Transitions in Long Term Care:
The role of a hospital/SNF
partnership in assuring effective
transitions of care
Aubrey L. Knight, M.D.
Chief, Geriatric and Palliative Medicine
Carilion Clinic
Roanoke, VA
Disclosure

I have no relevant relationships or
affiliations with any proprietary entity
producing health care goods or services.
Objectives
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Understand the risks inherent in
transitions from one site of care to
another
Identify processes at the time of transition
that can help to mitigate some of the risks
Recognize the role of the SNF and the
medical director in assuring the transition
is safe
It’s in the News
“Care Transitions: The Hazards of Going In
and Coming Out of the Hospital”-
Huffington Post 10/10
“Heart Failure Program Has Reduced
Readmissions by 30 Percent”The New York Times 9/11
“Don’t Come Back, Hospitals Say”THE WALL STREET JOURNAL- 6/11
It’s big business
It’s not rocket science
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Rather, it is:
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Good care
Good
communication
Attention to detail
Teamwork
So, what makes it so difficult?
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Complexity
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Technology
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Double-edged sword
Entropy
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Of systems
Of rules and regulations
Of patients
The concept of health care as a “team sport” has been slow to
evolve
Mal-aligned incentives
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Lack of payment for many of the things that could help
Throughput, current hospital payment methodology, etc
Fundamental Disconnect…
SNF
Hospital
Skilled Nursing
Facility
Home
Ambulatory
Care Clinic
Rehabilitation
Facility
Home Health
and Hospice
Complexity
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Of systems
Of rules and
regulations
Of patients
Technology- “the double-edged
sword”
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Meaningful use vs.
Meaningful care
Reliance on the
computer to do the
work of the human
EHRs that do not talk
Entropy
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The silo mentality of
our systems
“We’ve never done it
that way before”
Hospital
SNF
Home Care
Misaligned incentives
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Through-put- do
everything quickly…”get
them out of my…”
DRG’s- financial
incentives to shorter LOS
Medicare Part A
restrictions- Hospice in
the nursing home setting
Transitions of Care- Definition
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The movement of patients from one health care
practitioner or setting to another as their
condition or care needs change.
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Within settings
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Between settings
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Primary care to Specialty care
ED to inpatient
ICU to PCU to ward
Hospital to LTC (and back)
Hospital/LTC to home
Across health states
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Curative to palliative care
Each transition brings with it
opportunity for error
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Medication errors
Inefficient/duplicative care
Inadequate patient/caregiver preparation
Inadequate follow-up
Dissatisfaction
Litigation
Barriers to effective transitions
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Patient barriers
System barriers
Practitioner barriers
Patient barriers
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Patients are living longer and with age comes
chronic illness
Institutionalization fosters dependency and we
ask them to abruptly become independent
Health literacy
Ability to follow though with plans
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Transportation
Cognitive impairment
Cost of medications
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Medicare D “donut hole”
System barriers
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Complexity
Multiple providers
Shift work/Duty hours
Poor electronic communication
Poor understanding of the capabilities and
roles of home health, hospice, and SNF
Practitioner barriers
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Busyness
Specialization
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Hospitalist
Intensivist
SNFist
Extensivist
Outpatient only
Medicare – Excess
Readmission Rates - Penalties
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CMS will penalize hospitals for excess readmission rates
starting FFY 2013 (Oct. 2012)
Initial focus – HF, AMI, PNE
FFY2015 (starts Oct. 2014) may add chronic obstructive
pulmonary disease, CABG, percutaneous coronary
interventions, and some vascular surgery procedures.
Penalty
 FFY2013 – up to 1% all IP Medicare payments (CMC
approx $1.5m)
 FFY2014 – up to 2%
 FFY2015 – up to 3%
The other Transition
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Problems arise not just from transition
from the hospital to another site of care
When we send them home, the same risks
are present
Organizational guidance
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CMS 9th SOW statement about care
coordination
2009 Joint Commission Patient Safety
Standard #8 about medication
reconciliation
NQF Performance Measures for Care
Coordination
NTOCC tools and resources
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Patient Bill of Rights during Transitions of
Care
Multiple other tools
www.ntocc.org
Published models
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H2H- American College of Cardiology
Project Boost- Society of Hospital Medicine
Project RED
The Care Transitions Intervention
American College of Cardiology and
Institute for Healthcare
Improvement
Project BOOST
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Better Outcomes for Older Adults Through Safe
Transitions
Effort of the Society of Hospital Medicine
Resources and evidence-based interventions
Encourages team building and working through
system processes
Project RED
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Educate the patient
Make appointments
Discuss tests and results
Organize post-discharge
services
Confirm the medication
plan
Reconcile the discharge
plan
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Review process when
problems arise
Expedite the transmission
of the discharge summary
Assess patient
understanding
Give patient a written
discharge plan
Telephone reinforcement
in 2-3 days postdischarge
Improving the Discharge Process –
The Care Transitions Intervention
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Designed to encourage older patients and their
caregivers to assert a more active role during
care transitions
Elderly patients provided a transition coach
“4 pillars”
1.
2.
3.
4.
Medication self-management
Maintenance of Personal Health Record
Timely f/u with PCP and Specialists
Knowledge of potential complications and ways to manage them
if they occur
Coleman et al. Arch Intern Med.
2006; 166:1822-1828
Outcomes from effective transitions
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Improved patient/family satisfaction
Reduced health care cost
Decrease readmissions
Patients cared for at the right time, at the right place.
Ultimately Lower Health Care Costs
Reduced inefficiencies/duplication of
services
 Lower hospital and ED use
 National 30-day readmit rate- 1525%
 Reduced litigation/negative press
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IDEAS for success
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Involve stakeholders
Develop tools
Engage/empower patients and caregivers
Adapt technology so that there is the
ability to share information
Share information
Stakeholders
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Hospital administration (see CMS
penalties)
LTC administrators (mention bundled
payment and you’ll get their attention)
Hospital physicians
LTC Medical Director
Transition tools
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Checklist
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Discharge summary
Handoff
Medication reconciliation
Engage floor nurses and
case managers
Follow-up
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phone calls
appointments
Keep it simple
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We work in an incredibly
complex field
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6,000 drugs
ICD-9 has > 13,000
conditions
The basics can get lost in
the jungle of complexity
Checklists can help
simplify and standardize
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Airline pilots
The Discharge Summary and other
handoffs
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Physician summaries are the least reliable
source of medication lists- Am J Ger
Pharmacotherapy Aug 2011
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Summaries and Handoffs are our means
of communication and must be:
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Complete- “Antibiotics for one week”
Accurate- Inpatient and outpatient meds not
thoughtfully reconciled
Clear- “Follow-up CT scan in one week”
Medication Reconciliation
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Errors occur in deciding on and communicating
whether and which outpatient medications
should be continued when patients leave the
hospital or the nursing home
Over half of medication discrepancies were
classified as potentially causing moderate/severe
discomfort or clinical deterioration- Am J Ger
Pharmacotherapy Sept 2011
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Pharmacist-led models of medication
reconciliation continue to emerge
Medication Delays
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Being scrutinized more carefully
We need to not only approve meds, but
ask about next dose and availability
Solutions
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Early transfers
Partnerships with hospitals
Communication
Medications at discharge from the
SNF
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Are patients capable of following through?
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Insulin
Nebulizers
Whose role and for how long?
The handoff to the PCP
How do we know patients understand?
Nurse engagement
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Nurse Engagement Key to Reducing
Medical Errors: People more important
than technology- by Rick Blizzard, D.B.A. Health and
Healthcare Editor of the Gallup Organization, 2005
Follow up
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Post discharge calls
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Accountability
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By hospital case management, pharmacist,
PCMH…ANYONE
This is the lethal gap in the care. Someone needs to
take responsibility.
Follow up appointments
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Studies indicate that appointments within 7-14 days
make a difference
Patient
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Empowered to ask
Armed with
information
Knows whom to call
for answers
Make technology your friend
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EMR
Telemonitoring
Email/texting
Communication
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Understand to roles and
capabilities at the
various sites of care
Share your piece of the
puzzle
Be specific
Relational Coordination
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Relationships of:
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Shared goals
Shared knowledge
Mutual respect
Communication that is:
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Frequent
Timely
Accurate
Problem-solving
Real Health Care Reform
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Is local
Involves each stakeholder working as a
team
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Patient
Family
Providers
Institutions
Community agencies/resources
References
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Project Boost:
www.hospitalmedicine.org/ResourceRoomRedesign/RR_
CareTransitions/html_CC/project_boost_background.cfm
Project RED: www.bu.edu/fammed/projectred/
Care Transitions Intervention: www.caretransitions.org/
NTOCC: www.ntocc.org
H2H: www.H2Hquality.org
AMDA CPG on Transitions of Carewww.amda.com/tools/clinical/TOCCPG/index.html
Atul Gawande- http://gawande.com/