IOA Seminar January 28, 2010

1. Transitions of carePeggye Dilworth-Anderson, Ph.D.Professor, Health Policy and Managementinterim co-Director, Institute on Aging, University of North Carolina at Chapel HillMary H. Palmer, Ph.D., RNC, FAANUmphlet Professor in Aging, SCHOOL OF NURSINGinterim co-Director, Institute on Aging, University of North Carolina at Chapel Hill IOA Seminar January 28, 2010

2. Objectives • To define and describe transitions of care • To examine the relationship between transitions of care and care coordination • To examine the familial impacts of transitions of care • To present and discuss relevant case studies and potential solutions for improving transitions & transitional care

3. Defining Transitions of Care

4. Defining “Transitions of Care” • The movement of patientsfrom one health care provider or setting to another as their condition and care needs change. Transitions can occur: • Within settings • i.e. Intensive Care Unit & Treatment Ward • Between settings • i.e. Hospital & Home • Across different health states • i.e. Curative & Palliative Care

5. Defining “Transitions of Care” (cont.) • Patients with complex, continuous health care needs usually require services from multiple settings • Providers often operate independently • Potential for care fragmentation is great • Increases patient risk for: • Medical errors • Service duplication • Inappropriate care • “Falling through the cracks…” Coleman et al., 2003

6. “Transitional Care” • “Set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.” • Logistical arrangements • Patient and family education • Coordination & collaboration among Health Providers Coleman et al., 2003

7. Elder Care Transitions • Can be categorized as developmental, situational, or related to health and illness • Include retirement, loss of spouse and friends, relocation, and chronic illness • Some of these transitions are welcomed while many others are undesired

8. Transitions & Health: A Framework PROCESS INDICATORS TYPES OF TRANSITION HEALTHY TRANSITION PROCESSES NURSING THERAPEUTICS PATTERNS OF TRANSITION UNHEALTHY TRANSITION PROCESSES PROCESS INDICATORS

9. Challenges • Biopsychosocial Effects • Quantity of transitions may be overwhelming for patients & caregivers • Provider roles often unclear • Inconsistencies in communication • Affects older adults ,caregivers and practitioners

10. GSA 2010 • Why focus on Transitions of Care? • Grand opportunity to explore the circumstances surrounding significant life course transitions for older adults, including: • Health and Health care transitions • Social transitions • Financial transitions • Psychological transitions

11. GSA 2010 • Why focus on Transitions of Care? • Policy implications for addressing related circumstances • The vital role of health care reform • New Orleans: A City in Transition • Opportunity to discuss matters relevant to the local population

12. The Role of Care Coordination

13. Coordination of care is… • The successful hand-off of care between health professionals in various health care settings • Goal is to optimize patient outcomes • Communication of the patient’s care plan between care teams is imperative

14. Poor Coordination Leads To… • Medical errors and adverse drug events • Inability of elders to appropriately follow home care plans • Further hospitalization • Anxiety and dissatisfaction among patients and families

15. Familial Impacts

16. Transition of Care – Familial Impacts • Social • Juggling multiple roles • Physical • Stress; reduced sleep • Mental • Depression

17. Transition of Care – Familial Impacts (cont.) • Emotional • Burden of responsibility; family conflicts • Financial • Burden of treatment & care costs; financial strain

18. Improving Transitions

19. Recommendations for Improving Transitions • Involve the outpatient physician (PCP) in outpatient discharge planning • Use planning teams to assess the health and social needs of patients and their families during transitional periods

20. Recommendations for Improving Transitions, (cont.) • Ensure that patients and caregivers are allowed to input their values into care plans • Ensure that patients and caregivers have realistic expectations of what is to come in the next care setting • Train caregivers of the warning signs of a worsening condition

21. Transitional Care Programs, 2009 Levine et al., 2010

22. CASE STUDY #1 Transitions in Care: Pressure Ulcers and Urinary Incontinence in Hip Facture Patients Mary H. Palmer, Ph.D., RNC, FAAN

23. Hip FracturesSource Baumgarten et al 2009 • Approximately 317,000 hip fractures annually • $4 billion in hospital care alone • Most hip fracture patients are older than 70 years • Trigger mobility loss, increased dependency, poorer quality of life • High incidence of delirium post surgery

24. Why Transitions Matter • Care issues can slip through the cracks • Lack of information about condition-specific trajectories across care settings • Few condition-specific evidence based interventions • Quality of life and dignity issues • Costs of prevalent and incident symptoms and conditions

25. Pressure Ulcer Definition • “Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.” (National Pressure Ulcer Advisory Panel, 2007)

26. Stage I A small area of pink and purple discoloration can be seen in the left hip region of this 81 year old white female. This is characteristic of a Stage I ulcer. The epithelium is intact and there are no signs of blistering or separation of the epidermis from the underlying dermis.

27. Stage II The patient is a 75 year old black female with a Stage II ulcer in the right ischial region. The lesion is approximately 4 cm in length and 2.5 cm in width. This diffuse ulcer has a dark purple outer border, a lighter pink inner border resulting from the loss of epithelium, and a central portion with loss of epidermis and partial loss of the dermis.

28. Stage III The patient is an 89 year old black female with a Stage III ulcer on the right iliac crest. The epidermis and dermis are eroded. The subcutaneous tissue is exposed. There is a slight pink discoloration in the surrounding skin surface.

29. Stage IV There is a 12 cm  8 cm Stage IV ulcer on the ischium of this 87 year old black female. The wound is characterized by loss of epidermis, dermis and subcutaneous tissue. Necrotic damage to underlying muscle can be observed. A small sinus tract can be seen at the most inferior portion of the wound. There is likely an additional and larger sinus tract along the left margin of the ulcer. The depth of the sinus tracts is undetermined. The ulcer is surrounded by darkly pigmented skin along the periphery.

30. Methods • Aim: Incidence of pressure ulcers (new) • Trained research nurses conducted clinical assessments as soon after admission and alternating days for 21 days, for a total of 11 assessments. • Medical records audit • Enrollment after written informed consent

31. Results • 658 enrolled subjects from 8 hospitals in Maryland, Washington, DC, and Pennsylvania • Average age 83.2 years (SD 6.6 years) • 208 (31.6%) developed Stage 2 PUs after hospital admission

32. Results • 68% were living in the community before the hip fracture • Length of hospital stay 5.9 days (SD3.2) • Baseline urinary incontinence 18.3% (without fecal incontinence) • Mean baseline Mini Mental State Examination Score (MMSE) 18.4 (SD 10.9)

33. Results • APU incidence rates highest during initial hospitalization • Most APUs were on the sacrum (47.3%) followed by heels (19%) • APUs in rehabilitation and nursing homes were 40% and 30% higher than the rate at home. • PU risk persisted with 18.2% having an APU at the end of 3-week period.

34. Discussion • Medicare does not reimburse for hospital acquired pressure ulcers • Pressure ulcer prevention should be priority in hospital and post acute care settings • Need to better understand influence of APUs on long term outcomes in hip fracture patients

35. Urinary Incontinence • Complaint of any involuntary loss of urine (ICS, 2002) • 21% of 6,516 female hip fracture patients developed urinary incontinence during hospitalization (Palmer et al, 2002) • After adjusting for confounders, the following: admission from nursing homes, confusion, dependence on wheelchair, and pre-fracture dependence on others were risk factors

36. Urinary Incontinence – its role in hip fracture recovery • Data exist: • presence of urinary incontinence at baseline, at hospital discharge, and at clinical visits • use of indwelling catheters, straight catheterizations, and use of absorbent products • presence of urinary tract infections (UTIs) and use of antibiotics for UTIs

37. Urinary Incontinence and its role in hip fracture recovery • Effect on recovery trajectory – does hospital-acquired UI delay transitions to low intensity care setting? • Explore natural history of urinary incontinence in the immediate recovery period – does UI persist across care transitions? • Develop a predictive model of hospital acquired urinary incontinence

38. Conclusion • Relevance of understanding hospital acquired urinary incontinence: • Develop interventions to prevent incontinence from occurring and helping older adults prevent disability and return to pre-fracture functioning • Continence status effect on care transitions costs, caregiver burden, and dignity

39. Acknowledgements

40. Dr. Mona Baumgarten, University of Maryland, Principal Investigator, R01 AR 47711. Locus of Care & Pressure Ulcers in Hip Fracture Patients Baumgarten, M., et al. (2009). Pressure Ulcers in Elderly Patients with Hip Fracture Across the Continuum of Care, Journal of the American Geriatrics Society, 57: 863-870.

41. CASE STUDY #2 Transitions of Care and the Progression of Alzheimer’s Disease Peggye Dilworth-Anderson, Ph.D.

42. What is Alzheimer’s Disease (AD)? • Irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. • In most people with AD, symptoms first appear after age 60. • AD has no cure.

43. What is Alzheimer’s Disease (AD)? (cont) • AD is the most common form of dementia • Dementia is the loss of cognitive functioning, to such an extent that it interferes with a person’s daily life and activities. • Thinking, remembering, and reasoning • As many as 2.4 to 4.5 million Americans are living with AD.

44. What does Alzheimer’s Disease Look Like?

45. Regions of the Brain Affected by AD Frontal lobe - conscious thought; damage can result in mood changes Parietal lobe - plays important roles in integrating sensory information from various senses, and in the manipulation of objects; portions of the parietal lobe are involved with visuospatial processing

46. Regions of the Brain Affected by AD (cont) Occipital lobe - sense of sight; lesions can produce hallucinations Temporal lobe - senses of smell and sound, as well as processing of complex stimuli like faces and scenes.

47. The Progression of Alzheimer’s Disease

48. Transitions of Care: Progression of Alzheimer’s Disease (AD) According to Liken (2001) - Managing Transitions & Placement of Caring for a Relative with Alzheimer’s Disease: • Progressive cognitive impairment leaves individuals to depend on others for daily living tasks • Most individuals with AD are cared for at home by family members • In later stages, it becomes difficult to provide home care

49. Transitions of Care: Progression of Alzheimer’s Disease (AD) (cont.) Early Stage of AD: • Some memory loss; inability to perform some complex tasks • Normalization by family members and friends • Able to live alone or with an older spouse • No need to seek outside care or community support at this stage

50. Transitions of Care: Progression of Alzheimer’s Disease (AD) (cont.) Mid Stage of AD: • Severe memory loss; disorientation; cognitive impairment • Personality changes; behavioral problems • Wandering at night time • 24-hour supervision necessary • Families seek more community based support; facility placement