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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

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
Disclosure partnership in assuring effective transitions of care

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


Objectives
Objectives partnership in assuring effective transitions of care

  • 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 partnership in assuring effective transitions of care

“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”-

THE WALL STREET JOURNAL-6/11


It s big business
It’s big business partnership in assuring effective transitions of care


It s not rocket science
It’s not rocket science partnership in assuring effective transitions of care

  • Rather, it is:

    • Good care

    • Good communication

    • Attention to detail

    • Teamwork


So what makes it so difficult
So, what makes it so difficult? partnership in assuring effective transitions of care

  • 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


Aubrey l knight m d chief geriatric and palliative medicine carilion clinic roanoke va

SNF partnership in assuring effective transitions of care

Fundamental Disconnect…

Hospital

Skilled Nursing Facility

Home

Ambulatory Care Clinic

Rehabilitation Facility

Home Health and Hospice


Complexity
Complexity partnership in assuring effective transitions of care

  • Of systems

  • Of rules and regulations

  • Of patients


Technology the double edged sword
Technology- “the double-edged sword” partnership in assuring effective transitions of care

  • Meaningful use vs. Meaningful care

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

  • EHRs that do not talk


Entropy
Entropy partnership in assuring effective transitions of care

  • The silo mentality of our systems

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

Hospital

SNF

Home Care


Misaligned incentives
Misaligned incentives partnership in assuring effective transitions of care

  • 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 partnership in assuring effective transitions of care

  • 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 partnership in assuring effective transitions of care

  • Medication errors

  • Inefficient/duplicative care

  • Inadequate patient/caregiver preparation

  • Inadequate follow-up

  • Dissatisfaction

  • Litigation


Barriers to effective transitions
Barriers to effective transitions partnership in assuring effective transitions of care

  • Patient barriers

  • System barriers

  • Practitioner barriers


Patient barriers
Patient barriers partnership in assuring effective transitions of care

  • 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 partnership in assuring effective transitions of care

  • 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 partnership in assuring effective transitions of care

  • Busyness

  • Specialization

    • Hospitalist

    • Intensivist

    • SNFist

    • Extensivist

    • Outpatient only


Medicare excess readmission rates penalties
Medicare – Excess Readmission Rates - Penalties partnership in assuring effective transitions of care

  • 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 partnership in assuring effective transitions of care

  • 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 partnership in assuring effective transitions of care

  • 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


Aubrey l knight m d chief geriatric and palliative medicine carilion clinic roanoke va


Published models
Published models partnership in assuring effective transitions of care

  • H2H- American College of Cardiology

  • Project Boost- Society of Hospital Medicine

  • Project RED

  • The Care Transitions Intervention



Project boost
Project BOOST Improvement

  • 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 Improvement

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 Intervention

  • 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 Intervention

  • 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 Intervention

  • Involve stakeholders

  • Develop tools

  • Engage/empower patients and caregivers

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

  • Share information


Stakeholders
Stakeholders Intervention

  • 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 Intervention

  • Checklist

    • Discharge summary

    • Handoff

  • Medication reconciliation

  • Engage floor nurses and case managers

  • Follow-up

    • phone calls

    • appointments


Keep it simple
Keep it simple Intervention

  • 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 Intervention

  • 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 Intervention

  • 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 Intervention

  • 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 Intervention

  • 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 Intervention

  • 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 Intervention

  • 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


Patient
Patient Intervention

  • Empowered to ask

  • Armed with information

  • Knows whom to call for answers


Make technology your friend
Make technology your friend Intervention

  • EMR

  • Telemonitoring

  • Email/texting


Communication
Communication Intervention

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

  • Share your piece of the puzzle

  • Be specific


Relational coordination
Relational Coordination Intervention

  • Relationships of:

    • Shared goals

    • Shared knowledge

    • Mutual respect

  • Communication that is:

    • Frequent

    • Timely

    • Accurate

    • Problem-solving


Real health care reform
Real Health Care Reform Intervention

  • Is local

  • Involves each stakeholder working as a team

    • Patient

    • Family

    • Providers

    • Institutions

    • Community agencies/resources


References
References Intervention

  • Project Boost: www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/project_boost_background.cfm

  • Project RED: www.bu.edu/fammed/projectred/

  • Care Transitions Intervention: www.caretransitions.org/

  • NTOCC: www.ntocc.org

  • H2H: www.H2Hquality.org

  • AMDA CPG on Transitions of Care- www.amda.com/tools/clinical/TOCCPG/index.html

  • Atul Gawande- http://gawande.com/


Aubrey l knight m d chief geriatric and palliative medicine carilion clinic roanoke va

Questions? Intervention