07/19/11

TAMPA – Think of both sides, said Bruce Robinson, MD, CMD. "Whenever something goes wrong with a transition, what happens? If you’re in the nursing home, you say, ‘That dang hospital.’ If you’re in the hospital, you say, ‘That nursing home has to get its act together.’"

Dr. Robinson regularly sees patient transitions from both sides as chief of geriatrics at Sarasota (Fla.) Memorial Hospital and medical director of the Pines of Sarasota Nursing Home. From his perspective, only "a systems approach" can improve transfers between long-term care facilities and hospitals or other settings, he said.

Rather than assigning individual blame to a medical director, hospitalist, or discharge nurse, look for opportunities to improve the complex transfer systems among facilities in your community, Dr. Robinson urged his audience at the AMDA annual meeting.

Last year, AMDA published its first transitions-of-care guideline, which recommends discussions among providers before a transfer, a "discharge appointment" with the patient and family, and communication of the patient’s special needs to the next site of care. (To access a free online copy, visit www.amda.com/tools/clinical/TOCCPG/index.html).

"Oftentimes, the only thread that connects one site to the next is the patient," Hae-Kyoung Park, MD, CMD, said at the meeting. Medication reconciliation, including an accurate medication list and any outstanding questions, are among the key points in the 80-page AMDA guideline, Dr. Park said. "A good example might be insulin. A patient cannot self-inject and there is no caregiver. You can ask, ‘How do you take your medicine at home?’ "

"It would do well for us to work on the medication reconciliation to minimize adverse events," which are common after discharge from the hospital, Dr. Robinson said.

Also, providers should ensure that a patient is stable enough for transfer; define the next steps in their care; and make arrangements for durable medical equipment, follow-up testing, and physician appointments, said Dr. Park, who is chief of the transitional care section, geriatric service, at the James A. Haley Tampa VA Hospital.

Dr. Robinson offered the following cases to illustrate the importance of accuracy during a patient’s transition:

PIMr. G was a 77-year-old man hospitalized for exacerbation of chronic lung disease and pulmonary infiltrate and mass who was being transferred to a nursing home. He would require an x-ray 6 weeks after discharge to exclude cancer, but a discharge summary – with the information that a follow-up chest x-ray was required – was not sent to the nursing home.

"Discharge summaries are not nearly as good as they could be," Dr. Robinson said. "My big problem is when I don’t get them at all" at his nursing home.

PIAn 88-year-old resident of a nursing home was hospitalized for fever, tachypnea, and altered mental status. Her hospital record noted clinical sepsis, lactic acidosis, new-onset atrial fibrillation with rapid response, hyperglycemia, hypotension, and renal failure – but not the Clostridium difficile colitis she was diagnosed with in the nursing home or the metronidazole she was prescribed. In the hospital, she was prescribed ceftriaxone and moxifloxacin. The hospital record contained no document from the nursing home, and the existing diagnosis of C. difficile was not recognized "She progressively deteriorated. Diarrhea led to a positive stool for [C. difficile], but she died before first dose of metronidazole was given," Dr. Robinson said, noting that the woman was not his patient.

"This has to stop," he said "Even the information we send [from our nursing home], it’s clear to me, [doesn’t] make it through the system." Scanning documents into an electronic medical record system might improve the process, he added.

"Everyone is beginning to recognize how difficult this is for all of us," Dr. Robinson said. "One coordinating doctor is no longer the rule; there are many providers, procedures, and sites. Those of us working in long-term care ... have to get much better at understanding how we communicate." The science of patient safety includes asking, "What systems change can make this never happen again?" he said.

In addition to the AMDA guideline, other good transition models exist, Dr. Park said. Common elements of successful strategies include a clinician in charge of care transitions, patient awareness (for example, making sure a patient can repeat back what he or she is told to ensure understanding), and patient and caregiver empowerment.

Evidence-based model examples include the following:

--Care Transitions Intervention. This models addresses hospitalized patients 65 years and older and has demonstrated significant reductions in rehospitalization rates.

--Project RED (Re-Engineered Discharge). This model focuses on a broader age range (mean, 50 years). It features a nurse discharge advocate, an after-hospital care plan, and medication reconciliation via a pharmacist’s calling the patient’s home. The project is associated with a 30% reduction in 30-day hospitalization utilization, Dr. Park said.

--Transitional Care Model. This model’s focus is on older adults with two or more risk factors (such as previous hospitalizations or a poor self-function rating). The model demonstrated reductions in rehospitalization rates and health care costs.

--Guided Care. In this model, physician-nurse teams focus on geriatric outpatients with chronic conditions. Significant reductions in health care costs include decreased utilization of home health services.

--Project BOOST (Better Outcomes for Older Adults Through Safe Transitions). This model from the Society of Hospital Medicine includes the "Eight Ps" that identify increased transfer risks: problem medication, psychological diagnosis (such as depression), high-risk principal diagnosis, polypharmacy, poor health literacy, patient support, hospitalization in prior 6 months, and receipt of palliative care. Access the model at www.hospitalmedicine.org; search for BOOST.

"Can you think of any nursing home resident who does not meet at least one of these criteria?" Dr. Park asked. "We consider all our patients as the target population."CfA

Damian McNamara is with the Miami bureau of Elsevier Global Medical News.

<- Back to: AMDA Annual Conference Highlights