Final Presentation 30-Day Readmission Study - VCUHS IRB: HM13507

1. Final Presentation 30-Day Readmission Study - VCUHS IRB: HM13507 Vista Consulting MEd Adult Learning Students - Spring 2011 ADLT 636 Capstone Project Virginia Commonwealth University May 13, 2011 1

2. Today’s Presentation • Introduction • Research Question • Methodology • Findings and Implications • Recommendations • Future Research • Comments and Questions 2

3. Research Question What are the barriers to successful care transitions from the hospital to the outpatient setting? 3

4. Grounded Theory Approach (Creswell, 1998, Lincoln & Guba, 1985) • Naturalistic inquiry examining lived experiences • Exploratory study of perspectives and meanings people attribute to their experiences • developing themes and categories inductively • generating working hypotheses or claims from the data • analyzing narratives of participants' experiences 4

5. Participant Selection • Participants selected through purposeful and theoretical sampling • VCUHS - N9 & CCH3 patients & providers • Thirty-three patients and thirty-one providers participated in the study 5

6. Data Collection • Patient Interviews • 100+ interviews attempted • 33 interviews conducted • Single face-to-face interview • One interviewer + one notetaker • Interview recorded by hand notes • Debrief with interviewer and notetaker followed each interview 6

7. Data Collection • Provider Focus Groups • 9 focus groups, 31 participants • Nurses, resident physicians, hospitalists, clinical pharmacists, & social workers • 1-2 facilitators and 2 notetakers • Semi-structured interview with facilitator guide • Notes recorded by hand or using a computer to type notes • Debrief following each group 7

8. Interview Questions - Patients • First stage • What’s the biggest problem that you have with staying well so that you don’t need to come back to the hospital? Second Stage (after mid-point meeting) • How much control do you feel you have over managing your health? What do you feel you can do to manage your disease? 8

9. Interview Questions - Providers • First stage • What do you see and experience as the biggest impediments to a patient’s successful transition from the hospital to home? Second Stage (after mid-point meeting) • How do you integrate various provider team members into discharge planning? 9

10. Focus Group Participants

11. ConfidentialityA Critical Consideration • Did not record patient's name or identifying information with data • Speaker numbers used in provider focus groups, no names recorded with data • All data de-identified 11

12. Data Analysis(Creswell, 1998) • Patients: purposeful sampling • Providers: purposeful & theoretical sampling • Analysis: • Immersion in the data • Open coding • Emerging themes • Sort into sub categories • Key findings 12

13. Trustworthiness and Rigor(Creswell, 1998) • Debriefing following interviews and focus groups • Field notes • Paired coding • Weekly whole team debrief & discussion • Checking for self-bias • Thick, rich, and vivid descriptions from participants’ stories 13

14. Quotes from Patients & Providers Digital Story (photos used in story are generic, public photos from the worldwide web, not of any VCUHS patients or providers) 14

15. Society Local Community System Patient Provider

16. Findings • Themes • Patient learning and behavior change • Communication processes • Transition from hospital to community • Hospital systems, structures and processes 16

17. Findings – Theme 1 • Patient Education • Low education, low health literacy • Heightened, pervasive life stressors • Life circumstances, lifestyle choices • Delivery of patient education 17

18. A patient says, “It was a strepto, strepto something, …a great big word almost like the sound of strep throat but the doctor said it didn't have anything to do with strep throat.” A provider says, “We are guilty of using big words.” 18

19. A patient says, “I have a lot of mental stress - life itself, employment, health...I'm lucky that I don't have to work, but I want to. The economic times are hard. It's a strain, economy, life...” A provider says, “You can counsel someone, but if there are other stressors at home the patients will not understand that stopping smoking would be the best thing.” 19

20. A patient says, “...Even if they [providers] did [tell me things], I wouldn't know. That’s why I came to the hospital.” A provider says, “Lifestyle issues may contribute to readmission...like smoking and cocaine. [Patients have] skewed priorities.” 20

21. A provider says, “We need to have the patient act, as well, for behavior change that needs to happen. The hardest part is to change your behavior and it is hard for the patient to change.” A provider says, “To get people to buy in and make those changes we need to help them understand …But we don’t have the time in the hospital to help the patient and help them understand.” Provider: “You can counsel someone, but if there are other stressors at home the patients will not understand that stopping smoking would be the best thing.” 21

22. A patient’s son tells us, “I feel bad for people who don't have a translator [for the health and medical jargon]. If you don't have someone with you, you're screwed.” A provider says, “I would like to go over the medicine with them and have them tell me how they should take the medicine. I would like to have the time to do this all the time [with the patient], but I don’t.” 22

23. Findings – Theme 1 • Behavior Change • Competing demands • Other Influences (peers, family) • Lack of support and resources 23

24. A patient says, “My biggest barrier is not knowing how to put [myself] first.” A patient says his barriers to staying well are, “food, exercise, and taking medicine. When somebody or my parents distract me, I can’t do the things in the right way.” 24

25. A patient says, “[I was] doing stuff to take care of myself. Then I started hanging out with addicts, getting high. I was affected by peer pressure and my health fell down.” A patient says, “...He's [the doctor] gonna get me one of those pill boxes and I think that'll help. I've seen my ex-wife use the pillboxes, she has 17-20… medicines but she never misses or run out of the medicine.” 25

26. A patient says, “Thank God I have these children.” A provider says what makes a difference is, “People with family – who have support to help them, to encourage them [to take meds]. Patients who don’t feel that support won’t try so hard. [Without support] it's harder to find a reason [to do the right thing to manage disease].” 26

27. Findings • Theme 2 – Communication Processes • Inter-team and intra-team coordination • Team member relationships 27

28. A provider says, “Try to get social workers and care-coordinators more involved…It would be nice if [social workers] were more involved earlier on in the process instead of waiting until the patient is getting ready for discharge, or actually is home.” A social worker says, “MSW does not mean Medical Social Worker! It means Masters of Social Work. We are highly skilled and highly trained individuals.” 28

29. A nurse says, “Docs need to communicate with me! Use my leash!” (holding up phone) A provider says, [The discharge process] is such CHAOS!...it is all contradictory and trying to be done at the last minute too quickly, because we [nurses] find out at the last second when discharge is going to happen.” 29

30. A provider says, “[Nurses] end up doing social work, doctor’s work… I know they all have a lot of work. [Maybe if] roles were more clearly defined? [Maybe if] we had more staff?” A provider says, “We have not found an effective way to do rounds.” 30

31. A provider says, “Nursing staff don’t know the medicine teams so well.” A provider says, “[Nurses] may have a simple question but attendings don't want to be interrupted. So, [nurses] don't get info needed. [Nurses] can't just hang out for 15-20 minutes until the lecture is over. There's stuff to do.” 31

32. A provider says, “[Social workers] don’t realize that we (residents) don’t know the insurance stuff-they may even look down upon you if you don’t know this stuff.” A provider says, “Sometimes all is good but nursing gets hung up on one thing and this blocks discharge.” 32

33. Findings • Theme 3 – Transition to community • Continuity of medical care • Reliable transportation • Follow up • Readiness for discharge 33

34. A patient says, “My PCP nurse has really helped me. I am able to call her anytime, even the middle of the night.” A provider says, “When I have a problematic patient with a high likelihood of return, then I call them at home to check on them. It helps for reinforcing medication adherence and if they have questions once they are home, but I don’t always have time for that.” 34

35. A provider says, “One thing is timely follow up appointments. If the PCP for the patient is a resident then it is hard to get them in within two weeks. If they had a clinic; a “catch all clinic” for the in-between times that would be good.” A provider says, “We, as doctors, aren’t cognizant of these issues [prior authorization requirements, medication cost]” 35

36. A provider says, “Transportation can be a huge issue.  We give them a bus ticket.  We’re good at getting them home.  But how to get them back here [for meds and follow up treatment] is the question.” A patient says, “Before my legs were a problem I could walk to Rose's, Food Lion or McDonald's. Now I can’t . It's gonna be a problem...I have people I can call but I don’t want to inconvenience people.” 36

37. A provider says, “Often they just don’t understand that they are ready to leave now, and that they will be okay. If they leave, so they go home, then they come back.” A patient says, “I told them when they sent me home I wasn’t feeling right, I just didn’t feel well. I went home but a few days later I fell.  My friend found me passed out at home and I was readmitted-I was unconscious for three days. ” 37

38. Findings • Theme 4 – Health system structure and processes • Discharge planning • Discharge paperwork • Medication reconciliation • Medicine team structure 38

39. A provider says, “It would help if we could make the discharge summary given to the patient clearer-it is not user friendly.” A provider says, “Our discharge summary is a mess... At the point in the day when discharge is being coordinated, the patients are in a hurry [to leave] and it's difficult to reconcile errors [or] confusion in discharge orders.” 39

40. A provider says, “A lot of the times when patients are readmitted….I don’t go by what’s in the system [as to the meds the patient is taking], [instead] I ask them what they have with them…this tells my faith in the medical [record] system.” A provider says, “this stupid DIF is very confusing…there is no one standardized way of completing it.” 40

41. A provider says, “No accountability. No one wants to own [medication reconciliation]. It doesn’t hurt enough for anyone to take ownership.” A provider says, “Med rec list is NEVER right!” A provider says, “Whole ‘nother problem is that med rec is just not easy in the system” 41

42. A provider referring to supervision of interns making discharge decisions: “there are certain days when residents aren’t present, more likely things get missed on these days…things are missed.” A provider says, “The patient doesn’t know who is who [providers coming into room]. Thus, patient doesn’t listen to anyone who doesn’t have a white coat on.” 42

43. A provider says, “I think it’s more about what [attendings and residents] need to do as opposed to taking the time, interest, and commitment to look at patient individually and what’s best for them” A provider says, “The frequency and staggered nature of the attending rotation is not helping…it’s a mess [right now.]” 43

44. Implications • Theme 1: Patient Learning and Behavior Change • How can patients be made more central to the educational process? • What opportunities exist for providers to facilitate patient learning and change? Theme 2: Communication Processes • What about communication processes could, should or must be improved? 44

45. Implications • Theme 3: Transition to Home • What can we do to help patients successfully transition knowing how vulnerable they are? • How can we strengthen a patient’s connectionsto supports & resources knowing how important they are? Theme 4: Hospital System Structure • What are the system, structural, and process improvements we can make today? Tomorrow? In the next year? 45

46. Recommendations • Short-term Action Plan • 1. Discharge Process and Paper Work (DIF) • Increase communication with floor nurses • Patient friendly DIF format • Patient call back system • Increase integration of social workers • Social & community supports & resources 46

47. Recommendations 2. Medication Reconciliation • Literature review • Pharmacists or pharmacy student’s aid • 3. Communication skills and processes • Actual & desired condition • Develop the process and skills • Communication training • 4. Patient advocate/case manager 47

48. Recommendations • Longer Term Action Opportunities • What strategies or practices could be implemented to improve health literacy competency across provider teams? • How could reflective practice opportunities be included in process improvement & professional development? • How can every interaction between patient and provider be used to create an opportunity for change for both? 48

49. Recommendations • How can team members better understand and respect each others’ roles and responsibilities? • How can relationships and communication networks be increased with community organizations? • How could a whole system strategic visioning process be useful to address current issues and future direction? • Consider stakeholder representation within health system and community. 49

50. Literature Review – an Example • Piedmont Hospital, Atlanta - readmit rates  5% in one year for patients over 70 yrs • Improved medication reconciliation • Pharmacist now completes drug reviews • Identify high risk patients & ensure follow-up care • Preparing patients for what they need to do after they leave hospital • Single cover sheet with key info 50