SAFE CARE TRANSITIONS: BRIDGING SILOS OF CARE Karin Ouchida, MD Assistant Professor of Medicine Division of Geriatrics Montefiore Medical Center/AECOM Medical Director Montefiore Home Health Agency November 14, 2009 - PowerPoint PPT Presentation

Loading...

PPT – SAFE CARE TRANSITIONS: BRIDGING SILOS OF CARE Karin Ouchida, MD Assistant Professor of Medicine Division of Geriatrics Montefiore Medical Center/AECOM Medical Director Montefiore Home Health Agency November 14, 2009 PowerPoint presentation | free to download - id: 5fc8e0-MzJkM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

SAFE CARE TRANSITIONS: BRIDGING SILOS OF CARE Karin Ouchida, MD Assistant Professor of Medicine Division of Geriatrics Montefiore Medical Center/AECOM Medical Director Montefiore Home Health Agency November 14, 2009

Description:

A checklist was presented at the society s 2005 annual ... Adverse drug events accounted for 2.5% of estimated ED visits for ... Patient safety The Joint ... – PowerPoint PPT presentation

Number of Views:496
Avg rating:3.0/5.0

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: SAFE CARE TRANSITIONS: BRIDGING SILOS OF CARE Karin Ouchida, MD Assistant Professor of Medicine Division of Geriatrics Montefiore Medical Center/AECOM Medical Director Montefiore Home Health Agency November 14, 2009


1
SAFE CARE TRANSITIONS BRIDGINGSILOS OF
CAREKarin Ouchida, MDAssistant Professor of
MedicineDivision of GeriatricsMontefiore
Medical Center/AECOMMedical DirectorMontefiore
Home Health AgencyNovember 14, 2009
AGS
THE AMERICAN GERIATRICS SOCIETY Geriatrics Health
Professionals. Leading change. Improving care for
older adults.
2
Objectives
  • Identify complications of poor transitions
  • List key components of safe transitions
  • Distinguish different discharge services and
    settings
  • Appreciate the physicians role

3
Why should youcare about this?
  • Patient safety
  • The Joint Commission
  • Health care reform
  • Reduce avoidable re-hospitalizations
  • Increase accountability transparency

4
SURVEY OF PATIENTS ABOUT HOSPITAL EXPERIENCES
Doctors communicated well Always Usually Sometimes or never
Average for all reporting hospitals in the US 80 15 5
Average for all reporting hospitals in New York 76 18 6
Montefiore Medical Center 79 15 6
Mount Sinai Hospital 79 16 5
St Lukes Roosevelt Hospital 71 22 7
5
HOW OFTEN DO TRANSITIONS OCCUR?
  • After hip fracture, pts underwent an average of
    3.5 relocations
  • Between Thurs and Mon morning, 6?7 handoffs may
    occur
  • Medicare beneficiaries see a median of 2 PCPs and
    5 specialists yearly!

Boockvar et al. JAGS. 2004521826-1831. Horwitz
et al. Arch Intern Med. 20061661173-1177. Hoangm
ai et al. N Engl J Med. 20073561130-1139.
6
DEFINITION OF TRANSITIONAL CARE
  • The set of actions necessary to ensure the
    coordination and continuity of health care as
    patients transfer between different health care
    settings or levels of care

Coleman and Berenson. Ann Intern Med.
2004140533-536.
7
COMPLICATIONS OF POOR TRANSITIONS
  • Adverse events
  • Increased health care utilization
  • Patient dissatisfaction
  • Provider dissatisfaction

8
Adverse Events
  • Injury resulting from medical management vs.
    underlying disease
  • 1 in 5 patients experiences an adverse event
    during the hospital-to-home transition
  • 1/3 are preventable
  • 1/4 of patients are re-admitted to the hospital

Forster et al. Ann Intern Med. 2003138161-167.
9
Increased Health Care Utilization
  • 16 of Medicare beneficiaries are re-hospitalized
    within 30 days of discharge after a surgical
    admission
  • Vascular surgery 24
  • Major bowel surgery 17
  • 20?40 are re-admitted to a different hospital
  • Readmission is associated with increased
    mortality, impaired function, and nursing home
    placement
  • Cost of unplanned re-hospitalizations in 2004
    estimated at 17.4 billion

Jencks et at. N Engl J Med. 20093601418-1428. Bo
ockvar et al. J Am Geriatr Soc. 200351399-403.
10
4 CRITICAL COMPONENTSOF SAFE TRANSITIONS
  • Medication reconciliation
  • Patient education
  • Red flags
  • Who to call
  • Communication between sending and receiving
    providers
  • Timely follow-up

11
Case 1
  • A 78-year-old woman with a history of atrial
    fibrillation, CVA, and newly diagnosed breast
    cancer is admitted for mastectomy
  • Warfarin is held for surgery
  • The hospital course is complicated by delirium
    and UTI
  • The patient is discharged to subacute rehab
  • She is re-admitted after 5 days with rapid a-fib
    and sudden dysarthria/facial droop

12
CASE 1 MEDICATIONS
  • HOME
  • Atenolol 50 mg qd
  • Metformin 850 mg BID
  • Glucotrol 10 mg qd
  • Warfarin 3 mg qHS
  • Prevacid 30 mg qd
  • Calcium/vitamin D 600/400 IU BID
  • Alendronate 70 mg weekly
  • HOSPITAL
  • NPH 8 units qAM
  • Protonix 40 mg daily
  • Keflex 500 mg BID
  • Colace 300 mg qd
  • Senna 2 tabs qHS
  • DISCHARGE
  • NPH 8 units qAM
  • Protonix 40 mg daily
  • Keflex 500 mg BID

13
COMPONENT 1MEDICATION RECONCILIATION
  • How Start with an accurate pre-admission list
  • When Across the continuum of care
  • Why Most adverse events are medication-related
    (66)

Forster et al. 2003 Ann Intern Med.
2003138161-167.
14
Case 2
  • A 78-year-old woman with mild dementia, CAD, and
    DM is admitted with fever and abdominal pain
  • She is found to have acute cholecystitis and
    undergoes open cholecystectomy
  • The post-op course is complicated by mild
    cellulitis at the incision site
  • She is discharged on Keflex and Percocet for pain
    but not educated about warning signs/symptoms
  • She is re-admitted 7 days later with wound
    abscess and fecal impaction

15
COMPONENT 2 COACHING PATIENTS TO ACHIEVE SKILL
TRANSFER
  • Care Transitions Intervention www.caretransitions
    .org
  • Subjects 65 admitted with multiple chronic
    conditions Transitions Coach (APN, RN, MSW)
    simulates common transition challenges and
    coaches them to adopt effective strategies to
    respond
  • Resolving confusion over medications
  • Scheduling and preparation for follow-up visits
  • Identifying indicators of worsening condition
    (red flags) and knowing how to respond

Coleman et al. Arch Intern Med.
20061661822-1828.
16
SURVEY OF PATIENTS ABOUT HOSPITAL EXPERIENCES
Patients were given information about what to do during their recovery at home Yes, staff did give No, staff did not give
Average for all reporting hospitals in the US 80 20
Average for all reporting hospitals in New York 79 21
Montefiore Medical Center 78 22
Mount Sinai Hospital 78 22
St Lukes Roosevelt Hospital 67 33
17
Case 3
  • A 75-year-old man is admitted for elective hernia
    repair
  • He is given Ancef preoperatively and develops a
    rash, although he has no previous history of
    medication allergy
  • Post-op, he has hematuria, which resolves
    spontaneously a UA/urine culture and urine
    cytopathology are sent
  • When he is discharged to home, the discharge
    summary does not list Ancef allergy or note
    pending urine cytology

18
COMPONENT 3COMMUNICATION
  • System problems contributed to all preventable
    and ameliorable adverse events
  • Most common reason for failed transition poor
    communication between inpatient MD and patient or
    PCP (59)
  • Direct communication between inpatient MD and PCP
    occurred in only 3-20 of cases

Forster et al. Ann Intern Med. 2003138161-167. K
ripalani et al. JAMA. 2007297831-841.
19
Ways to Communicate
  • Discharge summary
  • Patient
  • Proprietary software
  • E-mail
  • Phone

20
Discharge Summaries
  • Key information is often missing
  • Responsible hospital MD (25)
  • Main diagnosis (18)
  • Discharge medications (20)
  • Specific follow-up plans (14)
  • Diagnostic test results (38)
  • Tests pending at discharge (65)
  • Available at follow-up visit only 12?34 of the
    time

Kripalani et al. JAMA. 2007297831-841. Kripalani
et al. J Hosp Med. 20072314-323.
21
THE IDEAL DISCHARGE FORM
  • Presenting problem
  • Key findings and test results
  • Final diagnoses
  • Condition at discharge (including functional and
    cognitive status if relevant)
  • Discharge destination
  • Discharge medications (purpose, cautions, changes
    in dose or frequency, meds that should be
    stopped)
  • Follow-up appointments
  • Pending labs/tests
  • Specialist recommendations
  • Documentation of patient education/understanding
  • Anticipated problems or suggestions
  • 24/7 call-back number
  • Referring/receiving providers
  • Advanced directives/code status

Halasyamani et al. J Hosp Med 20061354-360.
22
Pending Test Results
  • 2600 patients discharged from hospitalist
    services at 2 academic hospitals
  • 40 had test results returned after discharge
  • 10 required some action
  • Hospitalists and PCPs surveyed about 155 results
  • Unaware of 60
  • 40 were actionable, 13 urgent

Roy et al. Ann Intern Med. 2005143121-128.
23
Recommendations for Outpatient Workup
  • Of 700 discharges, 30 had outpatient work-up
    recommended
  • Diagnostic procedure (48)
  • Subspecialty referrals (35)
  • Laboratory tests (17)
  • 36 of work-ups were not completed
  • Availability of discharge summary increased
    likelihood that post-discharge work-up would be
    completed (OR 2.35)

Moore et al. Arch Intern Med. 20071671305-1311.
24
Case 4
  • An 80-year-old woman is admitted with fever,
    vomiting, and abdominal pain
  • She is found to have acute appendicitis and
    undergoes laparoscopic appendectomy
  • She is discharged home with instructions to
    follow-up in the surgery clinic in 4 weeks
  • She is re-admitted 2 weeks later with fever,
    altered mental status after a fall at home
  • The port sites are grossly infected

25
COMPONENT 4 TIMELY FOLLOW-UP
  • 50 of patients re-hospitalized within 30 days of
    discharge did not have an outpatient MD visit
    billed to Medicare
  • Benefits of timely follow-up
  • Lab monitoring
  • Reconcile medications
  • Check on home supports
  • Reinforce knowledge of red flags and emergency
    contact information

Jencks et al. N Engl J Med. 20093601418-1428. Fo
rster et al. Ann Intern Med. 2003138161-167.
26
CHALLENGES TO IMPROVING TRANSITIONAL CARE
  • Physicians
  • Awareness
  • Multiple providers
  • Time
  • Patients
  • Health illiteracy
  • Cognitive impairment
  • Language barriers
  • Lack of social support
  • Systems

27
Do we need transitionalists?
28
TRIAL OFDischarge SERVICES (1 of 5)
  • Subjects Adults admitted to medicine teaching
    service, discharged home
  • Design Randomized trial with block randomization
  • Intervention Nursing discharge advocate visit
    plus pharmacist phone call
  • Follow-up 30 days
  • Primary endpoint Number of ED visits and
    readmissions
  • Secondary endpoints Patient knowledge of
    diagnosis, PCP name, follow-up, preparedness for
    discharge

Jack et al. Ann Intern Med. 2009150178-187.
29
TRIAL OFDischarge SERVICES (2 of 5)
  • Nursing discharge advocate
  • Educated patient re dx, meds, follow-up
  • Arranged follow-up appointments
  • Set up post-discharge services
  • Reviewed and transmitted discharge summary to PCP
  • Provided pt with after-care plan
  • Pharmacist phone call 2?4 days post-discharge to
    review medications

Jack et al. Ann Intern Med. 2009150178-187.
30
TRIAL OFDISCHARGE SERVICES (3 of 5)
P .009
Jack et al. Ann Intern Med. 2009150178-187.
31
TRIAL OFDischarge SERVICES (4 of 5)
Usual care Intervention P-value
Able to identify discharge diagnosis 70 79 .017
Able to name PCP 89 95 .007
Follow-up with PCP 44 62 lt .001
Understood how to take meds after discharge 83 89 .049
Jack et al. Ann Intern Med. 2009150178-187.
32
TRIAL OFDischarge SERVICES (5 of 5)
  • In the intervention group
  • Follow-up with PCP made prior to discharge 94
    (vs. 35 in usual care)
  • D/C summary sent to PCP within 24 hours 90
  • Pharmacist reviewed meds with 50
  • 65 had at least 1 medication problem
  • 50 needed corrective action by pharmacist

33
A Strategy forEffecting Safe Transitions
  • If you dont have a transitionalist, identify and
    involve interdisciplinary team members who can
    help you with
  • Med reconciliation
  • Patient education
  • Communication
  • Follow-up

34
A TEAM APPROACH
  • Inpatient
  • Nurse
  • Social worker
  • Pharmacist
  • PT/OT
  • Medical students
  • Caregivers
  • Outpatient/Home
  • Home care nurse
  • Home care SW
  • Pharmacist
  • Home care PT/OT
  • Case managers
  • Caregivers

35
Identifying the Most Appropriate Discharge SETTING
  • Functional assessment
  • Activities of daily living and instrumental
    activities of daily living
  • Ambulation
  • Cognitive status
  • Home environment
  • Caregiver support

36
Short-Term Home Health Care
  • Skilled need RN, PT and/or speech therapy
  • Homebound assistance for person/device to leave
    the home
  • Intermittent care part-time, intermittent needs
  • Physician supervision must have outpatient MD to
    sign orders, address concerns
  • If the patient needs assistance with activities
    of daily living (ADLs) or instrumental ADLs,
    there must be sufficient/willing caregiver(s)

37
Rehabilitation Settings
HOME SUBACUTE ACUTE
Can tolerate PT for 30?60 min/day Medical and/or personal care needs can be met by short-term aide family support (eg, needs help with shopping, picking up meds) Can tolerate PT for 30?60 min/day Medical needs and/or personal care needs exceed what family can provide (eg, needs help getting to bathroom and/or administering meds, and is at high risk for falls) Aggressive PT/OT/ST 3h/day Great potential to achieve functional goals Impairment subject to serious decline if aggressive tx is not immediate
38
Home vs. Inpatient Rehabilitation
  • 234 patients randomized to home-based vs.
    inpatient rehab after total joint replacement
    followed for 1 year
  • Average stay in inpatient rehab 18 days
  • Number of home rehab visits 8
  • Functional outcomes equal
  • No significant difference in infection, DVT,
    infection, patient satisfaction
  • Lower cost for home-based rehab (3000)

Mahomed et al. J Bone Joint Surg Am.
2008901673-1680.
39
Skilled Nursing Facility
  • Skilled need for RN, PT/OT, or speech therapy
  • IV antibiotics
  • Wound care
  • Rehab
  • Medical or personal care needs exceed home
    supports

40
Summary
  • Care transitions are associated with increased
    adverse events and health care utilization
  • Safe transitions require medication
    reconciliation, patient education, provider
    communication, and timely follow-up
  • Functional assessment helps identify the most
    appropriate discharge setting
  • Physicians are responsible for ensuring safe
    transitions

41
Thank you for your time!
Visit us at
www.americangeriatrics.org
Facebook.com/AmericanGeriatricsSociety
Twitter.com/AmerGeriatrics
linkedin.com/company/american-geriatrics-society
About PowerShow.com