Angela Coladonato, MSN, RN, NEA-BC Tina Maher, BSN, RN, NE-BC Kathy Zopf-Herling, MSN, RN-BC

Transcription

1 Leveraging IT to Support a Re-engineered engineered Discharge Process Angela Coladonato, MSN, RN, NEA-BC Tina Maher, BSN, RN, NE-BC Kathy Zopf-Herling, MSN, RN-BC All speakers have completed commercial bias disclosure forms and do not have any conflicts of interest. January 2013

2 Disclosures It is the policy of Corexcel and IMNE to ensure fair balance, independence, objectivity, and scientific rigor in all programming. In compliance with the American Nurses Credentialing Center (ANCC) and the Accreditation Council for Pharmacy Education (ACPE), it is the policy of Corexcel and IMNE that faculty disclose all financial relationships with commercial interests over the past 12 months. Corexcel s provider status through the ANCC and IMNE s provider status through the ACPE, are limited to educational activities. Corexcel, IMNE, ANCC and ANCC do not endorse commercial products. 1

3 Objectives Understand the current discharge process and its impact on readmissions Discuss three components of a re-engineered discharge process Articulate ways in which IT can support the discharge process Review the discharge process and how it is used in daily practice Describe the impacts of a re-engineered discharge process 2

4 Agenda Current state of discharge nation-wide. Project RED History and purpose at TCCH Soarian Re-Engineered Discharge Project Goals Multi-disciplinary inputs to the new Discharge Plan Outputs- My Discharge Plan (Patient and facility Version) Identification and management of high risk patients Outcomes so far Questions/Discussion 3

5 Discharge: the Perfect Storm" for Patient Safety The hospital discharge is non-standardized and frequently marked with poor quality. Loose Ends Communication Poor Quality Info Poor Preparation Fragmentation 20% of Medicare patients readmitted within 30 days Only half had a visit in the 30 days after discharge N Engl J Med ;360(14):

6 Other references: the last place patients want to end up after a hospital stay is right back in the hospital millions of patients are readmitted to hospitals each year, and many of those admissions could have been prevented on average, 8 minutes of conversation occurs about how to care for oneself at home, so it is no surprise that patients end up in trouble.. (AHRQ 2011) More than 1/3 of required appointments for follow up not completed (Moore et al. Archives of Internal Medicine. 2007;167: ) 41% of inpatients discharged with a pending test result 37% actionable and 13% urgent 2/3 of physicians unaware of results (Roy, et. al. Annals of Internal Medicine. 2005; 143(2):121-8.) Patients are not prepared at discharge: 37% able to state the purpose of their medications; 42% able to state their diagnosis (Mayo Clinic Proceedings. August 2005; 80(8):

7 Our Story: Dr. B. Jack/AHRQ- the national RED Roll-Out Pilot Project TCCH asked to be one of 11 hospitals to participate nationally Answer the following questions: Does the Project RED 11 Element Checklist work in the real world? Can the Project RED 11 Element Checklist be used more efficiently? June 2011 site visit; Dr. Jack, Boston Implementation team, AHRQ CHF patients discharged to home from Telemetry = pilot population Pilot year: summer

8 Readmission Rate Data during pilot - FY11 vs. FY12 All Telemetry Patients with a Primary Diagnosis of CHF at Discharge 30 Day Readmissions 7

9 RED & HCAHPS : Enhancing Communication 8 8

10 RED Checklist Adopted by National Quality Forum as Safe Practice Make appointments for follow-up medical appointments and post discharge tests/labs. 2. Plan for the follow-up of results from lab tests or studies that are pending at discharge. 3. Organize post-discharge outpatient services and medical equipment. 4. Identify the correct medicines and a plan for the patient to obtain and take them. 5. Reconcile discharge plan with national guidelines. 6. Teach a written discharge plan (AHCP) the patient can understand. 7. Educate the patient about his/her diagnosis. 8. Assess the degree of the patient s understanding of this plan. 9. Review with the patient what to do if a problem arises. 10. Expedite transmission of the discharge summary to clinicians accepting care of the patient. 11. Provide telephone reinforcement of the Discharge Plan.

11 Our Story: Personalized Plan 10

12 List of Medicines: Why & How 11

13 TCCH Clinical Pharmacists: Medication Teaching Tylenol Brand Name Ventolin, ProAir, Proventil pain, fever Why am I taking this med? breathing problems, asthma What do I need to look for? too much can cause liver damage (read OTC labels), higher doses for long periods can increase warfarin effects "rescue" inhaler, fast heart beat, chest pain/pressure Uroxatral Dizziness,HA, avoid grapefruit juice, alcohol, enlarged prostate, kidney stones changes in sex ability Zyloprim gout/high uric acid upset stomach, rash/skin irritation Xanax anxiety, "nerves" drowsiness, dry mouth Cordarone, Pacerone abnormal heart rhythm constipation, sensitivity to sunlight (wear sunscreen) Elavil mood, migraine, nerve pain sedation, dry mouth, avoid grapefruit juice 12

14 Our Story : Appointment Calendar 13

15 Re-Engineered Discharge: TCCH Expansion Pilot project was a success. Biggest challenge= biggest opportunity! Replication of the AHCP in Soarian; collaboration once more! RED 11 element Checklist worked; what is TCCH model? Re-Engineer the discharge experience for all; additional interventions for some TCCH Re-Engineered Discharge: 5 Core RED Principles Discharge planning begins Day 1 all TCCH patients My Discharge Plan all TCCH patients Teach-back methodology all TCCH patients Follow-up apts. High Risk patients Follow-up phone calls High Risk patients 14

16 Re-Engineered Discharge: TCCH Expansion Staff education on discharge and teach back methodology High Risk patients: F/Up Apts. Unit Coordinators own the process Patient/family interaction & the MD offices huge value! High Risk patients: F/Up phone calls Modified script from the Project RED pilot year; hours after D/C Access the medical record ; document the call CV Nurse Navigator, Paramedics and Clinical Pharmacists Content to date: medication clarification, transition support & compliments Volunteers & transport staff: discharge at curb-side Reinforce importance of My Discharge Plan as TCCH says good-bye 15 15

17 Goal of Soarian Re-engineered engineered Discharge Leverage our already existing electronic interdisciplinary documentation and processes to create patient friendly discharge instructions: Make the small RED pilot scalable to benefit all of our patients. No niche system No double documentation and re-work for staff/physicians Leverage Soarian work flow engine to identify high risk patients and help ensure that key activities occur, such as making appts and post discharge phone calls. 16

18 Goal 1: Patient friendly discharge instructions The discharge plan that the patient receives is created from electronic interdisciplinary documentation that is captured in the natural course of providing care: Uses ADT information- Demographics Uses CPOE orders Uses Case Management -facility plans, VNA, DME, etc. Uses Discharge Medication Reconciliation Uses Nursing Documentation- MAK, Discharge Instructions, Shift Assessments, ADLs, Vital Signs Unit Coordinators pull in follow-up contact information; make appts Discharge Instructions Library Nutritionists, Diabetes Nurse Educators, NPs, PAs, RT, PT/OT can add discharge instructions too! Facility/VNA version has additional clinical data 17

19 Input: Case Management 18

20 Input: Clinicians via discharge instruction order sets 19

21 Specialty addendums can easily be added 20

22 Unit Coordinator Role Unit Coordinators add follow-up appointment informationaddresses, phone numbers, time frame, and, for high risk patients, make these appointments in consultation with the patient and family. This made possible due to successful CPOE and MAK implementation that reduced amount of time spent in order transcription. We were able to insert links into the assessment form so that physician office locations and contact information could be readily found and inserted into the form (and eventually the report) 21

23 Patient Ed form- last chapter for discharge: nurse and others enter specific instructions/appts 22

24 Populating follow up physician contact information 23

25 Find the clinician, cut and paste! 24

26 Nurses and other disciplines add instructions- free text or templated information. 25

27 Text block library for templated last licks instructions 26

28 Nurses Role Nurses are responsible for patient education throughout the patient s hospitalization. They use teach back methodology and a variety of tools, such as Lexicomp, ExitCare, total joint booklet, etc. At discharge, they add final discharge instructions individualized for the patient- either free text or from a document library. These become part of the discharge plan given to the patient. Nurses coordinate discharge, so help to ensure that the discharge plan given to the patient is complete and accurate. Nurses also review the final discharge plan with the patient before discharge. 27

29 Physicians, Nurses, Pharmacists: Medication Section Clinicians complete discharge medication reconciliation in Soarian, which will inform the patient what medications they should continue at home. Nurses administer medications in MAK, which populate the last dose taken Pharmacists pre-built Commonly Used to for top 400 discharged medications. 28

30 Discharge Medication Reconciliation and MAK 29

31 Nurses contribute some Clinical Data from Shift Assessments 30

32 Creating the Report Specs for the Discharge Plan 31

33 Report Specs: Identifying the look back period 32

34 33

35 Discharge Plan Features Labels are in Patient Friendly language. For example, Physician enters discharge diagnosis in Soarian, but the label on the report is My main medical problem, according to Dr. Smith was: Visually designed to be easy on the eye and welcoming. Change from historically, where we gave patients very important information in a manner that was overwhelming. Large Font and Landscape orientation Lots of Page Breaks so that (for example) the medication chart starts on a new page 34

36 First page- vaccines and general info about hospital 35

37 Clinician Orders inserted into the document 36

38 Medication instructions- DMR with MAK last dose time and common use of medications 37

39 Yield and Stop signs for PRN and stopped meds. 38

40 Instructional material inserted into document or typed in free text. t 39

41 Case Management section 40

42 Appointments section 41

43 Calendar included if appts made. 42

44 Final product Final product For SNF/VNA all the patient stuff plus more! 43

45 First page- some added sections on Advance Directives, general patient information. 44

46 Added sections for the Nursing Home/VNA version 45

47 Last set (within 24 hours) of vitals signs, O2 46

48 Part 2: Management of High Risk Patients Automated work flow processes to identify patients at risk (modified Boost criteria). List updates with changes: Poly pharmacy Recent 30 day Readmission, all cause Certain diagnoses: Stroke, AMI, HF, COPD, TIA, Psych Lives alone On Warfarin or Aspirin/Clopidogrel SNF patients excluded Creates high risk for readmission order visible in chart 47

49 Part 2: Management of High Risk Patients Populates a report showing all high risk patients on the unit/hospital and reason for inclusion Populates a report for after discharge phone calls: 48

50 Lessons Learned Need robust DC instructions in the text block library. Engage physicians and staff early and include broader stakeholders (we started with heart failure because they were the pilot) Get a top notch report writer! Make sure report runs consistently and quickly. Plan to spend a lot of time on report specifications and testing. Tell nurses to preview the report to ensure completeness and accuracy. Nurses will sometimes have to sign DMR as complete if clinician forgot. Need to review report for accuracy Allow that nurses will spend more time with patient at discharge reviewing this discharge document. 49

51 Summary From an organizational perspective, this project has been a huge success, and has been well received by our patients: Minimized duplication and manual entry Refocused Unit Coordinator role on a value added patient activity. More robust, automated identification of patients at high risk for readmission. Legible, and complete discharge plan that is well received by patients, primary care physicians and receiving facilities. My Discharge Plan it s like getting an award for discharge (patient quote) Huge paradigm shift for most clinical staff - instead of the focus being on what they could enter into the electronic medical record, they saw their normal documentation actually used to produce something that would benefit the patients. 50

52 TCCH : HCAHPS Discharge Domain 51 51

53 RED & HCAHPS: Enhancing Communication New 2013 HCAHPS Care Transition Questions 4 point scale; from Strongly Disagree to Strongly Agree During this hospital stay, staff took my preferences & those of my family/caregiver into account in deciding what my health care needs would be when I left When I left the hospital, I had a good understanding of the things I was responsible for in managing my health When I left the hospital, I clearly understood the purpose for taking each of my medications 52

54 TCCH : HCAHPS Care Transitions 53 53

55 Lots of positive feedback from community agencies: I just wanted to let you know, how pleased we are with the ease of discharge from your hospital to our community. Mrs. E was followed by your SW, Linda. She communicated well with our SW. And the information that was sent upon discharge was terrific and will follow the resident home. We have commented among ourselves what a great discharge program you have in your IT dept, and how helpful all this info was. It was a pleasure working with you, hope we can do again sometime in the future. Thanks, Maggie 54

56 Future Plans Roll out to Maternal Child Health next week! Continue to improve the discharge instructions library Continue to improve the report (My discharge plan) Add past med/surg history at request of SNFs Move sections for maximum emphasis/readability Add eprescribe transactions including quantity and refill Try to find a way not to have to print and copy report (patient portal/hie/electronic patient signature and electronic annotations. Query review to make report run faster (completed) Review newly available metrics reports and see where that leads us 55

57 Questions?

58 Download the Free Chapter The Chester County Hospital and Health System: Using Technology to Re-Engineer Discharge Processes and Enhance Transitional Care Part of the new series, Technology in the New World of Healthcare, from Siemens Healthcare. techseries

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