Navigating Care Transitions: Improving Patient Outcomes

1. Care Transitions Manuel A. Eskildsen, MD Division of Geriatric Medicine and Gerontology Emory University School of Medicine

2. Objectives • Define why transitions between different settings of care may result in poor patient outcomes. • Explain how communication problems between health providers and patients result in poor care transitions. • Define the different discharge options for a patient leaving the hospital.

3. Why does this matter? Patients are sick when they go to the hospital Patients in hospitals have more chronic health problems They are usually not 100% well when they leave the hospital Many things can go wrong when they leave… And go somewhere else www.janga.biz

4. What is Transitional Care? • Coordination that occurs when patients transfer between settings of care. • Communication needs to occur between physicians between different levels of care. • Discharge sites: • Home • Assisted living • A nursing facility for rehabilitation • Another hospital (for example, acute rehab)

5. Poor transitions can lead to: • Readmission to the hospital • Medication errors • Poor communication and patient dissatisfaction • Poor continuity of care because of poor communication with primary physician

6. Why is it difficult for patients? • You may still not feel well when you leave the hospital • You may have multiple new medications, and different doses of the old ones • Many new appointments. For example, a pt. with hip fracture, could have to see: • Primary care doctor • Orthopedist • Therapists • Home health nurses

7. Your cases for today • Complex care transitions • Difficulties in communication • Difficulties with medications • Different perspectives: • Hospital MD • Patient/Family • Case Manager • Receiving MD

8. Case 1 • 81 year old woman with CHF • Admitted with shortness of breath, leg swelling • Similar hospital stay last month • Given increases in diuretic doses in the hospital • By the way, daughter having increasing problems caring for her

9. Case 1 • Daughter is concerned about taking her home • They decide on transfer to the Golden Years Assisted Living Facility • They meet with nurse for 20 minutes • Doctor waits for a week to dictate discharge summary

10. Medication lists for Case 1 • Aspirin 81 mg per day • Furosemide (diuretic) 40 mg per day • Atenolol (beta blocker blood pressure agent) 25 mg per day • Atorvastatin (cholesterol drug) 40 mg per day • Lisinopril (ACE inhibitor blood pressure agent) 20 mg per day • Aspirin 81 mg per day • Furosemide 40 mg twice a day • Metoprolol (beta blocker blood pressure agent) 25 mg twice a day • Simvastatin (cholesterol drug) 40 mg once a day • Enalapril (ACE inhibitor blood pressure drug) 20 mg twice a day

11. Case 1 • Returns to her doctor’s office with a bagful of medications • The primary care doctor could only obtain history from the family • Discharge Summary was not available

12. Points that you brought up: • Involvement of the doctor is important • Transitions are confusing for patients, and more so when caregivers are stressed • Incentive for the hosp. physician to “get people out” • Hospitalist wants to avoid readmission • Difficulty for PCP to keep up with all his patients who are in the hospital • Importance of the discharge summary for continuity

13. Assisted Living

14. Assisted Living • Type of Senior Housing • For people with increasing care needs • They coordinate care • Help with meals, activities • Preserve a certain amount of independence • Preserves a sense of community

15. Home Health Services • Run by home health agencies • Supervised by a physician • For patients who are “homebound” • Include: • Nursing services (wound care, blood draws) • Physical therapy • Occupational Therapy

16. Case 2 • 88 year old man presented to EUH after a fall • X-ray shows a hip fracture • Had surgery – total hip replacement • Very complicated hospital course: confused, not able to ambulate much

17. Case 2 • Prior level of functioning: • Lived alone • Disheveled apartment • Repeated falls • Case manager and family agree that he is not ready to return home, and that he needs rehab at a Skilled Nursing Facility (SNF)

18. Case 2 • On day #8, the patient is discharged to a SNF for rehab • Still confused and weak • Receiving doctor gets a stack of papers and the medication list • Notes that the patient is still in pain • Patient and family are apprehensive – they don’t want to be in a “nursing home”

19. What you thought • What is a SNF? Why am I being “dumped” there? • Need for case manager to explain different options for discharge site • Agreement that home is not realistic option • Difficult role of the receiving physicians– dealing with patient expectations • Continuing focus on independence even after transfer to SNF

20. Skilled Nursing Facilities (SNF) • Can provide two different types of services • Residential care • Transitional care • For transitional care, patients come temporarily for: • Usually because they can’t receive needed services at home • For skilled services like rehabilitation • Physician care not as intense as in the hospital

21. SNF – Residential Care • For patients who cannot meet their care needs at home • Two “typical” patients: • The patient who is so immobilized that they need heavy care just to move from bed to toilet • Patient with Alzheimer’s dementia whose family can’t manage them at home

22. Better Care Transitions • Protocols in hospitals for discharge medications and communication • Discussion of “red flags” • Programs for nurse follow-up of hospital patients at home • Mandatory discharge summaries at time of discharge • More involvement of hospital physician in the discharge process