Improving Patient Understanding at Discharge: … Patient Understanding at Discharge: Medical...
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Improving Patient Understanding at Discharge: Medical Student Enhanced Patient Education Justin Slade, MS4, Lakshman Swamy, MD, Warren Hershman, MD, MPH, Britt Simonson, M.Ed. and Karin Sloan, MD Department of Medicine - Boston Medical Center / Boston University School of Medicine Background • Hospital discharges are important processes that frequently have poor outcomes. • One in five discharges is complicated by post-discharge adverse events, which may lead to preventable emergency department visits or hospital readmissions 1 . • A staggering 19.6% of hospitalized Medicare recipients nationwide are readmitted within 30-days of discharge 2 . • Poorly coordinated hospital discharges cause harm: • Patients leave the hospital unprepared • Adverse events can lead to patient harm and unnecessary utilization of hospital resources • Costs of care may increase, with an estimated $17.4 billion dollar cost to Medicare in 2004 for unplanned rehospitalizations 2 . • Limited health literacy is known to contribute towards poorly coordinated patient discharges. • It has been proven as a significant risk factor for 30-day hospital readmission (OR = 1.76) 3 . • Medical students are felt to be in a unique position to combat the negative effects of limited health literacy by delivering additional patient education leading up to and during the discharge process. • Students typically care for a smaller panel of patients than the house staff and face less of a documentation burden during the discharge process. • By spending additional time educating patients, students may benefit from development of their own patient education and discharge management skills that will be essential in their future careers as clinicians. Aim • To have third year medical students at Boston University School of Medicine collectively perform a total of 200 systematic patient discharge education (Medical Student Enhanced Patient Education) sessions with internal medicine patients at Boston Medical Center and other affiliated clinical sites by May 30, 2016 • To improve patient understanding of health, medications, and follow-up treatment plans in order to combat the negative effects of poor health literacy • To examine the effect that Medical Student Enhanced Patient Education sessions may have on the 30-day hospital readmission rate • To facilitate student engagement in pre-discharge patient education and follow-up coordination in order to better develop relevant clinical skills Methods • The IHI Model for Improvement has been used as the framework for guiding this effort. • Population: Adult patients admitted to medicine services and cared for by third-year medicine clerkship students at Boston Medical Center • Data Sources: Medical Student Patient Education (MSEPE) checklists completed and submitted by students, inpatient discharge summaries, student surveys (distributed electronically) • Variables of Interest: Number of completed MSEPE sessions per month; student assessment of patient’s understanding of disease, medications, and follow-up plan before and after MSEPE exercise; 30-day hospital readmission rate; time spent by students preparing for and performing MSEPE sessions with patients Solutions • The Medical Student Enhanced Patient Education checklist was designed to walk students through the process of providing education to patients as a supplement to current discharge teaching performed by residents, pharmacy, and nursing staff. • Before and after the MSEPE session, students assess a patient’s understanding of their disease and treatment plan • At the beginning of their clerkship, students are provided with an MSEPE card and a brief (10- 15 minute) orientation session for the exercise • Students have been asked to complete at least one MSEPE session and card with a patient they care for at Boston Medical Center during their third-year internal medicine clerkship (8 week duration). 11 Sessions 85% Student Participation 9 Sessions 64% Student Participation 8 Sessions 67% Student Participation 11 Sessions 79% Student Participation 6 7 8 9 10 11 12 13 14 15 16 0 1 2 3 4 Number of Completed MSEPE Sessions Month Number of Completed Medical Student Enhanced Patient EducationSessions Per Month Median = 10 PDSA 1 - Introduced MSEPE Checklist - Brief (10 minute) verbal student orientation PDSA 2 - Pocket sized MSEPE checklist card printed and distributed at student orientation - Introduced PowerPoint orientation session, which focused on patient selection and risk factors for readmission 13% 41% 46% 15% 49% 36% 13% 31% 56% 8% 31% 62% 5% 38% 56% 3% 10% 87% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Limited Moderate Full Limited Moderate Full Limited Moderate Full Diagnosis and Health Consequences Medication Benefits and Side-Effects Follow-UpPlan Percentage of Patients Student Assessment of Patient's Understanding Student Assessment of Patient Understanding Before and After Medical Student Enhanced Patient Education Exercise (n=39) Before After • After four months, students have cumulatively provided over 20 hours of pre-discharge education to 39 internal medicine patients at Boston Medical Center • Median Student Preparation Time = 28 minutes • Median MSEPE Session Time = 20 minutes 14.8%(n=27) 33.3%(n=3) 12.5%(n=8) 12.5%(n=16) 50.0%(n=2) 18.2%(n=11) 7.1%(n=14) 0%(n=1) 25.0%(n=4) 5.9%(n=22) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Limited Moderate Full Limited Moderate Full Limited Moderate Full Overall Diagnosis and Health Consequences Medication Benefits and Side-Effects Follow-UpPlan 30-Day Hospital ReadmissionRate Student Assessment of Patient's Understanding 30 - Day Hospital Readmission Rate Stratified By Student Assessment of Patient Understanding Post - MSEPE Exercise (n=27) Conclusions • Based on student assessment, patients exhibit improved understanding of their health, medications, and follow-up treatment plan following participation in the Medical Student Enhanced Patient education exercise. • MSEPE sessions have been successfully integrated within the third-year internal medicine clerkship, yet additional changes are necessary to promote more frequent completion of these sessions with patients. • There is a trend suggesting that student assessment of limited patient understanding of their diagnosis and health consequences or medication benefits and side-effects following the MSEPE exercise may serve as a risk indicator for 30-day hospital readmission. Next Steps • Expand use of the MSEPE exercise to all sites affiliated with the Boston University Internal Medicine clerkship (has to date only been at Boston Medical Center) • Encourage completion of more than one MSEPE card per clerkship student by distributing additional cards to students at orientation as well as a PDF file to print more copies if they desire. • Begin to gather patient perspective on impact of MSEPE exercise on their understanding of health, medications, and follow-up plan. • Print the optional student survey directly on MSEPE card to encourage a greater response rate • Plan for sustainability beyond this year by reducing number of administrative steps, increasing resident and faculty awareness of exercise, and creating a brief video presentation for efficient and reproducible student orientation References 1. “Adverse Events Among Medical Patients After Discharge From the Hospital.” Forster, A.; et al. CMAJ. 2004;170:345-349. 2. “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program.” Jencks, S.; et al. N Engl J Med. 2009;360(24):1418-1428. 3. “Health Literacy and 30-Day Postdischarge Hospital Utilization.” Jack, B.; et al. Journal of Health Communication 2012;17:325-338. 4. "Redefining Risk Factors for General Medicine Patients." Auerbach, A; et al. Journal of Hospital Medicine 2011;6:54-60. Results
Transcript of Improving Patient Understanding at Discharge: … Patient Understanding at Discharge: Medical...
Improving Patient Understanding at Discharge:Medical Student Enhanced Patient Education
Justin Slade, MS4, Lakshman Swamy, MD, Warren Hershman, MD, MPH, Britt Simonson, M.Ed. and Karin Sloan, MDDepartment of Medicine - Boston Medical Center / Boston University School of Medicine
Background• Hospitaldischargesareimportantprocessesthatfrequentlyhavepooroutcomes.
• Oneinfivedischargesiscomplicatedbypost-dischargeadverseevents,whichmayleadtopreventableemergencydepartmentvisitsorhospitalreadmissions1.
• Astaggering19.6%ofhospitalizedMedicarerecipientsnationwidearereadmittedwithin30-daysofdischarge2.
• Poorlycoordinatedhospitaldischargescauseharm:• Patientsleavethehospitalunprepared• Adverseeventscanleadtopatientharmandunnecessaryutilizationofhospital
resources• Costsofcaremayincrease,withanestimated$17.4billiondollarcosttoMedicarein
2004forunplannedrehospitalizations2.• Limitedhealthliteracyisknowntocontributetowardspoorlycoordinatedpatientdischarges.
• Ithasbeenprovenasasignificantriskfactorfor30-dayhospitalreadmission(OR=1.76)3.
• Medicalstudentsarefelttobeinauniquepositiontocombatthenegativeeffectsoflimitedhealthliteracybydeliveringadditionalpatienteducationleadinguptoandduringthedischargeprocess.• Studentstypicallycareforasmallerpanelofpatientsthanthehousestaffandfaceless
ofadocumentationburdenduringthedischargeprocess.• Byspendingadditionaltimeeducatingpatients,studentsmaybenefitfrom
developmentoftheirownpatienteducationanddischargemanagementskillsthatwillbeessentialintheirfuturecareersasclinicians.
Aim• Tohavethirdyearmedicalstudents atBostonUniversitySchoolofMedicinecollectively
performatotalof200systematicpatientdischargeeducation(MedicalStudentEnhancedPatientEducation)sessionswithinternalmedicinepatientsatBostonMedicalCenterandotheraffiliatedclinicalsitesbyMay30,2016
• Toimprovepatientunderstandingofhealth,medications,andfollow-uptreatmentplansinordertocombatthenegativeeffectsofpoorhealthliteracy
• ToexaminetheeffectthatMedicalStudentEnhancedPatientEducationsessionsmayhaveonthe30-dayhospitalreadmissionrate
• Tofacilitatestudentengagementinpre-dischargepatienteducationandfollow-upcoordinationinordertobetterdeveloprelevantclinicalskills
Methods• TheIHIModelforImprovementhasbeenusedastheframeworkforguidingthiseffort.• Population:Adultpatientsadmittedtomedicineservicesandcaredforbythird-yearmedicine
clerkshipstudentsatBostonMedicalCenter• DataSources:MedicalStudentPatientEducation(MSEPE)checklistscompletedandsubmitted
bystudents,inpatientdischargesummaries,studentsurveys(distributedelectronically)• VariablesofInterest:NumberofcompletedMSEPEsessionspermonth;studentassessmentof
patient’sunderstandingofdisease,medications,andfollow-upplanbeforeandafterMSEPEexercise;30-dayhospitalreadmissionrate;timespentbystudentspreparingforandperformingMSEPEsessionswithpatients
Solutions
• TheMedicalStudentEnhancedPatientEducationchecklistwasdesignedtowalkstudentsthroughtheprocessofprovidingeducationtopatientsasasupplementtocurrentdischargeteachingperformedbyresidents,pharmacy,andnursingstaff.
• BeforeandaftertheMSEPEsession,studentsassessapatient’sunderstandingoftheirdiseaseandtreatmentplan
• Atthebeginningoftheirclerkship,studentsareprovidedwithanMSEPEcardandabrief(10-15minute)orientationsessionfortheexercise
• StudentshavebeenaskedtocompleteatleastoneMSEPEsessionandcardwithapatienttheycareforatBostonMedicalCenterduringtheirthird-yearinternalmedicineclerkship(8weekduration).
11 Sessions85%StudentParticipation
9 Sessions64%StudentParticipation
8 Sessions67%StudentParticipation
11 Sessions79%StudentParticipation
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Num
berofCom
pletedM
SEPESessions
Month
NumberofCompletedMedicalStudentEnhancedPatientEducationSessionsPerMonth
Median=10
PDSA1- IntroducedMSEPEChecklist- Brief(10minute)verbalstudentorientation
PDSA2- PocketsizedMSEPE checklistcardprintedanddistributedatstudentorientation- IntroducedPowerPointorientation session,whichfocusedonpatientselectionandriskfactorsforreadmission
13%
41%
46%
15%
49%
36%
13%
31%
56%
8%
31%
62%
5%
38%
56%
3%
10%
87%
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90%
100%
Limited Moderate Full Limited Moderate Full Limited Moderate Full
DiagnosisandHealthConsequences MedicationBenefitsandSide-Effects Follow-UpPlan
PercentageofP
atients
StudentAssessmentofPatient'sUnderstanding
StudentAssessmentofPatientUnderstandingBeforeandAfterMedicalStudentEnhancedPatientEducationExercise(n=39)
Before
After
• Afterfourmonths,studentshavecumulativelyprovidedover20hoursofpre-dischargeeducationto39internalmedicinepatientsatBostonMedicalCenter
• MedianStudentPreparationTime=28minutes• MedianMSEPESessionTime=20minutes
14.8% (n=27)
33.3% (n=3)
12.5% (n=8) 12.5% (n=16)
50.0% (n=2)
18.2% (n=11)
7.1% (n=14)
0%(n=1)
25.0% (n=4)
5.9%(n=22)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Limited Moderate Full Limited Moderate Full Limited Moderate Full
Overall DiagnosisandHealthConsequences MedicationBenefitsandSide-Effects Follow-UpPlan
30-DayHospitalR
eadm
issionRate
StudentAssessmentofPatient'sUnderstanding
30-DayHospitalReadmiss ionRateStratified ByStudentAssessmentofPatientUnderstandingPost-MSEPEExercise(n=27)
Conclusions• Basedonstudentassessment,patientsexhibitimprovedunderstandingoftheirhealth,
medications,andfollow-uptreatmentplanfollowingparticipationintheMedicalStudentEnhancedPatienteducationexercise.
• MSEPEsessionshavebeensuccessfullyintegratedwithinthethird-yearinternalmedicineclerkship,yetadditionalchangesarenecessarytopromotemorefrequentcompletionofthesesessionswithpatients.
• Thereisatrendsuggestingthatstudentassessmentoflimited patientunderstandingoftheirdiagnosisandhealthconsequencesormedicationbenefitsandside-effectsfollowingtheMSEPEexercisemayserveasariskindicatorfor30-dayhospitalreadmission.
NextSteps• ExpanduseoftheMSEPEexercisetoallsitesaffiliatedwiththeBostonUniversityInternal
Medicineclerkship(hastodateonlybeenatBostonMedicalCenter)• EncouragecompletionofmorethanoneMSEPEcardperclerkshipstudentbydistributing
additionalcardstostudentsatorientationaswellasaPDFfiletoprintmorecopiesiftheydesire.
• BegintogatherpatientperspectiveonimpactofMSEPEexerciseontheirunderstandingofhealth,medications,andfollow-upplan.
• PrinttheoptionalstudentsurveydirectlyonMSEPEcardtoencourageagreaterresponserate
• Planforsustainabilitybeyondthisyearbyreducingnumberofadministrativesteps,increasingresidentandfacultyawarenessofexercise,andcreatingabriefvideopresentationforefficientandreproduciblestudentorientation
References1. “AdverseEventsAmongMedicalPatientsAfterDischargeFromtheHospital.”Forster,A.;etal. CMAJ.
2004;170:345-349.2. “RehospitalizationsAmongPatientsintheMedicareFee-for-ServiceProgram.”Jencks,S.;etal. NEngl J
Med.2009;360(24):1418-1428.3. “HealthLiteracyand30-DayPostdischarge HospitalUtilization.”Jack,B.;etal. JournalofHealth
Communication2012;17:325-338.4. "RedefiningRiskFactorsforGeneralMedicinePatients."Auerbach,A;etal.JournalofHospitalMedicine
2011;6:54-60.
Results
