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Improving Hospital Transfers for Long-Term Care Patients: Insights and Innovations

This presentation by Dr. Jeffrey P. Schaefer explores critical questions surrounding the hospitalization of long-term care (LTC) patients. It examines the frequency and reasons for hospital admissions, criteria for transfer, and alternative care options. The study highlights challenges faced by both acute care providers and LTC facilities post-discharge, as well as innovative strategies implemented elsewhere. Key insights address how to improve care pathways and reduce unnecessary hospitalizations, focusing on communication, expectations, and proactive planning.

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Improving Hospital Transfers for Long-Term Care Patients: Insights and Innovations

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Presentation Transcript

  1. LTC and the Hospital Jeffrey P Schaefer, MD slide update available at dr.schaeferville.com

  2. Disclosure No conflicts of interests

  3. Eight Questions… • How often & why are LTC patients admitted to hospital? • Do criteria for transfer to acute care exist? • Has ‘appropriateness of transfer’ been studied? • Are there local alternatives to hospital transfer? • What has been tried elsewhere? • What challenges face the acute care providers? • What challenges face the LTC provider post-d/c • Can we do better?

  4. Why are LTC patients admitted to hospital? … not much published data

  5. How often & why are LTC patients admitted to hospital? • Hip fracture • Pneumonia • Stroke • Chest pain • Heart Failure • Anemia Tidsskr Nor Laegeforen. 2005 Jun 30;125(13):1844-7

  6. American J Public Health 1994:84:1615 • Retrospective cohort of 2,120 nursing home patients that were initially admitted to their facility in 1982 and followed. • Munroe County, New York State

  7. fairly flat over time

  8. 25 – 35 % prevalence of each

  9. community based controls

  10. Predictors of Hospitalization • Bedbound (11%) vs ambulant (26%) • On-site Physician (21%) vs none (28%) • Male (29%) vs female (25%) • Co-morbidity  not statistically sig

  11. Criteria for Transfer?

  12. Criteria for Transfer to Hospital? • JAMA.2006; 295: 2503-2510.

  13. Pneumonia is the best studied… • I found no publications for other conditions… • some are self evidence (hip#) • for others  expectations drive actions

  14. Randomly allocate Ontario Nursing homes to a Clinical Pathway versus Usual Care • 20 LTC facilities were enrolled

  15. Results Pathway Usual Hospitalizations 8% 20% sig Hosp days / res 0.79 1.74 sig ER, not admit 1.2% 1.6% nd Death 3.1% 6.0% nd Falls 11% 10% nd T to N of v/s 2.5 2.7 nd

  16. Appropriateness of Transfer? Study: - retrospective - lacked criteria - but makes headlines - grain of truth

  17. What is the effect of: ‘Let me Decide’ on hospitalization of LTC residents (Australia) • “Let me decide” • education: family, patients, care providers • advanced care planning  create a Directive • Setting provided IV abx & transfusions

  18. Let me Decide (diamonds); Control (light squares) Bed days / Nursing Home Bed (control and intervention)

  19. Let me Decide (diamonds); Control (light squares) Mortality / 100 NH beds (control and intervention)

  20. Hazards of Hospitalization Ann Int Med 1993:118:219.

  21. Local Alternatives • JP Schaefer – Survey of Local Providers • HPTP Clinic – some MD’s accept • Wound Care Clinic – at least one does • IM Urgent Assessment Clinic - No • Day Medicine – some MD’s accept • Individual Specialists – few do ‘housecalls’

  22. What has been tried elsewhere? • What is the effect of direct admission to a focused unit in comparison to transfer to Emergency Department • Retrospective – quasi-experimental design

  23. Protocol • 24 bed acute care geriatric unit • multidisciplinary • within a 210 bed geriatric facility • primary care MD’s telephone in • receiving MD’s admit according to protocol • no surgery • no ICU

  24. Results • 80 direct admits compared to 46 ER admits • Deaths: 3 (all from ER)  nd • LOS: 12.5 day direct, 11.7 day ER  nd • Functional Status: nd • 80 ER admits avoided!

  25. What challenges face the acute care providers? • Communication Issues • Level of Care and Expectations • Family Spokesperson (Spokespeople) • Usual Physician or Care Provider • Medical Issues at Presentation • History of new Problem • What is the baseline level of functioning? • Medical Problem List • Medical Issues after Presentation • Avoidance of Iatrogenesis • Medication Reconciliation • Post-discharge Care

  26. What challenges face the LTC physician at discharge? • Tell me your stories…

  27. Opportunities… • 58 new beds at RGH April 2008 • 50+ new beds at PLC 2008-9 • ?? beds at FMC (renovations needed) • 2010  365 beds South Campus

  28. LTC  Hospital (ER Bypass) Admit to Acute Care Unit GIM / FamMed Attending Consultations as needed Psycho-Soc Intensive Symptom – Sign – Lab Result Protocol Driven Responses Day Unit Assessment & Re-assessments (e.g. RGH Day Med) LTC Physician Assessment telephone Manage at LTC (+/- external support) Acute Care Unit for LTC Consulting Physician

  29. Thank you! • Contact: jpschaef@ucalgary.ca dr.schaeferville.com

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