SAFE CARE
TRANSITIONS:
BRIDGING
SILOS OF CARE
AGS
Karin Ouchida, MD
Assistant Professor of Medicine
Division of Geriatrics
Montefiore Medical Center/AECOM
Medical Director
Montefiore Home Health Agency
November 14, 2009
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
OBJECTIVES
• Identify complications of poor transitions
• List key components of safe transitions
• Distinguish different discharge services and
settings
• Appreciate the physician’s role
Slide 2
WHY SHOULD YOU
CARE ABOUT THIS?
• Patient safety
 The Joint Commission
• Health care reform
 Reduce avoidable re-hospitalizations
 Increase accountability + transparency
Slide 3
SURVEY OF PATIENTS ABOUT
HOSPITAL EXPERIENCES
Doctors communicated well
Always
Usually
Sometimes
or never
Average for all reporting
hospitals in the US
80%
15%
5%
Average for all reporting
hospitals in New York
76%
18%
6%
Montefiore Medical Center
79%
15%
6%
Mount Sinai Hospital
79%
16%
5%
St Luke’s Roosevelt Hospital
71%
22%
7%
Slide 4
HOW OFTEN DO TRANSITIONS OCCUR?
• After hip fracture, pts
underwent an average
of 3.5 “relocations”
• Between Thurs and
Mon morning, 67
“handoffs” may occur
• Medicare beneficiaries
see a median of 2
PCPs and 5 specialists
yearly!
Boockvar et al. JAGS. 2004;52:1826-1831.
Horwitz et al. Arch Intern Med. 2006;166:1173-1177.
Hoangmai et al. N Engl J Med. 2007;356:1130-1139.
Slide 5
DEFINITION OF TRANSITIONAL CARE
The set of actions
necessary to ensure
the coordination and
continuity of health
care as patients
transfer between
different health care
settings or levels of
care
Coleman and Berenson. Ann Intern Med. 2004;140:533-536.
Slide 6
COMPLICATIONS OF POOR TRANSITIONS
• Adverse events
• Increased health care
utilization
• Patient dissatisfaction
• Provider
dissatisfaction
Slide 7
ADVERSE EVENTS
• Injury resulting from medical management vs.
underlying disease
• 1 in 5 patients experiences an adverse event
during the hospital-to-home transition
 1/3 are preventable
 1/4 of patients are re-admitted to the hospital
Forster et al. Ann Intern Med. 2003;138:161-167.
Slide 8
INCREASED HEALTH CARE
UTILIZATION
• 16% of Medicare beneficiaries are re-hospitalized within
30 days of discharge after a surgical admission
 Vascular surgery 24%
 Major bowel surgery 17%
 20%40% are re-admitted to a different hospital
• Readmission is associated with increased mortality,
impaired function, and nursing home placement
• Cost of unplanned re-hospitalizations in 2004:
estimated at $17.4 billion
Jencks et at. N Engl J Med. 2009;360:1418-1428.
Boockvar et al. J Am Geriatr Soc. 2003;51:399-403.
Slide 9
4 CRITICAL COMPONENTS
OF SAFE TRANSITIONS
1. Medication reconciliation
2. Patient education
 Red flags
 Who to call
3. Communication between sending and
receiving providers
4. Timely follow-up
Slide 10
CASE 1
• A 78-year-old woman with a history of atrial
fibrillation, CVA, and newly diagnosed breast
cancer is admitted for mastectomy
• Warfarin is held for surgery
• The hospital course is complicated by delirium
and UTI
• The patient is discharged to subacute rehab
• She is re-admitted after 5 days with rapid a-fib
and sudden dysarthria/facial droop
Slide 11
CASE 1: MEDICATIONS
HOME
• Atenolol 50 mg qd
• Metformin 850 mg
BID
• Glucotrol 10 mg qd
• Warfarin 3 mg qHS
• Prevacid 30 mg qd
• Calcium/vitamin D
600/400 IU BID
• Alendronate 70 mg
weekly
HOSPITAL
• NPH 8 units qAM
• Protonix 40 mg
daily
• Keflex 500 mg BID
• Colace 300 mg qd
• Senna 2 tabs qHS
DISCHARGE
• NPH 8 units qAM
• Protonix 40 mg
daily
• Keflex 500 mg BID
Slide 12
COMPONENT 1:
MEDICATION RECONCILIATION
• How: Start with an
accurate pre-admission list
• When: “Across the
continuum of care”
• Why: Most adverse
events are medicationrelated (66%)
Forster et al. 2003 Ann Intern Med. 2003;138:161-167.
Slide 13
CASE 2
• A 78-year-old woman with mild dementia, CAD, and
DM is admitted with fever and abdominal pain
• She is found to have acute cholecystitis and
undergoes open cholecystectomy
• The post-op course is complicated by mild cellulitis
at the incision site
• She is discharged on Keflex and Percocet for pain
but not educated about warning signs/symptoms
• She is re-admitted 7 days later with wound abscess
and fecal impaction
Slide 14
COMPONENT 2: COACHING PATIENTS
TO ACHIEVE SKILL TRANSFER
• Care Transitions Intervention® www.caretransitions.org
• Subjects: 65+ admitted with multiple chronic conditions
Transitions Coach (APN, RN, MSW) simulates common
transition challenges and coaches them to adopt
effective strategies to respond:
 Resolving confusion over medications
 Scheduling and preparation for follow-up visits
 Identifying indicators of worsening condition (“red flags”) and
knowing how to respond
Coleman et al. Arch Intern Med. 2006;166:1822-1828.
Slide 15
SURVEY OF PATIENTS ABOUT
HOSPITAL EXPERIENCES
Patients were given information about what
to do during their recovery at home
Yes, staff
did give
No, staff did
not give
Average for all reporting hospitals in the US
80%
20%
Average for all reporting hospitals in New York
79%
21%
Montefiore Medical Center
78%
22%
Mount Sinai Hospital
78%
22%
St Luke’s Roosevelt Hospital
67%
33%
Slide 16
CASE 3
• A 75-year-old man is admitted for elective hernia
repair
• He is given Ancef preoperatively and develops a
rash, although he has no previous history of
medication allergy
• Post-op, he has hematuria, which resolves
spontaneously; a UA/urine culture and urine
cytopathology are sent
• When he is discharged to home, the discharge
summary does not list Ancef allergy or note
pending urine cytology
Slide 17
COMPONENT 3:
COMMUNICATION
• System problems contributed to all preventable
and ameliorable adverse events
• Most common reason for failed transition = poor
communication between inpatient MD and patient
or PCP (59%)
• Direct communication between inpatient MD and
PCP occurred in only 3%-20% of cases
Forster et al. Ann Intern Med. 2003;138:161-167.
Kripalani et al. JAMA. 2007;297:831-841.
Slide 18
WAYS TO COMMUNICATE
Discharge summary
Patient
Proprietary software
E-mail
Phone
Slide 19
DISCHARGE SUMMARIES
• Key information is often missing:






Responsible hospital MD (25%)
Main diagnosis (18%)
Discharge medications (20%)
Specific follow-up plans (14%)
Diagnostic test results (38%)
Tests pending at discharge (65%)
• Available at follow-up visit only 12%34% of
the time
Kripalani et al. JAMA. 2007;297:831-841.
Kripalani et al. J Hosp Med. 2007;2:314-323.
Slide 20
THE “IDEAL” DISCHARGE FORM
•
•
•
•
Presenting problem
Key findings and test results
Final diagnoses
Condition at discharge
(including functional and
cognitive status if relevant)
• Discharge destination
• Discharge medications
(purpose, cautions, changes in
dose or frequency, meds that
should be stopped)
•
•
•
•
•
•
•
•
Follow-up appointments
Pending labs/tests
Specialist recommendations
Documentation of patient
education/understanding
Anticipated problems or
suggestions
24/7 call-back number
Referring/receiving providers
Advanced directives/code status
Halasyamani et al. J Hosp Med 2006;1:354-360.
Slide 21
PENDING TEST RESULTS
• 2600 patients discharged from hospitalist services
at 2 academic hospitals
 40% had test results returned after discharge
 10% required some action
• Hospitalists and PCPs surveyed about 155 results
 Unaware of 60%
 40% were actionable, 13% urgent
Roy et al. Ann Intern Med. 2005;143:121-128.
Slide 22
RECOMMENDATIONS FOR
OUTPATIENT WORKUP
• Of 700 discharges, 30% had outpatient work-up
recommended
 Diagnostic procedure (48%)
 Subspecialty referrals (35%)
 Laboratory tests (17%)
• 36% of work-ups were not completed
 Availability of discharge summary increased
likelihood that post-discharge work-up would be
completed (OR = 2.35)
Moore et al. Arch Intern Med. 2007;167:1305-1311.
Slide 23
CASE 4
• An 80-year-old woman is admitted with fever,
vomiting, and abdominal pain
• She is found to have acute appendicitis and
undergoes laparoscopic appendectomy
• She is discharged home with instructions to
follow-up in the surgery clinic in 4 weeks
• She is re-admitted 2 weeks later with fever,
altered mental status after a fall at home
• The port sites are grossly infected
Slide 24
COMPONENT 4:
TIMELY FOLLOW-UP
• 50% of patients re-hospitalized within 30 days of
discharge did not have an outpatient MD visit
billed to Medicare
• Benefits of timely follow-up:




Lab monitoring
Reconcile medications
Check on home supports
Reinforce knowledge of red flags and emergency
contact information
Jencks et al. N Engl J Med. 2009;360:1418-1428.
Forster et al. Ann Intern Med. 2003;138:161-167.
Slide 25
CHALLENGES TO IMPROVING
TRANSITIONAL CARE
• Physicians
 Awareness
 Multiple providers
 Time
• Patients




Health illiteracy
Cognitive impairment
Language barriers
Lack of social support
• Systems
Slide 26
DO WE NEED “TRANSITIONALISTS”?
Slide 27
TRIAL OF
DISCHARGE SERVICES (1 of 5)
• Subjects: Adults admitted to medicine teaching service,
discharged home
• Design: Randomized trial with block randomization
• Intervention: Nursing discharge advocate visit plus
pharmacist phone call
• Follow-up: 30 days
• Primary endpoint: Number of ED visits and readmissions
• Secondary endpoints: Patient knowledge of diagnosis,
PCP name, follow-up, preparedness for discharge
Jack et al. Ann Intern Med. 2009;150:178-187.
Slide 28
TRIAL OF
DISCHARGE SERVICES (2 of 5)
• Nursing discharge advocate
 Educated patient re: dx, meds, follow-up
 Arranged follow-up appointments
 Set up post-discharge services
 Reviewed and transmitted discharge summary to PCP
 Provided pt with “after-care plan”
• Pharmacist phone call 24 days post-discharge to
review medications
Jack et al. Ann Intern Med. 2009;150:178-187.
Slide 29
TRIAL OF
DISCHARGE SERVICES (3 of 5)
P = .009
Jack et al. Ann Intern Med. 2009;150:178-187.
TRIAL OF
DISCHARGE SERVICES (4 of 5)
Usual
care Intervention P-value
Able to identify discharge
diagnosis
70%
79%
.017
Able to name PCP
Follow-up with PCP
89%
44%
95%
62%
.007
< .001
Understood how to take
meds after discharge
83%
89%
.049
Jack et al. Ann Intern Med. 2009;150:178-187.
Slide 31
TRIAL OF
DISCHARGE SERVICES (5 of 5)
In the intervention group:
• Follow-up with PCP made prior to discharge: 94%
(vs. 35% in usual care)
• D/C summary sent to PCP within 24 hours: 90%
• Pharmacist reviewed meds with 50%
 65% had at least 1 medication problem
 50% needed corrective action by pharmacist
Slide 32
A STRATEGY FOR
EFFECTING SAFE TRANSITIONS
If you don’t have a transitionalist, identify and
involve interdisciplinary team members who can
help you with:
• Med reconciliation
• Patient education
• Communication
• Follow-up
Slide 33
A TEAM APPROACH
Inpatient
Outpatient/Home
•
•
•
•
•
•
•
•
•
•
•
•
Nurse
Social worker
Pharmacist
PT/OT
Medical students
Caregivers
Home care nurse
Home care SW
Pharmacist
Home care PT/OT
Case managers
Caregivers
Slide 34
IDENTIFYING THE MOST
APPROPRIATE DISCHARGE SETTING
Functional assessment:
• Activities of daily living and instrumental
activities of daily living
• Ambulation
• Cognitive status
• Home environment
• Caregiver support
Slide 35
SHORT-TERM HOME HEALTH CARE
• Skilled need: RN, PT and/or speech therapy
• Homebound: assistance for person/device to
leave the home
• Intermittent care: part-time, intermittent needs
• Physician supervision: must have outpatient MD
to sign orders, address concerns
• If the patient needs assistance with activities of
daily living (ADLs) or instrumental ADLs, there
must be sufficient/willing caregiver(s)
Slide 36
REHABILITATION SETTINGS
HOME
SUBACUTE
ACUTE
• Can tolerate PT for
3060 min/day
• Medical and/or
personal care
needs can be met
by short-term aide
+ family support
(eg, needs help
with shopping,
picking up meds)
• Can tolerate PT for
3060 min/day
• Medical needs and/or
personal care needs
exceed what family
can provide (eg,
needs help getting to
bathroom and/or
administering meds,
and is at high risk for
falls)
• Aggressive
PT/OT/ST 3h/day
• Great potential to
achieve functional
goals
• Impairment
subject to serious
decline if
aggressive tx is
not immediate
Slide 37
HOME VS. INPATIENT
REHABILITATION
• 234 patients randomized to home-based vs. inpatient
rehab after total joint replacement; followed for 1 year
• Average stay in inpatient rehab = 18 days
• Number of home rehab visits = 8
• Functional outcomes equal
• No significant difference in infection, DVT, infection,
patient satisfaction
• Lower cost for home-based rehab (~$3000)
Mahomed et al. J Bone Joint Surg Am. 2008;90:1673-1680.
Slide 38
SKILLED NURSING FACILITY
• Skilled need for RN, PT/OT, or speech therapy
 IV antibiotics
 Wound care
 Rehab
• Medical or personal care needs exceed home
supports
Slide 39
SUMMARY
• Care transitions are associated with increased
adverse events and health care utilization
• Safe transitions require medication reconciliation,
patient education, provider communication, and
timely follow-up
• Functional assessment helps identify the most
appropriate discharge setting
• Physicians are responsible for ensuring safe
transitions
Slide 40
THANK YOU FOR YOUR TIME!
Visit us at:
www.americangeriatrics.org
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