© joint commission resources module 3 the re-designed discharge process: patient discharge and...
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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
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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
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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)
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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
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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
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Patient Admission
Care and TreatmentEducation
Demonstrationof Learning Patient
DischargeProblemSolved!
Re-engineering Patient Discharge: Project RED
Critical pathwayReconcile admission medsEducate the patient aboutthe plan of careInitiate discharge planningrounds
Reinforce care planReinforce teachingProvide explanations fortests and studiesDiscuss family supportoptions at homeClarify primary care provider
Written dischargeplanInitiate teach backSchedule follow upappointmentsSchedule postdischarge phone call
Confirm medication planPending test resultsFollow up appointmentscheduleReinforce AHCPSend PCP written AHCPDischarge telephone call
Module 3
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Discharge Planning
Patient Admission
H & P
Rx Plan
PATIENT EDUCATION
Discharge Order
Written
Discharge Process
Discharge Event
DISCHARGE INSTRUCTIONS
Post-D/C Follow-up
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RED Checklist: Discharge and Follow Up
Eleven mutually reinforcing components:1. Medication reconciliation
2. Reconcile discharge plan with national guidelines
3. Follow-up appointments
4. Outstanding tests
5. Post-discharge services
6. Written discharge plan
7. What to do if problem arises
8. Patient education
9. Assess patient understanding
10. Discharge summary sent to PCP
11. Telephone reinforcement
Adopted by
National Quality Forum
as one of 30 US
"Safe Practices" (SP-15)
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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 MARAssist withmedication
reconciliation
Assist withmedicationteaching
Participate inDC Rounds
Educate patientabout diagnosis,
tests, and studies
Initiate DCorders
ReinforceDischarge Plan
Provide careand treatment
CompleteAHCP
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Complete the Care Plan
Medication reconciliation performed
Pending tests and results
Post-discharge services
Primary Care Provider
Follow up appointments
Information about condition(s)
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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
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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
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Post Discharge Services
Confirm with case manager that all services have been arranged
Add names of services and contact information to care plan
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Primary Care Provider (PCP)
Confirm name of PCP with patient
Add name and contact number of PCP to care plan
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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
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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)
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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)
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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?
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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
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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
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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
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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!
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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)
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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
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Teach-Back Steps*
1. Use simple lay language; explain concept or demonstrate process avoiding technical terms; use a professional translator if language issue exists
2. Ask patient/caregiver to repeat concept in own words and/or to demonstrate process
3. Identify/correct misunderstandings or incorrect procedure
4. Ask patient/caregiver to repeat concept and/or repeat 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
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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.”
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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
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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’)
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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
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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
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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 ___