Patient Discharge: An IT Tool for Measuring, Screening and Suppor ting Planning Decisions
Ivana Feldmeier, MD Nilda Figueroa, RN Maria Sevillano, EDD Jermia Ir ving April 22nd, 2014
it lik s ’ t Wha a g bein al it hosp t? n patie
Facts • •
38 million discharges in 2011 30% hospital discharges may be delayed for non-medical reasons (17% of all hospital days) 18% of patients are re-admitted within 30 days 90 million patients may do not understand their conditions/treatment regimen 31% did not meet at least 1 of the discharge planning requirements
it lik s ’ t Wha a g bein al it hosp t? n patie
Facts • • •
23% lacked post-discharge plans of care 16% lacked adequate discharge summaries $25 to $45 billion in wasteful spending in 2011 through available and unnecessary hospital re-admission Discharge patient services are available for only 12.2% patients prior to outpatient visit Physicians lacked awareness of pending tests in 40% of discharged patients
Key Elements in Patient Discharge Process
Overview Research Q#1 Current Processes toward discharge at the Internal Medicine Unit â€˘ Patient with CCI score greater than 4 had about 3 times the clinical discharge time of the patients with a low CCI score (p=0.01) â€˘ No relevance found for age, marital status, gender, cognitive status and polypharmacy
Overview Research Q#1 Current Processes toward discharge at the Internal Medicine Unit â€˘ Subjects of the sample with CCI score >=4 or on more than 7 medicines had three times the risk of a clinical discharge tine longer than 3 hrs compared to those who had lower CCI score or were on less than 7 medicines. (p=0.02) â€˘ Subjects on more than 7 medicines had four times the risk of being discharged to PAC compared to those who were not. (p=0.01)
Overview Research Q#2 Difficulties in the process toward discharge and aftercare at the Internal Medical Unit • • • •
Clinical discharge time was 3.7 plus or minus 2.1 hours 50% of discharge orders occurred before noon 10% of discharge orders occurred before 9:00 am 60% of the sample had a clinical discharge time longer the 3 hours
Overview Research Q#2 Difficulties in the process toward discharge and aftercare at the Internal Medical Unit • 95% of the sample really left the hospital in the afternoon • Patients who were discharged to a PAC facility had the double of clinical discharge time than those were discharged home (p=0.04) • Compared to patients who were discharged home, the patients who were discharged to a post-acute care (PAC) service were mostly married (p=0.01), older (>=67 y-o) (p=0.008), on more than seven medications (p=0.001), or had high CCI score (>= 5) (p=0.0007)
Overview Research Q#2 Discharge process identified the following problems
• Poor planning ahead for discharge process • Most of the tasks of the discharge process were completed in the afternoon • Deficient use of EMR to predict delayed discharge • Transportation efforts occurred late in the afternoon • Lack of an automated risk screening tool
Overview Research Q#3 Possible Improvements and Best Practices to reduce or eliminate these difficulties â€˘ Determine a list of criteria for screening patients who will more likely require a post-acute service â€˘ Screen patients early in the hospital stay to plan, if feasible, expected date of discharge and determine need for discharge planning â€˘ Plan patient discharge 24-hours in advance, scheduling for morning those patients who gather the criteria for regular discharge, and later the patients with more complex needs
Overview Research Q#4 Alternative situation for the discharge and aftercare process based on experiences and best practices • There is no “one size fits all” solution • Adjusting and setting an expected discharge date based on 24-hours of admission • Establishing a discharge checklist-most of the workload is done ahead of time
Overview Research Q#5 Health IT Tool improves inpatient discharge process
• Risk score-based on patient demographics and clinical factors • Flag will be displayed in green, yellow or red based on patient’s CCI score • Stakeholders have to log on immediately to address the problems • Patients’ need-allowing time to accommodate and coordinate discharge process in the morning (10 x 10 goal)
â€˘ Discharge planning is an ongoing process-involves multiple disciplines and departments â€˘ Discharge begins on Admissiondata is collected while the patient staying at the hospital â€˘ Ongoing assessment of EMR dataongoing assessment of discharge needs
Design-analyzin g an d categorizing exi sting tools, regulations and hospital policies and pro cedures in order to create a comprehensive IT tool
Purpose of Discharge Planning • To prepare patients and caregivers physiologically for transfer home, with the highest level of independence that is feasible • To provide continuity of care • Safety and efficacy
Patient Discharge Planning in Practice Understanding Discharge Timing Discharge process begins as soon as possible
• • • • • • • •
Feasibility Identify the competent caregiver • Education • Analysis practical issues • Coordination and Communication • Management
Benefits of a Patient Discharge Planning Increase focus on discharge process Alert staff early to prepare for patient discharge Increase coordination of care Create predictable patient discharge practice Increase physician satisfaction Decrease waits and late placements Increase patient satisfaction Earlier patient discharges decreased boarders
Conclusion Coordination and Communication Essential key roles in the patient-centered care and are increasingly the focus on measurement and requirements
Per formance Measure, calculate, and evaluate across different and multiple dimensions including financial ramifications, patient experience, clinical outcomes, etc. vital and necessary.
Health care IT Tool Key role in improving care through various applications such as electronic discharge summaries
Final Thought…. For the first time in human history, “ We have the science and computational power to help health professionals, and physicians quickly sort through vast troves of medical literature to determine what actions are best for each patient at each stage of diagnosis and treatment…It would be virtually unethical not to put these tremendous resources to work to improve care and lower costs” (Cosgrove, 2014)
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