1. LTC and the Hospital Jeffrey P Schaefer, MD slide update available at dr.schaeferville.com

3. Disclosure No conflicts of interests

4. Eight Questions… How often & why are LTC patients admitted to hospital? Do criteria for transfer to acute care exist? Has ‘appropriateness of transfer’ been studied? Are there local alternatives to hospital transfer? What has been tried elsewhere? What challenges face the acute care providers? What challenges face the LTC provider post-d/c Can we do better?

5. Why are LTC patients admitted to hospital? … not much published data

6. How often & why are LTC patients admitted to hospital? Hip fracture Pneumonia Stroke Chest pain Heart Failure Anemia Tidsskr Nor Laegeforen. 2005 Jun 30;125(13):1844-7

8. American J Public Health 1994:84:1615 Retrospective cohort of 2,120 nursing home patients that were initially admitted to their facility in 1982 and followed. Munroe County, New York State

10. fairly flat over time

11. 25 – 35 % prevalence of each

12. community based controls

13. Predictors of Hospitalization Bedbound (11%) vs ambulant (26%) On-site Physician (21%) vs none (28%) Male (29%) vs female (25%) Co-morbidity  not statistically sig

14. Criteria for Transfer?

15. Criteria for Transfer to Hospital? –JAMA.2006; 295: 2503-2510.

16. Pneumonia is the best studied… I found no publications for other conditions… – some are self evidence (hip#) – for others  expectations drive actions

19. Randomly allocate Ontario Nursing homes to a Clinical Pathway versus Usual Care 20 LTC facilities were enrolled

23. Results Pathway Usual Hospitalizations8% 20% sig Hosp days / res 0.79 1.74 sig ER, not admit 1.2% 1.6% nd Death 3.1% 6.0% nd Falls 11% 10% nd T to N of v/s 2.5 2.7 nd

24. Appropriateness of Transfer? Study: - retrospective - lacked criteria - but makes headlines - grain of truth

25. What is the effect of: ‘Let me Decide’ on hospitalization of LTC residents (Australia) “Let me decide” –education: family, patients, care providers –advanced care planning  create a Directive Setting provided IV abx & transfusions

26. Bed days / Nursing Home Bed (control and intervention) Let me Decide (diamonds); Control (light squares)

27. Mortality / 100 NH beds (control and intervention) Let me Decide (diamonds); Control (light squares)

28. Hazards of Hospitalization Ann Int Med 1993:118:219.

29. Local Alternatives JP Schaefer – Survey of Local Providers –HPTP Clinic – some MD’s accept –Wound Care Clinic – at least one does –IM Urgent Assessment Clinic - No –Day Medicine – some MD’s accept –Individual Specialists – few do ‘housecalls’

30. What has been tried elsewhere? What is the effect of direct admission to a focused unit in comparison to transfer to Emergency Department Retrospective – quasi-experimental design

31. Protocol 24 bed acute care geriatric unit multidisciplinary within a 210 bed geriatric facility primary care MD’s telephone in receiving MD’s admit according to protocol –no surgery –no ICU

32. Results 80 direct admits compared to 46 ER admits Deaths: 3 (all from ER)  nd LOS: 12.5 day direct, 11.7 day ER  nd Functional Status: nd 80 ER admits avoided!

33. What challenges face the acute care providers? Communication Issues –Level of Care and Expectations –Family Spokesperson (Spokespeople) –Usual Physician or Care Provider Medical Issues at Presentation –History of new Problem –What is the baseline level of functioning? –Medical Problem List Medical Issues after Presentation –Avoidance of Iatrogenesis –Medication Reconciliation –Post-discharge Care

34. What challenges face the LTC physician at discharge? Tell me your stories…

35. Opportunities… 58 new beds at RGH April 2008 50+ new beds at PLC 2008-9 ?? beds at FMC (renovations needed) 2010  365 beds South Campus

36. LTC  Hospital (ER Bypass) Symptom – Sign – Lab Result Protocol Driven Responses LTC Physician Assessment Acute Care Unit for LTC Consulting Physician telephone Manage at LTC (+/- external support) Day Unit Assessment & Re-assessments (e.g. RGH Day Med) Admit to Acute Care Unit GIM / FamMed Attending Consultations as needed Psycho-Soc Intensive

37. Thank you! Contact: jpschaef@ucalgary.ca dr.schaeferville.com