Transitions of Care Flashcards
Goal and Risk of transition of info in the ED?
Goal: Transfer information AND clarify who is responsible for patient care
Risk: delay between info exhange and physical relocation
Information from ED to Hospitalist should include the following: (4)
- Principal dx and problem list (acute and pertinent chronic)
- Med list (home and current)
- Pt cognitive status
- Test results / pending results (and who is responsible for those pending)
Additional info/workup may be requested by accepting physician for the following reasons:
emergency department
- Determine level of inpatient care
- Determine the appropriate admitting service
- Based on timing to obtain critical information
- ED Boarding can be a problem!
what office/process may save hours of waiting in the ED/Help reduce ED overcrowding?
Ambulatory Office / Direct Admit
how does Ambulatory Office / Direct Admit help the transition of info in the ED?
Must carefully select the pt:
* Ensure admission to correct care location and ensure they are not at risk for deterioration prior to admit.
* Prolonged wait at admission could lead to decompensation
Selection Recommendations for Direct Admission: (4)
- Admitting dx is fairly certain/No additional triage is needed
- Pt is clinically stable – does not require supp O2, immediate IV fluids, abx or urgent imaging
- Has been evaluated on day of admission by PCP
- Arrives at hospital early in day (before 4 pm) to facilitate communication between the admitting physician and the hospital team before shift change
Clear communication between the PCP and hospitalist should occur and include:
- Rationale for admission
- Working diagnosis
- Problem list
- Key history components and recent changes
- Relevant laboratory and radiologic results
- Medication list and allergies
- Patient/family preferences and support system
risks and benefits of Outlying Facility / Hospital
- Higher severity of illness / Medically complex
- Some transfer pts have shown improved outcomes for disease-specific transfers
- overall - higher levels of morbidity and mortality that cannot always be accounted for by severity of illness alone; Benefit should outweigh risk
risks of interhospital prior to transfer
- Delay in care initiation d/t lack of expertise
- Delay in care finding an accepting facility/Delayed transport
- Inappropriate transfer
risks of interhospital during transfer
- Decompensation during transfer
- Arrival at night
- Arrival to inappropriate level of care
risks of interhospital after transfer
- Discontinuity of care plan
- Unnecessary and/or duplicative testing
- Medication errors
- Back-end discontinuity
- No shared EMR
cons of SNF outlying facility for transition of info?
- Medically complex, frequently unable to provide a coherent MHx or describe their drug regimen.
- MC non-specific complaints (falls, dehydration, or confusion) and w/o accurate info, will result in more investigations, particularly head CTs.
- Less likely to be accompanied by a relative or caregiver
- Up to 10% transferred to ED w/o any documentation and up to an additional 40% are missing info - baseline cognitive function, current meds, and advance directive status
- At risk for med errors, unnecessary testing, and inappropriate/unwanted care
transitino responsibility of the ED
- Do pts leave the ED immediately after being accepted for admission?
- What problems might this cause?
- Institutions should develop a clear plan for transfer of responsibility: plan for shift changes and standardized order sets started before to an inpatient unit
When patients are admitted from the outpatient clinic setting or skilled nursing facilities, ____ is responsible for the patient while they remain at their facility and once the patient leaves they become the responsibility of the accepting provider.
the admitting/transferring provider
When admitting a patient, you must choose an admission status:
inpt or outpt
what is the 2-Midnight rule?
Used to guide if inpt or outpt
* Outpatient - admitting physician expects pt to need to stay in hospital < 2 midnights.
* Inpatient - pt to stay in the hospital across 2 midnights
Providers should treat patients as what admission type until expectations develop?
outpatient
What are the 3-4 unit types available at most hospitals
- ICU - broken down by systems or specialty in large centers
- IMC / Step Down Units - May not be present in smaller hospitals
- Telemetry Units - continuous ECG monitoring
- Medical / Surgical Wards - non-monitored units
may start in one unit and transfer to one or more other units throughout admission, based on condition
Complex hospital care delivery models have resulted in:
- increased fragmentation of care
- Created greater need for care coordination and focus on transitions, particularly for hospitalized elderly population
a fluid, dynamic exchange regarding a patient on admission, change of service, discharge, or any other time of communication
handoff
Handoffs are subject to and dependent on what?
- Subject to distraction and interruptions.
- Dependent on on-coming clinician’s confidence in the quality and completeness of the information.
what is the MC root cause of sentinel events
teamwork
communication
3 types of intrahospital handoffs
- shift change
- service change
- service transfer
The transfer of content and professional responsibility from one clinician to another at the end of the shift.
shift change
A permanent transfer of content and professional responsibility at end of one’s on-service time or rotation to a new physician or team of providers who will assume ongoing care of the patients.
service change
The change of service of a pt from care of one group of clinicians to an entirely different group of clinicians, usually from a different specialty or ward, to receive a different service that is unique to the receiver’s specialty or ward
Service transfer
which 2 types of intrahospital handoffs require written documentation
- service change
- service transfer
3 components of handoffs
- verbal communication
- written communication
- transfer of professional responsibility - Acknowledgment of accountability for a pt’s care is an important feature of successful handoffs.
Goal of verbal communication
Build a shared mental model for a patient, including tasks and priorities
- Allows for questioning and reading back information relayed and received.
- Focus on what the receiver really needs to know
4 core steps to the handoff process
- pre-handoff - sender organizes and updates written info for handoff
- arrival - sender completes pt care tsks to conduct handoff. negotiates time/place
- dialogue - A specific verbal exchange that takes place between sender(s) and receiver(s).
- post-handoff - Receiver integrates new info and assumes ongoing care of patient(s).
What is the IPASS handoff method?
- I – Introduction: Introduce yourself
- P– Patient: Name, identifiers, age, sex, location
- A—Assessment: “The problem”, procedure, etc.
- S—Situation: Current status/Circumstances, Uncertainty, Changes
- S—Safety Concerns: Critical lab values/reports; threats, pitfalls, alerts
what is the SBAR handoff method?
- S—Situation: What is going on with pt
- B—Background: Relevant info about hx, background, prior dx
- A—Assessment: What you think is going on and needed
- R—Recommendations: What you are asking the physician to do
why does the discharge transition represent a vulnerable time for pts?
- Adverse outcomes are common in the postdischarge period - medical error and an adverse event
- Leads to readmission
Components that lead to an unsuccessful DC transition
- Premature discharge, Inappropriate discharge setting
- Unrecognized medical, functional, social needs
- Poor social support, Low health literacy
- Specific clinical conditions - CHF, Psychiatric comorbidities
- Inadequate handoffs - Pending tests, Additional work-up, Incomplete or unreceived discharge summary
- Delayed or unscheduled follow-up
- Lack of advanced care planning
- Failure to ensure comprehension - Disease-specific education, DC instructions
- Medication-related problems - Adverse drug events, Failure to obtain necessary meds, Therapeutic duplication, Poor adherence
Key Elements of Discharge Care Coordination
- Appropriate Discharge Destination
- Proactive Scheduling of Follow-Up Appointments
- Careful m edication reconciliation
- Engagement of Patients and Caregivers
when should a discharge plan start?
Should begin at admission and continue throughout hospitalization in parallel to the medical evaluation and treatment plan
MC discharge locations
- home with or without caregivers
- home with home health services
- inpatient rehabilitation facilities
- skilled nursing facilities
- long-term acute care hospitals
- extended care facilities.
Physician services in a SNF?
Physician visit required every 30 d; often utilize nonphysician providers for medically necessary visits
physician services in an IRF?
inpt rehab
Face to face visits by a rehabilitation physician at least 3 times per week
physician serves in LTAC
Daily or near-daily physician visits; consultant specialists widely available
physician services in an ECF?
Physician visits every 30 d
physician services in home health?
Requires a physician (usually primary care) to oversee plan of care
rehab services in SNF?
Physical, occupational, speech therapy, approximately 1 h per day
rehab services in IRF?
Multimodal services, at least 3 h per day
rehab services in LTAC?
Multimodal services
reha services in ECF?
Physical, occupational, speech, recreational therapy
rehab services in home health?
Physical, occupational, speech therapy
when should follow-up appointments be made?
before the pt leaves the hospital to ensure access to follow-up care.
When should a patient follow-up? Consider:
- Severity of the patient’s acute illness
- Pre-existing comorbidities
- Patient’s ability to manage medications and self-care needs
- Social issues such as transportation and caregiver support
- Physician availability
For most patients, post-discharge follow-up within 7 to 14 days is reasonable, what considerations must you remember?
- pt should be given sufficient instructions at DC regarding “red flag” sx and who to contact with questions and concerns.
- For pts who are at high risk for readmission and adverse drug events, f/u as early as 48-72 hrs following DC may be preferable.
What is Medication Reconciliation?
Process by which a patient’s medication list is obtained, compared, and clarified across different sites of care, in order to decrease medication errors during transitions.
Benefits of medication reconciliation
- Opportunity to evaluate polypharmacy, screen for high alert drugs and potentially inappropriate medications, and identify drug-drug or drug-disease interactions.
- Assess medication adherence, address barriers to adherence, and communicate the updated medication list to the patient
medication reconciliation should include explicit notation of which meds have been ___, ___, or ___ during hospitalization
added, discontinued, or changed
Med rec, whose responsibility is it?
Requires a Multidisciplinary Team!
- pts
- nursing
- hospital pharm
- provider
- community pharm
- long-term care
A fundamental component of the DC planning process and may help bridge the discontinuity inherent between inpatient and outpatient settings.
Pt engagement and education
ways to improve or inplement pt engagement and education?
- Ask questions of their health care providers
- Enable patient access to medical information
- Support communication with care providers
- Facilitate self-management of illnesses
- Perform in small sessions throughout hospitalization, reiterate main points, provide written handouts
Pt recall and comprehend only about ½ of the information provided in a medical encounter!
how to review pt education and DC instructions to ensure pt comprehension?
teach back method
Steps should be taken to create patient-centered instructions that are:
- Clear
- Tailored to patient language and literacy
- Focused on critical details of self-management
DC instructions should include the following:
- Reason for hospitalization, treatment received, names of clinicians involved in care if questions arise postdischarge
- Pertinent test results as well as pending test results
- Diet and activity
- Medications, including any changes in regimen and potential side effects
- Follow-up appointments
- Identification of the person to contact with questions or concerns
- List of concerning symptoms and how to respond
Recommended components of the discharge summary
- Primary and secondary diagnoses
- Important test results
- Pending results and responsible party
- Recommendations regarding additional work-up or treatment plan
- Patient’s condition at discharge (including cognitive and functional status and abnormal exam findings)
- Complete list of reconciled medications
- Follow-up arrangements
- Identification and contact information for the sending and receiving providers
- Resuscitation status
- Documentation of patient education
