Chronic II- transitions/coordination of care
Case 2
An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose and within two days he was rehospitalized with uncontrollable bleeding.
Successful Coordinate Care
For health systems to successfully coordinate care, they must have The proper infrastructure, resources, leadership, A culture to support synchronized efforts, communication Collaboration among multidisciplinary teams of providers and specialists. ("What is", 2018)
Draft NTOCC Tools
Medication Reconciliation Transitions of Care List
ACUTE CARE COORDINATION
More complex level of care due to the critical and emergency nature of patients condition. The goal is to help reduce hospital readmissions rates, prevent avoidable ER visits, and contribute to a reduction in mortality rates. Care coordination continues when the emergency has passed and the patient is discharged from the hospital. Care coordinators confirm proper transition of care by: scheduling follow-up visits, making sure prescription medications are filled reviewing follow-up instructions follow up with patients a few days after they leave the hospital to check on their progress and answer questions.
Medication Errors Involving Reconciliation Failure
Most errors in transition period
The Case Management Society of America
The Case Management Society of America will positively impact and improve patient well being and patient health care outcomes ØWe envision case managers as pioneers of health care change: nursing case managers, disease managers, health care coaches, social workers, pharmacists, physicians and others who are key initiators of and participants in the health care team as patient care managers.
Case Management Interface with Clients and their Support Systems,
The health conditions and physical and educational needs of the patient population(s) served, as well as the needs of the family/caregivers, such as primary care, critical care, disease management, home health / hospice care.
What Is Care Coordination?
no consensus definition has fully evolved. A recent systematic review identified over 40 definitions of the term "care coordination." The systematic review authors combined the common elements from many definitions to develop one working definition for use in identifying reviews of interventions in the vicinity of care coordination and, as a result, developed a purposely broad definition: "Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care." For some purposes, they noted that other definitions may be more appropriate. This lack of consensus is perhaps not surprising given the many different participants involved in coordinating care.
Barriers to Care Coordination
ØSystem level barriers ØPractitioner level barriers ØPatient level barriers
Ineffective Transitions Lead to Poor Outcomes
ØWrong treatment ØDelay in diagnosis ØSevere adverse events ØPatient complaints ØIncreased healthcare costs ØIncreased length of stay
Case Manager Role on Team
"Professional case managers have an important part to play in informing the team about the client's needs because of their dynamic relationship with them. They help to clarify the client's barriers to the team, barriers that the patient may not express to the primary care provider or even the RN. The patient is the puzzle, and the professional case manager pulls all the information pieces together to give the full picture of the client to the team."
The Nurses Role
As front-line practitioners, nurses unique role making care transitions safe. Nurses are typically the first to ask about or notice changes in a patient's health condition Before patients leave the hospital, the nurse makes sure they understand information and how to care for themselves when they get home.
Effectiveness of Case Management
CM Programs for high-risk patients with chronic illness resulted in decreased hospital admissions, lengths of stay, readmissions, ED visits. Quality of life was improved; patients better able to manage their symptoms. For frail elderly, increased survival; increased functional ability without increased use of services
AGS Position Statement- 4, 5
Position 4: Education in transitional care should be provided to all health professionals involved in the transfer of patients across settings Position 5: Research should be conducted to improve the process of transitional care Professional educational institutions, specialty certification boards, licensing boards, and quality improvement programs should seek to improve, evaluate, and monitor health professionals' ability to collaborate across settings to execute a common plan of care. Core competencies include the incorporation of patients' and caregivers' preferences into a plan of care, active communication (telephonic, electronic, or printed paper) with health professionals across settings, attention to and coordination of individual elements of the plan of care, and ensuring timely transfer to the next level of care or follow-up in the ambulatory setting. To advance the understanding and practice of high-quality transitional care, research is needed to better understand how to empower persons with complex care needs and their caregivers to express their preferences and manage their care needs across healthcare settings. This line of inquiry further necessitates attention to the needs of persons from various ethnic and racial groups.
Reimbursement for Care Coordination
Reimbursement of case management services ACA provides some incentives Some payers have agreed to a per member per month reimbursement. Agreed to formula has yet to be developed.
Four Elements of Coordinated Care
Successful care coordination requires several elements: Easy access to a range of health care services and providers Good communications and effective care plan transitions between providers A focus on the total health care needs of the patient Clear and simple information that patients can understand
2008 Advisory Task Force
These groups represent over 200,000 health care professionals, 11,000 employers and 30,000,000 consumers throughout the United States
Current State of Healthcare
ØCare is complex ØCare is uncoordinated ØInformation is often not available to those who need it when they need it ØAs a result patients often do not get care they need or do get care they don't need
Cost of Morbidity Due to Medication Errors
ØEstimates: -Hospital care: $3.5 billion (2006 dollars) (Bates et al., 1997) -Outpatient Medicare: $887 million (2000 dollars) (Field et al., 2005) ØMany major costs are excluded, for example: -Failure to receive drugs that should have been prescribed -Patient non-compliance with prescribed drug regimens -Lost earnings and inability to perform household tasks -Errors that do not result in harm, but create extra work Medication errors can be very costly to patients and to the healthcare system. Several investigators have estimated financial burden associated with medication errors and the numbers are staggering. Understanding of the costs are somewhat limited. Additional costs excluded: •Failure to receive drugs that should have been prescribed •Drug use without a medically valid indication •compensation for pain and suffering
What is "Transition of Care"
ØThe movement of patients from one health care practitioner or setting to another as their condition and care needs change ØOccurs at multiple levels -Within Settings lPrimary care ó Specialty care lICU ó Ward -Between Settings lHospital ó Sub-acute facility lAmbulatory clinic ó Senior center lHospital ó Home -Across health states lCurative care ó Palliative care/Hospice Personal residence ó Assisted living Transition of care is the movement of patients from one health care practitioner or setting to another as their condition and care needs change and it necessarily occurs at multiple levels. It occurs 1) within settings, such as primary care and specialty care in the context of care in the community, 2) between settings, such as someone who moves from the hospital to the rehabilitation facility, and it occurs 3) across health states, such as from receiving care in the home to needing care in assisted living.
Challenges to Successful Transfers
•Lack of uniformity in coordinated care models •EHRs and communication The need to address patient concerns that their physicians are "not talking to each other." Dealing with specialists •Reimbursements from payers •Risk of harmful polypharmacy—adverse interactions caused by drugs prescribed by different doctors. •Coordinating with patients •Without the patient's cooperation, coordination does not work.
Hospital to Nursing Home
Adverse drug events (ADEs) attributable to medication changes occurred in 20% of bi-directional transfers -50% of ADEs were caused by discontinuation of medications during hospital stay Examples: Discontinue metoprolol - blood pressure rises to 208/108 mmHg; Discontinue insulin - blood glucose rises to >500 mg/dL. BACKGROUND: Care transitions are commonplace for ill older adults, but no studies to our knowledge have examined the occurrence of iatrogenic harm from medication changes during patient transfer. OBJECTIVES: To identify medication changes during transfer between hospital and nursing home and adverse drug events (ADEs) caused by these changes. METHODS: Participants were residents of 4 nursing homes in the New York City metropolitan area admitted to 2 academic hospitals. Nursing home and hospital medical records were reviewed to identify changes in medication regimens between sites. Medications were matched and compared regarding dosage, route, and frequency of administration. Two physician investigators used structured implicit review to identify ADEs attributable to transfer-related medication changes. RESULTS: During a total of 122 admissions, the mean numbers of medications altered during transfer from nursing home to hospital and hospital to nursing home were 3.1 and 1.4, respectively (P<.001 for comparison). Most changes in drug use were discontinuations, followed by dose changes and class substitutions. Of 71 bidirectional transfers that were reviewed by 2 physician investigators, ADEs attributable to medication changes occurred during 14 (20%). The overall risk of ADE per drug alteration (n = 320) was 4.4% (95% confidence interval, 2.5%-7.4%). Although most medication changes (8/14) implicated in causing ADEs occurred in the hospital, most ADEs (12/14) occurred in the nursing home after nursing home readmission. CONCLUSIONS: Medication changes are common during transfer between hospital and nursing home and are a cause of ADEs. Research is needed on interinstitutional patient care and systems interventions designed to prevent ADEs.
Elements of coordination of care models
Multidisciplinary communication, collaboration and coordination - including patient/caregiver education - from admission through transition Clinician involvement and shared accountability during all points of transition. Comprehensive planning and risk assessment throughout hospital stay. Standardized transition plans, procedures and forms. Standardized training. Timely follow-up, support and coordination after the patient leaves a care setting. If a patient is readmitted within 30 days, gain an understanding of why. Evaluation of transitions of care measures.
Examples Of Care Coordination in major parts of healthcare: PRIMARY CARE COORDINATION
The Guided Care model: a specially educated RN is responsible for patients with multiple chronic conditions. performs an initial assessment with the patient, works directly with the primary care providers Helps develop a care plan, and coordinates specialty care with other providers Ensure that nothing is missed and the plan is followed.
The Continuum of Health Care
The continuum of care is important to caregivers and patients alike, and it leads to an improvement of the satisfaction level, reduces costs and improves health. Health care providers are implementing coordinated care throughout the entire continuum of care, from primary care to long-term care. Care coordination is strengths all levels of care by introducing many of the elements of successful care coordination.
Independent Risk Factors for Having a Preventable ADE
The mean age was 84 years. Patients who had ADEs compared to those who did not have ADEs were similar on comorbid illness scales and % of residents with a diagnosis of dementia (about 60% in both groups). Those with ADEs had 9 or more medications in 36% of cases vs. 22% of those that did not have ADEs. The most frequently prescribed drugs were the classes gastrointestinal, non-opioid analgesics, cardiovascular, nutrients/supplements, and antibiotics.
Transition Issues Dramatically Impact Patient Care
see slide 7
Medication Error Type by Transition Category
sees slide 28-29 Improper dose/quantity= most at transition Prescribing error= most at admission Omission error: most at discharge
Data on Safety and Quality
Ø44,000-98,000 deaths/year in hospitals as a result of adverse drug events -Over 1,000,000 injuries ØEnormous practice variation -Estimated $450 billion unnecessary spending ØSlow translation of research to practice -One estimate 17 years
Costs of Adverse Drug Events
ØBates et al, 1997 -Additional length of stay associated with ADE = 2.2 days -Increased cost associated with ADE = $3244 -For preventable ADEs, increased length of stay = 4.6 days; increased cost = $5857 ØClassen et al, 1997 -91, 574 admissions over 4 years (1990-1993) in LDS hospital (tertiary care facility) -2227 patients developed an ADE -ADEs complicated 2.43 of 100 admissions -Excess cost associated with ADE was $2013
Case 1
ØDuring a patient's monthly follow-up appointment with the cardiologist, he informed the doctor that he was having trouble with one of his medications. The doctor asked which one. The patient said "The patch, the nurse told me to put on a new one every day and now I'm running out of places to put it!" The physician had him undress and discovered that the man had over a two dozen patches on his body.
Problems that Illustrate Inadequacies of Care Transitions
ØMedication errors ØIncreased health care utilization ØInefficient/duplicative care ØInadequate patient/caregiver preparation ØInadequate follow-up care ØDissatisfaction ØLitigation/Bad publicity There are a number a factors we can identify that highlight care transition inadequacies. Some of these we see daily in our practices, some of them we may only hear about by chance (e.g., patient satisfaction survey, newly published primary literature about these problems), and some we see in the press (e.g., nursing facility sued due to poor transition from hospital that possibly resulted in death).
Patient Level Barriers
ØPatients assume that someone is in charge of coordinating care ØPatients (and caregivers) are often the only common thread weaving between care sites ØYet they navigate the system with few tools or training to manage in this role
Practitioner Level Barriers
ØPractitioners often have not practiced in settings where they transfer patients ØSending practitioners may not communicate critical information to receiving practitioners ØPractitioners may not know the patient and his or her preferences for care ØPractitioners have no accountability
Hospital to Home
40% of patients experienced at least 1 medical error -Those with a "work-up" error* were 6 times more likely to be rehospitalized within 3 months *Work-up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart). OBJECTIVE: To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS: Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge. DESIGN: Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors. MEASUREMENTS: Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit. MAIN RESULTS: Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations. CONCLUSION: We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.
Follow-up of Hospitalized Elders with Heart Failure
An advanced practice nurse home follow-up program reduced 1 year hospitalization rates by over 60% with a mean cost savings of $4,845 per patient OBJECTIVES: To examine the effectiveness of a transitional care intervention delivered by advanced practice nurses (APNs) to elders hospitalized with heart failure. DESIGN: Randomized, controlled trial with follow-up through 52 weeks postindex hospital discharge. SETTING: Six Philadelphia academic and community hospitals. PARTICIPANTS: Two hundred thirty-nine eligible patients were aged 65 and older and hospitalized with heart failure. INTERVENTION: A 3-month APN-directed discharge planning and home follow-up protocol. MEASUREMENTS: Time to first rehospitalization or death, number of rehospitalizations, quality of life, functional status, costs, and satisfaction with care. RESULTS: Mean age of patients (control n=121; intervention n=118) enrolled was 76; 43% were male, and 36% were African American. Time to first readmission or death was longer in intervention patients (log rank chi(2)=5.0, P=.026; Cox regression incidence density ratio=1.65, 95% confidence interval=1.13-2.40). At 52 weeks, intervention group patients had fewer readmissions (104 vs 162, P=.047) and lower mean total costs ($7,636 vs $12,481, P=.002). For intervention patients, only short-term improvements were demonstrated in overall quality of life (12 weeks, P<.05), physical dimension of quality of life (2 weeks, P<.01; 12 weeks, P<.05) and patient satisfaction (assessed at 2 and 6 weeks, P<.001). CONCLUSION: A comprehensive transitional care intervention for elders hospitalized with heart failure increased the length of time between hospital discharge and readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs, thus demonstrating great promise for improving clinical and economic outcomes.
How to get ready for the Role of the Nurse
Education: Attain baccalaureate and advanced degrees Expand the scope of practice: promote nurses working to the extent of their education Diversify the workforce: ensure that the nursing workforce reflects patients' diverse backgrounds and cultural values Embrace technology: Use medical technology and EMR to improve quality and provide solutions to improve patient care Develop leadership skills: become fully empowered to provide excellent care and make the changes necessary to improve ineffectual systems. Be PROACTIVE: serve as successful and knowledgeable board or committee members, be familiar with governance, strategy, fundraising, financial systems, health law, and policy.
Case Management Interface with the Health Care Delivery Systems
Hospitals and integrated care delivery systems, including acute care, sub-acute care, long-term acute care (LTAC) facilities, skilled nursing facilities (SNF), rehabilitation facilities. Ambulatory care clinics and community based organizations, including student/ university counseling and health care centers. Corporations. Independent and private case management companies. Government-sponsored programs, e.g., correctional facilities, military health care/Veterans Administration, public health. Provider agencies and community facilities, i.e., mental health facilities, home health services, ambulatory and day care facilities. Geriatric services, including residential and assisted living facilities. Long-term care services, including home and community based services. Hospice, palliative, and respite care programs. Physician and medical group practices. Life care planning programs. Disease management companies.
Care Management: Implications for Medical Practice, Health Policy, and Health Services Research
Identify Populations with Modifiable Risks Future research is needed to determine the benefits to different patient segments of CM strategies. For some patient segments, emergency department admissions and hospital readmissions may be reduced. For others, medication errors may be decreased. For yet others, individual engagement in self-management may be enhanced Align Care Management Services to the Needs of the Population Coordination of Care Self-Management Support Outreach Identify and Train Personnel Appropriate to the Needed CM Services Once patients' needs for CM services have been determined, practices must decide how best to assign staff to deliver those services. Two approaches should be considered: (1) assigning or hiring a dedicated care manager or (2) distributing CM functions across two or more clinic personnel. Dedicated care managers have diverse backgrounds (e.g., pharmacists, registered nurses, social workers, clergy, dieticians, unlicensed health coaches, child and family advocates, and medical assistants). Assignment of clinically oriented CM services such as medication reconciliation should be based upon the training and level of licensure of personnel.
Case Studies
Mary: 61 Year old female with the following issues: 1. Breast Cancer treated with stem cell transplant 2. Inpatient hospital stay for 5 days with acute onset of viral pneumonia and is about to be discharged home with her family. a. Diagnosis of CHF made during this hospital stay-started on lisinopril and metoprolol in the hospital 3. Major Depression 4. Underweight (BMI 17) 5. Migraines 6. Irritable Bowel Syndrome Married for 40 years. Lives with husband and mother in Lake Oswego. She comes to OHSU for her care because she likes her PCP and is not interested in changing. Prior to her hospitalization she had been tired, lethargic, weak and short of breath for at least one week. She thought about calling the clinic to report her symptoms but it was the weekend and she figured the clinic was closed. Her husband called 911 on Sunday night because she could hardly "stand, talk, or breath." Medications Prior to Hospitalization Imitrex (sumatriptan) 50mg as needed for migraines Celexa (citalopram) 20mg daily Metamucil as needed How would you manage this patient's transition back to home in the first 2 weeks? What are some key assessment questions you would ask to determine her current state of understanding about her health status? What ongoing issues do you see for Mary and what education, support, and monitoring might she need?
The Statistics are Staggering...
Non-adherence statistics: •45% of hospital NRxes or Rx changes are never documented in out-patient medical records1 •12% of NRxes are never filled2 •29% don't complete LOT2 •22% take < than prescribed2 •Average hospital LOS due to medication non-compliance is 4.2 days2 Convene experts and apply evidence based clinical practice guidelines Despite wide distribution, evidence based clinical practice guidelines have not changed physician behaviors3 Medication Reconciliation across care settings is a Joint Commission National Patient Safety Goal Mobilize sanofi-aventis resources to optimize appropriate medication use across all channels National Quality Forum (NQF) endorsed 3-Item Care Coordination Measures to expand voluntary hospital consensus standards in care transitions4,5
Hospital Discharge
On discharge from the hospital, 30% of patients have at least one medication discrepancy* with the potential to cause possible or probable harm *Most common discrepancy is omission of pre-admit medication. BACKGROUND: In the hospital setting, postoperative admission is a key vulnerable moment when patients are at increased risk of medication discrepancies. This study measures the reduction of medication discrepancies associated with a combined intervention of structured pharmacist medication history interviews with assessments in a surgical preadmission clinic and a postoperative medication order form. METHODS: In the Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) study, patients who had a preadmission clinic appointment before undergoing surgical procedures were eligible for inclusion. Patients were excluded if they were scheduled for discharge the same day as their surgery. Eligible patients were randomly assigned to the intervention arm (structured pharmacist medication history interview with assessment and generation of a postoperative medication order form) or to the standard care arm (nurse-conducted medication histories and surgeon-generated medication orders). The primary end point was the number of patients with at least 1 postoperative medication discrepancy related to home medications. RESULTS: Between April 19, 2005, and June 3, 2005, a total of 464 patients were enrolled in the study, of which 227 and 237 patients were randomized to the intervention and standard care arms, respectively. In the intervention arm, 41 (20.3%) of 202 patients had at least 1 postoperative medication discrepancy related to home medications, compared with 86 (40.2%) of 214 patients in the standard care arm (P<.001). In the intervention arm, 26 (12.9%) of 202 patients had at least 1 postoperative medication discrepancy with the potential to cause possible or probable harm, compared with 64 (29.9%) of 214 patients in the standard care arm (P<.001). These were mostly omissions of reordering home medications. CONCLUSION: A combined intervention of pharmacist medication assessments and a postoperative medication order form can reduce postoperative medication discrepancies related to home medications.
Hospital Admission
On hospital admission, more than 50% of patients have at least one medication discrepancy* -Approximately 40% of those have potential to cause harm *Discrepancy defined as error between admission medication orders and patient interview of medication history. BACKGROUND: Prior studies suggest that unintended medication discrepancies that represent errors are common at the time of hospital admission. These errors are particularly worthy of attention because they are not likely to be detected by computerized physician order entry systems. METHODS: We prospectively studied patients reporting the use of at least 4 regular prescription medications who were admitted to general internal medicine clinical teaching units. The primary outcome was unintended discrepancies (errors) between the physicians' admission medication orders and a comprehensive medication history obtained through interview. We also evaluated the potential seriousness of these discrepancies. All discrepancies were reviewed with the medical team to determine if they were intentional or unintentional. All unintended discrepancies were rated for their potential to cause patient harm. RESULTS: After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria. Eighty-one patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy. The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration. CONCLUSIONS: Medication errors at the time of hospital admission are common, and some have the potential to cause harm. Better methods of ensuring an accurate medication history at the time of hospital admission are needed.
POST-ACUTE/LONG-TERM CARE COORDINATION
Patients who reside in rehabilitation, long-term care (LTC) or post-acute care (PAC) facilities May need to change to different care levels within facilities — as patients health changes. Require coordinated care to manage medications transfers and update care plans. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources The importance of this is increasing as studies show that "hospital discharges to post-acute care (PAC) facilities have increased rapidly" and "hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources." (Burke et al., 2016)
Study Outcomes: Pharmacist Intervention vs Usual Care
Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. The authors concluded that pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention. see slide 43
AGS Position Statement- 1 (American Geriatrics Statement)
Position 1: Clinical professionals must prepare patients and their caregivers to receive care in the next setting and actively involve them in decisions related to the formulation and execution of the transitional care plan The rationale for this position is that during a care transition, patients with complex care needs and their caregivers require preparation for what to expect at the next care site and the opportunity to provide input into the plan of care regarding their values and preferences. An important component of this preparation is to ensure that these patients and their caregivers have clear advice on how to manage their conditions, how to recognize warning symptoms that may indicate that their condition has worsened, how to contact a health professional who is familiar with their plan of care, and how to seek care in the setting to which they have moved.
AGS Position Statement- 2, 3
Position 2: Bidirectional communication between clinical professionals is essential to ensuring high quality transition care Position 3: Develop policies that promote high quality transitional care The rationale for position 2 is that during a care transition, the "sending" and "receiving" healthcare professionals require a uniform plan of care to facilitate communication and continuity across settings and an accessible record that contains a current problem list, medication regimen, allergies, advance directives, baseline physical and cognitive function, and contact information for caregivers and healthcare professionals. This communication can be telephonic, electronic, or through a paper medical record. The opportunity to collaborate with a "coordinating" health professional functioning across healthcare settings to reduce care fragmentation may enhance the care that professionals deliver. This professional should be skilled in the identification of changes in health status, assessment and management of multiple chronic conditions, managing medications, and collaboration with interdisciplinary healthcare professionals and caregivers. For position 3, the rationale is that policymakers need to recognize the critical role of transitional care in the quality and outcomes of care experienced by persons with complex care needs and commit to implementing new quality-improvement strategies. Performance indicators designed to measure the effectiveness of transitional care across different delivery settings are needed to ensure that both the "sending" and "receiving" providers are held accountable for the success or failure of a patient's transition. Whenever possible, quality improvement entities such as the National Committee for Quality Assurance, Quality Improvement Organizations (formerly known as Peer Review Organizations), the Joint Commission, state health departments, or a new quality improvement entity should monitor transitional care performance in fee-for-service and capitated practice environments. Finally, greater financial incentives are needed to improve transitional care. Essential elements of transitional care should become Medicare benefits (e.g., interinstitutional and interprofessional communication to coordinate their execution of each patient's care plan).
Case Management Interface with Various Reimbursement Sources
Public health insurance programs, e.g., Medicare, Medicaid, state-funded programs. Private health insurance programs, e.g., workers' compensation, occupational health, disability, liability, casualty, automotive, accident and health, long term care insurance, group health insurance, managed care organizations. Non-profit / NGO's for the unfunded
Current coordination of care models
Several evidence-based transitions of care models have been developed to improve patient outcomes. These models include: Care Transitions Intervention (CTI), Transitional Care Model (TCM), Better Outcomes for Older Adults through Safe Transitions (BOOST), The Bridge Model, Guided Care, Geriatric Resources for Assessment and Care of Elders (GRACE), Project RED (Re-Engineered Discharge).
Goals of Care Coordination
The goals of coordinated care improve health outcomes by ensuring that care from disparate providers is not delivered in silos, and to help reduce health care costs by eliminating redundant tests and procedures. The central goal of care coordination is shown in the middle of the diagram. The colored circles represent some of the possible participants, settings, and information important to the care pathway and workflow. The blue ring connecting the colored circles is Care Coordination—namely, anything that bridges gaps (white spaces) along the care pathway (i.e., care coordination activities or broad approaches hypothesized to improve coordination of care.
System Level Barriers
The healthcare system is often kept in information silos. An information silo is a management system incapable of reciprocal operation with other, related management systems. This expression is often used to describe management systems that focus inward with vertical information communication, making it difficult if not impossible for different departments to share information. Information silos within healthcare systems can cause problems at the patient care level such as prescribing a medication when a patient has known allergies or intolerance, discrepancies from different information sources, incomplete or inaccurate discharge instructions, and therapy duplication, as well as numerous other examples.
MEDICAL HOME - Team Based CareEveryone works to the top of their license!
Under such a model, traditional, hospital-based case management or utilization management could become a thing of the past. "In our ACO, we are moving toward eliminating the distinction between care coordinators, hospital case managers, and utilization management," Menacker says. "We recognize that as we move forward, those assisting transitions are all care coordinators, and it doesn't matter if a patient is in the hospital, in a nursing home, or at home. Patients need care coordination across the continuum." Hegwer, L. (2015). Innovation with care transitions. Leadership +. Retrieved from: https://api.hfma.org/Leadership/Archives/2015/Summer/Innovation_With_Care_Transitions/
Completing Recommended Outpatient Workups
Workup Type is the outpatient workup recommended upon discharge from the hospital. Completed indicates whether the recommended workup was done within 6 months after discharge. 240 workups recommended in 191 discharges. Of 693 hospital discharges, 191 discharged patients (27.6%) had 240 outpatient workups recommended by their hospital physicians. The most common diagnostic procedures were computed tomographic scans to follow up abnormalities seen on previous radiographic studies and endoscopic procedures to follow up gastrointestinal tract bleeding. Of recommended workups, 35.9% were not completed.
Utilization Outcomes
see slide 40 Intervention patients had lower rehospitalization rates at 30 days (8.3 vs 11.9, P = .048) and at 90 days (16.7 vs 22.5, P = .04) than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days (5.3 vs 9.8, P = .04) and at 180 days (8.6 vs 13.9, P = .046) than controls. The mean hospital costs were lower for intervention patients ($2058) vs controls ($2546) at 180 days (log-transformed P = .049). The authors concluded that coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.
Readmission Rates with Comprehensive Discharge Planning + Postdischarge Support
see slide 44 The objective of the study was to evaluate the effect of comprehensive discharge planning plus post discharge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs. DATA SOURCES: We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. ...CONCLUSION: Comprehensive discharge planning plus post discharge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
Adverse Events in Nursing Home Residents Transferred to the Hospital
Ø122 nursing home to hospital transfers Ø98% returned to the nursing home ØIn 86% of transfers, at least one medication order was altered (mean 1.4) -65% - discontinued -19% - dose changes -10% - substitutions Ø20% of changes resulted in an adverse event This study sought to identify medication changes during transfer between hospital and nursing home (NH), and adverse drug events (ADEs) caused by these changes. Participants were residents of 4 NHs in the New York City metropolitan area admitted to 2 academic hospitals. NH and hospital medical records were reviewed to identify changes in medication regimens between sites. Medications were matched and compared regarding dosage, route, and frequency of administration. Two physician investigators used structured implicit review to identify ADEs attributable to transfer-related medication changes. During a total of 122 admissions, the mean numbers of medications altered during transfer from NH to hospital and hospital to NH were 3.1 and 1.4, respectively (P<.001 for comparison). Most changes in drug use were discontinuations, followed by dose changes and class substitutions. Of 71 bidirectional transfers that were reviewed, ADEs attributable to medication changes occurred during 14 (20%). The overall risk of ADE per drug alteration (n = 320) was 4.4% (95% CI, 2.5%-7.4%). Although most medication changes (8/14) implicated in causing ADEs occurred in the hospital, most ADEs (12/14) occurred in the NH after readmission. The investigators concluded that medication changes are common during transfer between hospital and nursing home and are a cause of ADEs. Research is needed on interinstitutional patient care and systems interventions designed to prevent ADEs.
What is "Transitional Care?" cont
ØA 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 ØBased on a comprehensive care plan and availability of well-trained practitioners that have current information about the patient's goals, preferences, and clinical status. ØIncludes: -Logistical arrangements -Education of the patient and family -Coordination among the health professionals involved in the transition Persons whose conditions require complex, continuous care frequently require services from different practitioners in multiple settings, but practitioners in each setting often operate independently, without knowledge of the problems addressed, services provided, information obtained, medications prescribed, or preferences expressed in previous settings. The growing national trend for physicians and other clinicians to restrict their practices to single settings (e.g., hospitals, skilled nursing facilities, or ambulatory clinics) and not to follow complex patients as they move between settings heightens this potential for fragmentation of care. During transitions, these patients are at risk for medical errors, service duplication, inappropriate care, and critical elements of the care plan "falling through the cracks." Ultimately, poorly executed care transitions may lead to poor clinical outcomes; dissatisfaction among patients; and inappropriate use of hospital, emergency, postacute, and ambulatory services.
OIG Report - June '07
ØConsecutive Medicare stays involving inpatient and skilled nursing facilities ØKey findings ... -35% of consecutive stays were associated with quality-of-care problems and/or fragmentation of services -11% of individual stays within consecutive stay sequences involved problems with quality-of-care, admission, treatments or discharges
The Care Transitions Intervention
ØDoes encouraging older patients and their caregivers to assert a more active role in their care transition reduce rates of rehospitalization? (answer=yes) Randomized controlled trial (N=750) Transition coach Intervention built on 4 pillars Medication self-management Patient-centered record owned and maintained by patient Follow-up is timely with primary or specialty care Red flags and how patient should respond This was a randomized controlled trial in a large integrated delivery system located in Colorado. Subjects (N = 750) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions. Intervention patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care and to assert their preferences, and (3) continuity across settings and guidance from a "transition coach." Rates of rehospitalization were measured at 30, 90, and 180 days.
Role of Pharmacist Counseling in Preventing ADEs After Hospitalization
ØDoes pharmacist counseling before discharge reduce the rate of preventable ADEs? ØRandomized controlled trial of pharmacist intervention (n=92) vs usual care (n=84) ØIntervention on day of discharge -Medication reconciliation -Screening for nonadherence, previous drug-related problems, lack of drug efficacy, and side effects -Review of indications, directions for use, and potential side effects with patient Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. The objectives of this study were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. The study was a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs.
The Joint Commission National Patient Safety Goals
ØGoal 8: Accurately and completely reconcile medications across the continuum of care -8A: There is a process for comparing the patient/resident's current medications with those ordered for the patient/resident while under the care of the organization -8B A complete list of the resident's medications is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient/resident on discharge from the facility In July 2002, The Joint Commission approved its first set of National Patient Safety Goals (NPSGs) with related specific requirements for improving the safety of patient care in health care organizations. All Joint Commission accredited health care organizations are surveyed for implementation of the goals and requirements—or acceptable alternatives—as appropriate to the services the organization provides. The goals and requirements are prioritized from a "pool" of recommendations identified by the Sentinel Event Advisory Group as evidence- or consensus-based, cost-effective and practical. Each year, new recommendations from Sentinel Event Alert newsletters published in the previous year and from other authoritative sources are added to the pool. In 2004, The Joint Commission began developing program-specific NPSGs for each of its accreditation and certification programs in order to make the goals and requirements more relevant to the non-hospital accreditation programs.
Hospital to PCP transfer
ØMeta-analysis ØDirect communication between hospital physicians and primary care physicians occurred infrequently ØDischarge summary -Availability at first postdischarge visit low (12%-34%) -Remained poor at 4 weeks (51%-77%) -Affected quality of care in ~25% of follow-up visits -Often lacked important information (e.g., lab results, discharge medications, treatment, follow-up plan) The objectives of this study were to characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data sources included MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Observational studies investigating communication and information transfer at hospital discharge (n=55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n=18) were included. Data from observational studies were extracted on the availability, timeliness, content, format of discharge communications, and primary care physician satisfaction. Intervention results were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Direct communication between hospital physicians and primary care physicians occurred infrequently (3-20%). The availability of a discharge summary at the first postdischarge visit was low (12-34%) and remained poor at 4 weeks (51-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33-63%), treatment or hospital course (7-22%), discharge medications (2-40%), test results pending at discharge (65%), patient or family counseling (90-92%), and follow-up plans (2-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived document quality. The authors concluded that deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.
Case Examples of Medication Errors on Transition/Transfer
ØPatient with prior history of several arterial stent replacements -Receiving aspirin, enoxaparin, clopidogrel -Meds placed on hold prior to surgery for removal of toe; Physician did not reordered after surgery -2 of patient's coronary arteries with stents became 100% occluded; patient expired ØPatient transferred from ICU to step-down unit -Prior to transfer, patient received morning doses of scheduled meds -Administration of same meds repeated upon arrival to new unit due to unclear documentation and communication
Case Examples of Medication Errors on Admission
ØPatient's home medication recorded as Coreg® 25 mg twice daily on admission -Patient actually taking 6.25 mg twice daily at home -Patient received 4 doses of excessive strength and developed leg edema -Error was not discovered until after leg ultrasound test to rule out DVT ØNursing home patient receiving propranolol 20 mg/5mL twice daily -Admitting orders written as propranolol 20 mg/mL give 5 mL (which equates to 100 mg) twice daily -Patient received 5 doses of 100 mg strength before error was discovered
