Faculty Development: Teaching Triggers for Transitional Care A Train-the-Trainer Model

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Faculty DevelopmentTeaching Triggers for
Transitional CareA Train-the-Trainer Model

• Lindsay Mazotti, MD
• C. Bree Johnston, MD
• University of California, San Francisco
• Department of Medicine

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Acknowledgements

• This presentation was supported by the Donald W.
  Reynolds Foundation
• Thanks to the following people for modification/
  adapation of their materials
• Bill Lyons, MD University of Nebraska
• Helen Kao, MD Brad Sharpe, MD UCSF
• Catherine E. DuBeau, MD University of Chicago
  CHAMP Program http//champ.bsd.uchicago.edu

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Curricular Objectives

• Improve knowledge about transitions
• Understand the 3 domains of transitions in care
• Identify teachable moments in readmissions,
  transfers
• Increase awareness around good discharge
  summaries

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ROADMAP

• Background
• 3 Domains of Transitional Care
• Teaching Triggers
• A readmission
• A discharge summary
• An anticipated discharge
• Brainstorming

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Take Home Message

• Providing good transitional care requires
• ANTICIPATION PREPARATION
• DESTINATION
• INFORMATION
• EDUCATION

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Background Care Transitions

• Movements patients make between health care
  providers and different care settings

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TRANSITIONAL CARE

• Based on comprehensive care plan including
• Patients goals, preferences, and clinical status
• Logistical arrangements
• Patient and family education
• Coordination among health professionals and
  health care teams
• Includes both SENDING RECEIVING

Slide courtesy of Bill Lyons, MD University of
Nebraska
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Why you care

• Transitions are wrought with errors
• 25 of patients d/cd from an academic medical
  service had an adverse event within 3 weeks
• Nearly 50 were preventable
• Readmission rates within 30 days are as high as
  25
• Subject of national attention
• JCAHO is watching
• You find it personally satisfying to be a good
  doctor

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Brainstorm

• Why is it important to teach residents/students
  about transitional care?
• Have you had any successes in teaching about
  transitional care? Can you share?

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QUANTATIVE STUDIES SHOW

• In 2001, patients gt65 yo discharged from acute
  settings went
• to another institution ¼ of the time
• home with home health 11 of the time1
• 13 of Medicare beneficiaries transfer 3 in 30d
  post-discharge2
• Serious problems with discharge summaries,
  communication with PMDs, med reconciliation

• 1. Agency for Health Care Quality Research
  HCUPnet
• 2. Coleman et al. Health Services Research 2004

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QUALITATIVE STUDIES SHOW

• Patients dont understand what medications are
  for or anticipated side effects
• or when to resume normal activities
• and dont know what questions to ask, or whom to
  ask
• or what warning signs to watch for

Slide courtesy of Bill Lyons, MD University of
Nebraska
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WHAT IS 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 Integrated Care 2002

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3 Domains of a Transfer

• Where should they go?
• How to best transfer information?
• How to educate and prepare the patient?

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Mrs. Ima Notthriving

• 82 yo woman with multiple medical problems
  resides at SNF
• Hospitalized at Our Med Center early January for
  AMS, lethargy, UTI? (dirty sample, culture
  negative)
• Returned to SNF
• Admitted to your team 3 weeks later with with
  hypoxia and lethargy
• nonspecific EKG T-wave changes, O2 sat 90, known
  pleural effusion
• Increased fatigue and decreased PO intake x 1
  month

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Mrs. Notthriving

• PMH
• ESRD on HD
• CHF, L sided effusion
• Depression
• CAD s/p 5-6 MIs CABG
• H/o seizure disorder
• Meds include anti-hypertensives, PPI,
  anti-seizure, renal meds, pain meds, stool
  softeners

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Mrs. Notthriving

• SH
• Widowed, no children, retired
• Former neonatal nurse
• Resides at SNF x years, bedbound

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Mrs. Notthriving

• Exam 36.2 123/53 64 16 95-100RA
• Gen waxing waning lethargy
• RRR, III/VI systolic murmur LLSB
• Decreased BS on L
• L BKA, L femoral fistula
• Unable to assess orientation, pt follows
  commands, neuro grossly intact
• Labs normal
• CXR with known L sided effusion
• Dirty UA, gt50 WBC, culture negative (again)

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Teaching Trigger A ReadmissionExamine the 3
Domains of Her Transfer

• Appropriate d/c location with first d/c?
• How was our information transfer?
• Was the patient educated prepared?

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Walking Through Her Case
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Domain 1- DESTINATION Did we send her to the
right place after her last admission?
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Where should they go?

• What are the patients goals?
• for medical and functional recovery
• What are their risks?
• is benefit of the transition gt harms associated
  with transfer to a new venue?

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FACTORS ASSOCIATED WITH POOR DISCHARGE OUTCOMES
Destination Assessing Risk

• Agegt80
• 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

Slide courtesy of Bill Lyons, MD University of
Nebraska
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Where should they go?

• What are the patients goals?
• for medical and functional recovery?
• What are their risks?
• is benefit of the transition gt harms associated
  with transfer to a new venue?
• Is the new venue a good match?
• Does it match their medical, nursing, and
  functional needs?

Modified slide courtesy of Bill Lyons, MD
University of Nebraska
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Destination A Good Match?
Admitted to Hospital From
HOME
NURSING HOME
Acute Rehab
Home With Services
Home
Nursing Home
Slide courtesy of Catherine DuBeau, MD
University of Chicago CHAMP Program,
http//champ.bsd.uchicago.edu
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Domain 2- INFORMATION How was our information
transfer?
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• Has anyone taught in rounds or one-on-one about
  discharge summaries?

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Discharge Summaries Problems

• too much of the HP and too little of the
  hospital course
• lots of numbers about BUN and creatinine where
  it would have been sufficient to say that the
  patient was having mild renal insufficiency

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Quality Summaries

• What do receiving physicians want included in a
  DC summary?

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Quality Summaries What the PMDs want

• Evaluation of 226 physicians (56 generalists)
• Surveyed preferred content of D/C summaries
  ranked by importance

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TABLE 2Preferred Content of Discharge Summary
Ranked by Importance
OLeary et al, J Hosp Med, 2006.
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Teaching Trigger Review Ms. Notthrivings
Discharge SummaryA Group Exercise
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Mrs. NotthrivingsTransfer Summary

• Briefly, this is an 82-year-old female with
  CHF, end-stage renal disease on hemodialysis, and
  a seizure disorder who is referred to the
  Emergency Department after she was noted to be
  sleepy and disoriented with poor p.o. intake for
  the past 3 days. The patient's chief complaint
  was, "I feel lousy," endorsing fatigue and
  weakness. The patient was last dialyzed on the
  day of admission with 1-1.5 kg fluid removed.
  For past medical history, medications, social
  history, and family history, please refer to
  admission history and physical.

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• HOSP COURSE BY PROBLEM
• Lethargy/altered mental status
• Significant objective findings on admission
  included presence of a urinary tract infection
  and a large left-sided pleural effusion. Basic
  metabolic labs were within normal limits. A
  noncontrast head CT was obtained and was negative
  for an acute process. The patient was treated
  for a urinary tract infection with cephalexin.
  Urine cultures were negative. The patient will
  finish a 10 day course of cephalexin.
• With regards to the pleural effusion,
  thoracentesis was offered but was declined by the
  patient in the Emergency Department, which was
  appropriate given her lack of respiratory
  distress or hypoxia

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• The patient's mental status improved
  somewhat to the point where her family members
  felt she was at baseline. Of note, at baseline
  the patient is frequently quite somnolent,
  however, is able to arouse to voice.
• With regards to her pleural effusion, the
  plan is currently to continue hemodialysis for
  volume management and to follow the patient for
  development of symptoms at which point the
  therapeutic thoracentesis could be considered if
  needed.

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• DISPOSITION The patient will be transferred to
  her HD facility for her regularly scheduled
  hemodialysis. Afterwards, she will be
  transferred to SNF, where she had previously been
  living.
• CONDITION AT TRANSFER
• While the patient's altered mental status and
  lethargy have improved, she is frequently noted
  to be quite sleepy. In discussion with the
  patient's family and outpatient physicians, this
  is consistent with her baseline and she is felt
  safe to be transferred back to her Skilled
  Nursing Facility, to which the patient is eager
  to return.

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• FOLLOW-UP The patient will be seen by her
  primary nephrologist, Dr. Renal, at hemodialysis
  on the day of transfer.
• MEDICATIONS ON TRANSFER
• 1. Cephalexin suspension to complete a 10-14 day
  course started January 4.
• 2. Phenytoin 300 mg daily.
• 3. Escitalopram 10 mg daily.
• 4. Lansoprazole 30 mg daily.
• 5. Nephrovite.
• 6. Sevelmer.
• 7. Hydrocodone/APAP as needed.
• 8. Amlodipine 10 mg daily.

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• DISCHARGE DIAGNOSES
• 1. Altered mental status, likely secondary to
  urinary tract infection.
• 2. Urinary tract infection with negative urine
  culture.
• 3. Left-sided pleural effusion.
• 4. End-stage renal disease on dialysis.
• 5. Congestive heart failure.
• 6. Diabetes mellitus.
• 7. Sacral decubitus ulcer.

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Teaching Trigger Review a Discharge
SummaryWhat is missing?What could be more
explicit?What do you want to know as the
receiving MD?
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Discharge Summaries
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HPI / PMH PEX / LABS
HOSPITAL COURSE BY PROBLEM
HOSPITAL COURSE BY PROBLEM STUDIES/PROCEDURES
DISCHARGE MEDICATIONS
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DOA DOD Attending HPI / PMH / PEX
HOSPITAL COURSE BY PROBLEM 1,2, 3. . . 4 Code/Adv
Dir/Goals of Care Studies / Procedures /
Consultations
DISCHARGE CONDITION PROGNOSIS FUNCTION
DISCHARGE INSTRXNS
DISCHARGE FOLLOW-UP
DISCHARGE MEDICATIONS
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Recommended Standard Format

• ID, CC HPI 
• Hospital Course by Problem
• Pertinent Studies and Procedures
• Discharge Diagnoses 
• Discharge Medications
• Dispo
• Diet
• Function/Activity 
• Condition/Prognosis/Goals of Care
• Follow up Plans

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ID, CC, HPI

• Be succinct!
• ID, CC, HPI should be rolled into 1-3 lines
• This is the one-liner you deliver to your
  attending or to your friendly but overwhelmed
  specialty consultant who doesnt have time to
  hear the novella on your patient
• Your goal is to describe the Big Picture of who
  the patient is and what theyre in the hospital
  for

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Hospital Course By Problem

• MAJOR ACUTE PROBLEMS
• Main reasons for hospitalization
• PNA HYPOTENSION HYPOXIA
• could be just PNA with complications
• Chronic medical conditions requiring adjustments
• TIPS
• Should be SHORT, no more than 1 paragraph
• Do not need to focus on your thinking/
  differential dx
• Avoid narrative speech!

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Pertinent Studies Procedures

• Includes
• CT Scans, MRI, other radiologic studies
• Echocardiograms
• Interventional or Surgical Procedures
• IR instrumentation
• Cath
• Scopes
• Taps
• What would be important to know as a PMD and
  difficult to track down?

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Discharge Diagnoses

• List of major diagnoses from hospital stay 
• Does not include chronic illnesses (unless major
  changes)
• Not for billing
• gt10 TOO MANY

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Recommended Standard Format

• ID, CC HPI 
• Hospital Course by Problem
• Pertinent Studies and Procedures
• Discharge Diagnoses 
• Discharge Medications
• Dispo
• Diet
• Function/Activity 
• Condition/Prognosis/Goals of Care
• Follow up Plans

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Discharge Medications

• Some argue it is the most important part of the
  discharge summary
• Why???

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Discharge Medications

• Medication Errors are very very common at
  discharge
• In 375 geriatric pts, 14 had a medication
  discrepancy when they got home
• This increased rate of readmission by 2.5
• In a study of 400 discharged patients, 45 (11)
  had an adverse drug event
• 60 of those were preventable/ameliorable

Coleman EA Arch Intern Med 2005 Forster AJ. Ann
Intern Med 2003
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Discharge Medications

• In your discharge summary
• List the medications that were stopped
• Dont need doses, just the list

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Discharge Medications

• In your discharge summary
• List the medications that were stopped
• List the other medications with doses,
  directions, tapering, etc.
• Highlight changes in doses (bp meds,
  hypoglycemics, coumadin, etc.)
• Highlight all new medications

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DISCHARGE MEDICATIONS STOP Plavix, Lovastatin,
lisinopril, Imdur Combivent Neb Q4h
prn Alendronate 70mg/week PO ASA 325mg PO
daily Atorvastatin 80mg PO Qbedtime (replaces
lovastatin) Buproprion 500 PO 3x/day CaCo3 500 PO
3x/day Captopril 75mg PO Q8 (replaces
lisinopril) Diltiazsem 250mg PO 2x/day Docusate
250mg PO 2x/day Hydralazine 40mg PO 4x/day (new
medication) NPH 20units QAM, 5units Qbedtime
subQ Insulin Regular Sliding scale as
directed Ipratroprium 3 puffs 4x/day Imdur 120mg
PO daily (increased from 60mg daily) Mirtazapine
15mg PO Qbedtime
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Recommended Standard Format

• ID, CC HPI 
• Hospital Course by Problem
• Pertinent Studies and Procedures
• Discharge Diagnoses 
• Discharge Medications
• Disposition
• Discharge Diet
• Function/Activity 
• Condition/Prognosis/Goals of Care
• Follow up Plans

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Disposition

• Where is the patient going at the time of
  discharge
• Can be very very brief
• Home
• To SNF
• Deceased

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Discharge Diet

• Directions for patient, family, primary care
  doctor, etc.
• Three things to think about
• Specific type of diet (renal, cardiac, etc.)
• Diet consistency (readmit with aspiration)
• Tube feeds/TPN

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Recommended Standard Format

• ID, CC HPI 
• Hospital Course by Problem
• Pertinent Studies and Procedures
• Discharge Diagnoses 
• Discharge Medications
• Dispo
• Diet
• Function/Activity 
• Condition/Prognosis/Goals of Care
• Follow up Plans

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Function/Activity

• Need to document activity in all patients
• If healthy As tolerated
• Other possibilities
• Home with home PT
• Wheelchair bound

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Function/Activity

• Document function for frail older patients and
  ANY patient whose function
• Is impaired at baseline
• Declines prior to admission
• Declines during hospitalization

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Why list function?

• In hospitalized older adults, functional measures
  often fail to improve and frequently worsen
• gt 1/3 of older patients are discharged with worse
  functional status than baseline
• 1/2 of these patients acquire their deficits
  during their hospitalization
• In-hospital functional decline increases with
  age rates exceed 50 in patients over 85
• Covinsky KE et al. JAGS 200351451-58

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Include cognitive function

• Mental illness, mild cognitive impairment,
  dementia or delirium?
• Baseline vs discharge
• This conveys whether the patient has insight and
  ability to manage self-care
• Does the patient rely on a caregiver to follow
  the discharge treatment plan?

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Follow Up

• Follow up for the outpatient physician and
  follow-up for the patient
• Unbelievably important (and missed)
• In 2644 discharges, PCPs were unaware of 60 of
  tests that needed follow-up.
• Up to 65 of discharge summaries lacked test
  results pending at discharge.

Roy CL. Ann Intern Med. 2005. Kripalani S. JAMA.
2007.
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Follow Up

• Follow up for the outpatient physician
• Pending test results (labs, path, radiology)
• Outpatient referrals to specialists
• Physician of record for nursing home, home care,
  or hospice orders? (contact MD prior to
  discharge!)
• Follow up for the patient
• Next appointments
• Outpatient diagnostic studies

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Quality Summaries are

• Higher quality when length lt 2 pages
• Best in standardized format with minimal
  narrative
• Ideally
• SUCCINCT
• PERTINENT
• SPECIFIC

Modification of slide courtesy of Bill Lyons, MD
University of Nebraska
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Final Pearls

• Transfer summary is for receiving team, NOT
  medical records
• Avoid cutting pasting!
• Its OK (and better) to be brief
• Ask for feedback

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Teaching Trigger Was Ms. N (or her family)
educated?
AND PREPARATION. AND COMMUNICATION.
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Teaching TriggerWhat do patients leaving the
hospital need to be educated about?
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ISSUES TO COMMUNICATE WITH PATIENT, CAREGIVER
EDUCATION

• Reconcile d/c med list with previous regimen
  WITH THE PATIENT
• Discuss potential side effects of medications
• Activity/eating/bathing limitations, functional
  prognoses
• Communicate d/c date and plan IN ADVANCE
• Red flags that should prompt contacting and MD
  and WHO to contact

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Brainstorm What teaching triggers can you use
on day of discharge?How can we teach this
better?
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Teaching TriggerAn Anticipated Discharge

• Reviewing the 3 Domains
• Plan for Destination
• Improve Interdisciplinary Collaboration Involve
  your Case Manager
• Take team to SW rounds?
• Specific goals for Information Transfer
• What will we include in D/C Summary?
• What does your team anticipate going wrong?
• Discuss assign who will contact PMD at
  discharge AND DO IT
• Plan for Education
• Meeting with or calling family extra time with
  patient
• Improve Interdisciplinary Collaboration Involve
  your Pharmacist

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Review Curricular Objectives

• Improve knowledge about transitions
• Understand the 3 domains of transitions in care
• Identify teachable moments in readmissions,
  transfers
• Increase awareness around good discharge
  summaries

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ROADMAP Did we get there?

• Background
• 3 Domains of Transitional Care
• Teaching Triggers
• A readmission
• A discharge summary
• An anticipated discharge
• Brainstorming

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EpilogueMrs. Ns Jan 24 D/C Summary

• DISPOSITION
• Patient was transferred back to her skilled
  nursing facility. Dr. Attending had a goals of
  care discussion with Ima and discussed
  considering a Do Not Hospitalize order, since Ima
  finds her trips to the hospital 'taxing'. She
  agreed to this plan and was planning on talking
  to her niece about it. This plan was also
  communicated to Dr. Accepting at the SNF by Dr.
  Attending.