1. Transitions of Care: EP Perspective Post Acute and Long Term Care Update Mid-Atlantic Medical Directors Association Annual Meeting November 6, 2015 Sheraton Columbia Hugh F. Hill III, MD, JD, FACEP, FCLM Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine Councilor, Maryland Chapter, American College of Emergency Physicians

3. From your Brethren and Sistren in Your Friendly Local ED Ave et honorem, curationem et protectores veteris

4. Studies suggest that in over 90% of all NH-to-ED patient transitions, information essential to adequate emergency care is lacking. Communication by ED staff when patients are discharged back to NHs is often substandard as well. Hustey, Care Transitions Between Nursing Homes and Emergency Departments: A Failure to Communicate. AnnLTCare, V18,4,April 2010

6. 6 Transitional Care Definition: “A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same institution.” –American Geriatrics Society (2003)* *Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. Apr 2003;51(4):556-557.

7. 7 Transitional Care During transitions, patients are at risk for: Medical errors Service duplication Inappropriate care Critical elements of care plan “falling though the cracks” -AGS (2003)* *Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. Apr 2003;51(4):556-557.

8. 8 Transitional Care Conceptual model of effective transitional care (Coleman 2003)*: Communication between sending and receiving clinicians Preparation of the caregiver and patient for transition Reconciliation of medication lists Arranging a plan for follow-up of outstanding tests Arranging an appointment with receiving physician Discussing warning signs that might necessitate more emergent evaluation *Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society. Apr 2003;51(4):549-555.

9. 9 How to Improve Transitional Care Suggestions: –Changes to health care delivery systems (i.e. use of nurses to follow patients or expanding PACE programs) –Adoption of information transfer technology –Changes to health care policy (i.e. pay for coordination of care or make providers responsible for coordinating transitional care)

10. SAEM/ACEP Address Transitional Care Society for Academic Emergency Medicine (SAEM) Geriatric Task Force: Developed at recommendation of SAEM and American College of EM Identify and adopt quality measures to allow assessment of care provided to elderly patients Quality measures were vetted by: SAEM Geriatric Task Force SAEM annual meeting American Geriatrics Society (AGS) annual meeting

11. SAEM/ACEP Address Transitional Care Quality Measures If nursing home (NH) patient goes to ED, then paperwork should state: Reason for transfer Code status Medication allergies Contact information for: NH Primary care or on-call MD Resident’s HCPOA or closest family member

12. SAEM/ACEP Address Transitional Care Paperwork should include: Patient’s Medication Administration Record If NH patient goes to ED for requested studies, then: ED should document the performance of requested tests or the reason why such tests were not performed ED diagnosis Tests performed with results (and tests with pending results) ED provider should speak with the NH provider, primary care or on-call MD for the NH prior to discharge from the ED

13. National and Regional Programs Addressing Acute Care Hospital and SNF Transitions: State Action on Avoidable Rehospitalizations (STAAR) Program http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/STAAR/Pages /default.aspx Interventions to Reduce Acute Care Transfers (INTERACT) http://interact.fau.edu/ Quality Improvement Organizations, ICPC: http://www.cfmc.org/integratingcare/ Minnesota Reducing Avoidable Readmissions Effectively (RARE): http://www.rarereadmissions.org/ State of Maryland Efforts: http://www.mhaonline.org/quality/transitions-handle-with-care Health Information Exchange (HIE) and Regional Health Information Organization (RHIOs) Examples: http://mehi.masstech.org/what-we-do/hie/impact

14. Washington Bureaucratic/Political Aphorism “If you’re not at the table, you’re on the menu.”

15. 2007 THREE! Page Form “AMDA has developed and recommends the use of the Universal Transfer Form (UTF) to facilitate the transfer of necessary patient information from one care setting to another. Patient transfers are fraught with the potential for errors stemming from the inaccurate or incomplete transfer of patient information. Use of the UTF can help to minimize the occurrence of such errors by ensuring that patient information is transmitted fully and in a timely fashion. “

19. 2007 THREE! Page Form “AMDA has developed and recommends the use of the Universal Transfer Form (UTF) to facilitate the transfer of necessary patient information from one care setting to another. Patient transfers are fraught with the potential for errors stemming from the inaccurate or incomplete transfer of patient information. Use of the UTF can help to minimize the occurrence of such errors by ensuring that patient information is transmitted fully and in a timely fashion. “

20. James Jordan, Flickr

21. thespiritscience/stress

22. Askingforwhatyouwant.com

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