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2020 CASE MANAGEMENT PRACTICE IMPROVEMENT AWARD

PROJECT TITLE: Health Confidence & Simulation: A Novel Approach to Patient Education to Improve Patient Engagement & Reduce Readmissions

RECIPIENT: West Suburban Medical Center

CATEGORY: Patient Education

ABSTRACT: A review of the literature demonstrated that addressing the patient's “point of view” through a survey of risk focused on Social Determinants of Healthcare (SDoH) has been successful at creating better linkage and access to care/services needed by patients to self-manage their health. Using a survey tool based on the “PRAPARE” survey (used in outpatient settings), CM RN & SW surveyed all readmitted patients and identified and addressed gaps in self-management by providing community resources and services.  This had a minimal impact on the readmission rate for this patient population.  When the results obtained from this survey in the first three (3) months of data collection were evaluated, it demonstrated that the primary self-identified reason for readmission was a lack of understanding of the discharge instructions provided.  One of the leading SDoH factors has been identified as health literacy, defined by the Agency for Healthcare Research and Quality as “the degree to which an individual can obtain, process, and understand basic health information and services needed to make appropriate health decisions“(Jordan, 2016).  Health literacy differs from “basic literacy” in that it is more than the basic ability to read. According to Linda Jordan BSN RN, MHCM (2016) from The Joint Commission, “everyone, no matter how educated, is at risk for misunderstanding health information, especially if the issue is emotionally charged or complex”.  Further complicating the communication between healthcare providers and healthcare consumers is the potential for misunderstanding the information presented but feeling embarrassed to ask questions, seek clarification, or confirm their understanding.  Health literacy has a major impact on patient engagement or activation.  Dr. Eric Coleman notes that “engaged patients have better health outcomes and better healthcare experiences and are likely to use fewer healthcare services and cost the healthcare system less in case of dollars” (Wasson & Coleman, 2014). One measure of patient engagement is “health confidence” scoring, measured by the response to a single question: “How confident are you that you can control and manage most of your health problems?”  Rated on a scale of 0 (not confident) to 10 (very confident), with a desired response of 7 or higher; this single question can start a meaningful conversation between practitioner and patient and lead to increased health literacy, understanding, and engagement.

After the initial evaluation, the health confidence scoring tool was added to our survey. Of the 146 patients surveyed between November 2018 and July 2019, the average Health Confidence Score was 6.41 out of 10. This finding was interpreted that this patient population needed more intense case management interventions and more focused education better to prepare them for discharge and independent condition management.  Case managers have long made the connection between Social Determinants of Healthcare (SDoH) and increased risk for readmission through anecdotal observation.  Failure to create overarching strategies to address the gaps caused by SDoH continues to impact the care continuum’s ability to adequately equip the patient for success post-discharge.  Addressing patient health literacy and health confidence is as much a necessity as identifying patient’s extra-medical needs and linking them with needed services and resources to provide the patient with excellent patient-centered care, promote client self-advocacy and independence in alignment with the CMSA Standards of Practice (Morley & Walker, 2019).  

The vision for this project was to create an inpatient education intervention to better prepare patients with chronic medical conditions for more effective self-management after DC using a Skills Simulation Experience and focused one-on-one structured education format in a circuit-based intervention.  The Health Confidence Lab for patients admitted with COPD or CHF to receive focused chronic condition management education.  As an interdisciplinary intervention, the healthcare team presents standardized education in a circuit training presentation to allow for one-on-one interaction with healthcare professionals, using multiple teaching/learning strategies, to assist the participant in acquiring or reinforcing skills needed to successfully self-manage their conditions post-discharge.

For best results, this Health Confidence Lab experience occurs as close to the day before Discharge as possible. It brings all the patient teaching together with visual, video, and tactile learning opportunities. The patient’s family and caregivers are also encouraged to attend to learn how to support their “patient best.” The Health Confidence Lab is open daily, Monday through Friday, from 2:00 p.m. to 3:00 p.m.    

RESULTS / OUTCOMES:
Benchmark: Increase Patient Health Confidence Score
·  Baseline measurement: 6.71
·  Measurement as of 12.31/2019 post-intervention: 8.74

At the same time as the self-management inventory is administered, patients are asked to complete the one (1) question health confidence survey.  Created and validated by Dr J Wasson MD & Dr E Coleman MD MPH, the tool considers that “health confidence is an effective proxy for engagement, and practices can easily measure it using a single question: “How confident are you that you can control and manage most of your health problems? (Wasson & Coleman, 2014).”  Patients can rate their confidence on a scale from 0 (not very confident) to 10 (very confident). A score of 7 or higher is the desired response.  SIM LAB participants’ average health confidence score before intervention was 6.71 (under the baseline desired 7.0 or .95/1.00 desired outcome), and post-intervention was 8.74 (significantly higher than the 7.0 baseline or 1.25/1.00 desired outcome). The net gain is noted as 2.03 points on the 10-point scale.

Benchmark: 30-day Readmission Rates CHF/COPD
·  Baseline measurement: 24.35% 2018 CHF/ COPD readmissions
·  First measurement results: 10.12% CHF/ COPD readmissions for the participant group

Based on the current data analysis, there has been a reduction in readmissions for the participation group versus the non-participation group.   The intervention period (Jan-Dec 2019) noted a readmission rate for the target population of COPD/CHF patients of 10.12% compared to the non-participation group readmission rate of 21.05%.    This demonstrates a 10.93%-age point decrease in readmissions in the participation group.  Notably, SIM LAB participants accounted for 4.3% of all COPD/CHF readmissions for the 2019 data period.