Module 3
description
Transcript of Module 3
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 MAR
Assist 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