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Transitional Care: Coordinating Care
for our Most Vulnerable Patients
Michael A. LaMantia, MD, MPH
Indiana University Center for Aging Research
Regenstrief Institute, Inc.
Kevin Biese, MD, MAT
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation and
The John A. Hartford Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health.
All Rights Reserved.
Case One – Mr. S
• Mr. S: Friday, 7:30pm
» 85 yo with PMHx of moderate dementia from
ALF
» No paperwork or MAR
» Patient can’t give chief complaint
» Person on call from the facility who knows
patient has gone home
» Grandson states patient has been coughing
and that doctor at facility suspected PNA
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Case One – Mr. S
• PMHx:
» CAD
» Htn
» Moderate dementia
• Allegies: NKDA
• Meds: (grandson believes he remembers
these)
»
»
»
»
Metoprolol
Aricept
Aspirin 81 mg
Simvastatin
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Case One – Mr. S
» PE: 130/70 76 18 96%RA afebrile
• Patient slightly confused (this is change from
baseline according to grandson)
• NCAT, PERRL, MMM
• Reg S1S2, no m/r/g
• Some very mild crackles at right base otherwise
clear, normal work of breathing
• Rest of exam: unremarkable
» Labs: WBC 10.0 hgb 12.0 hct 36.0 plt 350, N
8.7, L 1.0, E 0.3
» Blood chemistry: WNL
» CXR: Possible developing right lower lobe
infiltrate vs. atelactasis. Clinical correlation
recommended
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Case One – Mr. S
• PORT score: 105 points --- Risk Class IV –
approximately 8-9% mortality
• You recommend hospitalization ---- but
• Grandson states he is HCPOA and patient
would not wish to be hospitalized. He wishes
to take patient home and care for him there.
Patient is confused but agreeable
• You prescribe course of levofloxacin and ask
that they see their provider on Monday
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Case One - Resolution
• Patient goes home and does well for 3 days
• He does so well, family does not follow-up
with PCP on Monday
• Tuesday evening: Patient returns with skin
bruising and blood in his urine
» Plt: WNL
» INR: 7.2
• When the patient’s pills are brought from
home, it is discovered he is taking warfarin
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Case One – Breakdown
• What went well?
• What could have gone better?
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Transitional Care
• Definition:
“A set of actions designed to ensure the
coordination and continuity of healthcare as
patients transfer between different locations or
different levels of care within the same
institution.”
–American Geriatrics Society (2003)*
*Coleman EA, Boult C. Improving the quality of transitional care for persons
with complex care needs. Journal of the American Geriatrics Society. Apr
2003;51(4):556-557.
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Transitional Care
• During transitions, patients are at risk for:
•
•
•
•
Medical errors
Service duplication
Inappropriate care
Critical elements of care plan “falling though the
cracks”
-AGS (2003)*
*Coleman EA, Boult C. Improving the quality of transitional care for
persons with complex care needs. Journal of the American
Geriatrics Society. Apr 2003;51(4):556-557.
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Transitional Care
• Conceptual model of effective transitional
care (Coleman 2003)*:
• Communication between sending and receiving
clinicians
• Preparation of the caregiver and patient for
transition
• Reconciliation of medication lists
• Arranging a plan for follow-up of outstanding
tests
• Arranging an appointment with receiving
physician
• Discussing warning signs that might
necessitate more emergent evaluation
*Coleman EA. Falling through the cracks: challenges and opportunities for
improving transitional care for persons with continuous complex care needs.
Journal of the American Geriatrics Society. Apr 2003;51(4):549-555.
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How to Improve Transitional Care
• Suggestions:
» Changes to health care delivery systems (i.e.
use of nurses to follow patients or expanding PACE
programs)
» Adoption of information transfer technology
» Changes to health care policy (i.e. pay for
coordination of care or make providers responsible for
coordinating transitional care)
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How to Improve Transitional Care
• Society for Academic Emergency Medicine
(SAEM) Geriatric Task Force:
» Developed at recommendation of SAEM and
American College of EM
» Identify and adopt quality measures to allow
assessment of care provided to elderly
patients
» Quality measures were vetted by:
• SAEM Geriatric Task Force
• SAEM annual meeting
• American Geriatrics Society (AGS) annual
meeting
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How to Improve Transitional Care
• Quality Measures 1-4:*
» If nursing home (NH) patient goes to ED, then
paperwork should state:
•
•
•
•
Reason for transfer
Code status
Medication allergies
Contact information for:
» NH
» Primary care or on-call MD
» Resident’s HCPOA or closest family
member
*Terrell et al. Quality Indicators for Geriatric Emergency Care. Academic
Emergency Medicine 2009; 16:441-449.
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How to Improve Transitional Care
• Quality Measures 5-6:
» If NH patient goes to ED, then paperwork
should include:
• Patient’s Medication Administration Record
» If NH patient goes to ED for requested
studies, then:
• Document the performance of requested tests
or the reason why such tests were not
performed
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How to Improve Transitional Care
• Quality Measures 7-9:
» If NH patient goes to ED and then will be
released from the ED, then:
• ED provider should speak with the NH provider,
primary care or on-call MD for the NH prior to
discharge from the ED
» If NH patient goes to ED and then will be
released from the ED, then written paperwork
should state:
• ED diagnosis
• Tests performed with results (and tests with
pending results)
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How to Improve Transitional Care
• Quality Measures 10-11
» If NH patient goes to ED and then is released
back to the NH, then:
• The patient should receive the recommended
follow-up
• The recommended changes to the patient’s
medications or plan of care should be followed
(or the reason why not followed documented)
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Case 2 – Mrs. J
• Mrs. J: Thursday evening, 5:30pm
» 82 year old woman who presents from home
accompanied by home aide with complaint of
“fall” --- she was carrying packages in dept
store and tripped over a bed
» List of PMHx:
•
•
•
•
Early memory changes
Hx of atrial fibrillation
Hx of compression fractures
COPD
» Patient sees PCP at UNC --- records are up to
date
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Case 2 – Mrs. J
• In speaking with patient, she complains of right
shoulder pain and is placed on backboard with C-collar
• CT of the neck shows acute comminuted fracture
involving the left articular pillar of C2
• Neurosurgery consultation obtained --- recommended
that patient stay in Miami J collar . (No f/u plan given)
• Patient released from the ED at 1:10am with nursing
aide –
• given prescription for vicodin
• advised to take ibuprofen also
• told to wear Miami J collar until released
• asked to follow-up with PCP – “call for next
available appointment”
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Case 2 – Mrs. J
• Next day (~4pm), PCP receives call from the
patient’s granddaughter , asking about why
patient went to ED --- she heard her grandma
broke her neck and is surprised she is at
home
• Patient’s son (primary caregiver) is in
Bahamas
• Call to house reveals aide at home isn’t
familiar with brace
• Neighbor who is retired nurse finds collar up
around patient’s nose and the patient with
uncontrolled pain
• Patient instructed to return to ED for further
evaluation
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Resolution
• PCP meets pt in ED and admits pt to
geriatrics service
• CXR shows Pthx developed in interim
• Patient hospitalized for several days
• Seen by neurosurgery in hospital and plan for
f/u developed
• Evaluated by PT/OT during hospitalization
• D/C’d home with additional help (son flew
home from Bahamas) and with close followup with PCP
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Case Two– Breakdown
• What went well?
• What could have gone better?
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Questions for Group
• What would it mean to provide truly great
transitional care to your patients?
• What are the barriers to providing improved
transitional care to the patients in your care
setting?
• What would it take to address these issues?
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Thank You!
• Questions/Comments?
• My contact information:
Michael LaMantia, MD, MPH
Assistant Professor of Medicine
Indiana University Center for Aging Research
Regenstrief Institute, Inc.
410 West 10th Street, Suite 2000
Indianapolis, IN 46202-3012
Tel: 317-423-5621
Fax: 317-423-5653
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Acknowledgements and
Disclaimer
This project was supported by funds from The Donald
W. Reynolds Foundation/The John A. Hartford
Foundation Geriatrics for Specialists Grant. This
information or content and conclusions are those of the
author and should not be construed as the official
position or policy of, nor should any endorsements be
inferred by The Donald W. Reynolds Foundation
and/or The John A. Hartford Foundation.
The UNC Center for Aging and Health, the UNC
Division of Geriatric Medicine, the UNC Department of
Emergency Medicine, and the American Geriatrics
Society also provided support for this activity. This
work was compiled and edited through the efforts of
Carol Julian.
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© The University of North Carolina School at
Chapel Hill, Center for Aging and Health.
All Rights Reserved.
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