IHI STAAR Fall Learning Session 2011: Breakout A – Early Assessment of Post-Discharge Needs

Laura Carr, PharmDJane Murray, MBAJessica Smith, RN

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Cross-Continuum Team

• Chris Annese, RN, El16• Paul Arpino, Pharmacist,

Clinical Operations Director• Victoria Brower, Project Mgr,

HPM4• Laura Carr, IP Pharmacist• Jacqui Collins, RN, CNS, El16• Gwen Crevensten, MD, Faculty,

CQS• Joanne Doyle, OP Pharmacist• Joanne Empoliti, CNS, Wh6• Kathleen Finn, MD, Clin

Educator• Theresa Gallivan, RN, Associate

Chief Nurse• Jeff Greenwald, MD, Medicine• Kathryn Hall, RN, Nurse Dir,

El16• Bob Hallisey, Pharmacist,

Clinical Specialist

• Yanie Jackson, MS, CQS• Joanne Kauffman, RN, Team

Mgr, Case Mngt• Deb Kiely, PHS Home Care • Colleen Macauley, RN,

Medicine• Mary Neagle, Project Mgr, CMP• Terry O’Malley, MD, Director,

Non-Acute Services• Kathleen Myers, RN, Nurse Dir,

El6 and Wh6• Karen Pickell, NP Patient Care

Services• David Ring, MD, Orthopedics• Nancy Sullivan, Director, Case

Mngt• Kristin Sybertz, RN, Team Mgr,

Case Mngt• Ryan Thompson, MD, Medicine

Executive Sponsors: Elizabeth Mort, MD, MPH & Andrew Karson, MD, MPHDay-to-Day Leads: Jane Murray, MBA

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Key Change – Perform an enhanced assessment of post-hospital needs

1. Discharge Nurse Role• New role piloted through STAAR

• Unit decided to keep position even after pilot was completed because team thought the role was extremely important

2. Pharmacist Role: pre-discharge visits to patients• Patients referred to Pharmacist by the Discharge Nurse

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• Three RNs (adding up to 1 FTE) serve exclusively as Discharge Nurses and follow patients from Admission to Discharge on Ellison 16 (Medicine)

– Approximately 40% of patients on floor are managed by Discharge Nurses• Inclusion Criteria

– >=10 medications– Any patient with diagnosis/reason for admission of:

• CHF• Pneumonia• Acute Renal Failure• Afib• Cancer Pain• Dehydration• UTI • Change in mental status

– English-speaking

Discharge Nurse Role - manage high-risk patients based on specific criteria

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Throughout the hospital stay, Discharge Nurses prepare the patient and family members for post-discharge needs• Advantages of Discharge Nurses for patients and family

members– Continuity with teaching - the same person is providing the patient

with disease education and medication reconciliation/education– Improves MD-RN-CM communication – Assist with post-discharge services such as arranging VNA visits,

educating patients on importance of follow-up appointments and coordinating transportation with family members

– Patients receive a folder which is compiled throughout the hospital stay with education materials, provider contact information, follow-up instructions, and labs/tests appointments

– Review Patient Discharge Medication List with individualized medication details which is given to patient at discharge

– Overall improvement in the quality of discharge information and communication

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Discharge Nurse Role has continually evolved to streamline workflow and brings focus to the discharge process early on• Changes tested

– Patients taking more active role in their care;• Sheet in patients’ folders to write down questions

throughout their stay and go over questions with nurse, physician, pharmacist, etc.

– Identified communication barriers between physicians, case managers and nurses; • Special Discharge Nurse pager created so there is single

point person for discharge questions• Discharge Nurse participates in 4pm rounds to help

identify patients who are ready for discharge

– Discharge dates were not communicated clearly to patient or care team on a regular basis;• anticipated discharge date added to white board at

nursing station to align the entire team and set expectations

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• Discharge Nurses refer patients to the Pharmacist if there is any confusion about medication while the patient is still in the hospital

• The goal is to provide medication reconciliation and counseling services to complex patients prior to discharge

• Pharmacist coordinates dispensing of medication if necessary

• Pharmacist reviews final medication list with patient and/or caregiver

Pharmacist Role – work with Discharge Nurse to reconcile medication and answer patients questions prior to discharge

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Pharmacist pre-discharge visits are important as evident in recent patient stories

• 60 year old woman admitted with PE going to rehab– found that Atorvastatin was missed on her PAML, and not

included on discharge orders– RPh was able to resolve issue prior to discharge and educate

patient on new Warfarin

• 75 year old man admitted with PNA going to SNF– patient on his second admission in two weeks– patient was on 22 meds– RPh found 6 errors in Discharge Orders including doubling of

patient’s new Metoprolol XL dose from 25mg QD to 25mg BID– RPh was able to resolve issue prior to discharge

• 74 year old man admitted with MRSA being discharged home– complex medication regimen of antibiotics and renal transplant

meds which could not be taken together– RPh created a med dose chart to accommodate 7 admin times– RPh called patient post-discharge to follow up

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Patients benefit from having Pharmacist perform additional review of medications prior to discharge• Pharmacist provides direct patient counseling

– High-risk patients continue to benefit from additional teaching and opportunities to ask medication related questions

• Common issues identified– Medication instruction not clearly written out for

patients • Antibiotic end dates • Taper instructions• PRN vs. standing orders

– Incomplete medication reconciliation – Differences between medical record and discharge

instructions/prescriptions to patients– Errors with high-risk medications including Warfarin,

Insulin, and Opioids

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Ellison 16 all-cause 30-day readmissions data

STAAR teams launch

Pharmacy post-discharge calls

RNs responsible for simple VNA

Discharge RN role

Pharmacy pre-discharge visits

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The overall readmission rate on the floor is trending downward, possibly aided by the Discharge Nurse Role• Ellison 16 Discharge Nurse Role Readmission Rate

– Between 12/1/2010 and 5/31/2011

– Between 7/1/2010 and 11/30/2010

Exclusions:1. Observation patients and patients transferred to another floor are excluded even if they met

inclusion criteria. Bad data was also excluded (e.g. double-entries, patients with no TSI record, etc)2. Discharges do not include rehab or hospice admissions, deceased, discharged against medical

advice, or transfer to another short-term facility or psych hospital or unit3. Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions

Meets Criteria Discharges ReadmissionsReadmission

RateNo 448 80 17.9%Yes 275 47 17.1%Total 723 127 17.6%

Meets Criteria Discharges ReadmissionsReadmission

RateNo 397 80 20.2%Yes 236 53 22.5%Total 633 133 21.0%

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More data required to determine the impact of pre-discharge Pharmacy visits on readmissions• Pre-discharge Pharmacy visit readmission rate

– Between 1/1/2011 and 5/31/2011

Exclusions:1. Observation patients and patients transferred to another floor are excluded even if they met

inclusion criteria. Bad data was also excluded (e.g. double-entries, patients with no TSI record, etc)2. Discharges do not include rehab or hospice admissions, deceased, discharged against medical

advice, or transfer to another short-term facility or psych hospital or unit3. Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions

Visits ReadmissionsReadmission

Rate30 7 23.3%

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Lessons learned from Discharge Nurse and Pharmacist

• Discharge process can be disjointed which is why having a single contact person (Discharge Nurse) coordinate the process increases patient, physician, case manager and nurse satisfaction

• Discharge Nurse Role improved workflow and provided standardized process; sets expectations for patients and providers as to what patient should know prior to discharge

• Having anticipated date of discharge provides a timeline for all providers and helps coordinate nursing assignments

• Pharmacist involvement is important both pre and post-discharge– Pre-discharge collaboration between Discharge Nurse

and Pharmacist to reconcile medication helps reduce medication errors

– Another program where the Pharmacist conducts post-discharge calls has shown a reduction in readmission rates (13% vs. 17%)

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Next steps

• Discharge Nurse Role is being presented to Nursing Leadership as a best practice to expand to additional units

• Increase collaboration with outpatient nurses to improve transitions in care

• Include an electronic copy of the Discharge Nurse note in the LMR (outpatient electronic record)

• Increase number of referrals to Pharmacy for pre-discharge visits – may require additional resources

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Appendix

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Patient Discharge Medication List (PDML) – New Medication

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PDML – List of medications to stop

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Pharmacist post-discharge calls have shown a reduction in readmission rates (13% vs. 17%)

Discharges* (1)Patients discharged from Ellison 16 629Patients who received a Pharmacy call # 101

% of patients who received a Pharmacy call 16.6%

Readmissions* (2)Patients readmitted who received a call # 13 / 101 = 12.9%

Patients readmitted who did not receive a call 91 / 528 = 17.2%Total Readmission rate 104 / 629 = 16.5%

Source:TSI EncountersUHC DatabasePharmacy Worksheets

*Includes only patients discharged Home from E16 # Excludes patients who fit criteria but declined call or RPh was unable to reach

Time period: January 11 to June 30, 2010(1) Discharges do not include rehab or hospice admissions, deceased, discharged against medical advice, or transfer to another short-term facility or psych hospital or unit

(2) Readmissions do not include rehab, hospice, chemotherapy, radiation, or dialysis readmissions