connecting the dots across the care continuum: acute to …the+dots_ponder_pokr… ·...
TRANSCRIPT
stmarymercy.org
Connecting the Dots Across the Care Continuum: Acute to Post Acute SMML Patient Discharge Folder & Health Care PlanCatherine Ponder, RN, BSN | Sue Klotz MS, BSN, RN-BC | Patty Pokrandt MS, BSN, RN-BC St. Mary Mercy Livonia, Livonia, MI
St. Mary Mercy Hospital is a 304 bed not for profit teaching hospital in Livonia Michigan. We are a member of St. Joseph Mercy Health System and Trinity Health. 63% of our patients are older than 65 years of age.
Background Coordinating care for discharge is essential and success depends on work of interdependent team.
Gaps in discharge process leading to avoidable readmissions were identified including medication discrepancies, unscheduled follow-up appointments, misunderstanding roles of community healthcare providers, and lack of education on disease symptoms.
Patients received a mass of unorganized instructions resulting in confusion and health illiteracy.
Clinicians overwhelmed with volume of information given to patients and concerned important information was indistinct.
Collaboration
Patient supported as an equal and
valuable partner in their health care
Desired OutcomesStandardization of the Discharge Process for nursing staff with individualized patient care planning to increase patient health literacy, satisfaction and thereby reduce readmission rate. What is important to the patient and caregiver?
This increases compliance with: National Patient Safety Goal (NPSG)
- NPSG .03.05.01 Education regarding anticoagulation therapy - NPSG .03.06.01 Medication reconciliation Centers for Medicare & Medicaid Services
- Hospital discharge planning worksheet Patients Perception of Care Reflected on HCAHPS Survey
Implementation/Dissemination Standardized Discharge Process Map developed with stakeholder input Developed a discharge nursing checklist/process to increase reliability Created a concise organized folder system for patient centered care plan, medication information, education, advance directives and follow-up appointments
Hospital-wide role out for new method provided at annual nursing education day
Discharge checklist placed in chart by clerk on admission
Nurse communicates purpose of folder to patient and care givers on admission
Nurse places all educational information in folder after review with patient
Multidisciplinary team members also places information in folder
Folder design included the following senior friendly adaptions Increase
Font Size Added icons Concise
information Easy use for
diminished dexterity
PRISM is a patient care risk prediction tool that measures 30-day mortality risk developed by Quality Institute of SJMHS.
Evaluation Patient SatisfactionDomain Improvement
- Discharge: 34th percenti le 6 mos. prior, November 2015 = 50th percentile rank
- Care Transitions: 31st percentile 6 mos. prior, November 2015 = 50th percentile rank
Medicare 30 Day Readmit Rate: 15% 6 mos. prior, November 2015 = 12.8%
Future Opportunities Continue to collaborate with nursing to improve discharge folder engagement
Pharmacy process improvement project for PRISM 1 and 2 patients: Ask 3 teach3
Continued patient engagement and assessment of tool
ResourcesVideo Links for SMMH D/C ProcessNursing Introduces D/C Folder: https://youtu.be/ra6Z5x10W0oTransition Coach Acute visit: https://youtu.be/NbPld2Ostl4Transitions Coach Home Visit: http://youtu.be/nGVXZCwSZ-k
References: Krumholz, H. (2013). Post-Hospital Syndrome - An acquired, transient condition of generalized risk. The New England Journal of Medicine, 368(2), 100 -102.Span, P.(2015, April 13) The Tangle of Coordinated Health Care. The New York Times, p.D3
Discharge Folder Concept Created
Discharge Committee
Marcy Corbat MBAPI analysis & Nursing
education on disharge process
Donna Gray CNO, MSN/Nurses
Input from Nursing Practice Council & Nursing Leadership
Marketing/Public Relations assist
with folder design
Dr. Mikkilineni/ Case Management/
Cheryl Malloch-Clafton, Pharm DInput from Patient Family Advisory
Council, Director of Quality, multidisciplinary team
Lauren BaileyVideo
developed
Jeff Renaud, BSNNursing roll out of discharge process
with folder via education day
2012 2013 -14 2015 - February 2015 - March 2015 - April 2015 - May 2015 - June 2015 - June - August
Name: ______________________________________________________________________________________
Discharge Date: ____________________________________________________________________________
When I get home, I will:
1. Follow-up Doctor Appointment: _____________________________ Time: ________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
I will take my folder to
all of my doctor visits.
My Discharge Instructions and Health Care Plan
You may receive a call from a nurse. If you have questions or concerns, please call your primary care physician.
Primary Care Physician:
_____________________________________________________
Phone number:
_____________________________________________________
Questions for My Doctor:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
4. ________________________________________________________________________________
5. ________________________________________________________________________________
Help I May Need:
How Can I Get My Health Information?
Patient Portal Our online patient portal allows access to your health
care information at any time. With the secure website you can:
• View hospital lab results
• View radiology results
• Access key health information
• Pay hospital bills
• View discharge information and instructions
The Patient Portal is free to use and completely secure. Visit stjoeshealth.org/patientportal-livonia for more information.
Medical Records To obtain a copy of your medical records, please
call our medical records office at 734-655-2320.
Thank you for choosing St. Mary Mercy Livonia.
Discharge Information
Symptoms and Health Problems
Help You May Need at HomeResources:
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
Education, Advance Directives and Goals of Care
Education:
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
ST. MARY MERCY LIVONIA
36475 Five Mile Road, Livonia, MI 48154734-655-4800
stmarymercy.org
DiscoverRemarkable
Health Management
Managing Medications
Follow-up care Appointments When to call
my doctor
Personal Care
Bathing Dressing Hygiene
Daily Activities
Preparing meals Shopping House work Yard work
You may receive a survey in the mail regarding your experience at the hospital. Thank you for providing us with your feedback.
Medications, Prescriptions and Side Effects I need help getting my medications. Yes No
New Medications: Possible Side Effects:
____________________________ ____________________________
____________________________ ____________________________
____________________________ ____________________________
Need a prescription filled before going home? Call 734-655-2325 to fill your prescription.
Transporation
Transportation options
Mobility
Walking Stairs Marketing/PR
Catherine Ponder, RN, BSN
Sue Klotz, MS, BSN, RN-BC
Patty Pokrandt MS, BSN, RN-BC
Name: ______________________________________________________________________________________
Discharge Date: ____________________________________________________________________________
When I get home, I will:
1. Follow-up Doctor Appointment: _____________________________ Time: ________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
I will take my folder to
all of my doctor visits.
My Discharge Instructions and Health Care Plan
You may receive a call from a nurse. If you have questions or concerns, please call your primary care physician.
Primary Care Physician:
_____________________________________________________
Phone number:
_____________________________________________________
Questions for My Doctor:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
4. ________________________________________________________________________________
5. ________________________________________________________________________________
Help I May Need:
How Can I Get My Health Information?
Patient Portal Our online patient portal allows access to your health
care information at any time. With the secure website you can:
• View hospital lab results
• View radiology results
• Access key health information
• Pay hospital bills
• View discharge information and instructions
The Patient Portal is free to use and completely secure. Visit stjoeshealth.org/patientportal-livonia for more information.
Medical Records To obtain a copy of your medical records, please
call our medical records office at 734-655-2320.
Thank you for choosing St. Mary Mercy Livonia.
Discharge Information
Symptoms and Health Problems
Help You May Need at HomeResources:
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
Education, Advance Directives and Goals of Care
Education:
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
ST. MARY MERCY LIVONIA
36475 Five Mile Road, Livonia, MI 48154734-655-4800
stmarymercy.org
DiscoverRemarkable
Health Management
Managing Medications
Follow-up care Appointments When to call
my doctor
Personal Care
Bathing Dressing Hygiene
Daily Activities
Preparing meals Shopping House work Yard work
You may receive a survey in the mail regarding your experience at the hospital. Thank you for providing us with your feedback.
Medications, Prescriptions and Side Effects I need help getting my medications. Yes No
New Medications: Possible Side Effects:
____________________________ ____________________________
____________________________ ____________________________
____________________________ ____________________________
Need a prescription filled before going home? Call 734-655-2325 to fill your prescription.
Transporation
Transportation options
Mobility
Walking Stairs
Discharge FolderCreated with input from frontline RNs and Patient Family Advisory Council
Primary Care Follow Up