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PreventingReadmissionswithDischargeEducation.pdf

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is a national focus for healthcare

reform. Consequently, patient dis-

charge education is increasingly

important for improving clinical

outcomes and reducing hospital

costs.

How does a nursing intervention

such as patient education impact

patient outcomes and healthcare

costs? According to the Centers for

Medicare and Medicaid Services

(CMS), nearly 20% of all Medicare

patients are readmitted to the hos-

pital within 30 days of discharge;

34% are readmitted within 90 days

of discharge.1

In 2012, the CMS began penal-

izing excess readmissions; these

penalties add up to about 1%

of Medicare payments. Almost

two-thirds of U.S. hospitals paid

the price in 2012. These fees

have increased up to a limit of

3% of total Medicare compensa-

tion. Typically amounting to over

$130,000 per penalized facility,

these fees have focused more

attention on the discharge pro-

cess and ways to prevent hos-

pital readmissions.1 This article

presents key educational tools

essential for preparing patients

to care for themselves at home,

improving patient outcomes, and

minimizing readmissions.

Reducing readmission risk

The CMS expects nurses and

other healthcare team members to

address modifiable factors that can

increase the chance of rehospital-

ization. These include:

• unplanned and early discharge or

insufficient postdischarge support

• inadequate follow-up

• therapeutic mistakes

• adverse drug events and other

medication-associated concerns

• failed handoffs

• complications after procedures

• patient falls, healthcare-associated

infections, and pressure ulcers.2

By Debra Polster, MS, APN, CCRN, CCNS

Preventing readmissions with

discharge education

Arm your patients with tools for success.

Reducing hospital readmissions

2 .0 CONTACT HOURS

Staff development special

32 October 2015 • Nursing Management www.nursingmanagement.com

Preventing readmissions with discharge education

Identifying patients at risk

for readmission up front and col-

laborating with care managers and

healthcare providers to minimize

the risk are essential. As many

as 79% of readmissions are con-

sidered preventable and a direct

result of uncoordinated care.2 The

Joint Commission recommends a

multifaceted approach to prevent

readmissions that includes expla-

nations of discharge instructions,

self-care, and ongoing or emer-

gency care; inventory of outpatient

resources/referrals; medication

reconciliation; and understandable

instructions for the patient and

family. A patient-individualized

approach noting preferred lan-

guage, culture, and the patient’s

health literacy level is also recom-

mended.3 When planning any care

transition, clinicians should draw

from a toolkit of effective patient

education strategies and resources

tailored to their patient population.

(See Meeting the standard of care for transitions.)

Baseline assessment

The multifaceted discharge pro-

cess begins on admission and

continues throughout the hospital

stay. The initial step is a baseline

patient assessment, including an

assessment of the patient’s risk of

readmission. Risk factors for read-

mission include clinical issues,

such as advanced chronic obstruc-

tive pulmonary disease (COPD),

heart failure, stroke, diabetes,

significant unintended weight

loss, depression, cancer, and

palliative care. Use of high-risk

medications, such as antibiotics,

glucocorticoids, anticoagulants,

opioids, antiepileptic drugs, anti-

psychotics, antidepressants, and

hypoglycemic agents, may also

increase the likelihood of readmis-

sion. Other factors raising the risk

include polypharmacy, previous

hospitalization (unscheduled hos-

pitalizations within the last 6 to 12

months), low health literacy level,

black race, and lack of social sup-

port with inadequate or no family

or friend contact by phone or in

person.4

Identifying a patient’s abil-

ity to perform self-care will help

the nurse prepare the patient for

discharge. According to Orem’s

Self-Care Deficit Theory, those

who can’t independently care

for themselves and need help for

everyday activities have a self-

care deficit.5 Other education

challenges include the nurses’

inability to identify patient self-

care deficits; for example, because

of limits to the time the nurse

can spend with the patient dur-

ing the admission. These deficits

may persist at discharge.6 Patients

who can’t care for themselves will

require additional resources, such

as home healthcare services or

physical therapy.

Nurses must dedicate time for

assessments and discharge teach-

ing. Effective patient teaching

requires uninterrupted blocks of

time. To support this, post signs

outside the patient’s room to

indicate a “do not disturb zone.”

Patient assignments may be

handed off so that the nurse can

give the patient his or her undi-

vided attention. Distractions, such

as the television, should be elimi-

nated and the patient needs to be

wearing any sensory aids he or

she normally uses, such as glasses

Meeting the standard of care for transitions21

Transition of Care Consensus Conference (TOCCC) guidelines published in 2009 are based on a multistakeholder consensus conference that included physicians, nurses, pharmacists, and representatives of governmental agen- cies. This team recommended that, at a minimum, the following data should be included in the transition record:

• principle diagnosis and problem list

• medication list (reconciliation), including over-the-counter medications/ herbals, allergies, and drug interactions

• patient’s medical home or the transferring coordinating healthcare provider/ facility and contact information

• patient’s cognitive status

• test results/pending results.

Ideally, the transition record should also contain additional details, such as:

• emergency plan, contact person, and contact number

• treatment and diagnostic plan

• prognosis and goals of care

• advance directives, power of attorney, and informed consent

• planned interventions, such as wound care • caregiver status.

The TOCCC report recommends that patients and their families/caregivers receive and understand the transfer record and be encouraged to participate in its development. All communication between patients, family, and caregivers must be secure and private, in compliance with the Health Insurance Portabil- ity and Accountability Act.

www.nursingmanagement.com Nursing Management • October 2015 33

or a hearing aid. (For more tips,

see Eye contact and other strategies.)

Assessing health literacy

A critical patient history element

is documentation of the patient’s

baseline knowledge and skills.

Patient educational assessments

should include health literacy,

defined as “the degree to which

individuals have the capacity to

obtain, process, and understand

basic health information and ser-

vices needed to make appropriate

health decisions.”7 A good way to

evaluate health literacy is to ask

patients to read their prescription

containers and explain how they

should take their medication.

An important component of

health literacy is reading ability

(literacy). This can be defined as

the ability to read, write, and speak

proficiently enough to function in

society and at work.7 A patient’s

ability to read instructions and

educational materials directly

affects his or her ability to adhere

to the medication regimen and

treatment plan. This is a challeng-

ing health issue for prescribers car-

ing for patients with low literacy

skills.3

A common misperception of

a patient with low literacy is that he

or she is deliberately nonadherent

with the health plan. Never forget

that a patient’s inadequate commu-

nication skills may not mean resis-

tance to the treatment plan or poor

intellect, but rather a low skill level.

People with low literacy skills may

have the capability to build up these

skills but haven’t had the chance to

do so for any number of reasons.8

Determining reading

level and readability

All education materials should

include a determination of literacy

level. Various formulas are avail-

able to ascertain the patient’s

reading grade level based on such

factors as sentence length and

word difficulty.

Keep in mind that the grade

level a patient completed in school

isn’t necessarily a good indicator of

reading ability. Rather than asking

about years of formal education,

the nurse should use a validated

assessment tool to assess literacy.

For example, The Newest Vital

Sign is a fast and precise bilingual

(English and Spanish) screening

test for general literacy, numeracy,

and comprehension skills applied

to health information.9 Numerancy

(math) skills are needed for many

health-related activities, such as

measuring medications; reading

food labels; and choosing among

health plans with differing pre-

miums, copays, and deductibles.10

This tool is intended for use in

primary care settings.

The Single Item Literacy

Screener has also been found to

have good sensitivity for evaluat-

ing a patient’s literacy and read-

ing skills when weighed against

other validated tools.11 To use it,

the nurse asks one question: “How

often do you need to have someone

help you when you read instruc-

tions, pamphlets, or other writ-

ten material from your doctor or

pharmacy?” The patient chooses

an answer from never (1) to always

(5). A score of 2 or more suggests a

need for literacy assistance.9

Patient education websites,

printouts, animations, and more can

be used at the bedside to help edu-

cate patients with low literacy skills.

Printed materials should be prepared

at the appropriate literacy level and

visual aids tailored to the patient’s

medical condition and needs.

As a general rule, patient educa-

tion materials should be written

at the eighth grade level or lower.8

Keep in mind, however, that an

appropriate reading level is only

one component of an effective

patient education tool.

Visual enhancements

Understanding how adults learn

can help nurses tailor education

to a patient’s advantage. (See Con- sider the patient’s learning style.) For

example, one patient may learn

best from reading printed instruc-

tions; another may prefer to watch

a demonstration. Blending ele-

ments from multiple adult learning

styles increases the likelihood that

patients will remember essential

information.

Eye contact and other strategies4

The AHRQ offers these suggestions for establishing and maintaining rapport with the patient during education sessions:

• offer a warm greeting

• establish eye contact

• slow down

• use plain, nonmedical words

• limit content

• use the teach-back technique

• repeat key points

• involve the patient, family, and significant others (with the patient’s permission)

• use visual displays to reinforce information.

34 October 2015 • Nursing Management www.nursingmanagement.com

Preventing readmissions with discharge education

Most people are visual learners,

so educational visual aids enhance

understanding and encourage

adherence to a treatment plan. Use

of visuals with animations or hand-

outs can be helpful. Large fonts,

colorful pictures, adequate white

space on the page, and key points

that are bulleted for emphasis are

all essential components. The use

of nonprinted educational materi-

als, such as video and audiotapes,

demonstrations, models, picto-

grams, and other visuals, is another

option.

Role-playing instructions and

simulation with the patient and

family can also be a valuable strat-

egy for patient learning. Work with

props and real equipment when

indicated. For example, nurses

should use crutches when explain-

ing how to use them correctly, or a

real wound dressing when teach-

ing about wound care. Including

the appropriate learning style will

increase the likelihood that patients

will remember the essential infor-

mation presented.9

Cultural competence

Cultural competence also influ-

ences the nurse’s ability to com-

municate meaningfully with the

patient. Cultural competence

allows the nurse to deliver care

in a way that’s considerate of and

responsive to the patient’s health

beliefs, practices, and culture.

According to the National Insti-

tutes of Health, “culture is often

described as the combination of a

body of knowledge, a body of belief,

and a body of behavior. It involves

a number of elements, including

personal identification, language,

thoughts, communications, actions,

customs, beliefs, values, and institu-

tions that are often specific to eth-

nic, racial, religious, geographic, or

social groups.”12 The nurse should

note these elements that influence a

patient’s beliefs about health, heal-

ing, wellness, illness, disease, and

delivery of health services.

With mounting concern for racial,

ethnic, and language disparities in

healthcare and the call for health-

care systems to support ever more

diverse patient populations, lan-

guage access services have become

increasingly a matter of national

importance. All nurses who are

responsible for patient education

should take part in formal educa-

tion in cross-cultural healthcare to

develop a full appreciation of how

culture and language influence

healthcare.12 Even bicultural and

bilingual nurses will be prompted

to serve patients with cultural and

language preferences that are differ-

ent from their own. Nurses should

work toward cultivating cultural

self-awareness, avoid making

assumptions about patients’ needs,

and be receptive to learning from

the patients themselves.

Plain talk about communication

According to The Joint Commission,

clear and effective communication

is a cornerstone of patient safety.13

When explaining a condition or

treatment, nurses must use plain

language to communicate as clearly

as possible. The message can get

lost in translation when nurses use

medical terminology that patients

don’t understand. Examples of

communicating in plain language

include using simple or everyday

language instead of medical or

nursing jargon, breaking down

complex information into smaller

chunks, and speaking directly to the

patient using active (not passive)

voice.7

When talking with the patient,

nurses need to speak slowly and

focus on the most significant “must

know” information, using the least

amount of information possible.

The most essential information

should be provided either first or

last, making important points clear.

Nurses should review, clarify, and

reteach as necessary.3

Encouraging patients to ask ques-

tions helps the nurse assess how

well the patient understands the

information being taught. Accord-

ing to the Agency for Healthcare

Research and Quality (AHRQ),

patients can feel embarrassed to

ask questions or may not even

know what questions they need to

ask.4 The following are tips from

Consider the patient’s learning style19,20

Adult learners respond best to an educational approach that suits their learn- ing style, which can be defined as an approach to learning based on individual strengths, weaknesses, and preferences. Although many people have one pre- ferred learning style, they benefit most from teaching that incorporates several other styles as well. Learning styles can be categorized as follows:

• verbal—written or spoken words

• visual—pictures, images

• aural—sounds, music

• physical (kinesthetic)—sense of touch

• logical—reasoning, systems

• social—a preference for learning in groups

• solitary—a preference for self-study, working alone.

www.nursingmanagement.com Nursing Management • October 2015 35

the AHRQ to help nurses promote

questions throughout the patient

encounter:

• Don’t appear rushed. Patients are

reluctant to ask questions if they

think nurses are too busy to talk

with them.

• Tell patients that you expect ques-

tions. For example, you could say,

“That was a lot of information. I’m

sure you must have questions.”

• Avoid asking a yes-or-no question,

such as, “Do you have any ques-

tions?” Patients often say no even if

they do have questions.

• Listen without interrupting.

Questions may emerge as the

patient talks.

• Encourage family members to

ask questions, too.4

The Ask Me 3 patient educa-

tion program was created by the

National Patient Safety Foundation

to help encourage effective commu-

nication between patients and care

providers with the goal of increas-

ing patient comprehension.14 This

program prompts patients to ask

about three things before ending an

encounter with a healthcare profes-

sional: What is my main problem? What do I need to do? Why is it impor- tant for me to do this? The National

Patient Safety Foundation recom-

mends encouraging patients to ask

as many questions as necessary for

complete comprehension.

Another tool, the AHRQ’s “Ques-

tions Are the Answer” campaign,

builds on 10 basic questions to

promote better communication

between patients and their health-

care team.15 Using the AHRQ’s

“question builder” tool, patients can

focus and individualize these basic

questions to learn more about their

medications, diagnostic studies, and

recommended treatments. Creating

an inventory of individualized ques-

tions can empower patients by help-

ing them get the information they

need to make educated choices about

their healthcare.

The teach-back technique

Also known as the “show-me”

method, the teach-back technique is

one of the simplest ways to bridge

the communication gap between

nurse and patient.9 It’s intended to

help the nurse verify the patient’s

understanding of new knowledge

and skills. An important point to

remember is that teach-back isn’t a

test of the patient’s knowledge; it’s

a way to confirm that the nurse has

explained what the patient needs

to know in a way that the patient

understands. This process can also

help staff members learn which

descriptions and communication

techniques work best with their

patients.

From the North Carolina Pro-

gram on Health Literacy, here

are a few suggestions for nurses

using the teach-back technique in

a patient teaching session.

• “I want to be sure that I explained

your medication correctly. Can you

tell me how you’re going to take

this medicine?”

• “We covered a lot today about

your diabetes, and I want to make

sure that I explained things clearly.

So let’s review what we discussed.

What are three strategies that will

help you control your diabetes?”9

Documentation

Accurate and timely documenta-

tion in the electronic health record

should reflect evaluation of knowl-

edge and skills taught and learned,

and demonstrated by the patient

in return. Documentation should

include the patient’s preferred learn-

ing style; barriers identified, such as

low literacy skills or limited finan-

cial support; preparedness to learn;

and relevant clinical information,

such as a new diagnosis or poorly

managed pain. Resources and sup-

port available at home should be

recorded with perceived barriers,

interventions to overcome barriers,

and outcome achieved.

Application to chronic diseases

One of the most common dis-

eases that require rehospitaliza-

tion within 30 days of discharge

is COPD. Patient teaching during

stable periods is recommended to

educate patients about self-care.

Many patients with COPD rely

on self-taught self-management

strategies during exacerbations

that they may not report. This sug-

gests that clinicians should give

more comprehensive education;

for example, teaching patients

Patients are reluctant to ask questions if they think nurses are too busy to talk with them.

36 October 2015 • Nursing Management www.nursingmanagement.com

Preventing readmissions with discharge education

about triggers to avoid, signs and

symptoms of exacerbations, strat-

egies to manage exacerbations,

and information about medica-

tions. When nurses simplify treat-

ment regimens and verify patient

knowledge and skill with new

inhalers, patients are better able to

self-manage their treatment and

prevent exacerbations.

Another common chronic disease

requiring in-depth education is dia-

betes. The American Diabetes Asso-

ciation (ADA) Standards of Medical Care in Diabetes provides clear guide-

lines for discharge planning and self-

management education.16 The ADA’s

revised recommendations published

in 2015 reinforce the importance

of diabetes education: “People with

diabetes should receive diabetes

self-management education (DSME)

and diabetes self-management

support (DSMS) according to the

national standards for DSME and

DSMS when their diabetes is diag-

nosed and as needed thereafter.”17

In an effort to improve self-

management of diabetes care,

discharge plans should include at

minimum:

• medication reconciliation. To

ensure continuity of the medica-

tion regimen, the patient’s medica-

tions must be verified to be sure no

essential medications were discon-

tinued and to ensure the safety of

new prescriptions. Ideally, prescrip-

tions for new or updated medica-

tions should be filled and discussed

with the patient and family at or

before discharge from the hospital.

• structured discharge communica-

tion. Information on medication

updates, lab tests and procedures,

and follow-up requirements must

be precisely and promptly com-

municated to outpatient providers,

including the primary care provider.

When the inpatient healthcare pro-

viders schedule follow-up visits

before discharge, the appointments

are more likely to be kept.

Outcome assessment

Metrics, including readmission

rates for patients at high risk for

COPD exacerbations, acute myo-

cardial infarction, pneumonia, and

heart failure, should be monitored

to determine education program

success. Patient satisfaction scores

for printed discharge instructions

may also reflect a practice change.

Ultimately, assessment and evalu-

ation of the patient’s new knowl-

edge and skills is the primary

goal of education.

Outcome evaluation can also be

determined in postdischarge phone

calls. Many hospitals have devel-

oped call centers to ensure follow-

up phone calls are consistently

made. A phone call may reveal that

the patient needs additional sup-

port at home. Follow-up visits with

healthcare providers may provide

additional support when indicated.

The literature notes a correla-

tion between improved nurse

knowledge and improved patient

knowledge.18 Nurses should seek

additional resources to build their

teaching skills. (For examples, see

the Nursing Management iPad app.)

Set patients up for success

Literacy, cognition, education level,

socioeconomic status, and level of

social support all contribute to a

patient’s adherence to discharge

instructions. Careful attention to

providing an individualized care

plan will set the patient up for suc-

cess. A well-orchestrated team of

nurses, healthcare providers, thera-

pists, pharmacists, respiratory care

providers, dietitians, and care manag-

ers can reduce readmissions, improve

the patient experience, and enhance

the patient’s quality of life. NM

REFERENCES

1. Centers for Medicare and Medicaid Services. Readmissions reduction program. www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ AcuteInpatientPPS/Readmissions- Reduction-Program.html.

2. Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599-605.

3. Schyve PM. The importance of discharge planning. www.commonwealthfund.org/~/ media/Files/Resources/2009/Reducing%20 Readmissions/Schyve_commonwealth.pdf.

4. Agency for Healthcare Research and Quality. Guide to patient and family engagement in hospital quality and safety. www.ahrq.gov/professionals/systems/ hospital/engagingfamilies/index.html.

5. Nursing theory. Self-care deficit theory. http://nursing-theory.org/theories-and- models/orem-self-care-deficit-theory.php.

6. Holland DE, Rhudy LM, Vanderboom CE, Bowles KH. Feasibility of discharge plan- ning in intensive care units: a pilot study. Am J Crit Care. 2012;21(4):e94-e101.

To build rapport with the patient, nurses should begin teaching sessions by offering a warm greeting and establishing eye contact.

www.nursingmanagement.com Nursing Management • October 2015 37

7. Health.gov. Quick guide to health literacy. www.health.gov/communication/literacy/ quickguide/factsbasic.htm.

8. Cornett S. Assessing and addressing health literacy. Online J Issues Nurs. 2009;14(3).

9. North Carolina Program on Health Literacy. www.nchealthliteracy.org.

10. National Numeracy. What is numeracy? www.nationalnumeracy.org.uk/what-is- numeracy/index.html.

11. Morris NS, MacLean CD, Chew LD, Litten- berg B. The single item literacy screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006;7:21.

12. National Institutes of Health. Clear communication: cultural competency. www.nih.gov/clearcommunication/ culturalcompetency.htm.

13. The Joint Commission. “What did the doctor say?” Improving health literacy to protect patient safety. www.jointcom

mission.org/assets/1/18/improving_ health_literacy.pdf.

14. National Patient Safety Foundation.Ask me 3. www.npsf.org/?page=askme3.

15. Agency for Healthcare Research and Quality. Questions are the answer. www. ahrq.gov/apps/qb.

16. Standards of medical care in diabetes. IX. Diabetes care in specific settings. Dia-

betes Care. 2013;36(suppl 1):S45-S49. 17. Standards of medical care in diabetes—

2015. Diabetes Care. 2015;38(suppl 1): S20-S30.

18. American Association of Colleges of Nursing. Creating a more highly qualified nursing workforce. www.aacn.nche.edu/ media-relations/fact-sheets/nursing- workforce.

19. Dictionary.com. Learning style. dictionary. reference.com/browse/learning+style.

20. Learning styles online.com. Overview of learning styles. www.learning-styles-online. com/overview.

21. Snow V, Beck D, Budnitz T, et al. Transi- tions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emer- gency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.

Debra Polster is a critical care clinical nurse specialist and the discharge project facilitator at Advocate Illinois Masonic Medical Center in Chicago, Ill.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

Adapted from Polster D. Patient discharge information: Tools for success. Nursing.

2015;45(5):42-49.

DOI-10.1097/01.NUMA.0000471590.62056.77

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