# Presentation: 114539

## Older Patient Care and Patient Safety Across Settings and Populations 

- Judith Sangl, ScD AHRQ/CQuIPS
- Based on material from:
- Eric A. Coleman, MD, MPH
- University of Colorado Health Sciences Center
- Weill Medical College of Cornell University
- Visiting Nurse Service of New York
- Mathey Mazey, Hartford Institute for Geriatric Nursing
- Mary Naylor, University of Pennsylvania

## Care of Older Adults is Health Care’s “Core” Business

- 57% of all visits to generalist physicians
- 63% of all visits to oncologists
- 50% of all hospital expenditures
- 80% of home care visits
- 90% of nursing home care
- Source: www.hartfordign.org

## Nature of the Problem

- Older adults with complex care needs frequently require care in multiple settings
- Yet health professionals in these settings often function independent from one another
- Care is often setting-centered -- not patient- centered
- Elderly w/ 1+ chronic conditions see average of 8 different physicians in year
- As a result, care is often fragmented
- Patient safety and quality are compromised

## Fundamental Disconnect...

**Hospital**

-  **Home**

**Ambulatory Care Clinic**

**Skilled Nursing Facility**** **

-  **Rehabilitation Facility**

-  **Hospice**

## Definition – Transitional Care

- “A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Transitional care encompasses both the sending and the receiving aspects of care.”
- Source: Position statement from the American Geriatrics Society, 2003

## Transitions Occur at Many Levels

- Within Settings
- Primary care & specialty care
- ICU & ward
- Between Settings
- Hospital & skilled nursing facility
- Hospital & home health
- Hospital and home
- Across health states
- Curative care & palliative care

## Transitional Care vs. Case Management

- Focus of transitional care is on time interval that begins with preparing a patient to leave one setting and be received in the next
- Many transitions are unplanned and occur in “real time” on nights and weekends
- Case management/disease management approaches are not structured to respond in a timely manner
- As a result, transitional care involves clinicians who do not have an ongoing relationship with the patient

## How Common Are Transitions? Medicare Current Beneficiary Survey

- What are the patterns of care during the 30-day period following hospitalization
- How can the quality of these care patterns be characterized?
*Coleman et al. HSR 2004;37(5):1423-1440*

## 45 Unique Care Patterns

| Single transfer | 61.2 % |
| --- | --- |
| Two transfers | 17.9 % |
| Three transfers |   8.5 % |
| > Four transfers |   4.3 % |
| Deaths |   8.1 % |

## Quality Problems During Care Transitions

- Inadequately prepared for next setting
- Conflicting advice for illness management
- Inability to reach the right practitioner
- Family caregivers repeatedly completing tasks left undone

## Adverse Events after Discharge

- Defined as an injury resulting from medical management rather than underlying disease
- 19 % had 1+ adverse events within 3 weeks
- Many were preventable
- Adverse drug events most common (66%)
- Forster et al. Annals of Internal Medicine 2003;138:161-7

## Errors Related to Discontinuity

- 3 Type of errors
- medication continuity
- test result follow-up
- work-up
- 49% had at least one error
- Moore et al. JGIM 2003;18:646-51

## Information Transfer and Technology

- Discharge/transfer information inadequate or not conveyed to next setting (*TNTC*)
- Hospital => NH Transfer, documentation was not legible 28% of time (Foley et al.)

## Lab Testing

- Delays in test result review are common (Poon, et al.)
- Current test result tracking and follow up systems in health care are inefficient and chaotic (Gandhi et al.)

## Challenges to Improving Quality of Transitions Occur at Multiple Levels

- Patient
- Practitioner
- Health care institution
- Information technology

## Patient Level

- Unprepared and uncertain about their role
- Patients discharged from 200 CA hospitals gave lowest rating to their transition to home (CHCF)
- Institutions foster dependency and complacency
- This changes _abruptly_ on transfer when expected to assume major role in self-care
- Prevalence of cognitive impairment intensifies this challenge

## Practitioner Level

- Rare for one clinician to orchestrate care across multiple settings
- Rise of hospitalists and SNFists
- Many practitioners have never practiced in settings to which they transfer patients

## Information Technology Challenges 

- Health information technology infrequently extends from hospital or clinic into post-acute care settings
- Interoperability remains a challenge
- Paucity of exemplar programs

## Current System for Referring Hospital Patient to Home Health Care

- CMS form 485 used to refer patient to HHC
- Rarely involves physician in generating the referral orders (SW or RN fills form)
- Hand-written form then faxed to HHA
- CMS form 485 ends up in a stack of papers in SW office after completion

## Cornell/VNSNY Hospital to Home Health Care Study Approach

- To restructure the format and initiation of an electronic CMS 485 to:
- Improve accuracy
- Promote evidence-based patient care
- Increase physician participation in the plan of care
- Enhance communication between physician and agency

## Cornell/VNSNY Hospital to Home Health Care Study Summary

- Successfully created electronic referral form
- Built-in evidence based order sets
- Easy to use, brings MD into discharge plan
- Takes MD 3 minutes to complete
- Allows MD to bill for managing home health care patient
- Accepted by HHA nurses
- Easy to read and easy to follow format
- More comprehensive orders

## Promising Innovations--Patients

- Patient and family caregiver often the first and last line of defense/safety
- Encouraging patients to assert a more active role reduces re-hospitalizations
- Transition Coaches and Personal Health Record tool as part of care transition intervention
*Coleman EA et al.  JAGS Nov 2004 1817-25*

- Coleman E et al.  JAGS Nov 2004 1817-25

## Provider Innovations-Expectations for Sending and Receiving Teams

**Sending team**: Identifying an appropriate “fit” between the patient’s needs and the next setting
- The care plan, orders, and a clinical summary precede the patient’s arrival
**Receiving team**: review the transfer forms, summary, and orders upon the patient’s arrival
- Clarify discrepancies regarding the care plan, the patient’s status, or the patient’s medications

## Promising Innovations-Practitioners

- Society for Hospital Medicine
- Core competencies for transitional care
- Consensus on the ideal hospital discharge
- Simple discharge checklist is being vetted
- Naylor et al/University of Pennsylvania
- APNs managed care 4 weeks post-hospital
- Reduced re-hospitalizations

## Best Practices

- Colorado Foundation for Medical Care (QIO)
- SNF and Hospital Collaborative to improve cross-setting communication for skin integrity
- Developed universal care transfer form
- Re-engineer work day of RNs in each setting to facilitate a 2-5 minute conversation

## Best Practices- Health Care System

- Lahey Clinic in Massachusetts
- Expand scope of monthly M&M rounds
- Included both hospital and SNF clinicians
- Revise contract language to promote safe and effective transfers

## “Healthy Handoffs” Colorado

- Improve information exchange at transfer
- Led by Colorado Patient Safety Coalition
- Hospitals, NHs, HHAs, ED, QIO, Purchasers
- Agree on essential data elements and method of communication
- Challenge to break down silos is not trivial

## Core Components of Effective Transitions

- Screening to identify high risk patients
- Identification of patient’s/caregiver’s goals and preferences
- Excellent communication between and among providers and across settings
- Patient/caregiver education regarding prevention and early identification of health problems
- Availability of APNs throughout transition to navigate system & promote continuity

## National Efforts

## Institute for Healthcare Improvement

- Soon to launch initiative on hospital discharge

## National Quality ForumEndorsed Safe Practices

*Ensure that care information is transmitted in a timely and clearly understandable form to all providers who need it*
- NQF has issued a call for performance measures for coordination of care out of the hospital

## JCAHO

- Patient Safety Goal—medication reconciliation
- Patient Safety Goal—improve timeliness of reporting critical test results

## Medication Reconciliation

- Resar et al.—breakdown medication changes
- Same medication, same dose
- Same medication, new dose
- New medication
- Medications you are to stop taking
- “NO TEARS” Tool (Lewis BMJ Aug 21, 2004)

## www.caretransitions.org

- Care Transitions Measure (CTM)
- Care Transitions Intervention
- Manual
- Video clips/ Order DVD
- Tools for patients and caregivers
- Medication Discrepancy Tool (MDT)
- Much much more....