DISCHARGE DISCHARGE PLANNINGPLANNING

Bill Lyons, MDBill Lyons, MD

BACKGROUNDBACKGROUND

• Surging interest from professional Surging interest from professional societies, payers, Joint Commissionsocieties, payers, Joint Commission

• Among reasons for the challengeAmong reasons for the challenge– Aging, increasingly complex populationAging, increasingly complex population– More, and more specialized, venuesMore, and more specialized, venues– Providers defining practice by locationProviders defining practice by location

CASE 1CASE 1

• Mrs. G, a 96-year-old woman is seen by Mrs. G, a 96-year-old woman is seen by her physician at a home visither physician at a home visit

• Progressive shortness of breath over 2-3 Progressive shortness of breath over 2-3 day periodday period

• No fever, chills, cough, chest painNo fever, chills, cough, chest pain

• Was discharged from hospital one week Was discharged from hospital one week beforebefore

CASE 2CASE 2

• 68 yo man transferred from acute hospital 68 yo man transferred from acute hospital to distant suburban SNF after uneventful to distant suburban SNF after uneventful valve replacementvalve replacement

• On warfarin + enoxaparin until INR 2.5-3.5On warfarin + enoxaparin until INR 2.5-3.5

• Progressively less ambulatoryProgressively less ambulatory

• INR rises to 17, even after warfarin held INR rises to 17, even after warfarin held and vitamin K administeredand vitamin K administered

• Cardiac arrestCardiac arrest

““BOUNCEBACKS”BOUNCEBACKS”

FACTORS ASSOCIATED WITH FACTORS ASSOCIATED WITH POOR DISCHARGE OUTCOMESPOOR DISCHARGE OUTCOMES

• Age>80Age>80• Fair-to-poor self-Fair-to-poor self-

rating of healthrating of health• Recent and frequent Recent and frequent

hospitalizationshospitalizations• Inadequate social Inadequate social

supportsupport• Multiple, active Multiple, active

chronic health chronic health problemsproblems

• Depression historyDepression history• Chronic disability and Chronic disability and

functional impairmentfunctional impairment• History of History of

nonadherence to nonadherence to therapeutic regimentherapeutic regimen

• Lack of documented Lack of documented patient/family patient/family educationeducation

INFORMATION TRANSFERINFORMATION TRANSFER

INFORMATION TRANSFERINFORMATION TRANSFER

• Discharge summary not for Med RecordsDischarge summary not for Med Records

• Discharge diagnoses should include: Discharge diagnoses should include: functional, cognitive, behavioral, affectivefunctional, cognitive, behavioral, affective

• Discharge instructions must include red Discharge instructions must include red flags, and whom to callflags, and whom to call

• Explicitly list follow-up studies, apptsExplicitly list follow-up studies, appts

INFO TRANSFER, cont.INFO TRANSFER, cont.

• Functional status: baseline, transferFunctional status: baseline, transfer

• The Big PictureThe Big Picture– Global goals of careGlobal goals of care– Preferred intensity of carePreferred intensity of care– Advance directivesAdvance directives

MEDICATIONSMEDICATIONS

• Reconciliation = (New List) – (Old List)Reconciliation = (New List) – (Old List)

• Tapering and stop schedulesTapering and stop schedules

• Document drug indicationsDocument drug indications

• Target symptoms for psychiatric drugsTarget symptoms for psychiatric drugs

OTHER PEARLSOTHER PEARLS

• Early involvement of PT and SWEarly involvement of PT and SW

• ““Dispo” daily in thought, speech, proseDispo” daily in thought, speech, prose

• Discuss discharge by goals, not scheduleDiscuss discharge by goals, not schedule

• Avoid discharge to SNF or home with HHC Avoid discharge to SNF or home with HHC on weekendson weekends

• Involve primary care providerInvolve primary care provider

• Involve clinical pharmacistInvolve clinical pharmacist

PLACES PATIENTS GOPLACES PATIENTS GO

POSSIBLE DISCHARGE POSSIBLE DISCHARGE LOCATIONSLOCATIONS

• Home with family supportHome with family support

• Home with HHCHome with HHC

• SNFSNF

• Nursing home, ALF, custodial careNursing home, ALF, custodial care

• Acute rehabAcute rehab

• LTACLTAC

• HospiceHospice

HOME WITH HOME WITH HOME HEALTH CAREHOME HEALTH CARE

• Medicare qualifiersMedicare qualifiers– Reasonable and necessaryReasonable and necessary– Skilled services (RN, PT, or ST) neededSkilled services (RN, PT, or ST) needed– If above needed, can bring in OT, SW, HHAIf above needed, can bring in OT, SW, HHA– Home bound: Leaving home is infrequent,Home bound: Leaving home is infrequent,

• ……requires great, taxing effortrequires great, taxing effort• ……requires supportive devices, transportation, help requires supportive devices, transportation, help

of othersof others• ……medically contraindicatedmedically contraindicated

HOME HEALTH CARE HOME HEALTH CARE FINANCINGFINANCING

• Medicare A: RN, PT, OT, ST, HHAMedicare A: RN, PT, OT, ST, HHA

• Medicare B: MD home visits, DME, labs – Medicare B: MD home visits, DME, labs – but with 20% co-paymentbut with 20% co-payment

• Homemaker services: no Medicare or Homemaker services: no Medicare or Medicaid coverageMedicaid coverage

SKILLED NURSING FACILITIESSKILLED NURSING FACILITIES

• Patient requires skilled care: IV therapy, Patient requires skilled care: IV therapy, artificial nutrition and hydration, complex artificial nutrition and hydration, complex wound care, ostomy care, rehabwound care, ostomy care, rehab

• Medicare pays 100% for first 20 days, then Medicare pays 100% for first 20 days, then 80% for remaining 80 days80% for remaining 80 days

• Coverage stops when goals met or patient Coverage stops when goals met or patient stops improvingstops improving

• Infrequent provider visits (~monthly)Infrequent provider visits (~monthly)

ACUTE REHAB HOSPITALACUTE REHAB HOSPITAL

• Medicare criteria:Medicare criteria:– Close medical supervision by physiatristClose medical supervision by physiatrist– Needs 24h rehab nursing careNeeds 24h rehab nursing care– Multidisciplinary needs, coordinated programMultidisciplinary needs, coordinated program– Reasonable expectation of gainReasonable expectation of gain– Able to participate in 3 hr/d of intense therapyAble to participate in 3 hr/d of intense therapy

• Typical patients: head/spine injuries, Typical patients: head/spine injuries, youngish-old after strokeyoungish-old after stroke

LONG-TERM ACUTE CARE LONG-TERM ACUTE CARE (LTAC)(LTAC)

• For complex, potentially unstable patients For complex, potentially unstable patients requiring ongoing hospital-level carerequiring ongoing hospital-level care

• Specialty Select in OmahaSpecialty Select in Omaha• Chronic ventilator patients, multiple IV Chronic ventilator patients, multiple IV

medications, extensive wound care, TPNmedications, extensive wound care, TPN• Medicare qualifiersMedicare qualifiers

– Frequent physician monitoringFrequent physician monitoring– Need for highly-skilled careNeed for highly-skilled care– Expected LOS 25+ daysExpected LOS 25+ days

NURSING HOME (CUSTODIAL)NURSING HOME (CUSTODIAL)

• Home with HHC < Care Needs < SNFHome with HHC < Care Needs < SNF

• Medicare does NOT coverMedicare does NOT cover

• Financing via private pay, Medicaid, long-Financing via private pay, Medicaid, long-term care insuranceterm care insurance

CASE 1 FOLLOW-UPCASE 1 FOLLOW-UP

• Hospitalization had been for viral Hospitalization had been for viral gastroenteritisgastroenteritis

• Furosemide held during hospitalizationFurosemide held during hospitalization

• Not resumed (or mentioned) at dischargeNot resumed (or mentioned) at discharge

• Result: pulmonary edemaResult: pulmonary edema

CASE 2 FOLLOW-UPCASE 2 FOLLOW-UP

• Autopsy: 1500 mL grossly bloody fluid in Autopsy: 1500 mL grossly bloody fluid in pericardium, hepatic congestionpericardium, hepatic congestion

• Positive feedback loop initiatedPositive feedback loop initiated

• No communication between SNF MD and No communication between SNF MD and CT Surgery re significance of climbing INR CT Surgery re significance of climbing INR valuesvalues