Bryan K. Ford, Ph.D., MSW
Assistant Professor of Medicine
Research Associate, Comprehensive Center for Healthy Aging
University of Alabama at Birmingham
Education Program Director
Geriatric Research, Education and Clinical Center
Birmingham VA Medical Center
At the conclusion of this module, participants will be able to:

Discuss the issues of care transitions for older persons.

Describe the several innovative approaches that address
care transitions with older people.

Recognize patient and caregiver needs as part of the
discharge planning protocol.

Understand how an interdisciplinary team approach is a
more successful method to manage care transitions with
older adults.

Older adults are particularly vulnerable to the
consequences of fragmented care as they
transition across health care settings.

Older people tend to have multiple chronic
conditions and multiple medications.

1 in 5 suffer an adverse event at time of discharge

Vague written discharge orders &insufficient direct
contact with the physician

Patients being unprepared for health selfmanagement; uninformed or misinformed about their
illnesses or medications; and unsupported in the area
of follow-up resources

Informal caregivers have little involvement in the
transition process
Ultimately, all of these issues culminate in –

greater general patient dissatisfaction and

higher rates of rehospitalization
(both impact the cost of care)

October 2012 - Medicare will base payments to
hospitals in part on consumer satisfaction scores

This means that “Medicare will begin
withholding 1 percent of its payments to
hospitals … [and] That money — $850 million in
the first year — will go into a pool to be doled
out as bonuses to hospitals that score above
average on several measures,” that include
patient satisfaction.
-Kaiser Health News, Aug 2011

Recent estimates suggest that “readmissions
cost Medicare $26 billion a year, with one in
five patients landing back in the hospital
within a month.”
-Washington Post, Sept 2011

82-year-old white male

Current issues: Coronary artery disease, recent
myocardial infarction, heart failure, & diabetes.

Medications :
▪hydrochlorathiazide (blood pressure),
▪aspirin (heart failure preventions)
▪insulin (diabetes)
▪enalapril (blood pressure & heart failure)
▪carvedilol (blood pressure & heart failure)
▪clopidogrel (coronary heart disease)

Symptoms: increased coughing, shortness of
breath. He also complains that he is not able to
walk as far as he used to and cannot sleep lying flat,
having to prop himself up on three pillows.

Actions: stopped the hydrochlorathiazide & started
on furosemide (Lasix).
Mr. Case

Two days later, Mr. Case fainted and hit his head on the kitchen
table and was brought to the Emergency Department.

Symptoms including: weakness, dizziness, confusion, & feeling
light-headed.

Further investigation determined that Mr. Case was confused
about his medications and had continued taking his previously
prescribed “water pills” along with his newly prescribed Lasix and
had become dehydrated.

During the second hospital stay, the social worker noted that Mrs.
Case appeared tired and somewhat confused about Mr. Case’s
medications. Mrs. Case repeatedly complained about one of the
nurses “attitude” during the second hospital stay. Mr. Case was
stabilized and released from the hospital.

The care transitions literature indicates that
interventions with the most impact:
 Begin soon after admission to the hospital
 Include follow-up in the home
 Are targeted to high risk groups
 Are patient-centered
… and are underutilized in clinical settings.
Three models:
1. The Care Transitions Program,
2.
The Transitional Care model and
3.
Project BOOST.

Care Transitions Intervention® (CTI® ) was is
designed to:
 identify potential threats to health
 teaches patients and caregivers to take an active
role

The CTI addresses four "pillars“ of care:
1) medication self-management,
2) a patient-centered record,
3) timely follow-up, and
4) "red flags”.

One of the key components of CTI® is the
transition coach.

The transition coach …
 helps patients across health care settings.
 meets with the patient both before & after
discharge.
 works to empower the patient.
 utilizes telephone support
-Coleman, Parry, et al., 2006; Coleman, et al., 2006.

The Transitional Care Model primarily
focuses on “high risk” patients that tend to
have the most trouble during transitions in
care.

“High risk” patients are identified as older
patients with “poor self-health ratings,
multiple chronic conditions, and history of
recent hospitalizations” (The Transitional
Care Model, 2012).

TCM uses a coordinating Transitional Care
Nurse that …
 Conducts a comprehensive assessment;
 Coordinates the patient’s discharge plan;
 Implements the care plan at home;
 Assists the patient & family in managing their care
needs; and
 Serves as the facilitator in the patient’s
communications

Project BOOST (Better Outcomes for Older Adults
through Safe Transitions)

Project BOOST provides the most comprehensive
assessment tool which is free to the public.

Project BOOST’s objectives include:
1) Identification higher risk patients on admission;
2) Reduce 30-day readmission rates for medical patients;
3) Reduce length of stay;
4) Improve facility patient satisfaction & H-CAHPS scores; and
5) Improve information flow between hospital & outpatient
providers.

By applying the screening tool outlined in
Project BOOST, Mr. Case would have been
assessed as high risk upon his first admission to
the hospital which would have identified his risk
factors.

BOOST’s 8P Screening Tool is a risk assessment
tool completed at admission to identify patients
who have an increased risk of adverse events
post-hospitalization, and utilizing the duration
of the hospitalization to mitigate these risks as
much as possible.
1. Problem medications: (ie: warfarin, insulin,
digoxin, and aspirin when used in
combination with clopidogrel.)
 Mr. Case is taking multiple medications
including a combination that puts him at risk,
especially when combined with clopidogrel.

Intervention steps:
 Medication specific education using Teach Back
 Monitoring plan developed and communicated to
patient and aftercare providers
 Specific strategies for managing adverse drug
events
 Follow-up phone call at 72 hours to assess
adherence and complications
2. Psychological or depression: The presence
of depression, either in screening evaluations
or by history, has been associated with
increased risk of rehospitalization.
 Mr. Case does not exhibit nor does he have a
history of psychological issues including
depression.

Intervention Steps: (if needed)
 Assessment of need for psychiatric aftercare
 Communication with aftercare providers
 Involvement/awareness of the support network
3. Principal diagnosis: (ie: cancer, stroke,
diabetes or glycemic complication, COPD and
heart failure.)
 Mr. Case’s diagnoses include those specified
to be at high risk for adverse events.

Intervention Steps:
 Disease specific education using Teach Back
 Action plan reviewed with patient/caregivers
regarding what to do and who to contact in the
event of worsening or new symptoms
 Discuss goals of care with patient/caregiver
4. Polypharmacy: Patients on 5 or more
medications are at an increased risk of an
adverse event after discharge.
 Mr. Case is on more than five medications.

Intervention Steps:
 Elimination of unnecessary medications
 Simplification of medication scheduling to
improve adherence
 Follow-up phone call at 72 hours to assess
adherence and complications
5. Poor Health Literacy: Use the “teach back
method” method for patient preparation and
education.
 Mr. & Mrs. Case are at least high school
educated but appear to have confusion about
medication and illnesses.

Intervention Steps:
 Committed caregiver involved in planning/
administration interventions
 Aftercare plan education using Teach Back
 Link to community resources for additional
patient/ caregiver support
 Follow-up phone call at 72 hours to assess
adherence and complications
6. Patient Support: The absence of a formal or
informal care giver has been associated with
higher rehospitalization rates.
 Mr. Case is accompanied and lives with his
spouse, however, it may be determined that
Mrs. Case might need help with care duties
due to her own medical issues.

Intervention Steps: (if needed)
 Follow-up phone call at 72 hours to assess
condition, adherence and complications
 Follow-up appointment with aftercare medical
provider within 7 days
 Involvement of home care providers of services
with clear communications of discharge plan to
those providers
7. Prior hospitalizations: (previous 6 months)
 Mr. Case has recently been hospitalized for
MI.

Intervention Steps:
 Review reasons for re-hospitalization in context of
prior hospitalization
 Follow-up phone call at 72 hours to assess
condition, adherence and complications
 Follow-up appointment with aftercare medical
provider within 7 days
8. Palliative Care: Engaging these services
actively has been shown to improve
symptom management, patient satisfaction
and limit resources , including
rehospitalizations for patients nearing end of
life.
 Mr. Case does not seem to be appropriate for
palliative care options at this time.

Intervention Steps: (if needed)
 Assess need for palliative care services
 Identify goals of care and therapeutic options
 Communicate prognosis with patient/family/caregiver
 Assess and address bothersome symptoms
 Identify services or benefits available to patients
based on advanced disease status
 Discuss with patient/family/caregiver role of palliative
care services and benefits and services available

Using the 8P Screening Tool, the hospital staff
can recognize risky issues at admission and
throughout a patient’s hospital stay, which could
prevent readmissions.

Furthermore, seeing the warning signs would
allow healthcare providers to engage directly
with family and caregivers on medication
education and possible home care assistance,
which could improve consumer satisfaction.
Thank you
bryanford@uabmc.edu