Dondero, Lynette M, RN

Mathiesen, Claranne, RN, MSN, CNRN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksPatient Care Services / NursingIt's So Hard to Say Good-bye with DCI (DischargeInstructions)Lynette M. Dondero RNLehigh Valley Health Network, Lynette_M.Dondero@lvhn.orgClaranne Mathiesen RN, MSN, CNRNLehigh Valley Health Network, Claranne.Mathiesen@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/patient-care-services-nursingPart of the Neurosciences Commons, and the Other Nursing CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtDondero, L., Mathiesen, C., & Knapp, K. (2014, March 6). It's so hard to say good-bye with DCI (discharge instructions). Poster presentedat: The American Association of Neuroscience Nurses (AANN) 46th Annual Education Meeting, Anaheim, CA.© 2014 Lehigh Valley Health NetworkReferences:1.	 	Bobay,	K.,	Jerofke,	T.,	Weiss,	M.,	&	Yakusheva,	O.	(2010).		Age-Related	Differences	in	Perception	of	Quality	of	Discharge		Teaching	and	Readiness	for	Hosptial	Discharge.		Geriatric	Nursing.		34(3),	178-1872.	 	Gilboy,	N	&	Howard,	P.	(2009).		Comprehension	of	Discharge	Instruction.		Advanced	Emergency	Nursing	Journal.	30(1),	4-11.3.	 	Ostward,	S.,	Davis,	S.,	Hersch,	G.,	Kelley,	C.	&	Godwin,	K.		(2008).		Evidence-Based	Educational	Guidelines	for	Stroke		Survivors	after	Discharge	Home.		Journal	of	Neuroscience	Nursing.		40(3),	173-191.The stroke center RN led a multidisciplinary team that included a call center RN, case manager, and unit staff to develop a standard survey to assess patient/caregiver follow through on discharge instructions.  A pilot of the phone survey was revised to identify any stroke transition needs and included depression screening using the PHQ2 instrument.  Ongoing review of survey results ensured capture used survey findings to improve patient post discharge experience and reduce early readmission. Abstract & Introduction AbstractAs a comprehensive stroke center, we strive to encompass the entire care continuum.  This starts in the Emergency department and ends with return home. Recently, we have implemented a followup phone call process.  Our call center nurses survey patients within 7 days of discharge. Within the survey, they inquire about: provider’s appointments, prescription and therapy compliance, depression screening, and reinforcement of discharge instructions.  Our review of patient data has also lead to Stroke Center RN interventions including: medication clarifications, depression identification and follow up appointments.  It is through the eyes of our patients that we create simpler, specific discharge instructions. Our goal is to meet patient’s and caregiver needs for adequate communication to enable smooth transitions after hospital discharge. An implementation of follow up phone call process has potential to reduce readmissions, discover depression after stroke and enable a more comprehensive patient experience.IntroductionIn 2012, The Joint Commission added multiple standards in the Disease-Specific Certification requirements that address the discharge process of stroke patients.  In our journey for Comprehensive Stroke Center certification we needed to develop a process to monitor the percentage of stroke patients who receive a follow-up phone call within 7 days of discharge.Methods•  From Sept 2012 to Aug 2013, 413 eligible patients were identified with 66% participating in our survey process. 90% of patients reported compliance with filling prescriptions and making followup appointments. 11% of patients screened positive on PHQ2 depression screen prompting further assessment and referral for evaluation by provider. •  Commonly noted by Call Center RN’s were questions related to discharge instructions, medication reconciliation and timeliness of scheduling outpatient appointments.  Use of the Call Center RN provided immediate access to provider scheduling and referral to health management resources.  Implications for Practice•  Often patients do not fully understanding Discharge Instructions and have questions post hospitalization.•  In the first week after a hospitalization, patients and caregivers are often overwhelmed and appreciate assistance in navigating outpatient care.•  Screening for depression can help identify patients at risk and expedite appropriate evaluation.•  Extending the role of the Stroke Center RN bridges the critical period before patients are seen by primary care provider.•  Partnership between the acute care team and the Call Center RN has developed stronger processes to support transitions after hospitalization in patients discharged to home.•  Future work is needed to correlate impact of phone followup with readmission.Outcomes/Results & Implications Learning Objectives•  Investigate specific deficits in current discharge instruction through a survey conducted within one week of discharge.•  Promote standard follow up phone call for stroke patients discharged to home or homecare from the hospital.•  Develop evaluation plan to capture data from survey results and initiate actions to ensure patients’ compliance and safety.•  Stroke Center RN:	 	 –	 	Identify	stroke	patients	discharged	to	home/home	care	 	 –	 	Provide	list	to	call	center	RN	 	 –	 	Triage	call	findings	regarding	d/c	instructions,	medication	issues,	follow-up	appointments,		follow-up	positive	depression	screens	 	 –	 	Communicates	potential	patient	needs	or	issues	to	neurologist	and	primary	care	provider	 	 –	 	Analyze	findingsTeam Member Roles•  Call Center RN:	 	 –	 	Call	to	patient/caregiver	within	7	days	of	discharge	 	 –	 	Mail	survey	if	unable	to	reach	x	2	calls	 	 –	 	Assists	with	making	post	hospital		appointments	and	referrals	to	community	resources	 	 –	 	Refers	to	Stroke	Center	RN	if	PHQ	2	depression	screen		positive	 	 –	 	Reinforce	stroke	education	and	ensures	caregiver	materials	provided	 	 –	 	Recruit	patient	/	caregiver	for	stroke	support	groupDischarge Phone Call Process Flow  Stroke Center RN Identifies Eligible Stroke Patient    Forward List to Call Center RN   Call or Mail Survey to Patient	 	 –	If	issues													Stroke	Center	RN	 	 –		If	no	issues	-	Data	Collected2nd	call	byPatient SurveyLehigh Valley Health Network, Allentown, PAIt’s So Hard to Say Good-bye with DCI (Discharge Instructions)Lynette Dondero, BSN, RN, MSPH and Claranne Mathiesen, MSN, RN, CNRN

It\u27s So Hard to Say Good-bye with DCI (Discharge Instructions)

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1310&amp;context=patient-care-services-nursing

It\u27s So Hard to Say Good-bye with DCI (Discharge Instructions)

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