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DISCHARGE PLANNING

DISCHARGE PLANNING. Bill Lyons, MD. BACKGROUND. Surging interest from professional societies, payers, Joint Commission Among reasons for the challenge Aging, increasingly complex population More, and more specialized, venues Providers defining practice by location. CASE 1.

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DISCHARGE PLANNING

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  1. DISCHARGE PLANNING Bill Lyons, MD

  2. BACKGROUND • Surging interest from professional societies, payers, Joint Commission • Among reasons for the challenge • Aging, increasingly complex population • More, and more specialized, venues • Providers defining practice by location

  3. CASE 1 • Mrs. G, a 96-year-old woman is seen by her physician at a home visit • Progressive shortness of breath over 2-3 day period • No fever, chills, cough, chest pain • Was discharged from hospital one week before

  4. CASE 2 • 68 yo man transferred from acute hospital to distant suburban SNF after uneventful valve replacement • On warfarin + enoxaparin until INR 2.5-3.5 • Progressively less ambulatory • INR rises to 17, even after warfarin held and vitamin K administered • Cardiac arrest

  5. “BOUNCEBACKS”

  6. Age>80 Fair-to-poor self-rating of health Recent and frequent hospitalizations Inadequate social support Multiple, active chronic health problems Depression history Chronic disability and functional impairment History of nonadherence to therapeutic regimen Lack of documented patient/family education FACTORS ASSOCIATED WITH POOR DISCHARGE OUTCOMES

  7. INFORMATION TRANSFER

  8. INFORMATION TRANSFER • Discharge summary not for Med Records • Discharge diagnoses should include: functional, cognitive, behavioral, affective • Discharge instructions must include red flags, and whom to call • Explicitly list follow-up studies, appts

  9. INFO TRANSFER, cont. • Functional status: baseline, transfer • The Big Picture • Global goals of care • Preferred intensity of care • Advance directives

  10. MEDICATIONS • Reconciliation = (New List) – (Old List) • Tapering and stop schedules • Document drug indications • Target symptoms for psychiatric drugs

  11. OTHER PEARLS • Early involvement of PT and SW • “Dispo” daily in thought, speech, prose • Discuss discharge by goals, not schedule • Avoid discharge to SNF or home with HHC on weekends • Involve primary care provider • Involve clinical pharmacist

  12. PLACES PATIENTS GO

  13. POSSIBLE DISCHARGE LOCATIONS • Home with family support • Home with HHC • SNF • Nursing home, ALF, custodial care • Acute rehab • LTAC • Hospice

  14. HOME WITH HOME HEALTH CARE • Medicare qualifiers • Reasonable and necessary • Skilled services (RN, PT, or ST) needed • If above needed, can bring in OT, SW, HHA • Home bound: Leaving home is infrequent, • …requires great, taxing effort • …requires supportive devices, transportation, help of others • …medically contraindicated

  15. HOME HEALTH CARE FINANCING • Medicare A: RN, PT, OT, ST, HHA • Medicare B: MD home visits, DME, labs – but with 20% co-payment • Homemaker services: no Medicare or Medicaid coverage

  16. SKILLED NURSING FACILITIES • Patient requires skilled care: IV therapy, artificial nutrition and hydration, complex wound care, ostomy care, rehab • Medicare pays 100% for first 20 days, then 80% for remaining 80 days • Coverage stops when goals met or patient stops improving • Infrequent provider visits (~monthly)

  17. ACUTE REHAB HOSPITAL • Medicare criteria: • Close medical supervision by physiatrist • Needs 24h rehab nursing care • Multidisciplinary needs, coordinated program • Reasonable expectation of gain • Able to participate in 3 hr/d of intense therapy • Typical patients: head/spine injuries, youngish-old after stroke

  18. LONG-TERM ACUTE CARE (LTAC) • For complex, potentially unstable patients requiring ongoing hospital-level care • Specialty Select in Omaha • Chronic ventilator patients, multiple IV medications, extensive wound care, TPN • Medicare qualifiers • Frequent physician monitoring • Need for highly-skilled care • Expected LOS 25+ days

  19. NURSING HOME (CUSTODIAL) • Home with HHC < Care Needs < SNF • Medicare does NOT cover • Financing via private pay, Medicaid, long-term care insurance

  20. CASE 1 FOLLOW-UP • Hospitalization had been for viral gastroenteritis • Furosemide held during hospitalization • Not resumed (or mentioned) at discharge • Result: pulmonary edema

  21. CASE 2 FOLLOW-UP • Autopsy: 1500 mL grossly bloody fluid in pericardium, hepatic congestion • Positive feedback loop initiated • No communication between SNF MD and CT Surgery re significance of climbing INR values

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