Improving Patient Understanding at Discharge:Medical Student Enhanced Patient Education

Justin Slade, MS4, Lakshman Swamy, MD, Warren Hershman, MD, MPH, Britt Simonson, M.Ed. and Karin Sloan, MDDepartment of Medicine - Boston Medical Center / Boston University School of Medicine

Background• Hospitaldischargesareimportantprocessesthatfrequentlyhavepooroutcomes.

• Oneinfivedischargesiscomplicatedbypost-dischargeadverseevents,whichmayleadtopreventableemergencydepartmentvisitsorhospitalreadmissions1.

• Astaggering19.6%ofhospitalizedMedicarerecipientsnationwidearereadmittedwithin30-daysofdischarge2.

• Poorlycoordinatedhospitaldischargescauseharm:• Patientsleavethehospitalunprepared• Adverseeventscanleadtopatientharmandunnecessaryutilizationofhospital

resources• Costsofcaremayincrease,withanestimated$17.4billiondollarcosttoMedicarein

2004forunplannedrehospitalizations2.• Limitedhealthliteracyisknowntocontributetowardspoorlycoordinatedpatientdischarges.

• Ithasbeenprovenasasignificantriskfactorfor30-dayhospitalreadmission(OR=1.76)3.

• Medicalstudentsarefelttobeinauniquepositiontocombatthenegativeeffectsoflimitedhealthliteracybydeliveringadditionalpatienteducationleadinguptoandduringthedischargeprocess.• Studentstypicallycareforasmallerpanelofpatientsthanthehousestaffandfaceless

ofadocumentationburdenduringthedischargeprocess.• Byspendingadditionaltimeeducatingpatients,studentsmaybenefitfrom

developmentoftheirownpatienteducationanddischargemanagementskillsthatwillbeessentialintheirfuturecareersasclinicians.

Aim• Tohavethirdyearmedicalstudents atBostonUniversitySchoolofMedicinecollectively

performatotalof200systematicpatientdischargeeducation(MedicalStudentEnhancedPatientEducation)sessionswithinternalmedicinepatientsatBostonMedicalCenterandotheraffiliatedclinicalsitesbyMay30,2016

• Toimprovepatientunderstandingofhealth,medications,andfollow-uptreatmentplansinordertocombatthenegativeeffectsofpoorhealthliteracy

• ToexaminetheeffectthatMedicalStudentEnhancedPatientEducationsessionsmayhaveonthe30-dayhospitalreadmissionrate

• Tofacilitatestudentengagementinpre-dischargepatienteducationandfollow-upcoordinationinordertobetterdeveloprelevantclinicalskills

Methods• TheIHIModelforImprovementhasbeenusedastheframeworkforguidingthiseffort.• Population:Adultpatientsadmittedtomedicineservicesandcaredforbythird-yearmedicine

clerkshipstudentsatBostonMedicalCenter• DataSources:MedicalStudentPatientEducation(MSEPE)checklistscompletedandsubmitted

bystudents,inpatientdischargesummaries,studentsurveys(distributedelectronically)• VariablesofInterest:NumberofcompletedMSEPEsessionspermonth;studentassessmentof

patient’sunderstandingofdisease,medications,andfollow-upplanbeforeandafterMSEPEexercise;30-dayhospitalreadmissionrate;timespentbystudentspreparingforandperformingMSEPEsessionswithpatients

Solutions

• TheMedicalStudentEnhancedPatientEducationchecklistwasdesignedtowalkstudentsthroughtheprocessofprovidingeducationtopatientsasasupplementtocurrentdischargeteachingperformedbyresidents,pharmacy,andnursingstaff.

• BeforeandaftertheMSEPEsession,studentsassessapatient’sunderstandingoftheirdiseaseandtreatmentplan

• Atthebeginningoftheirclerkship,studentsareprovidedwithanMSEPEcardandabrief(10-15minute)orientationsessionfortheexercise

• StudentshavebeenaskedtocompleteatleastoneMSEPEsessionandcardwithapatienttheycareforatBostonMedicalCenterduringtheirthird-yearinternalmedicineclerkship(8weekduration).

11 Sessions85%StudentParticipation

9 Sessions64%StudentParticipation

8 Sessions67%StudentParticipation

11 Sessions79%StudentParticipation

6

7

8

9

10

11

12

13

14

15

16

0 1 2 3 4

Num

berofCom

pletedM

SEPESessions

Month

NumberofCompletedMedicalStudentEnhancedPatientEducationSessionsPerMonth

Median=10

PDSA1- IntroducedMSEPEChecklist- Brief(10minute)verbalstudentorientation

PDSA2- PocketsizedMSEPE checklistcardprintedanddistributedatstudentorientation- IntroducedPowerPointorientation session,whichfocusedonpatientselectionandriskfactorsforreadmission

13%

41%

46%

15%

49%

36%

13%

31%

56%

8%

31%

62%

5%

38%

56%

3%

10%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Limited Moderate Full Limited Moderate Full Limited Moderate Full

DiagnosisandHealthConsequences MedicationBenefitsandSide-Effects Follow-UpPlan

PercentageofP

atients

StudentAssessmentofPatient'sUnderstanding

StudentAssessmentofPatientUnderstandingBeforeandAfterMedicalStudentEnhancedPatientEducationExercise(n=39)

Before

After

• Afterfourmonths,studentshavecumulativelyprovidedover20hoursofpre-dischargeeducationto39internalmedicinepatientsatBostonMedicalCenter

• MedianStudentPreparationTime=28minutes• MedianMSEPESessionTime=20minutes

14.8% (n=27)

33.3% (n=3)

12.5% (n=8) 12.5% (n=16)

50.0% (n=2)

18.2% (n=11)

7.1% (n=14)

0%(n=1)

25.0% (n=4)

5.9%(n=22)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Limited Moderate Full Limited Moderate Full Limited Moderate Full

Overall DiagnosisandHealthConsequences MedicationBenefitsandSide-Effects Follow-UpPlan

30-DayHospitalR

eadm

issionRate

StudentAssessmentofPatient'sUnderstanding

30-DayHospitalReadmiss ionRateStratified ByStudentAssessmentofPatientUnderstandingPost-MSEPEExercise(n=27)

Conclusions• Basedonstudentassessment,patientsexhibitimprovedunderstandingoftheirhealth,

medications,andfollow-uptreatmentplanfollowingparticipationintheMedicalStudentEnhancedPatienteducationexercise.

• MSEPEsessionshavebeensuccessfullyintegratedwithinthethird-yearinternalmedicineclerkship,yetadditionalchangesarenecessarytopromotemorefrequentcompletionofthesesessionswithpatients.

• Thereisatrendsuggestingthatstudentassessmentoflimited patientunderstandingoftheirdiagnosisandhealthconsequencesormedicationbenefitsandside-effectsfollowingtheMSEPEexercisemayserveasariskindicatorfor30-dayhospitalreadmission.

NextSteps• ExpanduseoftheMSEPEexercisetoallsitesaffiliatedwiththeBostonUniversityInternal

Medicineclerkship(hastodateonlybeenatBostonMedicalCenter)• EncouragecompletionofmorethanoneMSEPEcardperclerkshipstudentbydistributing

additionalcardstostudentsatorientationaswellasaPDFfiletoprintmorecopiesiftheydesire.

• BegintogatherpatientperspectiveonimpactofMSEPEexerciseontheirunderstandingofhealth,medications,andfollow-upplan.

• PrinttheoptionalstudentsurveydirectlyonMSEPEcardtoencourageagreaterresponserate

• Planforsustainabilitybeyondthisyearbyreducingnumberofadministrativesteps,increasingresidentandfacultyawarenessofexercise,andcreatingabriefvideopresentationforefficientandreproduciblestudentorientation

References1. “AdverseEventsAmongMedicalPatientsAfterDischargeFromtheHospital.”Forster,A.;etal. CMAJ.

2004;170:345-349.2. “RehospitalizationsAmongPatientsintheMedicareFee-for-ServiceProgram.”Jencks,S.;etal. NEngl J

Med.2009;360(24):1418-1428.3. “HealthLiteracyand30-DayPostdischarge HospitalUtilization.”Jack,B.;etal. JournalofHealth

Communication2012;17:325-338.4. "RedefiningRiskFactorsforGeneralMedicinePatients."Auerbach,A;etal.JournalofHospitalMedicine

2011;6:54-60.

Results