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Transitions of Care: From Hospital to SNF Steven Tam, MD Assistant Clinical Professor UCI Program in Geriatrics, Internal Medicine.

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Presentation on theme: "Transitions of Care: From Hospital to SNF Steven Tam, MD Assistant Clinical Professor UCI Program in Geriatrics, Internal Medicine."— Presentation transcript:

1 Transitions of Care: From Hospital to SNF Steven Tam, MD Assistant Clinical Professor UCI Program in Geriatrics, Internal Medicine

2 Educational Objectives Upon completion, the learner will be able to 1. Identify some of the potential problems in transitional care involving hospital discharges to Skilled Nursing Facilities (SNF) 2. Describe the adverse outcomes of poor transitional care 3. Will be introduced to writing proper discharge orders to SNF

3 Potential Problems with transitioning between Hospital and SNF Breidenbach, Bob. (photographer). (2007). [photo]. The Providence Journal. Retrieved September 13, 2011 from

4 Potential Problems with transitioning between Hospital and SNF Communication Communication Between Hospital and SNF (and patient and family) Between Hospital and SNF (and patient and family) Between Personnel within each facility (shift changes, and covering MDs) Between Personnel within each facility (shift changes, and covering MDs) Lack of Medication Reconciliation Lack of Medication Reconciliation Continue Home medications? Continue Home medications? Which medications Stopped Which medications Stopped Continuity of care (physicians, nursing staff) Continuity of care (physicians, nursing staff) Others? Others?

5 Potential Problems with transitioning between Hospital and SNF Communication can be a problem with all hospital discharges: Communication can be a problem with all hospital discharges: Studies show that hospital discharge summaries can be lacking in information Studies show that hospital discharge summaries can be lacking in information Approximately 11% of discharge letters and 25% of discharge summaries never reached the patient’s PCP. Approximately 11% of discharge letters and 25% of discharge summaries never reached the patient’s PCP. Important information to be communicated with the SNF includes medications, functional level, weight bearing status, follow-up plan Important information to be communicated with the SNF includes medications, functional level, weight bearing status, follow-up plan Lack of such information can lead to delays in care, and other adverse outcomes. Lack of such information can lead to delays in care, and other adverse outcomes.

6 Potential Problems with transitioning between Hospital and SNF Lack of Medication Reconciliation Lack of Medication Reconciliation Medication changes upon hospital admission or discharge are a reason for adverse events. Medication changes upon hospital admission or discharge are a reason for adverse events. Prospective study of 151 patients admitted to general internal medicine, found that a regularly used medication was discontinued in 46.4% of cases Prospective study of 151 patients admitted to general internal medicine, found that a regularly used medication was discontinued in 46.4% of cases In a study by Boockvar et al, adverse drug events attributable to medication changes occurred in 20% of transfers between nursing homes and acute-care hospitals. In a study by Boockvar et al, adverse drug events attributable to medication changes occurred in 20% of transfers between nursing homes and acute-care hospitals.

7 Adverse Outcomes Poor discharges can lead to: Poor discharges can lead to: Increased morbidity and mortality Increased morbidity and mortality Hospital Re-admissions Hospital Re-admissions Higher costs Higher costs Poor relationships between patients, families, the skilled nursing facilities, the hospital and professionals. Poor relationships between patients, families, the skilled nursing facilities, the hospital and professionals.

8 Adverse Outcomes Transfers from SNF account for 8.5% of Medicare admissions to acute care hospital Transfers from SNF account for 8.5% of Medicare admissions to acute care hospital 40% of these hospitalizations occur within 90 days of SNF admission 40% of these hospitalizations occur within 90 days of SNF admission From Jenckes et al., close to 1/5 th of all Medicare beneficiaries discharged from hospital are readmitted within 30 days From Jenckes et al., close to 1/5 th of all Medicare beneficiaries discharged from hospital are readmitted within 30 days Cost = $17.4 billion in 2004; 26.9% due to heart failure, 20.9% due to pneumonia Cost = $17.4 billion in 2004; 26.9% due to heart failure, 20.9% due to pneumonia

9 Proper Discharge Orders/Instructions If not included in the discharge summary, proper discharge orders/instructions should accompany the patient to the SNF If not included in the discharge summary, proper discharge orders/instructions should accompany the patient to the SNF Necessary Elements include: Necessary Elements include: Legible Name (pager) of discharging MD, unit Legible Name (pager) of discharging MD, unit Legible care orders (such as for wound care, lines) Legible care orders (such as for wound care, lines) Reconciled medication list Reconciled medication list Diagnoses Diagnoses Follow-up plan Follow-up plan

10 Discharge Orders/Instructions Patient Discharge to Other Facilities Instructions Patient Name:Medical Record Number: Admission Date: Discharge Date: Discharge To: Primary Diagnosis:Onset Dates Secondary Diagnosis:Onset Dates Procedures:Dates: Pertinent Studies (if not included in DC summary)` Allergies: Medications:

11 Discharge Orders/Instructions Additional Medical Orders: Physical Therapy: y/n Physical Activity Level (weight bearing status) Occupational Therapy: y/n Speech Therapy: y/n Wound Care: Line(s)/Foley Care: Diet: Red Flag Instructions: Follow up Visits: Pending Studies: Advanced Directives (if not included in DC summary): CPR: Tube Feeds: Attending Physician at time of Discharge: Further Hospitalizations: Contact #:

12 Clinical Vignette Now, look over the clinical vignette and practice writing your own discharge orders using the previous format! Now, look over the clinical vignette and practice writing your own discharge orders using the previous format!

13 References Transitions of Care in the Long-Term Care Continuum. Practice Guideline AMDA 2010 Transitions of Care in the Long-Term Care Continuum. Practice Guideline AMDA 2010 Boockvar KS, Fishman E et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Internal Medicine 2004; 164(5): Boockvar KS, Fishman E et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Internal Medicine 2004; 164(5): Jenckes SF, Williams MV et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 009; 360(14): Jenckes SF, Williams MV et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 009; 360(14):


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