Medical Director, Inpatient Rehabilitation Montefiore Medical Center, New York
Disclosure(s):
Aye Mon Win, DO: No financial relationships to disclose
Background and/or Objectives: Patient experience is 1 of 5 measures for CMS Star Ratings. The Discharge Information (DI) Domain on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey represents patients' readiness to return to the community safely. A performance improvement initiative began on the inpatient rehabilitation unit at Montefiore Medical Center with the aim to improve the DI score from a baseline 83.8% 12-month rolling score in quarter four of 2023 to 84.6% by quarter 4 of 2024 to meet the 3-star CMS rating goal.
Design: Discovery phase included gembas of the physician, nursing, and social work discharge visits, therapy family trainings, and patient experience committee meetings. Interventions were implemented using PDSA cycles.
Setting : Inpatient rehabilitation unit
Participants : Patients discharging to the community
Interventions: Discharge survey reminder card - tangible reminder to complete the HCHAPS survey. Discharge checklist- education topics the patient must acknowledge were covered prior to their discharge. Post-discharge phone call surveys- completed by the nurse manager, expanded to also be completed by unit secretaries to increase completion rate. Improving written discharge instructions in the after visit summary (AVS). The survey reminder card and discharge phone calls are interventions to increase HCAHPS survey completion. The discharge checklist, discharge phone calls, and improving the AVS seek to improve discharge education.
Main Outcome Measures: Outcome Measure: DI HCAHPs score. Process Measures: % of community discharges receiving discharge survey reminder card, % of community discharges receiving discharge checklist, % of community discharges captured by the discharge trackers, % of community discharges completing a discharge phone call survey
Results: DI Domain HCAHPs 12-month rolling average score improved to 94.4%
Conclusions: It is important to assess the process of how interdisciplinary teams provide patient education around discharge and consider the perspective and workflow of each team member. High Discharge Information domain scores require excellent communication with patients and effective utilization of tools.
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