1. Improving Communication at Transition from NH to ED Suzanne Gillespie, MD RD Division of Geriatrics/Aging March 6, 2009 2008 AMDA Foundation/Pfizer Quality Improvement Award: One Year Update Suzanne Gillespie, MD RD Division of Geriatrics/Aging March 6, 2009 2008 AMDA Foundation/Pfizer Quality Improvement Award: One Year Update

2. Background  University of Rochester Div of Geriatrics  Primary care for > 3,000 LTC residents  34 NH and ALF facilities  Monroe Community Hospital (MCH)  566-bed county-owned NH with an academic medical staff  Frequently send and receive patients to/from a variety of other medical settings in the region.  Routine  Emergently  University of Rochester Div of Geriatrics  Primary care for > 3,000 LTC residents  34 NH and ALF facilities  Monroe Community Hospital (MCH)  566-bed county-owned NH with an academic medical staff  Frequently send and receive patients to/from a variety of other medical settings in the region.  Routine  Emergently

3. Transitions of Care from NH  Frequently involve multiple people  Patient, Families, Nurses, SW, EMS, Doctors….  LTC (& EM providers) expressing frustrations about care communication on a daily basis. Grant Award: opportunity to translate frustrations into QI  Frequently involve multiple people  Patient, Families, Nurses, SW, EMS, Doctors….  LTC (& EM providers) expressing frustrations about care communication on a daily basis. Grant Award: opportunity to translate frustrations into QI

4. “LTC Quality Council”  Focused on improving transitional care between organizations  Bi-Monthly Meetings  Representatives  Medical Center, NH/ALF, home care  Emergency Medicine & Geriatric Medicine  Nursing, social work, physicians  Quality Management Leaders  Focused on improving transitional care between organizations  Bi-Monthly Meetings  Representatives  Medical Center, NH/ALF, home care  Emergency Medicine & Geriatric Medicine  Nursing, social work, physicians  Quality Management Leaders

5. NH to ED Transitions: Perceptions  ED and LTC teams expressed different perceptions of transitions of care  “doing a great job” “issues on a daily basis”  “incomplete” “inaccurate” “disorganized” “variable”  Variability in what each of the homes provided  Variability in how providers define good communication  Neither sending nor receiving caregivers know what to expect when a resident is transferred to the ED.  ED and LTC teams expressed different perceptions of transitions of care  “doing a great job” “issues on a daily basis”  “incomplete” “inaccurate” “disorganized” “variable”  Variability in what each of the homes provided  Variability in how providers define good communication  Neither sending nor receiving caregivers know what to expect when a resident is transferred to the ED.

6. Survey of ED and LTC Providers Respondents, n=155  Physicians (23%; n=36)  NPs/PAs (14%; n=21)  Nursing (63%; n=98)  Comparable #LTC and ED respondents  Experience in their field  41% reported >11 yr  Response rate = 32% Respondents, n=155  Physicians (23%; n=36)  NPs/PAs (14%; n=21)  Nursing (63%; n=98)  Comparable #LTC and ED respondents  Experience in their field  41% reported >11 yr  Response rate = 32%

7. There is good communication between EDs & NHs in this community Impressions of Nursing Home Care Transitions Percent who agree/disagree with the following statements… Somewhat agree Strongly agree NeutralSomewhat disagree Strongly Disagree Important information is lost during transitions of care between NHs & EDs

8. how often you believe the following occurs when a NH resident is transferred TO the ED for care? (1=NEVER, 7=ALWAYS) p<.01 ALWAYS NEVER * *

9. how often you believe the following occurs when a NH resident is transferred TO the ED for care? (1=NEVER, 7=ALWAYS) always never

10. How often you believe the following should occur, when a NH resident is transferred FROM the NH TO the ED,

11. a verbal communication at my position/level should occur (doctor/NP/PA)

12. a verbal communication at my position/level should occur (nursing)

13. Transfer Form  Focus group  Feedback  Survey input  Pilot  Revisions  Focus group  Feedback  Survey input  Pilot  Revisions

14. PRIMARY INFORMATION Extended Care Facility: Monroe Community HospitalPhone:(585) 760 - 6500 Code Status: FULL DNR MOLST (Include a copy) Transferred to: Allergies: Precautions: NONE VRE C-difficile Respiratory (type) ORSA Fall Seizure Wanders Reason for Transfer: Altered mental status (describe): Acute neuro change (describe): Fever Shortness of Breath Chest Pain Abdominal Pain Fall Injury-Site (describe): Weakness Blood sugar abnormality Other / further comments: Usual Mental Status: Alert, Oriented x Confused Verbal Non-verbal Vital Signs: TempHRR BPO2 sat % On lpm Last Weight: Provider to Contact: Name: Pager: Nurse to Contact: Name: Number: 760 - _ _ _ _ Medication changes in last 14 days: Lab studies done in last 72 hours? Yes No Unknown Skin Integrity: Intact Wounds—location & type:

15. SECONDARY INFORMATION Advanced Care Plans (Send Copies): MOLST DNR HCP POA Living Will Guardianship Language: English Other: Patient Adaptive Equipment: Dentures Glasses Hearing aid Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Other: Usual Respiratory Care: None Oxygen ___ lpm ATC HS BiPapSetting: CPAPSetting: VentSetting: Transfers Independent 1 assist 2 assist Lift Mobility Independent 1 assist 2 assist Non-ambulatory Bedfast Mobility Equipment Cane Wheel Chair Walker—type: Sent with Patient: Dentures: Upper Lower Glasses Hearing Aide Other: Patient Diet: Resident Eats: Independently with set-up total assist/fed Resident Drinks: Regular Thin Liquids Modified Liquids Consistency: Nectar, Honey, Pudding Smoking Status: Current Former Unknown Type of Residence: SNF Rehabilitation SNF Long-term care Assisted Living Home with Home Care Hospice House Other (describe): Dialysis (if applicable) Schedule (days/time): Center:Access: Immunizations Influenza Yes No Date:Pneumovax Yes No Date: COPIES TO SEND WITH RESIDENT: Facility Face SheetIf available: MOLST Last History & Physical Health Care Proxy Acute visits prompting transfer Living Will Last routine provider 30/60-d note POA Last 3 days of progress notes Guardianship Medical administration record Last EKG

16. Pilot  45 residents’ transitions audited  17 (38%) nothing- no information  16 (36%) used an old form  12 (27%) new form  100% code status  100% reason sent; often with extra detail  100% usual mental state  50% contact information  45 residents’ transitions audited  17 (38%) nothing- no information  16 (36%) used an old form  12 (27%) new form  100% code status  100% reason sent; often with extra detail  100% usual mental state  50% contact information

17. Pilot Challenges  Change  Xeroxing  Option to use something else… Revisions  Hospitalists call….  Acute Quality Measures  (Smoking, Vaccination, Wound status)  Streamline data included Process  Re-engage staff  Units pre-customize data  Re-assessment Challenges  Change  Xeroxing  Option to use something else… Revisions  Hospitalists call….  Acute Quality Measures  (Smoking, Vaccination, Wound status)  Streamline data included Process  Re-engage staff  Units pre-customize data  Re-assessment

18. Reflections  The improvement  is not just the form….it is the process  Most valuable aspect of this QI initiative  Introduction of joint accountability for transitions  Establishing a feedback mechanism  The improvement  is not just the form….it is the process  Most valuable aspect of this QI initiative  Introduction of joint accountability for transitions  Establishing a feedback mechanism

19. Next Steps  Reassess after revisions  Implement at other local facilities  Regional standard  Define the role of verbal communication  Improvements in Ed to NH transitions  Reassess after revisions  Implement at other local facilities  Regional standard  Define the role of verbal communication  Improvements in Ed to NH transitions