Implementing Multimedia Discharge Instructions for Cardiac Patients 65 Years and Older to Improve Outcomes

Discharge instructions are an integral part of the care continuum and support a successful transition from care facility to home. Patient safety becomes a major concern when discharge instruction is confusing or misunderstood. Modern discharge instructions are often difficult to understand, resulting in ineffective communication for patients with visual, hearing, cognitive and sensory limitations, as is the preponderance among older adults. Discharge instructions using a variety of multimedia and educational techniques may provide a means to satisfy the learning disparities, language barriers, and visual and auditory deficits of many older adults. This project aims to identify specific barriers older adults encounter in their attempt to understand current discharge instruction, and to develop a discharge instruction approach that would better address patients' questions and concerns prior to, and after, a cardiac procedure. The objectives of this project were to 1) evaluation of contemporary written discharge instructions for barriers to understanding; 2) identify barriers patient's experience with present discharge processes, designs for improved interventions, and methods for implementation and dissemination; 3) develop a prototype multimedia discharge instruction platform using a variety of educational modalities, with a focus on feasibility in the acute care setting for broader implementation; and 4) disseminate project findings to stakeholders via a poster presentation, a prototype of a re-designed discharge instruction platform, and a white-paper submitted to a professional meeting. Executing the project involved development of a questionnaire administered to both patients and health care providers to identify barriers patients encounter with modern discharge instruction, and to solicit ideas for improvement and application of a re-designed discharge tool. Evaluation of questionnaire responses highlighted perceived barriers, needed interventions, requirements for implementation, and methods for dissemination of effective discharge instructions. A multimedia discharge platform was developed based on participant response, using a variety of educational techniques and learning methods, including graphics, illustrations, video, audio, and text. At project completion, a poster presentation, prototype of the re-designed discharge platform, and a white paper was presented to local stakeholders. Older adults represent the largest patient population readmitted after an acute hospitalization, costing Medicare over $17 billion annually. Discharge instructions provide key information for a successful transition from the acute care setting. A re-design of current discharge instructions may satisfy many of the reading, literacy, and language disparities experienced by older adults, potentially decreasing hospital readmissions and morbidity, while improving patient outcomes.

Running head: MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Implementing Multimedia Discharge Instructions for Cardiac Patients 65 Years and Older to Improve Outcomes Pat Ellsworth RN, BSN, DNP Primary Care Student University of Utah In partial fulfillment of the requirements of the Doctor of Nursing Practice 1 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 2 Executive Summary Discharge instructions are an integral part of the care continuum and support a successful transition from care facility to home. Patient safety becomes a major concern when discharge instruction is confusing or misunderstood. Modern discharge instructions are often difficult to understand, resulting in ineffective communication for patients with visual, hearing, cognitive and sensory limitations, as is the preponderance among older adults. Discharge instructions using a variety of multimedia and educational techniques may provide a means to satisfy the learning disparities, language barriers, and visual and auditory deficits of many older adults. This project aims to identify specific barriers older adults encounter in their attempt to understand current discharge instruction, and to develop a discharge instruction approach that would better address patients' questions and concerns prior to, and after, a cardiac procedure. The objectives of this project were to 1) evaluation of contemporary written discharge instructions for barriers to understanding; 2) identify barriers patient's experience with present discharge processes, designs for improved interventions, and methods for implementation and dissemination; 3) develop a prototype multimedia discharge instruction platform using a variety of educational modalities, with a focus on feasibility in the acute care setting for broader implementation; and 4) disseminate project findings to stakeholders via a poster presentation, a prototype of a re-designed discharge instruction platform, and a white-paper submitted to a professional meeting. Executing the project involved development of a questionnaire administered to both patients and health care providers to identify barriers patients encounter with modern discharge instruction, and to solicit ideas for improvement and application of a re-designed discharge tool. Evaluation of questionnaire responses highlighted perceived barriers, needed interventions, requirements for implementation, and methods for dissemination of effective discharge instructions. A multimedia discharge platform was developed based on participant response, using a variety of educational techniques and learning methods, including graphics, illustrations, video, audio, and text. At project completion, a poster presentation, prototype of the re-designed discharge platform, and a white paper was presented to local stakeholders. Older adults represent the largest patient population readmitted after an acute hospitalization, costing Medicare over $17 billion annually. Discharge instructions provide key information for a successful transition from the acute care setting. A re-design of current discharge instructions may satisfy many of the reading, literacy, and language disparities experienced by older adults, potentially decreasing hospital readmissions and morbidity, while improving patient outcomes. Project Committee: Andrea Wallace, PhD, RN, Project Chair; Julie Balk, DNP, FNP-BC, FNP Specialty Track Director; Pam Hardin, PhD, RN, Assistant Dean MS & DNP Programs. Content Experts: Dr. Peter Forstall, MD, and Elaine Archuleta, APRN FNP-BC with Northern Utah Cardiovascular Associates. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 3 Table of Contents Executive Summary ........................................................................................................................ 2 Acknowledgments........................................................................................................................... 4 The Problem .................................................................................................................................... 5 Clinical Significance and Policy Implications of Uncertainty with Discharge Instructions .......... 6 Purpose and Objectives ................................................................................................................... 8 Review of Literature Concerning Hospital Discharge, Readmission, and Patient Barriers to Understanding Discharge Instruction ............................................................................................. 9 Review of Current CMS Discharge Requirements ....................................................................... 11 Barriers Older Adults Face with the Discharge Process ............................................................... 14 Categories of Discharge Instruction.............................................................................................. 16 Evaluating the Elderly Cardiac Patient for Appropriate Discharge Instructions .......................... 19 The Chronic Care Model (CCM) Theoretical Framework ........................................................... 20 Implementation and Evaluation of Project Objectives ................................................................. 22 Study Limitations .......................................................................................................................... 30 Future Recommendations ............................................................................................................. 30 DNP Essentials.............................................................................................................................. 31 Conclusion .................................................................................................................................... 32 References ..................................................................................................................................... 33 Appendix A: University of Utah IRB Exemption......................................................................... 38 Appendix B: Project Defense PowerPoint .................................................................................... 40 Appendix C: Survey Invite Letter ................................................................................................. 48 Appendix D: Survey Protocol ....................................................................................................... 49 Appendix E: Survey ...................................................................................................................... 50 Appendix F: Patient Discharge Instructions ................................................................................. 51 Appendix G: Poster Presentation .................................................................................................. 52 Appendix H: White Paper/Executive Summary ........................................................................... 53 Appendix I: Implementation and Evaluation Matrix .................................................................... 54 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 4 Acknowledgments I would like to thank Elaine Archuleta NP-AANC, and Dr. Peter Forstall M.D. for their direction, tireless dedication, and willingness to mentor and provide a remarkable learning experience that will remain with me always. I would also like to acknowledge and thank the most important people in my life, my husband and three children, as well as my extended family for supporting me through this difficult yet amazing journey, and providing me with the opportunity to further my education and realize my dreams. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 5 Implementing Multimedia Discharge Instructions for Cardiac Patients 65 Years and Older to Improve Outcomes The Problem In 2015, approximately 31,500,000 patients were discharged from hospitals around the United States, and in Utah, nearly 201,700 patients were discharged from area hospitals (American Hospital Directory, 2015). A 2015 study in the American Journal of Surgery suggests that 65% of patients discharged from hospitals do not have the reading skills or literacy necessary to understand their pre-printed discharge instructions (Timothy, 2016). Furthermore, the 2013 DISCHARGE study conducted by Yale-New Haven Hospital found more than 40% of adults 65 and older fail to fully understand the pre-printed discharge instructions given to them at time of discharge from the hospital (Horwitz, et al., 2013). Non-comprehension of discharge instructions among individuals 65 years and older fluctuates from 5 percent for follow-up appointment information, to 50% for post-discharge interventions (Albrecht, et al., 2014), with most adults failing to recall half the instruction given within five minutes of leaving the acute care setting (Kitching, 1990). Patient safety becomes a significant concern when individuals are unable to effectively transition from care facility to home because of confusion with their discharge instructions. Multimedia discharge instruction has the potential to provide many older patients with clear, interactive, and visually engaging instruction that addresses many of their concerns prior to hospital discharge, while permitting time to review important post-discharge information as inpatient, and afterward in the comfort of their home. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 6 Clinical Significance and Policy Implications of Uncertainty with Discharge Instructions The 2010 Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP) requiring the Centers for Medicare and Medicaid Services (CMS) reduce payments to hospitals with excess readmissions beginning October of 2012 (CMS, 2016). Overall, evidence suggests that non-comprehension of discharge instruction often contributes to in increased morbidity, mortality, healthcare spending, reduced healthcare reimbursements, avoidable 30-day readmissions, and overall decline in quality of life (Albrecht, et al., 2014). Elderly patients who are unable to understand their discharge instruction have an increased risk for hospital readmission, and when this happens, these readmissions are not only costly to Medicare, but to all other stakeholders as well. Today, hospital admission diagnoses for cardiovascular disease and subsequent cardiovascular procedure(s) is relatively common. According to a 2014 study, the prevalence of 30-day hospital readmissions following cardiovascular procedures was 23.9% (Kripalani, Theobald, Anctil, & Vasilevskis, 2015). In keeping with these statistics, nearly a quarter of all post-cardiac catheterization patients are readmitted inside 30 days, resulting in the unwarranted annual costs to Medicare of approximately $4.2 billion for readmissions following heart disease cardiac catheterization (CMS, 2016). While there are many factors that contribute to poor health outcomes after hospital discharge, several may be modifiable through improved instruction at the time of discharge and immediately thereafter. With 25% of Utah hospitals readmission rates due in part to patients having multiple (>6) chronic conditions (Utah Department of Health, 2010), providing easily understood discharge information may help to control, or eliminate many modifiable health behaviors, while enhancing the well-being and individual health outcomes of older patients post MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER cardiac procedure. Discharge information provided to patients regarding modifiable health behaviors may include tobacco cessation; abstaining from alcohol and drug abuse; refraining from over consumption of unhealthy foods and a sedentary lifestyle; avoiding risky behaviors; and participating in preventative health services, can increase the well-being and overall health of cardiac patients (CMS, 2012). Additionally, adherence to medications; understanding appropriate follow-up instruction; recognizing signs and symptoms of worsening health; and anticipatory planning for individual needs following hospitalization generally bring about better healing following cardiac procedure. Effective management of these factors, and more, often results in decreased hospital readmissions (CMS, 2012). Improved discharge instructions cannot eliminate non-modifiable health conditions that frequently increase risk for hospital readmission following cardiac procedure. That said, effectively designed discharge instruction may better provide patients with the following: • available community resources, • access to primary care providers, • access to public transportation, • location of pharmacies and grocery stores offering healthy food choices, and • access to social agencies offering support for the elderly or financially disadvantaged. An effective discharge instruction platform may potentially improve the recovery success of older individuals with multiple non-modifiable health conditions and or co-morbidities (CMS, 2012). The intent of discharge instructions is to provide a successful transition through the care continuum. When this purpose is not accomplished, elderly patients may experience increased confusion, frustration, possible medication errors, post-care infection or recurrent illness, and 7 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 8 ultimately, hospital readmission which cost Medicare about $17.4 billion annually (Kripalani, Theobald, Anctil, & Vasilevskis, 2015). Additionally, the discharge process provides several opportunities to educate patients on key aspects of self-care management in a way they can understand. If patient discharge summaries continue to be confusing, or difficult to comprehend, preventable hospital readmissions will continue to occur due to non-adherence with aftercare intervention and instruction, confusion with self-care direction, problems with medications, increased pain and suffering from adverse events, and increased difficulty with follow-up care (Choudhry, et al., 2016). Purpose and Objectives The aim of this project is to create post-cardiac procedure discharge instruction for older patients (>65 years) that are efficient, effective, and easily understood, to improve patient comprehension, enhance care, and reduce overall hospital readmissions in this population. To accomplish this purpose, a team of cardiac providers, nurse practitioners, and a student nurse practitioner (the Team) were assembled to address the following objectives, and consider implementation and evaluation of each objective. The objectives of this project were to: 1. Evaluate present pre-printed and verbal discharge instruction to assess current barriers to understanding that older adults may experience. 2. Identify actual barriers experienced with the present discharge process, designs for improved interventions, and methods for implementation and dissemination, all with the intent of effectively re-engineering current acute care setting discharge instruction. 3. Develop a prototype multimedia discharge instruction platform using a variety of educational modalities, with a focus on feasibility in an acute care setting for broader implementation; and MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 9 4. Disseminate project findings to stakeholders via a poster presentation, a working prototype of a simulated patient's discharge instruction, and submit a white paper to a professional meeting of the local cardiology community at large. Review of Literature Concerning Hospital Discharge, Readmission, and Patient Barriers to Understanding Discharge Instruction From June 5, 2016 to November 10, 2016, the following MeSH terms were used to search PubMed/MEDLINE, MedlinePlus, and CINAHL research databases: Patient discharge; patient discharge summaries; discharge planning; barriers to understanding discharge instruction; difficulty with discharge instruction; hospital readmissions and ineffective discharge; cardiac procedure readmissions; cardiac procedure discharge instructions; comprehensive discharge planning and barriers and older adults; health literacy and elderly and discharge process; patient understanding and discharge instruction; effective transition and acute care and discharge instruction; hospital discharge process and elderly cardiac patient; health literacy and patient and provider and communication; hospital discharge and readmission rates; written discharge instruction and verbal instruction; and multimedia discharge instruction. As older adults represent a significant proportion of today's healthcare use and costs, instruction given at discharge must be thorough, yet easily understood to improve comprehension and compliance with post-discharge care. Non-comprehension of discharge instruction among older adult's results in greater non-compliance with aftercare intervention(s) that could lead to poorer health outcomes (Albrecht, et al., 2014). Patient Discharge Data In 2015, approximately 31,500,000 patients were discharged from hospitals around the United States. In Utah alone, nearly 201,700 patients were discharged from area hospitals. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 10 Recent data on Utah hospital inpatient discharge following cardiac catheterization for ischemic heart disease in patients 65 years and older, report 706 patients were discharged from Utah hospitals from January 1 to December 31, 2013 (American Hospital Directory, 2015). Approximately 77.9% of all post heart-catheterization discharges were to home with selfcare (Utah Health Data Committee, 2015). Just under 13% of those patients were readmitted to the hospital within 30 days, according to a 2013 Statistical Brief published by the Agency for Healthcare Research and Quality (AHRQ) (Weiss, Elixhauser, & Steiner, 2013). Re-hospitalization and Readmission Data In 2009, an article in The New England Journal of Medicine proposed that nearly one-infive (19.6%) of the 11,855,702 Medicare beneficiaries (individuals 65 and older) discharged from hospitals in 2003-2004 were re-admitted within 30 days. The average length of stay (LOS) for re-hospitalized patients was a little over half a day longer than patients with the same initial diagnosis, and the cost to Medicare for unplanned re-hospitalizations in 2004 was approximately $17.4 billion (Jencks, Williams, & Coleman, 2009). Unplanned re-admissions accounted for over 17% of Medicare's total hospital payments in 2004. The 2013 Utah Hospital Financial and Utilization Profile reported that in addition to the initial cost for cardiac catheterization for heart disease ranging anywhere from $29,000 to over $35,000 (depending on the severity of disease), readmission expenditures for post-cardiac catheter complications in northern Utah hospitals between 2005-07 was significant. During that time, readmission rates at two northern Utah hospitals for patients following cardiac catheterization for ischemic disease varied from 3.2-3.5% for re-catheterization, to as high as 9.2-10.8% for subsequent heart bypass surgery with heart-catheterization (Utah Department of Health, 2010). As stated earlier, hospital readmissions cost Medicare more than $17 billion MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 11 annually (Kripalani, Theobald, Anctil, & Vasilevskis, 2015), indicating the annual cost to Medicare for hospital readmissions following ischemic cardiac catheterization at these two northern Utah hospitals was approximately $177 million, based on 2013 average facility charges (Utah Health Data Committee, 2015). Unnecessary Medicare expenditures affect every individual who accesses and relies on today's healthcare system. Certain avoidable factors attribute to unplanned hospital readmissions, and raise this very important question to local healthcare providers: By providing effective, efficient, and easily understood discharge instructions to patients pre- and postdischarge, can we curtail the 3% - 10% of cardiac catheter procedure readmissions, and their associated Medicare expenditures at these Northern Utah hospitals? Healthcare providers must acknowledge that discharge instructions are a critical component in the patients' recovery, and they cannot take a "one-size-fits-all" approach. Complete understanding of discharge instruction may help to prevent more avoidable hospitalizations through effective communication, with vast potential to improve elderly patients' quality of life, overall health, and financial wellbeing, while decreasing readmission rates and healthcare spending, which ultimately effects every individual that utilizes the U.S. healthcare systems. Review of Current CMS Discharge Requirements Discharge planning is the development of an individualized plan for patients prior to discharge from the hospital or an acute care facility to home, rehabilitation, or skilled nursing facility (Goncalves-Bradely, Lannin, Clemson, Cameron, & Shepperd, 2016). The intent of discharge planning is to ensure that patients are discharged at the appropriate time, and with the appropriate provisions for post- discharge services. Discharge planning also improves the efficiency and quality of healthcare delivery by facilitating the transition of the patient from the MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 12 acute care to the post-discharge setting, in addition to providing comprehensive information about the patient's condition, expected recovery course, and post-discharge care. Discharge planning helps to bridge the gap between the hospital and home (Goncalves-Bradely, Lannin, Clemson, Cameron, & Shepperd, 2016). Pre-discharge Preparation and Planning According to "Discharge Planning", a publication from the Department of Health and Human Services and Centers for Medicare & Medicaid Services (2014), Medicare-participating acute care hospitals and post-acute care facilities must include the following information, at a minimum, within their discharge instructions: Discharge summary and checklist. A summary of the patient's stay, including diagnosis, treatments, symptoms, management of symptoms, management of pain, and whether the patient was placed in protective isolation or physically restrained should be included. The summary may also include information regarding the patient's biophysical, psychological, and social needs. Medication therapy management, and information regarding the patient's return to the post-acute environment are frequently addressed including the need for any specialized medical equipment, permanent environmental modifications, or whether the patient is capable of addressing his/her needs independently or with assisted care (CMS, 2014). Other items that may be addressed in the summary and checklist include the availability of community-based services, medical supplies and equipment, transportation services, personal care and meal services, and hospice or palliative care services. If assessment of the patient indicates he/she is likely to require the added service of Home Health, according to Section 1861 (ee) of the Social Security Act (CMS, 2014), Medicare participating pre-acute care facilities and acute-care hospitals are required to provide each patient a complete list of Medicare-certified MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 13 Home Health Agencies that serve the patient's geographic area and participate in the Medicare Program. Medication reconciliation. A complete and correct list of prescription and over-thecounter medications is required at discharge, including instruction for any new medications or those that were discontinued by the hospital provider after discharge. The reconciled medication list should include the name of the medication, what the medication is taken for (indication for medication), dosage, route and time of each medication, and any significant risks or adverse drug effects appropriate to the individual patient's condition (CMS, 2014). Patient instruction for post-hospital care. Instruction should include the expected course for recovery, and patient education materials that are brief and easily understood, explaining the reason for hospitalization, as well as information that helps the patient to selfmanage their care at home. Verbal and written instruction should include information about resuming activity, or acceptable activity levels and limitations, resumption of diet or diet modifications, wound care or dressing changes, and any other specialized post-hospital care instruction the patient, caregiver/support person(s) may require (CMS, 2014). Complications indicating need for immediate medical attention. Instructions regarding adverse signs and symptoms that the patient may experience and that may indicate the need for immediate medical attention are crucial. This information must include written instruction regarding what the patient or his/her caregiver/support person(s) should do in the event, and whom they should contact if the adverse signs and symptoms persist (CMS, 2014). Patient follow-up care and appointment(s). When applicable, written or electronic instruction regarding follow-up appointments (including date and time), planned or pending receipt of diagnostic tests or laboratory results, contact information for practitioners or other MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 14 providers/suppliers involved in follow-up or after care (including telephone numbers and clinic address) should be provided as part of the discharge instruction process (CMS, 2014). Barriers Older Adults Face with the Discharge Process Increasingly, healthcare providers are acknowledging the challenges older adults face during transition from hospital to home. Some of the challenges and barriers faced by older adults that contribute to fragmented care, medication issues, and other adverse events and hospital readmissions include additional patient comorbidities, the timing of patient discharge, pre- and post-discharge functional limitations, financial and societal limitations, and healthcare literacy. Co-morbidities and Functional Limitations Many initial hospitalizations and re-hospitalizations cannot be avoided due to the natural progression of a patient's underlying disease process, acute exacerbation, or other comorbid factors. Two significant elements found to be related to increased hospitalization include the patient's inability to follow through with a prior discharge plan because of current health condition or limitation, and new and separate health problems unrelated to the initial admission (Epstein, Jha, & Orav, 2011). Older adults with congestive heart failure, chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, acute myocardial infarction, gastrointestinal bleeding, coronary artery disease, and chronic kidney disease have a higher incidence of hospitalization than individuals without these chronic disease processes (Epstein, Jha, & Orav, 2011). Functional limitations including diminished mobility, overall weakness, difficulty with self-care and activities of daily living (ALDs), all present difficulties to older individuals discharged to a MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 15 home habitus that is not conducive to their present state of health (Greyson, et al., 2014), or to their complete recovery. Socioeconomically Disadvantaged Older Adults For many older adults, today's hospital discharge instruction frequently overlook significant social and functional gaps in post-discharge care (Greyson, et al., 2014). The inability to obtain medications because of cost or lack of transportation is just one of many issues facing older adult's post-discharge. Challenges from paucity of income often overlap into the home environment after discharge. The scarcity of income frequently induces variable degrees of disability, increased poverty (because of declining physical health leading to, or as a result of change in nutritional intake), increased weakness, resulting in inaccessibility to needed resources and healthcare (Greyson, et al., 2014). Low Health Literacy and Limited Language Proficiency America is a heterogeneous society that is becoming more homogeneous as the different elements of our society come together into a harmonious common culture. That said, many individuals continue to struggle with language barriers and health literacy difficulties. Language and health care literacy deficits increase the non-comprehension and non-compliance of discharge instructions for all patient populations, carrying an increased burden for older adults discharged from the hospital (Albrecht, et al., 2014; Epstein, Jha, & Orav, 2011). Immigrants, refugees, and other individuals recent to the U.S. often experience social isolation, and lack the support of family and friends. Social support and the ability to communicate healthcare needs to others is an important component of recovery. Frequently, older adults experience an unanticipated decline in their social interaction and support network after acute care discharge, resulting in isolation and impaired efforts to obtain the appropriate MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 16 care needed for a full recovery (Greyson, et al., 2014). Lack of instrumental help, failure to understanding certain characteristics of their health, and the absence of emotional support, compel many individuals toward depression and loneliness and put them at risk for a longer recovery time (Greyson, et al., 2014). Discharge instructions should be comprehensible to patients and their families, and research suggests that individuals who understand their medical diagnoses and treatment plan are better prepared to participate in their care (Albrecht, et al., 2014; Choudhry, et al., 2016). Categories of Discharge Instruction The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented six discharge recommendations for healthcare facilities who provide written discharge instruction to heart failure patients. These categories also apply to post cardiac procedure, and other hospitalized patients. The six categories required by JCAHO to be included in discharge instruction include: activity, diet, weight, follow-up appointment(s), medication reconciliation including discharge medications, and instruction regarding worsening symptoms (Albrecht, et al., 2014). In today's busy hospitals, the two traditional forms of discharge instruction are type written and verbal reports. Typewritten Discharge Instruction Many hospitals incorporate JCAHO's recommendations into all discharge instructions provided to patients (Albrecht, et al., 2014). Most typewritten discharge instructions generally include a description of the presenting problem that precipitated the individual's hospitalization, results of tests and laboratory findings, final primary and, often, secondary diagnoses, and a written schedule of the patient's discharge medications including purpose, dose, time, and precautions if appropriate. The reconciled medication list may also compare pre-admission MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 17 medications with post-discharge medications and the reason for change (Zavala & Shaffer, 2011). Follow-up appointments, with name of provider, date, time address, and phone number are generally included, with some also providing the patient with visit purpose and suggested management plan. Finally, any anticipated or possible problems, along with suggested interventions are addressed, who to contact in case of emergency, and a signature is obtained from the patient or caregiver indicating understanding of the instructions and having received a copy (Zavala & Shaffer, 2011). Typewritten instruction are usually written at a level that can be modified by the discharging nurse, and should be equal to or less than a 6th grade literacy level. A 2005 study published in the Journal of General Internal Medicine found the majority of instructions given to healthcare patients, whether for discharge or other interventions, were written anywhere from a 5th grade level to a 10th grade level or higher (Pignone, DeWalt, Sheridan, Bekman, & Lohr, 2005), precluding many patients from understanding their aftercare instruction. Verbal Discharge Instruction The majority of discharge instructions provided to patients in today's acute healthcare facilities are pre-formatted instruction sheets, though in most settings, verbal instruction is given as well (McD-Taylor & Cameron, 2000). As the central purpose of discharge instruction is to improve the communication between the patient and provider, verbal instruction is desirable for patients, as it offers them the opportunity to ask questions and receive answers from the medical provider immediately, rather than if, or when, time allows. Verbal instruction, including nuances and pantomime, can be very educational as it frequently "paints a picture" more so than written instruction (Johnson, Sandford, & Tyndall, 2003). Written instruction is often considered a complement to, and not a replacement for verbal instruction from the healthcare provider/team MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 18 members, as verbal instructions are a critical component of the patient-doctor relationship. Verbal instruction and interaction offers the provider the opportunity to ensure the patient understands the instruction, while giving the patient the occasion to ask questions and clarify uncertainties (McD-Taylor & Cameron, 2000). Multimedia Discharge Instruction According to Richard Mayer's 2001 cognitive theory of multimedia learning, individuals "lean better from words and pictures than from words alone" (Mayer, 2014, para 5), which is especially true for individuals with low literacy, knowledge and comprehension deficits, as well as visual learners (Doolittle, 2002). With more than 40% of adults 65 and older failing to fully understand pre-printed hospital discharge instructions, according to the 2013 DISCHARGE study conducted by YaleNew Haven Hospital (Horwitz, et al., 2013), replacing pre-printed instructions with multimediadigital (visual/audio) discharge instruction may help to decrease the incidence of readmission following procedures for cardiac disease. Multimedia-digital instruction provides patients with easily understood interactive audio and visual instruction, while addressing specific questions and concerns prior to the patient's hospital discharge. Multimedia-digital discharge instructions can be tailored to meet the patient's healthcare needs and level of literacy, whether through language comprehension, level of cognition or knowledge, or personalized to meet their education or functional reading level. Easily understood multimedia instructions provided prior to hospital discharge permit the patient, family members, and caregivers time to address concerns prior to hospital discharge, while also permitting time to review important direction and seek additional clarification if necessary. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 19 The design of multimedia-digital instruction encompasses several different educational modalities including written text (no higher than a sixth-grade reading level), graphic illustrations, pictures, videos, animation, and audio instruction enabling patients with sight and hearing deficits, as well as language, literacy, and knowledge barriers to better understand their aftercare instructions. Understanding discharge instruction prior to release from the hospital can significantly decrease the overwhelming cost of hospital readmissions, reduce subsequent patient illness, injury or morbidity, while improving communication between patient, physician, facility, and overall patient outcomes and satisfaction (Wong, et al., 2011). Combination of Typewritten and Verbal A combination of typewritten and verbal instruction would provide patients with all of the information disclosed above, but must be written in language that is understood, and presented so the patient has a clear understanding of their diagnosis, prognosis, medications, after-care and follow-up. Evaluating the Elderly Cardiac Patient for Appropriate Discharge Instructions Multiple patient surveys have demonstrated that discharge instructions are often difficult to understand, and the information virtually impossible to retain, especially for hearing, visual, and cognitively impaired patients; older adults experience many, if not all of these deficits (Zeng-Treitler, Kim, & Hunter, 2008). In July 2014, the state of New York passed a law that would benefit visually impaired patients at discharge. The law stated that by October 2014, all New York "hospitals must provide blind and visually impaired patients with a large print version, or upon request of the patient, with an audio recording of the discharge plan and preadmission information" (Cipher Health, 2014, para 1). This law was enacted due to the overwhelming number of patients with visual, auditory, and cognitive deficits that spoke out MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 20 about being confused and uncertain about their recovery after a recent hospitalization. The law represents a governing body's acknowledgement of how critical discharge instructions are to a patient's recovery. New York State Governor Cuomo responded to the signing of the law in a memo stating, It is often difficult for patients to remember the extensive instructions given to them by their doctors upon discharge from a hospital. Blind or visually impaired patients might also have trouble writing down instructions, which would compound the difficulty of remembering them… The bill is necessary to ensure that such patients are able to access and follow the instructions given by their doctors" (Cipher Health, 2014, para 2). The realization that so many patients were not fully understanding their discharge instruction lead Cipher Health to create ECHO; developed to help visually impaired patients better understand and follow their discharge instructions, and to also allow each patient access to the discharge conversation, whether inpatient, or from the convenience of their home (Cipher Health, 2014). Furthermore, the Institute of Medicine suggests that more than half of all adults in America - nearly 90 million people - experience difficulty and lack of understanding with health information, resulting in greater rates of hospitalization and use of emergency services among those with decreased or limited health literacy, cognition, visual, hearing, speaking, and learning deficits (Institute of Medicine, 2004). The Chronic Care Model (CCM) Theoretical Framework The CCM endeavors to facilitate productive interaction between the patient with multiple comorbidities or chronic disease process(es) and the practice team in order to treat the patient and his/her illness(es) efficiently and effectively, thereby providing the patient with greater overall quality of life. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 21 A major emphasis of this model is on the informed, activated patient who has the "motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it" (MacColl Center for Health Care Innovation, 2016, slide 14). The other major focus is on the prepared practice team whose position it is to keep the patient informed, provide decision support, and necessary resources in order to deliver high-quality patient-centered care (MacColl Center for Health Care Innovation, 2016, slide 15). The idea of redesigning acute care discharge instructions to enable older adults to better understand their after-care instruction and self-manage their health aligns with the focus of the informed patient (or care provider) having the motivation, skills, confidence, and information necessary to make clear decisions regarding their health and the ability to self-manage it after hospital discharge. Healthcare teams are also positioned to provide the patient with accurate, effective, and timely instruction, decision support, and the necessary resources he/she needs to achieve their planned recovery. Older patients, or their caregivers, that correctly understand instruction given at discharge, and in the post-discharge environment, will be able to participate more fully in their prescribed therapies, and experience greater compliance leading to better healing - all of which results in reduced healthcare costs, and better health outcomes (Albrecht, et al., 2014). As discussed previously, older adults face several challenges during transition from the acute care setting to home, including barriers to understanding, communication, health literacy, and inability to follow through with the treatment plan because of current health limitations (Epstein, Jha, & Orav, 2011). The CCM offers healthcare teams a roadmap for executing productive interactions between the provider and patient with chronic disease(s), allowing team members to more effectively and efficiently treat the patient and his/her illness, resulting in MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 22 better health outcomes, financial wellbeing, and quality of life for the patient. Additionally, the CCM helps healthcare teams avoid gaps and deficits in the quality care they provide (MacColl Center for Health Care Innovation, 2016) which ultimately helps reduce hospital readmissions, resulting in lower overall healthcare spending for all stakeholders. Implementation and Evaluation of Project Objectives Discharge instructions provide important patient care and safety information enabling a successful transition from care facility to home. The objective of this scholarly project is to identify specific barriers older adults encounter when attempting to understand current discharge instruction, and to develop a discharge instruction approach that would better address patient questions and concerns prior to, and after, a cardiac procedure. To accomplish the objectives of this project, cardiac providers, nurse practitioners, and the primary researcher/nurse practitioner student (the Team) was assembled to address the following objectives, as well as consider implementation and evaluation of each objective. See Appendix I for Implementation and Evaluation Matrix. Objective 1. Evaluate present pre-printed and verbal discharge instruction to assess current barriers to understanding that older adults may experience. Implementation. IRB protocol was initiated in October 2017. The Team reviewed several versions of contemporary printed discharge instructions used in local acute care settings, as well as pamphlets and brochures discussing a variety of cardiac procedures. Review of these documents found the majority were written at a ninth-grade reading level or above; difficult medical terminology was used throughout; and minimal information about the patient's diagnosis, medication, complications and prognosis was provided. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 23 Using this information, a questionnaire was developed by the primary investigator and vetted by the Project Chair and Content Expert(s). The questionnaire was used to develop a web-based survey in REDCap (Appendix E), and the participant protocol was established that indicated parameters patients must meet to be eligible for participation in the survey. The protocol stipulates only elderly patients (≥65 yrs), or their caregivers (if the patient is unable to participate in the study because of physiological or cognitive disparities), who have undergone cardiac procedure(s) for heart disease within the last one to two years meet study criteria for participation. Persons excluded from participation include clinic patients who have not had any type of cardiac procedure; individuals having a hospitalized cardiac procedure >3-5 years previous; individuals currently involved in litigation with a healthcare institute following a cardiac procedure; and individuals or family members of patients who are deceased or died shortly after a cardiac procedure. The survey was designed to obtain patient/caregivers' perceptions of current discharge instruction, barriers they may have experienced to understanding, and ideas for improvement, and implementation of a re-designed discharge instruction model. Also, surveying of healthcare providers was integrated with the goal of obtaining their professional perception of current discharge instruction, barriers to understanding, interventions and methods for improvement, as well as implementation and/or dissemination of information to appropriate stakeholders. Other important components of the survey that appear essential to a successful discharge instruction platform, include, but are not limited to, providing patients with a strategy for receiving outstanding test and diagnostic reports, reconciling new and existing medications, educating patients and caregivers to avoid adverse events, and appropriate follow-up after MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 24 discharge. When not addressed in the discharge process, these factors further contribute to increased noncompliance, non-comprehension and hospital readmission rates (AHRQ, 2014). Evaluation. University of Utah IRB review board exemption was received on December 27, 2016 (appendix A). Survey approval was received on January 31, 2017, from REDCap, and the survey tool Barriers to Understanding Current Discharge Instructions (Appendix E) was moved into the Production phase. Beginning February 7, 2017, the primary investigator invited patients to participate in the survey after they arrived at the clinic. A brief introduction was provided regarding the research project, and patients who chose to participate were given a letter of consent (Appendix C). At the completion of their follow-up appointment, patients were provided with an electronic tablet enabling access to the survey. Each survey was completed in the Check-Out area, and patients returned the tablet to the primary researcher upon survey submission. Forty-three patients meeting study protocol were approached to take the survey along with 11 healthcare providers. Thirty-eight of the 43 patients agreed and were consented to survey. Objective 2. Identify actual barriers experienced with the present discharge process, designs for improved interventions, and methods for implementation and dissemination, all with the intent of effectively re-engineering current acute care setting discharge instruction. Implementation. Patient and providers were surveyed to determine wherein barriers existed within the current discharge instruction method. The survey discussed nine major areas of current discharge instructions and asked participants to consider which areas, for them, were most difficult to understand. The nine areas included: medical diagnosis, treatment plan, medications, common and adverse side effects/complications/signs and symptoms, aftercare MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 25 instruction, diet and exercise, lifestyle changes, follow-up appointments/referrals, and other (DME, monitors, other instruction). Other questions addressed hospital readmissions, interaction with healthcare providers, and whether adequate information, time, resources, and education was provided at discharge. Additionally, five different discharge platforms were discussed, including verbal, written, a combination of verbal and written, and digital multimedia instruction. Participants were asked to choose one discharge platform they would prefer over the others. Twenty-seven patients completed the survey, as well as 11 healthcare providers. The completed survey results were exported from REDCap into an Excel spreadsheet for descriptive data analysis. Evaluation. Information was abstracted and organized. A qualitative analysis was conducted by summarizing, comparing, and contrasting the abstracted data. Survey results indicated the following areas presented the greatest barriers to understanding for patients: 1) medical diagnosis; 2) medications; 3) aftercare instructions; 4) common and adverse side effects/signs and symptoms; 5) treatment plan; 6) diet and exercise; 7) lifestyle changes and other (DME, monitors, other instruction); and 8) follow-up appointments/referrals. According to the healthcare providers' responses, they perceived areas that presented the greatest barriers to understanding for patients were: 1) medications; 2) medical diagnosis; 3) treatment plan and aftercare instructions; 4) common and adverse side effects/signs and symptoms and lifestyle changes; 5) follow-up appointments/referrals. Providers felt patients understood instruction given in regard to diet and exercise, and that "other" (DME, monitors, other instruction) did not present significant barriers to understanding for their patient population(s). Areas of agreement between patients and providers on barriers to understanding include the medical diagnosis, medications, treatment plan and aftercare instruction, and common and adverse side effects/signs MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 26 and symptoms. These areas are the main focus for improvement within the newly re-designed discharge instruction platform. Older patients also preferred the customary printed/verbal format (combination) for instruction, whereas, providers preferred a digital discharge instruction platform. Objective 3. Develop a prototype multimedia discharge instruction platform using a variety of educational modalities, with a focus on feasibility in an acute care setting for broader implementation. Implementation. The re-designed printed and verbal discharge instruction prototype incorporates several multimedia modalities including text at no greater than a fifth-grade reading level, graphics, illustrations, and hyperlinks to additional information and education, video and animation (Appendix F). A document template was developed using Microsoft PowerPoint. This program allows for incorporation and utilization of a variety of different educational techniques (e.g. graphic illustration, audio, video, written text, and hyperlinking to other electronic resources). The re-designed discharge instruction document begins with the discharge summary highlighting the patient's diagnosis, medication changes and/or procedure, follow-up information, and appointments or referrals that have been scheduled. Detailed information regarding the plan of care, with expected course of recovery and specific aftercare instruction, and procedure complications or signs and symptoms to be mindful of is found following the discharge summary. Each section of the document provides printed information as well as several illustrations, graphics, and hyperlinks (or website addresses) to access additional education or information specific to the patient's current state of health, diagnosis, prognosis, procedures, medications, and health and lifestyle information. Following the patient specific MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 27 discharge instruction, a section for additional information, helpful resources, and specific health literature is included for the patient's information, and to provide supplemental education that may not have been covered during the discharge process. As with all information provided to patients, the document will require a patient signature acknowledging receipt of the discharge information. Signing can be accomplished with either a digital or written signature. Evaluation. The discharge platform has been evaluated by cardiologists and healthcare providers to determine if this type of instruction would be beneficial in their practice, and within their patient population(s). Healthcare providers have expressed a penchant for the printed platform in that it can also be presented as digital instructions to individuals in clinic and while in-patient following their procedure. This document is further adaptable when viewed as a digital document as all hyperlinks are active in that format, allowing patients to access additional information and education at their own pace, and prior to discharge. The digital document mirrors the printed document, and if the patient so chooses, can be given to them at discharge along with the printed format. Both platforms are easily understood and detailed, though instruction offered in digital format allows the patient to access supplementary information by visiting hyperlinked websites where they can receive further education about their diagnosis and plan of care including medications, procedures, and lifestyle changes. This template then becomes the basis of the multimedia discharge instruction and can be tailored to meet specific individual's needs, diagnoses, treatments, medications, and aftercare instruction. Due to the electronic nature of the template, this discharge tool has the potential to accommodate patients from diverse backgrounds, races, cultures, ethnicities, languages, education, health literacy and socioeconomic circumstances. Evaluation and feedback from content experts and the Project Chair has been incorporated into the working template. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 28 Objective 4. Disseminate project findings to stakeholders via a poster presentation, a working prototype of a simulated patient's digital discharge instruction, and submit a white paper to a professional meeting of the local cardiology community at large. Implementation. Utilizing descriptive analysis, survey data was summarized and the results analyzed to determine relationships between variables. Areas of greatest concern to patients were misunderstanding of the medical diagnosis, newly prescribed medications and their therapeutic effects, followed by aftercare instruction, treatment plans, and common and adverse complications related to their hospitalization. Older patients also preferred the standard printed and verbal format for instruction, whereas healthcare providers preferred the digital discharge platform. A presentation poster was developed detailing the evolution of the re-designed discharge instructions that utilize several educational modalities including written instruction, graphics, illustrations, and several hyperlinks to educational sites and videos (Appendix G). The working patient document combines written and digital instruction and is available in both printed and digital format. The patient document includes a discharge summary, information about the patient's diagnosis and prognosis, procedure and/or medication management, lifestyle changes, plan of care, symptoms and complications to be aware of and when to seek help, follow-up care, and scheduled appointments (Appendix F). Content experts and the Project Chair evaluated the presentation poster content as well as the simulated multimedia printed discharge instructions and provided feedback which was incorporated into the final presentation poster and working discharge instruction document. Evaluation. Once the poster and discharge instruction prototype was presented to stakeholders, and a whitepaper submitted to a professional meeting of the cardiology community MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 29 at large (Appendix H), continued conversation with stakeholders can determine whether individual provider's (those surveyed, and others in the cardiology community) intend to consider implementation of a re-designed multimedia discharge instructions. Options are available to providers to use either the printed document, digital document, or a combination of the two. It will be at the discretion of individual providers to decide whether to use the redesigned platform for their patient's post-cardiac procedure, or if the typical pre-printed and verbal discharge instructions, customarily given to all patients at discharge from the acute care setting, will remain the standard. Results Survey results were analyzed to determine relationships between variables and represented in a table, charts and graph on the presentation poster (Appendix G). Statistical significance for this study was defined by a significance level of p < 0.05 with a 95% Confidence Interval (CI). As indicated above, topics of greatest concern for patients and providers included discussion of the medical diagnosis, patient's prognosis, and newly prescribed medications and their use. Other areas of concern include aftercare instruction, the plan of care, and common and adverse complications related to the patient's recent hospitalization. Survey results indicated that 37% of all patients were concerned most with the medications that were newly prescribed, followed closely by their medical diagnosis, treatment plan, and after care instructions. Survey results also indicate that, of the five discharge platforms presented, older patients preferred the standard printed and verbal format (combined) for instruction 52% of the time, whereas 54% of healthcare providers preferred the digital discharge platform. Survey findings were contrary to the initial idea that a re-designed multimedia digital instruction model might MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 30 provide better patient understanding and outcomes, thus raising questions for future study regarding suitable discharge instruction design factors within specific patient populations. Study Limitations This study had several limitations including the small sample size, possible biased recall, and self-reporting of issues with, or misunderstanding of current discharge literature. Additionally, the population surveyed was over 65 years old, and many participants struggled with answering all survey questions, therefore over 21 surveys were thrown out for incompleteness. Other limitations focused on the participants themselves as all were familiar with standard discharge instruction, and few, if any, had experienced any other discharge platform. Lack of exposure to other discharge formats, patient difficulties with technology, and a small study population significantly limited options for improvement and implementation. Even with these limitations, qualitative analysis of several discharge topics highlighted information that is not provided, or inadequate in traditional discharge instructions. Future Recommendations This project is by no means an end to restructuring of discharge instructions, or the discharge process to improve the care continuum. As this type of platform is not widely implemented, further study is needed to determine what other confounding variables lead to greater self-management failure and subsequent hospital readmission within this population postdischarge. Additional evaluation is needed to determine the utilization and feasibility of multimedia discharge instructions in this population to determine the benefits of this platform, as well as future outcomes of patient's post-discharge, including evaluation of 30-day readmission rates for MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 31 all cause, morbidity, and mortality for those patients who receive multimedia discharge instructions, whether printed or digital, following a cardiac procedure. This conversation will need to be continued within the cardiology community, specifically in regard to the design of discharge instructions, the preferred platform, as well as with Mountain Star's IT department to facilitate use of digital instructions in the acute care setting, if deemed feasible DNP Essentials DNP Essentials are competencies that all DNP candidates should achieve throughout their academic journey. This project is defined by the following DNP Essentials: Essential II - Organizational and Systems Leadership for Quality Improvement and Systems Thinking Assessing, understanding, and developing a new process to address limitations in current discharge documents and procedures as it relates to the patient's level of comprehension to the instruction given. This project proposes to develop a new method of delivery for discharge instruction from an acute care facility that results in increased comprehension and compliance with aftercare instruction for individuals 65 years and older. Essential IV - Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care Development of a multimedia digital template for discharge instruction that utilizes a variety of education modalities resulting in a more efficient, effective discharge instruction that is easily understood by elderly (65 years and older) post-cardiac catheter patients. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 32 This project incorporates a number of DNP Essentials in different levels of its development and application. If successfully implemented, this project would increase the breadth of influence of several additional DNP Essentials not otherwise listed. Conclusion Developing a discharge platform that encompasses written text (no higher than a sixthgrade reading level), visual graphics, illustrations, and possibly video and animation within the discharge instruction, may help to decrease the complexity of the discharge process. Older adults experience several barriers to understanding with current discharge instruction. Areas of greatest concern for lack of understanding include the patient's medical diagnosis, medications and their use, treatment plans, aftercare instruction, and common and adverse side effects/signs and symptoms. These areas became the focus of improvement within the re-designed print and verbal discharge instruction platform prototype. Discharge instructions provide important patient care and safety information enabling a successful transition from care facility to home, and patient safety becomes a major concern when discharge instructions are not easily understood. This project sought to identify specific barriers older adults encounter in their attempt to understand current discharge instruction, and to develop a discharge instruction approach that would better address their questions and concerns prior to, and after a cardiac procedure. Incorporating a variety of multimedia educational modalities into a re-designed discharge instruction platform (printed or digital) may better enable patients with visual and auditory deficits, language, literacy, knowledge barriers, and other comorbidities that influence understanding, to better comprehend their aftercare instructions, thereby improving the opportunity for full recovery and better overall quality of life post cardiac procedure. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 33 References Albrecht, J. S., Gruber-Baldini, A. L., Hirshon, J. M., Brown, C. H., Goldberg, R., Rosenberg, J. H., . . . Furuno, J. P. (2014). 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(2016, April 18). Hospital Readmissions Reduction Program (HRRP). Retrieved from CMS.gov: https://www.cms.gov/medicare/medicare-fee-for-servicepayment/acuteinpatientpps/readmissions-reduction-program.html Doolittle, P. E. (2002, August). Multimedia Learning: Emperical results and practicle applications. Retrieved from Itma.vt.edu: http://www.itma.vt.edu/courses/distanceed/resources/multimedia_learning_theory.pdf Epstein, A. M., Jha, A. K., & Orav, E. J. (2011, December 15). The Relationship Between Hospital Admission Rates and Rehospitalizations. The New England Journal of Medicine, 365(24), 287-295. Retrieved from http://www.nejm.org/doi/pdf/10.1056/NEJMsa1101942 Goncalves-Bradely, D. C., Lannin, N. A., Clemson, L. M., Cameron, I. D., & Shepperd, S. (2016). Discharge planning from hospital (Review). Cochrane Database of Systematic Reviews, 2016(1), 1-103. doi:10.1002/14651858.CD000313.pub5 Greyson, S. R., Hoi-Cheung, D., Garcia, V., Kessell, E., Sarkar, U., Goldman, L., . . . 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Retrieved July 2, 2016, from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf Wong, E. L., Yam, C. K., Cheung, A. W., Leung, M. C., Chan, F. W., Wong, F. Y., & Yoeh, E.K. (2011). Barriers to effective discharge planning: A qualitative study investigating the perspectives of frontline healthcare professionals. Barriers to effective discharge planning: A qualitative study investigating the perspectives of frontline healthcare professionals, 11(242), 1-12. doi:10.1186/1472696311242 Zavala, S., & Shaffer, C. (2011, March). Do Patients Understand Discharge Instructions? Journal of Emergency Nursing, 37(2), 138-140. doi:10.1016/j.jen.2009.11.008 Zeng-Treitler, Q., Kim, H., & Hunter, M. (2008). Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Text with Pictographs. AMIA Annual Symposium Proceedings, 849-853. MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Appendix A University of Utah IRB Exemption 38 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 39 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Appendix B Project Defense PowerPoint 40 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 41 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 42 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 43 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 44 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 45 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 46 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 47 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Appendix C Survey Invite Letter 48 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Appendix D Survey Protocol for Barriers to Understanding Current Discharge Instructions Survey 49 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Appendix E Survey Barriers to Understanding Current Discharge Instruction This survey can be accessed at: https://redcap01.brisc.utah.edu/ccts/redcap/surveys/index.php?s=79YYDYYRKM 50 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Appendix F Patient Discharge Instructions 51 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER Appendix G Poster Presentation 52 MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 53 Appendix H White Paper/Executive Summary for Dissemination to Cardiology Community Discharge instructions provide key information for a successful transition from the acute care setting. Patient safety becomes a major concern when discharge instruction is confusing or misunderstood. Modern discharge instructions are often difficult to understand, resulting in ineffective communication for patients with visual, hearing, cognitive and sensory limitations, as is the preponderance among older adults. Discharge instructions using a variety of multimedia and educational techniques may provide a means to satisfy the learning disparities, language barriers, and visual and auditory deficits of many older adults. This research study's goal was to identify specific barriers older adults encounter in their attempt to understand current discharge instruction, and to develop a discharge instruction approach that would better address patients' questions and concerns prior to, and after, a cardiac procedure. The study objectives were to: 1) evaluate contemporary written discharge instructions for barriers to understanding; 2) identify barriers patient's experience with present discharge processes, designs for improved interventions, and methods for implementation and dissemination; 3) develop a prototype multimedia discharge instruction platform using a variety of educational modalities, with a focus on feasibility in the acute care setting for broader implementation; and 4) disseminate project findings to stakeholders via a poster presentation, a prototype of a re-designed discharge instruction platform, and a white-paper submitted to a professional meeting. Executing the project involved development of a questionnaire to survey both patients and healthcare clinicians to gather information about barriers patient's encounter with modern discharge instruction, and to solicit ideas for improvement and application of a re-designed discharge tool. Evaluation of questionnaire responses highlighted perceived barriers, needed interventions, requirements for implementation, and methods for dissemination of effective discharge instructions. Areas of greatest concern for misunderstanding included medical diagnosis, newly prescribed medications and their therapeutic effects, aftercare instruction, treatment plans, and common and adverse complications related to their hospitalization. A multimedia printed and digital discharge platform was developed based on participants' response, using a variety of educational techniques and learning methods, including graphics, illustrations, video, audio, and text. At project completion, a poster presentation, prototype of the re-designed discharge platform, and a white paper was presented to local stakeholders. Discharge instructions are an essential part of the care continuum and support a successful transition from care facility to home. A re-design of current discharge instructions may satisfy many of the reading, literacy, and language disparities experienced by older adults, thereby potentially decreasing hospital readmissions and morbidity, while improving patient outcomes MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 54 Appendix I Implementation and Evaluation Matrix Objective 1 Evaluate present pre-printed and verbal discharge instruction to assess current barriers to understanding older adults may experience Implementation • Initiate IRB approval process. • Review several pre-printed discharge instructions used in local acute care settings • Review other information given to patients about their health condition, procedure, and prognosis • Develop anonymous webbased questionnaire in REDCap Evaluation • Content Expert, Project Chair approve draft of cardiac patient survey • Obtain IRB Approval or Exemption • Receive production approval from REDCap to put questionnaire into production phase Objective 2 Obtain individual perspective(s) from various stakeholders to identify barriers older adults experience with current discharge instruction • Survey various consenting • Survey responses offer patients and healthcare concrete information providers regarding (opinions and perspectives) barriers to understanding from stakeholders, discharge instruction, identified barriers to designs for intervention, understanding current preand methods for printed discharge implementation and instructions, suggest dissemination in a digital interventions, and methods format for implementation and dissemination through a • Content Expert and Project multimedia platform Chair advise throughout Objective 3 Develop a prototype multimedia discharge instruction platform for cardiac patient's postprocedure • Create multimedia template using a variety of educational modalities in Microsoft PowerPoint. • Provide information about diagnosis, procedure, expected recovery, medication, details of aftercare/post-discharge home care, and follow-up instruction • Template populated with discharge information and • Professional stakeholders, Content Expert and Project Chair to approve template prior to publishing • Content Expert, Project Chair to continue providing any additional direction, feedback or alterations needed once template is published • Template contains information/instruction required by patients for optimal recovery MULTIMEDIA DISCHARGE INSTRUCTION FOR 65 AND OLDER 55 converted to .pdf or printed copy Objective 4 Disseminate project findings to stakeholders via a poster presentation, a working prototype, and submit a white paper to stakeholders and local cardiology community at large Implementation • Utilizing descriptive analysis summarize and describe survey data collection including most significant barriers and patient and provider preference for discharge instruction format. • Develop poster detailing the evolution of the redesigned discharge process utilizing several educational modalities to create a multimedia discharge platform • Content Expert and Project Chair to evaluate poster content and simulated multimedia discharge instruction prior to publication Evaluation • Poster presentation to board and cardiology clinic. Present simulated discharge instructions and whitepaper to other stakeholders and cardiology community at large • Continue conversation with cardiology community to address concerns with new platform, or make adjustments as requested. • Work with IT department to facilitate use of digital instructions in the acute care setting if feasible