2013 CNL® Summit January 17-19, 2013 Abstract Submission Form Abstract title: Improving Care Transitions for High Risk Patients Authors & credentials: Doris Cahueque, MS, RN, CNL Institution: Mease Countryside Hospital City/State: Safety Harbor, Florida Primary Contact Email: doris.cahueque@baycare.org Instructions: Please complete each of the following sections, when applicable. Each section should contain between 50 and 250 words, using Times New Roman, 12 point font. Background Information: In September 2010, our 54 bed medical surgical orthopedic unit realized we had an opportunity to improve patient satisfaction with discharge information. The HCAHPS composite score for Discharge Information on our floor was 74.31%, below the national 50th percentile. With a desire to improve, we looked for solutions and decided to use Project BOOST (Better Outcomes for Older adults through Safe Transitions) and the Six Sigma methodology. After acceptance into the program and being assigned a mentor, a multi-disciplinary team was assembled which included physicians, nursing, pharmacy, and case management. Aim: Sponsored by the Society of Hospital Medicine, Project BOOST (Better Outcomes for Older Adults through Safe Transitions) is a comprehensive program aimed at significantly reducing hospital readmissions by optimizing care transitions from the hospital to home while improving communication among health care providers. The project goals were to: - Develop a process to more effectively identify and address patient discharge needs on admission, - Improve interdisciplinary communication, and - Improve patient care transitions. Our target was to improve patient satisfaction with discharge information from 74.31% to 82%, a 10% improvement. Methods/Programs/Practices: Using the Six Sigma methodology, the team identified barriers to discharge planning and then developed a number of tools and interventions to address them. The Patient Discharge Needs Assessment tool was designed to stimulate patient thoughts about their discharge needs, thus improving the opportunity for a safe and timely discharge. The patient and/or their family, rather ADVANCING HIGHER EDUCATION IN NURSING One Dupont Circle NW, Suite 530 ∙ Washington, DC 20036 ∙ 202-463-6930 tel ∙ 202-785-8320 fax ∙ www.aacn.nche.edu than the nurse, completes the tool on admission to the unit. The information helps the nurse address gaps in care and facilitates more open nurse-patient communication regarding discharge needs. Clinical Nurse Leaders, also known as Patient Care Leaders, along with Social Services, Physical Therapy, and Home Health began daily huddles to address any discharge needs identified on the tool. Clinical Nurse Leaders also began calling high-risk patients, such as COPD, heart failure, or polypharmacy patients after discharge to ensure they understood their discharge instructions and follow up care. Finally, a form was developed to standardize the documentation for patients transferred to an external facility. Outcome Data The combined efforts allowed us to identify discharge needs earlier in the patient stay and begin the necessary interventons to deal with the challenges. It improved interdisciplinary communication and awareness, specifically improving the working relationship with the hospitalists. As a result, by April 2012, patient satisfaction with discharge information had improved from 74.31% to 83.57%, a statistically significant improvement (P=0.000, 2 Sample T). Conclusion: Not only has our unit sustained the improvements, but our HCAHPS scores continue to improve. In addition, when compared to other med/surg/tele units in the hospital, our unit continues to receive the highest patient satisfaction score for the discharge information HCAHPS composite. Based on the success of these innovations, the tools are currently being replicated throughout the four hospital system. AACN Call for Abstracts, 2013 CNL Summit 2