THE ROLE OF SUCCESSFUL CARE TRANSITIONS IN ACHIEVING AN AGE-FRIENDLY HEALTH CARE SYSTEM

TIMOTHY W. FARRELL, MD, AGSF

ASSOCIATE PROFESSOR OF MEDICINEADJUNCT ASSOCIATE PROFESSOR OF FAMILY MEDICINE

PHYSICIAN INVESTIGATOR, VA SLC GERIATRIC RESEARCH, EDUCATION, AND CLINICAL CENTER (GRECC)DIRECTOR, UNIVERSITY OF UTAH HEALTH IPE PROGRAM

17TH ANNUAL ROCKY MOUNTAIN GERIATRICS CONFERENCEAUGUST 27, 2019

DISCLOSURES

I have no relevant conflicts of interest to disclose.

BACK TO THE FUTURE

PATIENT R.G.

• “Unbefriended” older adult• Lives in a subsided senior housing facility• Multiple no-shows and poor medication

adherence• Near-catastrophic outcome when found

wandering the streets after 4 AM “discharge to nowhere” from the ED

4M ISSUES AT CRITICAL TRANSITION POINTS FOR PATIENT R.G.

Home and outpatient care

•Mobility: Transportation is tenuous•Medication adherence is uncertain at best•Mind and What Matters Most are pertinent due to lack of medical decision-making capacity

ED/hospital care

•What Matters Most is unclear and difficult to elicit in the ED•Medication reconciliation remain problematic

Transitional and intra-visit care

•All 4 “Ms” may be difficult to elicit if there is suboptimal communication involving R.G. and his health care teams.

INADEQUATE COMMUNICATION DURING TRANSITIONS OF CARE

• Study of hospital discharge summaries:– 21% lacked discharge medications– 38% lacked lab results– 25% never reached the PCP– 66% of PCPs contacted or treated patients before receiving

the discharge summary

Bodenheimer T. N Engl J Med 2008.

INFORMATION TRANSFER AT HOSPITAL DISCHARGE

• Large amount of information delivered in a short time • Often difficult for older adults to process

– Dementia, delirium, depression– Hearing and vision loss

• Limited health literacy must be considered– “Teach-back” method may help

HEALTH LITERACY

National Assessment of Adult Literacy, 2003

RISKS AND COSTS ASSOCIATED WITH TRANSITIONS OF CARE• Hospitalization as a sentinel event

– 2 out of 3 Medicare beneficiaries are readmitted or die within 1 year of their index hospitalization.*

• Transitions to nowhere– 10-fold increase in readmission rate when the PCP follow-up

interval exceeds 4 weeks.**

*Jencks SF, Williams MV, Coleman EA. N Engl J Med 2011.**Misky GJ, Wald HL, Coleman EA. J Hosp Med 2010.

WHAT HEALTH CARE WORKFORCE IS NEEDED TO ACHIEVE AGE-FRIENDLY TRANSITIONS?

CURRENT STATE OF THE GERIATRIC HEALTH CARE WORKFORCE• 5 to 8 million older Americans with one or more

mental health or substance use conditions– This population will triple in the next 3 decades

• 7,293 board-certified geriatricians and 1,577 board-certified geriatric psychiatrists are available to care for them

Farrell TW et al. State of the science: Interprofessional approaches to aging, dementia, and mental health. J Am Geriatr Soc 2018; 66: S40-S47.

INTERPROFESSIONAL TEAMS NEEDED FOR R.G.

Home and outpatient care

• Social work, law, community advocates, care management• Nursing, geriatrics, mental health, pharmacy, dentistry, OT, PT

ED/hospital care

• Social work, law, community advocates, care management• Nursing, geriatrics, pharmacy, OT, PT

Transitional care

• Social work, law, community advocates, care management• Nursing, geriatrics, pharmacy, transition navigator

PREPARING THE HEALTH CARE WORKFORCE TO EXECUTE SUCCESSFUL TRANSITIONS• Most health sciences training occurs in hospital

settings, but R.G.’s care is mainly delivered in the community

• Almost no health sciences training integrates disciplines such as law and social work

• Interprofessional education and practice (IPE/P) helps address this gap

INTERPROFESSIONAL LEARNING CONTINUUM

Institute of Medicine: Measuring the Impact of Interprofessoinal Education on Collaborative Practice and Patient Outcomes (2015).

SUMMARY

• Nowhere are the 4Ms more pertinent to Age Friendly Health Systems than in care transitions

• Effective communication within and among interprofessional teams is essential during care transitions

• A robust geriatrics workforce is necessary to sustain the Age Friendly Health Systems movement and ensure safe care transitions