1. By: Marie-Josée Pagé, DO
TRANSITIONS OF CARE
By: Marie-Josée Pagé, DO

2. Definition

3. Transitions of Care (TOC)
Transition of patients between levels of health care in a safe and timely manner.
Referred as a transitional care management visit, or TCM, in the outpatient setting
Ex: ED to the medical floor or ICU; ICU to medical floor; hospital to home; nursing home to home.

4. TCM settings Inpatient acute care hospital
Inpatient psychiatric hospital
Long term care hospital
Skilled nursing facility
Inpatient rehabilitation facility
Hospital outpatient observation
Partial hospitalization at a community mental health center
Medicare guidelines as of 2013

5. Background and purpose

6. Reduction of re-admissions rates continues to be an area of focus.
Literature review notes that the quality and timing of completion of the discharge summary affects the quality of post-discharge care

7. We hypothesized that appropriate discharge planning with specific details would decrease re-admissions to the hospital, increase outpatient revenues and provide best care to our patients.
Breakdowns…
Poor communication
Education breakdown
Accountability breakdowns
Inadequate risk assessment
Incomplete discharge summaries and/or discharge information
Limited access for special services
Language and cultural barriers
False assumptions about patient understanding of discharge instructions
After all, our hospital is a patient centered hospital; therefore project was established for better continuity of care.

8. Methods

9. Teaching
Internal medicine program was given 30 minute lectures every 6 months to improve discharge summaries and outpatient follow-up.
Attendings regularly discuss discharge planning with their teams and help identify Metro West patients to be followed in the outpatient setting.

10. Discharge summary Key elements: Admitting physician
Admitting diagnosis
Significant findings
Procedures and treatments provided
Results to be followed
Patient’s discharge condition
Discharge medications
Discontinued medications
Follow up appointments

11. Results

12. Retrospective cohort study to evaluate 30 day re-admission rates to Mount Carmel West in the past year with patient in heart failure exacerbation and COPD exacerbation or pneumonia.
Time period 1/1/16 to 3/31/16 and 4/1/16 (day of implementation) to 9/30/16
Measured number of admissions, re-admissions rates and hospital follow up in the outpatient setting.

13. Admissions Readmissions Readmission rate 1/1/16-3/31/16 255 40 15.68%
Admissions
Readmissions
Readmission
rate
1/1/16-3/31/16
255 40
15.68%
**4/1/16-6/30/16
336 35
10.33%
7/1/16-9/30/16
351 32
9.24%
**Implementation of the TCM project on 4/1/16

14. Readmission rate declined from 15
Readmission rate declined from 15.7% prior to implementation of the TOC project to 9.8% afterwards (p=0.0148).
Represents a 42% decline in the odds of readmission after the start of the project.

15. conclusion

16. Providing appropriate discharge planning with specific details in tandem with a multi-disciplinary effort to follow-up with the patient within 2 days of discharge appears to decrease re-admissions to the hospital and ultimately improve the health of our patients while decreasing health care costs.

17. Examples of the impact of tcm

18. An 80-year-old retired school teacher visited the emergency department four times in a month for exacerbations to a mild heart failure condition, twice requiring hospitalization. When provided with discharge instructions, she is able to repeat them back accurately. However, she doesn’t follow through with the instructions after returning home because she has not yet been diagnosed with dementia.
Ex by joint commision in June 2012

19. A 68-year-old man is readmitted for heart failure only one week after being discharged following treatment for the same condition. He brought all of his pill bottles in a bag; all of the bottles were full, not one was opened. When questioned why he had not taken his medication, he began to cry, explaining he had never learned to read and couldn’t read the instructions on the bottles.

20. Fin

21. References
Naylor M, Keating SA. Transitional Care: Moving patients from one care setting to another. The American journal of nursing. 2008;108(9 Suppl): doi: /01.NAJ a
Hugh A, Williams MV, Grigsby J, Coleman, EA. Better transitions: improving comprehension of discharge instructions. Frontiers of Health Services Management, 2009 Spring;25(3):11-32