Download transitional care

TRANSITIONAL CARE
module two
Bill Lyons, M.D.
UNMC Geriatrics
Asst. Professor
[email protected]
HIGH-QUALITY
TRANSITIONAL CARE
1.
2.
3.
4.
Reliable, accurate
information transfer
Preparation of patient,
family, caregiver
Support for selfmanagement
Empowerment of patient
to assert preferences
Coleman et al. Int J Integrat Care 2002
WHEN CONTEMPLATING
A TRANSFER
1. Patient’s global goals – medical and functional
recovery, in light of family support?
2. Risk-benefit ratio – is benefit of the transition
likely to exceed harms associated with transfer
to a new venue?
3. Quality of the match – is the proposed new
venue a good match for medical, nursing, and
functional needs?
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
TOO SICK FOR DISCHARGE?
PREDICTORS OF INSTABILITY
• New incontinence, chest
pain, dyspnea
• HR>100-130, 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
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
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
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
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?
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).
A. True
B. False
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.
post-test question 2
A hospital discharge summary shows the following on the discharge
diagnosis list:
1. Congestive heart failure with systolic dysfunction
2. Diabetes mellitus type 2
3. Benign prostatic hyperplasia
4. Sundowning
True or False:
Item number 4 should not have been included, as "sundowning" is
not a medical diagnosis.
A. True
B. False
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.
End