Risk Management
HCAHPS Series
Transforming
24 January 2015 • Nursing Management
www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Part 1
care transitions I By Jennifer Volland Volland, DHA DHA, MBB MBB, RN RN, CPHQ CPHQ, NEA-BC NEA-BC, FACHE FACHE, and Sarah Fryda n October 2014, five new questions became part of the publically reported Hospital Consumer Assessment of Healthcare Providers and Systems (hcahps) survey process that provides consumers with transparency of hospital metrics. Three of the five new questions in aggregate compose the Care Transition Measures.1 Although the hcahps questions have previously remained unchanged since their inception in March 2008, the focus on population health and a need for better care transitions between providers has emerged to the forefront as a requisite element of delivering patient-centered and safe care. No longer does the accountability for a patient end at discharge or a clinic doorstep; the handoff or first 30 days after a return to home (patient readmissions) are included in the interconnected process of helping an individual achieve and maintain the highest level of wellness possible.
Inherent risks in the system Coordinated care in combination with a decreased length of stay goes beyond cost avoidance to include value.2 In a complex healthcare system, triaging care to the most appropriate location is an area that clinicians can help navigate in partnership with patients and their loved ones. Effective care coordinawww.nursingmanagement.com
tion from a population health perspective creates a win-win for both the hospital and the transferred facility or patient’s personal physician. Patient posthospitalization 30-day readmissions are an unwanted outcome and, within a broader context, this includes hospital-acquired infections, medication errors, patient falls, and events related to ongoing patient care.3 Quantification of the extent of these events is nearly impossible. Approximately 86% of patient mishaps fail to be entered into hospital incident reporting databases. Sixtytwo percent of the time, this is due to staff not considering the incident a reportable item.4 Lesser lengths of stay compact the timeframe for a preventable adverse event to occur.
Turning patient feedback into action with intent Three questions were added in 2013 to comprise the hcahps survey Care Transition Measures, which are the lowest scoring item of the hcahps composites. These questions include: “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left” (focusing on when the patient was in the hospital); “When I left the hospital, I had a good understanding of the things I was responsible for in managing
Nursing Management • January 2015 25
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HCAHPS Series Part 1
my health” (focusing on discharge preparedness); and “When I left the hospital, I clearly understood the purpose for taking each of my medications” (focusing on medication understanding at time of hospital discharge).5 At a database level, the combination of the three questions comprising the Care Transition Measures—using a case-wise
processing technique applied to responses of all patients discharged in 2013—produced a top-box score of 50.6% where just over half of all patients felt that their care transition needs were met. Of the three measures, the question “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my
Figure 1: Care Transition Measure performance 70.0 60.1
% Top box
60.0 50.0
51.5
50.6 42.3
40.0 30.0 20.0 10.0 0.0
Care Transition Measure composite
During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left.
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
Figure 2: Care Transition Measure performance by hospital type 80.0 67.7
70.0 59.6
% Top box
60.0 50.0
60.6 52.6
50.4
59.9
51.3
42.0
40.0 30.0 20.0 10.0 0.0
Care Transition Measure composite
During this hospital stay, staff took my preferences and those of my family or caregiver into Nonspecialty hospitals account in deciding what my healthcare Specialty hospitals needs would be when I left.
26 January 2015 • Nursing Management
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
healthcare needs would be when I left” was the lowest-scoring item of the three, with only 42.3% of patients answering the top-box response. The second question, “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health” scored the second lowest, with a top-box score of 51.6%, and the question “When I left the hospital, I clearly understood the purpose for taking each of my medications” was the highest scoring of the three, with a top-box score of 60.1%. (See Figure 1.) Top box is defined as the percentage of patients who answered “strongly agree” among possible response selections.6 These trends were similar throughout the different segmentations of data. Specialty hospitals performed better, with an aggregated top-box score of 59.6%, than nonspecialty hospitals, with an aggregated top-box score of 50.4% for the Care Transition Measures composite. Similarly, for both types of hospitals, the question “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left” performed the lowest, with a 42% top-box score for nonspecialty hospitals and a 52.6% top-box score for specialty hospitals. (See Figure 2.) Examining scores by service type, the question “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left” performed the lowest among maternity care, medical, and surgical patients alike. In general, the Care Transition Measures performed the lowest among medical patients, with a top-box score of 38.1% for the www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Shifting from reactive to proactive tactics “The hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left the hospital.” Accounting for patient preferences involves matching the questions to the individual. This requires not only asking questions, but also asking the right questions.7 As part of the discharge planning process, clinicians will need to help the patient plan for exceptions to a greater degree than in the past. Taking preferences into account infers personalization of the patient encounter. The benefit of personalized information to a patient surpasses creating a welcome experience where a neurobehavioral connection also exists. Extensive research exists on neural networking models. Repeated stimulations of the same content build deeper cell-tocell bridges (synapses) within the brain. The more a pathway is used, www.nursingmanagement.com
Figure 3: Care Transition Measure performance by service type 80.0 69.6
70.0 60.0 % Top box
lowest performing question. The largest disparity in scores was for the question “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.” Medical patients reported a top-box score of 46.1% and maternity patients reported a top-box score of 63.3%, for a difference of 17.2%. (See Figure 3.) The challenge for organizations is translating the new hcahps questions from a source of patient feedback into action with intent. Knowing how to address each question requires a tactical answer. As a mandated and visible measure, can the organization improve its care transition processes quickly with agility while ensuring that existing processes are hardwired and new innovations are being implemented successfully?
50.0
63.3
59.2 45.8
54.4
47.7
46.3
55.2
55.4
63.5
46.1
38.1
40.0 30.0 20.0 10.0 0.0
Care Transition Measure composite Maternity care Medical Surgical
During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left.
the stronger it becomes and the more likely that information can be retrieved. Learning information through different modalities (hearing, seeing, touching) reinforces this process.8 Additionally, stress can produce an environment in which information is harder to retrieve. For populations at high risk for readmission, these individuals will encounter stress if there’s a need for intervention or treatment. Clinicians should have a strong education plan in place where content is reviewed multiple times before discharge in meaningful ways and discussed in a context that’s relevant to the patient. Retention increases through the creation of associations of previous knowledge with new information when content can be related to something the patient already knows. Personalizing information attaches the new content to the area of the brain that’s responsible for memories. When new information attaches to content already mastered, it helps put the fresh information into context. The new knowledge becomes stored as an integrated memory in
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
the frontal lobe of the brain where patterns of information become the pathways that memories can follow. This is known as relational memory.8 An effective method of personalizing the encounter is having the patient envision his or her home environment and inquiring “what if” while incorporating condition signs or symptoms and other aspects of care into a discussion of personal health goals. Imagery is used frequently by athletes to create an experience in the mind to feel ready for an event, plan strategies, and as a coping skill strategy to stay calm under pressure.9 An analogy is possible with the patient discharge planning process. Can the patient visualize the situations within his or her own environment that would prompt a need for follow-up with a physician? An assessment of the level of a patient’s support system, access to transportation, and ability to develop a plan should a situation arise can be conducted with the patient thinking about potential risk events within his or her own
Nursing Management • January 2015 27
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HCAHPS Series Part 1
context and creating linkages to information that’s already known. “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.” Patients and families have limited visibility into the healthcare world and processes that clinicians encounter every day. A need for hospitalization is due to an untoward event that can’t be managed independently. For most, unless the situation is a readmission or the patient has encountered previous hospitalizations, a hospital stay isn’t only fraught with new experiences, but also new questions, potential
before discharge for a safe transition across care settings. Using the structured format of “Ask Me 3” can lead to a deeper level of patient engagement in their care. The components of “Ask Me 3” include patients asking clinicians: “What’s my main problem?”; “What do I need to do”; and “Why is it important for me to do this?”11 Also, the use of openended questions helps the clinician proactively gauge the questions a patient or family may have, especially given their unfamiliarity of the situation. “When I left the hospital, I clearly understood the purpose for taking each of my medications.”
The ability to bridge patient feedback into tactical action provides the agility to move an organization forward from reactivity to proactivity. changes or additions in medications, modifications in daily diet and mobility parameters, and a myriad of other factors. It’s realistic to assume that patients and their loved ones may not know all of the questions that they should be asking before discharge. This is where the method of teach-back can help. Teach-back involves asking the patient to “teach back” what was said. When used correctly, it not only identifies where there may be challenges with health literacy, but also can help overcome barriers in understanding.10 Using teach-back helps the patient and clinician fully understand the information that’s being retained and pinpoint questions that still need to be answered
A lack of health literacy can be a barrier to ensuring proper care when a patient returns home. Health issues associated with older patients include 71% of adults over age 60 having difficulty using printed materials; 80% having difficulty with documents such as forms or charts, and 68% having difficulty interpreting numbers and performing calculations.12 To create an effective workaround, not only should hospital discharge medication information be provided in a font size large enough for those with visual difficulties to easily read the letters, but also the use of visual cues can be beneficial to reinforce instructions.13 Asking the family to fill prescriptions before discharge and conducting a final review with a take-home
28 January 2015 • Nursing Management
medication pillbox can reinforce understanding for patients who are considered high risk or take multiple medications. A second medication reconciliation process occurs in which the patient compares the medications already within the home environment with the medications to be administered after a period of hospitalization.14 A prefilled pillbox with a 1-week supply can reinforce the correct medication regimen with visual cues to ensure accuracy of subsequent set up. However, medication questions extend beyond the purpose of the medication and proper schedule of administration. In a 2004 study that examined the variation of medication understanding among older individuals, nearly 8% had a limited understanding across medications. The biggest issue was lacking a full understanding of the actions to take if a medication was missed. Although many individuals understood their medication regime (62%), individuals who had higher quantities of daily medications or lacked the understanding of multiple aspects of the medication were at higher risk for noncompliance.15 Involving the patient and family in the reconciliation process is a best practice for improving a patient’s medication management. For patients with complicated medication schedules, the hospital may want an additional education session conducted by the pharmacist with the patient and family, a follow-up phone call, and an in-home visit.16 If a patient doesn’t know a medication’s name, the medication’s purpose, how to administer a medication, or when to take the medication, a communication should occur with the primary care physician for additional education and reinforcement as part of the ongoing monitoring process. Additional www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
parameters may include follow-up with patients prescribed more than five medications or having more than two medication changes during their hospitalization.16 Engaging in a medication routine can have different meanings for patients. Helping them understand the purpose of the medication goes beyond the functionality of a pharmaceutical for patient-centered care. Four themes have been identified regarding medication meaning for patients: a meaningful encounter, bodily effects, unremitting nature, and exerting control. Some statements by patients include “I felt like if I took lorazepam that I’m failing”; “It’s this constant thing that you wish you could have a break from, but you can’t”; “The first time somebody told me I would have to take that for the rest of my life I got mad.”17 Working through these issues with patients can influence their understanding of medications and coping with the responsibility of managing their health. An additional question that warrants attention is whether there has been a time when the patient was unable to afford his or her medications. Polypharmacy is a frequent phenomenon among older individuals.18 This is an area for focus when discharging patients with multiple medications, which may be new or continued, and older patients at risk for medication noncompliance due to financial issues. During times of financial hardship, patients may become faced with deciding which medications to fill when dollars are limited. If patients don’t fully understand the importance of their medications, outreach back to their provider may not occur when hard choices are made independently. This bypasses a discussion about potential resources that may be available within the community or a review of www.nursingmanagement.com
current medications and development of an action plan in coordination with the primary care physician.
Destination: Coordination Successful care transitions across settings will require the coordination of multiple providers across different care continuum settings. An initial starting point of focus for many organizations will be the three Care Transition Measures that became publically reported in October 2014. Family preferences, an understanding of health self-management, and comprehension of the purpose of medications are only the beginning of multiple areas of potential focus for ensuring the safety and self-knowledge of patients and families. The ability to bridge patient feedback into tactical action provides the agility to move an organization forward from reactively to proactively addressing the Care Transition Measures. In the second part of this series, we answer the question: Does leadership rounding make a difference on HCAHPS scores? NM REFERENCES 1. Centers for Medicare and Medicaid Services. HCAHPS fact sheet. http://www. HCAHPSonline.org/files/August_2013_ HCAHPS_Fact_Sheet3.pdf. 2. Greene J. How much do you boost your hospital’s bottom line? Formulas to help you calculate the clue that hospitalists bring to the table. http://www. todayshospitalist.com/index.php/index. php?b=articles_read&cnt=492. 3. Levinson DR. Adverse events in hospitals: national incidence among Medicare beneficiaries. http://oig.hhs.gov/oei/reports/ oei-06-09-00090.pdf. 4. Levinson DR. Hospital incident reporting systems do not capture most patient harm. http://oig.hhs.gov/oei/reports/oei-06-0900091.pdf. 5. Coleman E. CTM-3. http://www.caretransitions.org/documents/CTM_FAQs.pdf. 6. National Research Corporation Hospital and Consumer Assessment of Healthcare Providers and Systems (HCAHPS) database, 2014.
7. Morris T. 3 ways to personalize the customer experience without getting to personal. http://www.parature.com/ personalize-cx/. 8. Willis J. Research based strategies to ignite student learning. http://www.ascd.org/ publications/books/107006/chapters/ Memory,_Learning,_and_Test-Taking_ Success.aspx. 9. Yukelson D. Teaching athletes visualization and mental imagery skills. http:// www.mascsa.psu.edu/dave/VisualizationHandout.pdf. 10. Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31(suppl 1): S96-S104. 11. National Patient Safety Foundation. Ask me 3. http://c.ymcdn.com/sites/www. npsf.org/resource/resmgr/Store/AskMe_ 8-pg_EN_ref-sample.pdf?hhSearchTerms= %22ask+and+3%22. 12. Glassman P. Health literacy. http:// nnlm.gov/outreach/consumer/hlthlit. html#A4. 13. Case Management Society of America. Case management adherence guidelines, version 2.0. http://www.cmsa.org/ portals/0/pdf/cmag2.pdf. 14. Volland J. Aligning hospital outcomes and accountability for patient safe transitions to home. California Association for Healthcare Quality Journal. 2011;35:18-21. 15. Spiers MV, Kutzik DM, Lamar M. Variation in medication understanding among the elderly. Am J Health Syst Pharm. 2004; 61(4):373-380. 16. Reducing Avoidable Readmissions Effectively. Medication Management. http://www.rarereadmissions.org/areas/ medmanagement.html. 17. Shoemaker SJ, Ramalho de Oliveira D. Understanding the meaning of medications for patients: the medication experience. Pharm World Sci. 2008;30(1):86-91. 18. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345-351. At the National Research Corporation in Lincoln, Neb., Jennifer Volland is vice president of Program Development and Sarah Fryda is a senior research associate. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000459101.17224.c3
Nursing Management • January 2015 29
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HCAHPS Series
Transforming
24 January 2015 • Nursing Management
www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Part 1
care transitions I By Jennifer Volland Volland, DHA DHA, MBB MBB, RN RN, CPHQ CPHQ, NEA-BC NEA-BC, FACHE FACHE, and Sarah Fryda n October 2014, five new questions became part of the publically reported Hospital Consumer Assessment of Healthcare Providers and Systems (hcahps) survey process that provides consumers with transparency of hospital metrics. Three of the five new questions in aggregate compose the Care Transition Measures.1 Although the hcahps questions have previously remained unchanged since their inception in March 2008, the focus on population health and a need for better care transitions between providers has emerged to the forefront as a requisite element of delivering patient-centered and safe care. No longer does the accountability for a patient end at discharge or a clinic doorstep; the handoff or first 30 days after a return to home (patient readmissions) are included in the interconnected process of helping an individual achieve and maintain the highest level of wellness possible.
Inherent risks in the system Coordinated care in combination with a decreased length of stay goes beyond cost avoidance to include value.2 In a complex healthcare system, triaging care to the most appropriate location is an area that clinicians can help navigate in partnership with patients and their loved ones. Effective care coordinawww.nursingmanagement.com
tion from a population health perspective creates a win-win for both the hospital and the transferred facility or patient’s personal physician. Patient posthospitalization 30-day readmissions are an unwanted outcome and, within a broader context, this includes hospital-acquired infections, medication errors, patient falls, and events related to ongoing patient care.3 Quantification of the extent of these events is nearly impossible. Approximately 86% of patient mishaps fail to be entered into hospital incident reporting databases. Sixtytwo percent of the time, this is due to staff not considering the incident a reportable item.4 Lesser lengths of stay compact the timeframe for a preventable adverse event to occur.
Turning patient feedback into action with intent Three questions were added in 2013 to comprise the hcahps survey Care Transition Measures, which are the lowest scoring item of the hcahps composites. These questions include: “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left” (focusing on when the patient was in the hospital); “When I left the hospital, I had a good understanding of the things I was responsible for in managing
Nursing Management • January 2015 25
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HCAHPS Series Part 1
my health” (focusing on discharge preparedness); and “When I left the hospital, I clearly understood the purpose for taking each of my medications” (focusing on medication understanding at time of hospital discharge).5 At a database level, the combination of the three questions comprising the Care Transition Measures—using a case-wise
processing technique applied to responses of all patients discharged in 2013—produced a top-box score of 50.6% where just over half of all patients felt that their care transition needs were met. Of the three measures, the question “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my
Figure 1: Care Transition Measure performance 70.0 60.1
% Top box
60.0 50.0
51.5
50.6 42.3
40.0 30.0 20.0 10.0 0.0
Care Transition Measure composite
During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left.
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
Figure 2: Care Transition Measure performance by hospital type 80.0 67.7
70.0 59.6
% Top box
60.0 50.0
60.6 52.6
50.4
59.9
51.3
42.0
40.0 30.0 20.0 10.0 0.0
Care Transition Measure composite
During this hospital stay, staff took my preferences and those of my family or caregiver into Nonspecialty hospitals account in deciding what my healthcare Specialty hospitals needs would be when I left.
26 January 2015 • Nursing Management
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
healthcare needs would be when I left” was the lowest-scoring item of the three, with only 42.3% of patients answering the top-box response. The second question, “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health” scored the second lowest, with a top-box score of 51.6%, and the question “When I left the hospital, I clearly understood the purpose for taking each of my medications” was the highest scoring of the three, with a top-box score of 60.1%. (See Figure 1.) Top box is defined as the percentage of patients who answered “strongly agree” among possible response selections.6 These trends were similar throughout the different segmentations of data. Specialty hospitals performed better, with an aggregated top-box score of 59.6%, than nonspecialty hospitals, with an aggregated top-box score of 50.4% for the Care Transition Measures composite. Similarly, for both types of hospitals, the question “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left” performed the lowest, with a 42% top-box score for nonspecialty hospitals and a 52.6% top-box score for specialty hospitals. (See Figure 2.) Examining scores by service type, the question “During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left” performed the lowest among maternity care, medical, and surgical patients alike. In general, the Care Transition Measures performed the lowest among medical patients, with a top-box score of 38.1% for the www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Shifting from reactive to proactive tactics “The hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left the hospital.” Accounting for patient preferences involves matching the questions to the individual. This requires not only asking questions, but also asking the right questions.7 As part of the discharge planning process, clinicians will need to help the patient plan for exceptions to a greater degree than in the past. Taking preferences into account infers personalization of the patient encounter. The benefit of personalized information to a patient surpasses creating a welcome experience where a neurobehavioral connection also exists. Extensive research exists on neural networking models. Repeated stimulations of the same content build deeper cell-tocell bridges (synapses) within the brain. The more a pathway is used, www.nursingmanagement.com
Figure 3: Care Transition Measure performance by service type 80.0 69.6
70.0 60.0 % Top box
lowest performing question. The largest disparity in scores was for the question “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.” Medical patients reported a top-box score of 46.1% and maternity patients reported a top-box score of 63.3%, for a difference of 17.2%. (See Figure 3.) The challenge for organizations is translating the new hcahps questions from a source of patient feedback into action with intent. Knowing how to address each question requires a tactical answer. As a mandated and visible measure, can the organization improve its care transition processes quickly with agility while ensuring that existing processes are hardwired and new innovations are being implemented successfully?
50.0
63.3
59.2 45.8
54.4
47.7
46.3
55.2
55.4
63.5
46.1
38.1
40.0 30.0 20.0 10.0 0.0
Care Transition Measure composite Maternity care Medical Surgical
During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left.
the stronger it becomes and the more likely that information can be retrieved. Learning information through different modalities (hearing, seeing, touching) reinforces this process.8 Additionally, stress can produce an environment in which information is harder to retrieve. For populations at high risk for readmission, these individuals will encounter stress if there’s a need for intervention or treatment. Clinicians should have a strong education plan in place where content is reviewed multiple times before discharge in meaningful ways and discussed in a context that’s relevant to the patient. Retention increases through the creation of associations of previous knowledge with new information when content can be related to something the patient already knows. Personalizing information attaches the new content to the area of the brain that’s responsible for memories. When new information attaches to content already mastered, it helps put the fresh information into context. The new knowledge becomes stored as an integrated memory in
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
the frontal lobe of the brain where patterns of information become the pathways that memories can follow. This is known as relational memory.8 An effective method of personalizing the encounter is having the patient envision his or her home environment and inquiring “what if” while incorporating condition signs or symptoms and other aspects of care into a discussion of personal health goals. Imagery is used frequently by athletes to create an experience in the mind to feel ready for an event, plan strategies, and as a coping skill strategy to stay calm under pressure.9 An analogy is possible with the patient discharge planning process. Can the patient visualize the situations within his or her own environment that would prompt a need for follow-up with a physician? An assessment of the level of a patient’s support system, access to transportation, and ability to develop a plan should a situation arise can be conducted with the patient thinking about potential risk events within his or her own
Nursing Management • January 2015 27
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HCAHPS Series Part 1
context and creating linkages to information that’s already known. “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.” Patients and families have limited visibility into the healthcare world and processes that clinicians encounter every day. A need for hospitalization is due to an untoward event that can’t be managed independently. For most, unless the situation is a readmission or the patient has encountered previous hospitalizations, a hospital stay isn’t only fraught with new experiences, but also new questions, potential
before discharge for a safe transition across care settings. Using the structured format of “Ask Me 3” can lead to a deeper level of patient engagement in their care. The components of “Ask Me 3” include patients asking clinicians: “What’s my main problem?”; “What do I need to do”; and “Why is it important for me to do this?”11 Also, the use of openended questions helps the clinician proactively gauge the questions a patient or family may have, especially given their unfamiliarity of the situation. “When I left the hospital, I clearly understood the purpose for taking each of my medications.”
The ability to bridge patient feedback into tactical action provides the agility to move an organization forward from reactivity to proactivity. changes or additions in medications, modifications in daily diet and mobility parameters, and a myriad of other factors. It’s realistic to assume that patients and their loved ones may not know all of the questions that they should be asking before discharge. This is where the method of teach-back can help. Teach-back involves asking the patient to “teach back” what was said. When used correctly, it not only identifies where there may be challenges with health literacy, but also can help overcome barriers in understanding.10 Using teach-back helps the patient and clinician fully understand the information that’s being retained and pinpoint questions that still need to be answered
A lack of health literacy can be a barrier to ensuring proper care when a patient returns home. Health issues associated with older patients include 71% of adults over age 60 having difficulty using printed materials; 80% having difficulty with documents such as forms or charts, and 68% having difficulty interpreting numbers and performing calculations.12 To create an effective workaround, not only should hospital discharge medication information be provided in a font size large enough for those with visual difficulties to easily read the letters, but also the use of visual cues can be beneficial to reinforce instructions.13 Asking the family to fill prescriptions before discharge and conducting a final review with a take-home
28 January 2015 • Nursing Management
medication pillbox can reinforce understanding for patients who are considered high risk or take multiple medications. A second medication reconciliation process occurs in which the patient compares the medications already within the home environment with the medications to be administered after a period of hospitalization.14 A prefilled pillbox with a 1-week supply can reinforce the correct medication regimen with visual cues to ensure accuracy of subsequent set up. However, medication questions extend beyond the purpose of the medication and proper schedule of administration. In a 2004 study that examined the variation of medication understanding among older individuals, nearly 8% had a limited understanding across medications. The biggest issue was lacking a full understanding of the actions to take if a medication was missed. Although many individuals understood their medication regime (62%), individuals who had higher quantities of daily medications or lacked the understanding of multiple aspects of the medication were at higher risk for noncompliance.15 Involving the patient and family in the reconciliation process is a best practice for improving a patient’s medication management. For patients with complicated medication schedules, the hospital may want an additional education session conducted by the pharmacist with the patient and family, a follow-up phone call, and an in-home visit.16 If a patient doesn’t know a medication’s name, the medication’s purpose, how to administer a medication, or when to take the medication, a communication should occur with the primary care physician for additional education and reinforcement as part of the ongoing monitoring process. Additional www.nursingmanagement.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
parameters may include follow-up with patients prescribed more than five medications or having more than two medication changes during their hospitalization.16 Engaging in a medication routine can have different meanings for patients. Helping them understand the purpose of the medication goes beyond the functionality of a pharmaceutical for patient-centered care. Four themes have been identified regarding medication meaning for patients: a meaningful encounter, bodily effects, unremitting nature, and exerting control. Some statements by patients include “I felt like if I took lorazepam that I’m failing”; “It’s this constant thing that you wish you could have a break from, but you can’t”; “The first time somebody told me I would have to take that for the rest of my life I got mad.”17 Working through these issues with patients can influence their understanding of medications and coping with the responsibility of managing their health. An additional question that warrants attention is whether there has been a time when the patient was unable to afford his or her medications. Polypharmacy is a frequent phenomenon among older individuals.18 This is an area for focus when discharging patients with multiple medications, which may be new or continued, and older patients at risk for medication noncompliance due to financial issues. During times of financial hardship, patients may become faced with deciding which medications to fill when dollars are limited. If patients don’t fully understand the importance of their medications, outreach back to their provider may not occur when hard choices are made independently. This bypasses a discussion about potential resources that may be available within the community or a review of www.nursingmanagement.com
current medications and development of an action plan in coordination with the primary care physician.
Destination: Coordination Successful care transitions across settings will require the coordination of multiple providers across different care continuum settings. An initial starting point of focus for many organizations will be the three Care Transition Measures that became publically reported in October 2014. Family preferences, an understanding of health self-management, and comprehension of the purpose of medications are only the beginning of multiple areas of potential focus for ensuring the safety and self-knowledge of patients and families. The ability to bridge patient feedback into tactical action provides the agility to move an organization forward from reactively to proactively addressing the Care Transition Measures. In the second part of this series, we answer the question: Does leadership rounding make a difference on HCAHPS scores? NM REFERENCES 1. Centers for Medicare and Medicaid Services. HCAHPS fact sheet. http://www. HCAHPSonline.org/files/August_2013_ HCAHPS_Fact_Sheet3.pdf. 2. Greene J. How much do you boost your hospital’s bottom line? Formulas to help you calculate the clue that hospitalists bring to the table. http://www. todayshospitalist.com/index.php/index. php?b=articles_read&cnt=492. 3. Levinson DR. Adverse events in hospitals: national incidence among Medicare beneficiaries. http://oig.hhs.gov/oei/reports/ oei-06-09-00090.pdf. 4. Levinson DR. Hospital incident reporting systems do not capture most patient harm. http://oig.hhs.gov/oei/reports/oei-06-0900091.pdf. 5. Coleman E. CTM-3. http://www.caretransitions.org/documents/CTM_FAQs.pdf. 6. National Research Corporation Hospital and Consumer Assessment of Healthcare Providers and Systems (HCAHPS) database, 2014.
7. Morris T. 3 ways to personalize the customer experience without getting to personal. http://www.parature.com/ personalize-cx/. 8. Willis J. Research based strategies to ignite student learning. http://www.ascd.org/ publications/books/107006/chapters/ Memory,_Learning,_and_Test-Taking_ Success.aspx. 9. Yukelson D. Teaching athletes visualization and mental imagery skills. http:// www.mascsa.psu.edu/dave/VisualizationHandout.pdf. 10. Schwartzberg JG, Cowett A, VanGeest J, Wolf MS. Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists. Am J Health Behav. 2007;31(suppl 1): S96-S104. 11. National Patient Safety Foundation. Ask me 3. http://c.ymcdn.com/sites/www. npsf.org/resource/resmgr/Store/AskMe_ 8-pg_EN_ref-sample.pdf?hhSearchTerms= %22ask+and+3%22. 12. Glassman P. Health literacy. http:// nnlm.gov/outreach/consumer/hlthlit. html#A4. 13. Case Management Society of America. Case management adherence guidelines, version 2.0. http://www.cmsa.org/ portals/0/pdf/cmag2.pdf. 14. Volland J. Aligning hospital outcomes and accountability for patient safe transitions to home. California Association for Healthcare Quality Journal. 2011;35:18-21. 15. Spiers MV, Kutzik DM, Lamar M. Variation in medication understanding among the elderly. Am J Health Syst Pharm. 2004; 61(4):373-380. 16. Reducing Avoidable Readmissions Effectively. Medication Management. http://www.rarereadmissions.org/areas/ medmanagement.html. 17. Shoemaker SJ, Ramalho de Oliveira D. Understanding the meaning of medications for patients: the medication experience. Pharm World Sci. 2008;30(1):86-91. 18. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345-351. At the National Research Corporation in Lincoln, Neb., Jennifer Volland is vice president of Program Development and Sarah Fryda is a senior research associate. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000459101.17224.c3
Nursing Management • January 2015 29
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
