Aubrey L. Knight, M.D. Chief, Geriatric and Palliative Medicine Carilion Clinic Roanoke, VA

1. Transitions in Long Term Care: The role of a hospital/SNF partnership in assuring effective transitions of care Aubrey L. Knight, M.D. Chief, Geriatric and Palliative Medicine Carilion Clinic Roanoke, VA

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

3. Objectives • Understand the risks inherent in transitions from one site of care to another • Identify processes at the time of transition that can help to mitigate some of the risks • Recognize the role of the SNF and the medical director in assuring the transition is safe

4. It’s in the News “Care Transitions: The Hazards of Going In and Coming Out of the Hospital”- Huffington Post 10/10 “Heart Failure Program Has Reduced Readmissions by 30 Percent”- The New York Times 9/11 “Don’t Come Back, Hospitals Say”- THE WALL STREET JOURNAL-6/11

5. It’s big business

6. It’s not rocket science • Rather, it is: • Good care • Good communication • Attention to detail • Teamwork

7. So, what makes it so difficult? • Complexity • Of systems • Of rules and regulations • Of patients • Technology • Double-edged sword • Entropy • The concept of health care as a “team sport” has been slow to evolve • Mal-aligned incentives • Lack of payment for many of the things that could help • Throughput, current hospital payment methodology, etc

8. SNF Fundamental Disconnect… Hospital Skilled Nursing Facility Home Ambulatory Care Clinic Rehabilitation Facility Home Health and Hospice

9. Complexity • Of systems • Of rules and regulations • Of patients

10. Technology- “the double-edged sword” • Meaningful use vs. Meaningful care • Reliance on the computer to do the work of the human • EHRs that do not talk

11. Entropy • The silo mentality of our systems • “We’ve never done it that way before” Hospital SNF Home Care

12. Misaligned incentives • Through-put- do everything quickly…”get them out of my…” • DRG’s- financial incentives to shorter LOS • Medicare Part A restrictions- Hospice in the nursing home setting

13. Transitions of Care- Definition • The movement of patients from one health care practitioner or setting to another as their condition or care needs change. • Within settings • Primary care to Specialty care • ED to inpatient • ICU to PCU to ward • Between settings • Hospital to LTC (and back) • Hospital/LTC to home • Across health states • Curative to palliative care

14. Each transition brings with it opportunity for error • Medication errors • Inefficient/duplicative care • Inadequate patient/caregiver preparation • Inadequate follow-up • Dissatisfaction • Litigation

15. Barriers to effective transitions • Patient barriers • System barriers • Practitioner barriers

16. Patient barriers • Patients are living longer and with age comes chronic illness • Institutionalization fosters dependency and we ask them to abruptly become independent • Health literacy • Ability to follow though with plans • Transportation • Cognitive impairment • Cost of medications • Medicare D “donut hole”

19. System barriers • Complexity • Multiple providers • Shift work/Duty hours • Poor electronic communication • Poor understanding of the capabilities and roles of home health, hospice, and SNF

20. Practitioner barriers • Busyness • Specialization • Hospitalist • Intensivist • SNFist • Extensivist • Outpatient only

22. Medicare – Excess Readmission Rates - Penalties • CMS will penalize hospitals for excess readmission rates starting FFY 2013 (Oct. 2012) • Initial focus – HF, AMI, PNE • FFY2015 (starts Oct. 2014) may add chronic obstructive pulmonary disease, CABG, percutaneous coronary interventions, and some vascular surgery procedures. • Penalty • FFY2013 – up to 1% all IP Medicare payments (CMC approx $1.5m) • FFY2014 – up to 2% • FFY2015 – up to 3%

23. 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

24. Organizational guidance • CMS 9th SOW statement about care coordination • 2009 Joint Commission Patient Safety Standard #8 about medication reconciliation • NQF Performance Measures for Care Coordination • NTOCC tools and resources

25. Patient Bill of Rights during Transitions of Care • Multiple other tools • www.ntocc.org

26. Published models • H2H- American College of Cardiology • Project Boost- Society of Hospital Medicine • Project RED • The Care Transitions Intervention

27. American College of Cardiology and Institute for Healthcare Improvement

28. Project BOOST • Better Outcomes for Older Adults Through Safe Transitions • Effort of the Society of Hospital Medicine • Resources and evidence-based interventions • Encourages team building and working through system processes

29. Educate the patient Make appointments Discuss tests and results Organize post-discharge services Confirm the medication plan Reconcile the discharge plan Review process when problems arise Expedite the transmission of the discharge summary Assess patient understanding Give patient a written discharge plan Telephone reinforcement in 2-3 days post-discharge Project RED

30. Improving the Discharge Process – The Care Transitions Intervention • Designed to encourage older patients and their caregivers to assert a more active role during care transitions • Elderly patients provided a transition coach • “4 pillars” • Medication self-management • Maintenance of Personal Health Record • Timely f/u with PCP and Specialists • Knowledge of potential complications and ways to manage them if they occur Coleman et al. Arch Intern Med. 2006; 166:1822-1828

31. Outcomes from effective transitions • Improved patient/family satisfaction • Reduced health care cost • Decrease readmissions Patients cared for at the right time, at the right place.

32. Ultimately Lower Health Care Costs • Reduced inefficiencies/duplication of services • Lower hospital and ED use • National 30-day readmit rate- 15-25% • Reduced litigation/negative press

33. IDEAS for success • Involve stakeholders • Develop tools • Engage/empower patients and caregivers • Adapt technology so that there is the ability to share information • Share information

34. Stakeholders • Hospital administration (see CMS penalties) • LTC administrators (mention bundled payment and you’ll get their attention) • Hospital physicians • LTC Medical Director

35. Transition tools • Checklist • Discharge summary • Handoff • Medication reconciliation • Engage floor nurses and case managers • Follow-up • phone calls • appointments

36. Keep it simple • We work in an incredibly complex field • 6,000 drugs • ICD-9 has > 13,000 conditions • The basics can get lost in the jungle of complexity • Checklists can help simplify and standardize • Airline pilots

37. The Discharge Summary and other handoffs • Physician summaries are the least reliable source of medication lists- Am J Ger Pharmacotherapy Aug 2011 • Summaries and Handoffs are our means of communication and must be: • Complete- “Antibiotics for one week” • Accurate- Inpatient and outpatient meds not thoughtfully reconciled • Clear- “Follow-up CT scan in one week”

39. Medication Reconciliation • Errors occur in deciding on and communicating whether and which outpatient medications should be continued when patients leave the hospital or the nursing home • Over half of medication discrepancies were classified as potentially causing moderate/severe discomfort or clinical deterioration- Am J Ger Pharmacotherapy Sept 2011 • Pharmacist-led models of medication reconciliation continue to emerge

41. 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

42. 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?

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

44. Follow up • Post discharge calls • By hospital case management, pharmacist, PCMH…ANYONE • Accountability • This is the lethal gap in the care. Someone needs to take responsibility. • Follow up appointments • Studies indicate that appointments within 7-14 days make a difference

45. Patient • Empowered to ask • Armed with information • Knows whom to call for answers

46. Make technology your friend • EMR • Telemonitoring • Email/texting

47. Communication • Understand to roles and capabilities at the various sites of care • Share your piece of the puzzle • Be specific

48. Relational Coordination • Relationships of: • Shared goals • Shared knowledge • Mutual respect • Communication that is: • Frequent • Timely • Accurate • Problem-solving

49. Real Health Care Reform • Is local • Involves each stakeholder working as a team • Patient • Family • Providers • Institutions • Community agencies/resources

50. References • Project Boost: www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/project_boost_background.cfm • Project RED: www.bu.edu/fammed/projectred/ • Care Transitions Intervention: www.caretransitions.org/ • NTOCC: www.ntocc.org • H2H: www.H2Hquality.org • AMDA CPG on Transitions of Care- www.amda.com/tools/clinical/TOCCPG/index.html • Atul Gawande- http://gawande.com/