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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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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
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 not rocket science
It’s not rocket science
  • Rather, it is:
    • Good care
    • Good communication
    • Attention to detail
    • Teamwork
so what makes it so difficult
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
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
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
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
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
Barriers to effective transitions
  • Patient barriers
  • System barriers
  • Practitioner barriers
patient 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
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
Practitioner barriers
  • Busyness
  • Specialization
    • Hospitalist
    • Intensivist
    • SNFist
    • Extensivist
    • Outpatient only
medicare excess readmission rates penalties
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
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
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
Published models
  • H2H- American College of Cardiology
  • Project Boost- Society of Hospital Medicine
  • Project RED
  • The Care Transitions Intervention
project boost
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
project red
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
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
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
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
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
Transition tools
  • Checklist
    • Discharge summary
    • Handoff
  • Medication reconciliation
  • Engage floor nurses and case managers
  • Follow-up
    • phone calls
    • appointments
keep it simple
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
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
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
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
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
  • 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
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
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
Relational Coordination
  • Relationships of:
    • Shared goals
    • Shared knowledge
    • Mutual respect
  • Communication that is:
    • Frequent
    • Timely
    • Accurate
    • Problem-solving
real health care reform
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-