discharge planning and transitions of care: where are they going and why?

UMMS CRIT Module III: Discharge Planning and Transitions of Care

Catherine DuBeau, MDChief of GeriatricsUniversity of Massachusetts

UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care

Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

Discharge Planning and Transitions of Care:Where are they going and why?

Opening the Black Box



• You admit an 80 yr old woman in transfer from a outside facility. There is no hospital summary, only loose papers and a cover sheet listing hospital admission date and meds (unclear if admission or transfer meds). Her family is unavailable.

• She is delirious, hypertensive, and severely impacted• The last labs sent with her are from 3 days old; Hgb was 7.8

and creat 2.2.• You call the hospital and the floor RN says the pt was

discharged on the previous shift and she knows nothing about the patient.

Exercise



• You admit an 80 yr old woman in transfer from a outside facility. There is no hospital summary, only loose papers and a cover sheet listing hospital admission date and meds (unclear if admission or transfer meds). Her family is unavailable.

• She is delirious, hypertensive, and severely impacted• The last labs sent with her are from 3 days old; Hgb was 7.8

and creat 2.2.• You call the hospital and the floor RN says the pt was

discharged on the previous shift and she knows nothing about the patient.

Exercise

This is a routine skilled nursing facility admission



Birth Marriage Age 50 Retirement Death

Episodes of Serious Illness

A Life

Courtesy Peter Boling, MD



Hospital:A-fib, Stroke

Hospital:MI, CHF

Hospital:CHF

6 days 4 days 8 days

18 days in hospital, 35 days in NH, 135 days of homecare, 312 days at home

Scope of the Problem:Hospital Admission = First of Multiple care transitions

NursingHome Stay

35

Home Health Episodes

45

28 62

Courtesy Peter Boling, MD



AHRQ HCUPnet http://www.ahrq.gov/data/hcup/factbk1/10shel.htm

Discharge from Hospital to Other Institutions increases with Age



• All team members should participate − begin early in hospital course

• Site of care after D/C should be warranted by patient’s needs• MD: Assess medical care needs, provide D/C summary and

orders, do med reconciliation

Discharge Planning



• All team members should participate − begin early in hospital course

• Site of care after D/C should be warranted by patient’s needs• MD: Assess medical care needs, provide D/C summary and

orders, do med reconciliation

Transition Planning



• Home• Home with services• Inpatient Rehab• Chronic Care Hospital• Skilled Nursing Facility (SNF)• Hospice

Where can patients go after hospitalization?



Who Pays For What?

Medicaid• to qualify, income and

assets must be below state eligibility levels

• $880/$2,000 indiv, $1090/$3,000 couple

• $8,000 set aside in burial contract

Medicare• Age > 65• Part A – hospital, SNF,

hospice; no premium• Part B – MD visits,

outpatient expenses, home health care; pay premium

• Part D – medications



• House, apartment; alone, with spouse and/or other family• Senior Housing• Continuing Care Retirement Community (CCRCs)• Assisted Living Facilities, Residential Care Facilities, Board and

Care• Nursing Home

Many possible options for “Home”



The provision of diagnostic, therapeutic or support services to the patient in the home for the purpose of restoring and maintaining his or her maximal level of comfort, function, and health.

Home Care

AMA Council on Scientific Affairs, JAMA 1990; 263 1241-1244

Levine SA et al. JAMA 2003; 290:1203-1207.



Medicare Services in Home Care

• Part A (hospital)– Visiting nurse– HHA– SW– Mental Heath– Dietician– OT/PT/ST

• Part B (20% co-pay)– MD Home Visit– Durable medical

equipment– Diagnostics

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.



• A physician can refer any patient with an acute skilled need to a home care agency

• Nursing care– Monitoring of vital signs, cor/pulm status– Wound care– DM monitoring and education– Medication management

• PT and OT• Speech therapy

Medicare: “Skilled” Home Care via Certified Home Health Agency



Durable Medical Equipment

• Covered by Medicare (mostly)• Specific Requirements

Courtesy of Jeremy Boal, MD



Non Durable Equipment

• Adult Incontinence Pads • Chux• Booties• Gloves• Wound care supplies• Not covered by Medicare• May be covered by Medicaid

http://www.northshorecare.com/pullons-surecare.html



• Homemaker• All bathroom equipment• Transportation• Personal or supportive long-term care

What Medicare Doesn’t Pay For



• Medicare pays if 3 day/night in hospital and 24 hr skilled nursing care needed– Duration of coverage depends on types and number of skilled

needs• Integrates features of acute care/rehab• Interdisciplinary staffing

– Nursing: RN, LPN, CNA, wound care– Therapies: PT/OT/ST, nutrition, SW, etc– Medical: MD, PAs, NPs– Other clinical: dental, podiatry, vision, psych, psychology, clinical

pharmacist

Skilled Nursing and Rehab in Nursing Homes



• Phlebotomy/Laboratory• Radiology• EKG• Venous dopplers• IVs: peripheral, PICC, etc• No Dobhoffs or Central Lines

Ancillary Services



• Needs and can tolerate intensive PT/OT (3 hrs/day)• Medically unstable for SNF

– Needs frequent MD evaluation (> q1-2 wk)– Rising Cr, dropping Hgb– Meds will need adjustment in < 24-48 hr (eg, BP meds,

diuretics)– Needs telemetry, daily/STAT labs

Acute Inpatient Rehab



• Medical needs– Summary of admitting problems and course– Active Problem list– Recent and important pending labs – Reconciled Medication List (incl admit meds and all changes) and

allergies– Advance directives: DPOA-HC, preferences, goals

• Functional support (ADL, IADL)– Disposition: where from and where next– Functional status: baseline and present– Social support and contact info

• Nursing needs: monitoring, wounds• Rehabilitative needs: PT, OT

4 Core Elements of Transition Information and Communication

discharge planning and transitions of care: where are they going and why?

Documents

primary care

hospital summary

umms crit module

umms initiative

geriatrics education

multiple care transitionsnur

transfer meds

days old hgb