CHAMP Nursing Home 101: Transitions of Care

1. CHAMPNursing Home 101:Transitions of Care Miriam B. Rodin, MD, PhD Division of Geriatric Medicine St. Louis University

2. Who said that? Didn’t send anyrecords. The patient is filthy. Hospital The doctor didn’t call back. Poor historian I can’t read it. Can’t reach the family. Not my patient I haven’t had this patient before. They didn’t do the labs. Uncooperative I can’t find the chart. Nursing Home Patient got to the floor late.

3. The hand-off is key to team effectiveness.

4. Transitions of Care: Learning Objectives • Demonstrate professionalism • Measure: Completeness, legibility of transfer orders and records; appropriate use of telephone by chart audit • Identify systemicproblems • Measure: Discharge plans anticipate slippage • Understand differences between acute and long term care • Measure: Improve appropriateness of referrals for NHP

5. Fumbled transitions are an important source of medical error. • Coleman EA, Berenson RA. Lost in transition. Annals Intern Med 2004;141:533-536. • Moore C et al. Tying up loose ends. Annals Intern Med 2007;167:1305-1311.

6. Outline • INTRODUCTION • Definition of “a nursing home” • Modern history of “the nursing home” • How a NH works • TRANSITIONS OF CARE • Nursing home to hospital • Hospital to nursing home • FREQUENT FUMBLES • Physician’s role in discharge planning • How to write effective transfer orders.

7. Definition • There is no such thing as a nursing home. • Levels of care defined by • Nursing procedural skills • Nurse-to-patient ratio • Number, frequency, duration of rehab modalities • Independent of site • Home health care (includes ALFs, “senior citizen apartments,” hospice) • Subacute • Long term care, e.g., chronic hospital • “Custodial,” supportive (NOT free-standing ALFs)

8. Modern History • 1965 • LBJ signs legislation enacting Medicare/Medicaid under Social Security. • “Nursing care” under Part A soon after. • 1987 • OBRA responds to quality of care concerns mandates Minimum Data Set (MDS) • 1998 • Legislation extends PPS to SNF • Implemented state-by-state ~2001 • Based on RUGs = SNF DRG • Physician E&M codes RVU for SNF

9. Modern History • Hospital LOS declines 1980’s-90’s • Quicker-sicker transfers strain LTC competence • Bed shortage despite building boom in capacity • Worsening nursing labor shortages • 2002 mean age of RN’s ~ 50 yrs. • INS closes door on Filipino RN exemption • IOM recommends AGAINST Federal staffing requirements for SNF designation • Average SNF staff turnover is about 100%/year

10. Outline • INTRODUCTION • Definition of “a nursing home” • Modern history of “the nursinghome” • How a NH works: Follow the money • TRANSITIONS OF CARE • Nursing home to hospital • Hospital to nursing home • FREQUENT FUMBLES • Physician’s role in discharge planning • How to write effective transfer orders.

11. Medicare for Dummies • Part A • Hospital, doctors’ bills while in the hospital. • 100 days acute/subacute rehab, skilled nursing in a facility. • When Part A is used up, “private” pay or Public Aid. • Medicare Hospice is a Part A benefit. 6 months. • Part B • 100 days outpatient medical, nursing, rehab (“home PT”) • Many low income people do not have Part B • Medicaid/Public Aid is Part B payer for those who qualify • Does not pay hospital or facility per diem. (Room and board) • Part D • The new one, pays for outpatient drugs PROVIDED that….

12. Your health care $$ • Public aid pays for the historic role of NH for those who qualify: supported residential care. This is a state-level function, NOT Medicare. • Public aid payments to nursing homes are one of the largest expenditures at the state level. • Medicare has a large, well organized political constituency. • Nursing home residents are not a well-organized constituency. • Everybody knows nursing homes are bad. • If you were the governor of a state with a budget shortfall, where would you make cuts?

13. State & Local incl MA Private 3rd party Federal incl MC Total Self-pay Excludes professional fees, Part B payments, DME, hospital costs incurred during NH stay

14. Post Hospital Care:Rehabilitation • MEDICARE Part A PAYS FOR 7 LEVELS OF REHAB while residing in a facility • 2 acute e.g. Rehab Institute of Chicago • 5 subacute • Acuity is defined by: • No. of modalities: • OT, PT, speech, swallowing and language, specialized rehabilitation nursing • No. of minutes per day. For acute rehab, 3 hours of daily participation are required.

15. Post Hospital Care:Skilled Nursing • Medicare Part A pays for 3 levels of skilled nursing in subacute SNF • Extensive: • IVs, ventilator or trach in the past 14 days • Special Care: • pneumonia, IV, wt. loss, decubs, tube feed, open wounds • Clinically complex: • all of the above and requiring MD E&M visit at least once per week; Rx change past 14 d, injections, dialysis, functional status decline & ADL<7

16. Medicare ABD • Part B covers outpatient bills • In the NH, starts when Part A days used up. • Many patients do not have Part B. It is optional and requires individual to pay monthly premium. • If no Part B, must self-pay or Public Aid. • Part D outpatient prescriptions. There is co-pay, monthly premium unless Medicaid eligible.

17. He who pays the piper calls the tune: • SNF licensure defined by Medicare • “State” survey findings are public record: www.cms.us.gov/nh or OSCAR files • Survey QI based on MDS: NO reward for pass; only punitive findings • Encourages paper compliance • Increases overhead: RN staff diverted from patient care. • Any complaint can trigger a survey

18. Level of care = Level of nursing • LevelCertificationNurse/Pt Ratio • ICU RN* 1:1-2 • Gens RN 1:4-6 • PCT 1:5-6 • SNF RN/LPN** 1:15-25; 40-60 • CNA*** 1:15; 30-40 • Supportive RN/LPN 1:25-50 • CNA 1:30 night • * Diploma,AA, BSN, MSN ** 12 mo, or AA *** variable 12 weeks. All require a state level certification exam through Dept. Prof Regulation

19. Follow the Money 2004 • Relative Utilization Groups = LTC DRG • Medicare 44 RUGs: $385-187/day • 100 days/Medicare qualifying hospital admission: Medicare 100% first 20 days, daily co-pay days 21-100 $109 paid by Public Aid if dual eligible • Medicare and Medicaid PA pay the same $ • But if < 65 straight PA varies by state • $125/d ($135 dementia) IL. $75/d in LA, less in Mississippi • PA “Exceptional care”: $185/d SNF • Self pay $125 RSS > $400 NS

20. Structure • For profit vs. not-for profit • Average size increase from <50 in 1950’s to 120 beds (IL, NY >300) • Administrator…requires a state license • DON (RN)…requires RN • Admissions director….point of contact for hospital case manager/discharge planner: Clerical. There are NO requirements • Medical director NOT employee, usually part-time, rarely on-site (Compare NY)

21. Summary: Post hospital “Rehab” “Subacute” “Skilled Nursing Facility” • No MD in house • Assume high patient-to-nurse ratio • Labs available but NOT on site (stat = 24 hr) • Portable radiology only; films read off-site next day. • No pharmacy on site; delivery 2x day. Limited formulary: Assume Public Aid formulary. • Nebs treatments, but no respiratory therapy • No EKG or telemetry

22. Outline • INTRODUCTION • Definition of “a nursing home” • Modern history of “the nursing home” • How a NH works • Physician in LTC • TRANSITIONS OF CARE • Nursing home to hospital • Hospital to nursing home • FREQUENT FUMBLES (and why they occur): • Physician’s role in discharge planning • How to write effective transfer orders.

23. “Once you’ve seen one nursing home you’ve seen one nursing home.” Jim Webster, MD

24. Patient should arrive from nursing home with: • Blue and white transfer sheet: • Chief Complaint or HPI • is the observation that made the nurse request transfer: will be in nursing talk “alteration of mental status” • Advance Directive: may be separate sheet • Baseline Functional Status: check off lower left • Face sheet • NH phone number • Next of Kin contact information • Name and phone number of PCP • Current MAR or POS; diagnoses at bottom of page will not be prioritized or even current. • Recent labs: unlikely but can request in the a.m.

25. Frequent Fumbles: Transfer From NH to Hospital • Patient rerouted to nearest hospital • No records available. • Patient unable to give history. • Transfer ordered by “covering” MD not PCP • Pressure to transfer high acuity residents • Illegible transfer sheets. • Incomplete or outdated information. • NH nurse doesn’t know resident (shift change, RN turn over ~100%/yr). • HIPAA confusion

26. Communicate with the Nursing Home • Let your fingers do the walking: • Day shift nurse for baseline: • FAX MDS? • PCP for • additional history • prognostic information • give heads up on discharge. It is appreciated. • DON • if trouble locating above • if any major change in status in hospital. They do care.

27. Hospital Discharge Critical Pathway Can this patient go home? • 1. Patient walks & performs ADL’s without assistance (direct observation)? NO • 2. Willing & able caregiver at home? NO • 3. Required medical treatment covered by outpatient insurance, e.g. IV ? NO • 4. Has > 1 daily skilled nursing requirement, i.e. wound care, trach, drains, Foleys, PICC lines, suctioning, IV, injections? YES • 5. Hospitalized for FTT, unsafe at home, • dementia, psychiatric or physical frailty? YES • 6. Hospice appropriate & no home caregiver? YES

28. Critical Pathway • If NO to Q. 1-3 • Can these supports be brought into the home long enough, often enough and soon enough to make discharge safe? • IF NO: Discuss NH transfer: See qualifying stay. • IF YES to Q. 4 • Is the patient medically stable to continue treatment at a non-acute facility?

29. Medicare Qualifying Stay • 72 hours acute stay: 3 midnights. • Clock starts with admission to floor not arrival in ER. • Medicare qualifying diagnosis • NO Q1 & 3; YES Q 4 & 6 (SNF or rehab) • Within 30 days of DC after qualifying stay • Can go home for a trial if unsure. If they fail, can still go directly to NH with Medicare coverage.) • NOTE: Hospital discharge before 3 midnights • Days are not cumulative. NHP would require a second 72 hour hospital stay. $$$$?

30. Critical Pathway: Discharge What is the goal of NH care for this patient? • Complete prolonged course of treatment • Can it be provided in another setting? • Recovery of previous level of function • Is this realistic? Is return home likely or not? • Rehab • Consult OT, PT on admission! • Acute PMR consult; Subacute = NH • Failure to progress in rehab Medicare will stop; self-pay will kick in. About a 10 day grace period.* • *Respite • Giving an exhausted caregiver a break may deflect future social admissions.

31. Critical PathwayMedically stable for NH transfer if • Could cruise on your discharge orders for up to 48 hrs. May not be seen by MD for 48-72 hrs. • Will be seen by MD generally 48 hrs, 5 days, 14 days then monthly. • Has been hemodynamically stable on present medical management > 24 hrs. • Can tolerate a possible 24 hr lapse in medication. • Does not require telemetry, daily or stat labs.

32. If “no” or “not sure” to any of the above: • Consider delaying discharge a day or two • Evaluate for chronic hospital (e.g. “vent unit.”) • Call the DON of the NH you are considering to discuss whether THIS facility is ready this patient. Yourself. • Include your med-surg floor RN in this discussion.

33. Medication errors • Most are unintentional discontinuations. • Up to 36% of discharges in one series had a potentially dangerous transcription error. • Bookvar K. et al Adverse events due to discontinuation in drug use and dose changes in patients transferred between acute and long term care facilities. Arch Int Med 2004;164:545-550.

34. Code status • Hospital code status remains the same after NH transfer 49% if the physicians talk to each other. Otherwise 9%. • Ghusn HF, Teasdale TA, Jordan D. Continuity of the do not resuscitate orders between hospital and nursing home settings. J Am Geriatric Soc. 1997;45:465-469

35. Do organizational factors contribute? • Probably not. • Bookvar KS, Burack OR. Organizational relationship between nursing homes and hospitals and quality of care during hospital –nursing home transfers. J Am Geriatric Soc. 2002;55:1078-1084

36. Frequent Fumbles Transition From Hospital to NH • Late discharges to evening shift nurse who has 50 patients • On-call MD does not know patient • Transfer sheet illegible or incorrect • Misspellings, wrong doses (decimal slide) • No active problem list or goals of therapy • Sparse, poor quality or no records • No sending MD name or pager • Discharging RN gone, chart off the floor • Hospital refuses to provide records “HIPAA” • Inappropriate orders (“Wean dopamine drip.”) • Unstable conditions (Foley dc’d on the way to the elevator, no trial of voiding, no record of this in transfer.) • Prn’s, especially analgesics should be scheduled.

37. Transfer Don’ts • “Sugar coat” the information to the patient or family about “sub-acute rehab.” • Sub-acute rehab is a RUG not a place. The place is a nursing home. • Expect the NH MD to “optimize” an unstable condition: “Titrate CPAP to RR.” • Expect stat labs; NH STAT = 24 hrs. • Expect > 2/d IVPB, IV push, IV drip or wean anything except at a “chronic acute” facility. • “We tried to wean her for 11 days so my attending thought she would do better with a slow taper in a subacute….”

38. Transfer Do's • Encourage family to visit LTCF before transfer. • As early in day as possible...write orders day before anticipated discharge. If >1 major change, reconsider. • Copy the whole chart AND send the dictation when available. • Senior team member reviews discharge sheet: • LEGIBLE, prioritized diagnoses. • Legible CURRENT orders. • Legible name & pager of MD, nursing unit. • Advance directives. • Flag conditions to be monitored. • Order and flag labs needed within 3 days. • Avoid IV; Change to p.o. if possible. If IV necessary, provide secure PICC access. • Remove unused IV, PICC, Foley etc. • Call DON ahead on drugs that cannot be late; special equipment (e.g. CPAP)

39. Poorly managed transitions of care cause • Poor patient care • Increased morbidity and mortality • Further disruption in continuity of care • Higher individual and system costs • Angry patients, angry families • Poor relationships between institutions and professionals

41. Ascertain within 48 hrs: Independent ADL? Directly observed: Gets to bathroom without assistance. Willing & able caregiver at home? Insurance? Outpatient SN, rehab, IV, drugs IF NO TO ANY: Medicare qualifying stay? 3 midnights IF NO: Reconsider discharge. Consider subacute rehab (SNF) Medicare qualifying diagnosis? >1 skilled nursing need: monitoring, IV, drains, g-tubes, open wounds, trach, injectables (heparin, insulin, Foleys don’t count) >1 significant medication change past 2 weeks ICU past 2 weeks IF NO and Unsafe at home: FTT, dementia, neglect, abuse Hospice appropriate, no caregiver at home Get social services involved ASAP Discharge Pathway IMAGINE the discharge plan WHILE writing admitting orders.