Transcript Pain Management in Older Adults

UMMS CRIT Module III:
Transitions in Care: Discharge Planning
Sarah McGee, MD, MPH
Florence LeClair, RN, BSN, CHPN
Linda Pellegrini, BS, MS
Kathleen H. Miller EdD, ACNP-BC, GNP-BC
Transitions in Care: Discharge Planning
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Transitions in Care: Discharge Planning
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Definition
• Transition in Care: refers to the movement of patients between health care
locations, providers or different levels of care within the same location as
their condition and care needs change
Change of care by:
− Setting, e.g. primary care→ specialty care →ICU care
hospital → subacute → ambulatory
− Health status, e.g. curative →palliative
− Provider, e.g. hospitalist → MD at skilled nursing
facility→ PCP
• “It is becoming increasingly uncommon for any one clinician to provide
continuous care to a patient transferring from one facility to another.”
Coleman, et al. JAGS 2003
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Definition
From a system perspective a safe transition from the
hospital to the community or a nursing home requires care
that centers on the patient and that transcends the
organizational boundaries.
Jenckes et al NEJM, April 2009
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Transitions
• 30.7% of hospital patients >65 y.o. are discharged to another institution
(2009)
• 17.0% are discharged home with services (2009)
• 19.6 % of Medicare beneficiaries are re-hospitalized within 30 days of
discharge
―Majority are unplanned
―Very costly (17.4B)
―Non-payment for readmissions
Agency for Health Care Quality Research HCUPnet
Jenckes et al NEJM, April 2009
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Discharge from Hospital to Other Institutions
increases with Age
AHRQ HCUPnet http://www.ahrq.gov/data/hcup/factbk1/10shel.htm
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Potential undesirable outcomes of transitions of care
• Adverse medication reactions
– 19% of individuals will experience adverse medication
reaction within 3 weeks of discharge from hospital
• Re-hospitalization
– 1/5 of Medicare beneficiaries are readmitted to the
hospital within 30 days of discharge
• Duplicated services
• Poor patient satisfaction
• Poor continuity of care
Jencks, et al. NEJM 2009
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
At Risk Populations
• Think about transitions for all discharges
• Greatest risk for poor outcomes:
– Multiple medical problems
– Cognitive deficits
– Depression
– Isolated/poor support system
– Non-English speaking
– Immigrants
– Few financial supports
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Transition Locations
• Home
– With skilled services
– Without skilled services
• Skilled Nursing Facility (SNF)
• Rehabilitation Hospital
• Long Term Acute Care ( LTAC)
• Assisted Living Facility/Rest Home
• Long Term Care Facility
• Hospice Residence
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Skilled Nursing Facility
•
Medicare A pays if 3 night hospital stay and 24 hr skilled nursing care needed
– Duration depends on types and number of skilled needs and patient progress
•
Interdisciplinary staffing
– Nursing: RN, LPN, CNA, wound care
– Therapies: PT/OT/ST, nutrition, SW, etc
– Medical: MD, PAs, NPs
•
– Other clinical: dental, podiatry, vision, psych, psychology, clinical
pharmacist
No EMR
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MP/NP off site
Pharmacy off site
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Stat labs, X-rays and IV’s available
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Rehabilitation Hospital
• Needs and can tolerate intensive rehab (PT/OT/ST 3 hrs/day)
• Medically unstable for SNF
– Needs frequent MD evaluation (> q1-2 wk)
– Need for frequent labs
– Medication adjustment in < 24-48 hr (eg, BP meds, diuretics)
– Telemetry
– Respiratory therapy
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Home with “Skilled” Care
with Certified Home Health Agency
• A physician can refer any patient with an acute skilled need to a
home care agency
• Homebound
• Qualifies for intermittent skilled care
• Nursing care
– Monitoring of vital signs, cardiac/pulm status
– Wound care
– DM monitoring and education
– Medication management
• PT and OT
• Speech therapy
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Elements for Effective/Safe Transition
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Communication
– With next provider and PCP
– With other members of interprofessional team
– Discharge assessment
– Discharge summary
– Prepare the patient and caregiver
Medication Reconciliation
Follow-up Plan
– Follow-up tests
– Follow-up appointments
Discussion of Warning Signs
Coleman, EA JAGS (2003) 52:549-555
Pacala, GRS 7
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Communication of Information
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Medical needs
– Summary of admitting problems and course
– Active Problem list
– Recent and important pending labs /tests
– Consistency b/n D/C summary and PDI
– Advance directives: HCP, DNR, preferences, goals
Functional support (ADL, IADL)
– Disposition: where from and where next
– Functional status: baseline and present
– Social support and contact info
Nursing needs: monitoring, wounds
Rehabilitative needs: PT, OT, ST
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Communication with patient and caregiver
• Engage the caregiver as an important part of the team and patient
advocate
• What have they been providing in past? Plans for future?
• What will they need to transition the patient to next setting?
• Make sure that patient and caregiver have an understanding of hospital
course and next steps
• Give instructions at a 6th grade level and assess for understanding
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Medication Reconciliation
• Compare to pre-hospital list to D/C list
• Define stop points for antibiotics
• Indication for new mediations
• Narcotics – with prescription
• Medications stopped and why
• Indication and schedule for prn medications
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Follow-Up
• Labs
– Culture results
– Pathology results
• Physician follow-up appointments
– Pts without PCP follow-up within 4 weeks of hospital d/c were 10 X
more likely to be readmitted than those with PCP follow-up
(Misky, Wald, Coleman 2010)
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Warning Signs
Signs and symptoms which should be assessed and plan for next
steps (ie)
– Weight gain
– Fever
– Wound drainage
– VS outside of parameters
– Labs outside of parameters
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
TRANSITIONS OF CARE
THE ROLE OF THE HOSPITAL
NURSE PRACTITIONER
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Transitions in Care: Role of the Hospital Nurse
Practitioner
• Interprofessional team finalizes the discharge plans
• Collaborates with other disciplines to coordinate the discharge plans
• Medication reconcilation for hospital and home medications
• Follow-up on diagnostic tests and treatment
• Updates discharge forms with any changes
• Follow-up physician appointments
• Communicates with receiving facility
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Transitions in Care: Role of Hospital Nurse Practitioner
• Meets with patient and family
– Discharge plan
– Medications
– Post discharge treatments
– Education about warning signs
– Follow-up physician appointments
• Answers questions
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
TRANSITIONS OF CARE
NURSE CASE MANAGER’S
ASSESSMENT AND PLAN
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Plan is based on the patient’s input and goals if possible (and/or
family)
• Determine type of services and resources available to address goals
• Evaluate barriers to care
financial, physical (stairs), family, transportation
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Discuss treatment plan options and level of care recommendations
with clinical team (Chief Residents, Residents, Hospitalists)
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Effects of Poor Communication on Transition
• Confusion about patient’s condition and appropriate care
• Duplicative Tests
• Inconsistent patient monitoring
• Medication errors
• Delays in Diagnosis
• Lack of follow through on referrals
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Smoother Transition for Mrs. H
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Discharge patient to SNF earlier in day or the next day
Reconcile discharge meds more accurately
Send scripts for controlled substances with pt. to SNF.
Ensure all referral paperwork is complete and thorough
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
TRANSITIONS OF CARE
THE ROLE OF THE NURSE
PRACTITIONER IN THE SNF
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Role of the NP in the SNF Receiving the patient
• Works collaboratively with physician to provide increased
clinical care and more intensive management of chronic medical
problems in the SNF as well as the following settings:
• Ambulatory Care – NF – Assisted Living Facility – Home
• Communicates with other team members
• Advanced care Planning
• Discharge Planning from SNF
• Coordinate care of medically/socially complex patients in home
setting
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Transitions of Care
• NP may be the sender or the receiver of patients. May have
received Mrs H at the SNF. In order to prevent readmission,
coordination with sending team could include:
• Earlier discharge- would help to clarify information on the
receiving end.
• Prevent readmission-accurate medication reconciliation
including pre-hospital meds and meeting with
family/patient to discuss goals of care.
UMMS CRIT 2012 Module III: Transitions in Care: Discharge Planning
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation