Module 2

1. Module 2 The Re-Designed Discharge Process: Patient Admission and Care and Treatment Education

2. 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

3. 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

4. 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

5. 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 Principles of the Re-Engineered Hospital Discharge

6. Comprehensive written discharge plan provided to patient prior to discharge Discharge information in patient’s language and literacy level Reinforcement of plan with patient after discharge Availability of case management staff outside of limited daytime hours Continuous quality improvement of discharge processes Principles of the Re-Engineered Hospital Discharge

7. Patient and Family Centered Safe Care • Community providers: • Nursing Home • Home Health & Hospice • Home Care • Physicians • Accountable Care Organizations Pre Patient Admission Discharge Order Written H&P; Assessments; Rx Plan Discharge Event Discharge Process Discharge Folder Passport for Home White Board, Rounding & Bedside Report PATIENT EDUCATION/ Prepare for Home FINAL DISCHARGE INSTRUCTIONS Post-D/C FOLLOW-UP MEDICATION MANAGEMENT

8. Admission and Care and Treatment Education Ascertain need for and obtain language assistance Medication Reconciliation Reconcile discharge plan with national guidelines Follow-up appointments Outstanding/pending lab & diagnostic tests follow-up Post-discharge services Written discharge plan What to do if problem arises Patient education Assess patient understanding Discharge summary sent to PCP Telephone reinforcement t

9. sample

10. 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

11. Financial Metrics The cost of second length of stay (readmission) Project costs Discharge process costs (current and redesigned)

12. 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

13. 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)

14. 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

15. 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?

16. 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

17. Identify the Patient • By admission unit • By admitting diagnosis • Heart failure: How do you identify these patients for core measure processes? • By physician

18. Identify the Patient • Who will notify the DA of the patient’s 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

19. DA Secondary Screening • DA reviews patient’s 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

20. Sample Log to Track Key Dates and Times

21. 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?

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

23. 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 patient’s concerns re: discharge • Continue development of care plan

24. Discharge Planning Rounds

25. 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)?

26. Patient’s 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

27. 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

28. 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

29. Case Managers • Post-discharge services • Social work • Utilization review • Financial support

30. Other Key Staff • Therapists • Disease management

31. 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?

32. 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

33. 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/

34. 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

35. 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

36. 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

37. Additional Teaching Tips* • Use visual aids and illustrations • Beware of words with multiple meanings • Avoid acronyms and other new words • Use idioms carefully • Provide a health context for numbers and mathematical concepts • Take a pause • Be an active listener • Address quizzical looks • Create a welcoming and supportive environment *www.pfizerhealthliteracy.com/public-health-professional/tips

38. 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?

39. 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

40. Gathering Care Plan Content • Start the Patient Care Plan on admission and add to it daily • Secure education material about the patient’s 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

41. Module 2: SummaryExpected Outcomes Identify patients who are members of the project’s 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

42. 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