Module 3 The Re-designed Discharge Process: Patient Discharge and Follow-up Care

1. Module 3The Re-designed Discharge Process: Patient Discharge and Follow-up Care Faculty from Joint Commission Resources Deborah M. Nadzam, PhD, FAAN Project Director and Kathleen Lauwers, RN, MSN Consultant

2. Accomplishments to Date (Module 1) • Project Charter initiated • Primary Care Practitioner referral base defined • Process map of current discharge process completed • Care plan structure (template, location, how D.A. will access it) finalized • Dates for training frontline staff set

3. Accomplishments to Date (Module 2) • Project metrics identified and planned • Patient inclusion criteria defined • Process for identifying patients and notifying D.A. defined • Multidisciplinary involvement and communication plan determined • Care plan process finalized (what and how to gather data for inclusion)

4. Objectives of Module 3 • 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 • Fax of plan to PCP • Finalize care plan completion and printing • Review how to conduct ‘teach-back’ with patient and family • Finalize process for making post-D/C calls

5. Module 3 Outline • Complete the care plan when discharge order is written • Teaching and ‘teach-back’ • Post-discharge activities • Measurement of process • Training of frontline staff

6. Module 3

7. Discharge Planning Discharge Order Written H & P Rx Plan Patient Admission Discharge Event Discharge Process PATIENT EDUCATION DISCHARGE INSTRUCTIONS Post-D/C Follow-up

8. RED Checklist: Discharge and Follow Up Eleven mutually reinforcing components: • Medication reconciliation • Reconcile discharge plan with national guidelines • Follow-up appointments • Outstanding tests • Post-discharge services • Written discharge plan • What to do if problem arises • Patient education • Assess patient understanding • Discharge summary sent to PCP • Telephone reinforcement Adopted by National Quality Forum as one of 30 US "Safe Practices" (SP-15)

10. Complete the Care Plan • Medication reconciliation performed • Pending tests and results • Post-discharge services • Primary Care Provider • Follow up appointments • Information about condition(s)

11. Medication Reconciliation • Hospital procedure for completing medication reconciliation at discharge • D.A. may participate and/or conduct final check on medications • Using final list, populate patient care plan, and complete additional columns (e.g., purpose, time of day visual) • The final list will be used to instruct the patient

12. Pending Tests/Results • Obtain information about tests and studies completed in hospital, but still pending results • Add pending test/results to the designated spot on the patient’s care plan, including which clinician is responsible for securing final results. • Encourage patient to discuss tests PCP; point out where the information is on the care plan

13. Post Discharge Services • Confirm with case manager that all services have been arranged • Add names of services and contact information to care plan

14. Primary Care Provider (PCP) • Confirm name of PCP with patient • Add name and contact number of PCP to care plan

15. Follow Up Appointments • Discuss best days of week and times of day with patient • Discuss transportation needs with patient (how will patient get to appointment?) • Place calls to clinicians’ offices to make appointments that meet patient’s time options • Leave message with clinician office to call patient (off hours and weekend) • Add appointments to care plan

16. Information about Condition(s) • Secure pre-printed information about patient’s condition to add to care plan • Add to care plan: • Signs and symptoms that warrant follow up with clinician • When to seek emergency care • How to contact the Discharge Advocate and PCP (phone numbers; paging instructions)

17. Sections of the Care Plan • Date of D/C; name and contact info for physician and D.A. • Medications • Pending tests and results • Follow-up appointments • Calendar • Other orders (diet, activity, etc) • Information about disease/condition • When and how to reach physician or go to E.D. • Form for writing own questions down • Map of campus for locating appointments (optional) • Other information about your center (optional)

18. As a team, answer the following questions: • Have all of these content areas been included in the final care plan template? • Can the D.A. access all of this content to add to the care plan? • From where? • How reliable? • How timely? • What gaps still exist that need to be addressed?

19. Final Teaching and Teach-Back • All education material • Care plan completed • 2 copies printed • Copy to Quality? • Meet in quiet place with patient/family • Review all parts of the care plan • Confirm patient/family understanding utilizing ‘teach-back’ methods

20. Health Literacy – Tips* • Avoid medical jargon • Speak slowly • Simple pictures when helpful • Emphasize what patient should do • Avoid unnecessary information • Welcome questions • Written materials: simple words, short sentences in bulleted format, lots of white space * Graham and Brookey

21. Teaching – Tips* • Elicit from patient their symptoms and understanding • 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

22. Teach-Back • A way to confirm that you have explained to the patient what they need to know • It is NOT a test of the patient, but rather a test of how well YOU have explained the concept • Use it with everyone; do not assume literacy or health literacy • Teach all staff how to do it!

23. Teach Back: Place the responsibility on yourself • “I want to be sure I didn’t leave anything out that I should have told you. Would you tell me what you are to do so that I can be sure you know what is important.” (Doak et al) • “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)

24. The teach-back technique • Do not ask a patient, “Do you understand?” • Do not ask “yes/no” questions • Instead, ask patients to explain or demonstrate how they will undertake a recommended treatment or intervention • Ask open-ended questions • If the patient does not explain correctly, assume that you have not provided adequate teaching and re-teach in a different way

26. Teach-Back Steps* • Use simple lay language; explain concept or demonstrate process avoiding technical terms; use a professional translator if language issue exists • Ask patient/caregiver to repeat concept in own words and/or to demonstrate process • Identify/correct misunderstandings or incorrect procedure • Ask patient/caregiver to repeat concept and/or repeat process to demonstrate understanding • Repeat Steps 3 and 4 until clinician is convinced comprehension and ability to perform process is adequate and safe. * Society of Hospital Medicine

27. 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 (like memory) • Environmental barriers (lack of support person at home) • Attitudinal barriers (lack of trust) • “Please demonstrate the activity I’ve just explained/shown to you.”

28. Post Discharge Activities • Transmit D/C summary and care plan to PCP • Fax: insure it is received and legible • Electronic: scan/ email if possible; insure it is received • Follow-up phone call to patient: 48--72 hours after discharge • Caller uses script that assess understanding of medication and follow-up appointments • Need for second call by clinician determined

29. Measurement of Process • Timeliness of RED activities • D.A. log data • Review patient care plans after discharge • % with medication list • % with care needs listed • % with post-discharge services and contacts listed • % with follow up appointments made • % with pending tests and results listed (or ‘none’)

30. Plan for Teaching Frontline Staff about Project • Why: understanding, buy-in, support, participation, clarification of roles • Who • Nursing and medical staff on participating units; pharmacists, case managers • When • Set date for live session and/or record • Prior to launch of RED intervention • Utilize provided slide deck and customize as necessary

31. Module 3: SummaryExpected Outcomes • D.A. aware of discharge order and completes care plan • Medication list • Pending test and results • Post-discharge services • PCP identified • Follow up appointments made • Final Teaching and Teach Back with Patient/Family • Arrange post-discharge follow up • Transmit summary and care plan to PCP • Phone patient within 48 hours • Complete measurement of discharge process • Finalize plans for teaching frontline staff

32. Progression to Module 4 Checklist • Processes in place to finalize care plan once discharge order is written ____ • Teach-back methods outlined ____ • Quality/P.I. staff understand project measurement requirements and prepared to gather data ____ • Process for transmitting D/C summary and care plan to PCP finalized ____ • Plans for teaching frontline staff finalized ____ • Team evaluation of Module 3 ___