Module 2

The Re-Designed Discharge Process: Patient Admission and

Care and Treatment Education

Accomplishments to Date

Process map of current discharge process completed

Primary care practitioner (PCP) referral base defined

Patient Care Plan structure finalized Project charter initiated Dates for training frontline staff set

Module 2 Objectives

Review discharge planning activities that begin on admission

Develop plan for identifying targeted patients on admission

Review Discharge Advocate (DA) initial contact with patient

Define roles of multidisciplinary team members in discharge planning

Confirm process for creating Patient Care Plan

Module 2 Outline

Project RED principles and components Current discharge process and suggested project

metrics Patient admission Care and treatment education Structure and process for completing Patient Care

Plan

Principles of the Re-Engineered Principles of the Re-Engineered Hospital DischargeHospital Discharge

1. Explicit delineation of roles and responsibilities

2. Discharge process initiation upon admission3. Patient education throughout hospitalization4. Timely accurate information flow: From PCP ► Among hospital team ► Back to

PCP 5. Complete patient discharge summary prior to

discharge

Principles of the Re-Engineered Principles of the Re-Engineered Hospital DischargeHospital Discharge

6. Comprehensive written discharge plan provided to patient prior to discharge

7. Discharge information in patient’s language and literacy level

8. Reinforcement of plan with patient after discharge

9. Availability of case management staff outside of limited daytime hours

10. Continuous quality improvement of discharge processes

Patient and Family Centered Safe Care

Pre Patient Admission

H&P; Assessments; Rx Plan

PATIENT EDUCATION/

Prepare for Home

Discharge Order

Written

Discharge Process Discharge Event

FINAL DISCHARGE INSTRUCTIONS

Post-D/C

FOLLOW-UPMEDICATION MANAGEMENT

Discharge Folder

Passport for Home

White Board, Rounding & Bedside Report

Community providers: •Nursing Home•Home Health &

Hospice•Home Care•Physicians

•Accountable Care Organizations

Admission and Care and Treatment Education

1. Ascertain need for and obtain language assistance2. Medication Reconciliation 3. Reconcile discharge plan with national guidelines4. Follow-up appointments5. Outstanding/pending lab & diagnostic tests follow-up6. Post-discharge services7. Written discharge plan8. What to do if problem arises9. Patient education10. Assess patient understanding11. Discharge summary sent to PCP12. Telephone reinforcementt

Physician

Nursing

DischargeAdvocate

Pharmacy

Sample Process Map: Patient Discharge

Patient AdmissionOrders

Initiate postdischarge phone

call

EstablishClinical

Pathway

AdmissionAssessment

MedicationReconciliation

Educate patientabout diagnosis,

tests, and studies

Identifytarget patient

Initiate dailydischarge

huddle

Initiate AfterHospital Plan

Collect data reProcess and

Outcome metrics

Schedule Postdischarge f/uappointment

Verify MDorders

Create MARAssist withmedication

reconciliation

Assist withmedicationteaching

Participate inDC Rounds

Educate patientabout diagnosis,

tests, and studies

Initiate DCorders

ReinforceDischarge Plan

Provide careand treatment

CompleteAHCP

sample

Outcome Metrics for Target Population

Average length of stay 30-day unplanned all-cause readmission

rate Pre/post data: Patient experience

related to discharge preparation Pre/post data: Frontline staff survey

related to discharge preparation Pre/post data – PCP survey related to

discharge preparation

Financial Metrics

The cost of second length of stay (readmission)

Project costs Discharge process costs (current and

redesigned)

Process Metrics

Average time to notify DA about new admission Average time from admission to first patient visit by DA

(initiation of care plan) – only for patients who meet all criteria

Percent of patients’ PCPs notified within 24 hours discharge

Percent of follow-up phone calls made within 48 hours

Process Metrics

Percent of follow-up calls requiring second call by pharmacist (if non-pharmacist makes first call)

Percent of patients completing post-discharge survey (30 days after discharge)

Process Metrics

Completion of care plan details– Percent of care plans with medication list

included– Percent of care plans with care needs included

(e.g., exercise, diet, main problem, when to call doctor)

– Percent of care plans with follow-up appointments listed

– Percent of care plans with pre-arranged discharge resources identified (e.g., home health, durable medical equipment)

– Percent of care plans with pending tests listed

Answer the Following Questions as a Team

What metrics do the project team want to use to assess the impact of the re-engineered discharge process?

If you decide to collect the process measure associated with time-related activities, how will that happen?

Will you use the patient phone survey? How? Will you use the frontline staff survey? How? Will you use the PCP survey? How? Will you measure the completeness of the Patient

Care Plan? Who will be responsible for overseeing the

measurement activities?

Project RED Components

The 11 components enable DAs to: Prepare patients for hospital discharge

Help patients safely transition from hospital to home

Promote patient self-health management

Support patients after discharge through follow-up phone call

Identify the Patient

By admission unit By admitting diagnosis

– Heart failure: How do you identify these patients for core measure processes?

By physician

Identify the Patient

Who will notify the DA of the patient’s admission?

How is the DA notified? – Pager

– Phone

DA should be notified within 12 hours to be able to see patient within 24 hours of admission

DA Secondary Screening

DA reviews patient’s admission notes Considers:

– Working diagnosis

– Language

– Likely disposition

– Availability of home or cell phone number

Determines if patient is a candidate for Project RED intervention

Sample Log to Track Key Dates and Times

Joe Smith Patient Name Patient Name

Date/Time of Admission

05-05; 1300

Date/Time DA Notified

05-05; 1700

Date/Time of Initial DA Visit With Patient

05-06; 1100

Date/Time of Daily DA Visits With Patient (Note All)

05-07; 0800

05-08; 1000

05-09; 1200

Date/Time of Discharge

05-09; 1400

Date/Time Care Plan Faxed to PCP

05-09; 1500

Date/Time of Post-Discharge Call

05-11; 1600

Answer the Following Questions as a Team

How will you first identify that a newly admitted patient is in the target population for this project?

How will the DA be notified that a potential Project RED patient has been admitted?

What secondary screening criteria will the DA use to confirm use of the Project RED intervention with the patient?

How will the DA track activities with new patients?

Meeting the Patient

Review the patient’s admission notes– History and physical

– Medication reconciliation

– Preliminary plan of care

Meet the patient and family– Describe DA’s role

– Assess concerns, including potential post-discharge needs

Initiate Patient Care Plan and checklist

Daily Work of the DA

Review progress and nursing notes Clarify any concerns with health care team Visit the patient

– Review treatment plan (as related to discharge)

– Begin educating as appropriate (condition, medications)

– Discuss patient’s concerns re: discharge Continue development of care plan

Discharge Planning Rounds

Multidisciplinary Team

Consider daily discharge rounds– Medical staff, nursing staff, pharmacy, case

management, and DA– Who will be supportive?– Where might resistance come from?

When is discharge order written?– Was it expected?– Weekend discharge?– Is there a timing expectation (e.g., time

from order to out the door)?

Patient’s Physician

Initiates patient plan of care based on critical pathway

Leads and participates in discharge planning rounds

Communicates potential date of discharge Supports the performance improvement process

Nursing Staff

Provide nursing care as planned Educate patient and family Communicate with each other Communicate with other members of the health

care team, including DA Participate in multidisciplinary rounds, including

those that may be specifically focused on discharge planning

Pharmacist

Verify physician orders Reconcile admission medications with

medications from home Collaborate with care team specific to discharge

needs Reconcile medications upon discharge Assist with patient medication questions

Case Managers

Post-discharge services Social work Utilization review Financial support

Other Key Staff

Therapists Disease management

Answer the Following Questions as a Team

Do you currently address discharge planning in multidisciplinary rounds?– What works well?– What could be improved?– Who participates?

If you do not do the above, why not?– What will it take to implement such rounds?– Who will be supportive?– Where might resistance be encountered?

What are the roles and responsibilities of members of the health care team, as related to discharge planning?

Teaching the Patient

Assess understanding of:– Reason for admission– Condition or diagnosis– Current medications

Begin teaching medications and condition Use teach-back methods (discussed in

Module 3)– Health literacy– Language– Culture

Ask Me 3*

Created by the Partnership for Clear Health Communication (National Patient Safety Foundation)

Three essential questions for patients:

– What is my main problem?

– What do I need to do?

– Why is it important for me to do this?

*National Patient Safety Foundation http://www.npsf.org/askme3/

Teaching Tips*

Elicit symptoms and understanding from the patient

Be aware of when teaching new concepts and ensure understanding

Eliminate jargon System-level support using technology

– Provide more robust health education vehicles to help the patient remember

– Be proactive during time between visits * Schillinger interview

Literacy Issues*

Clues that patient has general literacy issues:– Incompletely filled-out forms

– Frequently missed appointments

– Poor compliance

– Inability to identify the name, purpose, or timing of medication

– Not asking any questions

– Reaction to written materials “I forgot my glasses. Can you read it to me?” “I will read it at home.”

* Graham and Brookey

Health Literacy Tips*

Avoid medical jargon Speak slowly Provide simple pictures when helpful Emphasize what the patient should do Avoid unnecessary information Welcome questions Ensure written materials use simple words,

short sentences in bulleted format, and lots of white space

* Graham and Brookey

Additional Teaching Tips*

1. Use visual aids and illustrations2. Beware of words with multiple meanings3. Avoid acronyms and other new words4. Use idioms carefully5. Provide a health context for numbers and

mathematical concepts6. Take a pause7. Be an active listener8. Address quizzical looks9. Create a welcoming and supportive

environment

*www.pfizerhealthliteracy.com/public-health-professional/tips

Developing the Patient Care Plan

Accessing the care plan template

Accessing information for the care plan

Saving individual Patient Care Plan

Printing the care plan Storing the care plan

– Permanent part of the patient record?

Accessing the Patient Care Plan Template

IT department involvement– Build interfaces?

Written instructions for how to access the care plan template

Written description of care template sections, including what is entered manually and what is linked to other hospital systems

Written instructions for how and where to save the Patient Care Plan

Gathering Care Plan Content

Start the Patient Care Plan on admission and add to it daily– Secure education material about the

patient’s primary condition– Begin medication section, based on daily

discussions with medical team– Begin post-discharge services section– Identify PCP and add name to care plan

Module 2: SummaryExpected Outcomes

Identify patients who are members of the project’s targeted population

Alert the DA about new patients Screen for final acceptance into project Initiate discharge planning on admission Meet the patient (through the care team,

admission notes, and in person) Initiate care plan and maintain activities log Participate in daily rounds with health care team

to plan patient education and post-discharge services

Visit patient daily and educate during each visit Continue to add to Patient Care Plan

Progression to Module 3 Checklist

Before going to Module 3, determine the:

___ Metrics you will use to assess impact

___ Process for identifying candidate patients and notifying DA

___ Secondary screening criteria for including patient

___ Process for multidisciplinary rounds and/or updates on targeted patients

___ Process for accessing Patient Care Plan