Provide Real-Time Handover Communications - IHI

Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar

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Provide Real-Time Handover CommunicationsPeg Bradke and Eric Coleman

These presenters have

nothing to disclose

April 23, 2014

Session Objectives

Participants will be able to:

• Identify failures in current practice from the

literature and their own experience

• Describe handover improvements and useful

ways to get started

• List tips and techniques for partnering across the

continuum of care to get results


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Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.

“….effectively communicate post-

acute care plans to patients and

community-based providers of

care?”

How Might We….



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Recommended Changes

4. Provide Real-time Handover Communication

A. Give patient and family members a patient-friendly,

post-hospital care plan which includes a clear

medication list

B. Provide customized, real-time critical information to

the next clinical care provider(s)


Observe Current Discharge

Processes



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Communication Is a Two Way Street

Please share examples for when you reached out

to cross-setting partners to get their input.

Did you meet by phone or face-to-face?

Who did you meet with?

What surprised you?

Discharge Preparations

• Provide the patient and family caregivers with written information about what to expect when they return home and easy-to-read self-care and medication instructions

• Explore community support systems and resources to provide patient and family caregivers

• Plan ahead to keep patients comfortable on the trip home; consider pain medication administration and or filling prescriptions before patient goes home



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Post-hospital Follow-up Care

• Ensure that the patient and family caregivers

are present for discharge instructions

• Use Teach Back in your discharge instructions

• A single number to call for emergent needs and

non-emergent questions

• Current and baseline functional status of patient

not described, making it difficult to assess

progress and prognosis


Reconcile Medications

Review the patient’s pre-hospital and hospital medication regimens:

− Supplement with additional information about medications that was not evident at the time of admission

− Clarify whether medications that have been withheld should be restarted after discharge

− Convert hospital intravenous medications to oral medications

− Reconcile substitutions from the institution’s formulary and translate back to the original preparations to avoid duplication, medication errors, or unnecessary expense to the patient


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Reconcile Medications

• Can the patient:

- Read their medication labels?

- Afford the necessary medications and foods?

- Get to a pharmacy?

• Use highlighting on meds list to call attention to new

meds, dosage changes, or discontinued meds

• Encourage patients and families to use a tool or

document that does not require reliance on memory

Resources for Creating User-friendly

Medication Lists

How to Create a Pill Card

For more information, please visit the patient

safety and errors section at:

http://www.ahrq.gov/

Iowa Healthcare Collaborative (IHC)

Med Card

For more information, please visit:

http://www.ihconline.org/aspx/consumerresources.aspx#MedCard_Anchor

http://www.ahrq.gov/

http://www.ihconline.org/aspx/consumerresources.aspx


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How to Create a Pill Card (AHRQ)

User-friendly Medication Card (IHC)


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Our Most Formidable Challenge

Year after year we try to improve med rec

However gains have been modest

Not due to lack of trying

Why do you think medications represent

our most formidable challenge?

If the patient is transitioning home and will be receiving

care in primary care office or specialty practice:

• Ensure the discharge summary arrives prior to the visit

• Arrange for access to patient discharge instructions in

the office practice

• Without this critical information, providers may duplicate,

overlook important aspects of the care plan, or convey

conflicting information

Handovers to Physician Offices


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Warm Handover to Community Partners

Written handover communication for high-risk

patients is insufficient : direct verbal

communication allows for inquiry and clarification

Transition to Home Health Care, Long-term Care,

Skilled Nursing or Other Community Settings


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• Consider establishing HHC, SNF or LTC

liaisons that are based in the hospital (ex.

HHC liaison helps MDs determine

qualifications for HHC)

• Work with Liaisons and community partners

to standardize critical information to be

included in a handover communication tool


Skilled Nursing Facility or Other Community Settings


Skilled Nursing Facility or Other Community Settings

• Co-design handover communication

processes (i.e. preferred formats for

information)

• Create processes for bidirectional

communication for care coordination,

continual learning and ongoing

improvement efforts


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Handovers to Home Health Care, Skilled

Nursing Facilities or Community Services

• Share patient education materials and

educational processes across care settings

• Offer education for the staff in HHC, SNF, LTC

and community services

• Create processes for bidirectional communication

for care coordination, continual learning and

ongoing improvement efforts

INTERACT Transfer Tool

Available at: http://interact2.net/tools_v3.aspxnteract2.net


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“Warm Handovers” for High-risk Patients

• For high-risk patients, a clinician should call the post-

acute provider listed as the individual the patient will

call for emergent needs:

– Alerts the next care provider of the discharge

status and plan of care

– Provides a mechanisms for bidirectional

communication

– Allows for inquiry and clarification of questions

Coordination of Care

Discuss • How many services are wrapped around the patient and

family caregiver?

• Are they all communicating? Do they all understand the Plan of

Care?

• If there are multiple services involved is a “lead person” identified

and communicated?

• How many phone call is that patient/family caregiver

receiving after they get home?

• What are each of the calls purposes?


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Using Process Measures to

Guide Your Learning


Number of discharges in the sample where critical information is transmitted at the time of discharge to the next care site or person continuing care (e.g., home health care, long-term care facility, rehab care, physician office, or care at home)

Definition details on page 71 of the How-to Guide

What Are We Learning About Providing

Real-time Handover Communications?

• There are a “vital few” critical elements of patient

information that should be available at the time of

discharge for the community providers

– “Senders” and “receivers” agree upon the information

and design reliable processes to transfer information

effectively

• Written handover communication for high-risk

patients is insufficient; direct verbal

communication allows for inquiry and clarification


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What Are We Learning About Providing

Real-time Handover Communications?

• Ensure that the discharge summary is available for office visits prior to the patients appointment

• Consider designing standardized handover forms for the community, region, or state

• Written care plans for patients and family caregivers should use clear, user-friendly formats for describing care at home

Table Exercise

• What is your experience with initiating follow-up care?

• What have you learned?

• What do you plan to test?

Documents

Provide Real-Time Handover Communications - IHI