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Maria Brenny-Fitzpatrick DNP, FNP-C, GNP-BCDirector of Transitional Care and Post-Acute Services

University of Wisconsin Health

-What resident clinical information is needed at the time of transfer(transition) both into and out of the hospital setting-What are the responsibilities of all the stakeholders involved in a safe transition to and from the hospital setting-How to avoid the dreaded equipment and medication “surprises” that can complicate a transition back to you-Briefly: communication with physician offices

1980- Registered Nurse 2005 – co founded UW Acute Care for

Elders (ACE) interdisciplinary consult team Certified Family Nurse Practitioner and

Geriatric Nurse Practitioner 2012- Director of Transitional Care for UW

Health 2015- Doctorate in Nursing with a focus

on Systems Leadership 2015- Focused Transitional Care work

with Assisted Living Facilities and Skilled Nursing Facilities

2017- Director of Post-Acute Services added to title

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Develop, coordinate and evaluate transitional care initiatives across the UW Health system

Assure coordination to avoid duplication of programs, staff and services

Implement and evaluate these initiatives across the healthcare continuum

Make recommendations for improvement based upon evidence-based research and protocols

Facilitate collaborative relationships between post-acute venues to ensure strong partnerships and future interoperability to achieve the highest quality of care for shared patients

Dictated by Medicare, private insurers, and other payers

Changing at warp speed Medicare Accountable Care Organizations

(ACOs) and other innovative payment plans are driving much of the change in health care “Quality care at a lower cost”

Assisted Living Facilities are under consideration as an option for direct placement of patients from hospitals and Emergency Rooms

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- “Aging in place” results in residents whose health conditions changeover time…..becoming increasingly medically complex

- By default (and payment acceptance) “you” are their advocate in health care, especially during a transition

- Expectations placed upon you as providers of ALF services:- You are one of the key stakeholders in your residents transitions- You need to educate yourself and your staff to keep current with

the changing healthcare landscapes

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How is your facility and staff assuring that transitions are patient-centered?

All Transitions Should be Patient-Centered

A way of delivering services and social care that places the “resident” at the center of the activity

The resident is involved in every stage of the process… rather than the staff deciding what is best for the resident

“Nothing about me without me”….

Patient preferences Emotional support Physical comfort Information and education Continuity and transitions Coordination of care Access to Care Family and friends involved as appropriate

Johns Hopkins. Armstrong Institute for Patient Safety and Quality

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Individualization: care is personalized to the patient’s feelings, preferences and desired level of involvement in care

Responsiveness: patient needs are met in a caring and attentive manner

Proficiency: knowledgeable and skillful care is provided

Radwin, L, Castonguay, D., Keenan, C. 2016

Recognize they have capacity to express their wishes and to participate in many decisions

This becomes more difficult as the disease progresses

Residents with dementia are still entitled to choices as appropriate to their cognitive abilities◦ Requires more caregiver/family involvement if they

are available…(surrogates)◦ If surrogate is not available “you” are “it”

Anytime the resident's care transfers to/from the:◦ Doctor’s Office◦ Emergency Room◦ Hospital◦ Home Health◦ Anyplace that health care information is shared

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Care is rushed at the time of transition/handoff◦ Especially if urgent transfer

Responsibility fragmented◦ Who is responsible for making sure that the needed health

information is sent with the patient/received back?

No designated accountability of sender-receiver◦ Is the information reaching the right people?

Little (if any) standard communication (or tools) used across settings

Low patient/family engagement in their own health care◦ Resident is unable or family not available to help convey

information

Leads to: ◦ Confusion◦ Unnecessary tests◦ Medication errors◦ Delays in diagnosis and treatment

Poor quality of care in all settings Poor resident and family satisfaction Unnecessary clinic, ED and hospital visits Animosity between sites Frustration for everyone involved!

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Resident/family/significant supports You/your agency/your staff Primary Care Provider (PCP) and his/her staff Other healthcare team members: home

health, therapies, specialists Hospital staff◦ Nurses/coordinated care/discharge planners and

other providers◦ Physicians and other providers (NPs, PAs)

The planning and implementation of a move between care settings◦ Usually occurring as a result of an acute event

Involves more than changes in physical settings for you, your resident, and your staff◦ involves new responsibilities◦ new relationships◦ and typically new processes and care measures

What resident clinical information is needed at the time of transfer both into and out of the hospital setting?

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Alfred Johnson from state DHS has convened a team of multisite stakeholders to put together an “ALF Transitions Playbook”

Hopefully completed and distributed winter-spring 2018

Over the years, the Bureau of Assisted Living has identified regulatory concerns that have contributed to difficult assisted living facility (ALF) to hospital transitions

Notification of transfer/hospitalization to the client’s legal representative and physician

Providing necessary information at the time of transfer to assure a safe, efficient transition

Failure to provide medication administration and clinical treatments appropriate to the client’s needs

Failure to communicate and/or provide services to manage the client’s behaviors that may be harmful to themselves or others

Draft: Transitional Care Playbook DHS

Enough information so that everyone can safely take care of the patient

Consider having a packet on file with important information for each resident◦ Avoids the rush at time of transfer when

EMT’s/transporters are standing there waiting to take resident◦ Can still put “last minute” information in the

packet at time of transfer

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Face sheet and reason for transfer noted Name, address, type of ALF (level of care) Your name and direct dial phone number Progress notes from past 48 hours Medication administration record (MAR) Assisted Living Facility Capability Form Code Status Health Care Power of Attorney and/or Guardian HCPOA/Guardian Paperwork.

“Capitol Lakes sent a patient tonight with the most beautifully filled out

sticker on the front of the blue envelope with all of the info inside. This is wonderful.”

– Val Mack, Care Team Leader, UW Health ED

UW Health Blue Envelope

Assisted Living to Hospital Transfer Form

http://www.pathway-interact.com/tools/You will need to sign-in to set up

password

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Call ASAP after resident returns to you◦ Increases the chance of catching the person who

cared for the resident◦ Ask to talk with the nurse who cared for your

resident

Begin the conversation with nurse and discharge planner upon admission to hospital◦ Exchange phone numbers◦ Tell him/her about your facility and capabilities◦ Request/explain need for early notification of

medication changes, equipment, staff training

Request to be involved with decisions surrounding inpatient care (if necessary) and discharge planning upon admission◦ “should I call you, or will you call me”◦ “what time works best to contact you”

Most hospitals have a predetermined (auto-selected) packet of information that is sent to a facility when resident returns to you

Some hospitals may not be sending this to ALFs

If you are not receiving it: call hospital and talk with Director of Discharge Planning and request that packets be sent to you

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What are the responsibilities of all the stakeholders involved in a safe transition to and from the hospital setting?

Call hospital and ask to meet with Director of Discharge Planning or proxy

Note that you would like to work together to be sure that transitions between sites happen smoothly

Ask what they need from you when you send a resident into the ER or hospital

Review contents of a hospital discharge packet Does it contain everything you need?

Signed scripts for medications, equipment, etc. Do you understand all of the contents?

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Resident/Family/Significant supports You/your agency/your staff Primary Care Provider (PCP) and staff Other healthcare team members: home

health, therapies, specialists Hospital staff◦ Nurses/coordinated care/discharge planners and

other providers◦ Physicians and other providers (NPs, PAs)

Often dependent on the level of care the resident resides in:◦ Regardless: at time of acute crisis the healthcare

system looks to you to be the resident advocate and spokesperson (unless someone else is there in your place)◦ Note: review what types of authorization forms your

agency has in this regard What do your local healthcare systems need from you

to assure compliance to HIPAA laws?

Transfer needed: Contact Emergency Medical Services (EMS) (provide

facility location, resident’s name age, reason for transfer, baseline cognitive and functional status as pertinent)

Ensure that the appropriate transfer documents are given directly to EMS with instructions to give the information directly to the Emergency Department (ED) staff

Be sure resident’s labeled assistive devices (hearing aids, glasses, etc.) accompany the patient to ED as appropriate

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Contact the resident's legal representative and family as appropriate

Call the Emergency Department to notify them of transfer (provide resident name, age, baseline cognitive and functional status, reason for transfer)

Provide name and phone number of ALF’s Preferred Contact Person

Contact MCO within 24 hours or per their guidelines

Contact Primary Care Physician as appropriate

Resident is Admitted To Hospital: Ensure that assistive and/or behavioral devices (i.e.

hearing aids, walker, glasses, braces, weighted blanket) are with the client. If not, make arrangements for delivery to hospital

Contact the hospital discharge planner as soon as possible to collaborate on the treatment plan and discharge planning

Discuss medication regimen, share any specific resident needs to ensure medications that have proven to be contraindicated are not ordered or those which are effective are not adjusted (i.e. “Please ask provider not to alter Depakote for mood stabilization”)

Be sure to specify unique behavioral needs of the resident (i.e. approach from left side, avoid touching right arm).

Before Resident is Discharged: Review medications (with hospital staff) and ensure

prescriptions have been sent to the pharmacy Ensure and clarify needed durable medical equipment

(DME) (walkers, wheelchairs, etc.) or other services (e.g. oxygen) are identified, orders are placed, and supplies are transferred so that they will be in place upon client arrival

Coordinate transportation with hospital discharge planning staff

Update plan of care at your facility Assure that your staff are oriented and/or trained for

needed treatments

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Resident Returns to ALF: Receive and review discharge packet Review rehabilitation and treatment needs

(e.g. ST, OT, PT) Ensure the client attends post-discharge

follow up appointments as outlined in the client’s discharge summary/orders sent by hospital

Inform and educate your staff on necessary changes

Post -Discharge Appointments: Directions for date/time of post- discharge follow up

appointments will be found on hospital/ER discharge paperwork

If resident is not able to attend the appointment call the medical office request to reschedule

If the post-discharge follow up appointment is not already scheduled, call the medical office to schedule

Confirm date/time of follow-up appointment with resident and/or family

Assure that resident has transportation to and from appointment

Should notify you of decision to admit/send back Should involve you with discharge planning

especially if significant changes Should work with you in a collaborative manner◦ Provide you with signed prescriptions/orders◦ Suggestions for where to order durable medical

equipment, Oxygen (needs to be agreed upon early who will be ordering this, when it need to arrive)

◦ Referrals for Home Health and other agencies◦ Discussions regarding transportation back to facility

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At time of appointment send with the client a copy of MAR, copy of discharge orders/discharge summary (if available)

Send written list of concerns or questions you and/or the client may have since time of discharge

Enclose private health information in a secure envelope Enclose written instructions for clinic staff that you will

need written orders for medication and/or treatment changes

Provide clinic staff with a contact telephone number for you/ facility leadership staff in case there are questions or new instructions

Upon return from appointment review all records with resident/family as soon as possible

Establish clear line of communication so that you and resident are aware of the treatment plan, services rendered and goals

Establish clear understanding of planned length of service

Document clearly in resident’s record all of the above

Are they recommending a new treatment?◦ Ask if it is possible for them to train you/your staff

Encourage ◦ active involvement with healthcare decisions◦ them to ask for clarification of any uncertainties◦ them to use clear, respectful, collaborative

communications with doctors, nursing staff and discharge planners

Clearly communicate what information and orders you need returned directly to you post-discharge

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How to avoid the dreaded equipment and medication “surprises” that can complicate a transition back to you

What types of issues have you experienced regarding this?

Many doctors/providers and discharge planners do not know the difference between a Skilled Nursing Facility and an ALF

They assume that if it has a name….it’s a SNF Note: there is a great variation amongst

facilities as to what they can/cannot do…◦ Fax/send facility capabilities sheet if possible◦ Call and have early, frequent, professional,

conversations with nurse and/or discharge planners

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Maintain frequent contact with the discharge planner to assure your involvement in discharge planning

Ask, “What is the expected day of discharge?” Ask, “Have there been any medication changes?” Ask, “Have there been any behavioral or health

changes while in the hospital?" Review your facility clinical capabilities as they relate

to the ability to provide necessary clinical care. This includes clearly spelling out what services and treatments you can/cannot provide

Clarify availability, or lack thereof , of assistant devices like walkers, canes, etc. and how to obtain them as appropriate

Ask for discharge planners name, telephone number in case you have questions after discharge

Ask for name and phone number of Home Health/Durable Medical Equipment company that will be involved with resident’s care if already decided (they may give you a list of potentials for you to contact)

Engage the resident’s primary care provider (PCP) office early◦ Nurses and social workers there will be able to help you

if you have set a positive relationship

Pending the residents cognitive ability you may need to send an information packet with them to the appointment◦ Face Sheet◦ Functional levels (cognitive/physical)◦ Written reason for medical appointment◦ Current Medication list◦ Transportation arrangements for after appointment

Case Study: patient with dementia dropped off at clinic for appointment. Could not state where she was from etc.

Questions for PCP office: Call and speak with Nurse (not receptionist)◦ Clearly spell out your relationship with the resident◦ Ask specific questions/requests◦ Ask if they also need a fax request (do not duplicate requests);

puts multiple nurses to work on the same thing (or not)

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ALFs have not typically been closely integrated with healthcare systems

Assume an active role in helping your resident and respectfully requesting what you need

Establish a relationship with hospital staff when possible (Coalitions, phone calls, special interest groups)