CARE TRANSITIONS IN THE POST-ACUTE CARE SETTING: BARRIERS AND STRATEGIES FOR SUCCESS

Daryl Blewett MSN-Ed, RN, CRRN & Maeve Lopreiato, MPH, BSN, RN

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Discloser

• No relevant financial or nonfinancial relationship

• No relevant financial or nonfinancial relationships in the products or services

described, reviewed, evaluated or compared in this presentation.

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Objectives

1. Identify the greatest challenges to successful care transition into post-acute care and to the community

2. Describe the communication strategies to improve on care transitions

3. Illustrate the role of the CTN in preparing and aiding patients and families/caregivers for successful return to home/community

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Why does care transition matter?

• Joint Commission– Sentinel Event Alert- Hand off communications

• 2006 National Patient Safety Goal that addressed handoff communication

• 2010 standard: Provision of Care standard PC.02.02.01, element of performance (EP) 2

– Estimated 80 % of serious medical errors have a miscommunication during the hand-off between medical providers as a contributing factor- Solet et al (2005)

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Patient Safety in Transitions

• Potential errors:– Missed/wrong medication management– Fall risk– Loss of follow up with providers– Unknown mental status baseline

• Potential Outcomes:– Increased potential for re-admission– Longer recovery– Injury– Death– Poor patient satisfaction

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Layering on the Complexities- Patients

• Chronic disease estimates in NJ (BRFSS)- 65+ years– 32.0% of residents 65+ live with a disability– 21.5% have diabetes (2016 survey)– 61.4% have hypertension (2015 survey)– 11.4% with COPD (2016 survey)

• Social determinants and health, 2017 (Center for Improving America)– 10% of people had incomes below the poverty line– 41/100 housing units affordable and available– 8.6% were food insecure (at some point in the year, difficulty providing enough

food due to lack of money/resources)

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Layering on the Complexities- Health Systems and Policy

• Changes in payment structure– Bundled payments

• Quantity of providers – Acute Care facilities

• 14 systems within New Jersey, ranging in size from 2-17 organizations – Affiliates

• >150 Affiliates listed through NJHA• Inpatient post-acute services, home care, hospice, etc.

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“Root causes of ineffective transitions of care”-Joint Commission “Hot Topics in Health Care: Transitions of Care

1. Communication breakdowns2. Patient education breakdowns3. Accountability breakdowns.

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Communication Break Downs

• Incomplete informationi. Partial history, not completed test results, missed information preceding

hospital stayii. Missing data within institutions, between clinician and patient, and across

institutions• Ineffective communication

i. Ineffective methods- EMRs which do not “talk” to one anotherii. Insufficient time/resources for hand offiii. Lack of standardized procedures (SBAR)

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Patient education breakdowns

• Conflicting recommendations• Multiple receivers of information• Uniformed patient may not understand the importance of following the care plan (Coleman,

et al 2004)• Makaryus et al (2005)- less than 50% of patients surveyed post-discharge could list their

diagnoses, the name(s) of their medication(s), their purpose, or the major side effect(s)• Poor inclusion in discharge planning process

– 2018 study by Abu et al found disagreement among clinicians related to the discharge conversation:

• Wait until a more specific and realistic plan is available?• Start conversation with multiple possible outcomes (and potentially overwhelm)

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Accountability Breakdowns

• Inconsistent practice in assuming responsibility to assure the health care is coordinated across various setting/ across providers (Snow et al [2009] & Coleman et al [2004])

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New Jersey’s Patients

• In New Jersey in 2016* there were: – 952,140 inpatient acute care hospital discharges

• 39.52% were Medicare Beneficiaries• 12.98% Medicaid Beneficiaries

– >3 million ED visits• 15.67% were Medicare Beneficiaries • 15.21% Medicaid Beneficiaries

*Most recent year of data available for query from NJSHAD public database

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952,140 inpatient acute care hospital discharges

76%

2%

12%

3% Home

Hospice - Home

Hospice - Health care facility

Acute care facility

Skilled nursing facility

Inpatient rehabilitation

Long-term acute care facility or hospital

Intermediate care facility

Other health care facility

Expired

Left against medical advice/AMA

Other, Not documented, or Unable to determine (UTD)

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The Patient as the Driving Force

• Discharge disposition appropriateness– Decision based on clinical necessity as well as patient preference

• Is a successful hand off to the wrong location still a successful hand off?– Efforts need to both work on the process (hand offs and collaborative efforts) as

well as finding the right fit for the patient

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Post – Acute Strategies To Improve Care Transitions

• Enhanced Communication• Cross-facility collaboration• Working with ACOs• Patient Family Education- Care Partners• Development of the Care Transition Nurse (CTN) at Kessler

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Enhanced Communication

• Enhanced Communication– Nurse Navigators– Stroke Coordinators– Nurse to nurse handoff– Transfer records

• Epic/Care Everywhere– Sharing discharge disposition

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Collaboration across Provider types

• Collaborating with post acute provider– Stroke Coordinators– Trauma Coordinators – Navigators – Case Managers – Social Workers

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Working in ACOs

• Working closely with ACOs – Giving weekly updates – Sharing the patients discharge disposition

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Strategies of Transitions of Care

• Patient/Family Education – Care Partner program

• Starts the day of Admission • Family meetings • Includes the whole

rehabilitation team

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Care Transitions Nurse

• Care Transitions Nurse – Patient/Caregiver education – Medication management – Follow-up phone calls

• Medication review• Follow up PCP appointments

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Care Transitions Nurse

• Increase patient satisfaction • Increases patient/caregiver discharge to community • Increases patient/caregiver confidence for home discharge • Decreased medication errors at home

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Conclusion

• Insurance Companies– ACOs

• Acute Care Hospitals– Case Managers– Social Worker– Navigators

• Post-Acute Providers – Case Managers– Social Worker

• Primary Care Physicians

• Patient

Who is in Charge of Transitions of Care ?

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Who is in Charge of Transitions of Care ?

EVERYONE!

This is why communication between Care Providers is so important.

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Citations

• Solet DJ, et al: Lost in translation: challenges and opportunities in physician-to-physician communication during patient hand-offs. Academic Medicine, 2005;80:1094-9

• Snow V, et al: Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. Journal of Hospital Medicine, July/August 2009;4(6):364-370

• Coleman EA, Berenson RA: Lost in translation: challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine, 2004;140:533-536

• Abu et al. Are we “missing the big picture” in transitions of care? Perspective of healthcare providers managing patients with unplanned hospitalization. Applied Nursing Research, 2018;44:60-66

• Makaryus AN, Friedman, EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clinic Preceedings. 2005 Aug;80(8):991-4.