Final Presentation

30-Day Readmission Study

VCUHS
IRB: HM13507

Vista Consulting
MEd Adult Learning Students - Spring 2011
A. Hord, E. Howard, L. Hudson, P. McFarline, M. McGregor,
L. Morgan, S. McMinn, J. West, E. Yoo
ADLT 636 Capstone Project
Virginia Commonwealth University
May 13, 2011 1
 Today’s Presentation

• Introduction
• Research Question
• Methodology
• Findings and Implications
• Recommendations
• Future Research
• Comments and Questions
2
 Research Question

What are the barriers to

successful care transitions
from the hospital to the
outpatient setting?

3
 Grounded Theory Approach
(Creswell, 1998, Lincoln & Guba, 1985)

• Naturalistic inquiry examining lived

experiences
• Exploratory study of perspectives and
meanings people attribute to their
experiences
• developing themes and categories
inductively
• generating working hypotheses or
claims from the data
• analyzing narratives of participants'
experiences
4
 Participant Selection

• Participants selected through

purposeful and theoretical sampling
• VCUHS - N9 & CCH3 patients &
providers
• Thirty-three patients and thirty-one
providers participated in the study

5
 Data Collection

Patient Interviews
• 100+ interviews attempted
• 33 interviews conducted
• Single face-to-face interview
• One interviewer + one notetaker
• Interview recorded by hand notes
• Debrief with interviewer and notetaker
followed each interview
6
 Data Collection
Provider Focus Groups
•9 focus groups, 31 participants
•Nurses, resident physicians, hospitalists,
clinical pharmacists, & social workers
•1-2 facilitators and 2 notetakers
•Semi-structured interview with facilitator
guide
•Notes recorded by hand or using a
computer to type notes
•Debrief following each group
7
Interview Questions - Patients

First stage
•What’s the biggest problem that you have
with staying well so that you don’t need to
come back to the hospital?

Second Stage (after mid-point meeting)

•How much control do you feel you have
over managing your health? What do you
feel you can do to manage your disease?

8
Interview Questions - Providers

First stage
•What do you see and experience as the
biggest impediments to a patient’s
successful transition from the hospital to
home?
Second Stage (after mid-point meeting)
•How do you integrate various provider team
members into discharge planning?

9
Focus Group Participants

Provider Group Participants

Clinical Pharmacists 4
Resident Physicians 5
Hospitalists 3
Nursing participants 15
Social Workers 4

Total Providers 31
 Confidentiality
A Critical Consideration

• Did not record patient's name or

identifying information with data
• Speaker numbers used in provider
focus groups, no names recorded
with data
• All data de-identified

11
 Data Analysis
(Creswell, 1998)

• Patients: purposeful sampling

• Providers: purposeful & theoretical
sampling
• Analysis:
• Immersion in the data
• Open coding
• Emerging themes
• Sort into sub categories
• Key findings
12
 Trustworthiness and Rigor
(Creswell, 1998)

• Debriefing following interviews and

focus groups
• Field notes
• Paired coding
• Weekly whole team debrief &
discussion
• Checking for self-bias
• Thick, rich, and vivid descriptions
from participants’ stories
13
Quotes from Patients &
Providers

Digital Story

(photos used in story are

generic, public photos from the
worldwide web, not of any VCUHS
patients or providers)

14
 Society

Local Community

Patient System

Provider
 Findings

Themes
1.Patient learning and behavior change
2.Communication processes
3.Transition from hospital to community
4.Hospital systems, structures and
processes

16
 Findings – Theme 1

Patient Education

•Low education, low health literacy

•Heightened, pervasive life stressors
•Life circumstances, lifestyle choices
•Delivery of patient education

17
 A patient says,
“It was a strepto, strepto something, …
a great big word almost like the sound
of strep throat but the doctor said it
didn't have anything to do with strep
throat.”

A provider says,
“We are guilty of using big words.”

18
 A patient says,
“I have a lot of mental stress - life itself,
employment, health...I'm lucky that I don't
have to work, but I want to. The economic
times are hard. It's a strain, economy,
life...”

A provider says,
“You can counsel someone, but if there
are other stressors at home the patients
will not understand that stopping smoking
would be the best thing.”
19
 A patient says,
“...Even if they [providers] did [tell me
things], I wouldn't know. That’s why I
came to the hospital.”

A provider says,
“Lifestyle issues may contribute to
readmission...like smoking and cocaine.
[Patients have] skewed priorities.”

20
 A provider says,
“We need to have the patient act, as well,
for behavior change that needs to
happen. The hardest part is to change
your behavior and it is hard for the patient
to change.”

A provider says,
“To get people to buy in and make those
changes we need to help them
understand …But we don’t have the time
in the hospital to help the patient and
help them understand.”
21
 A patient’s son tells us,
“I feel bad for people who don't have a
translator [for the health and medical
jargon]. If you don't have someone with
you, you're screwed.”

A provider says,
“I would like to go over the medicine with
them and have them tell me how they
should take the medicine. I would like to
have the time to do this all the time [with
the patient], but I don’t.”
22
 Findings – Theme 1

Behavior Change

•Competing demands
•Other Influences (peers, family)
•Lack of support and resources

23
 A patient says,
“My biggest barrier is not
knowing how to put [myself] first.”

A patient says his barriers to staying well are,

“food, exercise, and taking medicine. When
somebody or my parents distract me, I can’t
do the things in the right way.”

24
 A patient says,
“[I was] doing stuff to take care of myself.
Then I started hanging out with addicts,
getting high. I was affected by peer
pressure and my health fell down.”

A patient says,
“...He's [the doctor] gonna get me one of
those pill boxes and I think that'll help. I've
seen my ex-wife use the pillboxes, she has
17-20… medicines but she never misses
or run out of the medicine.”
25
 A patient says,
“Thank God I have these children.”

A provider says what makes

a difference is,
“People with family – who have support to
help them, to encourage them [to take
meds]. Patients who don’t feel that support
won’t try so hard. [Without support] it's
harder to find a reason [to do the right
thing to manage disease].”
26
 Findings

Theme 2 – Communication Processes

•Inter-team and intra-team coordination

•Team member relationships

27
 A provider says,
“Try to get social workers and care-
coordinators more involved…It would be
nice if [social workers] were more involved
earlier on in the process instead of waiting
until the patient is getting ready for
discharge, or actually is home.”

A social worker says,

“MSW does not mean Medical Social
Worker! It means Masters of Social Work.
We are highly skilled and highly trained
individuals.”
28
 A nurse says,
“Docs need to communicate with me! Use
my leash!” (holding up phone)

A provider says,
[The discharge process] is such
CHAOS!...it is all contradictory and trying
to be done at the last minute too quickly,
because we [nurses] find out at the last
second when discharge is going to
happen.”
29
 A provider says,
“[Nurses] end up doing social work,
doctor’s work… I know they all have a lot
of work. [Maybe if] roles were more clearly
defined? [Maybe if] we had more staff?”

A provider says,
“We have not found an effective way to do
rounds.”

30
 A provider says,
“Nursing staff don’t know the medicine
teams so well.”

A provider says,
“[Nurses] may have a simple question but
attendings don't want to be interrupted. So,
[nurses] don't get info needed. [Nurses]
can't just hang out for 15-20 minutes until
the lecture is over. There's stuff to do.”

31
 A provider says,
“[Social workers] don’t realize that we
(residents) don’t know the insurance stuff-
they may even look down upon you if you
don’t know this stuff.”

A provider says,
“Sometimes all is good but nursing gets
hung up on one thing and this blocks
discharge.”

32
 Findings
Theme 3 – Transition to community

•Continuity of medical care

•Reliable transportation
•Follow up
•Readiness for discharge

33
 A patient says,
“My PCP nurse has really helped me. I am
able to call her anytime, even the middle of
the night.”

A provider says,
“When I have a problematic patient with a
high likelihood of return, then I call them at
home to check on them. It helps for
reinforcing medication adherence and if
they have questions once they are home,
but I don’t always have time for that.”
34
 A provider says,
“One thing is timely follow up
appointments. If the PCP for the patient is
a resident then it is hard to get them in
within two weeks. If they had a clinic; a
“catch all clinic” for the in-between times
that would be good.”

A provider says,
“We, as doctors, aren’t cognizant of these
issues [prior authorization requirements,
medication cost]”
35
 A provider says,
“Transportation can be a huge issue.  We
give them a bus ticket.  We’re good at
getting them home.  But how to get them
back here [for meds and follow up
treatment] is the question.”

A patient says,
“Before my legs were a problem I could
walk to Rose's, Food Lion or McDonald's.
Now I can’t . It's gonna be a problem...I
have people I can call but I don’t want to
inconvenience people.”
36
 A provider says,
“Often they just don’t understand that they
are ready to leave now, and that they will
be okay. If they leave, so they go home,
then they come back.”

A patient says,
“I told them when they sent me home I
wasn’t feeling right, I just didn’t feel well. I
went home but a few days later I fell.  My
friend found me passed out at home and I
was readmitted-I was unconscious for
three days. ” 37
 Findings
Theme 4 – Health system structure and
processes

•Discharge planning
•Discharge paperwork
•Medication reconciliation
•Medicine team structure

38
 A provider says,
“It would help if we could make the
discharge summary given to the patient
clearer-it is not user friendly.”

A provider says,
“Our discharge summary is a mess... At
the point in the day when discharge is
being coordinated, the patients are in a
hurry [to leave] and it's difficult to reconcile
errors [or] confusion in discharge orders.”

39
 A provider says,
“A lot of the times when patients are
readmitted….I don’t go by what’s in the
system [as to the meds the patient is
taking], [instead] I ask them what they
have with them…this tells my faith in the
medical [record] system.”

A provider says,
“this stupid DIF is very confusing…there is
no one standardized way of completing it.”
40
 A provider says,
“No accountability. No one wants to own
[medication reconciliation]. It doesn’t hurt
enough for anyone to take ownership.”

A provider says,
“Med rec list is NEVER right!”

A provider says,
“Whole ‘nother problem is that med rec is
just not easy in the system”
41
 A provider referring to supervision of
interns making discharge decisions:
“there are certain days when residents
aren’t present, more likely things get
missed on these days…things are missed.”

A provider says,
“The patient doesn’t know who is who
[providers coming into room]. Thus, patient
doesn’t listen to anyone who doesn’t have
a white coat on.”

42
 A provider says,
“I think it’s more about what [attendings
and residents] need to do as opposed to
taking the time, interest, and commitment
to look at patient individually and what’s
best for them”

A provider says,
“The frequency and staggered nature of
the attending rotation is not helping…it’s a
mess [right now.]”
43
 Implications

Theme 1: Patient Learning and

Behavior Change
• How can patients be made more central
to the educational process?
• What opportunities exist for providers to
facilitate patient learning and change?
Theme 2: Communication Processes
• What about communication processes
could, should or must be improved?
44
 Implications

Theme 3: Transition to Home

•What can we do to help patients successfully
transition knowing how vulnerable they are?
•How can we strengthen a patient’s
connections to supports & resources knowing
how important they are?
Theme 4: Hospital System Structure
•What are the system, structural, and process
improvements we can make today? Tomorrow?
In the next year?
45
 Recommendations

Short-term Action Plan

1. Discharge Process and Paper Work (DIF)
•Increase communication with floor nurses
•Patient friendly DIF format
•Patient call back system
•Increase integration of social workers
•Social & community supports & resources

46
 Recommendations
2. Medication Reconciliation
•Literature review
•Pharmacists or pharmacy student’s aid
3. Communication skills and processes
•Actual & desired condition
•Develop the process and skills
•Communication training
4. Patient advocate/case manager

47
 Recommendations
Longer Term Action Opportunities
•What strategies or practices could be
implemented to improve health literacy
competency across provider teams?
•How could reflective practice opportunities
be included in process improvement &
professional development?
•How can every interaction between patient
and provider be used to create an
opportunity for change for both?
48
 Recommendations

• How can team members better

understand and respect each others’
roles and responsibilities?
• How can relationships and
communication networks be increased
with community organizations?
• How could a whole system strategic
visioning process be useful to address
current issues and future direction?
• Consider stakeholder representation
within health system and community. 49
Literature Review – an Example

Piedmont Hospital, Atlanta - readmit rates

 5% in one year for patients over 70 yrs
•Improved medication reconciliation
• Pharmacist now completes drug
reviews
•Identify high risk patients & ensure follow-
up care
•Preparing patients for what they need to
do after they leave hospital
• Single cover sheet with key info
50
 Ideas for Future Research
• Gather patient data focusing on patient
insight versus knowledge of disease state
and self-care management.
• Research/develop an assessment tool for
patient knowledge, insight, and self-
efficacy.
• Health literacy & communication self-
assessment tool for providers.
• Evaluate current medication reconciliation
process at VCUHS.
• Examine current communication channels
and relationships between community
health resources and VCUHS. 51
 Limitations

• Length of semester limited whole

project.
• Only one third of patient interviews
attempted were able to be completed.
• Limited attendance in some focus
groups.

52
Questions
&
Comments?

53