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Reducing Avoidable Readmissions: Measuring and Influencing Change

To wrap up the 2-day “Reducing Avoidable Readmissions Course” from the Institute for Healthcare Improvement, was a session on measuring results. The session, while helping to provide measures and objects was as focused on how to manage change in an organization, with the understanding that within healthcare organizations this can often be akin to turning a cruise ship.

One presenter, describing a successful partnership between a hospital and skilled nursing facility to improve transitions in care mentioned that it took over 3 years to implement the program. She expressed frustration that often people’s roles changed in this period but seemed to accept that this length of time was pretty typical, and considering it was an inter-organizational transformation that is probably true, and possibly fast.

When planning to make changes within your organization, here are some great ideas for influencing change and getting it to stick.

  • Set realistic goals. For example, when trying “Teach Back” ask physicians and nurses to try teach back with their last patient every day. This will give them the experience without unrealistic expectations and if the new method takes a bit longer at first doing it with the last patient will not disrupt the schedule.
  • Use the lean principles of the 5 Whys to get to the root of why something is broken.
  • Make sure that new processes do not increase workload and have perceived value, using the “highly adoptable” formula from Chris Hayes.
Source: Christ Hayes, www.highlyadoptableQI.com

Source: Christ Hayes, www.highlyadoptableQI.com

  • Involve frontline staff in process design. They will be the ones who need to implement it so make them part of the solution.
  • Determine what you will measure before implementing so you can gage success.
  • Test changes under a variety of conditions before trying to replicate across an organization. That way, you will be prepared for any potential adoption blockers.
  • Prepare for and manage relapses. People may revert to older processes if the new ones fail. Plan for this, and see it as a learning opportunity rather than a failure.
  • Make the change about improving patient care. Even though the goal may also include reducing readmissions, lowering costs, and increasing predictability, these are topics that are hard to rally people around. Remember why you and your colleagues entered healthcare: to help people. Appeal to the highest goal of improving patient’s experience and health.

Posted in: Behavior Change, Healthcare transformation, Outcomes

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Using “Teach Back” To Decrease Patient Readmissions

Marshall McLuhan, the late Canadian philosopher, famously said both “the medium is the message” and “the medium is the massage” meaning that the delivery mechanism of information provides insight into the meaning and can also shape the meaning.

In a recent course I attended from the Institute for Healthcare Improvement on “Preventing Avoidable Readmissions” there was a lot of focus on missed messages whether between healthcare professionals or from healthcare professionals and patients. Some of these messages were missed because of the delivery mechanism, and one session in particular focused on a concept called “teach back” which was designed to ensure that the message of discharge instructions actually landed with patients.

Source: IHI.org

Source: IHI.org

Throughout the course, the same refrain was heard that improving communications between healthcare providers and to patients were key to improving health outcomes. Examples of poor or rushed communications were provided across the course and included:

  • Patients in the emergency department not knowing why they were actually admitted
  • Conflicting discharge instructions from different hospital departments
  • Rushed conversations with patients

As well, patients often interpret information differently than intended. For example, when patients are discharged they hear “better” rather than “recovering.” As well the messages often don’t land because patients are thinking ahead to the implications of the information, for example, when told of impending necessity for surgery they are thinking about needing to take time of work, or who will walk the dog.

In our work at Wellpepper, we have interviewed many patients about why they don’t adhere to treatment plan instructions, and what most of them tell us is that when hearing the instructions in the first place they felt like they understood but when they got home they realized that they didn’t. Think about this with respect to how these messages are often delivered: patient have limited time with healthcare professionals, they are often intimidated and don’t want to ask questions, and then frequently the handouts they are sent home with don’t correspond to what they thought they heard.

Thinking about how instructions are delivered to patients can help tremendously with patient understanding and follow up. The IHI course presented some practical strategies both for delivering the information and for testing patient comprehension wrapped in some specific strategies referred to as “Teach Back.”

Healthcare professionals learn many things in their studies, but information design, learning styles, and comprehension are not necessarily part of that. Understanding that people learn in different ways, that patients are often distracted by bigger life issues when you are trying to teach them, and that a patient’s ability to demonstrate what you taught them better indicates they can go home and replicate are all tools to improve patient comprehension and adherence. As well, often it is not just the patient who needs this information but also the patient’s caregiver.

The basic principles of Teach Back include:

  • Making sure that information is easy to understand. For example avoiding medical jargon, written for a 5th grade reading level, and including only the most important information.
  • Delivering the information in a way that shows the patient you care, and that the information is important. For example, taking the time to walk through the information, sitting down and looking at the patient, and using a warm and caring tone of voice.
  • Testing for understanding. Ask the patient to explain what you taught them in their own word and if appropriate to demonstrate what you taught them.

We loved this particular session as it’s in keeping with our findings that patients want to adhere to programs provided you provide them with the right tools. As well, we have been recommending a teach-back style when recording video tasks with Wellpepper. First explain the task to the patient, whether that’s physical therapy, wound care, or using an inhaler. Next have the patient demonstrate to you that they can do it. When the patient is able to show you they can do it without extra help or prompting, record the patient and make this part of the patient instructions that you send home with them.

Teach back and informational design concepts may seem like they are taking healthcare outside of a traditional realm. They may also seem like they take more time. In the short term that might be true, but in the long run you will need to spend less time with these patients as they will be self-activated, which needs to be the goal of any readmissions prevention program.

Posted in: Behavior Change, Healthcare motivation, Healthcare Policy, Healthcare transformation, Outcomes

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Reducing Avoidable Readmissions: Care Transitions

This is the second in our series, recapping the lessons learned from the Institute for Healthcare Improvement’s Reducing Avoidable Readmissions course.

Care transitions are seen as key to improving readmission rates, and understanding that readmissions are not just the hospital’s responsibility but involve a care team that includes the patient, the patient’s caregiver, homecare, and skilled nursing depending on where the patient is discharged.

Both ensuring good care transitions to decrease readmissions, but also discharging to the right facility are crucial for lowering costs and improving care. Post-acute care shows the greatest discrepancy in costs per patient and is growing at 6% annually for Medicare patients. Today, 40% of Medicare patients discharge to a post-acute care facility, and 33% of patients in these facilities experience a care-related adverse event. By 2017, skilled nursing facilities could face penalties of up to 3% of Medicare payments for readmissions, thus there are real incentives to improve transitions, if patient safety isn’t enough to effect change.

The first step in improving care transitions is to ensure that the patient is going to the right setting, and this requires a decision by the care team that includes the patient and the patent’s caregivers. If money is not an object, many hospitals discharge to skilled nursing as a way of insuring that the patient doesn’t readmit. However, if care transitions are not handled properly, this adds costs without improving quality.

One of the biggest challenges in care transitions, is that there are no universally agreed upon assessment tools for determining the best next step for patients on hospital discharge, hence the over prescribing of skilled nursing. Beginning to track readmissions and outcomes should help organizations stratify risk and begin to be able to predict the best setting based on data. In addition to data, interview patients. Often missed care transitions are only identified by the patient him or herself as they are more aware of what was lost in transition.

Possibly because of the make-up of the attendees in the course, the transition from hospital to skilled nursing was a hot topic. Hospital attendees admitted to have little insight into how skilled nursing facilities worked. Skilled nursing attendees expressed frustration with the amount of patient information they received when admitting a patient. One attendee begged “just let me see the patient’s medical record.”

In order to facilitate better transitions, cross-functional teams need to be developed and these need to include members of the receiving facility. One skilled nursing facility reported significantly better transitions by simply placing one of their nurses in the hospital part-time to meet with patients before they were transferred.

These teams must have support at two levels: the executive level must provide resources and be open to changes recommended by the functional team that handles the care transitions. Functional teams must feel empowered to change and improve processes for care. Organizations that are pursing ACO models and bundled payments were seen as great opportunities for these types of cross-organizational and cross-discipline care teams.

The INTERACT tool is a way to ensure that the receiving organization gets the right patient care information during this transition. Unfortunately, given the lack of interoperability of medical systems, this approach requires additional paper work. There is no easy way to share patient records between EMRs or organizations, or sometimes within the same organization.

Other best practices in patient transfer include:

  • “warm handovers” that is, no patient is transferred with out a real-time conversation between physicians
  • Sending the patient with a 3-day supply of medication so there is no interruption and include pharmacy in the transfer team
  • Following up with the skilled nursing facility by phone within 24-48 hours post transfer
  • Sending information about patient preferences. One example was given of a patient who preferred to take her medication with Coke. She was greeted at the skilled nursing facility with a Coke and her medication.
  • Regular meetings between skilled nursing and hospital
  • Relationship building and storytelling for all parties to understand constraints that other side is facing
  • Creating a standard follow up and communication protocol based on patient risk of readmission

Post Acute Care Follow Up Communications

In keeping with the opening statement of the course, there is no silver bullet, just a lot of practical common sense advice, and clear and timely communication.

Next we’ll look at some best practices for discharging to home and the role of the primary care physician.

Posted in: Health Regulations, Healthcare motivation, Healthcare Policy, Healthcare Technology, Healthcare transformation

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