Faculty Development: Teaching Triggers for Transitional Care “A Train-the-Trainer Model”

1. Faculty Development:Teaching Triggers for Transitional Care“A Train-the-Trainer Model” Lindsay Mazotti, MD C. Bree Johnston, MD University of California, San Francisco Department of Medicine

2. Acknowledgements • This presentation was supported by the Donald W. Reynolds Foundation • Thanks to the following people for modification/ adapation of their materials: • Bill Lyons, MD; University of Nebraska • Helen Kao, MD & Brad Sharpe, MD; UCSF • Catherine E. DuBeau, MD; University of Chicago CHAMP Program http://champ.bsd.uchicago.edu

3. Curricular Objectives • Improve knowledge about transitions • Understand the 3 domains of transitions in care • Identify teachable moments in readmissions, transfers • Increase awareness around good discharge summaries

4. ROADMAP • Background • 3 Domains of Transitional Care • Teaching Triggers • A readmission • A discharge summary • An anticipated discharge • Brainstorming

5. Take Home Message Providing good transitional care requires: • ANTICIPATION & PREPARATION • DESTINATION • INFORMATION • EDUCATION

6. Background: Care Transitions • Movements patients make between health care providers and different care settings

7. TRANSITIONAL CARE • Based on comprehensive care plan including: • Patient’s goals, preferences, and clinical status • Logistical arrangements • Patient and family education • Coordination among health professionals and health care teams • Includes both SENDING & RECEIVING Slide courtesy of Bill Lyons, MD; University of Nebraska

8. Why you care • Transitions are wrought with errors • 25% of patients d/c’d from an academic medical service had an adverse event within 3 weeks • Nearly 50% were preventable • Readmission rates within 30 days are as high as 25% • Subject of national attention • JCAHO is watching • You find it personally satisfying to be a “good” doctor

9. Brainstorm • Why is it important to teach residents/students about transitional care? • Have you had any successes in teaching about transitional care? Can you share?

10. QUANTATIVE STUDIES SHOW • In 2001, patients >65 yo discharged from acute settings went… • to another institution ¼ of the time • home with home health 11% of the time1 • 13% of Medicare beneficiaries transfer ≥3 in 30d post-discharge2 • Serious problems with discharge summaries, communication with PMD’s, med reconciliation 1. Agency for Health Care Quality Research HCUPnet 2. Coleman et al. Health Services Research 2004

11. QUALITATIVE STUDIES SHOW • Patients don’t understand what medications are for or anticipated side effects • … or when to resume normal activities • …and don’t know what questions to ask, or whom to ask • …or what warning signs to watch for Slide courtesy of Bill Lyons, MD; University of Nebraska

12. WHAT IS HIGH-QUALITY TRANSITIONAL CARE? • Reliable, accurate information transfer • Preparation of patient, family, caregiver • Support for self-management • Empowerment of patient to assert preferences Coleman et al. Int J Integrated Care 2002

13. 3 Domains of a Transfer • Where should they go? • How to best transfer information? • How to educate and prepare the patient?

14. Mrs. Ima Notthriving • 82 yo woman with multiple medical problems; resides at SNF • Hospitalized at Our Med Center early January for AMS, lethargy, UTI? (dirty sample, culture negative) • Returned to SNF • Admitted to your team 3 weeks later with with hypoxia and lethargy • nonspecific EKG T-wave changes, O2 sat 90%, known pleural effusion • Increased fatigue and decreased PO intake x “1 month”

15. Mrs. Notthriving • PMH: • ESRD on HD • CHF, L sided effusion • Depression • CAD: s/p 5-6 MI’s & CABG • H/o seizure disorder • Meds include anti-hypertensives, PPI, anti-seizure, renal meds, pain meds, stool softeners

16. Mrs. Notthriving • SH • Widowed, no children, retired • Former neonatal nurse • Resides at SNF x years, bedbound

17. Mrs. Notthriving • Exam: 36.2 123/53 64 16 95-100%RA • Gen: waxing waning lethargy • RRR, III/VI systolic murmur LLSB • Decreased BS on L • L BKA, L femoral fistula • “Unable to assess orientation”, pt follows commands, neuro grossly intact • Labs normal • CXR with known L sided effusion • Dirty UA, >50 WBC, culture negative (again)

18. Teaching Trigger: A ReadmissionExamine the 3 Domains of Her Transfer • Appropriate d/c location with first d/c? • How was our information transfer? • Was the patient educated & prepared?

19. Walking Through Her Case

20. Domain 1- DESTINATION Did we send her to the right place after her last admission?

21. Where should they go? • What are the patients goals? • for medical and functional recovery • What are their risks? • is benefit of the transition > harms associated with transfer to a new venue?

22. Age>80 Fair-to-poor self-rating of health Recent and frequent hospitalizations Inadequate social support Multiple, active chronic health problems Depression history Chronic disability and functional impairment History of nonadherence to therapeutic regimen Lack of documented patient/family education FACTORS ASSOCIATED WITH POOR DISCHARGE OUTCOMES Destination: Assessing Risk Slide courtesy of Bill Lyons, MD; University of Nebraska

23. Where should they go? • What are the patients goals? • for medical and functional recovery? • What are their risks? • is benefit of the transition > harms associated with transfer to a new venue? • Is the new venue a good match? • Does it match their medical, nursing, and functional needs? Modified slide courtesy of Bill Lyons, MD; University of Nebraska

24. Destination: A Good Match? Admitted to Hospital From: HOME NURSING HOME Home Home With Services Acute Rehab Nursing Home Slide courtesy of Catherine DuBeau, MD; University of Chicago CHAMP Program, http://champ.bsd.uchicago.edu

25. Domain 2- INFORMATION How was our information transfer?

26. Has anyone taught in rounds or one-on-one about discharge summaries?

27. Discharge Summaries: Problems • “too much of the H&P and too little of the hospital course” • “lots of numbers about BUN and creatinine where it would have been sufficient to say that the patient was having mild renal insufficiency”

28. Quality Summaries: What do receiving physicians want included in a DC summary?

29. Quality Summaries: What the PMD’s want… • Evaluation of 226 physicians (56% generalists) • Surveyed preferred content of D/C summaries ranked by importance

30. TABLE 2:Preferred Content of Discharge Summary Ranked by Importance O’Leary et al, J Hosp Med, 2006.

31. Teaching Trigger: Review Ms. Notthriving’s Discharge SummaryA Group Exercise

32. Mrs. Notthriving’sTransfer Summary “Briefly, this is an 82-year-old female with CHF, end-stage renal disease on hemodialysis, and a seizure disorder who is referred to the Emergency Department after she was noted to be sleepy and disoriented with poor p.o. intake for the past 3 days. The patient's chief complaint was, "I feel lousy," endorsing fatigue and weakness. The patient was last dialyzed on the day of admission with 1-1.5 kg fluid removed. For past medical history, medications, social history, and family history, please refer to admission history and physical.”

33. HOSP COURSE BY PROBLEM • Lethargy/altered mental status: “Significant objective findings on admission included presence of a urinary tract infection and a large left-sided pleural effusion. Basic metabolic labs were within normal limits. A noncontrast head CT was obtained and was negative for an acute process. The patient was treated for a urinary tract infection with cephalexin. Urine cultures were negative. The patient will finish a 10 day course of cephalexin. With regards to the pleural effusion, thoracentesis was offered but was declined by the patient in the Emergency Department, which was appropriate given her lack of respiratory distress or hypoxia…”

34. “ …The patient's mental status improved somewhat to the point where her family members felt she was at baseline. Of note, at baseline the patient is frequently quite somnolent, however, is able to arouse to voice. With regards to her pleural effusion, the plan is currently to continue hemodialysis for volume management and to follow the patient for development of symptoms at which point the therapeutic thoracentesis could be considered if needed.”

35. DISPOSITION: “The patient will be transferred to her HD facility for her regularly scheduled hemodialysis. Afterwards, she will be transferred to SNF, where she had previously been living.” • CONDITION AT TRANSFER: “While the patient's altered mental status and lethargy have improved, she is frequently noted to be quite sleepy. In discussion with the patient's family and outpatient physicians, this is consistent with her baseline and she is felt safe to be transferred back to her Skilled Nursing Facility, to which the patient is eager to return.”

36. FOLLOW-UP: The patient will be seen by her primary nephrologist, Dr. Renal, at hemodialysis on the day of transfer. • MEDICATIONS ON TRANSFER: 1. Cephalexin suspension to complete a 10-14 day course started January 4. 2. Phenytoin 300 mg daily. 3. Escitalopram 10 mg daily. 4. Lansoprazole 30 mg daily. 5. Nephrovite. 6. Sevelmer. 7. Hydrocodone/APAP as needed. 8. Amlodipine 10 mg daily.

37. DISCHARGE DIAGNOSES: 1. Altered mental status, likely secondary to urinary tract infection. 2. Urinary tract infection with negative urine culture. 3. Left-sided pleural effusion. 4. End-stage renal disease on dialysis. 5. Congestive heart failure. 6. Diabetes mellitus. 7. Sacral decubitus ulcer.

38. Teaching Trigger: Review a Discharge SummaryWhat is missing?What could be more explicit?What do you want to know as the receiving MD?

39. Discharge Summaries

40. HPI / PMH PEX / LABS HOSPITAL COURSE BY PROBLEM HOSPITAL COURSE BY PROBLEM STUDIES/PROCEDURES DISCHARGE MEDICATIONS

41. DOA DOD Attending HPI / PMH / PEX HOSPITAL COURSE BY PROBLEM 1,2, 3. . . 4 Code/Adv Dir/Goals of Care Studies / Procedures /Consultations DISCHARGE CONDITION PROGNOSIS FUNCTION DISCHARGE INSTRXNS DISCHARGE FOLLOW-UP DISCHARGE MEDICATIONS

42. Recommended Standard Format • ID, CC & HPI  • Hospital Course by Problem • Pertinent Studies and Procedures • Discharge Diagnoses  • Discharge Medications • Dispo • Diet • Function/Activity  • Condition/Prognosis/Goals of Care • Follow up Plans

43. ID, CC, HPI • Be succinct! • ID, CC, HPI should be rolled into 1-3 lines • This is the one-liner you deliver to your attending or to your friendly but overwhelmed specialty consultant who doesn’t have time to hear the novella on your patient • Your goal is to describe the Big Picture of who the patient is and what they’re in the hospital for

44. Hospital Course By Problem • MAJOR ACUTE PROBLEMS • Main reasons for hospitalization • PNA & HYPOTENSION & HYPOXIA could be just “PNA with complications” • Chronic medical conditions requiring adjustments TIPS: • Should be SHORT, no more than 1 paragraph • Do not need to focus on your thinking/ differential dx • Avoid narrative speech!

45. Pertinent Studies & Procedures • Includes: • CT Scans, MRI, other radiologic studies • Echocardiograms • Interventional or Surgical Procedures • IR instrumentation • Cath • Scopes • Taps What would be important to know as a PMD and difficult to track down?

46. Discharge Diagnoses • List of major diagnoses from hospital stay  • Does not include chronic illnesses (unless major changes) • Not for billing • >10 = TOO MANY

47. Recommended Standard Format • ID, CC & HPI  • Hospital Course by Problem • Pertinent Studies and Procedures • Discharge Diagnoses  • Discharge Medications • Dispo • Diet • Function/Activity  • Condition/Prognosis/Goals of Care • Follow up Plans

48. Discharge Medications • Some argue it is the most important part of the discharge summary • Why???

49. Discharge Medications • Medication Errors are very very common at discharge • In 375 geriatric pts, 14% had a medication discrepancy when they got home • This increased rate of readmission by 2.5 • In a study of 400 discharged patients, 45 (11%) had an adverse drug event • 60% of those were preventable/ameliorable Coleman EA Arch Intern Med 2005 Forster AJ. Ann Intern Med 2003

50. Discharge Medications In your discharge summary: • List the medications that were stopped • Don’t need doses, just the list