How to implement a successful care transition improvement plan

Having an electronic health records system in place doesn’t solve the problem of ensuring thorough documentation by everyone who gives services to a patient.

In 2014, there were 28 million patient discharges in U.S. hospitals. The Centers for Medicare & Medicaid Services estimates that in 2017, 6 million senior citizens were readmitted to hospitals.

Unfortunately, the readmissions problem was a similar one that our facility was experiencing.

Two particular cases come to mind:
  • We had one patient admitted to the hospital with a stroke. The speech therapist did an evaluation and said that the patient had dysphagia. They made diet recommendations and suggested safe swallow strategies, but they were not communicated or documented, or listed upon discharge. The patient was subsequently re-admitted.
  • In another instance, a patient with COPD, who was new to oxygen, was going home. The patient got home, and his oxygen had not been delivered. He didn’t know who was supposed to be delivering it, what time they were bringing it or other details. No coordination had been done on the patient’s behalf. The patient was readmitted.

These were scenarios that we knew we could fix. Our hospital has 225 members on the medical staff, and we have 40 specialties. There were many moving parts that were all responsible for patient safety and we knew we needed to do something.

I decided to make it my capstone project to find a solution to this problem. I wanted to make sure that we were doing the best job possible for all our stakeholders—the patient, their family and the hospital. We wanted to make sure that the patients were being informed of their post discharge care, and we also wanted to see our HCAHPS scores improve, which would happen if we had more meaningful discharges. Overall, our immediate goal was safe patient discharge. Our long term goal was overcoming barriers and staff perceptions.

For one week, I looked at all discharges going home. I reviewed charts that had multiple disciplines involved with their care (such as speech, physical therapy, occupational therapy, respiratory, the Center for Diabetes and others), and I noticed some troubling issues related to documentation and communication. There were potential issues in the areas of patients with home services and equipment, patients with recommended mechanics with food, patients with home oxygen, diabetes patients, as well as patients with mobility and safety issues.

For example, I noticed that the social workers had notes in the chart 20 percent of the time. The speech, physical therapy, occupational therapy, the Center for Diabetes, and the respiratory departments had no entries. That’s when I discovered a barrier—that certain departments simply didn’t have the ability to enter any discharge notes. For those that could enter notes, staff believed that there were too many clicks, or that it wasn't part of their daily workflow, so they weren't being compliant with using it. In addition to that, there were also instances of duplicate documentation.

Further delving into these patient charts, I noticed that there was a disconnect within multidisciplinary teams. For example, our Social Services department only put in notes that the nurse needed to know 60 percent of the time. Our Center for Diabetes entered notes 50 percent of the time. This information wasn’t always updated. Physical therapy, occupational therapy, and the speech department had interventions, but they were only shared within their group. Certain intervention notes were meaningful only to those specific departments, but they weren’t meaningful to the nurses. If a nurse didn’t know what a certain department’s abbreviations meant on their notes, then how could they make those interventions meaningful to themselves and their staff?

The first step was to put together a multidisciplinary education committee. The goals of the team were to communicate the bottom line to other team members, and communicate transitions of care instructions from each discipline to the patient and their family. We wanted to have information flow from daily work processes. The rule of thumb was if you interacted with a patient, then you should be making discharge notes in their chart.

We knew that we needed to do something different with our team meetings because we had to know what needed to be done for the patient. That was a big culture change for us. The meetings needed to be focused on engaging staff in the discharge process, and identifying the key questions: What prevents a patient from going home today? What does the patient need? What type of insurance do they have? Who do they call if they have questions?

We discussed each department’s responsibility in the process, the importance of making sure that discharge instructions were thorough and complete, and the importance of each person’s role to make sure that the patient had a clear understanding of their care plan.

We believe that the discharge process should start on admission, and that it should be a part of a team’s daily workflow. So we created a 10-question assessment template across divisions that showed the chronological workflow. We had to overcome a lot of barriers to get the staff to be receptive to even doing it. We included an educational component so staff knew how to use it properly, which included re-education for transitional employees.

Before this process, we realized that many assumptions were made. For example, the pharmacist thought that the physician was going to teach the patient how to use their inhaler and vice versa. According to the Center for Medicare and Medicaid Services, 80 percent of serious medical errors and events occur because of miscommunication. That was a staggering statistic that we did not want to see happen at our institution.

The results of the documentation were encouraging. After implementation of the shared assessment, compliance for both communication and discharge information went to 100 percent for all disciplines. The rule of thumb was if you interact with the patient, the expectation is that you place documentation for both transition and communication.

During a patient stay, all departments are responsible for their piece of the pie. We found that when all staff document on the assessments and each department placed a plan into the discharge order, we had successful results.

From start to finish, this initiative took 10 months to complete. We were pleased to see these improvements, because we realized that each department truly had ownership of the patient, which is a key element in a transition of care.

One of the biggest lessons we learned was that there needs to be clear communication among those on the disciplinary team. If your patients are being readmitted to your institution, then something is wrong with the hand-off between departments. We wanted our patients to have a successful transition, and we believed that this could be achieved through improved interdisciplinary coordination and communication.

All departments play a key part in a successful patient transition. Some of the key takeaways we learned were to not assume that everything is done correctly, to constantly evaluate your processes, and to provide education to your team. Combined with good interdisciplinary coordination and care, you’ll have the tools you need to ensure that your patient is well cared for from Day 1 of admission.

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