When a patient begins receiving home health services, they may not be thinking about what will happen when the care episode ends. However, home health organizations need to start thinking about discharge right away – even during the initial intake of a new patient – to ensure the patient will be set up for success and improved outcomes.
Several hospitals have improved their discharge process by using the IDEAL discharge planning process. Arlene Maxim, RN, HCS-C, Senior Vice President of Clinical Services for Axxess, encourages home health organizations to use this process to ensure better patient outcomes and improve scores for value-based purchasing.
IDEAL Discharge Planning
The acronym IDEAL represents the following attributes of discharge planning:
- Include the patient and family as full partners in the discharge planning process.
- Discuss with the patient and family five key areas to prevent problems at home.
- Educate the patient and family in plain language about the patient’s condition, the discharge process and next steps at every opportunity throughout the episode.
- Assess how well clinicians have explained the diagnosis, condition and next steps in the patient’s care to the patient and family and use teach back.
- Listen to and honor the patient and family’s goals, preferences, observations and concerns.
These elements of discharge planning integrate health literacy, patient-specific needs and improving the patient experience, which are priorities for the Centers for Medicare and Medicaid Services (CMS).
“As we look at the Quadruple Aim from CMS, that is a very important part, making sure that that patient and family is integrated in every single piece of care that we provide to the patient, including teaching,” Maxim said.
Steps to Take Every Visit
On every visit during an episode, clinicians should make sure they’re educating the patient and family about the diagnosis and any medications. Maxim encourages clinicians to incorporate ‘teach back’ by asking the patient and family to repeat back the information and ensure their understanding.
“Not understanding medications is the number one reason patients are re-hospitalized,” Maxim said. “Making sure they understand the medications and do the ‘teach back’ will be really, really important for organizations scoring well [on value-based purchasing] at discharge.”
Clinicians should also discuss the patient’s progress toward their goals of care at every visit.
“We have to work toward those goals,” Maxim said. “We can’t just put it down as a line item on the plan of care. It has to be something we’re actually going to listen to the patient about, understand why they want that goal and whether or not it’s an appropriate goal to make for that patient.”
Maxim also encourages involving the patient and family in all care practices throughout the visit. It’s important to have family caregivers learn along with the patient to support them during and after the episode of care.
“I encourage team responsibilities in discharge planning,” Maxim said. “The family members have a responsibility to make sure that the discharge goes smoothly and the patient’s being taken care of.”
Discharge Planning for Value-Based Purchasing
Value-based purchasing scores come from three data sources: Outcome Assessment and Information Set (OASIS) items, Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores and hospitalizations or emergency room visits. All three of these areas are impacted by discharge planning.
“With value-based purchasing, discharge has taken on a whole new look,” Maxim said. “We have to make sure that what we’ve taught … [the patient and family] really understand and that we’ve made an impact on keeping them out of the hospital, keeping them safe at home. That’s exactly what we need to do.”
Axxess Home Health, a cloud-based home health software, includes tools for patient and family education and documentation of the teach back process in the clinical record for improved outcomes.
