VA Palo Alto created a patient-friendly After Hospital Care Plan tailored to their patients’ needs and integrated with their EMR.
Our discharge instructions were pretty much unreadable. There were pages and pages of text with no formatting to make it easier to understand or read. They looked like a receipt from the DMV or IRS. We had Krames on Demand for educational materials and those are great, but they focus on diseases and aren’t a care plan.
What We Tried
We saw the After Hospital Care Plan as part of Project RED and it was so obviously a better version of discharge notes than what we had. Our care transitions team started with the After Hospital Care Plan and tailored it to the needs of our patients and the VA’s system.
A few of the key parts of our after hospital care plan are:
● A 3-month calendar showing all of the patient’s upcoming appointments and pertinent dates
● A section on “what to do if a problem arises” so patients feel prepared to handle different situations
● Personal goals rather than doctor recommendations. We can recommend that a patient exercises for 30 minutes a day, but if they realistically can only exercise twice a week, then that should be their goal
● Compiled list of prescriptions that includes those from the current hospitalization and also existing prescriptions from before the hospitalization
● Clear visualizations for prescriptions that are taken on a sliding scale or those that need to be tapered
● A place for patients to write questions for their primary care providers
The After Hospital Care Plan pulls directly from our EMR and other systems so that it can be printed with the click of a button. That was not an easy accomplishment and took two years to fully integrate. We believed the After Hospital Care Plan was very valuable though, so even before the complete integration we were creating the care plan for our patients manually. It meant we saw fewer patients, but they were able to get the full benefit of a clear after hospital care plan.
The After Hospital Care Plan is a really great discharge tool for patients. We’ve heard that 50% of patients who receive one bring it to their first follow up appointment after discharge. That means they’re actually using it as a tool to manage their health. We also have patients who don’t want follow up calls or home visits, but still ask for the After Hospital Care Plan.
Spending the time to truly integrate the plan with our EMR was worth it as well. It meant we had to spend over a year creating the plans manually, but that year gave us the time to test and refine what needed to be in the care plan. It also helped show the value of the care plan before making a large IT investment. Now the care plan can be generated instantly and it has allowed us to work with many more patients.
This is not a cheap or easy endeavor. We piloted the After Hospital Care Plan for two years before we could get it fully integrated with our EMR. When we began the pilot, it took nurses a few hours to fill out one After Hospital Care Plan. Over time we got it down to 20-30 minutes and now it’s instantaneous, but it took a lot of patience and persistence to get here.