HCAHPS: Global Domain for Discharge

1. HCAHPS: Global Domain for Discharge The Finley Hospital

2. Objectives • Describe “best practice” methodologies associated with patient perception of readiness for discharge • Examine areas of “excellence” that potentially strengthen and/or tie into patient perception of readiness for discharge • Discuss individual roles of the interdisciplinary team that impact patient perception of care/readiness for discharge • Describe three interventions that you can trial in your facility to improve HCAHPs discharge scores

3. How did we get here? • Finley Hospital Discharge Domain scores have been consistently above the 90th percentile • The scores are in the top 10% nationwide • IHS Affinity groups such as the Patient Experience Team and the Case Management Team started asking us about what we do.

4. Finley IHS

5. What we know today • We know that people are really interested in what we are doing • We cannot name just one or two things that we have worked on that make are scores what they are • We have many things that we are doing that are working well

6. Discharge Domain Questions • The discharge domain has two questions in the domain scoring • During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? • During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

7. Discharge Domain continued • Both questions are Yes or No • In other words: Pass/Fail • There is no way for the person to rate the quality of the discussion or the written instructions.

8. Best Practice & Areas of Excellence • Press Ganey Solution Starters • For standard questions the solution starter gives the question definition and improvement solutions.

9. Press Ganey Solution Starter Ideas • Some of the ideas on the Solution Starters include: • Include the right people with the patient for both the discussion on the help needed at home and the review of the written discharge instructions • Address questions and concerns they have about the plan and the instructions before they leave

10. More Solution Starter ideas • Use white boards, note pads for questions and take-home packets for communication during the stay • Discharge instructions need to be simple and easy to read – health literate • Use the discharge phone calls to answer questions and reinforce information • Let them know who to call if they have questions

11. Best Practice & Areas of Excellence • Project RED (Re-Engineered Discharge) • Developed by researchers at Boston University Medical Center (BUMC) • The Agency for Healthcare Research and Quality (AHRQ) funded the development of the Project RED tool kit • Effective at reducing readmissions and post-hospital emergency visits

12. Project RED Checklist Eleven activities that should be completed for every patient • Medication Reconciliation • The plan matches with national guidelines • Doing the right thing at the right time • Follow-up appointments are set • Communicate outstanding tests • Arrange post-discharge services

13. Project RED Checklist continued • Written discharge instructions • What to do if problems arise • Patient education throughout stay • Assess patient understanding • Discharge summary sent to PCP • Telephone reinforcement

14. Improving Discharge Satisfaction May Also Improve

15. What Do We Know About Our Improvement? • We know that improvement has been consistent over the past three years • We have reduced variation in scoring, so we are more consistent in maintaining a narrower range of scores

16. Finley Discharge Global Score by Year 2009-2011 Mean 92.87 Mean 95.38 Mean 87.83 Significant reduction in variation and increase in mean score per year demonstrated over 3 years

17. Comparing Data to Improvements • 2009 and Prior • Right people at the interdisciplinary team meetings for communication • Focus on patient satisfaction • Scripting for case managers and social workers • Focus on reducing length of stay

18. Comparing Data to Improvements 2010 • Move to new med-surg units • Focus on updating new custom white boards • Goals • Anticipated DC date • Anticipated DC plan • Focus on CM leading daily care conference • Focus on CM seeing patients daily • Discharge phone calls – Fall 2010

19. Comparing Data to Improvements • Focus on preventing re-admissions by: • Daily readmission report to Case Managers • Readmission data collection on specific data elements • Communication to Physician Champion of any readmission from primary admitting physician • Special Case Management /Social Work process trialed with one “Frequent flyer” patient to see if we can better meet needs including • Reviewed patient admission history and costs in multi-disciplinary care committee • Assigned physician (did not have primary care at first) • Assigned unit to be admitted to • Assigned Case Manager and Social Work Professional to see patient whenever readmitted 2011 and Forward Focus

20. Case Management Timeline for Change

21. 5MS HCAHPs Global Nursing, Physician and Discharge Questions Both Nursing and Physician global scores have risen annually along with information on symptoms/problems to report to the physician

22. OB HCAHPs Global Nursing, Physician and Discharge Questions OB scores are holding consistent and fairly high across all three years.

23. Discharge Domain Percentile Rank by Unit % = unit survey response/overall response

24. Percent of Overall HCAHPS Surveys Returned by Unit

25. What is Working Case Managers (RNs) Round on All Inpatients Daily rounding by Case Managers Scripting for Case Managers: What can we do to help you get ready for discharge? What are your goals for discharge? What problems do you anticipate may occur at discharge?

26. What is Working Social Workers are assigned to patients based on need. Examples: Over 65 years, Major surgery, Nursing Home Placement, Need for Home IV Therapy Social Work Scripting: How do you feel about going home? Any concerns or worries?

27. What is Working Communication Between Disciplines • Case Managers and Social Workers are assigned to units and work well together • Case Managers and Social Workers report to same Director • Daily Care Conference on Med Surg units that includes: Charge Nurse, Case Manager, Social Worker, Pharmacy, Physical Therapy and other disciplines when requested • Targeted conversations on re-admitted patients

28. It Takes a Village….Daily Care Conferences

29. Communication • Large white boards in prominent place in Med-Surg areas • Include names of nurse, tech, case manager and social worker • Include anticipated discharge date and plan for discharge such as home or nursing home • Patients and Families may write questions and notes on the white board

30. White Board Example

31. Education • Disease management education is primarily a nursing function, but also provided as needed by case management, when appropriate ex therapy, dietary • A case manager is one of the presenters at the Joint Camp a class for patients preparing for their new joint replacement • Joint Camp presentation includes typical plan for discharge

32. Education • Written discharge instructions are a mix between home grown mainly for surgical patients and Micromedex instructions • Booklets for specific groups such as the total joint population and the new moms/parents

33. Core Measures • Core Measure patients are identified on admission or as soon as possible after admission • Core Measure patients (CHF, Pneumonia and AMI) receive specially made folders that include several types of patient education material as soon as they are identified as having a core measure diagnosis.

34. Core Measure Folder

35. Follow-up appointments When possible they are made prior to discharge • Staff check with patient regarding what time of day is best for the patient for follow up appointment • Appointment is made by unit secretary • Return appointment is written on an appointment card with specific instructions if lab or x-ray is needed prior • Orders for lab or x-rays are faxed to the office where the tests are to be performed

36. Hand-off communication • If patient is discharged with home-care or to a nursing facility information is faxed prior to discharge to agency • Nursing staff call nurse to nurse report to home care agency or the nursing facility • Medication list and copy of discharge instructions are faxed to My Nurse for follow up phone calls.

37. Home medications • Medication list reviewed with patient and family • New medications or changes in medication dosages are reviewed in detail • Prescriptions are faxed to pharmacy of patient’s choice if requested

38. Home Equipment • Equipment needed for ambulation is ordered and delivered to room by physical therapy • Home supplies such as commode, hospital bed, or any other large item is ordered by social worker and delivered to the patient’s home prior to discharge if possible

39. Teach Back • After instructed by nurse, patient or family will do a return demonstration of care such as dressing changes, trach cares, catheter cares, emptying drains, etc. • Nurse will assess readiness or re-educate if needed

40. Ready to Go • Home care instructions specific to diagnosis are reviewed with patient and family member. • Medication list reviewed • Follow up appointment reviewed • Nurse or nursing tech take patient to the hospital exit and assist into vehicle

41. At Home Follow-Up • Med- Surg patients receive a phone call from My Nurse within 48 hours of going home • My Nurse reviews medications and discharge instructions prior to making the phone call • Scripted questions are asked to patient (teach-back) • Patient has opportunity to ask nurse questions

42. OB Follow up Visit • Suite Beginnings • All new mothers and babies have a one time home visit by an obstetric nurse

43. What Else Is Going On? • Work on reducing readmissions • Monthly reporting/posting of patient satisfaction data • Affiliated with The Studor Group • Leader rounding on patients • Leader rounding on staff • Hardwiring intentional rounding • Thank-you notes to staff • Monthly meeting model • Employee selection • WOW orientation ideas • Next up – hardwiring AIDET

44. Take Aways – what can you do? • Using the best practice guidelines assess the discharge process at your facility using observations, feedback from your patients and families and your staff • Start with something small and work up to the bigger things to change • Solicit leadership support • Align goals of hospital and unit leaders

45. Sharing or Questions • Please consider sharing specific things that are working in your facility • Questions?

46. Contact Information • For more information about the discharge or case management process at Finley Hospital please contact either:Teresa Neal, Director Of Performance Improvement, 563-589-2553 or Teresa.Neal@finleyhospital.org Cindy Weidemann, Risk, Safety and Survey Readiness Coordinator 563-589-2607 or Cindy.Weidemann@finleyhospital.org Chris Wilson, Director 4MS and Rehabilitation, 563-557-2788 or Christine.Wilson@finleyhospital.org