Succeeding in the Post-Acute Market Strive for 5 Effective Communication with Physicians, Hospitals and Other Partners and Miscellaneous Other Topics

Transcription

1 Succeeding in the Post-Acute Market Strive for 5 Effective Communication with Physicians, Hospitals and Other Partners and Miscellaneous Other Topics Luis L Gonzalez, Jr, MD FACP FAAHPM CMD

2 Objectives At the end of this presentation the audience should be able to: 1. Summarize coordination between hospitals and skilled nursing facilities 2. Be able to identify admission issues related to success or failure 3. Recognize value of detailed discharge planning 4. Discuss the benefits of an active facility medical director 5. Be ready to implement AMDA Choosing Wisely Campaign

3 Partnering Study by Lehigh Valley Health Network 1. Patient discharge destination volume by SNF day all-cause readmission rate 3. CMS Nursing Home Compare 5-Star rating 4. Health network affiliation of the SNF medical director 5. Hospital network associated attending physicians 6. SNF participation in hospital related activities, meetings M.B. Maly et al JAMDA 13 (2012)

4 Reflections of the 30-day Readmit 1. SNF immediate ability to care for the patient 2. Overall quality of the patient placement 3. SNF physician comfort level with the facility s nursing staff

5 Admission Process Telephone call, text, e-discharge, Curaspan, Allscripts to admissions staff Nurse case review- med list, identify specials needs Therapy review Accept admission Report nurse to nurse, meds, DME, oxygen, other Transport Admission Physician orders

6 Admission Failures Surprises Family High cost Medication mismanagement Documentation failure, inconsistencies

7 Admission Success Diligent admission manager Accurate (honest) information from hospital Director of nursing involvement Medical director availability Attending physician cooperation Family expectations/early relationship Establish goals, care plan, team involvement

8 Discharge Planning When does it start? Why important? Who should be involved? What are the components? Home health MEDICATIONS PCP/specialist follow-up What reduces 30 day readmission?

9 Medication Reconciliation Hospital admit to discharge Hospital discharge to SNF SNF admission to discharge Reviewed 1696 medications in 132 transition records of 44 patients Identified 1002 discrepancies, equal across the 3 transitions Discrepancy: incompatibility in a patient's documented medication regimen including addition, omission, therapeutic exchange, changes and duplication; medication changes that were not clearly supported Hospital admission, hospital discharge, SNF admission, SNF discharge Sinvani JAMDA 14 (2013)

10 Discrepancy Unintentional Potential for harm- omission of bowel regimen for patients on opioids, CAD patient no aspirin, omission antibiotics, duplication of meds, therapeutic exchange correction 86% had at least one unintentional discrepancy Discrepancies per patient between medication changes in each transition 100% left SNF with more meds than when they entered the hospital Intentional Deliberate decision

11 Medication Reconciliation Reduce Discrepancies Pharmacist electronic medication review Improved communication between providers across setting Improved communication between providers and patients

12 Error Rate in Single Transition Community to hospital- 54%-67% Hospital to home- 46%-70% Hospital to SNF/LTC- 75%

13 Medication Reconciliation Other studies have revealed: 50% of patients discharged from the hospital will have a medication error resulting in adverse drug reactions, rehospitalizations, increased costs 75% of these are likely preventable

14 30-Day Unplanned Readmission CMS- Hospital Compare AMI, CHF, Pneumonia, Hop/Knee replacement, Stroke Traditional fee for service Medicare Includes VAH Medicare managed care plans are not included Risk adjustment, significance testing CABG started 2015

15 Active Facility Medical Director Define active: Participates as attending Attends QA Reports issues, suggests solutions Availability, responsiveness Education

16 Re-admissions MedPAC % hospital discharges readmitted within 30 days 75% avoidable $12 billion excess health care costs; other estimates as high as $44 billion

17 Hospital Interventions to Reduce 30-Day Readmissions 43 article review Unable to identify single intervention attributable to reduction in re-hospitalization Categories Discharge planning protocols Comprehensive geriatric assessment Discharge support arrangements Educational interventions Ann Int Med. 2011;155:

18 Interventions Pre-discharge Patient education Discharge planning Medications reconciliation Appointment scheduling Post-discharge Timely follow-up Timely PCP communication Follow-up telephone call Patient hot line Patient visit

19 Two Common Bundle Items Patient Centered Discharge Instructions Post discharge telephone call

20 Sex in the Nursing Home Up to one-third of seniors over 75 are sexually active Does your nursing home have a sexuality policy? Policies need to protect resident s rights to express themselves sexually while ensuring everyone s safety Staff training How do families react?

21 Court Case Husband charged with rape of his wife suffering from Alzheimer s disease residing in a nursing home Staff did not believe she could consent Acquitted since Alzheimer s may be able to give consent to certain actions

22 AMDA Choosing Wisely 1. Don t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings. 2. Don t use Sliding Scale Insulin for long-term diabetes management for individuals residing in the nursing home. 3. Don t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.

23 AMDA Choosing Wisely 4. Don t prescribe antipsychotic medications for behavioral psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior. 5. Don t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy. 6. Don t place an indwelling urinary catheter to manage urinary incontinence.

24 AMDA Choosing Wisely 7. Don t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years. 8. Don t obtain a C. difficile toxin test to confirm cure if symptoms have resolved. 9. Don t recommend aggressive or hospital-level care for a frail elder without a clear understanding of the individual s goals of care and the possible benefits and burdens. 10. Don t initiate antihypertensive treatment in individuals >60 yrs. old with SBP<150 or DBP <90