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 SOCIETYGeriatrics 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

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WHY SHOULD YOUCARE ABOUT THIS?

• Patient safetyThe Joint Commission

• Health care reformReduce avoidable re-hospitalizations Increase accountability + transparency

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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%

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

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ADVERSE EVENTS• Injury resulting from medical management vs.

underlying disease• 1 in 5 patients experiences an adverse event

during the hospital-to-home transition1/3 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.

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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

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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

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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

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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

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COMPONENT 2: PATIENT EDUCATION

• Care transitions intervention

• Subjects: 65+, community dwelling, no dementia, admitted with CAD, COPD, CVA, hip fracture, etc.

• Advance practice nurse educates about: Medications Personal health record Scheduling and preparation for follow-up visits Indications of worsening condition (“red flags”) and whom

to contact

Coleman et al. Arch Intern Med. 2006;166:1822-1828.Slide 15

DECREASEDRE-HOSPITALIZATION RATES

30 days 90 days 180 days0

5

10

15

20

25

30

35

8

17

26

12

23

31Intervention (n=379)Control (n=371)

P = .048

Slide 16Coleman et al. Arch Intern Med. 2006;166:1822-1828.

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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%

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

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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.

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WAYS TO COMMUNICATE

Discharge summaryPatientProprietary softwareE-mailPhone

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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.

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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 22

PENDING TEST RESULTS• 2600 patients discharged from hospitalist services

at 2 academic hospitals40% had test results returned after discharge10% 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 23

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 24

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 infectedSlide 25

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 26

CHALLENGES TO IMPROVING TRANSITIONAL CARE

• Physicians Awareness Multiple providers Time

• Patients Health illiteracy Cognitive impairment Language barriers Lack of social support

• SystemsSlide 27

DO WE NEED “TRANSITIONALISTS”?

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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 29

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 30

TRIAL OFDISCHARGE SERVICES (3 of 5)

Hospital utilizations ED visits Readmissions0

20406080

100120140160180200

116

61 55

166

9076

Intervention (n=370)Usual care (n=368)

P = .01

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% .007Follow-up with PCP 44% 62% < .001Understood how to take meds after discharge 83% 89% .049

TRIAL OFDISCHARGE SERVICES (4 of 5)

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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

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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

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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

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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

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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)

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REHABILITATION SETTINGS

HOME SUBACUTE ACUTE• Can tolerate PT for

3060 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 3060 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

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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 39

SKILLED NURSING FACILITY• Skilled need for RN, PT/OT, or speech therapy

IV antibioticsWound careRehab

• Medical or personal care needs exceed home supports

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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

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