STAAR Model and Teach Back

NoCVA HEN Virginia Readmission CollaborativeJune 11, 2012

This presenter has nothing to disclose

Session Objectives

After this session participants will be able to:

• Describe IHI strategies for diagnosing local opportunities to improve processes of transitions in patient care

• Identify methods of prioritizing initial interventions

• Describe the method for 360o case reviews

• Discuss process and outcome measures

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Systems of Care

“The quality of patients’ experience is the “north star” for systems of care.” –Don Berwick

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Learning from Observation

Gather the current state of patient teaching and learning

• Identify a staff member to observe while teaching a patient

• Get permission from the patient

• Observe from the patient and family perspective

• What went well & what could improve?

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Diagnostics

• 360° review─ Chart reviews

─ Interviews with patients and families

─ Interviews with community providers

• Observations─ Assessment

─ Discharge processes for senders and receivers

─ Patient teaching and learning

─ Patient and family experiences of transitions

• Data analyses─ Outcome measures

─ Process measures

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Diagnostic Reviews

• Teams complete a formal review of the last five readmissions every 3 months (chart review and interviews)

• Members from the cross-continuum team hear first-hand about the transitional care problems “through the patients’ eyes”

─ Help prioritize where to start

─ Engage the “hearts and minds” of clinicians and catalyzes action toward problem-solving

─ Identify many opportunities for learning from a small sampling of cases

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Diagnostic Reviews: Charts

IHI How to Guide page 9

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Diagnostic Chart Review Questions

1. Number of days between discharge and readmission? Build a histogram.

2. Follow-up visit scheduled?

3. Patient able to attend visit?

4. Any urgent clinic or Emergency Department visits?

5. Functional status at discharge?

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Diagnostic Chart Review Questions

6. A clear discharge plan?

7. Evidence of “Teach Back”?

(checking what patient understood?)

8. Documented reasons for readmission?

9. Social conditions contributed to the readmission?

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Diagnostic Reviews: Interviews

IHI How-to Guide page 9

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Interviews with Patients, Family Members, Care Team Members

1. How do you think you/the patient became sick enough to return to hospital?

2. Was there a physician visit before return?

3. Any difficulties in scheduling or getting to the visit?

4. How is the patient taking pills each day?

5. Typical meals since patient got home?

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Patients Tell Us How to Improve Care!

• Inadequately prepared for next setting

• Conflicting advice for illness management

• Inability to reach the right practitioner

• Repeatedly leaving tasks undone

Eric Coleman, MD

Your Turn

Count the Opportunities in this

Case Study:The Power of Stories

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James, 68 years old, lives at home with wife Martha

• Admitted to the hospital with shortness of breath

• Diagnosis: pneumonia + underlying onset of heart failure

• Instructed on new medications + diet before discharge

• Told to see his physician in the office in two weeks

• After returning home reminded to schedule physician’s office

• Finally able to set up a visit for three weeks later

• Never filled furosemide Rx; thought the expense unnecessary

• Noticed swelling in legs; didn't want to bother "busy doctor"

Putting a Human Face on the Problem:James and Martha

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James readmitted to hospital after 11 days• Increased SOB, mildly elevated BNP • Weight increase of 25 lbs, marked edema lower legs• Stress level high; blood pressure elevated, new drug added

Martha admitted for emergent surgery; James still in the hospital

• After James’ discharge he began eating fast food• Worried about his wife, juggled visits to her bedside, managed the roofing project on their home • Martha came home from the hospital, James readmitted with exacerbation of his HF

Putting a Human Face on the Problem:James and Martha

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How many opportunities did you identify in the story of James and Martha?

Changing Paradigms

Traditional Focus:

• Clinicians teaching

• Immediate clinical needs

• Patients

Transformational Focus:

• What is the patient learning?

• Whole person and their social needs

• Patient and family members are essential members of the care team

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Diagnostic Reviews: Outcome Measures

• Patient experience

• 30-day all-cause readmission rates for:

─ All conditions

─ Conditions of interest

─ Medicare

─ All populations

• Rehospitalization rates if available

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Diagnostic Reviews: Process Measures

• % of patients with family involvement in early assessment of discharge needs

• % of patients with Teach-back

• % of content patients can teach back

• % of patients with critical info transfer at discharge

• % of patients receiving customized, patient friendly post hospital care plan

• % of patients with office visit scheduled before discharge; days between discharge and visit

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Diagnostic Reviews: Process Measures

IHI How-to Guide Page 97

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65%

70%

75%

80%

85%

90%

95%

100%

APN VNA In Hospital

Successful Teach Back RateAug ‘06 – Sep ’10 (4 questions)

Updated 12/20/10

VNA teachback

initiated

Follow-up phone calls

initiated

Nurse competency evaluations in health literacy started

% Patients with Follow-up Appointment Scheduled for Three to Five days after Discharge Nov 07 – Jul 10

0%

10%

20%

30%

40%

50%

60%

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100%

Nov-0

7

Jan-0

8M

arM

ay Jul

Sep Nov

Jan-0

9M

arM

ay Jul

Sep Nov

Jan-1

0M

arM

ay Jul

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Identifying Opportunities: Observations

In Hospitals

• Admission assessment processes

• Admission and discharge med reconciliation

• Bedside rounding

• Patient education

• Discharge and transfer preparation

• Last 2-3 hours of patient stay

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Identifying Opportunities: Observations

In community settings (e.g., in the home with home care), physician’s office post hospital visit, and facilities (e.g. SNF, nursing home, rehab):─Receiving patient processes─ Intake med reconciliation─Patient education─Preparing for readmission to acute care─Preparing for discharge or transfer

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Identifying Opportunities: Observations of Patient Teaching

What can you learn about the current state of patient teaching and learning?

• For patients being taught self-care, e.g., reasons to call the physician after discharge ─Look for teaching and Teach Back: staff tone

of voice, attitude, non-shaming language, body language, plain terminology, request for Teach Back in the patient’s own words, and no “do you understand?” questions

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Ideas for Small Tests of Change

• What are your ideas for next steps for identifying opportunities?

• What are you curious about?

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30 Day All-Cause Readmissions

30 Day Readmissions for HF Pilot Nursing Units: Any Dx of HF

0%

5%

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Time Period

% o

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Goal Line: 16% (30% reduction)

2009 Average = 24%2010 Average = 18 %2011 Average = 13%

90-Day All Cause Readmissions

90 Day Readmissions for Heart Failure Patients

20%

25%

30%

35%

40%

45%

50%

Time Period

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Goal Line: 31% (30% reduction)

Average for 2009 = 40.2%Average for 2010= 31%

Average for 2011 = 26%

30% Reduction from 2006 (45.2%) to 2010

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Don Berwick’s Tips for “Getting Started”

Get goals state a clear aim

Get bold start TODAY

Get together assemble a team and involve patients & families

Get the facts clarify the gap and identify opportunities

Get to the field your front-lines of care

Get a clock set a completion date

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Questions?

Gail A. Nielsen

Director of Learning and Innovation

Iowa Health System

nielsega@ihs.org

Kate Bones

Project Director, STAAR

Institute for Healthcare Improvement

kbones@ihi.org

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