Transitions in Long Term Care: The role of a hospital/SNF partnership in assuring effective transitions of care

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Transitions in Long Term Care The role of a
hospital/SNF partnership in assuring effective
transitions of care

• Aubrey L. Knight, M.D.
• Chief, Geriatric and Palliative Medicine
• Carilion Clinic
• Roanoke, VA

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Disclosure

• I have no relevant relationships or affiliations
  with any proprietary entity producing health care
  goods or services.

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Objectives

• Understand the risks inherent in transitions from
  one site of care to another
• Identify processes at the time of transition that
  can help to mitigate some of the risks
• Recognize the role of the SNF and the medical
  director in assuring the transition is safe

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Its in the News
Care Transitions The Hazards of Going In and
Coming Out of the Hospital- Huffington Post
10/10
Heart Failure Program Has Reduced Readmissions
by 30 Percent- The New York Times 9/11
Dont Come Back, Hospitals Say- THE WALL
STREET JOURNAL- 6/11
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Its big business
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Its not rocket science

• Rather, it is
• Good care
• Good communication
• Attention to detail
• Teamwork

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So, what makes it so difficult?

• Complexity
• Of systems
• Of rules and regulations
• Of patients
• Technology
• Double-edged sword
• Entropy
• The concept of health care as a team sport has
  been slow to evolve
• Mal-aligned incentives
• Lack of payment for many of the things that could
  help
• Throughput, current hospital payment methodology,
  etc

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Fundamental Disconnect
Hospital
Skilled Nursing Facility
Home
Ambulatory Care Clinic
Rehabilitation Facility
Home Health and Hospice
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Complexity

• Of systems
• Of rules and regulations
• Of patients

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Technology- the double-edged sword

• Meaningful use vs. Meaningful care
• Reliance on the computer to do the work of the
  human
• EHRs that do not talk

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Entropy

• The silo mentality of our systems
• Weve never done it that way before

Hospital
SNF
Home Care
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Misaligned incentives

• Through-put- do everything quicklyget them out
  of my
• DRGs- financial incentives to shorter LOS
• Medicare Part A restrictions- Hospice in the
  nursing home setting

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Transitions of Care- Definition

• The movement of patients from one health care
  practitioner or setting to another as their
  condition or care needs change.
• Within settings
• Primary care to Specialty care
• ED to inpatient
• ICU to PCU to ward
• Between settings
• Hospital to LTC (and back)
• Hospital/LTC to home
• Across health states
• Curative to palliative care

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Each transition brings with it opportunity for
error

• Medication errors
• Inefficient/duplicative care
• Inadequate patient/caregiver preparation
• Inadequate follow-up
• Dissatisfaction
• Litigation

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Barriers to effective transitions

• Patient barriers
• System barriers
• Practitioner barriers

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Patient barriers

• Patients are living longer and with age comes
  chronic illness
• Institutionalization fosters dependency and we
  ask them to abruptly become independent
• Health literacy
• Ability to follow though with plans
• Transportation
• Cognitive impairment
• Cost of medications
• Medicare D donut hole

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System barriers

• Complexity
• Multiple providers
• Shift work/Duty hours
• Poor electronic communication
• Poor understanding of the capabilities and roles
  of home health, hospice, and SNF

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Practitioner barriers

• Busyness
• Specialization
• Hospitalist
• Intensivist
• SNFist
• Extensivist
• Outpatient only

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Medicare Excess Readmission Rates - Penalties

• CMS will penalize hospitals for excess
  readmission rates starting FFY 2013 (Oct. 2012)
• Initial focus HF, AMI, PNE
• FFY2015 (starts Oct. 2014) may add chronic
  obstructive pulmonary disease, CABG, percutaneous
  coronary interventions, and some vascular surgery
  procedures.
• Penalty
• FFY2013 up to 1 all IP Medicare payments (CMC
  approx 1.5m)
• FFY2014 up to 2
• FFY2015 up to 3

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The other Transition

• Problems arise not just from transition from the
  hospital to another site of care
• When we send them home, the same risks are present

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Organizational guidance

• CMS 9th SOW statement about care coordination
• 2009 Joint Commission Patient Safety Standard 8
  about medication reconciliation
• NQF Performance Measures for Care Coordination
• NTOCC tools and resources

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• Patient Bill of Rights during Transitions of Care
• Multiple other tools
• www.ntocc.org

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Published models

• H2H- American College of Cardiology
• Project Boost- Society of Hospital Medicine
• Project RED
• The Care Transitions Intervention

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American College of Cardiology and Institute for
Healthcare Improvement
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Project BOOST

• Better Outcomes for Older Adults Through Safe
  Transitions
• Effort of the Society of Hospital Medicine
• Resources and evidence-based interventions
• Encourages team building and working through
  system processes

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Project RED

• Educate the patient
• Make appointments
• Discuss tests and results
• Organize post-discharge services
• Confirm the medication plan
• Reconcile the discharge plan

• Review process when problems arise
• Expedite the transmission of the discharge
  summary
• Assess patient understanding
• Give patient a written discharge plan
• Telephone reinforcement in 2-3 days
  post-discharge

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Improving the Discharge Process The Care
Transitions Intervention

• Designed to encourage older patients and their
  caregivers to assert a more active role during
  care transitions
• Elderly patients provided a transition coach
• 4 pillars
• Medication self-management
• Maintenance of Personal Health Record
• Timely f/u with PCP and Specialists
• Knowledge of potential complications and ways to
  manage them if they occur

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Outcomes from effective transitions

• Improved patient/family satisfaction
• Reduced health care cost
• Decrease readmissions

Patients cared for at the right time, at the
right place.
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Ultimately Lower Health Care Costs

• Reduced inefficiencies/duplication of services
• Lower hospital and ED use
• National 30-day readmit rate- 15-25
• Reduced litigation/negative press

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IDEAS for success

• Involve stakeholders
• Develop tools
• Engage/empower patients and caregivers
• Adapt technology so that there is the ability to
  share information
• Share information

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Stakeholders

• Hospital administration (see CMS penalties)
• LTC administrators (mention bundled payment and
  youll get their attention)
• Hospital physicians
• LTC Medical Director

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Transition tools

• Checklist
• Discharge summary
• Handoff
• Medication reconciliation
• Engage floor nurses and case managers
• Follow-up
• phone calls
• appointments

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Keep it simple

• We work in an incredibly complex field
• 6,000 drugs
• ICD-9 has gt 13,000 conditions
• The basics can get lost in the jungle of
  complexity
• Checklists can help simplify and standardize
• Airline pilots

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The Discharge Summary and other handoffs

• Physician summaries are the least reliable source
  of medication lists- Am J Ger Pharmacotherapy Aug
  2011
• Summaries and Handoffs are our means of
  communication and must be
• Complete- Antibiotics for one week
• Accurate- Inpatient and outpatient meds not
  thoughtfully reconciled
• Clear- Follow-up CT scan in one week

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Medication Reconciliation

• Errors occur in deciding on and communicating
  whether and which outpatient medications should
  be continued when patients leave the hospital or
  the nursing home
• Over half of medication discrepancies were
  classified as potentially causing moderate/severe
  discomfort or clinical deterioration- Am J Ger
  Pharmacotherapy Sept 2011
• Pharmacist-led models of medication
  reconciliation continue to emerge

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Medication Delays

• Being scrutinized more carefully
• We need to not only approve meds, but ask about
  next dose and availability
• Solutions
• Early transfers
• Partnerships with hospitals
• Communication

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Medications at discharge from the SNF

• Are patients capable of following through?
• Insulin
• Nebulizers
• Whose role and for how long?
• The handoff to the PCP
• How do we know patients understand?

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Nurse engagement

• Nurse Engagement Key to Reducing Medical Errors
  People more important than technology- by Rick
  Blizzard, D.B.A. Health and Healthcare Editor of
  the Gallup Organization, 2005

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Follow up

• Post discharge calls
• By hospital case management, pharmacist,
  PCMHANYONE
• Accountability
• This is the lethal gap in the care. Someone
  needs to take responsibility.
• Follow up appointments
• Studies indicate that appointments within 7-14
  days make a difference

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Patient

• Empowered to ask
• Armed with information
• Knows whom to call for answers

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Make technology your friend

• EMR
• Telemonitoring
• Email/texting

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Communication

• Understand to roles and capabilities at the
  various sites of care
• Share your piece of the puzzle
• Be specific

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Relational Coordination

• Relationships of
• Shared goals
• Shared knowledge
• Mutual respect
• Communication that is
• Frequent
• Timely
• Accurate
• Problem-solving

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Real Health Care Reform

• Is local
• Involves each stakeholder working as a team
• Patient
• Family
• Providers
• Institutions
• Community agencies/resources

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References

• Project Boost www.hospitalmedicine.org/ResourceRo
  omRedesign/RR_CareTransitions/html_CC/project_boos
  t_background.cfm
• Project RED www.bu.edu/fammed/projectred/
• Care Transitions Intervention www.caretransitions
  .org/
• NTOCC www.ntocc.org
• H2H www.H2Hquality.org
• AMDA CPG on Transitions of Care-
  www.amda.com/tools/clinical/TOCCPG/index.html
• Atul Gawande- http//gawande.com/

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Questions?