NHMS is addressing these challenges through a series of innovative quality improvement initiatives. NMHS’s newest initiative is the CHF self-care college. In this paper, we describe the initiative, its implementation, and evaluation to date.
Self-Care College
Background
The idea for the self-care college grew out of discussions with Nurse Link coaches, registered nurses employed by NMHS, who call CHF patients at their homes following discharge. The first call, within 48 hours following discharge, is to reconcile medications, conduct patient education, and confirm follow-up appointments. Three subsequent weekly calls focus on additional education and recognizing “red flags ” utilizing the IHI “teach back” method, in which patients are asked to restate instructions or concepts in their own words. During regular biweekly meetings with physicians to monitor patient progress, Nurse Link coaches observed that many patients (and in some cases, their caregivers) had difficulty following their discharge instructions. In particular, patients did not understand how to properly weigh themselves, how and when to take their medications, or how to ensure their diet met physicians’ guidelines. Although patients were being provided with written and oral instructions as part of the discharge process and through post-discharge follow-up communications, they did not properly implement those instructions once they returned home.
A multidisciplinary team consisting of NMHS physician leaders and representatives from pharmacy, dietary, physical therapy, cardiac rehabilitation, nursing, and case management met to brainstorm ways to overcome this challenge. What emerged from these discussions was the idea for a simulation-based learning experience for patients prior to discharge.
Simulation-based learning is not a new concept. It has been utilized for many years in aviation, health care, and the military as a way to train people in high-risk professions, using realistic scenarios in a controlled environment, without risk to participants. Participants receive immediate feedback from trained instructors as to whether they are performing critical functions properly, providing an opportunity to practice areas in which there is a need to improve technique, speed, or implementation of actions in the correct order. It has been proven to be a highly effective type of learning experience that results in better retention of skills, both cognitive and procedural, and it reduces preventable adverse events [7]. Simulation-based learning in medicine has traditionally been limited to clinician education, where providers practice on computerized patient simulators or other substitutes for live patients. To our knowledge, the concept of simulation learning has not been extended to patient education initiatives.
Simulation-based learning would actively engage patients in learning the necessary self-care skills rather than being passive recipients of information. As the self-care college team often says, “You don’t learn to ride a bike by reading a book; neither should you be asked how to manage CHF by reading a pamphlet.”
Learning Stations
Participants in the self-care college rotate sequentially through 3 learning stations: weight, diet and medications. The main location for the self-care college is a conference room on the cardiac unit of NMMC. At each station, patients are asked to perform the tasks they will be required to do at home. If they cannot complete the task, the deficit is recognized and addressed. This might include referring the patient to home health care, ensuring that a Nurse Link coach contacts him or his caregiver to reiterate medication instructions or ensuring that his case manager refers him to appropriate social services. Although no formal cognitive assessment is conducted, if the team perceives that the patient has a cognitive impairment that could prevent him from being able to perform self-care activities, this information is relayed to the case manager.