Module 3

The Re-Designed Discharge Process: Patient Discharge and Follow-up Care

Accomplishments to Date (Module 1)

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

Accomplishments to Date(Module 2)

Project metrics identified and planned Patient inclusion criteria defined Process for identifying patients and

notifying Discharge Advocate (DA) defined

Multidisciplinary involvement and communication plan determined

Patient Care Plan process finalized (what data to include and how to gather it)

Module 3 Objectives

Finalize process for identifying a PCP for patients who do not have one

Identify resources to provide patient information Review completion of discharge preparation

Medication reconciliation Pending test results Follow-up appointments Sending plan to PCP

Finalize care plan completion and printing Review how to conduct teach-back with patient

and family Finalize process for making post-discharge calls

Module 3 Outline

Completing the Patient Care Plan Teaching and teach-back Conducting post-discharge activities Measuring the process Training frontline staff

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 Process Map: Patient Discharge

Completing the Patient Care Plan

Medication reconciliation Pending tests and results Post-discharge services PCP Follow-up appointments Information about condition

Medication Reconciliation

Hospital procedure for completing medication reconciliation at discharge

DA may participate and conduct final check on medications

Using final list, populate Patient Care Plan and complete additional columns (e.g., purpose, time of day)

Final list used to instruct the patient

Pending Tests and Results

Obtain information about tests and studies completed in hospital but have results pending

Add pending tests and results to the Patient Care Plan, including which clinician is responsible for getting final results

Encourage patient to discuss tests with PCP, point out where the information is on the Patient Care Plan

Post-Discharge Services

Confirm with case manager that all services have been arranged

List services and contact information in Patient Care Plan

Primary Care Provider

Confirm name of PCP with patient Add PCP name and contact number to

Patient Care Plan

Follow-up Appointments

Discuss best days of week and times of day with patient

Discuss transportation needs Call clinicians’ offices to make appointments

that meet patient’s time options– Leave message with clinician’s office to call

patient if calling outside of normal hours or on a weekend

Add appointments to Patient Care Plan

Information About Condition

Get pre-printed information about patient’s condition to add to Patient Care Plan

Add to Patient Care Plan:– Signs and symptoms that warrant followup

with clinician– When to seek emergency care– How to contact the DA and PCP (phone

numbers and paging instructions)

Patient Care Plan Sections

Date of discharge Name and contact information for physician and DA How to reach physician and when to seek emergency care Medications Pending tests and results Follow-up appointments Calendar Other orders (diet, activity, etc.) Information about disease or condition Form for writing down questions Map for locating appointments (optional) Other information about your center (optional)

Answer the Following Questions

as a Team

Have all the content areas been included in the final Patient Care Plan template?

Can the DA access all the content to add to the Patient Care Plan?– From where?– How reliably?– How timely?

What gaps still exist that need to be addressed?

Teaching and Teach-Back

All education material Care plan completed

– Two printed copies– Copy to quality department

Meet in quiet place Review all parts of the Patient Care Plan Confirm understanding using teach-back

methods

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

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

Teach-Back

Way to confirm that you have explained what the patient needs to know

Not a test of the patient but rather a test of how well you explained a concept

Should be used with every patient; never assume literacy or health literacy

All staff should know how to do it

Teach-Back: Place Responsibility on Yourself

“I want to be sure I didn’t leave anything out that I should have told you. Please, in your own words, tell me what you will be doing when you get home so that I can be sure I have explained it correctly.”

“I want to be sure that I did a good job explaining your blood pressure medications because this can be confusing. Can you tell me what changes we decided to make and how you will now take the medication?” (Pfizer Web site)

“When you go home and your grandchild asks you what the doctor said about your heart, how are you going to explain this to your grandchild?” (Schillinger interview on AHRQ Web site)

Teach-Back Technique

Do not ask a patient, “Do you understand?”

Do not ask yes/no questions Ask patients to explain or demonstrate

how they will undertake a recommended treatment or intervention

Ask open-ended questions Assume that you have not provided

adequate teaching if the patient does not explain correctly. Re-teach in a different way.

From the U.S. Health Resources and Services Administration

Teach-Back – Show Me Method

Teach-Back Steps*

1. Use simple lay language; explain the concept or demonstrate the process avoiding technical terms; use a professional translator if a language barrier exists

2. Ask the patient or caregiver to repeat the concept in his or her own words or to demonstrate the process

3. Identify and correct misunderstandings or an incorrect procedure

4. Ask the patient or caregiver to repeat the concept or repeat the process to demonstrate understanding

5. Repeat steps 3 and 4 until clinician is convinced comprehension and ability to perform process is adequate and safe

* Society of Hospital Medicine

Beyond Comprehension

“Do you see yourself as able to follow these instructions?”

“Is there anything you can think of that will keep you from following these instructions?”– Functional barriers (e.g., memory)– Environmental barriers (e.g., lack of support

person at home)– Attitudinal barriers (e.g., lack of trust)

“Please demonstrate the activity I’ve just explained to you or shown you.”

Resources for Teach Back

Coaching Teach-Back Self-Evaluation Tool Conviction Confidence Scale Discharge Instructions - Teach-Back Co

mpletion Rate Observation Tool

Conducting Post-Discharge Activities

Transmit discharge summary and Patient Care Plan to PCP– By fax: Ensure it is received and legible– By e-mail: Ensure it is received

Follow-up phone call to patient 48 to 72 hours after discharge– Caller uses script that assess understanding

of medication and follow-up appointments– Need for second call by clinician determined

Measuring the Process

Timeliness of RED activities– DA log data

Review Patient Care Plans after discharge– Percent with medication list– Percent with care needs listed– Percent with post-discharge services and

contacts listed– Percent with follow-up appointments made– Percent with pending tests and results

listed (or “none”)

Teaching Frontline Staff

Why?– Gain understanding, buy-in, participation, role

clarification Who?

– Nursing and medical staff on participating units, pharmacists, case managers

When?– Prior to launch of RED implementation – Set date for live or recorded session

How?– Customize slide deck as necessary

Module 3: SummaryExpected Outcomes

DA aware of discharge order and completes Patient Care Plan– Medication list– Pending tests and results– Post-discharge services– PCP identified– Follow-up appointments made

DA conducts final teaching and teach-back with patient and family

Post-discharge followup occurs– Transmit summary and Patient Care Plan to

PCP– Phone patient within 48 to 72 hours

Measurement of discharge process complete Plans for teaching frontline staff finalized

Progression to Module 4 Checklist

___ Processes to finalize Patient Care Plan after discharge order is written in place

___ Teach-back methods outlined___ Quality and performance improvement staff

understand project measurement requirements and are prepared to gather data

___ Process for transmitting discharge summary and Patient Care Plan to PCP finalized

___ Plans for teaching frontline staff finalized