School of Medicine and Health Sciences Poster Presentations

Title

The Patient Passport: A Patient-Centered Discharge Intervention to Reduce Readmissions

Poster Number

297

Document Type

Poster

Publication Date

3-2016

Abstract

Background: The transition of care from the inpatient to outpatient setting is complicated, often resulting in adverse events and subsequent readmissions, higher costs, and worse patient outcomes. Inadequate patient education, incomplete discharge instructions, and lack of patient understanding of medication changes, post-discharge follow up plans, and their reason for hospitalization remain significant areas for improvement. Efforts to address these challenges in transitions of care are at the forefront of many Quality Improvement (QI) endeavors.

This QI study focuses on a specific step in the complicated discharge process by implementing a patient-centered discharge tool called a Patient Passport, with the goal of improving patient understanding of the discharge plan in attempt to reduce avoidable readmissions by 10% by December 2016.

Methods: Five PDSA cycles were carried out over six months, with the primary objectives being to design an effective, evidence-based Patient Passport, assess how to best incorporate it into the current discharge process, evaluate barriers to completion and collection of the survey, and pilot incremental changes to the survey and its distribution and collection process. The primary outcome measure is reduction in readmission rates to the Medicine floor at GW Hospital. Interim process measures that are currently being used include: Number of Passports distributed per PDSA cycle; number of Passports collected per PDSA cycle; number of Passports completed per PDSA cycle; and barriers to distribution and collection.

Results: Barriers were encountered in piloting the Patient Passport for discharge, ranging from logistical issues (pen availability), to time constraints for the nursing and medical staff, to lack of a systemic distribution and collection system for the Patient Passport, resulting in Passports getting lost. These barriers will be systematically addressed in future PDSA cycles, as noted below.

Conclusions & Next Steps: A patient-centered intervention to improve the transition of care from the inpatient to the outpatient setting has great potential in reducing avoidable readmissions. At GW Hospital, a systematic process needs to be put in place to distribute and collect the Patient Passport such that the implementation can be scaled up, and the percentage of readmissions appropriately measured. Subsequent PDSA cycles will focus on the design of a distribution and collection process with the initial scale up to be completed on the Gold Team on the cardiac floor of the hospital. Active participation of nursing staff, medical staff, and hospital administrators will be essential in ensuring the success of this endeavor to reduce readmissions.

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Presented at: GW Research Days 2016

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The Patient Passport: A Patient-Centered Discharge Intervention to Reduce Readmissions

Background: The transition of care from the inpatient to outpatient setting is complicated, often resulting in adverse events and subsequent readmissions, higher costs, and worse patient outcomes. Inadequate patient education, incomplete discharge instructions, and lack of patient understanding of medication changes, post-discharge follow up plans, and their reason for hospitalization remain significant areas for improvement. Efforts to address these challenges in transitions of care are at the forefront of many Quality Improvement (QI) endeavors.

This QI study focuses on a specific step in the complicated discharge process by implementing a patient-centered discharge tool called a Patient Passport, with the goal of improving patient understanding of the discharge plan in attempt to reduce avoidable readmissions by 10% by December 2016.

Methods: Five PDSA cycles were carried out over six months, with the primary objectives being to design an effective, evidence-based Patient Passport, assess how to best incorporate it into the current discharge process, evaluate barriers to completion and collection of the survey, and pilot incremental changes to the survey and its distribution and collection process. The primary outcome measure is reduction in readmission rates to the Medicine floor at GW Hospital. Interim process measures that are currently being used include: Number of Passports distributed per PDSA cycle; number of Passports collected per PDSA cycle; number of Passports completed per PDSA cycle; and barriers to distribution and collection.

Results: Barriers were encountered in piloting the Patient Passport for discharge, ranging from logistical issues (pen availability), to time constraints for the nursing and medical staff, to lack of a systemic distribution and collection system for the Patient Passport, resulting in Passports getting lost. These barriers will be systematically addressed in future PDSA cycles, as noted below.

Conclusions & Next Steps: A patient-centered intervention to improve the transition of care from the inpatient to the outpatient setting has great potential in reducing avoidable readmissions. At GW Hospital, a systematic process needs to be put in place to distribute and collect the Patient Passport such that the implementation can be scaled up, and the percentage of readmissions appropriately measured. Subsequent PDSA cycles will focus on the design of a distribution and collection process with the initial scale up to be completed on the Gold Team on the cardiac floor of the hospital. Active participation of nursing staff, medical staff, and hospital administrators will be essential in ensuring the success of this endeavor to reduce readmissions.