Discharge Information Yes, patients were given information about what to do during their recovery Vikki Choate, MSN, RN, CCM, RN-BC, CPHQ Nashville, TN May 14-15, 2013
Learning Objectives At the end of this session, participants will be able to: Describe the CMS Readmissions Reduction Program List two tools to help meet patients need for information at discharge Describe how Evidence-Based Leadership tactics may be leveraged to improve HCAHPS Discharge Information results **
Discharge Process - Connecting to Purpose I had no idea that my symptoms might return and if they did, that I should call 911 immediately..i almost died! I didn t realize that I should stop taking my other insulin when I got home. I ended back up in the hospital and I missed my grandson s wedding. The nurse handed me my discharge papers as they were wheeling me off the unit. I didn t know what was in there why wouldn t they tell me before I left? Source: Patient Call Manager
Wouldn t it Be Great if it was This Simple?
Why is Getting Discharge Right So Important? Estimated 1 out of 5 of Medicare beneficiaries are readmitted within 30 days $17.4 billion spent annually on unplanned readmissions Despite our best efforts, readmissions are not decreasing: Condition 2007 2010 2006-2009 Heart Attack 19.8% 19.9% Heart Failure 24.8% 24.5% Pneumonia 18.4% 18.2% Source: The American Journal of Managed Care 17 (2011): 41-48
Reality of Adverse Events Post Discharge Nearly 1 in 5 patients * 400 patients surveyed 76 (19%) had adverse events after discharge Nosocomial Infection Fall Type of Adverse Events Other 8% 4% 5% Procedure Related 17% 66% Adverse Drug Event Source: Adverse Events After Discharge from Hospital, Annals of Internal Medicine, February 2003 * 81 events occurred in 76 patients
CMS Hospital Readmissions Reduction Program** Authorized by the Affordable Care Act Aims to reduce cost of unplanned readmissions Heart Attack, Heart Failure and Pneumonia Began October 1, 2012 Impacts PPS hospitals 1% Medicare based on calculations for fee-forservice claims (July 1, 2008 June 30, 2011)
More in Store 1% 1.25% 1. 5% 1. 75% 2% 1% 2% 3% 3% 3%
Organizations Coached by Studer Group Outperform the Nation across HCAHPS Composites Studer Group Difference over Non-Partners in National Percentile Ranking Overall Rating 23 Willingness to Recommend 17 Pain Management 15 Nursing Communication Communication of Medications Clean and Quiet 6 15 17 percentile points higher Discharge Instructions 19 Responsiveness of Staff 5 Doctor Communication 4 Studer Group Difference over Non-Partners in National Percentile Ranking 0 5 10 15 20 25 Source: The graph above shows a comparison of the average percentile rank for Studer Group Partners that have received EBL coaching since Oct 2008 and non-partners for each composite; updated 1.23.13 using 2Q11-1Q12 CMS data.
HCAHPS: When You Left The Hospital 19. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? Yes No 20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Yes No Source: HCAHPS Survey, Appendix D
Supporting Effective Discharge Discharge planning truly begins on admission Evidence based clinical decision support used to clearly define readiness for discharge Patient, family, and caregiver are actively involved Effective medication education and reconciliation
Supporting Effective Discharge Follow-up appointments made prior to discharge Discharge Folders actively used to provide education, facilitate decisions & house information Discharge Checklists used to reduce error Post Visit Calls placed to assess patient self care knowledge and capability; reinforce patient education
Discharge Folders Medication information including master list of all meds (name, purpose, side effects, start date if new); prescriptions Easily understood information on condition(s) Patient Pass to Go Home Written discharge instructions Written list of symptoms to look out for Follow-up appointment details Important names and phone numbers Thank You Card
Discharge Folder: Patient Pass to Go Home
Discharge Folder: Symptoms Stop Light Report GREEN ZONE = All Clear Your Normal Weight I am breathing normally for me I have no swelling I have not gained any weight (or less than 3 pounds) I have no chest pain I can do my usual activities YELLOW ZONE = Caution If you have any of the following signs or symptoms: Increase shortness of breath with activity Increased swelling in hands, feet, lower legs or abdomen Increased cough Increase in number of pillows needed Dizziness Fatigue or tiredness Decreased desire for food Unrelieved chest pain Weight gain of 3 or more pounds in one day or 5 pounds in one week GREEN ZONE Means: Your symptoms are under control Continue taking your medications as ordered Continue daily weights - WEIGH YOURSELF DAILY, at the same time each day, using the same scale. Record your results in a notebook Follow low salt diet Keep doctor appointments YELLOW ZONE Means: Your symptoms may indicate that you need an adjustment of your medications Call your primary doctor or First Nurse First Nurse: Ames: 515-239-6877 Marshalltown: 641-754-6877 Anywhere in Iowa: 800-524-6877 Primary Doctor / Number: RED ZONE= Medical Alert Unrelieved shortness of breath at rest Unrelieved chest pain or pressure at rest Wheezing or chest tightness at rest A racing or skipping heart Need to sit in chair to sleep Weight gain of more than 5 pounds in one day Confusion RED ZONE Means: The symptoms you have may be from a change in your heart health, and you will need to be checked at your doctor s office or in the emergency room at the hospital. If necessary dial 911
Discharge Folder: A Case Study Implemented Discharge Folders 1Q12 Baseline Discharge Info = 86.67 April - June 2012 July-Sept 2012 Oct-Dec 2012 VBP Performance Period April 12-Dec 12 Hoffman Estates, IL - SAMC 6 North Hoffman Estates, IL - St. Alexius Medical Center Hoffman Estates, IL - SAMC 6 North Hoffman Estates, IL - SAMC 6 North 67.96 76.56 83.44 Overall Rating 74.12 71.49 76.07 73.88-1.00-1.00-1.00 Would Recommend 74.03 79.89 77.95 77.61 76.56 81.64 85.70 Communication with Nurses 81.53 81.71 79.39 80.82 76.56 81.64 85.70 Nurse Respect 90.57 88.57 87.32 88.66 76.56 81.64 85.70 Nurse Listen 83.02 87.14 84.29 84.97 76.56 81.64 85.70 Nurse Explain 83.02 81.43 78.57 80.83 60.89 66.98 71.85 Communication about Medications 56.16 67.03 65.53 63.28 60.89 66.98 71.85 Med Explanation 75.68 81.40 84.09 80.65 60.89 66.98 71.85 Med Side Effects 44.44 60.47 54.76 53.72 83.54 86.97 89.72 Discharge Information 90.78 89.00 90.68 90.08 83.54 86.97 89.72 Help After Discharge 95.92 94.03 91.30 93.51 83.54 86.97 89.72 Symptoms to Monitor 88.24 86.57 92.65 89.25 0.00 0.00 0.00 Number of Surveys 53 70 71 194
Post-Visit Calls
Percentile Rank Post-Visit Calls A Case Study Instructions to Care for Yourself at Home No Call Call 100 90 80 70 60 50 40 30 20 10 0 46 96 98 35 37 95 26 98 99 98 30 41 27 95 97 20 89 95 97 Tactic and Tool Implemented: Post Visit Calls 10 12 14 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 17 94 Source: New Jersey Hospital, Total beds = 775; 3Q2007 2Q2010
Using Evidence-Based Leadership Tactics to Support Effective Discharge** Daily Huddles Nurse Leader Rounding Hourly Rounding Bedside Shift Report M in the Box Post-Visit Calls
Daily Huddles Nurse leader: Connects to purpose, why important Sets expectations for the day Obtains agreement from care delivery team Provides outcomes from Nurse Leader Rounding Reviews HCAHPS results
Nurse Leader Rounding Nurse Leader: Validates expectations being executed Assesses Patient Communication Board Explores M in the Box Inquires about new info in Discharge Folder Asks about plan of care for the day Positions the Post-Visit Call during pre-discharge round
Hourly Rounding Primary Care Nurse: Keeps Patient Communication Board up to date Uses the board to involve patient in care planning and to facilitate education Uses M in the Box to educate on new meds Keeps Discharge Folder in designated location, updates as appropriate, uses to provide education and insures patient & family are aware of its contents and value
Bedside Shift Report Off-going Primary Care Nurse: Asks patient to describe the plan of care and any decisions made affecting discharge Utilizes M in the Box to have patient demonstrate knowledge of new medications On-coming Primary Care Nurse: Asks patient to show and describe new materials in Discharge Folder Updates Patient Communication Board
Post Visit Calls Nurse Caller: Communicates the hospital s commitment to safe and effective discharge Assesses the patient s self-reported condition Asks to review information provided about symptoms and health problems to watch out for Reinforces education as indicated Thanks patient for opportunity to provide care
Execution Triangle Accountability Results Consistency Reliability
Discharge Process Connecting to Purpose I have been a diabetic for 30 years and I ve been in the hospital many, many times. I left after 3 days in your care having learned more about my diabetes than I have over the past 3 decades combined. Thank you! My discharge plan was so thorough the nurses thought about everything. By the time I left, I knew that I would be fine and could take care of myself. My primary care doctor was so impressed with the discharge folder I brought to my follow-up visit. He told me it would keep me out of the hospital.
Review Learning Objectives Are we able to: Describe the CMS Readmissions Reductions Program? List two tools to help meet patients need for information at discharge? Describe how Evidence-Based Leadership tactics may be leveraged to improve HCAHPS Discharge Information results?
Thank You! Vikki Choate, MSN, RN, CCM, RN-BC, CPHQ 207.607.2218 vikki.choate@studergroup.com