Improving Patient Transition and Satisfaction with Discharge Follow-Up Calls

By: Paige Barnes, MSN, RN, CEN Nurse Manager – Medical/Surgical Department Marshall Medical Center

Problem • 30 day readmissions • Patients with repeat visits (not within 30 days) due to not being engaged in their health care or not following discharge instructions.

• Community members bypass the hospital to go to a larger hospital because of the perception of better quality care at the larger facility.

Rationale • Readmissions delay patient health improvement and are costly to the health system.

• Communication between patients and providers can be limited due to patient load or providers not being aware of psychosocial issues that may impact patient upon discharge.

• Patients often do not understand instructions but do not ask questions or give indications they do not understand.

Proposed Change • Review of hospital readmissions to determine possible causes.

• Implementation of follow up call process within 2-3 days after discharge.

• Implementation of documentation tool for calls. • Measurement of change in metrics after follow up calls initiated.

Population and Institution • All adult medical surgical patients who are discharged to home or to caregiver’s home.

• 25 bed critical access hospital

Significance and Feasibility • Hospitals across the US are struggling with how to improve outcomes, reduce readmissions and improve patient satisfaction (HCAHPS). • Larger hospitals associated with universities often have multiple resources available, whereas smaller hospitals may not always have the same resources to affect large scale change. • Studying how follow up calls may improve outcomes, patient satisfaction, and readmission rates can potentially help small and rural hospitals affect change in their facilities.

Planning-Literature Review • Harrison, P.L., Hara, P.A., Pope, J.E., Young, M.C., and Rula, E.Y. (2011). The impact of post discharge telephonic follow-up on hospital readmissions. Population Health Management 14(1), 27-32. Retrieved from http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=5&sid=98 24c2b-a725-4a03-9232-f5b5b9004f70%40sessionmgr4008&hid=4101 “22% of patients admitted to general medicine services either die, are readmitted, or visit an emergency room within 30 days of discharge” “High readmission rates experienced in the American health system are generally attributed to inadequate communication with the patient and among the patient’s doctors at the time of discharge, and a failure of physicians to follow up after discharge, AEB the fact over half of patients who were hospitalized within 30 days did not visit a physician’s office between the 2 admissions”

Planning – Literature Review • Bryant, A. (2011). Development of guidelines for the selection of appropriate reading materials for clients with low health literacy. JOCEPS: The Journal of Chi Eta Phi Sorority, 56(1),17- 20 “In 2004, the Institute of Medicine issued a report on health literacy called "A Prescription to End Confusion." That report describes that 90 million adults have trouble understanding and acting on health information. They go on to document how health information is unnecessarily complex, and that clinicians throughout the health care system need health literacy training to improve how we communicate”(Bryant, 2011).

Resources • Re-Engineered Discharge (RED) Toolkit by the Agency for Healthcare Research and Quality (AHQR).

• Patient records – physician discharge summary, provided education

• Community providers’ process for scheduling follow up appointments and review of records.

Implementation Process Identified Need

Met with UR, CNO, Nurse Manager

Researched EBP

Formulated Tool and Criteria

Edited form to be more user friendly

Review of Process 6 months later

Implemented Calls

Approved by Medical Quality Committee

Added metric to hospital and department scorecard.

MMC’s Purpose for the Calls • Assuring patients have picked up medication and are taking appropriately.

• Do patients know the what, why, and what to look for with medications? (What is the medication? Why do you take it? What are side effects or considerations you need to know?).

• Do patients have follow up appointment scheduled and do they have reliable transportation to the appointment?

• Ensuring patients know our relationship does not end when they are discharged.

Additional Important Points • Home Health/DME services – has the equipment been delivered, provider come to the home? Does the patient or family know how to contact the correct people should they have a question?

• Safety considerations in the home related to their hospital stay. (falls, life alert, medication help, food preparation).

• Does the patient know what symptoms indicate a worsening of their health condition and what to do?

Results • Decrease in 30 day readmissions since start January 2016.

• Improvement in HCAHPS scoring trend from January to present. (limited number of responses each month to be statistically accurate, so we look more at trend line).

HCAHPS Overall Jan-June 2016

Willing to Recommend Jan-May 2016

Care Transition Jan-June 2016

Moving Forward • Teach Back/Ask Me 3 from National Patient Safety Foundation is being utilized for all patient teaching starting at admission.

• All clinical staff are being observed during a discharge for use of the method and coached as needed.

• May introduce another follow up call later in the month (after the initial calls) for one more opportunity to check on patient engagement.

Ask Me 3® Health information is not clear at times. The Ask Me 3® program run by the National Patient Safety Foundation can help. The program gives you three questions to ask your health care provider during a health care visit, either for yourself or for a loved one. They are:

• What is my main problem? • What do I need to do? • Why is it important for me to do this? Asking questions can help you be an active member of your health care team. For more information on Ask Me 3, please visit www.npsf.org/askme3 Ask Me 3 is a registered trademark licensed to the National Patient Safety Foundation (NPSF). Marshall Medical Center is not affiliated with nor endorsed by NPSF.

References • Bryant, A. (2011). Development of guidelines for the selection of appropriate reading materials for clients with low health literacy. JOCEPS: The Journal of Chi Eta Phi Sorority, 56(1), 17-20

• Harrison, P.L., Hara, P.A., Pope, J.E., Young, M.C., and Rula, E.Y. (2011). The impact of post discharge telephonic follow-up on hospital readmissions. Population Health Management 14(1). Pg 27-32. Retrieved from http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=5&sid=9b82 4c2b-a725-4a03-9232-f5b5b9004f70%40sessionmgr4008&hid=4101

• Health Literacy Universal Precautions Toolkit, 2nd Edition. February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacy-toolkit/healthlittoolkit2.html

References • Jack BW, Paasche-Orlow MK, Mitchell SM, et al. An overview of the Re-Engineered Discharge (RED) Toolkit. (Prepared by Boston University under Contract No. HHSA290200600012i.) Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 12(13)-0084.

• National Patient Safety Foundation. Ask me 3: Good questions for your good health. www.npsf.org/askme3

Paige Barnes, MSN, RN, CEN Nurse Manager, Medical/Surgical Unit Marshall Medical Center [email protected] 931-270-3635