TRANSITIONAL CARE

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TRANSITIONAL CARE

• Bill Lyons, M.D.
• UNMC Geriatrics

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TRANSITIONAL CARE

• Actions designed to ensure coordination and
  continuity of care as patients transfer between
  different venues
• IOM has called for greater integration of care
  delivery across settings
• Why the challenge is greater
• Aging population greater complexity
• Proliferation of care venues
• Providers increasingly define practice by location

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CASE 1

• Mrs. G, a 96 yo woman is seen by her physician at
  a home visit.
• For 2-3 day period has been feeling progressively
  short of breath
• No fever, chills, cough, chest pain
• Had been discharged from hospital about one week
  before

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CASE 2

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

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PATTERNS OF TRANSFER, LAPSES IN QUALITY

• In 2001 older (65 yo) patients discharged from
  acute settings were discharged
• to another institution ¼ of the time
• to home with home health 11 of the time
• Agency for Health Care Quality Research HCUPnet

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PATTERNS AND LAPSES, contd

• Study of posthospital transfers of Medicare
  beneficiaries in 30-day period after discharge
• Single transfer 60
• Two transfers 18
• Three transfers 9
• Four or more transfers 4
• Coleman et al. Health Services Research 2004

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PATTERNS AND LAPSES, contd

• Study of 300 consecutive admissions to 10 New
  York City nursing homes from 25 area hospitals
• Legible transfer summaries in only 72
• Clinical data often missing (ECG, CXR, etc.)
• Contact info for hospital professionals who
  completed summaries present in less than half
• Henkel G. Caring for the Ages 2003

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QUALITATIVE STUDIES

• Patients dont understand medication side effects
• or when to resume normal activities
• and dont know what questions to ask, or whom to
  ask
• or what warning signs to watch for
• They also lack confidence in their ability to
  assure care plan reflects their needs and values

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HIGH-QUALITY TRANSITIONAL CARE

• Reliable, accurate information transfer
• Preparation of patient, family, caregiver
• Support for self-management
• Empowerment of patient to assert preferences
• Coleman et al. Int J Integrat Care 2002

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WHEN CONTEMPLATING A TRANSFER

• Patients global goals medical and functional
  recovery, in light of family support?
• Risk-benefit ratio is benefit of the transition
  likely to exceed harms associated with transfer
  to a new venue?
• Quality of the match is the proposed new venue
  a good match for medical, nursing, and functional
  needs?

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FACTORS ASSOCIATED WITH POOR DISCHARGE OUTCOMES

• Agegt80
• 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

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TOO SICK FOR DISCHARGE? PREDICTORS OF INSTABILITY

• New incontinence, chest pain, dyspnea
• HRgt100-130, HRlt50, RRgt24-30, SBPlt90, SBPgt180,
  DBPgt110
• Arrhythmias

• O2 satlt90
• Tgt38.3C
• Poor oral intake
• Altered mental status
• Wound infection

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TIPS ON INFORMATION TRANSFER

• Transfer summary is for receiving team, not
  medical records department
• Discharge diagnoses should also include
  functional, cognitive, behavioral, and affective
  disorders
• Discharge meds should be more than a list

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INFORMATION TRANSFER, contd

• D/C instructions should include signs, symptoms,
  and red flags also, who to call
• Explicitly list follow-up studies and
  appointments
• Social history names and contact information
  for caregivers, surrogate decision makers

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INFORMATION TRANSFER, contd

• Include functional status at baseline and at
  time of transfer
• If you have seen the forest (not just the trees),
  say so overall goals of care, preferred
  intensity of care, advance directives

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RECONCILING A MEDICATION REGIMEN

• List the medications, including schedules for
  tapering or discontinuation
• Identify which medications are new
• Identify which doses are new
• Which previously taken drugs are to be stopped?

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ISSUES TO COMMUNICATE WITH PATIENT, CAREGIVER

• Reconcile d/c med list with previous regimen
• Potential side effects of medications
• Activity limitations, functional prognoses

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PATIENT, CAREGIVER ISSUES, contd

• Signs, symptoms, and red flags that should prompt
  a call
• Whom to call if concerns arise
• What to expect at the new site

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ADDED PEARLS

• Document purpose for drugs, target symptoms for
  psychiatric medications
• Involve SW and PT early in hospitalization
• Disposition heading in daily note

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ADDED PEARLS, contd

• Encourage and participate in interdisciplinary
  team rounds
• Involve clinical pharmacist
• Communicate d/c plan to primary care provider

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A FEW WORDS ABOUT MEDICARE

• Skilled nursing facilities
• Qualifying hospital stay (gt72 hrs)
• Skilled nursing, rehabilitative therapy, or both
• Up to 100 days, but coverage stops when goals met
  or patient stops improving
• Home healthcare
• Patient must be homebound
• Require intermittent skilled nursing (and perhaps
  PT, OT, ST, SW)

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CASE 1 DISCUSSION

• Hospitalization had been for nausea and vomiting
  with dehydration
• Furosemide held during hospitalization
• Not resumed at discharge
• No instructions regarding reinitiating the drug
• Result pulmonary edema

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CASE 2 DISCUSSION

• Autopsy 1500 mL grossly bloody fluid in
  pericardium ? tamponade, hepatic congestion
• Positive feedback loop initiated
• No communication between SNF MD and CT Surgery re
  significance of climbing INR values