Heart Failure Improvement Across the Continuum

1. Heart Failure Improvement Across the Continuum Hospital to Home: Optimizing the Transition January 2009 Florida Hospital Assoc. Peg M. Bradke, RN, MA Director, Heart Care Services St. Luke’s Hospital, Cedar Rapids, Iowa

2. February 2006 • St. Luke’s joined the Institute for Health Improvement Innovation Project for Transitions to Home. • Work concentrated on the Heart Failure patient.

3. Strategies in Place • Heart Failure work team in place • Congestive Heart Failure class • Utilizing BNP to identify HF patients • Follow-up phone calls • Setting up discharge appointments • Pad/pencil at bedside for patient • A lot of work on CMS indicators

4. First Steps • Heart Failure Work Group reorganized to include: • Home Care representative • Family member of a HF patient • Long-Term Care representative • Physician Clinic representative These views added new context to our efforts.

5. MeasurementHow will we know a change is improvement? HF 30-day readmission rate: (Unit of focus or hospital-wide) • HF is primary, secondary or lower level diagnosis • Patient with HF had a readmission for HF within 30 days of a readmission for HF • Use your own definition or CHF Toolkit measures at www.IHI.org http://www.ihi.org/NR/rdonlyres/708DEB58-6082-453A-B26A-3391290EC0AD/0/MIFCHFPercentofCongestiveHeartFailurePatientDischargeswithReadmissionWithin30Days.doc Hospital 30-day (all) readmission rate: • Patient with HF was readmitted for any reason For both measures: • Exclude chemo day patients treated on the unit • If focusing your work on a single unit, the HF readmission or all readmission rates for that unit will be needed • Display monthly on a line (run) chart for last twelve months. 

6. AIM Statement(From February 2006 Initial Transition to Home IHI Kick-off Meeting) • By January 1, 2007, St. Luke’s Hospital’s Telemetry Unit and Medical Unit will reduce unplanned readmissions by 50% (from 12 to 6%) by improving the transition home process for all Heart Failure patients. • Our methodology will include the patient and caregiver - ensuring that they fully understand their diagnosis, plan of care and follow-up care with physician.

7. What Changes Can We MakeThat Will Result in Improvement? • Four Key Changes to Achieve an Ideal Care Transition from Hospital to Home: • Enhanced Assessment of Patients • Enhanced Teaching and Learning • Patient-Centered Communication Hand-offs • Post Hospital Follow-up

8. Result of the IHI Collaborative Work on Transitions • Transforming Care at the Bedside How-to Guide http://www.ihi.org/NR/rdonlyres/8F0551D1-DCD7-4EE7-BEE0-7C0DFBB5F6AB/5867/TransitionsHome_HowtoGuide_Final102207.pdf

9. Enhancing the Admission Assessment for Post-Discharge Needs

10. Enhanced Admission Assessment for Post Discharge Needs • Identify the appropriate family caregivers • Partner with home care agencies, primary care offices and clinics, and long-term care facilities • Communicate to all members of the care team the discharge plan and what needs to happen • Estimate the home-going date on admission and anticipate needs • Estimate standard discharge criteria

11. Heart Failure Work Group Reorganized to Include: • Home Care representative • Family member of a HF patient • Long-Term Care representative • Physician Clinic representative These views added new context to our efforts.

12. Sample of White Board

13. Sample of SBAR Kardex

14. Communication • Daily discharge huddle at 10:00 AM • Bedside reporting • Both opportunities to review plan for day and anticipate discharge needs

15. Reconcile Medications Upon Admission • Involve the patient and family caregivers, care providers, physicians, pharmacy • Reconcile on admission (suitably trained professional) • Include record of the reconciliation in the medical record • Ensure drug changes during the admission are reconciled, updated, accurate and timely • Consider using a personalized medication

16. Chart Review Tool • Known reason(s) for readmission. • What did the patient or family think contributed to the readmission? • Any self-care instructions misunderstood? • Evidence of teach back documented? • What did the physician or office staff think contributed? • Was a follow-up physician visit scheduled? Attended? • Number of days between the discharge and physician’s office visit. Number of days between discharge and readmission • Any urgent clinic/ED visits before readmission? • Functional status of the patient on discharge? • Clear discharge plan documented?

17. Interview Questions Asked to Patients/ Caregiver Readmitted With Heart Failure • Can you tell me in your own words why you think you ended up sick enough to be readmitted again? • Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night? • Where are your scale and calendar located? • Have you seen your doctor since you were discharged from the hospital? • Do you have all of your medications? How do you set your pills up every day? • Were there any appointments that kept you from taking any of your pills?

18. Enhancing Understanding in the Patient Education Process

19. Redesign the patient education process to improve patient/family or caregiver understanding of self care: Identify the appropriate family or caregivers Involve right learners in all critical education Identify how the patient and family or caregiver learn best Redesign written material Redesign teaching methods Enhanced Understanding in the Patient Education Process

20. Enhanced Teaching andLearning Redesign patient teaching material: • During acute care hospitalizations for HF, only essential education is recommended • Reinforce within 1-2 weeks after discharge • Continue for 3-6 months Adams, KF et al: HFSA 2006 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure Vol. 12, No. 1, pg 61 February 2006

21. Intervention:Patient Education Material Key “small tests of change”” • Reviewed content of educational materials utilizing health literacy concepts. • Outpatient Heart Failure class utilized as focus group for content. • Family member on team, along with her siblings, reviewed content for understanding Health Literacy.

22. Keys to Success Utilizing Health Care Literacy Concepts • On all written materials, matched terminology to what we said in class. • Used term Heart Failure as opposed to Congestive Heart Failure or Chronic HF • Removed ranges • Increased font size • Added more white space

23. Keys to Success with Health Literacy • Use universal health literacy communications principles to redesign written teaching materials: User-friendly written materials use: • Simple words (1-2 syllables) • Short sentences (4-6 words) • Short paragraphs (2-3 sentences) • No medical jargon • Headings and bullets • Highlighted or circled key information

24. Heart Failure Magnet

25. Warning Signs and Symptoms

26. Heart Failure Handout

27. Diet Information

28. On-Line Discharge Instruction

29. Evaluation of New Patient Education Material Results from 15 follow-up phone calls: • “Information very helpful.” • Able to state where information was and reported that they were referring to it. • Understood content. • Successfully answered teach back questions related to “water pill,” diet and weight. • Improvement opportunity – patients were often unclear when they had multiple physicians which one to call for the symptoms (magnet revised).

30. Enhanced Teaching and Learning Redesign patient teaching: • Stop and check for understanding using Teach Back after teaching each segment of the information • If there is a gap, review again • Another way to close the loop

31. Redesign Patient Teaching • Slow down when speaking to the patient and family and break messages into short statements • Use plain language, breaking content into short statements • Segment education to allow for mastery

32. Enhanced Teaching and Learning Utilizing “Teach Back” • Explain needed information to the patient or family caregiver. • Ask in a non-shaming way for the individual to explain in his or her own words what was understood. • Example: “I want to be sure that I did a good job of teaching you today about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the doctor?” • Return demonstration or show back

33. Teach Back Questions • What is the name of your water pill? • What weight gain should you report to your doctor? • What foods should you avoid? • Do you know what symptoms to report to your doctor?

34. Enhanced Teaching and Learning • Use Teach Back daily • In the hospital • During home visits and follow-up phone calls • To assess the patients’ and family caregivers’ understanding of discharge instructions and ability to do self-care • To close understanding gaps between: • Caregivers and patients • Professional caregivers and family caregivers

35. Teach Back Success • Percent of time patients can teach back 90% or more of content taught related to the transition to home utilizing the four questions related to self management of heart failure • Stop and check for understanding using Teach Back after teaching each segment of information • Assess patient’s, family’s or caregiver’s ability and confidence

36. Improving Teach Back Results

37. Staff Competency Validation for Teachback • Methodology • The learning station will use discussion, role playing and patient teaching scenarios to help RN’s communicate effectively to patient/family.

38. Staff Competency Validation for Teachback • Objectives – Each participant will be able to: • Define health literacy • Learn clear communication strategies • Define plain language • Learn and utilize the “teach back” method in a shame-free way

39. Staff Competency Validation for Teachback • Each participant will participate in a role-play providing education to a patient. The following will be assessed: • Ability to do teach back in a shame-free way; tone is positive • Utilizes plain language for explanations • Does not ask patient, “Do you understand?” • Uses statements such as “I want to make sure I explained everything clearly to you.” “Can you please explain it back to me in your own words?” Or, as an example, “I want to make sure I did a good job explaining this to you because it can be very confusing. Can you tell me what changes we decided to make and how you will take your medicine now?” • If needed, participant will clarify and reinforce the explanation to improve patient understanding.

40. Patient and Family Centered Transition Communication

41. Patient-Centered Transition Communication • Provide next caregiver customized real-time information: • What to expect at home • Easy to read self-care instructions • Reasons to call for help • Number to call for emergent and non-emergent needs and questions • Share patient education materials and education processes across all care settings • Physicians, home care and other involved clinicians transmit information at time of discharge • Include anticipated, important next steps in the transition, including concerns about the patients • Ask receiving care teams for their preferred format, mode of communication and specific information needs about the patient’s functional status • Ask receiving care teams for their preferred format, mode of communication and specific information needs about the patient’s functional status • Continually improve by aggregating the experience of patients, families, and caregivers and designing improvements

43. Example of Class Calendar

44. St. Luke’s Heart Failure Continuum • Teach back in hospital using new teaching material • Standardized HF on-line discharge instructions • Home Care complimentary visit 24 to 48 hours post discharge – use teach back again • Physician office visit within three to five days • Advance Practice Nurse follow-up phone call on seventh day post discharge – teach back repeated • Outpatient Heart Failure class – seeing increased participation • Collaboration with cardiology office Heart Failure Clinic

45. Post Acute Care Follow-Up

46. Post Acute Care Follow-Up • High risk patients: prior to discharge, schedule a face-to-face follow-up visit (home care visit, care coordination visit, or physician office visit) to occur within 48 hours after discharge • Moderate risk patients: prior to discharge, schedule follow-up phone call within 48 hours and schedule a physician office visit within five days

47. Post Acute Care Follow-Up High-risk patients: • Patient has been admitted two or more times in the past year • Patient failed “Teach Back” or the patient or family caregiver has low degree of confidence to carry out self-care at home • Patient and family caregiver have the phone number for questions and concerns • Consider home care or discharge coach

48. Post Acute Care Follow-Up Moderate risk patients: • Patient has been admitted once in the past year • Patient or family caregiver has moderate degree of confidence to carry out self-care at home • Prior to discharge, schedule follow-up phone call within 48 hours • Schedule a physician office visit within five days

49. Intervention: Home Care Visit24-48 Hours Post Discharge • Small test of change October 2006 • Education to all Home Care staff • Visit 48 hours after discharge • Visit outline • Medication Reconciliation • Review of diet and foods in-house • Teach back on water pill, diet and weight • Vital signs Hardwired process in January 2007

50. Cost for Heart Failure Program • Home Care visit: $110.00 • St. Luke’s covers $58.00; the remainder of $52.00 is absorbed • Follow-up phone calls: $10,000 • Education material • Magnet: $1.00 • Total with handouts: $1,200