1. TRANSITIONAL CARE module two
Bill Lyons, M.D.
UNMC Geriatrics
Asst. Professor

2. HIGH-QUALITY TRANSITIONAL CARE
Reliable, accurate information transfer
Preparation of patient, family, caregiver
Support for self-management
Empowerment of patient to assert preferences
Coleman et al. Int J Integrat Care 2002
Welcome to Module 2 on Transitional Care in Geriatrics.
Based on his group’s research, Coleman and colleagues have proposed four characteristics of high-quality transitional care. First, there must be reliable and accurate transfer of information from the sending clinicians (such as those in a hospital) to the receiving clinicians (such as those in a skilled nursing facility). Second, there must be adequate preparation of the patient and the family or caregiver. Third, there must be support provided to the patient and caregiver to allow for self-management of chronic conditions. And finally, the patient should feel – and be – empowered to assert her own care preferences.

3. WHEN CONTEMPLATING A TRANSFER
Patient’s global goals – medical and functional recovery, in light of family support?
Risk-benefit ratio – is benefit of the transition likely to exceed harms associated with transfer to a new venue?
Quality of the match – is the proposed new venue a good match for medical, nursing, and functional needs?
There are three big things to keep in mind as you contemplate transferring a patient from one care venue to another. First, what are the patient’s global goals for medical and functional improvement? How much is the family willing and able to do to help? Some patients are able to be discharged from hospital to home, if the social support there is adequate, whereas other patients with identical medical or functional problems have no choice but to enter a skilled nursing facility. Second, how attractive is the risk-benefit ratio for the transfer? Each additional transfer brings with it a risk of discontinuity errors and confusion. Perhaps keeping a patient in the hospital for an extra day or two, for example, will allow her to go directly home, without a short nursing home stay. Finally, does the place match the patient? That is, can the destination provide the mix of medical, nursing, and rehabilitation services that the patient requires? Acute rehabilitation hospitals, subacute units, custodial nursing homes, and inpatient hospices are all very different facilities, and it makes sense to know something about the capabilities of such institutions in your area.

4. FACTORS ASSOCIATED WITH POOR DISCHARGE OUTCOMES
Age>80
Fair-to-poor self-rating of health
Recent and frequent hospitalizations
Inadequate social support
Multiple, active chronic health problems
Depression history
Chronic disability and functional impairment
History of nonadherence to therapeutic regimen
Lack of documented patient/family education
A number of studies have identified characteristics that predict increased likelihood of poor outcomes after hospital discharge. Such poor outcomes would include problems like early re-hospitalization or presentation to an emergency department. This slide lists these factors, and most of these probably come as no surprise. Older age, especially older than 80, predicts increased risk. So does a self-rating of health of “fair” or “poor.” Frequent hospitalizations, poor social support at home, serious comorbidities, and chronic functional impairments all predict increased risk. A history of depression, independent of those other issues, increases the risk of poor discharge outcomes. Not surprisingly, so does a patient’s history of not adhering to a recommended therapeutic regimen. Finally – and importantly, since this reflects an area where we clinicians can modify the risk – patients whose hospital charts reflect that the patient or family were educated about the transfer are at reduced risk compared to those whose charts lacked such documentation.

5. TOO SICK FOR DISCHARGE? PREDICTORS OF INSTABILITY
New incontinence, chest pain, dyspnea
HR> , HR<50, RR>24-30, SBP<90, SBP>180, DBP>110
Arrhythmias
O2 sat<90%
T>38.3C
Poor oral intake
Altered mental status
Wound infection
Research has also shown which clinical characteristics indicate that a patient is perhaps too sick to be discharged from the hospital. This slide lists several of those indicators of potential instability. First, we should think twice about discharging patients who have new incontinence, chest pain, or shortness of breath. Second, we should be look closely at vital signs, and be careful in transferring patients whose heart rate, respiratory rate, blood pressure, temperature, or oxygen saturation are in the ranges shown. Third, patients with arrhythmias (aside from established atrial fibrillation) deserve a second look. Fourth, patients with poor oral intake are at risk after hospital discharge. Fifth, patients with acute confusion need careful evaluation before discharge. If you do transfer a patient who is delirious, it is important to document the existence of this confusional state for the next care team, and to indicate what workup has been done to identify contributors. Finally, patients with wound infections may be too sick for transfer.

6. TIPS ON INFORMATION TRANSFER
Transfer summary is for receiving team, not medical records department
Discharge diagnoses should also include functional, cognitive, behavioral, and affective disorders
Discharge meds should be more than a list
Let’s turn to the subject of information transfer during patients’ transitions, and start with some general tips. The first point to bear in mind is that the transfer or discharge summary is of course constructed for the benefit of the receiving clinical team, not the medical records department. This obvious point can be forgotten because we tend to get more feedback from Medical Records, particularly when we are late with discharge summaries. A second tip relates to the list of discharge diagnoses that is always a part of the transfer summary. Although medical diagnoses like heart failure and diabetes are important, so too are other kinds of diagnoses that some doctors may not think to incorporate. These include functional diagnoses, such as gait disorder or urinary incontinence; cognitive disorders, like dementia; behavioral disorders, like nocturnal agitation due to Alzheimer’s disease; and affective disorders, such as depression. The next tip involves the discharge medications. This part of the transfer summary should be more than the traditional list, and we will take up this subject in a minute.

7. INFORMATION TRANSFER, cont’d
D/C instructions should include signs, symptoms, and red flags; also, who to call
Explicitly list follow-up studies and appointments
Social history: names and contact information for caregivers, surrogate decision makers
The discharge instructions on transfer summaries often include diet and activity orders, and little else. It is important to also list potentially worrisome signs and symptoms or “red flags” that might arise and that should be reported, along with information on whom to call. Next, in this era of ever-shorter hospital stays, it often happens that we discharge patients from the hospital while there are still laboratory studies pending; these follow-up or pending studies should be highlighted in the discharge summary. Besides follow-up studies, follow-up appointments are important to include in transfer summaries, particularly if the patient has been seen in the hospital by a surgeon or a consultant who will wish to see the patient again in the outpatient arena. Information related to social history is crucial to include in transfer documents, as the next clinical team will likely need to know the names and contact information for caregivers, family, and surrogate decision makers.

8. INFORMATION TRANSFER, cont’d
Include functional status: at baseline and at time of transfer
If you have seen the forest (not just the trees), say so: overall goals of care, preferred intensity of care, advance directives
A couple other kinds of information are vital to transmit to the new team caring for the patient. First, what was the patient’s functional status, both at baseline (before she became sick), and at the time of transfer? The fact that a patient could ambulate in the community before she became ill, and now needs assistance for bed-to-chair transfers, is very useful to the professionals who will be assuming her care. Next, the transfer documents should say something about the patient’s preferred intensity of care. It often happens in the hospital that the clinical team facilitates a major decision with the patient and family, such as whether to focus strictly on comfort, or whether future transfers to hospital are desired. These kinds of high-stakes discussions – where everybody sees the forest, not just the trees – need to be documented for the next care providers.

9. RECONCILING A MEDICATION REGIMEN
List the medications, including schedules for tapering or discontinuation
Identify which medications are new
Identify which doses are new
Which previously taken drugs are to be stopped?
Let’s turn now to a critical part of good transitional care, namely, the reconciliation of the medication regimen. The transfer papers should include four things related to the discharge medications. First – and this part is usually done routinely – all the discharge medications with their respective doses and frequencies should be spelled out. Stop dates or tapering schedules, as might be needed for antibiotics or corticosteroids, should be specified. Second, medications on the discharge list that are new to the patient from before care in the current venue should be highlighted. Third, drugs whose doses are new also need to be highlighted. Finally, the transfer documents should specifically list any medications which were taken before – say, at the time of hospital admission – but that are to be stopped.
This completes Module 2. To proceed to the question, close this window, advance to page 2 in this learning unit, and click on Module 2 question. Then, proceed to Module #3, or take a break if you like.

10. post-test question 1
You are preparing to make a home visit to Mrs. R, an 89-year-old woman who was recently discharged home from the hospital. She has been hospitalized five times in the last six months, and on the telephone she told you that her health "is really in the toilet." Her current problem list includes coronary artery disease and heart failure, poorly-controlled type 2 diabetes, Parkinson's disease, chronic bronchitis, depression, and venous stasis dermatitis. She lives alone, although her daughter stops by after work most days to assist with dressing, bathing, personal hygiene, and shopping. This daughter has expressed little enthusiasm for assisting with medication management, as "Mom pretty much takes whatever medicines she feels like taking, no matter what you guys prescribe." In your review of the hospital discharge summary you find no evidence of education (regarding illness, medications, self-management) provided to the patient or her daughter. True or False: This patient is at high risk of poor transitions-related outcome (eg, early hospital readmission).
True
False

11. Correct Answer: A. True
Feedback:
This was probably not a difficult question. Mrs. R possesses every risk factor mentioned in the module for poor discharge outcomes: age over 80, fair-to-poor self-rating of health, recent and frequent hospitalizations, inadequate social support, multiple and active chronic health problems, history of depression, disability and functional impairments, history of nonadherence to the therapeutic regimen, and lack of documented patient and family education.

12. post-test question 2
A hospital discharge summary shows the following on the discharge diagnosis list:
Congestive heart failure with systolic dysfunction
Diabetes mellitus type 2
Benign prostatic hyperplasia
Sundowning
True or False:
Item number 4 should not have been included, as "sundowning" is not a medical diagnosis.
True
False

13. Correct Answer: False
Feedback: The inclusion of "sundowning" on the list will probably be very helpful for the receiving team, particularly if this patient shows behavioral problems at his new care venue in the afternoon or evening. (It would be even more helpful to know whether this behavioral problem is chronic, and is thought to be attributable to dementia, or whether it results from delirium, whose workup has been completed.) In general, functional or behavioral diagnoses – even if not classically "medical" - are extremely helpful for the clinicians who will be assuming care of complex elders.
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