Patient Safety in Transitions of Care Whose responsibility? Yours, Mine ,Whose? Patient Safety in Transitions of Care

Learning Objectives Describe the care transitions process Identify potential lapses in the care transitions process Describe the effects of unsafe transitions Describe the role providers play in patient transitions Discuss effective team based collaboration that promotes safety in transitions of care

A Patient’s Story Video Clip

Ms Brown 84 yr old female with a history of diabetes, hypertension, atrial fibrillation and hyperthyroidism recently admitted for pneumonia Hospital course complicated by several hazards of hospitalization including delirium, restraints, deconditioning resulting in a fall Ms Brown improved and was discharged home. At the time of discharge, she was oriented to place and person but not to time

Ms Brown She was sent home without instructions on how to care for herself She lives alone and had great difficulty getting out of bed to use the toilet, and she could not prepare meals for herself She was confused about her medications and had great difficulty managing them She had to be readmitted for blood sugars running above 600mg/dl

Scope of Problem Patients experience heightened vulnerability during transitions between settings Quality and patient safety are compromised during this vulnerable period

Scope of Problem Hazards of Poorly Executed Transitions High rates of medication errors Inappropriate discharge and discharge setting Inaccurate care plan information transfer Lack of appropriate follow-up care The multitude of adverse effects that can be attributed to poorly executed care transitions is often underappreciated

Scope of Problem Outcomes of Poorly Executed Transitions Re-hospitalization Greater use of hospital emergency, post-acute, and ambulatory services Further functional dependency Permanent institutionalization

Care Transitions Process Patient Admitted Assessment Define Problem Treatment Plan Patient Treated Investigations Procedures Consultations Patient improved and discharged Readiness for Discharge Discharge Setting Discharge Education Care Coordination Provider Communication Post Discharge Follow-up DC Summary Medication Reconciliation Follow-up appointments Follow-up Consultations Follow-up tests The usual process of care of a patient from admission to discharge is shown – describe process

Provider Role in Care Transitions Patient Admitted Assessment Define Problem Treatment Plan Patient Treated Investigations Procedures Consultations Supportive Care Treatment of illness Patient improved and discharged Readiness for Discharge Discharge Setting Discharge Education Care Coordination Provider Communication Post Discharge Follow-up DC Summary Medication Reconciliation Follow-up appointments Follow-up Consultations Follow-up tests Have participants discuss the role of various healthcare providers in the care transitions process shown above

Provider Role in Care Transitions Clinician – Physician, Nurse Practitioner, Physician Assistant Pharmacist Nurse Case Manager Social Worker Have participants discuss the role of various healthcare providers in the care transitions process shown above

Potential Lapses in Care Transitions Process Patient improved and ready for discharge Readiness for Discharge Discharge Setting Discharge Education Medication Reconciliation Care Coordination Provider Communication PCP communication DC Summary Discharged to the next care setting Medication Compliance Dietary Compliance Keep follow-up appointments Transportation Caregiver support Home Health/ Community Resources Post Discharge Follow-up DC Summary review Medication Reconciliation Follow-up appointments Follow-up Consultations Follow-up tests Potential areas for lapses during the care transitions process are shown above – discuss with participants these potential areas for lapses.

Factors Contributing to Failure in Transitions of Care Failed Transitions System- Related Factors Provider - Related Factors Patient - Related Factors Summarize factors that can contribute to failure in transitions of care.

Discharge Planning How can we improve the patient’s experience at discharge? Do we understand our roles and how crucial they are in ensuring that our patients are safe at discharge? How best can we collaborate to implement a discharge plan that ensures patient safety? Interactive discussion, get participants to answer each question and facilitate discussion; summarize answers at the end of side presentation

Discharge Planning Do we understand that we should work as a team with one focus – to promote patient safety? Do we understand that promoting safety may entail identifying potential errors by team members and resolving these? Do we feel safe communicating potential errors to team members? How best can we communicate with each other? Interactive discussion, get participants to answer each question and facilitate discussion; summarize answers at the end of side presentation

Competencies for Interprofessional Collaborative Practice Values/Ethics for Interprofessional Practice Competency Domain 1 Roles/Responsibilities Competency Domain 2: Interprofessional Communication Competency Domain 3 Teams and Teamwork Competency Domain 4: Important attributes of interprofessional collaborative practice include:

Ms Brown Let’s review Ms Brown’s discharge planning process……….. Review case discussion worksheet