Problem Addressed

• Frequent (but often preventable) readmissions: One study found that almost one-fifth of individuals with an initial preventable admission had at least one preventable readmission within 6 months, at a cost of approximately $730 million.¹ A Medicare Payment Advisory Committee report notes that 11.5 percent of Medicare patients are readmitted within 15 days of their initial discharge, while 17.6 percent are readmitted within 30 days; 76 percent of 30-day readmissions were considered preventable.²
• Insufficient patient understanding of care and care needs: Many readmissions occur because hospitalized patients and their family members do not adequately understand their postdischarge care needs, including complicated medication regimens and the need for periodic followup care from different health care providers. In fact, at discharge, patients often do not know which medications their physicians have prescribed, when their followup appointments should take place and, in some cases, why they were hospitalized in the first place.³ One study of recently discharged patients found that 64 percent reported not being told before discharge how to manage their care at home.⁴

Description of the Innovative Activity

• Eligibility: At Crawford Long, patients over the age of 18 years who did not have underlying dementia (or who had dementia but had a reliable caregiver) were considered eligible for the program.
• Discharge Patient Education Tool: This form provides basic patient information as well as admission and discharge dates; names of physicians who provided care; patient diagnoses; test results; a summary of the most important treatment interventions received in the hospital; required followup appointments, tests, and other care; symptoms to watch for; and required medications. The form is written in first-person language to enhance patient understanding and attachment to the information. In the pilot test at Crawford Long, a nurse case manager completed the form, confirmed its accuracy with the patient’s physician, and reviewed it with the patient before discharge. The patient was given the Discharge Patient Education Tool to take home for later reference.
• Discharge Knowledge Assessment Tool: This form is used by clinicians or investigators to record the patient’s responses to teach-back questions related to information presented on the Discharge Patient Education Tool and to determine the accuracy of patient understanding and recall. At Crawford Long, a research assistant visited with study participants and used the Discharge Knowledge Assessment Tool to assess patient understanding of discharge instructions; patients were permitted to refer to the Discharge Patient Education Tool during this teach-back process.
• Medication reconciliation forms: A medication reconciliation form is completed at patient admission, listing all medications used before admission (including pills, patches, inhalers, eye drops, over-the-counter medications, and supplements). A discharge medication form lists the prescription and nonprescription medications to be taken after discharge, along with reasons for taking the medication and prescribed doses. During the pilot test at Crawford Long, a pharmacist completed these forms and reviewed the discharge form with patients before discharge.

References/Related Articles

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Results

• Better understanding of diagnoses, testing, and treatment: Very few program participants failed to understand their diagnoses, compared with roughly one in five of those in the control group. Program participants were twice as likely as those in the control group to understand the tests they received in the hospital, and 50 percent more likely to understand the treatment received.
• Improved knowledge of followup care: Nearly all program participants knew the dates and times of their required followup appointments, compared with less than 20 percent of those in the control group.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Establishing an organizational framework for quality improvement: Several initial steps are required, including obtaining support from institutional leadership; establishing a team that includes stakeholders from various disciplines; and establishing team rules, general goals, and specific quantifiable improvement aims to be achieved by delineated dates.
• Estimating financial costs and benefits: Estimates of the program's financial impact (based on factors such as payer mix, occupancy rate, and others) and the resources required should be developed.
• Analyzing the existing process: The project team should analyze the existing education process used at discharge and identify key areas for improvement. Important areas for consideration include tools used to assess patient/family preparedness for discharge; the medication reconciliation process, including how polypharmacy issues are addressed; patient handoff, including processes and tools for communicating with physicians and with subsequent care sites; and evaluation methods for assessing the quality of the current discharge process.
• Implementing a new process: The team should design a new process that incorporates relevant Patient Safe-D and Project BOOST resources, including (but not limited to) a tool to evaluate a patient’s risk of readmission, an assessment of patient preparedness for discharge, the Discharge Patient Education Tool, medication reconciliation tools, and tools to facilitate and confirm communication with providers at the next site of care.
• Evaluating the new process: The team should collect, analyze, and present data showing the impact of the new discharge process. Outcomes evaluated might include length of stay, 30-day rehospitalization rates, and patient satisfaction. Process measures might include patient/caregiver understanding of treatments, followup care required, and warning signs and response.
• Ongoing refinement: Based on findings from the evaluation, the team should continue to improve the discharge process by examining whether the needs of all patients are being addressed, whether hospital staff have embraced the new process, and/or whether further simplification is possible.

Resources Used and Skills Needed

• Staffing: The project can be implemented with existing discharge planning or nursing staff who can incorporate the Discharge Patient Education Tool and other discharge planning tools into their daily activities.
• Costs: Patient Safe-D tools are available free of charge through Project BOOST (see Tools and Other Resources section below) and can be implemented with minimal funds, using existing staff resources.

Funding Sources

Tools and Other Resources

• The Discharge Patient Education Tool (DPET). Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Tools&Template=/CM/ContentDisplay.cfm&ContentID=12941.
• The Discharge Knowledge Assessment Tool (DKAT). Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Tools&Template=/CM/ContentDisplay.cfm&ContentID=12942.

• Medication reconciliation at admission. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Tools&Template=/CM/ContentDisplay.cfm&ContentID=12943.
• Medication reconciliation at discharge. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Tools&Template=/CM/ContentDisplay.cfm&ContentID=12944.

Getting Started with This Innovation

• Obtain senior administrator support: To win administrator support, share data on the program's potential to reduce readmissions and improve physician and patient satisfaction. A direct line of communication to a senior administrative “champion” can be very helpful.
• Consider financial implications: For many institutions, current payment mechanisms do not create a financial incentive to support activities that reduce rehospitalizations. As a result, the potential financial impact of better discharge education should be estimated.
• Create a multidisciplinary project team: The discharge process involves a number of different disciplines. The project team should include representatives from the medical staff, nursing, pharmacy, discharge staff, care management, and social work. Former patients can also be valuable team members.
• Learn quality improvement techniques: Understanding the principles, strategies, and tools for quality improvement is critical before the success of any program to improve discharge education. Institutions often have quality improvement officers that can assist teams in designing processes.
• Set appropriate project goals: Goals should be "SMART" (specific, measurable, achievable, realistic, and time-defined).
• Use a process flow mapping tool: Formally mapping the discharge process will ensure that team members have a good understanding of the current discharge process and opportunities for improvement.
• Expect and prepare for more patient questions: Engaging patients in the discharge process will likely encourage them to ask questions or request more information (in fact, clinicians should invite patients to do so). Answering these questions will add some time to the discharge process, but the time will be well spent, as it will enhance patients' understanding of their condition, treatment, and required followup care.

Sustaining This Innovation

• Continue to monitor and refine the discharge process: Ongoing, regularly scheduled assessments of the process are necessary to ensure that improvements are sustained.

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