Transitions in Long Term Care: The role of a hospital/SNF partnership in assuring effective transiti...
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Aubrey L. Knight, M.D. Chief, Geriatric and Palliative Medicine Carilion Clinic Roanoke, VA PowerPoint PPT Presentation

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Transitions in Long Term Care: The role of a hospital/SNF partnership in assuring effective transitions of care. Aubrey L. Knight, M.D. Chief, Geriatric and Palliative Medicine Carilion Clinic Roanoke, VA. Disclosure.

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Aubrey L. Knight, M.D. Chief, Geriatric and Palliative Medicine Carilion Clinic Roanoke, VA

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Transitions in Long Term Care: The role of a hospital/SNF partnership in assuring effective transitions of care

Aubrey L. Knight, M.D.

Chief, Geriatric and Palliative Medicine

Carilion Clinic

Roanoke, VA


  • I have no relevant relationships or affiliations with any proprietary entity producing health care goods or services.


  • Understand the risks inherent in transitions from one site of care to another

  • Identify processes at the time of transition that can help to mitigate some of the risks

  • Recognize the role of the SNF and the medical director in assuring the transition is safe

It’s in the News

“Care Transitions: The Hazards of Going In and Coming Out of the Hospital”-

Huffington Post 10/10

“Heart Failure Program Has Reduced Readmissions by 30 Percent”-

The New York Times 9/11

“Don’t Come Back, Hospitals Say”-


It’s big business

It’s not rocket science

  • Rather, it is:

    • Good care

    • Good communication

    • Attention to detail

    • Teamwork

So, what makes it so difficult?

  • Complexity

    • Of systems

    • Of rules and regulations

    • Of patients

  • Technology

    • Double-edged sword

  • Entropy

    • The concept of health care as a “team sport” has been slow to evolve

  • Mal-aligned incentives

    • Lack of payment for many of the things that could help

    • Throughput, current hospital payment methodology, etc


Fundamental Disconnect…


Skilled Nursing Facility


Ambulatory Care Clinic

Rehabilitation Facility

Home Health and Hospice


  • Of systems

  • Of rules and regulations

  • Of patients

Technology- “the double-edged sword”

  • Meaningful use vs. Meaningful care

  • Reliance on the computer to do the work of the human

  • EHRs that do not talk


  • The silo mentality of our systems

  • “We’ve never done it that way before”



Home Care

Misaligned incentives

  • Through-put- do everything quickly…”get them out of my…”

  • DRG’s- financial incentives to shorter LOS

  • Medicare Part A restrictions- Hospice in the nursing home setting

Transitions of Care- Definition

  • The movement of patients from one health care practitioner or setting to another as their condition or care needs change.

    • Within settings

      • Primary care to Specialty care

      • ED to inpatient

      • ICU to PCU to ward

    • Between settings

      • Hospital to LTC (and back)

      • Hospital/LTC to home

    • Across health states

      • Curative to palliative care

Each transition brings with it opportunity for error

  • Medication errors

  • Inefficient/duplicative care

  • Inadequate patient/caregiver preparation

  • Inadequate follow-up

  • Dissatisfaction

  • Litigation

Barriers to effective transitions

  • Patient barriers

  • System barriers

  • Practitioner barriers

Patient barriers

  • Patients are living longer and with age comes chronic illness

  • Institutionalization fosters dependency and we ask them to abruptly become independent

  • Health literacy

  • Ability to follow though with plans

    • Transportation

    • Cognitive impairment

    • Cost of medications

      • Medicare D “donut hole”

System barriers

  • Complexity

  • Multiple providers

  • Shift work/Duty hours

  • Poor electronic communication

  • Poor understanding of the capabilities and roles of home health, hospice, and SNF

Practitioner barriers

  • Busyness

  • Specialization

    • Hospitalist

    • Intensivist

    • SNFist

    • Extensivist

    • Outpatient only

Medicare – Excess Readmission Rates - Penalties

  • CMS will penalize hospitals for excess readmission rates starting FFY 2013 (Oct. 2012)

  • Initial focus – HF, AMI, PNE

  • FFY2015 (starts Oct. 2014) may add chronic obstructive pulmonary disease, CABG, percutaneous coronary interventions, and some vascular surgery procedures.

  • Penalty

    • FFY2013 – up to 1% all IP Medicare payments (CMC approx $1.5m)

    • FFY2014 – up to 2%

    • FFY2015 – up to 3%

The other Transition

  • Problems arise not just from transition from the hospital to another site of care

  • When we send them home, the same risks are present

Organizational guidance

  • CMS 9th SOW statement about care coordination

  • 2009 Joint Commission Patient Safety Standard #8 about medication reconciliation

  • NQF Performance Measures for Care Coordination

  • NTOCC tools and resources

  • Patient Bill of Rights during Transitions of Care

  • Multiple other tools


Published models

  • H2H- American College of Cardiology

  • Project Boost- Society of Hospital Medicine

  • Project RED

  • The Care Transitions Intervention

American College of Cardiology and Institute for Healthcare Improvement

Project BOOST

  • Better Outcomes for Older Adults Through Safe Transitions

  • Effort of the Society of Hospital Medicine

  • Resources and evidence-based interventions

  • Encourages team building and working through system processes

Educate the patient

Make appointments

Discuss tests and results

Organize post-discharge services

Confirm the medication plan

Reconcile the discharge plan

Review process when problems arise

Expedite the transmission of the discharge summary

Assess patient understanding

Give patient a written discharge plan

Telephone reinforcement in 2-3 days post-discharge

Project RED

Improving the Discharge Process – The Care Transitions Intervention

  • Designed to encourage older patients and their caregivers to assert a more active role during care transitions

  • Elderly patients provided a transition coach

  • “4 pillars”

    • Medication self-management

    • Maintenance of Personal Health Record

    • Timely f/u with PCP and Specialists

    • Knowledge of potential complications and ways to manage them if they occur

Coleman et al. Arch Intern Med. 2006; 166:1822-1828

Outcomes from effective transitions

  • Improved patient/family satisfaction

  • Reduced health care cost

  • Decrease readmissions

Patients cared for at the right time, at the right place.

Ultimately Lower Health Care Costs

  • Reduced inefficiencies/duplication of services

  • Lower hospital and ED use

  • National 30-day readmit rate- 15-25%

  • Reduced litigation/negative press

IDEAS for success

  • Involve stakeholders

  • Develop tools

  • Engage/empower patients and caregivers

  • Adapt technology so that there is the ability to share information

  • Share information


  • Hospital administration (see CMS penalties)

  • LTC administrators (mention bundled payment and you’ll get their attention)

  • Hospital physicians

  • LTC Medical Director

Transition tools

  • Checklist

    • Discharge summary

    • Handoff

  • Medication reconciliation

  • Engage floor nurses and case managers

  • Follow-up

    • phone calls

    • appointments

Keep it simple

  • We work in an incredibly complex field

    • 6,000 drugs

    • ICD-9 has > 13,000 conditions

  • The basics can get lost in the jungle of complexity

  • Checklists can help simplify and standardize

    • Airline pilots

The Discharge Summary and other handoffs

  • Physician summaries are the least reliable source of medication lists- Am J Ger Pharmacotherapy Aug 2011

  • Summaries and Handoffs are our means of communication and must be:

    • Complete- “Antibiotics for one week”

    • Accurate- Inpatient and outpatient meds not thoughtfully reconciled

    • Clear- “Follow-up CT scan in one week”

Medication Reconciliation

  • Errors occur in deciding on and communicating whether and which outpatient medications should be continued when patients leave the hospital or the nursing home

  • Over half of medication discrepancies were classified as potentially causing moderate/severe discomfort or clinical deterioration- Am J Ger Pharmacotherapy Sept 2011

  • Pharmacist-led models of medication reconciliation continue to emerge

Medication Delays

  • Being scrutinized more carefully

  • We need to not only approve meds, but ask about next dose and availability

  • Solutions

    • Early transfers

    • Partnerships with hospitals

    • Communication

Medications at discharge from the SNF

  • Are patients capable of following through?

    • Insulin

    • Nebulizers

  • Whose role and for how long?

  • The handoff to the PCP

  • How do we know patients understand?

Nurse engagement

  • Nurse Engagement Key to Reducing Medical Errors: People more important than technology- by Rick Blizzard, D.B.A. Health and Healthcare Editor of the Gallup Organization, 2005

Follow up

  • Post discharge calls

    • By hospital case management, pharmacist, PCMH…ANYONE

  • Accountability

    • This is the lethal gap in the care. Someone needs to take responsibility.

  • Follow up appointments

    • Studies indicate that appointments within 7-14 days make a difference


  • Empowered to ask

  • Armed with information

  • Knows whom to call for answers

Make technology your friend

  • EMR

  • Telemonitoring

  • Email/texting


  • Understand to roles and capabilities at the various sites of care

  • Share your piece of the puzzle

  • Be specific

Relational Coordination

  • Relationships of:

    • Shared goals

    • Shared knowledge

    • Mutual respect

  • Communication that is:

    • Frequent

    • Timely

    • Accurate

    • Problem-solving

Real Health Care Reform

  • Is local

  • Involves each stakeholder working as a team

    • Patient

    • Family

    • Providers

    • Institutions

    • Community agencies/resources


  • Project Boost:

  • Project RED:

  • Care Transitions Intervention:

  • NTOCC:

  • H2H:

  • AMDA CPG on Transitions of Care-

  • Atul Gawande-


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