IHI STAAR Fall Learning Session 2011: Breakout A – Early Assessment of Post-Discharge Needs

1. IHI STAAR Fall Learning Session 2011: Breakout A – Early Assessment of Post-Discharge Needs Laura Carr, PharmD Jane Murray, MBA Jessica Smith, RN

2. Cross-Continuum Team Chris Annese, RN, El16 Paul Arpino, Pharmacist, Clinical Operations Director Victoria Brower, Project Mgr, HPM4 Laura Carr, IP Pharmacist Jacqui Collins, RN, CNS, El16 Gwen Crevensten, MD, Faculty, CQS Joanne Doyle, OP Pharmacist Joanne Empoliti, CNS, Wh6 Kathleen Finn, MD, Clin Educator Theresa Gallivan, RN, Associate Chief Nurse Jeff Greenwald, MD, Medicine Kathryn Hall, RN, Nurse Dir, El16 Bob Hallisey, Pharmacist, Clinical Specialist Yanie Jackson, MS, CQS Joanne Kauffman, RN, Team Mgr, Case Mngt Deb Kiely, PHS Home Care Colleen Macauley, RN, Medicine Mary Neagle, Project Mgr, CMP Terry O’Malley, MD, Director, Non-Acute Services Kathleen Myers, RN, Nurse Dir, El6 and Wh6 Karen Pickell, NP Patient Care Services David Ring, MD, Orthopedics Nancy Sullivan, Director, Case Mngt Kristin Sybertz, RN, Team Mgr, Case Mngt Ryan Thompson, MD, Medicine Executive Sponsors: Elizabeth Mort, MD, MPH & Andrew Karson, MD, MPH Day-to-Day Leads: Jane Murray, MBA

3. Key Change – Perform an enhanced assessment of post-hospital needs Discharge Nurse Role New role piloted through STAAR Unit decided to keep position even after pilot was completed because team thought the role was extremely important Pharmacist Role: pre-discharge visits to patients Patients referred to Pharmacist by the Discharge Nurse

4. Three RNs (adding up to 1 FTE) serve exclusively as Discharge Nurses and follow patients from Admission to Discharge on Ellison 16 (Medicine) Approximately 40% of patients on floor are managed by Discharge Nurses Inclusion Criteria >=10 medications Any patient with diagnosis/reason for admission of: CHF Pneumonia Acute Renal Failure Afib Cancer Pain Dehydration UTI Change in mental status English-speaking Discharge Nurse Role - manage high-risk patients based on specific criteria

5. Throughout the hospital stay, Discharge Nurses prepare the patient and family members for post-discharge needs Advantages of Discharge Nurses for patients and family members Continuity with teaching - the same person is providing the patient with disease education and medication reconciliation/education Improves MD-RN-CM communication Assist with post-discharge services such as arranging VNA visits, educating patients on importance of follow-up appointments and coordinating transportation with family members Patients receive a folder which is compiled throughout the hospital stay with education materials, provider contact information, follow-up instructions, and labs/tests appointments Review Patient Discharge Medication List with individualized medication details which is given to patient at discharge Overall improvement in the quality of discharge information and communication

6. Discharge Nurse Role has continually evolved to streamline workflow and brings focus to the discharge process early on Changes tested Patients taking more active role in their care; Sheet in patients’ folders to write down questions throughout their stay and go over questions with nurse, physician, pharmacist, etc. Identified communication barriers between physicians, case managers and nurses; Special Discharge Nurse pager created so there is single point person for discharge questions Discharge Nurse participates in 4pm rounds to help identify patients who are ready for discharge Discharge dates were not communicated clearly to patient or care team on a regular basis; anticipated discharge date added to white board at nursing station to align the entire team and set expectations

7. Discharge Nurses refer patients to the Pharmacist if there is any confusion about medication while the patient is still in the hospital The goal is to provide medication reconciliation and counseling services to complex patients prior to discharge Pharmacist coordinates dispensing of medication if necessary Pharmacist reviews final medication list with patient and/or caregiver Pharmacist Role – work with Discharge Nurse to reconcile medication and answer patients questions prior to discharge

8. Pharmacist pre-discharge visits are important as evident in recent patient stories • 60 year old woman admitted with PE going to rehab • found that Atorvastatin was missed on her PAML, and not included on discharge orders • RPh was able to resolve issue prior to discharge and educate patient on new Warfarin • 75 year old man admitted with PNA going to SNF • patient on his second admission in two weeks • patient was on 22 meds • RPh found 6 errors in Discharge Orders including doubling of patient’s new Metoprolol XL dose from 25mg QD to 25mg BID • RPh was able to resolve issue prior to discharge • 74 year old man admitted with MRSA being discharged home • complex medication regimen of antibiotics and renal transplant meds which could not be taken together • RPh created a med dose chart to accommodate 7 admin times • RPh called patient post-discharge to follow up

9. Patients benefit from having Pharmacist perform additional review of medications prior to discharge • Pharmacist provides direct patient counseling • High-risk patients continue to benefit from additional teaching and opportunities to ask medication related questions • Common issues identified • Medication instruction not clearly written out for patients • Antibiotic end dates • Taper instructions • PRN vs. standing orders • Incomplete medication reconciliation • Differences between medical record and discharge instructions/prescriptions to patients • Errors with high-risk medications including Warfarin, Insulin, and Opioids

10. Ellison 16 all-cause 30-day readmissions data Discharge RN role Pharmacy pre-discharge visits STAAR teams launch RNs responsible for simple VNA Pharmacy post-discharge calls

11. The overall readmission rate on the floor is trending downward, possibly aided by the Discharge Nurse Role Ellison 16 Discharge Nurse Role Readmission Rate Between 12/1/2010 and 5/31/2011 Between 7/1/2010 and 11/30/2010 • Exclusions: • Observation patients and patients transferred to another floor are excluded even if they met inclusion criteria. Bad data was also excluded (e.g. double-entries, patients with no TSI record, etc) • Discharges do not include rehab or hospice admissions, deceased, discharged against medical advice, or transfer to another short-term facility or psych hospital or unit • Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions

12. More data required to determine the impact of pre-discharge Pharmacy visits on readmissions Pre-discharge Pharmacy visit readmission rate Between 1/1/2011 and 5/31/2011 • Exclusions: • Observation patients and patients transferred to another floor are excluded even if they met inclusion criteria. Bad data was also excluded (e.g. double-entries, patients with no TSI record, etc) • Discharges do not include rehab or hospice admissions, deceased, discharged against medical advice, or transfer to another short-term facility or psych hospital or unit • Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions

13. Lessons learned from Discharge Nurse and Pharmacist • Discharge process can be disjointed which is why having a single contact person (Discharge Nurse) coordinate the process increases patient, physician, case manager and nurse satisfaction • Discharge Nurse Role improved workflow and provided standardized process; sets expectations for patients and providers as to what patient should know prior to discharge • Having anticipated date of discharge provides a timeline for all providers and helps coordinate nursing assignments • Pharmacist involvement is important both pre and post-discharge • Pre-discharge collaboration between Discharge Nurse and Pharmacist to reconcile medication helps reduce medication errors • Another program where the Pharmacist conducts post-discharge calls has shown a reduction in readmission rates (13% vs. 17%)

14. Next steps Discharge Nurse Role is being presented to Nursing Leadership as a best practice to expand to additional units Increase collaboration with outpatient nurses to improve transitions in care Include an electronic copy of the Discharge Nurse note in the LMR (outpatient electronic record) Increase number of referrals to Pharmacy for pre-discharge visits – may require additional resources

15. Appendix

16. Patient Discharge Medication List (PDML) – New Medication

17. PDML – List of medications to stop

18. Pharmacist post-discharge calls have shown a reduction in readmission rates (13% vs. 17%) *Includes only patients discharged Home from E16 # Excludes patients who fit criteria but declined call or RPh was unable to reach Time period: January 11 to June 30, 2010 (1) Discharges do not include rehab or hospice admissions, deceased, discharged against medical advice, or transfer to another short-term facility or psych hospital or unit (2) Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions