Improving Care Transitions for Older Adults

1. Improving Care Transitions for Older Adults Ali Afrookteh, MD Steven Kravet, MD Eric Howell, MD Param Dedhia, MD Alicia I. Arbaje, MD, MPH

2. CASE PRESENTATION • 88 yof admitted to ED after fall at home – unable to walk • Recently discharged from a nursing home after 3 months recuperating from a stroke • Past history of hypertension, multiple strokes, osteoporosis, anxiety/depression

3. ED VISIT • Patient’s right leg shortened, externally rotated • X-ray confirms displaced fracture femoral neck • Case complicated by • glucose of 400 • BP 170/100 • Admitted to orthopedic physician

4. Transitions of Care Getting from home or clinic to the Emergency Department

5. ED overcrowding • Between 1993 and 2003 26% increase in ED visits • Population 12%, admits 13% • 91% report overcrowding • 40% say daily • Ambulance diversion once per minute • 1.7% of patients leave WOBS • 27% return, 4% need admission FUTURE OF EMERGENCY CARE, HOSPITAL-BASED EMERGENCY CARE. AT THE BREAKING POINT. The National Academies Press

6. ED overcrowding • Boarding of admitted patients is a significant root cause • 73% reported boarding in 2004 FUTURE OF EMERGENCY CARE, HOSPITAL-BASED EMERGENCY CARE. AT THE BREAKING POINT. The National Academies Press. Rights secured.

7. Efficiency, satisfaction and safety concerns • ED not conducive to non-emergent care • Constant interruptions, lack of full records • More costly and much longer than office care • Pulls resources (people, supplies, space) from true emergent needs • JC data: ½ of sentinal events due to ED delays, 31% overcrowding as factor FUTURE OF EMERGENCY CARE, HOSPITAL-BASED EMERGENCY CARE. AT THE BREAKING POINT. The National Academies Press

8. Facilitating ED throughput • Many solutions look internal in ED • Staffing, training, funding, research, EMS standards • Key recommendation is multi-disciplinary approaches to eliminate boarding and improve throughput Lynn et al. Annals of Emergency Med. 1991

9. Facilitating ED throughput • Observation units • Active Bed Management • Hospitalist led efforts to control flow to all inpatient units • Hospital support required to build administrative functions for hospitalists

10. Comparison of throughput times before and after ‘Active Bed Management’ Howell et al. Unpublished data

11. Comparison of % Hours of Red & Yellow Alert Before & After ‘Active Bed Management’ * p < 0.0001 Howell et al. Unpublished data

12. Facilitating direct admissions • Data on direct to cath lab processes show improved outcomes • No data on other types of admissions and outcomes Sillesen et al. J Electrocardiol. 2008

13. Facilitating direct admissions 2006 Johns Hopkins Bayview QI project • Clinic calls Hospitalist and arranges direct admission • Patient to admitting, not ED • Baseline 75% of patient sent to ED get admitted • Total GIM clinic patients admitted through ED fell from 50% to 17%

14. Conclusions • The clinic or home to ED node is the first stage in the transition of care • ED overcrowding contributes to efficiency, satisfaction, and safety concerns • Boarding admitted patients in the ED is considered the major bottleneck • Multidisciplinary solutions are required, including hospitalist inpatient bed management and improved direct admission processes

15. Back to our patients: • How many of you have had patients beg you to not send them to the ED? • Imagine that a patient with an acute presentation in clinic (abdominal pain, severe orthopedic problem, gastroenteritis, new onset a-fib) can go directly to the medicine service, bypassing the ED • If you or your parent were the patient, how would that impact your satisfaction and safety?

16. Transitions of Care From Home, Clinic or Emergency Department to the Hospital Ward

17. CASE: HOSPITAL COURSE • Hospitalist consult with next day transfer to patient’s internist • Surgical insertion bipolar hip prosthesis • Post op anemia – transfusion required • Post op confusion • Slow progress with rehab

18. Transitions of Care & Patient Perceptions • Vast majority satisfied with hospitalist – PCP communications (90%) • Majority thought PCP had important info to give to the hospitalist • Medical information (88%) • Personal and family information (64%) • Patient treatment and decision making preferences (55 & 64% respectively) • Majority thought the hospitalist had important medical information for PCP (82%) Hruby, how do patients view the role of the primary care physician in inpatient care? (Dis Mon. 2002 Apr;48(4):230-8.)

19. Transitions of Care & Physician Perception • Most PCPs desire handoff communication (78%) • 63% of PCPs “always or usually” received D/C summaries • 56% of PCPs thought handoff satisfactory • Mode of communication preferred varies: • Telephone • Face-to-face • Fax • Discharge summary Pantilat, primary care physician attitudes regarding communication with hospitalists (Dis Mon. 2002 Apr;48(4):218-29.)

20. The Reality • Hospitalist-PCP communication documented 3-20% of time • Phone notification of D/C 31% of time • Less than 1/3 of PCPs do not receive D/C summary by f/u appointment! Hruby, how do patients view the role of the primary care physician in inpatient care? Pantilat, primary care physician attitudes regarding communication with hospitalists Van Walraven, dissemination of discharge summaries. Not reaching follow-up physicians (Can Fam Physician. 2002 Apr;48:737-42.) Kripalani, Deficits in communication and information transfer between hospital-based and primary care physicians, JAMA 2007 Feb 28;297(8):831-41

21. Inadequate Transfer Information on DC Summary • No diagnostic test results (33-63%) • No hospital course/treatment (7-22%) • No discharge meds (2-40%) • Pending tests not listed (65%) • Patient counseling (90-92%) • Lack of follow-up plan listed (2-43%) Kripalani, Deficits in communication and information transfer between hospital-based and primary care physicians, JAMA 2007 Feb 28;297(8):831-41

22. The Effect • 41% of patients discharged with pending test results • 9.4% could require action • Of the 9.4% • 37.1% “actionable”- change in plan of care needed • 12.6% “urgent” - action required • MDs unaware 61% of time Roy, Patient safety concerns arising from test results that return after hospital discharge, Ann Intern Med, 2005;143(2):121-128

23. The Effect • ¼ of discharged patients require outpatient workup • More than one third not done (35.9%) • Discharge summaries improved work up rate • Increased time from D/C to F/U appointment decrease work up rate Moore, Tying up loose ends, discharging patients with unresolved medical issues, arch uint med, 2007;167:1305-1311

24. The Effect • 1 in 5 (23%) discharges with adverse event • Symptoms (68%) • Symptoms and non-permanent disability (25%) • Permanent disability (3%) • Death (3%) • 72% of adverse events due to medications • 16% due to “therapeutic errors” • Half of events for preventable or ameliorable Forster, Adverse events among medical patients after discharge from hospital (CMAJ 2004;170(3):345-9

25. What can be done?

26. Physician Transitions of Care Improvements • ANY communication to PCP improves outcomes! • Make a call to the PCP • Dictate DC summary on day of DC • Hand the patient the DC summary to take to PCP Marks, Asthma: communication between hospital and general practitioners, J peadiatr child health. 1999;35:251-254 van Walraven, effect of discharge summary availability during post-discharge visits on hospital readmission (J Gen Intern Med. 2002 Mar;17(3):186-92.) Kripalani, Deficits in communication and information transfer between hospital-based and primary care physicians

27. Although PCPs Like a Call… • Most prefer telephone contact • (77%) • Contact on admission & discharge important • (73%, 78%) • Although less than half thought interruption needed for important tests • (48%) • Few thought daily notification important • (6%) Pantilat, primary care physician attitudes regarding communication with hospitalists

28. Physician Transitions of Care Improvements • Dictate DC summary on day of DC • Currently often received too late (69%) • Hand the patient the DC summary to take • Joint Commissions 30 days too long • Data show the DC summery- • Helps PCP, improves visit quality • May help reduce readmit rate Pantilat, primary care physician attitudes regarding communication with hospitalists Van Walraven, effect of discharge summary availability during post-discharge visits on hospital readmission (J Gen Intern Med. 2002 Mar;17(3):186-92.) Kripalani, Deficits in communication and information transfer between hospital-based and primary care physicians Moore, Tying up loose ends, discharging patients with unresolved medical issues, arch uint med, 2007;167:1305-1311

29. IT Based Improvements • Hospital database generated DC summaries: • More likely to include important info • PE • Test results • Pending tests • Meds • Are shorter • May be more clear van Walraven, Dictaded versus database-generated discharge summaries: a randomized clinical trial. CMAJ. 1999;160:319-326 Archbold, Evaluation of a computer generated discharge summary for patients with acute coronary syndrome. Br J Gen Pract. 1998;48:1163-1164

30. Transition Coach • Eric Coleman Transition Coach (n=750): • “Transitions Coach” • Empowered patients • Hospital & home • Phone contact • Reduced readmissions • Reduced Cost ~ $300k a year Coleman, The care transitions intervention, results of a randomized controlled trial. Arch Int Med. 2006;166:1822-1828

31. Discharge Planner • May decrease readmission rates • Potential decrease in mortality • Some models demonstrate cost effectiveness in context of global care • They do improve PCP follow up rate and cost per case • Likely decreased LOS From NY Times Naylor, J Cardiovasc Nurs. 1999 Oct;14(1):44-54. Naylor,Res Nurs Health. 1990 Oct;13(5):327-47. Cowan, (J Nurs Adm. 2006 Feb;36(2):79-85. Einstadter, J Gen Intern Med. 1996 Nov;11(11):684-8. Palmer, Am J Med. 2001 Dec 1;111(8):627-32.)

32. Pharmacists & Transitions of Care • Pharmacist medication reconciliation • Helpful with adverse drug events (ADEs) • Decrease medication-ED visits • Increases patient satisfaction • HOMER trial- increased readmissions?!? Schnipper, Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006 Mar 13;166(5):565-71 Dudas, The impact of follow-up telephone calls to patients after hospitalization.Am J Med. 2001 Dec 21;111(9B):26S-30S Holland, Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ. 2005 Feb 5;330(7486):293

33. Transitions of Care From the Hospital to the Community

34. CASE:POST HOSPITAL COURSE • Transferred to nursing home by orthopedics • Staff contacts different primary physician who decreases her psychotropic meds • Patient becomes agitated/combative • Her personal physician sees her, readjusts meds, mental status improves • Rehab restarted

35. Objectives • Understand the importance of care transitions in the older adult population • Identify risk factors for suboptimal care transitions • Consider strategies for successful care transitions and innovative solutions

36. Transitions within the Healthcare Environment ED Visit Inpatient Hospitalization OR Floor ICU Skilled Nursing Facility Long-Term Care Facility Home +/- Home Health Care Specialists PCP

37. Why Care about Transitions? Care Transitions of Older Adults 30 Days Post-Discharge Defn. = Continuity during handoffs • Common occurrence • Potential danger points • Older adults vulnerable • Lack of evaluation measures Bates, JAMA 1997: 277(4) 307-11; Coleman, Ann Int Med 2004: 141(7) 533-36; Forster, Ann Int Med 2003: 138(3) 161-7; Moore, JGIM 2003: 18(8) 646-51; RWJF, 2004

38. Why Are Older Adults at Increased Risk? They have more • chronic conditions • complex medical regimens • hospitalizations • transitions after discharge …and more healthcare providers # physicians RWJF, 2004

39. Arbaje, The Gerontologist, 2008 (in press)

40. Murtaugh, Medical Care 2002:40 (3)227-36

41. Policy Restructuring reimbursement Performance measurement Organizations Information technology Integration of delivery systems Providers Training Standardization Team-based care Patients Personal health record Self-management Group visits Promising Innovations

42. Provider Perspectives • Difficulty accessing colleagues • “You could blame the outpatient doc or the hospitalist… the real problem is there’s no good way to communicate with the outpatient doc.”—Hospitalist • Varying perceptions of accountability • “It’s harder for me to find the hospitalist than for them to find me…I’m in one place, one phone number, unlike people in the hospital.”—PCP • Agreement on importance of various types of communication • “It’s important at the time of discharge to verbally communicate any transition hot potatoes, for example checking the patient’s potassium within a short period of time.’”—Hospitalist Arbaje, 2008 (in preparation)

43. Study Design and Methods Hospitalized patients ≥ 70 yrs. Intervention Group Control Group • Consultation by Geri-FITT team • Treatment of geriatric syndromes • Patient education • Communication w/ next site of care • 2-day post-discharge follow-up phone call • Collection of administrative data, evaluation of discharge paperwork • 2-week post-discharge satisfaction survey call • 30-day post-discharge readmission survey phone call • 90-day post-discharge readmission survey phone call

44. Impact on Patient Satisfaction P = 0.06

45. Impact on Utilization P = 0.03

46. Summary • Transitional care is important element for safe and effective health care. • Suboptimal transitional care is especially dangerous for older adults. • Innovative solutions to improve transitional care should target different components of the health care system.

47. Clinical Implications • Devise strategies to prevent delirium and other geriatric syndromes across care settings • Keep all providers abreast of up-to-date patient information • Help older adults and their caregivers navigate the healthcare system

48. Summary: Home/Clinic to ED • The clinic or home to ED node is the first stage in the transition of care • ED overcrowding contributes to efficiency, satisfaction, and safety concerns • Boarding admitted patients in the ED is considered the major bottleneck • Multidisciplinary solutions are required, including hospitalist inpatient bed management and improved direct admission processes

49. Summary: Home/Clinic/ED to the Hospital • The is a disparity in the perception as opposed to the reality regarding the communication that occurs between hospitalists and primary care providers about patient care. • The lack of information commonly expected on discharge summaries leads to missed opportunities and concerns of safe patient practices. • Any communication from hospitalist to primary care providers improves outcomes.

50. Summary: Hospital to the Community • Suboptimal care during transitions is especially dangerous for older adults. • There are patient- and system-level factors that place older adults at risk for receiving suboptimal care during transitions. • Physicians experience difficulty accessing colleagues during transitions and vary in their perceptions of accountability towards the patient. • Innovative solutions to improve transitional care should target different components of the healthcare system (policy, organizations, providers, patients).