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SAFE CARE TRANSITIONS:
BRIDGINGSILOS OF CARE
Karin Ouchida, MDAssistant Professor of Medicine
Division of GeriatricsMontefiore Medical Center/AECOM
Medical DirectorMontefiore Home Health Agency
November 14, 2009
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
AGS
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 YOUCARE ABOUT THIS?
• Patient safetyThe Joint Commission
• Health care reformReduce avoidable re-hospitalizations Increase accountability + transparency
Slide 3
Slide 4
SURVEY OF PATIENTS ABOUT HOSPITAL EXPERIENCES
HOW OFTEN DO TRANSITIONS OCCUR?
• After hip fracture, pts underwent an average of 3.5 “relocations”
• Between Thurs and Mon morning, 67 “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 preventable1/4 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 COMPONENTSOF 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 medication-related (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
Slide 16
SURVEY OF PATIENTS ABOUT HOSPITAL EXPERIENCES
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
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 resultsUnaware 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 completedAvailability 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
• SystemsSlide 26
DO WE NEED “TRANSITIONALISTS”?
Slide 27
TRIAL OFDISCHARGE 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 OFDISCHARGE 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 24 days post-discharge to review medications
Jack et al. Ann Intern Med. 2009;150:178-187.Slide 29
TRIAL OFDISCHARGE SERVICES (3 of 5)
Jack et al. Ann Intern Med. 2009;150:178-187.
P = .009
Jack et al. Ann Intern Med. 2009;150:178-187.
Usual care Intervention P-value
Able to identify discharge diagnosis 70% 79% .017
Able to name PCP 89% 95% .007
Follow-up with PCP 44% 62% < .001
Understood how to take meds after discharge 83% 89% .049
TRIAL OFDISCHARGE SERVICES (4 of 5)
Slide 31
TRIAL OFDISCHARGE 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 FOREFFECTING 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• Nurse• Social worker• Pharmacist• PT/OT• Medical students• Caregivers
Outpatient/Home• 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
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 antibioticsWound careRehab
• 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
Visit us at:
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
www.americangeriatrics.org
THANK YOU FOR YOUR TIME!
linkedin.com/company/american-geriatrics-society
Slide 41