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

2. 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.

3. 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

4. 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)

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. Assisted Living

14. 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

15. 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

16. 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

17. 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)

18. 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”

19. 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

20. 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

21. 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

22. 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