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TRANSITIONAL CARE

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TRANSITIONAL CARE Bill Lyons, M.D. UNMC Geriatrics TRANSITIONAL CARE Actions designed to ensure coordination and continuity of care as patients transfer between ... – PowerPoint PPT presentation

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Title: TRANSITIONAL CARE


1
TRANSITIONAL CARE
  • Bill Lyons, M.D.
  • UNMC Geriatrics

2
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

3
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

4
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

5
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

6
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

7
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

8
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

9
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

10
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?

11
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

12
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

13
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

14
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

15
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

16
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?

17
ISSUES TO COMMUNICATE WITH PATIENT, CAREGIVER
  • Reconcile d/c med list with previous regimen
  • Potential side effects of medications
  • Activity limitations, functional prognoses

18
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

19
ADDED PEARLS
  • Document purpose for drugs, target symptoms for
    psychiatric medications
  • Involve SW and PT early in hospitalization
  • Disposition heading in daily note

20
ADDED PEARLS, contd
  • Encourage and participate in interdisciplinary
    team rounds
  • Involve clinical pharmacist
  • Communicate d/c plan to primary care provider

21
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)

22
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

23
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
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