Transitions in Care: Discharge Planning

2. Transitions in Care: Discharge Planning

3. Transitions in Care: Discharge Planning

4. 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

5. 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

6. 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

7. Discharge from Hospital to Other Institutionsincreases with Age AHRQ HCUPnet http://www.ahrq.gov/data/hcup/factbk1/10shel.htm

8. 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

9. 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

10. 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

11. 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 • MP/NP off site • Pharmacy off site • Stat labs, X-rays and IV’s available

12. 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

13. 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

14. Elements for Effective/Safe Transition • 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

15. Communication of Information • 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

16. 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

17. 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

18. 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)

19. 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

20. TRANSITIONS OF CARE The Role of the Hospital Nurse Practitioner

21. 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

22. 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

23. TRANSITIONS OF CARE NURSE CASE MANAGER’S ASSESSMENT AND PLAN

24. 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 • Discuss treatment plan options and level of care recommendations with clinical team (Chief Residents, Residents, Hospitalists)

25. 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

26. Smoother Transition for Mrs. H • 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

27. TRANSITIONS OF CARE The Role of the Nurse Practitioner in the SNF

28. 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

29. 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.