TRANSITIONAL CARE module three

1. TRANSITIONAL CAREmodule three Bill Lyons, M.D. UNMC Geriatrics Asst. Professor wlyons@unmc.edu

2. ISSUES TO COMMUNICATE WITH PATIENT, CAREGIVER • Reconcile d/c med list with previous regimen • Potential side effects of medications • Activity limitations, functional prognoses

3. PATIENT, CAREGIVER ISSUES, cont’d • Signs, symptoms, and red flags that should prompt a call • Whom to call if concerns arise • What to expect at the new site

4. ADDED PEARLS • Document purpose for drugs, target symptoms for psychiatric medications • Involve SW and PT early in hospitalization • ‘Disposition’ heading in daily note

5. ADDED PEARLS, cont’d • Encourage and participate in interdisciplinary team rounds • Involve clinical pharmacist • Communicate d/c plan to primary care provider

6. A FEW WORDS ABOUT MEDICARE • Skilled nursing facilities • Qualifying hospital stay (>72 hrs) • Skilled nursing, rehabilitative therapy, or both • Up to 100 days, but coverage stops when goals met or patient stops improving • Home healthcare • Patient must be homebound • Require intermittent skilled nursing (and perhaps PT, OT, ST, SW)

7. CASE 1 DISCUSSION • Hospitalization had been for nausea and vomiting with dehydration • Furosemide held during hospitalization • Not resumed at discharge • No instructions regarding reinitiating the drug • Result: pulmonary edema

8. CASE 2 DISCUSSION • Autopsy: 1500 mL grossly bloody fluid in pericardium  tamponade, hepatic congestion • Positive feedback loop initiated • No communication between SNF MD and CT Surgery re significance of climbing INR values

9. Post-test question 1 • Each of the following entries represents a hypothetical medication list on a transfer summary document. Which one best illustrates a proper medication listing with reconciliation? • HCTZ 12.5 mg PO qdRisperidone 0.5 mg PO q12h prn agitationSeptra DS one PO bid • HCTZ 12.5 mg PO qdRisperidone 0.5 mg PO q12h prn agitation (striking out at caregivers)Septra DS one PO bid • HCTZ 12.5 mg PO qd (reduced from previous 25 mg daily)Risperidone 0.5 mg PO q12h prn agitation (striking out at caregivers)Septra DS one PO bid • HCTZ 12.5 mg PO qd (reduced from previous 25 mg daily)Risperidone 0.5 mg PO q12h prn agitation (striking out at caregivers)Septra DS one PO bid for 4 more days • HCTZ 12.5 mg PO qd (reduced from previous 25 mg daily)Risperidone 0.5 mg PO q12h prn agitation (striking out at caregivers)Septra DS one PO bid for 4 more daysStop taking furosemideStop taking ibuprofen

10. Correct Answer:    (e) HCTZ 12.5 mg PO qd (reduced from previous 25 mg daily)Risperidone 0.5 mg PO q12h prn agitation (striking out at caregivers)Septra DS one PO bid for 4 more daysStop taking furosemideStop taking ibuprofen Feedback: The entry shown in (e) best illustrates the principles by showing the change from the previous hydrochlorothiazide dose, the specific behavioral indication for risperidone used as needed, the duration of treatment for the antibiotic Septra, and the clear statement that previously-taken furosemide and ibuprofen are to be stopped. Entries (a) through (d) are, by comparison, less complete.

11. post-test question 2 This module finished up the discussion of a patient who died shortly after transfer to a skilled nursing facility. Autopsy revealed hemopericardium with tamponade, and laboratory work at his facility had shown progressively rising INR values preceding his arrest. This case illustrated which of the following "lessons" of transitional care: a. The importance of reconciling the discharge medication list with the previous regimen b. The fact that Medicare coverage for postacute SNF care will stop when goals of care are met or when the patient stops improving c. The importance of involving SW early during hospitalization d. The importance of listing an indication for each medication in the discharge list e. The importance of highlighting "red flags" that should prompt a call or further workup

12. Correct Answer:  e.  The importance of highlighting "red flags" that should prompt a call or further workup Feedback: The investigation of this incident revealed that physicians with extensive experience caring for patients after valve replacement surgery (which this patient had undergone before hospital discharge) commonly recognize progressive increases in INR as evidence of congestive hepatopathy, a condition which may arise in the setting of cardiac tamponade. The SNF clinicians had not considered this diagnosis during the period of rising INR values. Had rising INR's been labeled as a red flag by the discharging physicians, it is possible that this patient terminal event might have been averted End.