Project Timeframe: October, 2012 – ongoing
Hospital care is usually a brief, intensive intervention in a patient’s overall health and well being. For many patients hospital intervention is sufficient, and the patient is able to return to a normal routine without additional concern.
However, for patients living with chronic conditions life after discharge needs to be different than it was before. These patients need to pay careful attention to taking their medication at the right dose at the right time, to maintain appropriate diet and exercise, and to be aware of indicators of when it is prudent for them to seek medical attention. All too often without this ongoing care and attention the patient risks urgent readmission for an exacerbation of their chronic illness. This can frequently lead to an ongoing spiral of repeated admission and readmission and increased patient debility.
BMH recognized that, despite the best efforts of their Primary Care Physicians, many patients know little more than the basics of appropriate self care for a chronic illness. We identified that the hospital stay was the critical “teaching moment” in the lives of these patients. While they were with us we could provide intensive, repeated education.
We recognized, however, that education needed to be a two-way-street. Telling a patient what to do was only part it. If we expected patients or their caregivers to know what to do once they got home they needed to be able to tell articulate it in their own words. Only then would it become part of their daily life.
To educate all patients and their family/caregivers in appropriate disease management techniques, including appropriate diet, exercise, medication management, on-going testing (if needed), and symptoms or indicators that would indicate need for medical assessment and possible intervention by the Primary Care Physician.
In October, 2012, we put together a multidisciplinary Task Force including the Medical Director of the Hospitalist Program, the VP of Patient Care Services, The Executive Director of Quality and Care Management, the Education Coordinator, a unit Nurse Manager, and Care Managers to research evidence based educational tools and to develop a patient /caregiver education protocol.
The team developed the following plan:
- During Interdisciplinary Continuing Care Rounds the first day following admission, the Attending Physician identifies one or more primary education needs for appropriate disease management
- Using Exit Care, a proprietary education discharge tool that can be modified to meet individual needs, a Care Manager immediately prints a patient education summary which is then placed in a specially identified folder in the patient’s room
- At least once each day a Care Manager provides education to the patient and their family/caregivers using the Exit Care document as a guide. This education includes asking the patient/caregiver to “teach back” what they’d just heard.
- Education is reinforced by the patient’s Nurse, using the same document.
- The Exit Care document remains in the patient’s room at all times and the patient and their family/caregiver are encouraged to do self-study
- All educational efforts are document on a special Education Flowsheet in our electronic medical record, including an assessment of the patient’s ability to teach back or need for further reinforcement
- On the day of discharge the patient’s Care Manager reviews all educational materials with the patient/caregiver, reinforcing what has been taught and fielding any additional questions
- In the post-discharge follow-up phone call, a Nurse questions the patient about appropriate self-care, reinforces the education provided, and conducts coaching as needed. If appropriate the Nurse also makes a referral for further assistance from the Community Health Team
We are currently gathering data on the number of patients educated according to protocol. We also gather data regarding readmissions, and assess whether the readmission might have been preventable had appropriate self-care been in place.
We hope in the near future to correlate these two data sets and complete a more comprehensive analysis.
Michele Rowland, RN, LICSW
Executive Director, Quality, Utilization and Care Management
Brattleboro Memorial Hospital
17 Belmont Avenue, Brattleboro, VT 05301