MI system leads in effort to improve transitions

Hospitals will be hearing a great deal more about care transitions and reducing readmissions in coming years. Discharge planners and hospitalist leaders will be searching for models that are affordable, effective, and sustainable.

The University of Michigan Health System in Ann Arbor is involved in a collaborative care transition project that builds on its use of Project BOOST (Better Outcomes for Older adults through Safe Transitions) tools and strategies.

Hospitals and leaders involved in discharge planning should keep in mind that medical staff and DP staff try their best to provide high-quality care to patients, but the nature of their schedules can make communication among providers challenging, says Christopher Kim, MD, MBA, an assistant professor of internal medicine in pediatrics and an assistant medical director for the faculty group practice at the University of Michigan Health System in Ann Arbor. Kim, who is closely involved in the care transition project, also is an assistant chief of staff for the office of clinical affairs at the health system.

"We collaborate to ensure each patient's hospital stay is the best it can be, but when it's time for patients to leave, the process could be improved," Kim says. "This is one of the quality improvement needs that Project BOOST has helped us recognize."

Patient care transitions require input from all disciplines, including hospitalists, floor nurses, discharge planning nurses, social workers, therapists, and primary care physicians, he notes.

"But often, we're not working purposely together; we're working at our own pace and direction," Kim says. "BOOST helps us focus our efforts and energy better as we work on that particular phase of the patient's care."

Based on the health system's Project BOOST experience and its more recent involvement in the Michigan provider-insurer care transition initiative, Kim offers these suggestions for how hospitals can improve their discharge planning communication and process:

• Use a risk assessment tool to identify at-risk patients:Hospitals could develop their own risk assessment tool or select one that has been used successfully by other facilities.

Kim recommends they check out Project BOOST's 7P screening tool (available for download at www.hospitalmedicine.org).

The two-page checklist covers these seven main risk assessment areas:

— problem medications;

— punk (depression);

— principal diagnosis;

— polypharmacy;

— poor health literacy;

— patient support;

— prior hospitalization.

"These are pretty broad categories," Kim notes. "But what using the tool has helped us recognize in our own patient population is that most of our patients actually have one or more of these problems when we screen them."

• Create interventions based on findings from screening tool: "The next step is how do we engage the hospital's health care staff to address those aspects of the patient's risks?" Kim says.

The BOOST 7P screening tool includes recommended interventions under each of the risk areas. For example, the problem medications section has these checkboxes:

— medication-specific education using teach-back provided to patient and caregiver;

— monitoring plan developed and communicated to patient and aftercare providers where relevant (e.g. warfarin, digoxin, and insulin);

— specific strategies for managing adverse drug events reviewed with patient/caregiver;

— follow-up phone call at 72 hours to assess adherence and complications.

The screening tool's second page includes a nine-point universal patient discharge checklist, plus five considerations for increased risk patients.

"This tool helps us to ensure the patient's transition and needs have been addressed by somebody," Kim says. "It includes a look at the patient's social needs prior to going home and medication reconciliation."

The additional considerations list such items as having direct communication with the principal care provider before discharge and having phone contact with the patient or caregiver within 72 hours post-discharge to assess the patient's condition, discharge plan comprehension, adherence, and to reinforce follow-up.

"In the past, we've probably recognized that the patient had one or more risk factors or needs, but how we intervened was a siloed process," Kim says. "Now, we want patients actively monitored from the get-go, and we'll have the entire team involved in the discharge process."

• Focus on education and using teach-back method:Hospital discharge planning should continually assess and improve patient education strategies.

Kim recommends using the teach-back method, which also is promoted in BOOST materials.

The teach-back concept encourages patients to actively participate and become engaged in their medication and medical condition, Kim notes.

A first step is to explain how the patient's medications have changed and listing prescriptions that are added or deleted. Then the discharge planner will reinforce what the patient already knows about existing prescriptions.

The teach-back part is when the discharge planner asks patients to acknowledge their understanding with a question such as: "We'd like to be sure we did a good job of explaining this to you. Would you mind repeating back to me what I just explained to you about your condition or medication?"

• Think outside the hospital care box when addressing patients' transition issues:The BOOST 7P screening tool includes a general assessment of preparedness (GAP) section that lists logistical issues and psychosocial issues that generally fall outside the purview of hospital medicine.

"We use the risk assessment to collect more information about patients' needs, perhaps to pick up on something we've overlooked," Kim says. "Perhaps we could have made more of an effort to speak with the patient and caregivers at home, or we could have ensured a better handoff to the primary care physician."

The screening tool's logistic issues include assessing whether the home has been prepared for the patient's arrival and whether the patient will have transportation to the initial follow-up visit. Under psychosocial issues, the tool has providers assess whether the patient's substance abuse/dependence has been evaluated and whether a support circle for the patient has been identified.

Another example of thinking outside the box involves having hospital transition planning include consideration of palliative services.

"Patients who are hospitalized multiple times for chronic diseases sometimes are deemed terminal, but they might not have the opportunity to discuss the option of consulting with a palliative care specialist," Kim explains. "Palliative care is a specialty area that could be very helpful to the patient and patient's family."

If hospital discharge providers identify patients who have had repeated hospitalizations within a six-month period, and their chronic disease status appears to be worsening, they might suggest the patient and family speak with a palliative care specialist, he adds.

Some hospitals will make a palliative care consultation an automatic referral when such patients are identified.

• Stress collaboration:"A critical piece is how we can all work together to improve the transition phase of patient care," Kim says.

It's no longer useful for each discipline to do their part alone.

"This is why we've initiated discharge or transition care rounds where we gather together all of these disciplines," Kim says.