Module 2

The Re-Designed Discharge Process:

Patient Admission and
Care and Treatment Education

Accomplishments to Date
Process map of current discharge

process completed
Primary care practitioner (PCP) referral
base defined
Patient Care Plan structure finalized
Project charter initiated
Dates for training frontline staff set

Module 2 Objectives
Review discharge planning activities that

begin on admission
Develop plan for identifying targeted
patients on admission
Review Discharge Advocate (DA) initial
contact with patient
Define roles of multidisciplinary team
members in discharge planning
Confirm process for creating Patient
Care Plan

Module 2 Outline
Project RED principles and

components
Current discharge process and
suggested project metrics
Patient admission
Care and treatment education
Structure and process for
completing Patient Care Plan

Principles of the Re-Engineered

Hospital Discharge
1. Explicit delineation of roles and
responsibilities
2. Discharge process initiation upon admission
3. Patient education throughout hospitalization
4. Timely accurate information flow:
From PCP Among hospital team Back to
PCP
5. Complete patient discharge summary prior to
discharge

Principles of the Re-Engineered

Hospital Discharge
6. Comprehensive written discharge plan
provided to patient prior to discharge
7. Discharge information in patients language
and literacy level
8. Reinforcement of plan with patient after
discharge
9. Availability of case management staff outside
of limited daytime hours
10. Continuous quality improvement of discharge
processes

Discharge Planning

H&P
Rx Plan

Discharge
Order
Written

Patient
Admission

Discharge
Event
Discharge Process

PATIENT EDUCATION

DISCHARGE INSTRUCTIONS
Post-D/C
Follow-up

Admission and
Care and Treatment Education
Project Reds 11 mutually reinforcing components:
1. Medication reconciliation
2. Reconcile discharge plan with national guidelines
3. Follow-up appointments
4. Outstanding tests
5. Post-discharge services
6. Written discharge plan
7. What to do if problem arises
8. Patient education
9. Assess patient understanding
10. Discharge summary sent to PCP
11. Telephone reinforcement

Outcome Metrics for Target

Population
Average length of stay

30-day unplanned all-cause

readmission rate
Pre/post data: Patient experience
related to discharge preparation
Pre/post data: Frontline staff survey
related to discharge preparation
Pre/post data PCP survey related to
discharge preparation

Financial Metrics
The cost of second length of stay

(readmission)
Project costs
Discharge process costs (current and
redesigned)

Process Metrics
Average time to notify DA about new

admission
Average time from admission to first
patient visit by DA (initiation of care
plan) only for patients who meet all
criteria
Percent of patients PCPs notified within
24 hours discharge
Percent of follow-up phone calls made
within 48 hours

Process Metrics
Percent of follow-up calls requiring

second call by pharmacist (if nonpharmacist makes first call)

Percent of patients completing postdischarge survey (30 days after
discharge)

Process Metrics

Completion of care plan details

Percent of care plans with medication list
included
Percent of care plans with care needs included
(e.g., exercise, diet, main problem, when to call
doctor)
Percent of care plans with follow-up
appointments listed
Percent of care plans with pre-arranged
discharge resources identified (e.g., home health,
durable medical equipment)
Percent of care plans with pending tests listed

Answer the Following Questions

as a Team
What metrics do the project team want to use
to assess the impact of the re-engineered

discharge process?
If you decide to collect the process measure
associated with time-related activities, how will
that happen?
Will you use the patient phone survey? How?
Will you use the frontline staff survey? How?
Will you use the PCP survey? How?
Will you measure the completeness of the
Patient Care Plan?
Who will be responsible for overseeing the
measurement activities?

Project RED Components

The 11 components enable DAs to:
Prepare patients for hospital discharge
Help patients safely transition from

hospital to home
Promote patient self-health management

Support patients after discharge through

follow-up phone call

Identify the Patient

By admission unit

By admitting diagnosis
Heart failure: How do you identify

these patients for core measure

processes?

By physician

Identify the Patient

Who will notify the DA of the patients

admission?
How is the DA notified?
Pager

Phone

DA should be notified within 12 hours to

be able to see patient within 24 hours of

admission

DA Secondary Screening
DA reviews patients admission notes

Considers:
Working diagnosis
Language

Likely disposition
Availability of home or cell phone number

Determines if patient is a candidate for

Project RED intervention

Sample Log to Track

Key Dates and Times
Joe Smith
Date/Time of
Admission
Date/Time DA
Notified
Date/Time of Initial
DA Visit With Patient
Date/Time of Daily
DA Visits With
Patient (Note All)
Date/Time of
Discharge
Date/Time Care
Plan Faxed to PCP
Date/Time of PostDischarge Call

05-05; 1300
05-05; 1700
05-06; 1100
05-07; 0800
05-08; 1000
05-09; 1200
05-09; 1400
05-09; 1500

05-11; 1600

Patient Name

Patient Name

Answer the Following Questions

as a Team
How will you first identify that a newly admitted

patient is in the target population for this

project?
How will the DA be notified that a potential
Project RED patient has been admitted?
What secondary screening criteria will the DA
use to confirm use of the Project RED
intervention with the patient?
How will the DA track activities with new
patients?

Meeting the Patient

Review the patients admission notes
History and physical
Medication reconciliation
Preliminary plan of care

Meet the patient and family

Describe DAs role
Assess concerns, including potential post-

discharge needs

Initiate Patient Care Plan and checklist

Daily Work of the DA

Review progress and nursing notes

Clarify any concerns with health care team

Visit the patient
Review treatment plan (as related to

discharge)
Begin educating as appropriate (condition,
medications)
Discuss patients concerns re: discharge
Continue development of care plan

Discharge Planning Rounds

Multidisciplinary Team
Consider daily discharge rounds
Medical staff, nursing staff, pharmacy,
case management, and DA
Who will be supportive?
Where might resistance come from?

When is discharge order written?

Was it expected?
Weekend discharge?
Is there a timing expectation (e.g., time
from order to out the door)?

Patients Physician
Initiates patient plan of care based on critical

pathway
Leads and participates in discharge planning
rounds
Communicates potential date of discharge
Supports the performance improvement process

Nursing Staff

Provide nursing care as planned

Educate patient and family
Communicate with each other
Communicate with other members of the health
care team, including DA
Participate in multidisciplinary rounds, including
those that may be specifically focused on
discharge planning

Pharmacist
Verify physician orders

Reconcile admission medications with

medications from home
Collaborate with care team specific to discharge
needs
Reconcile medications upon discharge
Assist with patient medication questions

Case Managers
Post-discharge services

Social work
Utilization review
Financial support

Other Key Staff

Therapists

Disease management

Answer the Following Questions

as a Team
Do you currently address discharge planning
in multidisciplinary rounds?
What works well?
What could be improved?
Who participates?

If you do not do the above, why not?

What will it take to implement such rounds?
Who will be supportive?
Where might resistance be encountered?

What are the roles and responsibilities of

members of the health care team, as related
to discharge planning?

Teaching the Patient

Assess understanding of:
Reason for admission
Condition or diagnosis
Current medications

Begin teaching medications and

condition
Use teach-back methods (discussed in
Module 3)
Health literacy
Language
Culture

A True Story*
Public health nurse: Jill, I see you are taking
birth control pills. Tell me how you are taking
them.
Jill: Well, some days I take three; some days I
dont take any. On weekends, I usually take
more.
Public health nurse: How did your doctor tell you
to take them?
Jill: He said these pills were to keep me from
getting pregnant when I have sex, so I take them
anytime I have sex.
* Graham S and Brookey J. 2008.

Ask Me 3*
Created by the Partnership for Clear

Health Communication (National Patient

Safety Foundation)
Three essential questions for patients:
What is my main problem?
What do I need to do?
Why is it important for me to do this?
*National Patient Safety Foundation
http://www.npsf.org/askme3/

Teaching Tips*
Elicit symptoms and understanding from

the patient
Be aware of when teaching new
concepts and ensure understanding
Eliminate jargon
System-level support using technology
Provide more robust health education
vehicles to help the patient remember
Be proactive during time between visits
* Schillinger interview

Literacy Issues*
Clues that patient has general literacy issues:
Incompletely filled-out forms
Frequently missed appointments
Poor compliance
Inability to identify the name, purpose, or timing of

medication
Not asking any questions
Reaction to written materials
I forgot my glasses. Can you read it to me?
I will read it at home.

* Graham and Brookey

Health Literacy Tips*

Avoid medical jargon

Speak slowly
Provide simple pictures when helpful
Emphasize what the patient should do
Avoid unnecessary information
Welcome questions
Ensure written materials use simple words,
short sentences in bulleted format, and lots of
white space
* Graham and Brookey

Additional Teaching Tips*

1.
2.
3.
4.
5.
6.
7.
8.
9.

Use visual aids and illustrations

Beware of words with multiple meanings
Avoid acronyms and other new words
Use idioms carefully
Provide a health context for numbers and
mathematical concepts
Take a pause
Be an active listener
Address quizzical looks
Create a welcoming and supportive
environment
*www.pfizerhealthliteracy.com/public-health-professional/tips

Developing the
Patient Care Plan
Accessing the care plan

template
Accessing information for
the care plan
Saving individual Patient
Care Plan
Printing the care plan
Storing the care plan
Permanent part of the
patient record?

Accessing the
Patient Care Plan Template
IT department involvement
Build interfaces?

Written instructions for how to access

the care plan template

Written description of care template
sections, including what is entered
manually and what is linked to other
hospital systems
Written instructions for how and
where to save the Patient Care Plan

Gathering Care Plan Content

Start the Patient Care Plan on admission

and add to it daily

Secure education material about the
patients primary condition
Begin medication section, based on daily

discussions with medical team

Begin post-discharge services section
Identify PCP and add name to care plan

Module 2: Summary
Expected Outcomes
Identify patients who are members of the
projects targeted population
Alert the DA about new patients
Screen for final acceptance into project
Initiate discharge planning on admission
Meet the patient (through the care team,
admission notes, and in person)
Initiate care plan and maintain activities log
Participate in daily rounds with health care team

to plan patient education and post-discharge

services
Visit patient daily and educate during each visit
Continue to add to Patient Care Plan

Progression to Module 3
Checklist
Before going to Module 3, determine the:
___ Metrics you will use to assess impact
___ Process for identifying candidate
patients and notifying DA
___ Secondary screening criteria for
including patient
___ Process for multidisciplinary rounds
and/or updates on targeted patients
___ Process for accessing Patient Care
Plan