Care Transitions Manuel A. Eskildsen, MD Division of Geriatric Medicine and Gerontology Emory University School of Medicine

Objectives Define why transitions between different settings of care may result in poor patient outcomes. Explain how communication problems between health providers and patients result in poor care transitions. Define the different discharge options for a patient leaving the hospital.

Why does this matter? Patients are sick when they go to the hospital Patients in hospitals have more chronic health problems They are usually not 100% well when they leave the hospital Many things can go wrong when they leave… And go somewhere else www.janga.biz

What is Transitional Care? Coordination that occurs when patients transfer between settings of care. Communication needs to occur between physicians between different levels of care. Discharge sites: Home Assisted living A nursing facility for rehabilitation Another hospital (for example, acute rehab)

Poor transitions can lead to: Readmission to the hospital Medication errors Poor communication and patient dissatisfaction Poor continuity of care because of poor communication with primary physician

Why is it difficult for patients? You may still not feel well when you leave the hospital You may have multiple new medications, and different doses of the old ones Many new appointments. For example, a pt. with hip fracture, could have to see: Primary care doctor Orthopedist Therapists Home health nurses

Your cases for today Complex care transitions Difficulties in communication Difficulties with medications Different perspectives: Hospital MD Patient/Family Case Manager Receiving MD

Case 1 81 year old woman with CHF Admitted with shortness of breath, leg swelling Similar hospital stay last month Given increases in diuretic doses in the hospital By the way, daughter having increasing problems caring for her

Case 1 Daughter is concerned about taking her home They decide on transfer to the Golden Years Assisted Living Facility They meet with nurse for 20 minutes Doctor waits for a week to dictate discharge summary

Medication lists for Case 1 Aspirin 81 mg per day Furosemide (diuretic) 40 mg per day Atenolol (beta blocker blood pressure agent) 25 mg per day Atorvastatin (cholesterol drug) 40 mg per day Lisinopril (ACE inhibitor blood pressure agent) 20 mg per day Aspirin 81 mg per day Furosemide 40 mg twice a day Metoprolol (beta blocker blood pressure agent) 25 mg twice a day Simvastatin (cholesterol drug) 40 mg once a day Enalapril (ACE inhibitor blood pressure drug) 20 mg twice a day

Case 1 Returns to her doctor’s office with a bagful of medications The primary care doctor could only obtain history from the family Discharge Summary was not available Transfer summaries in 2003 Henkel article showed that only 72% of discharge summaries were legible.

Points that you brought up: Involvement of the doctor is important Transitions are confusing for patients, and more so when caregivers are stressed Incentive for the hosp. physician to “get people out” Hospitalist wants to avoid readmission Difficulty for PCP to keep up with all his patients who are in the hospital Importance of the discharge summary for continuity

Assisted Living

Assisted Living Type of Senior Housing For people with increasing care needs They coordinate care Help with meals, activities Preserve a certain amount of independence Preserves a sense of community

Home Health Services Run by home health agencies Supervised by a physician For patients who are “homebound” Include: Nursing services (wound care, blood draws) Physical therapy Occupational Therapy

Case 2 88 year old man presented to EUH after a fall X-ray shows a hip fracture Had surgery – total hip replacement Very complicated hospital course: confused, not able to ambulate much

Case 2 Prior level of functioning: Lived alone Disheveled apartment Repeated falls Case manager and family agree that he is not ready to return home, and that he needs rehab at a Skilled Nursing Facility (SNF)

Case 2 On day #8, the patient is discharged to a SNF for rehab Still confused and weak Receiving doctor gets a stack of papers and the medication list Notes that the patient is still in pain Patient and family are apprehensive – they don’t want to be in a “nursing home”

What you thought What is a SNF? Why am I being “dumped” there? Need for case manager to explain different options for discharge site Agreement that home is not realistic option Difficult role of the receiving physicians– dealing with patient expectations Continuing focus on independence even after transfer to SNF

Skilled Nursing Facilities (SNF) Can provide two different types of services Residential care Transitional care For transitional care, patients come temporarily for: Usually because they can’t receive needed services at home For skilled services like rehabilitation Physician care not as intense as in the hospital

SNF – Residential Care For patients who cannot meet their care needs at home Two “typical” patients: The patient who is so immobilized that they need heavy care just to move from bed to toilet Patient with Alzheimer’s dementia whose family can’t manage them at home

Better Care Transitions Protocols in hospitals for discharge medications and communication Discussion of “red flags” Programs for nurse follow-up of hospital patients at home Mandatory discharge summaries at time of discharge More involvement of hospital physician in the discharge process