctly�.,� �So I can be sure I have given you clear instruction�,� �I want to make sure I did a good job explaining to you�� to get the patient to return demonstration or repeat instructions. Use open ended questions to encourage dialog with patients. Don�t quiz the patient, this can make the patient uncomfortable and less willing to learn. As a healthcare provider, take responsibility for adequately teaching the patient. Use sentences like: �So I can be sure I have explained everything to you correctly�.,� �So I can be sure I have given you clear instruction�,� �I want to make sure I did a good job explaining to you�� to get the patient to return demonstration or repeat instructions.

17. Greater Lansing AreaCare Transitions Heart Failure Work Group Teach-Back Create a shame free environment to encourage questions. Explain many people have difficulty understanding medical information. Ask if they want a family member or friend to assist them. 17 Nobody likes to feel �stupid.� It is essential to make patient feel comfortable about asking question about what they do not understand. Explain that medical information can be difficult for the best of us and all questions are important. Having another person with them can be a comfort and possibly encourage more questions to confirm understanding.Nobody likes to feel �stupid.� It is essential to make patient feel comfortable about asking question about what they do not understand. Explain that medical information can be difficult for the best of us and all questions are important. Having another person with them can be a comfort and possibly encourage more questions to confirm understanding.

18. Greater Lansing AreaCare Transitions Heart Failure Work Group Teach-Back Slow down. Don�t appear rushed. Sit down Use plain language. Stop and check for understanding. 18 Slow down, you move too fast, you�ve got to make the morning last. If you appear rushed and don�t have time for the patient, it appears they are not important to you. Sitting with the patient lets them know you are focused on them. When giving the patient a lot of information, stop and check for understanding throughout the learning session. Encourage the patient to ask questions.Slow down, you move too fast, you�ve got to make the morning last. If you appear rushed and don�t have time for the patient, it appears they are not important to you. Sitting with the patient lets them know you are focused on them. When giving the patient a lot of information, stop and check for understanding throughout the learning session. Encourage the patient to ask questions.

19. Greater Lansing AreaCare Transitions Heart Failure Work Group Teach-Back (poor example): �These are signs of heart failure you need to watch for: Dyspnea on exertion Weight gain from fluid retention Edema in your lower extremities and abdomen Fatigue Dry, hacky cough Difficulty breathing when supine.� 19 Here is an example of using language that may be difficult for the patient to understand. If you speak fast and are rushed, it is even more difficult. Then if you ask the patient if he/she understands, the patient most likely will just nod their head.Here is an example of using language that may be difficult for the patient to understand. If you speak fast and are rushed, it is even more difficult. Then if you ask the patient if he/she understands, the patient most likely will just nod their head.

20. Greater Lansing AreaCare Transitions Heart Failure Work Group Teach-Back (good example): �I am going to talk to you about the signs of heart failure. The signs of heart failure are: Shortness of Breath Weight gain from fluid build-up Swelling in feet, ankles, legs or stomach Dry, hacky cough Feeling more tired, no energy It�s harder for you to breath when lying down� 20 This is a better example of going over symptoms of heart failure using simple to understand language. After going over the sign and symptoms, ask the patient to repeat a them to ensure understanding. Limit giving the patient too much information at one time. It�s better to give smaller amounts and then repeat the informtion.This is a better example of going over symptoms of heart failure using simple to understand language. After going over the sign and symptoms, ask the patient to repeat a them to ensure understanding. Limit giving the patient too much information at one time. It�s better to give smaller amounts and then repeat the informtion.

21. Greater Lansing AreaCare Transitions Heart Failure Work Group Examples of Teach-Back: �I would like you to explain how you will be taking your medications, so I can be sure I explained everything to you correctly.� What is the name of your water pill? What symptoms would you report to your doctor? What foods should you avoid? 21 Further example of teach-back questions, that encourage the patient to answer with out a yes or no.Further example of teach-back questions, that encourage the patient to answer with out a yes or no.

22. Greater Lansing AreaCare Transitions Heart Failure Work Group 22 The �My Heart Failure Knowledge Passport� Give it to patients early for: Education Knowledge Direction Empowerment It took the Heart Failure Work Group a little over six months to design, produce, and launch the �My Heart Failure Knowledge Passport.� By giving the passport to the patient on admission to the hospital, skilled nursing facility, in the home, or at the physician office you are providing them with the education material they need to gain knowledge and direction, and most of all empowering them to manage their disease.It took the Heart Failure Work Group a little over six months to design, produce, and launch the �My Heart Failure Knowledge Passport.� By giving the passport to the patient on admission to the hospital, skilled nursing facility, in the home, or at the physician office you are providing them with the education material they need to gain knowledge and direction, and most of all empowering them to manage their disease.

23. Greater Lansing AreaCare Transitions Heart Failure Work Group Have the patient take ownership and know their disease 23 Encourage the patient to take ownership of their disease. If the patient has been readmitted, what may have triggered the readmission? Are they aware of what caused their heart failure? Do they know what type of heart failure they have? Encourage the patient to take ownership of their disease. If the patient has been readmitted, what may have triggered the readmission? Are they aware of what caused their heart failure? Do they know what type of heart failure they have?

24. Greater Lansing AreaCare Transitions Heart Failure Work Group Assist when needed by providing unknown medical information. 24 The role of the healthcare worker is to support the patient and guide them through their disease management. Heart failure is a life style self help disease. We need to give the patient the tools to work with.The role of the healthcare worker is to support the patient and guide them through their disease management. Heart failure is a life style self help disease. We need to give the patient the tools to work with.

25. Greater Lansing AreaCare Transitions Heart Failure Work Group 25 Encourage patient ownership of their med list. Emphasize cautions and follow-ups for medications, i.e. labs for Coumadin and digoxin. Remind patients to update their medication list. Encourage patient ownership of their med list. Emphasize cautions and follow-ups for medications, i.e. labs for Coumadin and digoxin. Remind patients to update their medication list.

26. Greater Lansing AreaCare Transitions Heart Failure Work Group 26 The heart failure focus group talked freely about keeping medication list on their computers and printing them out when they went to their appointments. For those patients with more advanced technology, encourage them to attach their current medication list to the passport. The heart failure focus group talked freely about keeping medication list on their computers and printing them out when they went to their appointments. For those patients with more advanced technology, encourage them to attach their current medication list to the passport.

27. Greater Lansing AreaCare Transitions Heart Failure Work Group 27 Educate the patient on the importance of getting vaccinated for flu and pneumonia. Patients with HF are more likely to be hospitalized if they don�t stay healthy. Vaccines are a good way to prevent a hospitalization. Educate the patient on the importance of getting vaccinated for flu and pneumonia. Patients with HF are more likely to be hospitalized if they don�t stay healthy. Vaccines are a good way to prevent a hospitalization.

28. Greater Lansing AreaCare Transitions Heart Failure Work Group 28 Start the discussion of an advance directive. If not to make a decision immediately, to at least think about who would make medical decisions for them in an emergency. Encourage the patient to make their wishes known to others. Start the discussion of an advance directive. If not to make a decision immediately, to at least think about who would make medical decisions for them in an emergency. Encourage the patient to make their wishes known to others.

29. Greater Lansing AreaCare Transitions Heart Failure Work Group 29 Suggest the patient keep a Dr. Bag to take with them when going to medical appointments. Emphasize the importance of informing their provider of all visits to other healthcare providers. Consider using the first line to enter the name of the provider who gave the patient the passport.Suggest the patient keep a Dr. Bag to take with them when going to medical appointments. Emphasize the importance of informing their provider of all visits to other healthcare providers. Consider using the first line to enter the name of the provider who gave the patient the passport.

30. Greater Lansing AreaCare Transitions Heart Failure Work Group 30 Evaluate what the patient knows about their disease. Encourage the patient to ask questions and be prepared to answer them. Supplement the passport with additional educational material.Evaluate what the patient knows about their disease. Encourage the patient to ask questions and be prepared to answer them. Supplement the passport with additional educational material.

31. Greater Lansing AreaCare Transitions Heart Failure Work Group 31 Potential hospital readmissions can be avoided by patients knowing and managing their symptoms, and knowing when to call their physician. If the patient has been readmitted, what may have triggered the readmission?Potential hospital readmissions can be avoided by patients knowing and managing their symptoms, and knowing when to call their physician. If the patient has been readmitted, what may have triggered the readmission?

32. Greater Lansing AreaCare Transitions Heart Failure Work Group 32 Review the patient�s medications with them. Ask if they have any concerns about their medications. Do they have difficulty taking their medications or do they have difficulty obtaining their medications? Review the patient�s medications with them. Ask if they have any concerns about their medications. Do they have difficulty taking their medications or do they have difficulty obtaining their medications?

33. Greater Lansing AreaCare Transitions Heart Failure Work Group 33 Stress the importance of the patient taking responsibility for their medications and what side effects to look for.Stress the importance of the patient taking responsibility for their medications and what side effects to look for.

34. Greater Lansing AreaCare Transitions Heart Failure Work Group 34 Diet is a major contributor to HF decompensation. If the patient has been readmitted, what behaviors may have triggered the readmission?Diet is a major contributor to HF decompensation. If the patient has been readmitted, what behaviors may have triggered the readmission?

35. Greater Lansing AreaCare Transitions Heart Failure Work Group 35 Include dietitians in the education of the patient.Include dietitians in the education of the patient.

36. Greater Lansing AreaCare Transitions Heart Failure Work Group 36

37. Greater Lansing AreaCare Transitions Heart Failure Work Group 37 Include Physical therapy, Occupational therapy, or cardiac rehab in the patient�s education pathway.Include Physical therapy, Occupational therapy, or cardiac rehab in the patient�s education pathway.

38. Greater Lansing AreaCare Transitions Heart Failure Work Group 38 Work with patients on identifying early signs of decompensation and when to report these to their provider. Early intervention can possible avoid a hospitalization.Work with patients on identifying early signs of decompensation and when to report these to their provider. Early intervention can possible avoid a hospitalization.

39. Greater Lansing AreaCare Transitions Heart Failure Work Group 39 Monitoring weight is one of the easiest and most effective means to catch early signs of worsening heart failure. Also checking for excess swelling in the legs, ankles, feet and belly. Consider asking if their shoes have gotten tighter, or the waist band on their pants feels a bit snug. Monitoring weight is one of the easiest and most effective means to catch early signs of worsening heart failure. Also checking for excess swelling in the legs, ankles, feet and belly. Consider asking if their shoes have gotten tighter, or the waist band on their pants feels a bit snug.

40. Greater Lansing AreaCare Transitions Heart Failure Work Group 40 Encourage the patient to keep a weight log to monitor changes in their weight on a daily basis. On discharge, make sure the patient has a means to weight themselves. If they have a scale, do they have any difficulty reading it? Encourage the patient to keep a weight log to monitor changes in their weight on a daily basis. On discharge, make sure the patient has a means to weight themselves. If they have a scale, do they have any difficulty reading it?

41. Greater Lansing AreaCare Transitions Heart Failure Work Group 41 Reinforce the correlation between sodium and weight gain. Stress the importance of taking their diuretic. Reinforce the correlation between sodium and weight gain. Stress the importance of taking their diuretic.

42. Greater Lansing AreaCare Transitions Heart Failure Work Group 42 The magnet was designed not only for the patient, but also caregivers and family members. It can help the later support the patient in their management if needed. It is an out in the open reminder to the patient where they are at with their symptoms and may prompt them to take action quicker when symptoms do arise.The magnet was designed not only for the patient, but also caregivers and family members. It can help the later support the patient in their management if needed. It is an out in the open reminder to the patient where they are at with their symptoms and may prompt them to take action quicker when symptoms do arise.

43. Greater Lansing AreaCare Transitions Heart Failure Work Group 43 Encourage the patient to use the note page for questions or concerns as they arise, for their next provider visit. Encourage the patient to use the note page for questions or concerns as they arise, for their next provider visit.

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45. Care Transitions Team: Donna Beebe, Project Manager dbeebe@mpro.org or 248-465-7354 Katie Brown, Project Coordinator kbrown@mpro.org or 248-465-7385 Sandra Soronen, Project Coordinator ssoronen@mpro.org or 248-465-7347 Barbara J. Smith, Project Coordinator bsmith@mpro.org or 248-465-1310 45