STAAR Model and Teach Back NoCVA HEN Virginia Readmission Collaborative June 11, 2012

1. STAAR Model and Teach BackNoCVA HEN Virginia Readmission CollaborativeJune 11, 2012 This presenter has nothing to disclose

2. Session Objectives After this session participants will be able to: • Describe IHI strategies for diagnosing local opportunities to improve processes of transitions in patient care • Identify methods of prioritizing initial interventions • Describe the method for 360o case reviews • Discuss process and outcome measures

3. Systems of Care “The quality of patients’ experience is the “north star” for systems of care.” –Don Berwick 3

4. Learning from Observation Gather the current state of patient teaching and learning • Identify a staff member to observe while teaching a patient • Get permission from the patient • Observe from the patient and family perspective • What went well & what could improve?

5. Diagnostics • 360° review • Chart reviews • Interviews with patients and families • Interviews with community providers • Observations • Assessment • Discharge processes for senders and receivers • Patient teaching and learning • Patient and family experiences of transitions • Data analyses • Outcome measures • Process measures 5

6. Diagnostic Reviews • Teams complete a formal review of the last five readmissions every 3 months (chart review and interviews) • Members from the cross-continuum team hear first-hand about the transitional care problems “through the patients’ eyes” • Help prioritize where to start • Engage the “hearts and minds” of clinicians and catalyzes action toward problem-solving • Identify many opportunities for learning from a small sampling of cases 6

7. Diagnostic Reviews: Charts ) IHI How to Guide page 9 7

8. Diagnostic Chart Review Questions • Number of days between discharge and readmission? Build a histogram. • Follow-up visit scheduled? • Patient able to attend visit? • Any urgent clinic or Emergency Department visits? • Functional status at discharge? 8

9. Diagnostic Chart Review Questions 6. A clear discharge plan? 7. Evidence of “Teach Back”? (checking what patient understood?) 8. Documented reasons for readmission? 9. Social conditions contributed to the readmission? 9

10. Diagnostic Reviews: Interviews IHI How-to Guide page 9 10

11. Interviews with Patients, Family Members, Care Team Members • How do you think you/the patient became sick enough to return to hospital? • Was there a physician visit before return? • Any difficulties in scheduling or getting to the visit? • How is the patient taking pills each day? • Typical meals since patient got home? 11

12. Patients Tell Us How to Improve Care! • Inadequately prepared for next setting • Conflicting advice for illness management • Inability to reach the right practitioner • Repeatedly leaving tasks undone Eric Coleman, MD

13. Your Turn Count the Opportunities in this Case Study: The Power of Stories 13

14. Putting a Human Face on the Problem: James and Martha • James, 68 years old, lives at home with wife Martha • Admitted to the hospital with shortness of breath • Diagnosis: pneumonia + underlying onset of heart failure • Instructed on new medications + diet before discharge • Told to see his physician in the office in two weeks • After returning home reminded to schedule physician’s office • Finally able to set up a visit for three weeks later • Never filled furosemide Rx; thought the expense unnecessary • Noticed swelling in legs; didn't want to bother "busy doctor"

15. Putting a Human Face on the Problem: James and Martha • James readmitted to hospital after 11 days • Increased SOB, mildly elevated BNP • Weight increase of 25 lbs, marked edema lower legs • Stress level high; blood pressure elevated, new drug • added • Martha admitted for emergent surgery; James still in the hospital • After James’ discharge he began eating fast food • Worried about his wife, juggled visits to her bedside, • managed the roofing project on their home • Martha came home from the hospital, James readmitted • with exacerbation of his HF

16. How many opportunities did you identify in the story of James and Martha?

17. Changing Paradigms Traditional Focus: • Clinicians teaching • Immediate clinical needs • Patients Transformational Focus: • What is the patient learning? • Whole person and their social needs • Patient and family members are essential members of the care team 17

18. Diagnostic Reviews: Outcome Measures • Patient experience • 30-day all-cause readmission rates for: • All conditions • Conditions of interest • Medicare • All populations • Rehospitalization rates if available 18

19. Diagnostic Reviews: Process Measures • % of patients with family involvement in early assessment of discharge needs • % of patients with Teach-back • % of content patients can teach back • % of patients with critical info transfer at discharge • % of patients receiving customized, patient friendly post hospital care plan • % of patients with office visit scheduled before discharge; days between discharge and visit 19

20. Diagnostic Reviews: Process Measures IHI How-to Guide Page 97 20

21. Successful Teach Back Rate Aug ‘06 – Sep ’10 (4 questions) VNA teachback initiated Follow-up phone calls initiated Nurse competency evaluations in health literacy started Updated 12/20/10

22. % Patients with Follow-up Appointment Scheduled for Three to Five days after Discharge Nov 07 – Jul 10 22

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24. Identifying Opportunities: Observations In Hospitals • Admission assessment processes • Admission and discharge med reconciliation • Bedside rounding • Patient education • Discharge and transfer preparation • Last 2-3 hours of patient stay

25. Identifying Opportunities: Observations In community settings (e.g., in the home with home care), physician’s office post hospital visit, and facilities (e.g. SNF, nursing home, rehab): • Receiving patient processes • Intake med reconciliation • Patient education • Preparing for readmission to acute care • Preparing for discharge or transfer

26. Identifying Opportunities: Observations of Patient Teaching What can you learn about the current state of patient teaching and learning? • For patients being taught self-care, e.g., reasons to call the physician after discharge • Look for teaching and Teach Back: staff tone of voice, attitude, non-shaming language, body language, plain terminology, request for Teach Back in the patient’s own words, and no “do you understand?” questions

27. Ideas for Small Tests of Change • What are your ideas for next steps for identifying opportunities? • What are you curious about?

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29. 30 Day All-Cause Readmissions

30. 90-Day All Cause Readmissions

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33. Don Berwick’s Tips for “Getting Started” Get goals state a clear aim Get bold start TODAY Get together assemble a team and involve patients & families Get the facts clarify the gap and identify opportunities Get to the field your front-lines of care Get a clock set a completion date 33

34. Questions?

35. Gail A. Nielsen Director of Learning and Innovation Iowa Health System nielsega@ihs.org Kate Bones Project Director, STAAR Institute for Healthcare Improvement kbones@ihi.org