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TRANSITIONAL CARE

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TRANSITIONAL CARE Powered By Docstoc
					 Faculty Development:
 Teaching Triggers for
   Transitional Care

“A Train-the-Trainer Model”
          Lindsay Mazotti, MD
         C. Bree Johnston, MD
   University of California, San Francisco
          Department of Medicine
          Acknowledgements
   This presentation was supported by the
    Donald W. Reynolds Foundation
   Thanks to the following people for
    modification/ adapation of their materials:
     Bill Lyons, MD; University of Nebraska
     Helen Kao, MD & Brad Sharpe, MD; UCSF
     Catherine E. DuBeau, MD; University of
      Chicago CHAMP Program
      http://champ.bsd.uchicago.edu
        Curricular Objectives
   Improve knowledge about transitions
   Understand the 3 domains of transitions in
    care
   Identify teachable moments in readmissions,
    transfers
   Increase awareness around good discharge
    summaries
                ROADMAP
   Background
   3 Domains of Transitional Care
   Teaching Triggers
     A readmission
     A discharge summary

     An anticipated discharge

   Brainstorming
        Take Home Message
     Providing good transitional care requires:
   ANTICIPATION & PREPARATION
   DESTINATION
   INFORMATION
   EDUCATION
                 Background:
                Care Transitions
   Movements patients
    make between health       Outpatient Clinic
                                                    Inpatient
    care providers and             PMD
                                                  Medical Team

    different care settings



                               Vising Home            SNF
                                  Nurses           Care Team
          TRANSITIONAL CARE
   Based on comprehensive care plan including:
       Patient’s goals, preferences, and clinical status
       Logistical arrangements
       Patient and family education
       Coordination among health professionals and health
        care teams


   Includes both SENDING & RECEIVING


                            Slide courtesy of Bill Lyons, MD; University of Nebraska
                 Why you care
   Transitions are wrought with errors
   25% of patients d/c’d from an academic medical
    service had an adverse event within 3 weeks
       Nearly 50% were preventable
   Readmission rates within 30 days are as high as
    25%
   Subject of national attention
   JCAHO is watching
   You find it personally satisfying to be a “good”
    doctor
                Brainstorm
   Why is it important to teach
    residents/students about transitional care?

   Have you had any successes in teaching
    about transitional care? Can you share?
    QUANTATIVE STUDIES SHOW
   In 2001, patients >65 yo discharged
    from acute settings went…
       to another institution ¼ of the time
       home with home health 11% of the time1
   13% of Medicare beneficiaries
    transfer ≥3 in 30d post-discharge2
   Serious problems with discharge
    summaries, communication with
    PMD’s, med reconciliation

                               1. Agency for Health Care Quality Research HCUPnet
                               2. Coleman et al. Health Services Research 2004
    QUALITATIVE STUDIES SHOW
   Patients don’t understand what
    medications are for or anticipated side
    effects
   … or when to resume normal activities
   …and don’t know what questions to ask,
    or whom to ask
   …or what warning signs to watch for


                     Slide courtesy of Bill Lyons, MD; University of Nebraska
        WHAT IS HIGH-QUALITY
        TRANSITIONAL CARE?
1.   Reliable, accurate
     information transfer
2.   Preparation of patient,
     family, caregiver
3.   Support for self-
     management
4.   Empowerment of
     patient to assert
     preferences



                               Coleman et al. Int J Integrated Care 2002
       3 Domains of a Transfer
                                DESTINATION

   Where should they
    go?
   How to best transfer
    information?
   How to educate and
    prepare the patient?

                  INFORMATION                 EDUCATION
            Mrs. Ima Notthriving
   82 yo woman with multiple medical problems;
    resides at SNF
   Hospitalized at Our Med Center early January
    for AMS, lethargy, UTI? (dirty sample, culture
    negative)
       Returned to SNF
   Admitted to your team 3 weeks later with with
    hypoxia and lethargy
       nonspecific EKG T-wave changes, O2 sat 90%,
        known pleural effusion
       Increased fatigue and decreased PO intake x “1
        month”
               Mrs. Notthriving
   PMH:
       ESRD on HD
       CHF, L sided effusion
       Depression
       CAD: s/p 5-6 MI’s & CABG
       H/o seizure disorder


   Meds include anti-hypertensives, PPI, anti-
    seizure, renal meds, pain meds, stool softeners
            Mrs. Notthriving
   SH
     Widowed, no children, retired
     Former neonatal nurse

     Resides at SNF x years, bedbound
                Mrs. Notthriving
   Exam: 36.2 123/53 64 16 95-100%RA
       Gen: waxing waning lethargy
       RRR, III/VI systolic murmur LLSB
       Decreased BS on L
       L BKA, L femoral fistula
       “Unable to assess orientation”, pt follows commands,
        neuro grossly intact
   Labs normal
   CXR with known L sided effusion
   Dirty UA, >50 WBC, culture negative (again)
  Teaching Trigger: A Readmission
Examine the 3 Domains of Her Transfer
                                    DESTINATION
   Appropriate d/c
    location with first d/c?
   How was our
    information transfer?
   Was the patient
    educated &
    prepared?
                      INFORMATION                 EDUCATION
Walking Through Her Case
  Domain 1- DESTINATION
Did we send her to the right place after
         her last admission?
           DESTINATION




 INFORMATION                 EDUCATION
            Where should they go?
1.       What are the patients goals?
     •     for medical and functional recovery
2.       What are their risks?
     •     is benefit of the transition > harms
           associated with transfer to a new venue?
        Destination: Assessing Risk
       FACTORS ASSOCIATED WITH POOR
           DISCHARGE OUTCOMES
   Age>80                           Depression history

   Fair-to-poor self-rating         Chronic disability and
    of health                           functional impairment
   Recent and frequent              History of nonadherence
    hospitalizations                    to therapeutic regimen
   Inadequate social                Lack of documented
    support                             patient/family education
   Multiple, active chronic
    health problems          Slide courtesy of Bill Lyons, MD; University of Nebraska
            Where should they go?
1.       What are the patients goals?
     •     for medical and functional recovery?
2.       What are their risks?
     •     is benefit of the transition > harms
           associated with transfer to a new venue?
3.       Is the new venue a good match?
     •     Does it match their medical, nursing, and
           functional needs?

                         Modified slide courtesy of Bill Lyons, MD; University of Nebraska
  Destination: A Good Match?

         Admitted to Hospital From:

  HOME                                                 NURSING
                                                        HOME



Home      Home            Acute                      Nursing Home
          With            Rehab
         Services
                    Slide courtesy of Catherine DuBeau, MD; University of Chicago
                    CHAMP Program, http://champ.bsd.uchicago.edu
   Domain 2- INFORMATION
   How was our information transfer?

               DESTINATION




INFORMATION                  EDUCATION
Has anyone taught in rounds or
  one-on-one about discharge
         summaries?
Discharge Summaries: Problems
   “too much of the H&P and too little of the
    hospital course”

   “lots of numbers about BUN and creatinine
    where it would have been sufficient to say that
    the patient was having mild renal insufficiency”
     Quality Summaries:
What do receiving physicians want
   included in a DC summary?
      Quality Summaries:
     What the PMD’s want…

 Evaluation of 226 physicians (56%
  generalists)
 Surveyed preferred content of D/C
  summaries ranked by importance
               TABLE 2:
Preferred Content of Discharge Summary
         Ranked by Importance
                                 Mean rating
                                 (scale of 1-10)
 Medications at discharge                9.69
 Follow-up issues                        9.09
 Discharge Diagnosis                     9.02
 List of Procedures Performed            8.79
 Pending test results                    8.68
 Procedure Reports                       8.16
 Stress Test Reports                     8.07
 Labs from last hospital day             7.03
 Meds at admission                       6.91
 All lab results                         6.22
                                O’Leary et al, J Hosp Med, 2006.
   Teaching Trigger:
Review Ms. Notthriving’s
  Discharge Summary

    A Group Exercise
         Mrs. Notthriving’s
         Transfer Summary
“Briefly, this is an 82-year-old female with CHF,
end-stage renal disease on hemodialysis, and a
seizure disorder who is referred to the
Emergency Department after she was noted to
be sleepy and disoriented with poor p.o. intake
for the past 3 days. The patient's chief
complaint was, "I feel lousy," endorsing fatigue
and weakness. The patient was last dialyzed on
the day of admission with 1-1.5 kg fluid
removed. For past medical history, medications,
social history, and family history, please refer to
admission history and physical.”
HOSP COURSE BY PROBLEM
 Lethargy/altered mental status:

 “Significant objective findings on admission
 included presence of a urinary tract infection and
 a large left-sided pleural effusion. Basic
 metabolic labs were within normal limits. A
 noncontrast head CT was obtained and was
 negative for an acute process. The patient was
 treated for a urinary tract infection with
 cephalexin. Urine cultures were negative. The
 patient will finish a 10 day course of cephalexin.
 With regards to the pleural effusion,
 thoracentesis was offered but was declined by
 the patient in the Emergency Department, which
 was appropriate given her lack of respiratory
 distress or hypoxia…”
“ …The patient's mental status improved
somewhat to the point where her family members
felt she was at baseline. Of note, at baseline the
patient is frequently quite somnolent, however, is
able to arouse to voice.

With regards to her pleural effusion, the plan is
currently to continue hemodialysis for volume
management and to follow the patient for
development of symptoms at which point the
therapeutic thoracentesis could be considered if
needed.”
   DISPOSITION: “The patient will be
    transferred to her HD facility for her regularly
    scheduled hemodialysis. Afterwards, she will be
    transferred to SNF, where she had previously
    been living.”

   CONDITION AT TRANSFER:
    “While the patient's altered mental status and
    lethargy have improved, she is frequently noted
    to be quite sleepy. In discussion with the
    patient's family and outpatient physicians, this is
    consistent with her baseline and she is felt safe
    to be transferred back to her Skilled Nursing
    Facility, to which the patient is eager to return.”
   FOLLOW-UP: The patient will be seen by her
    primary nephrologist, Dr. Renal, at hemodialysis on
    the day of transfer.

   MEDICATIONS ON TRANSFER:
1. Cephalexin suspension to complete a 10-14 day
   course started January 4.
2. Phenytoin 300 mg daily.
3. Escitalopram 10 mg daily.
4. Lansoprazole 30 mg daily.
5. Nephrovite.
6. Sevelmer.
7. Hydrocodone/APAP as needed.
8. Amlodipine 10 mg daily.
 DISCHARGE DIAGNOSES:
1. Altered mental status, likely
  secondary to urinary tract infection.
2. Urinary tract infection with negative
  urine culture.
3. Left-sided pleural effusion.
4. End-stage renal disease on dialysis.
5. Congestive heart failure.
6. Diabetes mellitus.
7. Sacral decubitus ulcer.
     Teaching Trigger:
Review a Discharge Summary

       What is missing?
 What could be more explicit?
What do you want to know as the
        receiving MD?
Discharge Summaries
      HPI / PMH
      PEX / LABS
   HOSPITAL COURSE BY PROBLEM
HOSPITAL COURSE BY
    STUDIES/PROCEDURES
     PROBLEM
            DISCHARGE
           MEDICATIONS
                         DOA
                         DOD
                      Attending

                 HPI / PMH / PEX



        HOSPITAL COURSE BY PROBLEM
      1,2, 3. . . 4 Code/Adv Dir/Goals of Care

       Studies / Procedures / Consultations



DISCHARGE
CONDITION
PROGNOSIS   DISCHARGE      DISCHARGE        DISCHARGE
FUNCTION    INSTRXNS       FOLLOW-UP        MEDICATIONS
Recommended Standard Format
       ID, CC & HPI
       Hospital Course by Problem
       Pertinent Studies and Procedures
       Discharge Diagnoses
       Discharge Medications
       Dispo
       Diet
       Function/Activity
       Condition/Prognosis/Goals of Care
       Follow up Plans
                  ID, CC, HPI
   Be succinct!
   ID, CC, HPI should be rolled into 1-3 lines
   This is the one-liner you deliver to your attending
    or to your friendly but overwhelmed specialty
    consultant who doesn’t have time to hear the
    novella on your patient
   Your goal is to describe the Big Picture of who
    the patient is and what they’re in the hospital for
    Hospital Course By Problem
   MAJOR ACUTE PROBLEMS
       Main reasons for hospitalization
       PNA & HYPOTENSION & HYPOXIA
        could be just “PNA with complications”

   Chronic medical conditions requiring
    adjustments

TIPS:
 Should be SHORT, no more than 1 paragraph
 Do not need to focus on your thinking/ differential dx
 Avoid narrative speech!
    Pertinent Studies & Procedures
   Includes:
       CT Scans, MRI, other radiologic studies

       Echocardiograms

       Interventional or Surgical Procedures
            IR instrumentation
            Cath
            Scopes
            Taps


    What would be important to know as a PMD
           and difficult to track down?
        Discharge Diagnoses
   List of major diagnoses from hospital stay
   Does not include chronic illnesses (unless
    major changes)
   Not for billing
   >10 = TOO MANY
Recommended Standard Format
       ID, CC & HPI
       Hospital Course by Problem
       Pertinent Studies and Procedures
       Discharge Diagnoses
       Discharge Medications
       Dispo
       Diet
       Function/Activity
       Condition/Prognosis/Goals of Care
       Follow up Plans
       Discharge Medications
   Some argue it is the most important part of
    the discharge summary
   Why???
       Discharge Medications
   Medication Errors are very very common
    at discharge
   In 375 geriatric pts, 14% had a medication
    discrepancy when they got home
          This increased rate of readmission by 2.5
   In a study of 400 discharged patients, 45
    (11%) had an adverse drug event
          60% of those were preventable/ameliorable

                                         Coleman EA Arch Intern Med 2005
                                         Forster AJ. Ann Intern Med 2003
      Discharge Medications
           In your discharge summary:

1)   List the medications that were stopped
      1)   Don’t need doses, just the list
      Discharge Medications
           In your discharge summary:

1)   List the medications that were stopped
2)   List the other medications with doses,
     directions, tapering, etc.
      1)   Highlight changes in doses (bp meds,
           hypoglycemics, coumadin, etc.)
      2)   Highlight all new medications
DISCHARGE MEDICATIONS:
STOP Plavix, Lovastatin, lisinopril, Imdur

Combivent Neb Q4h prn
Alendronate 70mg/week PO
ASA 325mg PO daily
Atorvastatin 80mg PO Qbedtime (replaces lovastatin)
Buproprion 500 PO 3x/day
CaCo3 500 PO 3x/day
Captopril 75mg PO Q8 (replaces lisinopril)
Diltiazsem 250mg PO 2x/day
Docusate 250mg PO 2x/day
Hydralazine 40mg PO 4x/day (new medication)
NPH 20units QAM, 5units Qbedtime subQ
Insulin Regular Sliding scale as directed
Ipratroprium 3 puffs 4x/day
Imdur 120mg PO daily (increased from 60mg daily)
Mirtazapine 15mg PO Qbedtime
Recommended Standard Format
       ID, CC & HPI
       Hospital Course by Problem
       Pertinent Studies and Procedures
       Discharge Diagnoses
       Discharge Medications
       Disposition
       Discharge Diet
       Function/Activity
       Condition/Prognosis/Goals of Care
       Follow up Plans
                Disposition
   Where is the patient going at the time of
    discharge
   Can be very very brief

                     Home
                    To SNF
                   Deceased
               Discharge Diet
    Directions for patient, family, primary
     care doctor, etc.
    Three things to think about:
    1)   Specific type of diet (renal, cardiac, etc.)
    2)   Diet consistency (readmit with aspiration…)
    3)   Tube feeds/TPN
Recommended Standard Format
       ID, CC & HPI
       Hospital Course by Problem
       Pertinent Studies and Procedures
       Discharge Diagnoses
       Discharge Medications
       Dispo
       Diet
       Function/Activity
       Condition/Prognosis/Goals of Care
       Follow up Plans
              Function/Activity
   Need to document activity in all patients

   If healthy: “As tolerated”
   Other possibilities:
       “Home with home PT”
       “Wheelchair bound”
               Function/Activity
   Document function for frail older patients and
    ANY patient whose function
       Is impaired at baseline
       Declines prior to admission
       Declines during hospitalization
            Why list function?
   In hospitalized older adults, functional measures
    often fail to improve and frequently worsen
   > 1/3 of older patients are discharged with worse
    functional status than baseline
   1/2 of these patients acquire their deficits during
    their hospitalization
   In-hospital functional decline increases with age:
    rates exceed 50% in patients over 85

                   Covinsky KE et al. JAGS 2003;51:451-58
     Include cognitive function
   Mental illness, mild cognitive impairment,
    dementia or delirium?
   Baseline vs discharge
   This conveys whether the patient has insight and
    ability to manage self-care
   Does the patient rely on a caregiver to follow the
    discharge treatment plan?
                   Follow Up
   Follow up for the outpatient physician and
    follow-up for the patient
   Unbelievably important (and missed)

   In 2644 discharges, PCPs were unaware of 60%
    of tests that needed follow-up.
   Up to 65% of discharge summaries lacked test
    results pending at discharge.

                                     Roy CL. Ann Intern Med. 2005.
                                     Kripalani S. JAMA. 2007.
                      Follow Up
   Follow up for the outpatient physician
       Pending test results (labs, path, radiology)
       Outpatient referrals to specialists
       Physician of record for nursing home, home care, or
        hospice orders? (contact MD prior to discharge!)
   Follow up for the patient
       Next appointments
       Outpatient diagnostic studies
        Quality Summaries are…
   Higher quality when length < 2 pages
   Best in standardized format with minimal
    narrative
   Ideally
     SUCCINCT
     PERTINENT

     SPECIFIC



                Modification of slide courtesy of Bill Lyons, MD; University of Nebraska
                   Final Pearls
   Transfer summary is for
    receiving team, NOT medical
    records

   Avoid cutting & pasting!

   It’s OK (and better) to be brief

   Ask for feedback
        Teaching Trigger:
Was Ms. N (or her family) educated?
               DESTINATION




 INFORMATION
                             EDUCATION
                              AND PREPARATION….
                              AND COMMUNICATION….
  Teaching Trigger:
What do patients leaving
the hospital need to be
   educated about?
                  EDUCATION
         ISSUES TO COMMUNICATE WITH
             PATIENT, CAREGIVER
   Reconcile d/c med list with previous
    regimen & WITH THE PATIENT
   Discuss potential side effects of
    medications
   Activity/eating/bathing limitations, functional
    prognoses
   Communicate d/c date and plan IN
    ADVANCE
   “Red flags” that should prompt contacting
    and MD and WHO to contact
           Brainstorm:
What teaching triggers can you use
       on day of discharge?

  How can we teach this better?
            Teaching Trigger:
         An Anticipated Discharge
   Reviewing the 3 Domains
   Plan for Destination
       Improve Interdisciplinary Collaboration: Involve your Case
        Manager
       Take team to SW rounds?
   Specific goals for Information Transfer
       What will we include in D/C Summary?
       What does your team anticipate going “wrong”?
       Discuss & assign who will contact PMD at discharge AND DO IT
   Plan for Education
       Meeting with or calling family; extra time with patient
       Improve Interdisciplinary Collaboration: Involve your Pharmacist
Review: Curricular Objectives
   Improve knowledge about transitions
   Understand the 3 domains of transitions in
    care
   Identify teachable moments in readmissions,
    transfers
   Increase awareness around good discharge
    summaries
ROADMAP: Did we get there?
   Background
   3 Domains of Transitional Care
   Teaching Triggers
     A readmission
     A discharge summary

     An anticipated discharge

   Brainstorming
              Epilogue:
    Mrs. N’s Jan 24 D/C Summary
   DISPOSITION
    “Patient was transferred back to her skilled
    nursing facility. Dr. Attending had a goals
    of care discussion with Ima and discussed
    considering a Do Not Hospitalize order,
    since Ima finds her trips to the hospital
    'taxing'. She agreed to this plan and was
    planning on talking to her niece about it.
    This plan was also communicated to Dr.
    Accepting at the SNF by Dr. Attending.”

				
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