THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

1. SAFE CARE TRANSITIONS: BRIDGINGSILOS OF CAREKarin Ouchida, MDAssistant Professor of MedicineDivision of GeriatricsMontefiore Medical Center/AECOMMedical DirectorMontefiore Home Health AgencyNovember 14, 2009 AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

2. Objectives • Identify complications of poor transitions • List key components of safe transitions • Distinguish different discharge services and settings • Appreciate the physician’s role

3. Why should youcare about this? • Patient safety • The Joint Commission • Health care reform • Reduce avoidable re-hospitalizations • Increase accountability + transparency

4. SURVEY OF PATIENTS ABOUT HOSPITAL EXPERIENCES

5. HOW OFTEN DO TRANSITIONS OCCUR? • After hip fracture, pts underwent an average of 3.5 “relocations” • Between Thurs and Mon morning, 67 “handoffs” may occur • Medicare beneficiaries see a median of 2 PCPs and 5 specialists yearly! Boockvar et al. JAGS. 2004;52:1826-1831. Horwitz et al. Arch Intern Med. 2006;166:1173-1177. Hoangmai et al. N Engl J Med. 2007;356:1130-1139.

6. DEFINITION OF TRANSITIONAL CARE The set of actions necessary to ensure the coordination and continuity of health care as patients transfer between different health care settings or levels of care Coleman and Berenson. Ann Intern Med. 2004;140:533-536.

7. COMPLICATIONS OF POOR TRANSITIONS • Adverse events • Increased health care utilization • Patient dissatisfaction • Provider dissatisfaction

8. Adverse Events • Injury resulting from medical management vs. underlying disease • 1 in 5 patients experiences an adverse event during the hospital-to-home transition • 1/3 are preventable • 1/4 of patients are re-admitted to the hospital Forster et al. Ann Intern Med. 2003;138:161-167.

9. Increased Health Care Utilization • 16% of Medicare beneficiaries are re-hospitalized within 30 days of discharge after a surgical admission • Vascular surgery 24% • Major bowel surgery 17% • 20%40% are re-admitted to a different hospital • Readmission is associated with increased mortality, impaired function, and nursing home placement • Cost of unplanned re-hospitalizations in 2004: estimated at $17.4 billion Jencks et at. N Engl J Med. 2009;360:1418-1428. Boockvar et al. J Am Geriatr Soc. 2003;51:399-403.

10. 4 CRITICAL COMPONENTSOF SAFE TRANSITIONS • Medication reconciliation • Patient education • Red flags • Who to call • Communication between sending and receiving providers • Timely follow-up

11. Case 1 • A 78-year-old woman with a history of atrial fibrillation, CVA, and newly diagnosed breast cancer is admitted for mastectomy • Warfarin is held for surgery • The hospital course is complicated by delirium and UTI • The patient is discharged to subacute rehab • She is re-admitted after 5 days with rapid a-fib and sudden dysarthria/facial droop

12. CASE 1: MEDICATIONS HOME • Atenolol 50 mg qd • Metformin 850 mg BID • Glucotrol 10 mg qd • Warfarin 3 mg qHS • Prevacid 30 mg qd • Calcium/vitamin D 600/400 IU BID • Alendronate 70 mg weekly HOSPITAL • NPH 8 units qAM • Protonix 40 mg daily • Keflex 500 mg BID • Colace 300 mg qd • Senna 2 tabs qHS DISCHARGE • NPH 8 units qAM • Protonix 40 mg daily • Keflex 500 mg BID

13. COMPONENT 1:MEDICATION RECONCILIATION • How: Start with an accurate pre-admission list • When: “Across the continuum of care” • Why: Most adverse events are medication-related (66%) Forster et al. 2003 Ann Intern Med. 2003;138:161-167.

14. Case 2 • A 78-year-old woman with mild dementia, CAD, and DM is admitted with fever and abdominal pain • She is found to have acute cholecystitis and undergoes open cholecystectomy • The post-op course is complicated by mild cellulitis at the incision site • She is discharged on Keflex and Percocet for pain but not educated about warning signs/symptoms • She is re-admitted 7 days later with wound abscess and fecal impaction

15. COMPONENT 2: Patient Education • Care transitions intervention • Subjects: 65+, community dwelling, no dementia, admitted with CAD, COPD, CVA, hip fracture, etc. • Advance practice nurse educates about: • Medications • Personal health record • Scheduling and preparation for follow-up visits • Indications of worsening condition (“red flags”) and whom to contact Coleman et al. Arch Intern Med. 2006;166:1822-1828.

16. DECREASEDRE-HOSPITALIZATION RATES Coleman et al. Arch Intern Med. 2006;166:1822-1828.

17. SURVEY OF PATIENTS ABOUT HOSPITAL EXPERIENCES

18. Case 3 • A 75-year-old man is admitted for elective hernia repair • He is given Ancef preoperatively and develops a rash, although he has no previous history of medication allergy • Post-op, he has hematuria, which resolves spontaneously; a UA/urine culture and urine cytopathology are sent • When he is discharged to home, the discharge summary does not list Ancef allergy or note pending urine cytology

19. COMPONENT 3:COMMUNICATION • System problems contributed to all preventable and ameliorable adverse events • Most common reason for failed transition = poor communication between inpatient MD and patient or PCP (59%) • Direct communication between inpatient MD and PCP occurred in only 3%-20% of cases Forster et al. Ann Intern Med. 2003;138:161-167. Kripalani et al. JAMA. 2007;297:831-841.

20. Ways to Communicate • Discharge summary • Patient • Proprietary software • E-mail • Phone

21. Discharge Summaries • Key information is often missing: • Responsible hospital MD (25%) • Main diagnosis (18%) • Discharge medications (20%) • Specific follow-up plans (14%) • Diagnostic test results (38%) • Tests pending at discharge (65%) • Available at follow-up visit only 12%34% of the time Kripalani et al. JAMA. 2007;297:831-841. Kripalani et al. J Hosp Med. 2007;2:314-323.

22. THE “IDEAL” DISCHARGE FORM • Presenting problem • Key findings and test results • Final diagnoses • Condition at discharge (including functional and cognitive status if relevant) • Discharge destination • Discharge medications (purpose, cautions, changes in dose or frequency, meds that should be stopped) • Follow-up appointments • Pending labs/tests • Specialist recommendations • Documentation of patient education/understanding • Anticipated problems or suggestions • 24/7 call-back number • Referring/receiving providers • Advanced directives/code status Halasyamani et al. J Hosp Med 2006;1:354-360.

23. Pending Test Results • 2600 patients discharged from hospitalist services at 2 academic hospitals • 40% had test results returned after discharge • 10% required some action • Hospitalists and PCPs surveyed about 155 results • Unaware of 60% • 40% were actionable, 13% urgent Roy et al. Ann Intern Med. 2005;143:121-128.

24. Recommendations for Outpatient Workup • Of 700 discharges, 30% had outpatient work-up recommended • Diagnostic procedure (48%) • Subspecialty referrals (35%) • Laboratory tests (17%) • 36% of work-ups were not completed • Availability of discharge summary increased likelihood that post-discharge work-up would be completed (OR = 2.35) Moore et al. Arch Intern Med. 2007;167:1305-1311.

25. Case 4 • An 80-year-old woman is admitted with fever, vomiting, and abdominal pain • She is found to have acute appendicitis and undergoes laparoscopic appendectomy • She is discharged home with instructions to follow-up in the surgery clinic in 4 weeks • She is re-admitted 2 weeks later with fever, altered mental status after a fall at home • The port sites are grossly infected

26. COMPONENT 4: TIMELY FOLLOW-UP • 50% of patients re-hospitalized within 30 days of discharge did not have an outpatient MD visit billed to Medicare • Benefits of timely follow-up: • Lab monitoring • Reconcile medications • Check on home supports • Reinforce knowledge of red flags and emergency contact information Jencks et al. N Engl J Med. 2009;360:1418-1428. Forster et al. Ann Intern Med. 2003;138:161-167.

27. CHALLENGES TO IMPROVING TRANSITIONAL CARE • Physicians • Awareness • Multiple providers • Time • Patients • Health illiteracy • Cognitive impairment • Language barriers • Lack of social support • Systems

28. Do we need “transitionalists”?

29. TRIAL OFDischarge SERVICES(1 of 5) • Subjects: Adults admitted to medicine teaching service, discharged home • Design: Randomized trial with block randomization • Intervention: Nursing discharge advocate visit plus pharmacist phone call • Follow-up: 30 days • Primary endpoint: Number of ED visits and readmissions • Secondary endpoints: Patient knowledge of diagnosis, PCP name, follow-up, preparedness for discharge Jack et al. Ann Intern Med. 2009;150:178-187.

30. TRIAL OFDischarge SERVICES (2 of 5) • Nursing discharge advocate • Educated patient re: dx, meds, follow-up • Arranged follow-up appointments • Set up post-discharge services • Reviewed and transmitted discharge summary to PCP • Provided pt with “after-care plan” • Pharmacist phone call 24 days post-discharge to review medications Jack et al. Ann Intern Med. 2009;150:178-187.

31. TRIAL OFDISCHARGE SERVICES (3 of 5) P = .009 Jack et al. Ann Intern Med. 2009;150:178-187.

32. TRIAL OFDischarge SERVICES (4 of 5) Jack et al. Ann Intern Med. 2009;150:178-187.

33. TRIAL OFDischarge SERVICES (5 of 5) In the intervention group: • Follow-up with PCP made prior to discharge: 94% (vs. 35% in usual care) • D/C summary sent to PCP within 24 hours: 90% • Pharmacist reviewed meds with 50% • 65% had at least 1 medication problem • 50% needed corrective action by pharmacist

34. A Strategy forEffecting Safe Transitions If you don’t have a transitionalist, identify and involve interdisciplinary team members who can help you with: • Med reconciliation • Patient education • Communication • Follow-up

35. A TEAM APPROACH Inpatient • Nurse • Social worker • Pharmacist • PT/OT • Medical students • Caregivers Outpatient/Home • Home care nurse • Home care SW • Pharmacist • Home care PT/OT • Case managers • Caregivers

36. Identifying the Most Appropriate Discharge SETTING Functional assessment: • Activities of daily living and instrumental activities of daily living • Ambulation • Cognitive status • Home environment • Caregiver support

37. Short-Term Home Health Care • Skilled need: RN, PT and/or speech therapy • Homebound: assistance for person/device to leave the home • Intermittent care: part-time, intermittent needs • Physician supervision: must have outpatient MD to sign orders, address concerns • If the patient needs assistance with activities of daily living (ADLs) or instrumental ADLs, there must be sufficient/willing caregiver(s)

38. Rehabilitation Settings

39. Home vs. Inpatient Rehabilitation • 234 patients randomized to home-based vs. inpatient rehab after total joint replacement; followed for 1 year • Average stay in inpatient rehab = 18 days • Number of home rehab visits = 8 • Functional outcomes equal • No significant difference in infection, DVT, infection, patient satisfaction • Lower cost for home-based rehab (~$3000) Mahomed et al. J Bone Joint Surg Am. 2008;90:1673-1680.

40. Skilled Nursing Facility • Skilled need for RN, PT/OT, or speech therapy • IV antibiotics • Wound care • Rehab • Medical or personal care needs exceed home supports

41. Summary • Care transitions are associated with increased adverse events and health care utilization • Safe transitions require medication reconciliation, patient education, provider communication, and timely follow-up • Functional assessment helps identify the most appropriate discharge setting • Physicians are responsible for ensuring safe transitions

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