A Patient & Family Discharge Planning Model that Works

1. A Patient & Family Discharge Planning Model that Works SEPONL April 4th, 2014

2. Or, Goodbyes Matter • How can we ensure a “Good Fit” when we say Good-bye?

3. Objectives..& a thought • The Larger Context • One Community Hospital’s Story • Implementing a Model • Highlighting the Tools that are its Glue • Consider Webster: • “..Discharge-to relieve of a burden, to release from confinement…” • “..Transition-a passage or movement from one stage to another..”

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5. The Context & the Patient-a Fit? “…collection of readmission data reflects Medicare’s view that hospitals should be responsible for patients’ well-being even after they go home…” (2013) “The last place patients want to end up after a hospital stay is right back in the hospital….on average 8 minutes of conversation occurs about how to care for oneself at home, so no surprise that patients may have trouble” (2011) “…not our parents’ medicine…” (2012)

6. The Quality of the Good-byes • How many readmissions are “preventable” with standardization? No one knows • Evidence: Re-hospitalizations & poor routines: • Lack of coordinated hand-offs • Hospital resources: How to Maximize? • High Risk approach vs. Dx specific focus • Understand patients: who/why come back • Our nursing teams: how to shift from Discharge to a Transition in Care paradigm

7. The Quality of the Good-byes • Hospitals’ responsibility does not end at discharge • Recognize dangers of transition • Set patients/families up for success (2013) • Positive associations between the patient experience and: • Adherence to prevention/treatment • Health care resource use (2013) • Bundled Intervention Models: • Naylor’s Transitional Care Model • Coleman’s Care Transitions Interventions • Jack’s Project RED

8. The Context/VBP & the Patient • “Transitions”-largest slice HCAHPS pie • Transition questions added (2013) • During hospital stay ,staff took my preferences & my family’s into account • When I left, I had a good understanding of the things I was responsible for • When I left, I clearly understood the purpose of taking my medications • Discharge centered on patient=Success • Domains: RN Communication, the 5 “Discharge” items,Responsiveness,Medications • “…HCAHPS is not about Happiness..”

9. Penn Medicine Chester County Hospital • CCH 263 bed community hospital • Rich history, 120 years • Penn Medicine: • September, 2013 • HUP-1st teaching hospital, 1874 • Pennsylvania Hospital, the nation’s first, 1751 • Penn Presbyterian Hospital • CCH & Project RED My home away from home

10. CCH & Project RED-our Story • Project “RED” (Re-Engineered Discharge) Background • Safe Discharge is best when clinical team integrates efforts • Communication deficits at Discharge are common; the “Perfect Storm” of patient safety • RED research, Dr. Brian Jack (Annals Internal Medicine , 2009) • Dr. B. Jack/AHRQ/CCH-the national RED Roll-Out Contract • Does the Project RED 11 Element Checklist work in the real world? • Can the Project RED 11 Element Checklist be used more efficiently? • June 2011 site visit; Dr. Jack, Boston Implementation team, AHRQ • Participants: Senior Team, physician & nursing leaders, front line nursing staff, Case Mgt., Nursing Informatics, IT,HIM • CHF patients on Telemetry = pilot population • Our Core RED interdisciplinary team was formed, and still meets!

11. Project RED Checklist – From Admission! • Make appointments for follow-up medical appointments and post discharge tests/labs. • Plan for the follow-up of results from lab tests or studies that are pending at discharge. • Organize post-discharge outpatient services and medical equipment. • Identify the correct medicines and a plan for the patient to obtain and take them. • Reconcile discharge plan with national guidelines. • Teach a written discharge plan (AHCP) the patient can understand. • Educate the patient about his/her diagnosis. • Assess the degree of the patient’s understanding of this plan. • Review with the patient what to do if a problem arises. • Expedite transmission of the discharge summary to clinicians accepting care of the patient. • Provide telephone reinforcement of the Discharge Plan. • (new!) Obtain language assistance for patients/families

12. Integrated HCAHPS Benefits

13. RED Benefits HCAHPS? Absolutely! • Discharge Planning Begins on Day 1 • RED = Guide to building relationships • RED = Promotes self-management skills • RED = Patient education throughout the stay • RED = Patients & clinical team; common goals • RED = Family engagement • RED = Patient learning as the closing message • RED = Tools for you to link patient safety & the patient experience

14. CCH Project RED Pilot Year: 2011-2012 • AHCP recreated in word (available as a PDF/AHRQ website) • RED’s Discharge Educator role = our Telemetry nurses • Telemetry RNs taught the AHCP to patients; what a moment! • All trained on the use of “Teach-Back”—now a RN Competency • Unit Coordinators making F/Up apts: Patient & family satisfier • Clinical Pharmacist inclusion with the CHF pilot patients • Physician Office Practice outreach—utilization of the AHCP • Volunteers & Transport staff: Discharge reminder at curb-side • 48 hour post discharge F/Up phone calls • Project RED script • Medication clarification, review F/Up apts, transition support • Our patients, families, staff & physicians loved Project RED!

15. CCH’s AHCP “it’s like an award for discharge”

16. CCH’s List of Medicines & Why/How

17. CCH Clinical Pharmacists: Medication Teaching

18. CCH Appointment Calendar

19. Readmission Rate- FY11 vs. FY12 • All Telemetry Patients with a Primary Diagnosis of CHF at Discharge • 30 Day Readmissions

20. CCH: 2012-2013 • Were we getting to a Better Fit?

21. Enlarging our CCH Team! 2012-2013 • Clinical & IT experts worked as 1 team - “priceless” • Replication of the AHCP into an electronic version • Stories of the patient experience shaped the goals of this enlarged team • RED’s Checklist worked; expansion for all CCH • CCH Re-Engineered Discharge: 5 Core Principles • Discharge planning begins Day 1 all CCH patients • “My Discharge Plan” all CCH patients • Teach-back methodology all CCH patients • Follow-up appts. High Risk patients • Follow-up phone calls High Risk patients

23. My Discharge Plan example

24. My Discharge Plan example: Yield and Stop signs

25. Text block library for templated “last licks” instructions

26. High Risk for Readmission Patients • Automated work flow processes to identify patients at risk • High Risk criteria include: polypharmacy, recent admission, key CMS diagnoses, lack of support at home • Identification of High Risk in real time for staff • Creates High Risk for readmission “order” in chart • Unit Coordinators making F/Up Appts : PCP & specialists • 48 hour F/Up phone calls-High Risk patients • Automated work flow produces call list daily • Clinical Pharmacists, Paramedics, CV Nurse Navigator

27. High Risk Patients • Populates a report showing all high risk patients on the unit/hospital and reason for inclusion • Populates a report for after discharge phone calls:

28. Pre and Post Measures: Re-Engineered Discharge

29. CCH : HCAHPS Discharge Domain

30. CCH : HCAHPS Care Transitions

31. HCAHPS Trending - Domains related to Project RED Implementation Project RED Implementation Dates: Telemetry – Sept 2011 House-wide – Sept 2012

32. Enhancing our Model • Patient’s White Board: planning information • Rapid Daily Rounds • “Plan for the Day, Plan for the Stay” • Interdisciplinary group meets at set time daily • All stand & are prepared, one-two minutes per patient • Teach-back becoming part of culture • Patient/family feel “safe” to ask questions • Bedside Handoff between shifts • Open Visitation • Summer 2013; a Nursing Council initiative • Bedside Delivery of Medications • Telemetry Pilot in 2011; house-wide in 2012 • Enables patients to receive new medications prior to D/C • Walgreens’ Pharmacy Tech integrated into nursing teams

33. Are we there yet? • “..higher patient satisfaction with inpatient care & discharge planning is associated with lower 30 day readmission rates…” (2011)

34. A Model & the Patient: Good Fit? • Motivation/partnership with patients/families • Never been healthy; “what does healthy look like”? • How to set up small “wins” in just a few days • Are we truly assessing Self-Management skills? • Applicability to Transitions in Care • Patient Experience—understanding the whole • Care Transition results appear to show less than 50% take patient/family preferences into account upon discharge • People in top 5% of spending--11x more likely to report fair to poor physical health • Patients who report excellent health overall-their HCAHPS ratings 1.5 x higher than poor health

35. Do we know their expectations at D/C? DATA SATISFACTION COLLECTED PATIENT STORIES OVER A PERIOD OF TIME

36. The Patient’s Voice 2013-2014 • Bedside Survey Pilot 2011-2012: • Consistently: “I have heard little about D/C” • Bedside Surveys: electronic solution • Charge RNs/Day 2—Mini iPads • Real time service recovery • Real time data sharing/reports available • Kick-off Fall 2013 • Revised: January 2014 • Revised D/C question: “Have you heard about” • “Do you have any concerns about going back to your home environment?” & Explain • Winter 2014: Readmission Survey • Day 2, identified from our High Risk workflow

37. Current Data Overview

38. Chester County Hospital Readmission Survey

39. Chester County Hospital Readmission Survey

40. Next Steps/Concluding Remarks • Reinforce: Bundled interventions vs series of tasks • Discharge Model-Yes; Transition Model-not quite Yet! • Spotlight on community hand-off & feedback • Immediate follow-up care for the most vulnerable • Palliative Care referrals as part of our culture • Senior Team Core Group formed; partner with original team • Our understanding of why patients come back • Review All-Cause, but understand Potentially Preventable • Re-evaluate opportunities with High Risk list/F/Up phone calls • Meaningful analysis of successes and returns (SNF/NVNA) • Unplanned 7 day Readmissions • Bedside Survey expansion: insights for the entire clinical team • Conduct Case Reviews on patients who return/succeed

41. You Can Do It Too!

42. A Good Fit-we’re getting there • “..the way we communicate with patients/families about their health substantially influences their motivation for action & behavior change..” (2011)

43. Thank you! Carli Meister Director, Customer Relations & Risk Penn Medicine Chester County Hospital cmeister@cchosp.com