Problems at Discharge:
Closing The Gap On
“Self-Management” and
Readmissions
Bradi B. Granger, PhD, RN, FAHA, FAAN
Duke Heart Center Nursing Research
Program
Avoidable Readmissions Associated with Poor
Discharge Readiness
• Problem
– “Readiness” for discharge inadequate in 50-70% cases
– Rate of readmission is high (20% in HF in 30 days)
– Costs are high ($32 billion/year)
• Innovative Solution to Close the Gap
–
–
–
–
Communication at discharge – Medication reconciliation (AHRQ)
Skill-based education – The Joint Commission criteria
Communication at follow-up – EHR Meaningful Use, calls, visits,
Behavioral economics - Technology to reinforce beliefs, behaviors
• The Patient’s View
– Shared goals and skill-based learning for medication management
• Future of Improving Care Transition – skills in context
National GAPS in Care Transition Resources
• Inpatient resources
– Discharge preparedness checklist (AHRQ): APP, Care Nurse, PRM
• GAP- Medication-education (arrangements for payment - medications,
f/u appointment transportation and cardiac rehab)
– Follow up at 48 hr: Call center personnel, Call algorithm
• GAP- Medication access facilitator (both payment and transportation)
• GAP – Provider communication- common location for documentation
• Outpatient resources
– Appointment attendance verification: Call center personnel, Maestro
– SDA, specialty and PCP clinic care: good review/reinforcement
• GAP – Medication management skills, transportation for f/u
• GAP – Meaningful Use criteria: MyChart access , Bi-Directional
communication 
• GAP – Post d/c patient access to literacy appropriate d/c instructions
• GAP – Provider communication- common location for documentation
3
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4
We DON’T HAVE - Pillbox Continuity Model
The Drag & Drop Pillbox:
Patient-Centered, Skill-Based
Medication Management
Funded by The Duke Endowment
Skill-Based Learning Improves Outcomes
Simulation improves:
– Learner confidence
– Learner knowledge
– Learner performance
– Learner critical thinking
15
http://www.youtube.com/watch?v=ilpOR1lS7Lk
16
17
Drag and Drop:
Skill-Based Learning Improves Outcomes
• Medication Literacy
• Patient Confidence and Performance
• Data Capture and Real-Time Feedback
– Med Ed and Med Rec in “learning healthcare systems”
– Real-time data and feedback to improve med outcomes
• Patient-Provider Engagement
• Shared Goal Setting
• Meaningful Use
Graphic courtesy of DIHI (Mark Dakkak and RJ Andrews)
20
What Works for Patient Adherence to Guidelines?
Programs to Combine Proven, Scalable Interventions
• Communication at discharge
– Teach-back improves shared goal setting and access
• Skill-based educational methods
– Teach-back improves medication adherence
• Communication at follow up (phone or visit)
– F/U calls (two-way interaction) provide reminders
– Telephone technology (modules) improve engagement
– F/U in community settings improve sustainability
• Feedback to reinforce beliefs
– Behavioral economics + influence health behaviors
– Home monitoring devices improve two-way engagement
21
Broad Implications for Drag & Drop Pillbox
• The Joint Commission Accreditation goals
– National Patient Safety Goal 03.06.01 revised elements
– “maintain and communicate accurate patient med info”
• CMS Process of Care Core Measures
– www.hospitalcompare.hhs.gov/
– Incorporation of med rec list in discharge instructions
• Consumer Assessment of Healthcare Providers/Systems
(HCAHPS and CAHPS) www.hcahpsonline.org/home.aspx
• Meaningful Use of Electronic Health Records
– HITECH Act