Hospitals, Home Health and Hazards Karen Jeselun, RN, BSN

Hospitalist Role  Hospital Practice  Internal Medicine or Pediatrician  Employee vs. Contractor Primary Care Physician Role  Office Practice  Specialty Varies

Risk Management Concerns Arizona Revised Statutes: : 24 “Unprofessional Conduct” (Q) Any conduct or practice that is or might be harmful or dangerous to the health of the patient or public. This includes discharging a patient from the hospital who will require ongoing care that was imparted while under the care of the Hospitalist. This is considered abandonment. (SS) Prescribing, dispensing or furnishing a prescription medication or a prescription-only device as defined in section 32–1901 to a person unless the licensee first conducts a physical examination of that person or has previously established a doctor–patient relationship. (SS) Prescribing, dispensing or furnishing a prescription medication or a prescription-only device as defined in section 32–1901 to a person unless the licensee first conducts a physical examination of that person or has previously established a doctor–patient relationship.

Is this a problem? YES! Survey data from the Arizona Association for Home Care shows that 30% of patients discharged to HHAs without attending physicians are re- admitted to hospitals within 72 hours.

Solutions on the Horizon Hospitalist Stakeholders Taskforce Membership Arizona Medical Association (ARMA) Arizona Medical Association (ARMA) Arizona Association for Home Care Arizona Association for Home Care Health Services Advisory Group Health Services Advisory Group MICA MICA Arizona Hospital Association Arizona Hospital Association Arizona Osteopathic Association Arizona Osteopathic Association Arizona College of Emergency Physicians Arizona College of Emergency Physicians Arizona Nurses Association Arizona Nurses Association

Solutions on the Horizon Hospitalist Stakeholders Taskforce Membership continued…. Arizona Hospice and Palliative Care Organization Arizona Hospice and Palliative Care Organization Blue Cross Blue Shield of Arizona Blue Cross Blue Shield of Arizona Hospitalist Groups Hospitalist Groups Various Hospital Systems Various Hospital Systems

Solutions on the Horizon Taskforce Goals Prevent the discharge of patients from the hospital without appropriate arrangements for continued outpatient care. Prevent the discharge of patients from the hospital without appropriate arrangements for continued outpatient care. Facilitate the transfer of patients from the hospital to the outpatient setting in a seamless fashion. Facilitate the transfer of patients from the hospital to the outpatient setting in a seamless fashion. Prevent the occurrences of medical errors and patient misunderstanding during this transition period. Prevent the occurrences of medical errors and patient misunderstanding during this transition period. Assist the hospitalist in finding an outpatient physician to assume patient care. Assist the hospitalist in finding an outpatient physician to assume patient care.

Solutions on the Horizon  Algorithm  Liability Decision  Forms  Web site Development  Ongoing Physician Education  And ???

IMMEDIATE ATTENTION–HOSPITAL FOLLOW-UP PLANS HOSPITALIST - DISCHARGE TRANSITION FORM Hospitalist Physician ____________________________PCP _____________________________________ Back Line Pager Phone # ________________________Back Line Pager Phone # ___________________ Patient/DOB __________________________________Health Plan ______________________________ Date Admitted/Re-admitted ______________________Date Discharged___________________________ PCP Called ‪ Yes ‪ NoPCP Called ‪ Yes ‪ No Discharge Diagnosis: 1. _______________________________________ 7. _______________________________________________ 2. _______________________________________ 8. _______________________________________________ 3. _______________________________________ 9. _______________________________________________ 4. _______________________________________ 10. _______________________________________________ 5. _______________________________________ 11. _______________________________________________ 6. _______________________________________ 12. _______________________________________________ Chronic Medical Problems: 1. ____________________________________________________________________ 2. ____________________________________________________________________ 3. ____________________________________________________________________ 4. ____________________________________________________________________ 5. ____________________________________________________________________ 6. ____________________________________________________________________ Allergies: ______________________________________

HOSPITALIST - DISCHARGE TRANSITION FORM CONTINUED... Discharge Medication: Indication: Name NewDoseFrequencyIndication/Plan/Duration Follow up date: _______________________With: ________________________________________________ Plan of care: _________________________________________________________________________________ Follow up concerns:____________________________________________________________________________ Consultants Involved: ‫ None 1. ________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ Pertinent Lab/X-Ray/Procedures Results 1. _________________________________________________________________________________________ 2.__________________________________________________________________________________________ 3. _________________________________________________________________________________________ Complications/Adverse Reaction/etc. 1. _________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ *See Release on Reverse _______________________________________________________________________________ Signature - Hospitalist Signature - PCP Signature - Hospitalist Signature - PCP

IMMEDIATE CONFIRMATION REQUESTED PCP COMMUNICATION FORM – ADMISSION Revised 1/1/04 Hospitalist Physician ____________________________PCP _____________________________________ Patient Name __________________________________Health Plan ______________________________ Date Admitted/Re-admitted ______________________Date Discharged___________________________ Admission Diagnosis: 1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________ 4. ___________________________________________________________________________________________ 5. ___________________________________________________________________________________________ 6. ___________________________________________________________________________________________ Chronic Medical Problems: 1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________ 4. ___________________________________________________________________________________________ 5. ___________________________________________________________________________________________ 6. ___________________________________________________________________________________________ Medications: 1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________ 4. ___________________________________________________________________________________________ 5. ___________________________________________________________________________________________ 6. ___________________________________________________________________________________________ 7. ___________________________________________________________________________________________ 8. ___________________________________________________________________________________________ 9. ___________________________________________________________________________________________ 10. __________________________________________________________________________________________ Last OV: _______________________

What Can You Do?  Facilitate communication between hospitalists and PCPs.  Promote the use of the ARMA Web site  Promote the use of the Hospital Discharge forms  Participate in physician educational forums

Questions?

Thank you!

RESULTS of AAHC SURVEY APRIL 15, respondents 1. How often do you find the “referring” physician will not be the “attending” physician who will be signing the POC (485) ? who will be signing the POC (485) ? Less than 10% of the time30% Less than 10% of the time30% 10% - 25% of the time10% 26% - 50% of the time10% 51% - 75% of the time20% 76% - 100% of the time30% 2. Have home health admissions or delays in treatment been affected? Less than 10% of the time40% 10% - 25% of the time30% 26% - 50% of the time20% 51% - 75% of the time10% 76% - 100% of the time 0% 3. What have you done to get the patients the care that they need? Persistence in making multiple phone calls to any and all physicians the patient has ever seen. Involve hospital case managers. Adamant with discharge planners about needing a physician to follow the patient’s plan of care prior to acceptance of the patient. Plan admission visit after the physician has seen the patient. 4. Have patients been sent back to the hospital within 72 hours due to not having a physician to cover? Yes 30% Yes 30% No 70% 5. Are there specific physician practices in your community who are willing to take new home care patients? (Please define these groups, such as residents who work with a teaching hospital, etc.) Yes 70% but with restrictions that they see the patient first 50% answered – private physician 50% answered – group practices No 30% No 30%

RESULTS of AAHC SURVEY CONTD… 6. Do you have a relationship with a Physician(s) who is willing to oversee the care of your home health patients who do not have a Primary Care Physician? Yes 30% Yes 30% No 70% No 70% If yes, please explain: Medical Director on rare occasions, ED physician, Hospitalist with Own practice. Own practice. 7. Some physician groups do not feel qualified to care for the complex needs of home health patients, but are willing to become knowledgeable in the various types of treatments. I.e. Lovenox. Please list the top five medical therapies your patients need: (Listed in the order of most frequently mentioned) (Listed in the order of most frequently mentioned) 10 Wound care 8 Diabetic care 7 Lovenox 4 Ortho Rehab 3 Fragmin 2 Medication management 2 Respiratory medication management 1 IV’s 1 Post – surgical management 1 Symptom management 1 S/P chemo 1 Dialysis complications 1 Enteral feedings 1 Ostomy care 1 Hypertension 1 Urinary cath care 1 Compression wraps