chan intervention strategy- post-discharge follow up

chan intervention strategy- post-discharge follow up

by Brian -

From the perspective of the providers

  1. Tool—type: Alert
  2. Target Population: provider/ hospital system administration 
  3. Target Behavior:
    1. 1.     Improve provider follow up behaviors / completing contact and reaching pt within certain time
  4. PRECEDE Category:
    1. Pre-disposing- why one should change – do they know how to do it. (predisposing factors)
    2. Enabling- make it easy to do –built in work flow
    3. Reinforcing- align rewards/penalties. Incentivize providers to schedule and complete these post-discharge communications
  5. Platform: telephone/

 

 

B. For a multi-tool intervention strategy, use the PER worksheet attached to describe how you will address each of the PRECEDE framework components (Predisposing, Enabling and Reinforcing). You may download this PER worksheet and/or copy/paste.

 

PER Worksheet. 

 

Target Behavior

Completion of post-discharge follow up communication

Target Audience

Discharge planners

Other Key Individuals

Attending physicians, Outpatient clinicians, nurse care managers

PREDISPOSING

ENABLING

REINFORCING

KNOW

BE ABLE TO DO (skills)

REMINDED

Inpatient teams should know what 2-3 main problems may arise upon discharge to home.

Hospital staff familiar with patients hospital course/mgt plan be able to touch base with patients post-hospitalization

Reminders/alerts built into discharge order set

 

Email communication from provider to discharge planner re: what needs to f/up on, immediate concerns/questions.

 

 

 

BELIEVE/VALUE

ACCESS TO

POSITIVE REINFORCEMENT

Continuity of information/follow up is good for patient care

Patient phone numbers and medical chart/communication

Documentation of call/contact in patient chart

 

Metrics can be documented and reported each month.

 

 

 

INTENTION

ACCESS REMOVED

NEGATIVE REINFORCEMENT

Discover problems or issues that arise before requiring readmission/ED visit

 

Additional resources/burden on hospital staff/case managers/ physicians. Issues that arise on phone calls will need to be dealt with by hospital personal ? vs clinic personel? Missed phone calls? Lack of phone ?

 

 

 

OTHER

 

SOCIAL SUPPORT

 

 

Institutional pressure

 

 

Peer pressure from colleagues

 

 

 

 

 

 

 

 

 

 

Re: chan intervention strategy- post-discharge follow up

by JESSICA COHAN -

Hi Brian,

As I have told you before, I think this is a GREAT idea.  I think it will be really important to have a defined person/people on each service that is responsible for this phone call.  The challenge is that everyone is already super busy so if you don't make it clear who is expected to do it, I think it will be more likely to get overlooked.  This may need to be a different person on each team depending on the structure and may need to be decided on by the team but somehow you will need to figure out how to help them ensure that the intervention is sustainable in spite of this.  

Good luck!

Re: chan intervention strategy- post-discharge follow up

by Grace -

Hey Brian,

In reading this I thought of the electronic system that the VA uses (CPRS), I know they have reminders scheduled into the chart and the reminders need to be cleared. For example, regular PTSD and alcohol screens based on the patient's history.  I was thinking for your project if there would be a way to make these reminders in the chart and have them required to be cleared after the phone-call is made. Just a thought.

Re: chan intervention strategy- post-discharge follow up

by Lisa Thompson -

Hi Brian, Nice job!

You stated that a reinforcing factor would be to "Incentivize providers to schedule and complete these post-discharge communications". What incentives were you planning to use?

In positive reinforcement you mentioned "metrics" to be evaluated, would these be reduced number of re-admits within 1 week of hospitalization? Are there other metrics that could be directly associated with phone call follow-up that incentivize the discharge planner to complete the calls? After lecture today, getting non face-to-face calls reimbursed would be a great idea! 

In the enabling column,one "access removed" would be building time into the schedule to make the calls and allow for consult time to address issues that come up during the phone call.

 

Re: chan intervention strategy- post-discharge follow up

by Ralph Gonzales -

or another way to think about "Access Removed" is "what things can we remove that will improve access to the behavior of interest?"… so here this would include removing competing time demands (like protecting 30-60 minutes each day from other activities to concentrate on the readmission stuff).