Bryan K. Ford, Ph.D., MSW Assistant Professor of Medicine Research Associate, Comprehensive Center for Healthy Aging University of Alabama at Birmingham.

Three Intervention Tools Useful in Care Transitions with Older Adults

Bryan K. Ford, Ph.D., MSW Assistant Professor of MedicineResearch Associate, Comprehensive Center for Healthy AgingUniversity of Alabama at Birmingham Education Program DirectorGeriatric Research, Education and Clinical CenterBirmingham VA Medical Center

Learning Objectives:

At the conclusion of this module, participants will be able to:

Discuss the issues of care transitions for older persons.

Describe the several innovative approaches that address care transitions with older people.

Recognize patient and caregiver needs as part of the discharge planning protocol.

Understand how an interdisciplinary team approach is a more successful method to manage care transitions with older adults.

THE PROBLEM OF CARE TRANSITIONS

Older adults are particularly vulnerable to the consequences of fragmented care as they transition across health care settings.

Older people tend to have multiple chronic conditions and multiple medications.

THE PROBLEM OF CARE TRANSITIONS

1 in 5 suffer an adverse event at time of discharge

Vague written discharge orders &insufficient direct contact with the physician

Patients being unprepared for health self-management; uninformed or misinformed about their illnesses or medications; and unsupported in the area of follow-up resources

Informal caregivers have little involvement in the transition process

THE PROBLEM OF CARE TRANSITIONS

Ultimately, all of these issues culminate in –

greater general patient dissatisfaction and

higher rates of rehospitalization

(both impact the cost of care)

Patient Satisfaction

October 2012 - Medicare will base payments to hospitals in part on consumer satisfaction scores

This means that “Medicare will begin withholding 1 percent of its payments to hospitals … [and] That money — $850 million in the first year — will go into a pool to be doled out as bonuses to hospitals that score above average on several measures,” that include patient satisfaction.

-Kaiser Health News, Aug 2011

Rapid Rehospitalizations

Recent estimates suggest that “readmissions cost Medicare $26 billion a year, with one in five patients landing back in the hospital within a month.”

-Washington Post, Sept 2011

Mr. Case

82-year-old white male

Current issues: Coronary artery disease, recent myocardial infarction, heart failure, & diabetes.

Medications : ▪hydrochlorathiazide (blood pressure),▪aspirin (heart failure preventions)▪insulin (diabetes) ▪enalapril (blood pressure & heart failure)▪carvedilol (blood pressure & heart failure)▪clopidogrel (coronary heart disease)

Symptoms: increased coughing, shortness of breath. He also complains that he is not able to walk as far as he used to and cannot sleep lying flat, having to prop himself up on three pillows.

Actions: stopped the hydrochlorathiazide & started on furosemide (Lasix).

Mr. Case

Mr. Case rehospitalized

Two days later, Mr. Case fainted and hit his head on the kitchen table and was brought to the Emergency Department.

Symptoms including: weakness, dizziness, confusion, & feeling light-headed.

Further investigation determined that Mr. Case was confused about his medications and had continued taking his previously prescribed “water pills” along with his newly prescribed Lasix and had become dehydrated.

During the second hospital stay, the social worker noted that Mrs. Case appeared tired and somewhat confused about Mr. Case’s medications. Mrs. Case repeatedly complained about one of the nurses “attitude” during the second hospital stay. Mr. Case was stabilized and released from the hospital.

WHAT WE KNOW FROM THE LITERATURE

The care transitions literature indicates that interventions with the most impact: Begin soon after admission to the

hospital Include follow-up in the home Are targeted to high risk groups Are patient-centered

… and are underutilized in clinical settings.

Care Transition Interventions

Three models: 1. The Care Transitions Program,

2. The Transitional Care model and

3. Project BOOST.

The Care Transitions Program®

Care Transitions Intervention® (CTI® ) was is designed to: identify potential threats to health teaches patients and caregivers to take an

active role The CTI addresses four "pillars“ of care:

1) medication self-management, 2) a patient-centered record,3) timely follow-up, and 4) "red flags”.

The Care Transitions Program®

One of the key components of CTI® is the transition coach.

The transition coach … helps patients across health care settings. meets with the patient both before & after

discharge. works to empower the patient. utilizes telephone support

-Coleman, Parry, et al., 2006; Coleman, et al., 2006.

The Transitional Care Model

The Transitional Care Model primarily focuses on “high risk” patients that tend to have the most trouble during transitions in care.

“High risk” patients are identified as older patients with “poor self-health ratings, multiple chronic conditions, and history of recent hospitalizations” (The Transitional Care Model, 2012).

The Transitional Care Model

TCM uses a coordinating Transitional Care Nurse that … Conducts a comprehensive assessment; Coordinates the patient’s discharge plan; Implements the care plan at home; Assists the patient & family in managing

their care needs; and Serves as the facilitator in the patient’s

communications

Project BOOST

Project BOOST (Better Outcomes for Older Adults through Safe Transitions)

Project BOOST provides the most comprehensive assessment tool which is free to the public.

Project BOOST’s objectives include: 1) Identification higher risk patients on admission; 2) Reduce 30-day readmission rates for medical patients; 3) Reduce length of stay; 4) Improve facility patient satisfaction & H-CAHPS scores; and 5) Improve information flow between hospital & outpatient

providers.

Revisiting Mr. Case

By applying the screening tool outlined in Project BOOST, Mr. Case would have been assessed as high risk upon his first admission to the hospital which would have identified his risk factors.

BOOST’s 8P Screening Tool is a risk assessment tool completed at admission to identify patients who have an increased risk of adverse events post-hospitalization, and utilizing the duration of the hospitalization to mitigate these risks as much as possible.

BOOST’s 8P Screening Tool

1. Problem medications: (ie: warfarin, insulin, digoxin, and aspirin when used in combination with clopidogrel.)

Mr. Case is taking multiple medications including a combination that puts him at risk, especially when combined with clopidogrel.

BOOST’s 8P Screening Tool

Intervention steps: Medication specific education using

Teach Back Monitoring plan developed and

communicated to patient and aftercare providers

Specific strategies for managing adverse drug events

Follow-up phone call at 72 hours to assess adherence and complications 

BOOST’s 8P Screening Tool

2. Psychological or depression: The presence of depression, either in screening evaluations or by history, has been associated with increased risk of rehospitalization.

Mr. Case does not exhibit nor does he have a history of psychological issues including depression.

BOOST’s 8P Screening Tool

Intervention Steps: (if needed) Assessment of need for psychiatric

aftercare

Communication with aftercare providers

Involvement/awareness of the support network

BOOST’s 8P Screening Tool

3. Principal diagnosis: (ie: cancer, stroke, diabetes or glycemic complication, COPD and heart failure.)

Mr. Case’s diagnoses include those specified to be at high risk for adverse events.

BOOST’s 8P Screening Tool Intervention Steps:

Disease specific education using Teach Back

Action plan reviewed with patient/caregivers regarding what to do and who to contact in the event of worsening or new symptoms

Discuss goals of care with patient/caregiver

BOOST’s 8P Screening Tool

4. Polypharmacy: Patients on 5 or more medications are at an increased risk of an adverse event after discharge.

Mr. Case is on more than five medications.

BOOST’s 8P Screening Tool

Intervention Steps: Elimination of unnecessary medications

Simplification of medication scheduling to improve adherence

Follow-up phone call at 72 hours to assess adherence and complications

BOOST’s 8P Screening Tool

5. Poor Health Literacy: Use the “teach back method” method for patient preparation and education.

Mr. & Mrs. Case are at least high school educated but appear to have confusion about medication and illnesses.

BOOST’s 8P Screening Tool

Intervention Steps: Committed caregiver involved in

planning/ administration interventions Aftercare plan education using Teach

Back Link to community resources for

additional patient/ caregiver support Follow-up phone call at 72 hours to

assess adherence and complications

BOOST’s 8P Screening Tool

6. Patient Support: The absence of a formal or informal care giver has been associated with higher rehospitalization rates.

Mr. Case is accompanied and lives with his spouse, however, it may be determined that Mrs. Case might need help with care duties due to her own medical issues.

BOOST’s 8P Screening Tool Intervention Steps: (if needed)

Follow-up phone call at 72 hours to assess condition, adherence and complications

Follow-up appointment with aftercare medical provider within 7 days

Involvement of home care providers of services with clear communications of discharge plan to those providers

BOOST’s 8P Screening Tool

7. Prior hospitalizations: (previous 6 months)

Mr. Case has recently been hospitalized for MI.

BOOST’s 8P Screening Tool

Intervention Steps: Review reasons for re-hospitalization in

context of prior hospitalization

Follow-up phone call at 72 hours to assess condition, adherence and complications

Follow-up appointment with aftercare medical provider within 7 days

BOOST’s 8P Screening Tool

8. Palliative Care: Engaging these services actively has been shown to improve symptom management, patient satisfaction and limit resources , including rehospitalizations for patients nearing end of life.

Mr. Case does not seem to be appropriate for palliative care options at this time.

BOOST’s 8P Screening Tool Intervention Steps: (if needed)

Assess need for palliative care services Identify goals of care and therapeutic options Communicate prognosis with

patient/family/caregiver Assess and address bothersome symptoms Identify services or benefits available to

patients based on advanced disease status Discuss with patient/family/caregiver role of

palliative care services and benefits and services available

How it helps Mr. Case

Using the 8P Screening Tool, the hospital staff can recognize risky issues at admission and throughout a patient’s hospital stay, which could prevent readmissions.

Furthermore, seeing the warning signs would allow healthcare providers to engage directly with family and caregivers on medication education and possible home care assistance, which could improve consumer satisfaction.

Thank you

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