Organization of the RED Content 

Before a patient leaves the hospital, the nurse prepares the MayaRED “After Hospital Care Plan (AHCP)” that summarizes the discharge plan based on RED principles. An example is found HERE. The AHCP displays the key information that patients must know to know what to do to care for themselves when they return home. It uses large fonts, colors, icons, pictures that make is understandable to patients of all health literacy levels. 

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Delivery of MayaRED

The nurse then brings a tablet device to the patient room and pushes the button to begin the educational session. Using personalized conversational dialogue, Maya teaches the AHCP shown on the computer screen while the patient follows along on the hard copy that they are holding in their hands. The patient responds by clicking the response options.

 

MayaRED teaches the following content

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• Discharge Diagnosis: The dialogue is designed to build trust in that the doctors and nurses have designed  a discharge plan ”specifically for me” that is effective, and that it is important to take the meds as prescribed, and to follow- up with the doctors so your recovery can be monitored. The words describing the diagnosis are carefully chosen and based on current evidence-based data from national or specialty organizations. All content is referenced. The dialogue to be easily adapted to local hospital protocols. Nurse tell us that they would like to deliver this level of detail, but because of time, and sometimes knowledge, they often do not. MayaRED insure that every patient hears this important information – every time.

• Secondary Medical Conditions and Social Determinant of Health (SDoH): As a patient’s attention span is limited and they are anxious to go home, we have made a design decision to focus on those factors most likely to impact 30 day all-cause readmission. Therefore, Maya does not talk in detail about the other diagnoses. However, detailed information is available on the Maya app portal when they go home.

• Medication: All medicines the patients is to take when they go home are listed. Medicines are labeled as NEW, DOSE CHANGED, NO CHANGE and STOPPED. A summary of why the medicine is important and things to look for are discussed for all NEW and DOSE CHANGED meds. Those NOT CHANGED are not discussed, BUT descriptions are available on the MAYA APP when they go home. Maya emphasizes the importance taking all medicines as prescribed and the importance of follow-up so medicines can be monitored and possibly up-titrated after discharge. 

• Post-Discharge Appointments and Calendar. MayaRED describes the details of all the post-discharge follow-up appointments (e.g., date, time, address, purpose) with primary care, specialists, therapy etc. in the AHCP and on the screen. The appointments are color coded to a calendar listing all follow-up activities in the next 30 days. Patients and family caregivers tell us the greatly appreciate the Calendar often saying they hang it on their refrigerator.

• What to do if a problem arises. MayaRED explains to every patient what to look for that could indicate worsening of their condition. MayaRED describes who to call if there is a problem and gives them permission to do so. This allows early care rather than waiting for an emergency situation requiring visiting an emergency room. The symptoms to look for are specific to the primary diagnosis when available. The AHCP contains and Maya discusses the  

• Diet. Multiple diets are available in the dropdown menus (see the MayaRED document entitled “Instructions for Using MayaRED”). Maya provides introduction to each of the diets, then allows the patient to continue to learn about the diet on the MAYA APP, which can also monitor progress. Maya also asks the patient if they would like a referral for nutritional support and, if so, records this request in the “session report” for the discharge provider to act on after the interaction.  

• Exercise. Maya describes the level of exercise recommended by the discharge team. Maya also asks the patient if they would like a referral for physical therapy, and, if so, records this request in the “session report” for the discharge provider to act on after the interaction.   

• Upcoming tests. Data show that many tests ordered to be done after discharge are not done. Maya emphasizes the important of having these tests done and provides the date, time and location of where to go to have the test done.

• Tests Completed, but the Results are Pending at Discharge. Tests already done can be lost in the transition and not followed up appropriately. The AHCP lists these tests, and MayaRED discusses that the patient should ask the doctors about these tests at follow-up visits. The gives the patient permission to remind doctor to check the results helping insure that these tests do not fall through the cracks.

• Medical Equipment Needed at Home. The AHCP lists and Maya discusses the purpose of and how to use any medical equipment such as a cane, oxygen, CPAP, hospital bed, nebulizer etc.  

• Information Specific to the Hospital or Health System. The dropdown can also contain a section where information specific to the discharging hospital can be printed in the AHCP and discussed by Maya. This could include information about special services provided (e.g,. smoking), required screens (e.g., suicidality), etc.  

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MayaRED uses state-of-the art educational techniques.

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Teach-Back. Maya confirms patient understanding by asking questions about the medicines and appointments using the evidence-based “Teach Back” technique. If the question is answered incorrectly, MayaRED records this is the “session report” giving the discharge provider a chance to evaluate if the patient understands instructions, and if not, to implement an alternative plan.

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Questions are the Answer. CMS requires that patients have a chance to ask questions at the time of discharge. MayaRED delivers that Agency for Health Research and Quality best practice called “Questions are the Answer”. After each section of teaching, MayaRED asks if the patient has questions, and if so, records this on the session report where they nurse or doctor can respond to them. 

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Session Report. At the end of the teaching session, MayaRED prints out a report for the discharge provider to review with the patient before the patient goes home. The report documents (a) Topics discussed. (b) Patient understanding based on “teach back” results, and (c) Any questions the patient might have about specific topic areas. The session report give the doctors and nurses a chance to clarify understanding, to answer patient questions, and to correct any errors identified in the discharge plan. 

 

Reinforcing the Discharge Plan

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Post-Discharge Notifications. MayaRED explains how the patient can download the MayaMD App to their mobile phone. In the patient portal on the app, the patient can choose to receive post-discharge reminders about appointments and medicines at times convenient to the patient, a functionality shown to reduce readmission.

Documentation of the AHCP and Session Report in the Electronic Health Record (EHR). The AHCP and Session Report can be electronically downloaded to the EHR documenting the discharge education and post-discharge plan. 

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Dissemination of the AHCP and Session Report to Post-discharge Providers and Home Caregivers. After the teaching session, with patient permission, the providers caring for the patient and the patient home caregivers can access the AHCP containing the discharge medicines, appointments etc. and the Session Report.

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Transition to Remote Patient Monitoring. Eligible chronic care patients also have access to the MayaMD Remote Patient Monitoring (RPM) system that provides reminders to take their readings of clinical measures using automated transmitting devices (e.g., blood pressure monitor, pulse oximeter, scale, glucometer). The MayaMD Provider Portal displays the clinical measures, shows trends graphically, and notifies chronic care providers about any abnormal readings using individualized guidelines from the ordering provider.  

 

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