Older Patient Care and Patient Safety Across Settings and Populations

1
Older Patient Care and Patient Safety Across
Settings and Populations

• Judith Sangl, ScD AHRQ/CQuIPS
• Based on material from
• Eric A. Coleman, MD, MPH
• University of Colorado Health Sciences Center
• Weill Medical College of Cornell University
• Visiting Nurse Service of New York
• Mathey Mazey, Hartford Institute for Geriatric
  Nursing
• Mary Naylor, University of Pennsylvania

2
Care of Older Adults is Health Cares Core
Business

• 57 of all visits to generalist physicians
• 63 of all visits to oncologists
• 50 of all hospital expenditures
• 80 of home care visits
• 90 of nursing home care
• Source www.hartfordign.org

3
Nature of the Problem

• Older adults with complex care needs frequently
  require care in multiple settings
• Yet health professionals in these settings often
  function independent from one another
• Care is often setting-centered -- not patient-
  centered
• Elderly w/ 1 chronic conditions see average of 8
  different physicians in year
• As a result, care is often fragmented
• Patient safety and quality are compromised

4
Fundamental Disconnect
Hospital
Skilled Nursing Facility
Home
Ambulatory Care Clinic
Rehabilitation Facility
Hospice
5
Definition Transitional Care

• A set of actions designed to ensure the
  coordination and continuity of health care as
  patients transfer between different locations or
  different levels of care within the same
  location. Transitional care encompasses both the
  sending and the receiving aspects of care.
• Source Position statement from the American
  Geriatrics Society, 2003

6
Transitions Occur at Many Levels

• Within Settings
• Primary care specialty care
• ICU ward
• Between Settings
• Hospital skilled nursing facility
• Hospital home health
• Hospital and home
• Across health states
• Curative care palliative care

7
Transitional Care vs. Case Management

• Focus of transitional care is on time interval
  that begins with preparing a patient to leave one
  setting and be received in the next
• Many transitions are unplanned and occur in real
  time on nights and weekends
• Case management/disease management approaches are
  not structured to respond in a timely manner
• As a result, transitional care involves
  clinicians who do not have an ongoing
  relationship with the patient

8
How Common Are Transitions? Medicare Current
Beneficiary Survey

• What are the patterns of care during the 30-day
  period following hospitalization
• How can the quality of these care patterns be
  characterized?
• Coleman et al. HSR 200437(5)1423-1440

9
(No Transcript)
10
45 Unique Care Patterns
11
Quality Problems During Care Transitions

• Inadequately prepared for next setting
• Conflicting advice for illness management
• Inability to reach the right practitioner
• Family caregivers repeatedly completing tasks
  left undone

12
Adverse Events after Discharge

• Defined as an injury resulting from medical
  management rather than underlying disease
• 19 had 1 adverse events within 3 weeks
• Many were preventable
• Adverse drug events most common (66)
• Forster et al. Annals of Internal Medicine
  2003138161-7

13
Errors Related to Discontinuity

• 3 Type of errors
• medication continuity
• test result follow-up
• work-up
• 49 had at least one error
• Moore et al. JGIM 200318646-51

14
Information Transfer and Technology

• Discharge/transfer information inadequate or not
  conveyed to next setting (TNTC)
• Hospital gt NH Transfer, documentation was not
  legible 28 of time (Foley et al.)

15
Lab Testing

• Delays in test result review are common (Poon, et
  al.)
• Current test result tracking and follow up
  systems in health care are inefficient and
  chaotic (Gandhi et al.)

16
Challenges to Improving Quality of Transitions
Occur at Multiple Levels

• Patient
• Practitioner
• Health care institution
• Information technology

17
Patient Level

• Unprepared and uncertain about their role
• Patients discharged from 200 CA hospitals gave
  lowest rating to their transition to home (CHCF)
• Institutions foster dependency and complacency
• This changes abruptly on transfer when expected
  to assume major role in self-care
• Prevalence of cognitive impairment intensifies
  this challenge

18
Practitioner Level

• Rare for one clinician to orchestrate care across
  multiple settings
• Rise of hospitalists and SNFists
• Many practitioners have never practiced in
  settings to which they transfer patients

19
Information Technology Challenges

• Health information technology infrequently
  extends from hospital or clinic into post-acute
  care settings
• Interoperability remains a challenge
• Paucity of exemplar programs

20
Current System for Referring Hospital Patient to
Home Health Care

• CMS form 485 used to refer patient to HHC
• Rarely involves physician in generating the
  referral orders (SW or RN fills form)
• Hand-written form then faxed to HHA
• CMS form 485 ends up in a stack of papers in SW
  office after completion

21
Cornell/VNSNY Hospital to Home Health Care Study
Approach

• To restructure the format and initiation of an
  electronic CMS 485 to
• Improve accuracy
• Promote evidence-based patient care
• Increase physician participation in the plan of
  care
• Enhance communication between physician and
  agency

22
Cornell/VNSNY Hospital to Home Health Care Study
Summary

• Successfully created electronic referral form
• Built-in evidence based order sets
• Easy to use, brings MD into discharge plan
• Takes MD 3 minutes to complete
• Allows MD to bill for managing home health care
  patient
• Accepted by HHA nurses
• Easy to read and easy to follow format
• More comprehensive orders

23
Promising Innovations--Patients

• Patient and family caregiver often the first and
  last line of defense/safety
• Encouraging patients to assert a more active role
  reduces re-hospitalizations
• Transition Coaches and Personal Health Record
  tool as part of care transition intervention
• Coleman EA et al. JAGS Nov 2004 1817-25

24
Provider Innovations-Expectations for Sending and
Receiving Teams

• Sending team Identifying an appropriate fit
  between the patients needs and the next setting
• The care plan, orders, and a clinical summary
  precede the patients arrival
• Receiving team review the transfer forms,
  summary, and orders upon the patients arrival
• Clarify discrepancies regarding the care plan,
  the patients status, or the patients
  medications

25
Promising Innovations-Practitioners

• Society for Hospital Medicine
• Core competencies for transitional care
• Consensus on the ideal hospital discharge
• Simple discharge checklist is being vetted
• Naylor et al/University of Pennsylvania
• APNs managed care 4 weeks post-hospital
• Reduced re-hospitalizations

26
Best Practices

• Colorado Foundation for Medical Care (QIO)
• SNF and Hospital Collaborative to improve
  cross-setting communication for skin integrity
• Developed universal care transfer form
• Re-engineer work day of RNs in each setting to
  facilitate a 2-5 minute conversation

27
Best Practices- Health Care System

• Lahey Clinic in Massachusetts
• Expand scope of monthly MM rounds
• Included both hospital and SNF clinicians
• Revise contract language to promote safe and
  effective transfers

28
Healthy Handoffs Colorado

• Improve information exchange at transfer
• Led by Colorado Patient Safety Coalition
• Hospitals, NHs, HHAs, ED, QIO, Purchasers
• Agree on essential data elements and method of
  communication
• Challenge to break down silos is not trivial

29
Core Components of Effective Transitions

• Screening to identify high risk patients
• Identification of patients/caregivers goals and
  preferences
• Excellent communication between and among
  providers and across settings
• Patient/caregiver education regarding prevention
  and early identification of health problems
• Availability of APNs throughout transition to
  navigate system promote continuity

30
National Efforts
31
Institute for Healthcare Improvement

• Soon to launch initiative on hospital discharge

32
National Quality ForumEndorsed Safe Practices

• Ensure that care information is transmitted in a
  timely and clearly understandable form to all
  providers who need it
• NQF has issued a call for performance measures
  for coordination of care out of the hospital

33
JCAHO

• Patient Safety Goalmedication reconciliation
• Patient Safety Goalimprove timeliness of
  reporting critical test results

34
Medication Reconciliation

• Resar et al.breakdown medication changes
• Same medication, same dose
• Same medication, new dose
• New medication
• Medications you are to stop taking
• NO TEARS Tool (Lewis BMJ Aug 21, 2004)

35
www.caretransitions.org

• Care Transitions Measure (CTM)
• Care Transitions Intervention
• Manual
• Video clips/ Order DVD
• Tools for patients and caregivers
• Medication Discrepancy Tool (MDT)
• Much much more.