1. Transitions In Care: Why They Are Important, And How To Improve Them Senior Medicine Rotation Emory University School of Medicine

2. Objectives Define the different discharge options for a patient leaving the hospital. List the reasons why care transitions frequently compromise safety for complex patients. Recognize patients who are at risk for poor outcomes after hospital discharge. Enumerate methods for improving safety in care transitions.

3. 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 Other settings (e.g., acute rehab, hospice) What is Transitional Care?

4. Sites for Discharge - Home The most common site of hospital discharge, even for complicated patients. Complicated patients may receive home health care. Those patients have to be “homebound” and under the care of an MD. Home health services include nursing, rehabilitation, home health aides.

5. Assisted Living Facilities Intermediate level of assistance between independent living and a nursing home. These facilities provide housing in a community setting, with enhanced services. They may provide services such as meals, personal care, help with medications. They usually offer multiple activities.

6. Skilled Nursing Facility (SNF) Patients may be discharged to a SNF instead of home when there are “skilled needs”. Most common need is rehabilitation Goal of care is usually for patient to recover previous level of function to be discharged home. MDs are responsible for care, but see patients much less often than in the hospital.

7. Nursing Home Nursing facilities also provide residential care. The main reasons for admit to a nursing home for long-term care are: Behavioral problems (e.g., agitation) in patients with advanced dementia. Inability to perform basic ADLs such as self-feeding and transfers. Nursing homes are staffed 24 hours with nurses and nurses aides, and provide medical services.

8. Other settings of Care Acute Rehabilitation Hospitals Usually for a subgroup of patients who can tolerate three hours of rehab a day Length of stay is about 2 weeks. Hospice Care To enroll for a hospice benefit, a physician has to state that a patient has less than 6 months to live. Patients in hospice receive enhanced services like medication for pain and shortness of breath, and 24 hr nurse availability. Can be done at home or at an inpatient facility.

9. Why Are Care Transitions Important? Patients with chronic health problems will be sick before and after they leave the hospital. Quality of care may suffer with care transitions: Medication errors Hospital Readmission Poor communication with patients and other providers Patient dissatisfaction and confusion

10. Why Do Things Go Wrong? Because of financial demands, hospitals are discharging patients who are sicker and more complex than before. Hospital physicians have incentives to “get patients out” of the hospital. Because the patient is no longer under their care, hospital MDs lack a “feedback loop” to improve quality.

11. Reasons for Post-Hospital Quality Problems

12. Medication Errors Medication lists change in ways great and small after hospital discharge. Thus patients may have trouble keeping to the hospital team’s instructions. Gray et al. (Annals of Pharmacotherapy, 1999) found 20% of patients have adverse med reactions post- discharge. Coleman et al. (Arch Intern Med, 2005) found 14% of patients discharged to home had 1 or more medication discrepancy.

13. Hospital Readmission In one study, 19.6% of Medicare beneficiaries were readmitted in 30 days (Jencks et al., NEJM, 2009). Readmission results in increased costs for the healthcare system. Risk for hospital readmission increases with: Older age, more complex medical problems Poor family support at home Moderate to severe functional impairment.

14. Poor Communication Providers and Patients Qualitative studies show patients and caregivers: Are unprepared for their role in the next care setting Do not understand essential steps in the management of their condition Cannot contact appropriate health care practitioners for guidance Are frustrated by having to perform tasks practitioners have left undone.

15. Poor Communication Providers and Other Providers Study of 300 consecutive admissions to 10 New York City nursing homes from 25 area hospitals Legible transfer summaries in only 72% Clinical data often missing (ECG, CXR, etc.) Contact info for hospital professionals who completed summaries present in less than half Henkel G. Caring for the Ages 2003

16. Patient Predictors in Care Transitions

17. Patient Factors Associated with Poor Discharge Outcomes Age>80 Fair-to-poor self-rating of health Recent and frequent hospitalizations Inadequate social support Multiple, active chronic health problems Depression history Chronic disability and functional impairment History of non- adherence to therapeutic regimen Lack of documented patient/family education Slide courtesy of William Lyons, MD – Univ. of Nebraska

18. Indicators That a Patient May Be Too Sick to Be Discharged New shortness of breath or chest pain Abnormal vital signs: –Tachycardia (over 100) –Tachypnea (RR over 24) –Fever Arrhythmias Low O2 sats Poor oral intake (lower than baseline) Delirium Slide adapted from William Lyons, MD – Univ. of Nebraska

19. How To Improve Care Transitions

20. How To Improve Outcomes We’ve identified several factors associated with poor discharge outcomes. Actions that could improve outcomes exist at the individual and the health systems level. Increasing awareness of the problem (as you are doing now) is a first step.

21. Health Systems Issues Currently, financial incentives do not exist for hospital physicians to communicate with PCPs or families at discharge. Generally, hospital teams do not receive negative feedback from their patients after they have left the hospital (unless they are readmitted). Putting in place strong interdisciplinary teams

22. Interdisciplinary Teams Most hospital settings will have teams from different disciplines for complex, older patients. May include: Social worker/Case manager Nursing Therapists: Physical/Occupational/Speech

23. Individual Issues Improving the quality of discharge summaries may improve communication across settings. Educating patients at discharge about their illness and medication may help decrease readmission rates. (Coleman et al., Arch Int Med 2006). Assessing discharge readiness. Discharge checklists may help to cover vital areas.

24. Discharge Checklist Society of Hospital Medicine Medication education and reconciliation Assessing cognitive readiness for discharge and self-care. Discharge Summary (ready at discharge). Patient Instructions – special attention to hazardous meds (e.g., warfarin, furosemide). Identifying clear follow-up plan with their physician

25. Summary Physicians have many discharge options for their patients, and choosing well matters. Poor communication is the greatest discharge pitfall, and can lead to poor outcomes. Learning which patients may be too sick for discharge could also prevent readmission. Improved health systems and communication may help improve post-discharge outcomes.

26. Bibliography Gray, S., Mahoney, J., & Blough, D. (1999). Adverse drug events in elderly patients receiving home health services following hospital discharge. Annals of Pharmacotherapy, 33, 1147-1153. Jencks SF, et al. (2009). Rehospitalizations in the Medicare fee-for-service program. N Engl J Med, 360, 1418-28. Coleman, E. A., Smith, J. D., Raha, D., & Min, S. J. (2005). Posthospital medication discrepancies: prevalence and contributing factors. Archives of Internal Medicine, 165, 1842-1847. Coleman, E. A., & Berenson, R. A. (2004). Lost in transition: challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine, 140, 533-536. Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-j. (2006). The Care Transitions Intervention: Results of a Randomized Controlled Trial. Archives of Internal Medicine, 166, 1822-1828. All images provided by Lavanet.