Transcript transitional care - Society of Hospital Medicine

Faculty Development:
Teaching Triggers for
Transitional Care
“A Train-the-Trainer Model”
Lindsay Mazotti, MD
C. Bree Johnston, MD
University of California, San Francisco
Department of Medicine
Acknowledgements
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This presentation was supported by the
Donald W. Reynolds Foundation
Thanks to the following people for
modification/ adapation of their materials:
Bill Lyons, MD; University of Nebraska
 Helen Kao, MD & Brad Sharpe, MD; UCSF
 Catherine E. DuBeau, MD; University of
Chicago CHAMP Program
http://champ.bsd.uchicago.edu
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Curricular Objectives
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Improve knowledge about transitions
Understand the 3 domains of transitions in
care
Identify teachable moments in readmissions,
transfers
Increase awareness around good discharge
summaries
ROADMAP
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Background
3 Domains of Transitional Care
Teaching Triggers
A readmission
 A discharge summary
 An anticipated discharge
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Brainstorming
Take Home Message
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Providing good transitional care requires:
ANTICIPATION & PREPARATION
DESTINATION
INFORMATION
EDUCATION
Background:
Care Transitions
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Movements patients
make between health
care providers and
different care settings
Outpatient Clinic
PMD
Vising Home
Nurses
Inpatient
Medical Team
SNF
Care Team
TRANSITIONAL CARE
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Based on comprehensive care plan including:
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Patient’s goals, preferences, and clinical status
Logistical arrangements
Patient and family education
Coordination among health professionals and health
care teams
Includes both SENDING & RECEIVING
Slide courtesy of Bill Lyons, MD; University of Nebraska
Why you care
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Transitions are wrought with errors
25% of patients d/c’d from an academic medical
service had an adverse event within 3 weeks
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Nearly 50% were preventable
Readmission rates within 30 days are as high as
25%
Subject of national attention
JCAHO is watching
You find it personally satisfying to be a “good”
doctor
Brainstorm
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Why is it important to teach
residents/students about transitional care?
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Have you had any successes in teaching
about transitional care? Can you share?
QUANTATIVE STUDIES SHOW
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In 2001, patients >65 yo discharged
from acute settings went…
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to another institution ¼ of the time
home with home health 11% of the time1
13% of Medicare beneficiaries
transfer ≥3 in 30d post-discharge2
Serious problems with discharge
summaries, communication with
PMD’s, med reconciliation
1. Agency for Health Care Quality Research HCUPnet
2. Coleman et al. Health Services Research 2004
QUALITATIVE STUDIES SHOW
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Patients don’t understand what
medications are for or anticipated side
effects
… or when to resume normal activities
…and don’t know what questions to ask,
or whom to ask
…or what warning signs to watch for
Slide courtesy of Bill Lyons, MD; University of Nebraska
WHAT IS HIGH-QUALITY
TRANSITIONAL CARE?
1.
2.
3.
4.
Reliable, accurate
information transfer
Preparation of patient,
family, caregiver
Support for selfmanagement
Empowerment of
patient to assert
preferences
Coleman et al. Int J Integrated Care 2002
3 Domains of a Transfer
DESTINATION
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Where should they
go?
How to best transfer
information?
How to educate and
prepare the patient?
INFORMATION
EDUCATION
Mrs. Ima Notthriving
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82 yo woman with multiple medical problems;
resides at SNF
Hospitalized at Our Med Center early January
for AMS, lethargy, UTI? (dirty sample, culture
negative)
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Returned to SNF
Admitted to your team 3 weeks later with with
hypoxia and lethargy
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nonspecific EKG T-wave changes, O2 sat 90%,
known pleural effusion
Increased fatigue and decreased PO intake x “1
month”
Mrs. Notthriving
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PMH:
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ESRD on HD
CHF, L sided effusion
Depression
CAD: s/p 5-6 MI’s & CABG
H/o seizure disorder
Meds include anti-hypertensives, PPI, antiseizure, renal meds, pain meds, stool softeners
Mrs. Notthriving
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SH
Widowed, no children, retired
 Former neonatal nurse
 Resides at SNF x years, bedbound
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Mrs. Notthriving
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Exam: 36.2 123/53 64 16 95-100%RA
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Gen: waxing waning lethargy
RRR, III/VI systolic murmur LLSB
Decreased BS on L
L BKA, L femoral fistula
“Unable to assess orientation”, pt follows commands,
neuro grossly intact
Labs normal
CXR with known L sided effusion
Dirty UA, >50 WBC, culture negative (again)
Teaching Trigger: A Readmission
Examine the 3 Domains of Her Transfer
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Appropriate d/c
location with first d/c?
How was our
information transfer?
Was the patient
educated &
prepared?
INFORMATION
DESTINATION
EDUCATION
Walking Through Her Case
Domain 1- DESTINATION
Did we send her to the right place after
her last admission?
DESTINATION
INFORMATION
EDUCATION
Where should they go?
What are the patients goals?
1.
•
for medical and functional recovery
What are their risks?
2.
•
is benefit of the transition > harms
associated with transfer to a new venue?
Destination: Assessing Risk
FACTORS ASSOCIATED WITH POOR
DISCHARGE OUTCOMES
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Age>80
 Depression history
Fair-to-poor self-rating
 Chronic disability and
of health
functional impairment
Recent and frequent
 History of nonadherence
hospitalizations
to therapeutic regimen
Inadequate social
 Lack of documented
support
patient/family education
Multiple, active chronic
health problems
Slide courtesy of Bill Lyons, MD; University of Nebraska
Where should they go?
What are the patients goals?
1.
•
for medical and functional recovery?
What are their risks?
2.
•
is benefit of the transition > harms
associated with transfer to a new venue?
Is the new venue a good match?
3.
•
Does it match their medical, nursing, and
functional needs?
Modified slide courtesy of Bill Lyons, MD; University of Nebraska
Destination: A Good Match?
Admitted to Hospital From:
HOME
Home
NURSING
HOME
Home
With
Services
Acute
Rehab
Nursing Home
Slide courtesy of Catherine DuBeau, MD; University of Chicago
CHAMP Program, http://champ.bsd.uchicago.edu
Domain 2- INFORMATION
How was our information transfer?
DESTINATION
INFORMATION
EDUCATION
Has anyone taught in rounds or
one-on-one about discharge
summaries?
Discharge Summaries: Problems
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“too much of the H&P and too little of the
hospital course”
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“lots of numbers about BUN and creatinine
where it would have been sufficient to say that
the patient was having mild renal insufficiency”
Quality Summaries:
What do receiving physicians want
included in a DC summary?
Quality Summaries:
What the PMD’s want…
Evaluation of 226 physicians (56%
generalists)
 Surveyed preferred content of D/C
summaries ranked by importance
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TABLE 2:
Preferred Content of Discharge Summary
Ranked by Importance
Mean rating
(scale of 1-10)
Medications at discharge
9.69
Follow-up issues
9.09
Discharge Diagnosis
9.02
List of Procedures Performed
8.79
Pending test results
8.68
Procedure Reports
8.16
Stress Test Reports
8.07
Labs from last hospital day
7.03
Meds at admission
6.91
All lab results
6.22
O’Leary et al, J Hosp Med, 2006.
Teaching Trigger:
Review Ms. Notthriving’s
Discharge Summary
A Group Exercise
Mrs. Notthriving’s
Transfer Summary
“Briefly, this is an 82-year-old female with CHF,
end-stage renal disease on hemodialysis, and a
seizure disorder who is referred to the
Emergency Department after she was noted to
be sleepy and disoriented with poor p.o. intake
for the past 3 days. The patient's chief
complaint was, "I feel lousy," endorsing fatigue
and weakness. The patient was last dialyzed on
the day of admission with 1-1.5 kg fluid
removed. For past medical history, medications,
social history, and family history, please refer to
admission history and physical.”
HOSP COURSE BY PROBLEM
 Lethargy/altered mental status:
“Significant objective findings on admission
included presence of a urinary tract infection and
a large left-sided pleural effusion. Basic
metabolic labs were within normal limits. A
noncontrast head CT was obtained and was
negative for an acute process. The patient was
treated for a urinary tract infection with
cephalexin. Urine cultures were negative. The
patient will finish a 10 day course of cephalexin.
With regards to the pleural effusion,
thoracentesis was offered but was declined by
the patient in the Emergency Department, which
was appropriate given her lack of respiratory
distress or hypoxia…”
“ …The patient's mental status improved
somewhat to the point where her family members
felt she was at baseline. Of note, at baseline the
patient is frequently quite somnolent, however, is
able to arouse to voice.
With regards to her pleural effusion, the plan is
currently to continue hemodialysis for volume
management and to follow the patient for
development of symptoms at which point the
therapeutic thoracentesis could be considered if
needed.”
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DISPOSITION: “The patient will be
transferred to her HD facility for her regularly
scheduled hemodialysis. Afterwards, she will be
transferred to SNF, where she had previously
been living.”
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CONDITION AT TRANSFER:
“While the patient's altered mental status and
lethargy have improved, she is frequently noted
to be quite sleepy. In discussion with the
patient's family and outpatient physicians, this is
consistent with her baseline and she is felt safe
to be transferred back to her Skilled Nursing
Facility, to which the patient is eager to return.”
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FOLLOW-UP: The patient will be seen by her
primary nephrologist, Dr. Renal, at hemodialysis on
the day of transfer.
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MEDICATIONS ON TRANSFER:
1. Cephalexin suspension to complete a 10-14 day
course started January 4.
2. Phenytoin 300 mg daily.
3. Escitalopram 10 mg daily.
4. Lansoprazole 30 mg daily.
5. Nephrovite.
6. Sevelmer.
7. Hydrocodone/APAP as needed.
8. Amlodipine 10 mg daily.
DISCHARGE DIAGNOSES:
1. Altered mental status, likely
secondary to urinary tract infection.
2. Urinary tract infection with negative
urine culture.
3. Left-sided pleural effusion.
4. End-stage renal disease on dialysis.
5. Congestive heart failure.
6. Diabetes mellitus.
7. Sacral decubitus ulcer.
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Teaching Trigger:
Review a Discharge Summary
What is missing?
What could be more explicit?
What do you want to know as the
receiving MD?
Discharge Summaries
HPI / PMH
PEX / LABS
HOSPITAL COURSE BY PROBLEM
HOSPITAL COURSE BY
STUDIES/PROCEDURES
PROBLEM
DISCHARGE
MEDICATIONS
DOA
DOD
Attending
HPI / PMH / PEX
HOSPITAL COURSE BY PROBLEM
1,2, 3. . . 4 Code/Adv Dir/Goals of Care
Studies / Procedures / Consultations
DISCHARGE
CONDITION
PROGNOSIS
FUNCTION
DISCHARGE
INSTRXNS
DISCHARGE
FOLLOW-UP
DISCHARGE
MEDICATIONS
Recommended Standard Format
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ID, CC & HPI
Hospital Course by Problem
Pertinent Studies and Procedures
Discharge Diagnoses
Discharge Medications
Dispo
Diet
Function/Activity
Condition/Prognosis/Goals of Care
Follow up Plans
ID, CC, HPI
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Be succinct!
ID, CC, HPI should be rolled into 1-3 lines
This is the one-liner you deliver to your attending
or to your friendly but overwhelmed specialty
consultant who doesn’t have time to hear the
novella on your patient
Your goal is to describe the Big Picture of who
the patient is and what they’re in the hospital for
Hospital Course By Problem
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MAJOR ACUTE PROBLEMS
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Main reasons for hospitalization
PNA & HYPOTENSION & HYPOXIA
could be just “PNA with complications”
Chronic medical conditions requiring
adjustments
TIPS:
 Should be SHORT, no more than 1 paragraph
 Do not need to focus on your thinking/ differential dx
 Avoid narrative speech!
Pertinent Studies & Procedures
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Includes:
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CT Scans, MRI, other radiologic studies
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Echocardiograms
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Interventional or Surgical Procedures
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IR instrumentation
Cath
Scopes
Taps
What would be important to know as a PMD
and difficult to track down?
Discharge Diagnoses
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List of major diagnoses from hospital stay
Does not include chronic illnesses (unless
major changes)
Not for billing
>10 = TOO MANY
Recommended Standard Format
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ID, CC & HPI
Hospital Course by Problem
Pertinent Studies and Procedures
Discharge Diagnoses
Discharge Medications
Dispo
Diet
Function/Activity
Condition/Prognosis/Goals of Care
Follow up Plans
Discharge Medications
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Some argue it is the most important part of
the discharge summary
Why???
Discharge Medications
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Medication Errors are very very common
at discharge
In 375 geriatric pts, 14% had a medication
discrepancy when they got home
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This increased rate of readmission by 2.5
In a study of 400 discharged patients, 45
(11%) had an adverse drug event
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60% of those were preventable/ameliorable
Coleman EA Arch Intern Med 2005
Forster AJ. Ann Intern Med 2003
Discharge Medications
In your discharge summary:
1)
List the medications that were stopped
1)
Don’t need doses, just the list
Discharge Medications
In your discharge summary:
1)
2)
List the medications that were stopped
List the other medications with doses,
directions, tapering, etc.
1)
2)
Highlight changes in doses (bp meds,
hypoglycemics, coumadin, etc.)
Highlight all new medications
DISCHARGE MEDICATIONS:
STOP Plavix, Lovastatin, lisinopril, Imdur
Combivent Neb Q4h prn
Alendronate 70mg/week PO
ASA 325mg PO daily
Atorvastatin 80mg PO Qbedtime (replaces lovastatin)
Buproprion 500 PO 3x/day
CaCo3 500 PO 3x/day
Captopril 75mg PO Q8 (replaces lisinopril)
Diltiazsem 250mg PO 2x/day
Docusate 250mg PO 2x/day
Hydralazine 40mg PO 4x/day (new medication)
NPH 20units QAM, 5units Qbedtime subQ
Insulin Regular Sliding scale as directed
Ipratroprium 3 puffs 4x/day
Imdur 120mg PO daily (increased from 60mg daily)
Mirtazapine 15mg PO Qbedtime
Recommended Standard Format
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ID, CC & HPI
Hospital Course by Problem
Pertinent Studies and Procedures
Discharge Diagnoses
Discharge Medications
Disposition
Discharge Diet
Function/Activity
Condition/Prognosis/Goals of Care
Follow up Plans
Disposition
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Where is the patient going at the time of
discharge
Can be very very brief
Home
To SNF
Deceased
Discharge Diet
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Directions for patient, family, primary
care doctor, etc.
Three things to think about:
1)
2)
3)
Specific type of diet (renal, cardiac, etc.)
Diet consistency (readmit with aspiration…)
Tube feeds/TPN
Recommended Standard Format
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ID, CC & HPI
Hospital Course by Problem
Pertinent Studies and Procedures
Discharge Diagnoses
Discharge Medications
Dispo
Diet
Function/Activity
Condition/Prognosis/Goals of Care
Follow up Plans
Function/Activity
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Need to document activity in all patients
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If healthy: “As tolerated”
Other possibilities:
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“Home with home PT”
“Wheelchair bound”
Function/Activity
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Document function for frail older patients and
ANY patient whose function
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Is impaired at baseline
Declines prior to admission
Declines during hospitalization
Why list function?
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In hospitalized older adults, functional measures
often fail to improve and frequently worsen
> 1/3 of older patients are discharged with worse
functional status than baseline
1/2 of these patients acquire their deficits during
their hospitalization
In-hospital functional decline increases with age:
rates exceed 50% in patients over 85
Covinsky KE et al. JAGS 2003;51:451-58
Include cognitive function
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Mental illness, mild cognitive impairment,
dementia or delirium?
Baseline vs discharge
This conveys whether the patient has insight and
ability to manage self-care
Does the patient rely on a caregiver to follow the
discharge treatment plan?
Follow Up
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Follow up for the outpatient physician and
follow-up for the patient
Unbelievably important (and missed)
In 2644 discharges, PCPs were unaware of 60%
of tests that needed follow-up.
Up to 65% of discharge summaries lacked test
results pending at discharge.
Roy CL. Ann Intern Med. 2005.
Kripalani S. JAMA. 2007.
Follow Up
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Follow up for the outpatient physician
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Pending test results (labs, path, radiology)
Outpatient referrals to specialists
Physician of record for nursing home, home care, or
hospice orders? (contact MD prior to discharge!)
Follow up for the patient
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Next appointments
Outpatient diagnostic studies
Quality Summaries are…
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Higher quality when length < 2 pages
Best in standardized format with minimal
narrative
Ideally
SUCCINCT
 PERTINENT
 SPECIFIC
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Modification of slide courtesy of Bill Lyons, MD; University of Nebraska
Final Pearls
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Transfer summary is for
receiving team, NOT medical
records
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Avoid cutting & pasting!
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It’s OK (and better) to be brief
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Ask for feedback
Teaching Trigger:
Was Ms. N (or her family) educated?
DESTINATION
INFORMATION
EDUCATION
AND PREPARATION….
AND COMMUNICATION….
Teaching Trigger:
What do patients leaving
the hospital need to be
educated about?
EDUCATION
ISSUES TO COMMUNICATE WITH
PATIENT, CAREGIVER
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Reconcile d/c med list with previous
regimen & WITH THE PATIENT
Discuss potential side effects of
medications
Activity/eating/bathing limitations, functional
prognoses
Communicate d/c date and plan IN
ADVANCE
“Red flags” that should prompt contacting
and MD and WHO to contact
Brainstorm:
What teaching triggers can you use
on day of discharge?
How can we teach this better?
Teaching Trigger:
An Anticipated Discharge
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Reviewing the 3 Domains
Plan for Destination
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Specific goals for Information Transfer
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Improve Interdisciplinary Collaboration: Involve your Case
Manager
Take team to SW rounds?
What will we include in D/C Summary?
What does your team anticipate going “wrong”?
Discuss & assign who will contact PMD at discharge AND DO IT
Plan for Education
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Meeting with or calling family; extra time with patient
Improve Interdisciplinary Collaboration: Involve your Pharmacist
Review: Curricular Objectives
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Improve knowledge about transitions
Understand the 3 domains of transitions in
care
Identify teachable moments in readmissions,
transfers
Increase awareness around good discharge
summaries
ROADMAP: Did we get there?
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Background
3 Domains of Transitional Care
Teaching Triggers
A readmission
 A discharge summary
 An anticipated discharge
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Brainstorming
Epilogue:
Mrs. N’s Jan 24 D/C Summary
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DISPOSITION
“Patient was transferred back to her skilled
nursing facility. Dr. Attending had a goals
of care discussion with Ima and discussed
considering a Do Not Hospitalize order,
since Ima finds her trips to the hospital
'taxing'. She agreed to this plan and was
planning on talking to her niece about it.
This plan was also communicated to Dr.
Accepting at the SNF by Dr. Attending.”