Topic: Patient-centered Care at Discharge
The transition period from hospital to home is vulnerable and has often been referred to as “post-hospital syndrome”.1 Apart from the physiological stressors, patients are frequently overwhelmed by the changes caused by an acute hospitalization event. Safe transition from hospital to the home entails provision of multiple care processes2 – scheduling follow-up appointments and providing written and oral instructions for medication management, wound care, nutrition counselling, etc. The quality of discharge is measured by some of the aforementioned processes, which in turn influences outcomes such as adverse drug events, readmissions, and patient satisfaction.2-4
As the chief surgeon of the hospital, a recent patient letter expressing dissatisfaction with the discharge instructions has triggered a quality problem. Patients discharged to the community without home health services are inadequately prepared for self-care after hospital discharge. Hence, this patient population is at a higher risk for poor outcomes.5
Patient’s lack of readiness for self-care post hospital discharge can be assessed using the classic Donabedian framework6 (see Appendix 1). Contextual and structural elements of a hospital underpins a safe hospital discharge; some structural elements of this quality issue7 can be evaluated by – 1) Assessing whether the electronic medical record (EMR) generates a patient-centered discharge summary; 2) Identifying key staff member(s) in every team that coordinate the discharge process and/or are responsible for providing specific instructions to the patient at discharge; 3) Presence of standard operating procedures for patients discharged on self-care; 4) Patient’s disease burden, socioeconomic status, and health literacy.
The specific tasks and processes8 related to safe transitions directly impact readiness for discharge and can be evaluated by measuring – 1) Number of patients who received a complete discharge summary; 2) Number of patients who received medication counseling on the day of hospital discharge; 3) Number of patients who received a follow-up phone call after hospital discharge; 4) Number of patients who had a follow-up appointment scheduled prior to discharge; 5) Patient satisfaction with the discharge information.
Finally, post discharge, the lack of readiness for self-care is associated with several health outcomes, such as – adverse drug events, unplanned health care utilization like emergency room visits and preventable readmissions, medication adherence, mortality, and overall patient satisfaction.9
In the last decade, although patient’s discharge readiness has been the focus of quality improvement, not all measures are practical to assess our specific quality problem (see Appendix 2). For instance, the “Heart Failure (HF): Detailed Discharge Instructions” measure assesses whether or not detailed self-care written instructions were measured in hospitalized HF patients. Alternatively, the “CAC-3 Home Management Plan of Care Document” measure targets pediatric asthma patients.10 Data for both these measures can easily be collected by the EMR; however, both these measures only quantify the receipt of a complete discharge document and focus on specific populations. Additionally, these measures are not endorsed by the National Quality Forum (NQF).10 B-PREPARED11 is a 11-item patient perceptions survey about discharge readiness for all adult hospitalized patients. It has robust construct validity and predicts healthcare utilization; that said, although it has been used in several projects, it does not have an endorsement from the NQF, notwithstanding higher response burden.12 The “3-Item Care Transition Measure (CTM-3)13 is a validated and NQF endorsed measure that quantifies patient’s perspective on the quality of discharge preparedness and is currently publicly reported.
After deploying the Donabedian Framework, patient’s discharge readiness is best measured by using a process/intermediate outcome measures as it comprehensively measures the quality problem and does so in a timely manner. Structure measures only identify the presence or absence of resources, which, although necessary, may not comprehensively assess the specific elements of a safe and effective discharge. Several structural, provider, and patient level factors are associated with outcome measures such as adverse events, readmissions, emergency room visits, and overall satisfaction with care. Risk-adjustment for these factors will be essential to establish a meaningful association with outcomes.14 Despite being important indicators, aforementioned outcomes may not accurately measure the patient satisfaction with the discharge process.
Description of Assessment
Based on the review of existing measures, I will employ CTM-3 to measure discharge readiness in adults (18 years and above) discharging to community without any home health services. The CTM-3 is a shorter version of the 15-item version and these questions are highly correlated with those scores. Each of the three questions measure the quality of the discharge instructions from the patient’s perspective. The three questions are – i) The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital ii) When I left the hospital, I had a good understanding of the things I was responsible for in managing my health iii) When I left the hospital, I clearly understood the purpose for taking each of my medications.15Respondents select one response on a Likert scale from “Strongly Disagree” to “Strongly Agree”. The numerator for this hospital level measure is the sum of CTM-3 scores for all eligible patients and denominator is the number of eligible sampled hospitalized patients discharged to the community.15
The CTM-3 measure is suitable to measure this quality issue for many reasons15 – it has a low response burden and targets the process and quality of discharge prom the patient perspective, instead of the mere completion of the task (i.e., patient-centered). Secondly, this measure does not necessitate risk adjustment since good quality of discharge is applicable to all types of patients irrespective of their co-morbidities, socioeconomic status or health literacy.15 Thirdly, the items predict unplanned healthcare utilization13. As mentioned in the previous section, it is endorsed by the National Quality Forum (NQF)10 and is also part of the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.16 Lastly, it is also available and validated in other languages, can be administered to diverse racial populations.15
The CTM-3 scores will be evaluated internally at the team/unit level in order to establish internal benchmarks. Additionally, these data will also be reviewed in subset of populations to ascertain the lack of patient-centered discharge services in specific high risk populations. The variation in scores by team/unit and disease will allow us to examine the differences in care processes within the hospital. However, the CTM-3 data should also be assessed at the overall hospital level as this will allow the hospital to establish a baseline and use it for external benchmarking.
Even though the measures will be assessed at the unit/team level for internal benchmarking, the overall hospital level scores will be compared with national standardssince the CTM-3 score is part of the HCAHPS survey16 Additionally, these data are now part of the public reporting platform and will allow for inter-hospital comparison, nationally.16
Description of the Data Source
The CTM-3 is a patient self-report measure. Keeping patient-centered care in mind, it focuses on the quality of the process and not whether or not the task was done. Unfortunately, this data cannot be identified from any other source but as a second option it can be incorporated as part of the routine discharge or follow-up documentation in the EMR. This method will ease the data collection and analysis process and provide data for all hospitalized adults but will require changes to the EMR and may initially incur additional costs.
A computer generated simple random sample of patients stratified by unit/team should be targeted for this survey with aim of completing at least 300.15 Patients might be less likely to respond to survey questions depending on the mode of administration and therefore the preferred mode of administration can be identified at the time of discharge (phone, email or mail). It is also possible that the days since discharge and therefore patient’s recovery affect the responses. For instance, if CTM-3 is administered the day after discharge, patients may not be able to assess discharge readiness accurately since they have had not have some time to care for themselves. Alternatively, if administered closer to 30 days after discharge they may not accurately recall their discharge experience and how they felt about discharge readiness.
Therefore, for the purposes of this assessment, CTM-3 will be administered within 10 days of discharge (original measure can be assessed until 30 days).
Quality of care transitions significantly impacts the hospital, individual providers, and patients. In order to make any hospital-wide change or change existing standard operating procedures it is important to solicit buy-in from the senior leadership.17 Results of this assessment should also be disseminated to hospital providers participating in the discharge process. Since these providers are at the frontline providing care and their compensation may be tied to quality of care, their perspective will be key to identify potential gaps in existing workflow(s).18 Lastly, one could share this information with a random subset of patients with poor and high CTM-3 scores. Patient engagement has been identified as a key component of a “learning health system”.19,20
Currently, CTM-3 measures are publicly reported with hospitals being penalized for any excess 30-day readmissions for several clinical conditions (e.g., acute myocardial infarction, heart failure, pneumonia, and hip/knee replacement).21 Consequently, for the management audience, CTM-3 scores and the corresponding readmission rates for the hospital can be compared with competitors. Individual inpatient providers might be interested in CTM-3 scores for patients who were cared for by their team and/or by disease type. For patients, CTM-3 data can be shared as part of patient engagement activities in focus groups settings to gain insights on what processes led to their eventual satisfaction or dissatisfaction.
Conclusion from the initial quality assessment
The raw scores for each of the three CTM-3 questions range from 1 (Disagree) to 4 (Strongly Agree). Subsequently, the mean raw CTM-3 scores (Sum/Total Number of valid responses) are converted to a 0 – 100 score using linear transformation.15 Based on the initial quality assessment, CTM-3 score for the overall hospital was 75 with the lowest and highest scoring unit having a score of 70 and 80, respectively.
Quality improvement goal(s)
The overall quality improvement goal is to ensure that all hospitalized adult patients discharged with home health services feel adequately prepared to care for themselves at home, as measured by an improvement in CTM-3 scores. There is sparse information on what constitutes a meaningful change in the CTM-3 scores; however, the measure steward recommends that a minimum increase of 5 to 7 points would be considered clinically significant.22 Therefore, the overall goal will be met when there is an increase in CTM-3 scores by at least 7 points for the overall hospital (i.e., ≥ 82) and each unit (compared to the baseline scores), one year after intervention implementation in all units.
Potential ways to meet this goal
Most interventions that focus on improving patient preparedness after hospital discharge focus on reducing hospital readmissions. Several interventions related to care transitions have been tested – prior to discharge: patient education, discharge planning, medication reconciliation, and scheduling appointments; during discharge: use of transition coach, and discharge instructions; after discharge: follow-up phone calls, provider follow-up, and home visit.23 Depending on the use and type of one or more components, studies have shown to be effective in reducing readmissions and patient satisfaction with varying results.
“Project BOOST” is an intervention where the clinical team conducts thorough risk assessments and uses teach-back methods to provide targeted interventions and generate patient-centered transition records.24 The “Care Transitions Intervention” consists of a designated transition coach to guide patients or caregivers through the transition process, focusing on medication self-management, use of health record, provider follow-up, and skills to identify and manage expected symptoms.25 On the contrary, the “Transforming care at the Bedside” intervention developed for heart failure patients begins at hospital admission to identify patient needs early on and use that information to reconcile medication and plan services at discharge.26 Finally, “Project RED” (Re-Engineered Discharge)27 has 12 specific and related components delivered through a discharge educator (DE).28
Selection of a quality improvement intervention
While there are many evidence-based interventions to choose from, Project RED is suitable to improve the discharge process for various reasons. The tools and approach is specifically designed to ensure that patients understand how to care for themselves after discharge. This approach has not only been shown to improve patient satisfaction, but also reduce unplanned health care utilization. Moreover, the intervention design was sponsored by Agency of Healthcare Research and Quality (AHRQ) and is also endorsed by National Quality Forum, Institute for Healthcare Improvement, The Leapfrog Group, and Centers for Medicaid and Medicare Services (CMS).27-29
RED has 12 components – assess the need and provide language translation when required, schedule and organize follow-up appointments, labs and outpatient services/equipment, perform medication reconciliation, reconcile discharge plan, provider a patient-centered written plan or after-hospital care plan (AHCP), educate patient about their condition and steps to take in case of a problem, assess patient’s understanding of the plan, forward the plan to outpatient providers and lastly conduct a follow-up phone call to reiterate and answer any questions.
Design of the quality improvement intervention
Before commencing the improvement intervention, there will be a six-month preparation phase, wherein an “executive sponsor” will be appointed to lead the vision for improving the discharge process. He/she will subsequently identify a project leader and multidisciplinary implementation team consisting of quality consultants, physicians, nurses, pharmacists, case managers, social workers, information technology (IT) specialists, interpreter services etc.,.28 This team will be responsible for creating training materials, monitoring the progress, and overseeing the operations of Project RED in all units. Prior to implementing RED, the IT department will re-design the current discharge documentation to align with RED’s AHCP, with the expectation that it will be modified as implementation is rolled out.
To incorporate RED components across the hospital, it is important to make small iterative changes, unit by unit, to ensure overall sustainability. A series of Plan-Do-Study-Act (PDSA) cycle(s)30 will be utilized to implement RED and will start with the lowest performing unit. The primary implementation team will identify a “change champion” for their unit’s pilot test, and familiarize themselves with the materials and toolkits. Each unit will go through the following PDSA cycle for one month:
Plan – For the first 3 days, the change champion along with the unit staff will map the current discharge process in their unit including the people conducting each task (Appendix 3). Subsequently, existing tasks will be mapped to each RED component and the team will identify “process owners”. These process owners could be one or more individuals, contingent on existing staffing and workflow. There are several implementation measures to monitor each component; however, along with the CTM-3 scores for each patient receiving RED, we will select the following implementation measures as they directly impact the processes measured by CTM-3 – 1) number of patients who discharge with an AHCP, 2) number of patients who received education about their discharge plan, 3) number of patients who confirmed understanding of their discharge plan and 4) number of people who received a post discharge phone call within three days.28
Do – From the fourth day to the twenty-fifth day, the DE(s) will perform the intervention and IT will give access to complete and print the AHCP feature in the electronic medical record. During this phase, the change champion and project leaders will observe the new processes, recording issues and deviations.
Study – The last five days of this cycle will involve assessment and analysis of the data that was collected during the previous phase. As described in the comparison section, difference in pre and post CTM-3 scores will be compared with a control group to assess if the intervention is having a clinically significant impact on the CTM-3 scores. Additionally, we will utilize the implementation measures to identify if the components were successfully delivered or not.
Act – Once the data is analyzed, the “process owners” and “change champion” will review the data and make necessary modifications such as changing the job responsibilities or the work-flow to avoid pitfalls. Additionally, the results will be shared with the primary implementation team who will then make tweaks to their existing plans. Subsequently the project leader will sign-off on the second PDSA cycle in the same unit and new PDSA cycle in the next unit.
Engaging leadership and providers in the intervention
While the actual intervention is conducted by the frontline staff, engaging the leadership is important to make any transformative change as they set the tone and culture for the hospital. The leadership can be informed about the intervention and its effectiveness through presentations describing case examples. Once there is buy-in from the leadership, the intervention goals, vision and plans will be introduced to the providers through hospital grand rounds. Such gatherings can be utilized to identify prospective project leaders and implementation team members.31 Additionally, engaging well-respected peers will avoid the sense of imposing an intervention and would rather foster collective ownership. Lastly, throughout the PDSA cycles, results will be available via a dashboard in order to encourage healthy competition as well as provide data for feedback at the unit or individual level.
Potential Barriers and Facilitators
As identified by a recent study, some of the barriers that may hinder successful implementation are lack of buy-in and poor vision from the leadership, the need for modifications to existing electronic medical record systems, unavailability of a multidisciplinary implementation team in all units, and negative attitude amongst the staff or clinician autonomy.32,33 Specifically, the lack of trust in the intervention negatively impacts the time and effort contributed by each team member thereby influencing fidelity of the intervention.
Despite some challenges, there are several facilitators and improvements that go beyond remedying patient preparedness for self-care. Patient-centered care transitions achieved through the Project RED intervention result in better communication within teams and with external stakeholders. Engaging with patients in the context of providing transitional care allows the hospital to gain insights on how to adapt or redesign other services both at an individual provider level and at health system level.34 Leadership and management buy-in may potentially be easier to obtain for RED than other interventions as it has shown to significantly reduce readmissions, has a good return on investment, enhances the hospital brand and image and also comply with national guidelines as previously mentioned.28
Selection of reassessment measure
The mean CTM-3 scores after the intervention improved by 10 points for the overall hospital (largest increase for a unit being 11 and the smallest increase being 4). These results conform to the results reported by other studies in the literature.22,35-37 Interventions with some or more components similar to RED that target care transitions have shown a varied improvements in CTM-3 scores (increase in 2 -14 points). For instance, a 3-day post-discharge phone call showed a difference of approximately 2 points22 and a “geriatric floating transition team” resulted in a 3 point difference37 between intervention and control groups. In another study, discharge planner in a internal medicine unit resulted in a 14 point increase in CTM-3 scores.36
In order to evaluate the overall success of the intervention, CTM-3 scores will be compared for the overall hospital and each unit before and one-year after implementation. Additionally, difference in difference (DID) analysis38 will be utilized throughout the interim phase to compare CTM-3 scores in a particular intervention unit and a control unit (where the PDSA cycle has not occurred). The DID method for interim analyses will allow us to immediately evaluate the causality of the intervention to improve the discharge process. Additionally, it will control for Hawthorne effects as it is possible that awareness of this quality problem might lead to change in discharge processes in other units who have yet not received the intervention. Lastly, DID circumvents the hazard of regression to the mean, especially if we initiate the intervention in the lowest performing unit.38
Evidence of effectiveness of intervention
Patient satisfaction and preparedness for discharge were secondary outcomes in the original randomized controlled trial of Project RED. Patient perceptions of care often don’t correlate with provision of services39 but in case of this intervention the mutually reinforcing strategies27 had a significant impact on both the process and outcome of hospital discharge. Intervention group participants were more likely to visit their primary care providers, understood their primary problem, how to take their medicines and overall felt more prepared than the control group. All these results were statistically significant.27
Unintended consequences or cost-effectiveness of the intervention
The AHRQ toolkit mentions that the roles and responsibilities of the discharge educator or advocate can be fulfilled by existing staff member (s).28 Although this may be cost-effective, it may lead to dissatisfaction amongst staff members due to their increased job duties or redundancies in the tasks.27 Additionally, there is some evidence that lack of a dedicated staff member can have muted effects of the intervention.40 While it may not be feasible to hire new staff initially, the leadership could consider it in the future as adherence to the original protocol has been shown to have a good return on investment – reduction in cost per patient (~$400), billing for additional services, improve patient retention and continuity of care and also prepare the hospital to comply with CMS value-based care initiatives and reimbursement programs.27
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20. Kelley M, James C, Alessi Kraft S, et al. Patient perspectives on the learning health system: The importance of trust and shared decision making. The American Journal of Bioethics. 2015;15(9):4-17.
21. Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed September 27, 2018.
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29. Enderlin CA, McLeskey N, Rooker JL, et al. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatr Nurs. 2013;34(1):47-52. doi: S0197-4572(12)00278-9 [pii].
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34. Scott AM, Li J, Oyewole-Eletu S, et al. Understanding facilitators and barriers to care transitions: Insights from project ACHIEVE site visits. The Joint Commission Journal on Quality and Patient Safety. 2017;43(9):433-447.
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Appendix 1: Assessing Patient’s Readiness for Discharge from Hospital using the Donabedian Framework
Appendix 2: Comparison of measures to assess patient preparedness for discharge*
|B-PREPARED||CTM-3||Heart Failure (HF): Detailed Discharge Instructions||CAC-3 Home Management Plan of Care (HMPC) Document Given to Patient|
|Population||All hospitalized patients (18 years and above)||All hospitalized patients (18 years and above)||Adult Heart failure patients (18 years and above)||Pediatric Asthma inpatients (2 – 18 years)|
|Data Source||Patient Survey||Patient Survey||Electronic/Paper Medical Record||Electronic/Paper
*Adapted from the National Quality Forum website
Appendix 3: Project RED Unit Worksheet (Mock Example with selected RED Components)
Name of Unit: Orthopedic
Change Champion: XYZ (Charge Nurse)
Date: October 1st, 2018
|RED Component||Person Responsible
PDSA Cycle 1
|Ascertain need for language services||XYZ (Social Worker)||XYZ (Social Worker)|
|Make Appointments for follow-up care||None||XYZ (Case Manager)|
|Identify correct medicines and plan for||Depends on availability:
XYZ (Resident) ?
XYZ (Pharmacist) ?
XYZ (Attending) ?
|Teach AHCP||None||XYZ (Discharge Nurse)|
|Patient education about diagnosis||Depends on availability:
XYZ (Resident) ?
XYZ (Attending Physician) ?
|XYZ (Attending Physician)|
|Conduct Follow-up phone call||None||XYX (Pharmacist)|
*Adapted from AHRQ RED Toolkit (Table 1)28