Check-EN
Project status
Collaborators
Brigid McCreary, MSOD, RD, CSG, LDN
Kristen Dwinnells, MA, RDN, LDN, CNSC
Marianne Aloupis, MS
Laurie Panichelli, PT, DPT
Lauren McLaughlin, RN, WTA
Sarah Tokarczyk, PT, DPT, MHA
Natasha Hakkal, MD
Innovation leads
Funding
Innovation Accelerator Program
Opportunity
People with severe malnutrition or pathology restricting eating by mouth require feeding through a tube, known as enteral nutrition (EN). Approximately 80 patients are discharged from the Hospital of the University of Pennsylvania (HUP) on EN each month. EN patients are 1.4 times more likely to be readmitted within 30 and 90 days, with a significant proportion of readmissions related to EN. The median cost of readmission in this patient population is $30,000.
Intervention
Check-EN is a multifaceted program that aims to improve patient care and satisfaction in this high-risk population by addressing issues with comprehension, compliance, and continuity of care that result in readmissions.
Check-EN ensures that patients have the right supplies, training, and support to manage their care after discharge. Key features of the program include:
- A streamlined and fully coordinated discharge process
- Support from Penn Medicine Home Health to facilitate the transition from inpatient to outpatient care
- Provision of EN supplies upon discharge for use until long-term medical equipment is delivered to the patient's home
- Hands-on education before discharge and educational materials delivered digitally after discharge
- Enrollment into a text messaging program managed by Way to Health that monitors progress for 30 days and connects patients to support as needed
Impact
Data from early pilots suggests that Check-EN can prevent EN-related readmissions and emergency department visits. With Check-EN, issues that often lead to readmissions, such as clogged tubes, formula intolerance, dehydration, and missing supplies, were eliminated or resolved quickly in an outpatient setting. Check-EN was also shown to dramatically reduce the time clinicians spent coordinating discharge and providing care to EN patients after they returned home. The program saved an average of 13 hours per patient, time that home health clinicians could be using to provide much-needed care to additional patients. Feedback about patient and caregiver experience has also been positive.
This project is part of our 2021 Innovation Accelerator class. In phase two, the team plans to expand pilots to other health system departments, automate the text-messaging hovering tool, optimize integration with the electronic health record, improve education materials, and continue optimizing care pathways. A “crush and flush” medical device is also being developed to help prepare meals and medication for EN feedings.
Way to Health Specs
Learn more about the platformInnovation Methods
Show me
Show me
Show me
Instead of relying on a verbal recount of experience, ask users to show you how they use a product or service. What people say they do is often quite different than what they do.
Observing users in action will help you understand the spectrum of experiences users can have with the same product or service.
Surveys, interviews, questionnaires, and focus groups don’t tell you what you need to know. Prompting users to show instead of tell often reveals what others have missed.
Show me
We visited patient homes to observe feeding and medication administration processes firsthand. In one house, we saw a color-coded schedule of tasks that a family created to coordinate the efforts of multiple caregivers and learned that administering medications properly required a complicated process that took more than an hour and had to be completed three times a day. These visits helped understand the experience of the end-user and identify caregivers as a critical piece of the puzzle in preventing readmissions. They also helped us realize that we would need to solve for the complexity of managing EN if we were going to have an impact.
A day in the life
A day in the life
A day in the life
One of the best ways to learn more about a problem area is to experience it yourself. Immerse yourself in the physical environment of your user.
Do the things they are required to do to gain a firsthand experience of the challenges they face. Completing a day in the life exercise will enable you to uncover actionable insights and build empathy for the people you're hoping to help.
A day in the life
Members of our team wore a feeding tube for a day and followed the same schedule of feeding and medication administration that one of the pilot patients was given. They used the discharge instructions and educational materials that the hospital sends home as a guide. Through this exercise, we learned just how much work it is to manage the complicated EN schedule and how stressful it can be to try and coordinate your day. It also helped us deepen empathy for our end user and identify elements of the educational materials that needed to be improved.
Eye of the beholder
Ask users to wear a GoPro, keep a diary, or snap photos throughout their day. Artifacts like these will help you understand their first-person perspective.
Eye of the beholder
Eye of the beholder
We asked patients and caregivers to snap and share photos of their experience after discharge. The images we received of kitchen tables covered in supplies and medications showed just how overwhelming it can be to stay organized while navigating the complex schedule of feedings and medications that EN patients manage. This led us to design a goody bag for patients with pockets to keep feeding tube supplies organized and a booklet with pictures to help guide them as they learn to manage their new routine.
Journey map
Journey map
Journey map
A journey map is a visualization of a user's process to accomplish a task. Journey mapping involves plotting user actions onto a timeline.
Details on users' thoughts, emotions, and feedback are then added to the timeline to provide a holistic view of the experience or journey. Journey mapping will help you uncover what's working well in the current state and identify key pain points that need addressing.
You can build a journey map based on several users' observations, creating an archetype user journey, or you can use a template in real time as you conduct individual observations of users.
Journey map
We mapped EN patient experience from the time of tube placement until they successfully managed their EN at home, capturing all the critical moments in the process and the people patients interacted with at each touchpoint. We also mapped the discharge process from the clinician's perspective to create a big picture of all the steps needed for an EN discharge to be successful. Doing this helped clarify where communication breakdowns and redundant work were happening and led to productive discussions among the clinical teams about who should own each step in the EN discharge process.
Fake back end
Fake back end
Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end
We gave patients and caregivers a number they could text when issues or questions arose after discharge. Check-EN team members managed the service, answering questions and helping resolve issues in real-time. This pilot enabled us to identify the most common problems patients were facing, pinpoint issues with educational materials, and catch and resolve patient problems before they led to readmissions or unnecessary ED visits. Insights from this pilot informed the design of Check-EN's text messaging program, now managed by Way to Health.