Improving Care Transitions for High Risk Patients

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: [email protected]
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.
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
- 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.
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
One Dupont Circle NW, Suite 530 ∙ Washington, DC 20036 ∙ 202-463-6930 tel ∙ 202-785-8320 fax ∙
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
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