Transitions of Care: From Hospital to SNF

1. Transitions of Care:From Hospital to SNF Steven Tam, MD Assistant Clinical Professor UCI Program in Geriatrics, Internal Medicine

2. Educational Objectives Upon completion, the learner will be able to Identify some of the potential problems in transitional care involving hospital discharges to Skilled Nursing Facilities (SNF) Describe the adverse outcomes of poor transitional care Will be introduced to writing proper discharge orders to SNF

3. Potential Problems with transitioning between Hospital and SNF Breidenbach, Bob. (photographer). (2007). [photo]. The Providence Journal. Retrieved September 13, 2011 from http://shenews.projo.com/2007/11/indy-star-brady.html.

4. Potential Problems with transitioning between Hospital and SNF • Communication • Between Hospital and SNF (and patient and family) • Between Personnel within each facility (shift changes, and covering MDs) • Lack of Medication Reconciliation • Continue Home medications? • Which medications Stopped • Continuity of care (physicians, nursing staff) • Others?

5. Potential Problems with transitioning between Hospital and SNF • Communication can be a problem with all hospital discharges: • Studies show that hospital discharge summaries can be lacking in information • Approximately 11% of discharge letters and 25% of discharge summaries never reached the patient’s PCP. • Important information to be communicated with the SNF includes medications, functional level, weight bearing status, follow-up plan • Lack of such information can lead to delays in care, and other adverse outcomes.

6. Potential Problems with transitioning between Hospital and SNF • Lack of Medication Reconciliation • Medication changes upon hospital admission or discharge are a reason for adverse events. • Prospective study of 151 patients admitted to general internal medicine, found that a regularly used medication was discontinued in 46.4% of cases • In a study by Boockvaret al, adverse drug events attributable to medication changes occurred in 20% of transfers between nursing homes and acute-care hospitals.

7. Adverse Outcomes • Poor discharges can lead to: • Increased morbidity and mortality • Hospital Re-admissions • Higher costs • Poor relationships between patients, families, the skilled nursing facilities, the hospital and professionals.

8. Adverse Outcomes • Transfers from SNF account for 8.5% of Medicare admissions to acute care hospital • 40% of these hospitalizations occur within 90 days of SNF admission • From Jenckes et al., close to 1/5th of all Medicare beneficiaries discharged from hospital are readmitted within 30 days • Cost = $17.4 billion in 2004; 26.9% due to heart failure, 20.9% due to pneumonia

9. Proper Discharge Orders/Instructions • If not included in the discharge summary, proper discharge orders/instructions should accompany the patient to the SNF • Necessary Elements include: • Legible Name (pager) of discharging MD, unit • Legible care orders (such as for wound care, lines) • Reconciled medication list • Diagnoses • Follow-up plan

10. Discharge Orders/Instructions

11. Discharge Orders/Instructions

12. Clinical Vignette • Now, look over the clinical vignette and practice writing your own discharge orders using the previous format!

13. References • Transitions of Care in the Long-Term Care Continuum. Practice Guideline AMDA 2010 • Boockvar KS, Fishman E et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Internal Medicine 2004; 164(5): 545-550. • Jenckes SF, Williams MV et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 009; 360(14): 1418-1428.