Transcript transitional care - Society of Hospital Medicine

TRANSITIONAL CARE
Bill Lyons, M.D.
UNMC Geriatrics
TRANSITIONAL CARE
• Actions designed to ensure coordination and
continuity of care as patients transfer between
different venues
• IOM has called for greater integration of care
delivery across settings
• Why the challenge is greater:
– Aging population – greater complexity
– Proliferation of care venues
– Providers increasingly define practice by location
CASE 1
• Mrs. G, a 96 yo woman is seen by her physician
at a home visit.
• For 2-3 day period has been feeling progressively
short of breath
• No fever, chills, cough, chest pain
• Had been discharged from hospital about one
week before
CASE 2
• 68 yo man transferred from acute hospital to
distant suburban SNF following uneventful
aortic valve replacement
• On warfarin, plus enoxaparin until INR 2.5-3.5
• Progressively less ambulatory
• INR rises to 17, even after warfarin held and
vitamin K administered
• Cardiac arrest
PATTERNS OF TRANSFER,
LAPSES IN QUALITY
• In 2001 older (65+ yo)
patients discharged from
acute settings were
discharged…
– to another institution ¼
of the time
– to home with home
health 11% of the time
Agency for Health Care Quality
Research HCUPnet
PATTERNS AND LAPSES, cont’d
• Study of posthospital transfers of Medicare
beneficiaries in 30-day period after discharge
• Single transfer 60%
• Two transfers 18%
• Three transfers 9%
• Four or more transfers 4%
Coleman et al. Health Services Research 2004
PATTERNS AND LAPSES, cont’d
• Study of 300 consecutive admissions to 10 New
York City nursing homes from 25 area hospitals
• Legible transfer summaries in only 72%
• Clinical data often missing (ECG, CXR, etc.)
• Contact info for hospital professionals who
completed summaries present in less than half
Henkel G. Caring for the Ages 2003
QUALITATIVE STUDIES
• Patients don’t understand medication 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
• They also lack confidence in their ability to
assure care plan reflects their needs and values
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 Integrat Care 2002
WHEN CONTEMPLATING
A TRANSFER
1. Patient’s global goals – medical and functional
recovery, in light of family support?
2. Risk-benefit ratio – is benefit of the transition
likely to exceed harms associated with transfer
to a new venue?
3. Quality of the match – is the proposed new
venue a good match for medical, nursing, and
functional needs?
FACTORS ASSOCIATED WITH
POOR DISCHARGE OUTCOMES
• Age>80
• Fair-to-poor self-rating
of health
• Recent and frequent
hospitalizations
• Inadequate social
support
• Multiple, active chronic
health problems
• Depression history
• Chronic disability and
functional impairment
• History of nonadherence
to therapeutic regimen
• Lack of documented
patient/family education
TOO SICK FOR DISCHARGE?
PREDICTORS OF INSTABILITY
• New incontinence, chest
pain, dyspnea
• HR>100-130, HR<50,
RR>24-30, SBP<90,
SBP>180, DBP>110
• Arrhythmias
•
•
•
•
•
O2 sat<90%
T>38.3C
Poor oral intake
Altered mental status
Wound infection
TIPS ON
INFORMATION TRANSFER
• Transfer summary is for
receiving team, not
medical records
department
• Discharge diagnoses
should also include
functional, cognitive,
behavioral, and affective
disorders
• Discharge meds should
be more than a list
INFORMATION TRANSFER,
cont’d
• D/C instructions should include signs,
symptoms, and red flags; also, who to call
• Explicitly list follow-up studies and
appointments
• Social history: names and contact information
for caregivers, surrogate decision makers
INFORMATION TRANSFER,
cont’d
• Include functional status:
at baseline and at time of
transfer
• If you have seen the
forest (not just the trees),
say so: overall goals of
care, preferred intensity
of care, advance
directives
RECONCILING A
MEDICATION REGIMEN
• List the medications, including schedules for
tapering or discontinuation
• Identify which medications are new
• Identify which doses are new
• Which previously taken drugs are to be stopped?
ISSUES TO COMMUNICATE
WITH PATIENT, CAREGIVER
• Reconcile d/c med list
with previous regimen
• Potential side effects of
medications
• Activity limitations,
functional prognoses
PATIENT, CAREGIVER ISSUES,
cont’d
• Signs, symptoms, and red
flags that should prompt
a call
• Whom to call if
concerns arise
• What to expect at the
new site
ADDED PEARLS
• Document purpose for
drugs, target symptoms
for psychiatric
medications
• Involve SW and PT early
in hospitalization
• ‘Disposition’ heading in
daily note
ADDED PEARLS, cont’d
• Encourage and participate in interdisciplinary
team rounds
• Involve clinical pharmacist
• Communicate d/c plan to primary care provider
A FEW WORDS ABOUT
MEDICARE
• Skilled nursing facilities
– Qualifying hospital stay (>72 hrs)
– Skilled nursing, rehabilitative therapy, or both
– Up to 100 days, but coverage stops when goals met
or patient stops improving
• Home healthcare
– Patient must be homebound
– Require intermittent skilled nursing (and perhaps PT,
OT, ST, SW)
CASE 1 DISCUSSION
• Hospitalization had been for nausea and
vomiting with dehydration
• Furosemide held during hospitalization
• Not resumed at discharge
• No instructions regarding reinitiating the drug
• Result: pulmonary edema
CASE 2 DISCUSSION
• Autopsy: 1500 mL grossly bloody fluid in
pericardium  tamponade, hepatic congestion
• Positive feedback loop initiated
• No communication between SNF MD and CT
Surgery re significance of climbing INR values