1. TRANSITIONAL CAREmodule two Bill Lyons, M.D. UNMC Geriatrics Asst. Professor wlyons@unmc.edu

2. 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 Integrat Care 2002

3. WHEN CONTEMPLATING A TRANSFER • Patient’s global goals – medical and functional recovery, in light of family support? • Risk-benefit ratio – is benefit of the transition likely to exceed harms associated with transfer to a new venue? • Quality of the match – is the proposed new venue a good match for medical, nursing, and functional needs?

4. 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

5. New incontinence, chest pain, dyspnea HR>100-130, HR<50, RR>24-30, SBP<90, SBP>180, DBP>110 Arrhythmias O2 sat<90% T>38.3C Poor oral intake Altered mental status Wound infection TOO SICK FOR DISCHARGE? PREDICTORS OF INSTABILITY

6. TIPS ON INFORMATION TRANSFER • Transfer summary is for receiving team, not medical records department • Discharge diagnoses should also include functional, cognitive, behavioral, and affective disorders • Discharge meds should be more than a list

7. INFORMATION TRANSFER, cont’d • D/C instructions should include signs, symptoms, and red flags; also, who to call • Explicitly list follow-up studies and appointments • Social history: names and contact information for caregivers, surrogate decision makers

8. INFORMATION TRANSFER, cont’d • Include functional status: at baseline and at time of transfer • If you have seen the forest (not just the trees), say so: overall goals of care, preferred intensity of care, advance directives

9. RECONCILING A MEDICATION REGIMEN • List the medications, including schedules for tapering or discontinuation • Identify which medications are new • Identify which doses are new • Which previously taken drugs are to be stopped?

10. post-test question 1 You are preparing to make a home visit to Mrs. R, an 89-year-old woman who was recently discharged home from the hospital. She has been hospitalized five times in the last six months, and on the telephone she told you that her health "is really in the toilet." Her current problem list includes coronary artery disease and heart failure, poorly-controlled type 2 diabetes, Parkinson's disease, chronic bronchitis, depression, and venous stasis dermatitis. She lives alone, although her daughter stops by after work most days to assist with dressing, bathing, personal hygiene, and shopping. This daughter has expressed little enthusiasm for assisting with medication management, as "Mom pretty much takes whatever medicines she feels like taking, no matter what you guys prescribe." In your review of the hospital discharge summary you find no evidence of education (regarding illness, medications, self-management) provided to the patient or her daughter. True or False: This patient is at high risk of poor transitions-related outcome (eg, early hospital readmission). • True • False

11. Correct Answer: A. True Feedback: • This was probably not a difficult question. Mrs. R possesses every risk factor mentioned in the module for poor discharge outcomes: age over 80, fair-to-poor self-rating of health, recent and frequent hospitalizations, inadequate social support, multiple and active chronic health problems, history of depression, disability and functional impairments, history of nonadherence to the therapeutic regimen, and lack of documented patient and family education.

12. post-test question 2 A hospital discharge summary shows the following on the discharge diagnosis list: • Congestive heart failure with systolic dysfunction • Diabetes mellitus type 2 • Benign prostatic hyperplasia • Sundowning True or False: Item number 4 should not have been included, as "sundowning" is not a medical diagnosis. • True • False

13. Correct Answer: False Feedback: The inclusion of "sundowning" on the list will probably be very helpful for the receiving team, particularly if this patient shows behavioral problems at his new care venue in the afternoon or evening. (It would be even more helpful to know whether this behavioral problem is chronic, and is thought to be attributable to dementia, or whether it results from delirium, whose workup has been completed.) In general, functional or behavioral diagnoses – even if not classically "medical" - are extremely helpful for the clinicians who will be assuming care of complex elders. End