From Hospital to Home: Medical Students Observe Patients in Transition Martha S. Terry, MD Assistant Professor of Clinical Family and Community Medicine University of Missouri-Columbia June 21, 2006

Why home visits for M3’s? Adverse events are common as patients transition from hospital to home Medication errors cause the majority of adverse events System problems produce most errors Forster, A.J. et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine 2003;138:161-7.

Why home visits for M3’s? Students have little or no contact with patients in transition Home visits teach importance of discharge planning and communication Students participate in a quality improvement project

Why home visits forM3’s? Study measured attitudes toward elderly among medical students and family practice residents Negative attitudes increased with level of training Brooks, TR. Journal of the National Medical Association, 85:61-64 (1993)

M3 Home Visit Project Each M3 participates during a required family medicine clerkship rotation Students spend one week on the family medicine inpatient service Students select a patient they have followed in the hospital for a home visit

M3 Home Visit Project, continued Home visits are done at the end of the students’ week on the inpatient service Students visit patients with a geriatrician, 1-2 days after hospital discharge Findings from the visit are relayed to the patient’s MD and the inpatient team

Before the Visit: Patient Selection Students choose patients, with assistance –Multidisciplinary rounds led by a geriatrician –Inpatient attending –Home visit preceptor Focus on frail elderly patients

At the Home Visit Assess medical and functional status Perform targeted home safety evaluation Evaluate medication adherence Estimate risk of harm from med errors

After the Home Visit Students contact: the primary MD and the inpatient team

Role of the Student Students act as an important link between the patient, the inpatient team, and the primary MD. Patient Student Inpatient Team Primary MD Student

Medication Errors Results of the M3 Home Visit Project

Patient characteristics (n=59) 68% female 73% home-dwelling 12% diagnosed with dementia Median age: 75

Medications per patient n=59 Median: 11 Range: 1-25

Medication Errors by Type % Patients with ≥1 Error n=59

Medication Errors: Estimating Risk of Harm Low risk: Unlikely to cause a problem –Acetaminophen prn –Stool softener Moderate risk: Might cause a problem –No beta blocker after MI –HCTZ added on top of home diuretic

Medication Errors: Estimating Risk of Harm High risk: Likely to cause a problem –Pneumonia—no antibiotic –Renal failure—high-dose NSAID at home –Hospice patient—no pain medication

Medication Errors by Risk % Patients with ≥1 Error n=59

Analysis No association with medication errors and: Age Gender Number of medications Dementia diagnosis Patient location (Home vs. Facility)

Hospital discharge summary: A gold standard? Discharge summary error(s) in 47% of patients Why? –Admitting history inaccurate –“Correct” medication list does not exist –Cognitive impairment –Family/caregivers unavailable –Lack of time

How Errors Happen Discharge summary errors OR Patient unaware of changes in medications or doses THEY ARE PREVENTABLE!

Effects of Medication Reconciliation (12/1/2005) Before n=46 After n=13 43%62% Discharge Summaries with ≥1 Med Error Trend to more errors? (Not significant.)

Case example 82 year old woman admitted with CHF exacerbation, angina, anemia Hospital stay: 4 days Discharged to: Home Dementia: No

Case example, continued Medications: –Total, per discharge summary: 14 –Extra meds: 2 –Missing meds: 5 –Wrong dose meds: 2

Case example, continued Extra MedsRisk Fiber supplement BIDLow Acetaminophen prnLow

Case example, continued Missing MedsRisk Atorvastatin 10 mgLow (2 days only) Docusate 100 mgLow (1 day only) Metoprolol 150 mgModerate (several doses) Aspirin 81 mgLow (1 day only) Triamcinolone creamLow

Case example, continued Wrong Dose MedsRisk HydralazineHigh (1/2 dose) FurosemideHigh (1/2 dose)

Case example, continued Discharge summary NOT a source of error Patient filled medication box incorrectly Unable to implement medication changes 1. Multiple meds—barely fit in box 2. Doses in multiples of tablets 3. Home health nurse only once a week

M3 Home Visit Project: A Tool for Quality Improvement Education –Students –Residents –Faculty Action –“Medication bag” plan—M3’s can participate –Departmental seminar

Improving quality of care through transitions 1. Better communication 2. Better systems 3. Better patient education 4. Other ideas?