Transitions in Long Term Transitions in Long Term Care: The role of a Care: The role of a

hospital/SNF partnership in hospital/SNF partnership in assuring effective transitions assuring effective transitions

of careof care

Aubrey L. Knight, M.D.Aubrey L. Knight, M.D.Chief, Geriatric and Palliative Chief, Geriatric and Palliative

MedicineMedicineCarilion ClinicCarilion ClinicRoanoke, VARoanoke, VA

DisclosureDisclosure

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

ObjectivesObjectives

Understand the risks inherent in Understand the risks inherent in transitions from one site of care to transitions from one site of care to anotheranother

Identify processes at the time of Identify processes at the time of transition that can help to mitigate transition that can help to mitigate some of the riskssome of the risks

Recognize the role of the SNF and Recognize the role of the SNF and the medical director in assuring the the medical director in assuring the transition is safetransition is safe

“Care Transitions: The Hazards of Going In and Coming Out of the Hospital”-

Huffington Post 10/10

It’s in the NewsIt’s in the News

“Don’t Come Back, Hospitals Say”-

THE WALL STREET JOURNAL- 6/11

“Heart Failure Program Has Reduced Readmissions by 30 Percent”-

The New York Times 9/11

It’s big businessIt’s big business

It’s not rocket scienceIt’s not rocket science

Rather, it is:Rather, it is: Good careGood care Good Good

communicationcommunication Attention to detailAttention to detail TeamworkTeamwork

So, what makes it so So, what makes it so difficult?difficult?

ComplexityComplexity Of systemsOf systems Of rules and regulationsOf rules and regulations Of patientsOf patients

TechnologyTechnology Double-edged swordDouble-edged sword

EntropyEntropy The concept of health care as a “team sport” has been The concept of health care as a “team sport” has been

slow to evolve slow to evolve Mal-aligned incentivesMal-aligned incentives

Lack of payment for many of the things that could helpLack of payment for many of the things that could help Throughput, current hospital payment methodology, etcThroughput, current hospital payment methodology, etc

Hospital

HomeAmbulatory Care Clinic

Skilled Nursing Facility

SNF

Rehabilitation Facility

Home Health and Hospice

Fundamental Disconnect…

ComplexityComplexity

Of systemsOf systems Of rules and Of rules and

regulationsregulations Of patientsOf patients

Technology- “the double-edged Technology- “the double-edged sword”sword”

Meaningful use vs. Meaningful use vs. Meaningful careMeaningful care

Reliance on the Reliance on the computer to do the computer to do the work of the humanwork of the human

EHRs that do not EHRs that do not talktalk

EntropyEntropy

The silo mentality The silo mentality of our systemsof our systems

““We’ve never done We’ve never done it that way before”it that way before”

Hospital

SNF Home Care

Misaligned incentivesMisaligned incentives

Through-put- do Through-put- do everything everything quickly…”get them quickly…”get them out of my…”out of my…”

DRG’s- financial DRG’s- financial incentives to shorter incentives to shorter LOSLOS

Medicare Part A Medicare Part A restrictions- Hospice in restrictions- Hospice in the nursing home the nursing home settingsetting

Transitions of Care- Transitions of Care- DefinitionDefinition

The movement of patients from one health The movement of patients from one health care practitioner or setting to another as care practitioner or setting to another as their condition or care needs change.their condition or care needs change. Within settingsWithin settings

Primary care to Specialty carePrimary care to Specialty care ED to inpatientED to inpatient ICU to PCU to wardICU to PCU to ward

Between settingsBetween settings Hospital to LTC (and back)Hospital to LTC (and back) Hospital/LTC to homeHospital/LTC to home

Across health statesAcross health states Curative to palliative careCurative to palliative care

Each transition brings with it Each transition brings with it opportunity for erroropportunity for error

Medication errorsMedication errors Inefficient/duplicative careInefficient/duplicative care Inadequate patient/caregiver Inadequate patient/caregiver

preparationpreparation Inadequate follow-upInadequate follow-up DissatisfactionDissatisfaction LitigationLitigation

Barriers to effective Barriers to effective transitionstransitions

Patient barriersPatient barriers System barriersSystem barriers Practitioner barriersPractitioner barriers

Patient barriersPatient barriers

Patients are living longer and with age Patients are living longer and with age comes chronic illnesscomes chronic illness

Institutionalization fosters dependency Institutionalization fosters dependency and we ask them to abruptly become and we ask them to abruptly become independentindependent

Health literacyHealth literacy Ability to follow though with plansAbility to follow though with plans

TransportationTransportation Cognitive impairmentCognitive impairment Cost of medicationsCost of medications

Medicare D “donut hole”Medicare D “donut hole”

System barriersSystem barriers

Complexity Complexity Multiple providersMultiple providers Shift work/Duty hoursShift work/Duty hours Poor electronic communicationPoor electronic communication Poor understanding of the Poor understanding of the

capabilities and roles of home health, capabilities and roles of home health, hospice, and SNFhospice, and SNF

Practitioner barriersPractitioner barriers

BusynessBusyness SpecializationSpecialization

HospitalistHospitalist IntensivistIntensivist SNFistSNFist ExtensivistExtensivist Outpatient onlyOutpatient only

Medicare – Excess Medicare – Excess Readmission Rates - Readmission Rates -

PenaltiesPenalties CMS will penalize hospitals for excess readmission CMS will penalize hospitals for excess readmission rates starting FFY 2013 (Oct. 2012)rates starting FFY 2013 (Oct. 2012)

Initial focus – HF, AMI, PNEInitial focus – HF, AMI, PNE FFY2015 (starts Oct. 2014) may add chronic FFY2015 (starts Oct. 2014) may add chronic

obstructive pulmonary disease, CABG, percutaneous obstructive pulmonary disease, CABG, percutaneous coronary interventions, and some vascular surgery coronary interventions, and some vascular surgery procedures.procedures.

PenaltyPenalty FFY2013 – up to 1% all IP Medicare payments FFY2013 – up to 1% all IP Medicare payments

(CMC approx $1.5m)(CMC approx $1.5m) FFY2014 – up to 2%FFY2014 – up to 2% FFY2015 – up to 3%FFY2015 – up to 3%

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

Organizational guidanceOrganizational guidance

CMS 9CMS 9thth SOW statement about care SOW statement about care coordinationcoordination

2009 Joint Commission Patient Safety 2009 Joint Commission Patient Safety Standard #8 about medication Standard #8 about medication reconciliationreconciliation

NQF Performance Measures for Care NQF Performance Measures for Care CoordinationCoordination

NTOCC tools and resourcesNTOCC tools and resources

Patient Bill of Rights during Patient Bill of Rights during Transitions of CareTransitions of Care

Multiple other toolsMultiple other tools www.ntocc.orgwww.ntocc.org

Published modelsPublished models

H2H- American College of CardiologyH2H- American College of Cardiology Project Boost- Society of Hospital Project Boost- Society of Hospital

MedicineMedicine Project REDProject RED The Care Transitions InterventionThe Care Transitions Intervention

American College of Cardiology American College of Cardiology and Institute for Healthcare and Institute for Healthcare

ImprovementImprovement

Project BOOSTProject BOOST

BBetter etter OOutcomes for utcomes for OOlder Adults Through lder Adults Through SSafe afe TTransitionsransitions

Effort of the Society of Hospital MedicineEffort of the Society of Hospital Medicine Resources and evidence-based Resources and evidence-based

interventionsinterventions Encourages team building and working Encourages team building and working

through system processesthrough system processes

Project REDProject RED

Educate the patientEducate the patient Make appointmentsMake appointments Discuss tests and Discuss tests and

resultsresults Organize post-Organize post-

discharge servicesdischarge services Confirm the Confirm the

medication planmedication plan Reconcile the Reconcile the

discharge plandischarge plan

Review process when Review process when problems ariseproblems arise

Expedite the Expedite the transmission of the transmission of the discharge summarydischarge summary

Assess patient Assess patient understandingunderstanding

Give patient a written Give patient a written discharge plandischarge plan

Telephone Telephone reinforcement in 2-3 reinforcement in 2-3 days post-dischargedays post-discharge

Coleman et al. Arch Intern Med. Coleman et al. Arch Intern Med. 2006; 166:1822-18282006; 166:1822-1828

Improving the Discharge Improving the Discharge Process – The Care Transitions Process – The Care Transitions

InterventionIntervention Designed to encourage older patients and Designed to encourage older patients and

their caregivers to assert a more active role their caregivers to assert a more active role during care transitionsduring care transitions

Elderly patients provided a transition coachElderly patients provided a transition coach ““4 pillars”4 pillars”

1.1. Medication self-management Medication self-management 2.2. Maintenance of Personal Health RecordMaintenance of Personal Health Record3.3. Timely f/u with PCP and SpecialistsTimely f/u with PCP and Specialists4.4. Knowledge of potential complications and ways to Knowledge of potential complications and ways to

manage them if they occurmanage them if they occur

Outcomes from effective Outcomes from effective transitionstransitions

Improved patient/family satisfactionImproved patient/family satisfaction Reduced health care costReduced health care cost Decrease readmissionsDecrease readmissions

Patients cared for at the right time, at the right place.

Ultimately Lower Health Care CostsUltimately Lower Health Care Costs

Reduced inefficiencies/duplication Reduced inefficiencies/duplication of servicesof services

Lower hospital and ED useLower hospital and ED use National 30-day readmit rate- 15-National 30-day readmit rate- 15-

25%25% Reduced litigation/negative pressReduced litigation/negative press

IDEAS for successIDEAS for success

IInvolve stakeholdersnvolve stakeholders DDevelop toolsevelop tools EEngage/empower patients and ngage/empower patients and

caregiverscaregivers AAdapt technology so that there is the dapt technology so that there is the

ability to share information ability to share information SShare informationhare information

StakeholdersStakeholders

Hospital administration (see CMS Hospital administration (see CMS penalties)penalties)

LTC administrators (mention bundled LTC administrators (mention bundled payment and you’ll get their payment and you’ll get their attention)attention)

Hospital physiciansHospital physicians LTC Medical DirectorLTC Medical Director

Transition toolsTransition tools

ChecklistChecklist Discharge summaryDischarge summary HandoffHandoff

Medication Medication reconciliationreconciliation

Engage floor nurses Engage floor nurses and case managersand case managers

Follow-up Follow-up phone callsphone calls appointmentsappointments

Keep it simpleKeep it simple

We work in an incredibly We work in an incredibly complex fieldcomplex field 6,000 drugs6,000 drugs ICD-9 has > 13,000 ICD-9 has > 13,000

conditionsconditions The basics can get lost in The basics can get lost in

the jungle of complexitythe jungle of complexity Checklists can help Checklists can help

simplify and standardizesimplify and standardize Airline pilotsAirline pilots

The Discharge Summary and The Discharge Summary and other handoffsother handoffs

Physician summaries are the least Physician summaries are the least reliable source of medication lists- reliable source of medication lists- Am J Am J Ger Pharmacotherapy Aug 2011Ger Pharmacotherapy Aug 2011

Summaries and Handoffs are our Summaries and Handoffs are our means of communication and must be:means of communication and must be: Complete- “Antibiotics for one week”Complete- “Antibiotics for one week” Accurate- Inpatient and outpatient meds Accurate- Inpatient and outpatient meds

not not thoughtfullythoughtfully reconciled reconciled Clear- “Follow-up CT scan in one week”Clear- “Follow-up CT scan in one week”

Medication ReconciliationMedication Reconciliation

Errors occur in deciding on and Errors occur in deciding on and communicating whether and which communicating whether and which outpatient medications should be continued outpatient medications should be continued when patients leave the hospital or the when patients leave the hospital or the nursing homenursing home

Over half of medication discrepancies were Over half of medication discrepancies were classified as potentially causing classified as potentially causing moderate/severe discomfort or clinical moderate/severe discomfort or clinical deterioration- deterioration- Am J Ger Pharmacotherapy Sept 2011Am J Ger Pharmacotherapy Sept 2011

Pharmacist-led models of medication reconciliation continue to emerge

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

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?

Nurse engagementNurse engagement

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

Follow upFollow up

Post discharge callsPost discharge calls By hospital case management, pharmacist, By hospital case management, pharmacist,

PCMH…ANYONEPCMH…ANYONE AccountabilityAccountability

This is the lethal gap in the care. Someone This is the lethal gap in the care. Someone needs to take responsibility. needs to take responsibility.

Follow up appointmentsFollow up appointments Studies indicate that appointments within 7-14 Studies indicate that appointments within 7-14

days make a differencedays make a difference

Patient Patient

Empowered to askEmpowered to ask Armed with Armed with

informationinformation Knows whom to Knows whom to

call for answerscall for answers

Make technology your friendMake technology your friend

EMREMR TelemonitoringTelemonitoring Email/textingEmail/texting

CommunicationCommunication

Understand to roles Understand to roles and capabilities at and capabilities at the various sites of the various sites of carecare

Share your piece of Share your piece of the puzzlethe puzzle

Be specificBe specific

Relational CoordinationRelational Coordination

Relationships of:Relationships of: Shared goalsShared goals Shared knowledgeShared knowledge Mutual respectMutual respect

Communication that Communication that is:is: FrequentFrequent TimelyTimely AccurateAccurate Problem-solvingProblem-solving

Real Health Care ReformReal Health Care Reform

Is localIs local Involves each stakeholder working as Involves each stakeholder working as

a teama team PatientPatient FamilyFamily ProvidersProviders InstitutionsInstitutions Community agencies/resourcesCommunity agencies/resources

ReferencesReferences

Project Boost: Project Boost: www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/project_boost_background.cfm

Project RED: Project RED: www.bu.edu/fammed/projectred/ Care Transitions Intervention: Care Transitions Intervention:

www.caretransitions.org/ NTOCC: NTOCC: www.ntocc.org H2H: H2H: www.H2Hquality.org AMDA CPG on Transitions of Care- AMDA CPG on Transitions of Care-

www.amda.com/tools/clinical/TOCCPG/index.html Atul Gawande- Atul Gawande- http://gawande.com/

Questions?