Project Timeframe: January 2014 – ongoing
Problem: This project was done in follow-up to a project we initiated last year regarding patient education. In that project we outlined the need for patient and family education to support patient compliance with appropriate self-care and medication regime to prevent readmission and risk of increased patient debility.
That project paced heavy reliance on our Care Managers for both initiating patient/family education and continuing it on a daily basis. However, despite the best efforts of our Care Manager team, patients continued to tell us through standard surveys and post-discharge follow-up phone calls that they did not have a clear understanding of their medical issues nor of appropriate self-care. An internal audit of Care Manager Education efforts identified significant gaps, especially on weekends when only one Care Manager is available Saturday and only one available for phone consult on Sunday. Clearly, we needed to find a more consistent way of providing education.
Goal: Our goal for this project remains the same as that of last year: 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.
Interventions: In January, 2014, the original multidisciplinary Task Force regrouped. This Task Force included the Medical Director of the Hospitalist Program, the VP of Patient Care Services, The Executive Director of Quality and Care Management, a unit Nurse Manager, and Care Managers to address our goal. The team quickly identified that the one constant in any patient’s care was their assigned nurse, who saw the patient repeatedly during their shift.
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, as a resource, Nurses begin to provide education to the patient and their family/caregivers
- Nurse are instructed to making every contact with the patient a “teaching moment”, providing incremental educational moments and reinforcing previous conversations.
- Nurses are also instructed to test for teach back, using simple conversational techniques to test if the patient comprehends appropriate steps for self-care and can demonstrate that knowledge.
- On the day of discharge the patient’s nurse 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.
Measures: We are currently gathering data on the number of patients educated according to this revised protocol. We also gather data regarding re-admissions, 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