Published in the September 2013 issue of Today’s Hospitalist
IT WAS AN EYE-OPENING MOMENT for the hospitalist trying to admit a patient to a nursing home based on three large envelopes stuffed with patient information from a two-week hospital stay. The doctor was part of a group of physicians who wanted to see what it’s like on the post-acute care side. By touring the nursing home with their post-acute care colleagues, the hospitalists hoped to gain insights into how to reduce bouncebacks to the hospital from post-acute care.
The tour was held two years ago for physicians with IPC The Hospitalist Company, a national physician practice company. The hospitalists worked at the Christiana Care Health System in Wilmington, Del., where IPC staffs both the acute-care hospitalists and the post-acute practice.
“Your patient is going to a SNF. Should you follow her there?” Our July 2019 article covers the growing pressure on skilled nursing facilities to keep patients from bouncing back to the hospital.
The visit paid off by inspiring the hospitalists to make some changes. First, they exchanged their direct phone numbers with the post-acute care physicians. They then revamped the discharge process to ensure that a pared-down discharge summary was sent to the post-acute care facility before the patient arrived. That new form contains only a summary of what had and had not worked, along with what strategies to consider if the patient decompensates, and a list of comorbidities and needed medications.
The hospitalists also began having a floor nurse call the post-acute facility 24 hours after transfer to answer any questions and check on the patient. All that enhanced communication got results: After six months, hospital readmissions from the skilled nursing facilities (SNFs) dropped 28%, from 7.4% to 5.3%.
“Post-acute care readmissions are largely due to the fact that people don’t consider what the next step is,” says Heather Zinzella-Cox, MD, director of post-acute care of IPC Delaware, who organized the site visit. Often, Dr. Zinzella-Cox explains, the physician or nurse at the facility receiving the patient is inundated with too much information “but still doesn’t really know what to do right away.
In only a short amount of time, a lot can go wrong. And given liability concerns, the facility simply sends the patient back to the emergency department (ED), which then automatically admits the patient.
“Folks are coming into SNFs on multiple meds and at high risk,” says Tyler Jung, MD, chief medical officer of Health Essentials, a health care coordination company based in Santa Ana, Calif., that specializes in providing post-acute care. “If you’re not careful to bring a team mentality, you’ll have two different stakeholders: the hospitalist and the SNF doctor.”
For hospitalists, the failure to create that team mentality means more readmissions. Here’s a look at what some groups are doing to improve transition planning and reduce the number of bouncebacks from post-acute facilities.
The variables in post-acute care
While 25% of patients bounce back within 30 days, experts say that figure may be as high as 40% of patients coming from SNFs. Now that patients being transferred to SNFs and nursing homes are sicker than ever, the need for a good transition is even more critical.
“SNFs today are housing the med/surg patients of yesteryear,” says Dr. Jung.
But another major complication is how many variables in care hospitalists run into with different post-acute care facilities.
“At many SNFs, the most sophisticated piece of equipment is a fax,” points out Jerry Wilborn, MD, IPC’s national medical director for post-acute services. Most SNFs have no ability to perform diagnostic tests, while ordered medications can take 72 hours to reach patients, not the one hour hospitalists are used to in hospitals.
The presence of RNs may be very limited, with more SNF care provided by LPNs. And while physicians attending in SNFs in his market see patients as often as medical necessity dictates, Dr. Wilborn notes that physicians in other facilities may go weeks without visiting, relying instead on information passed along on the phone from nurses.
And while some say the lack of EHRs “and most post-acute care facilities don’t have them “are to blame for communication lapses, experts emphasize that content trumps technology. The answer, Dr. Zinzella-Cox says, is to find algorithms and strategies to improve patient care and reduce readmissions.
Everything from better collaboration to adding post-acute hospitalists to work much more closely with acute-care physicians is on the table. IPC is also using a CMS innovation grant to test pilot algorithms for transitions of care handoffs. One algorithm has a new template in the chart for an order set and discharge note.
Where to start
Sources say that coming up with a targeted discharge summary is a great place to start.
Robert Young, MD, MS, is a hospitalist at Chicago’s Northwestern Memorial Hospital who chairs the Society of Hospital Medicine’s post-acute care task force to create a post-acute care transitions toolbox. What happens now, Dr. Young says, is that “a busy nurse may flip through a ream of paper at night” to determine what a new patient needs before he or she calls the SNF doctor for voice orders.
“If there’s a special type of diet or the patient needs special dressings,” explains Dr. Young, “unless the discharging doctor writes it out in a formatted way that the nursing home staff member can read, a lot of things can get dropped.”
Raj Mahadevan, MD, is founder of Cape Coral Hospitalists in Ft. Myers, Fla., with physicians working in several hospitals and SNFs. Dr. Mahadevan follows patients into post-acute settings.
“We get 60 pages of nursing notes from some hospitalists,” Dr. Mahadevan says, “instead of the one piece we need telling us why the patient is here. This is what prompts us to say, ‘We don’t understand the patient very well’ and send the patient back.”
While he appreciates having consultants’ notes and progress notes for patients who’ve been in the hospital a long time, he says what he really needs is a good history and physical, and a discharge summary.
Hospitalists at Regions Hospital in St. Paul, Minn., take a good discharge summary a step further, making a point to document specific goals of care.
“We are trying to shift from discharge summaries that contain an historical record to something more proactive,” says Rick Hilger, MD, a hospitalist at Regions and medical director for care management.
“We want to make sure we document any conversations with patients and families that involved goals of care,” Dr. Hilger explains. “An example would be, ‘Family would like to see if Mr. Smith can get back to his functional baseline after his acute pneumonia. If he clinically does not do well over the next 1-2 weeks and has a poor quality of life, family would like to pursue hospice.’ Or, ‘Goal is for patient to not be rehospitalized unless it is for pain that can’t be controlled at the nursing home.’ This kind of information has really improved coordination of care.”
That’s just the information post-acute care clinicians need, says Dr. Zinzella-Cox. She is one of 16 post-acute hospitalists who work with IPC Delaware’s 16 acute-care hospitalists, communicating through a shared virtual office.
“Give me an ‘if/then’ scenario,” she says. “Tell me how to keep your patient out of the hospital. Pretend I don’t know anything about medicine. You’re not going to step on my toes. Spell it out for me.”
The timeliness of information is also key. In 2010, Regions began mandating that all patients going to a nursing home or rehab center have a discharge summary physically go with them. That’s a big change from the previous 30-day window. “I don’t know how we got by with that,” says Dr. Hilger.
Another innovation to consider is a “warm handoff,” says Dr. Jung.
That handoff can be via phone, e-mail or fax, but it shouldn’t be a message on an answering machine. “Give details to make sure the SNF doctor has the proper narrative of the patient or the family,” Dr. Jung says. ” ‘I’m moving Mr. Jones to you tonight. Here are the issues, the things I really can’t put in the transfer summary: I’ve reduced this dose, or you really need to work with the daughter because the expectations are far from what we can accomplish.’ Otherwise, nobody knows the context of the case, so the facility transfers the patient back.”
Northwestern is also working on warm physician handoffs. “The process of determining who to contact at the nursing facility and how to contact that person can take a lot of effort and time,” says Dr. Young. “The better idea is for the people negotiating the referral ” the social worker, the SNF clinical liaison or the nursing home admissions staff “to have the contact information.” That way, the hospital physician will have a contact number for the warm handoff.
“A phone call is huge in our world,” says IPC’s Dr. Wilborn. “Even though they take time, if we did more direct phone calls, continuity would be better, readmissions would be lower and the number of meds would be reduced.”
Like IPC, hospitalists should also consider holding joint meetings, even if SNF physicians aren’t part of the same group as their acute-care colleagues. According to Dr. Young at Northwestern, hospitalists and SNF clinicians should form a quality improvement team to help come up with a standard package of discharge information and a standard format for orders, including a care plan and medication list.
Meeting with SNF personnel can also uncover good news. In 2012, the Main Line Health System, with four acute-care hospitals in suburban Philadelphia, convened a meeting of 80 people from throughout the entire system to improve care transitions and reduce readmissions.
The hospitalists at the meeting were pleasantly surprised to learn about the level of care that SNFs within the system can provide.
“We didn’t realize that they can do an IV and IV antibiotics,” says Jonathan Stallkamp, MD, Main Line’s director of hospital medicine. “We thought you had to keep those patients in the hospital and do a PICC line.”
Grace Wummer, RN, MSN, the system’s director of patient care coordination, said that meeting and successive ones helped identify more than two dozen gaps the health care system is now working on to improve transitional care. While the resulting initiatives target all preventable readmissions, several also try to reduce the number of readmissions from patients in post-acute care.
And that means targeting the ED. SNF physicians ” or more often, nurses “default to sending patients to the ED, while ED physicians then default to admitting those patients.
“The problem is this: The ED thinks if the nursing home sends the patient, it wants the patient admitted,” Dr. Young says. “In reality, the SNF physician may have wanted a specific evaluation or treatment given and, if appropriate, then have the patient return to the SNF.” According to Dr. Stallkamp, “For the ED, admitting is often quicker than trying to contact a SNF doctor and arrange transport back to the SNF.”
Second opinions in the ED
One initiative that Main Line Health has put in place is to embed case managers in the ED. While those case managers help physicians determine observation vs. inpatient status, they also help arrange transportation for patients back to the SNF.
And when patients arrive in the ED from a SNF, it’s the hospitalists who get in touch with the SNF doctor directly and give a second opinion about whether or not the patient needs to be admitted. “We have a good relationship with SNF doctors, several of whom come from our hospitalist group,” says Dr. Stallkamp. “They trust our opinion, and we also provide assurance to the ED doc to send the patient back.”
Dr. Mahadevan credits the Interventions to Reduce Acute Care Transfers (INTERACT) program “a quality improvement project for nursing homes funded by the Commonwealth Fund “with prompting him to recently bring the key players from both the post-acute and acute-care side together to develop guidelines on who needs to go to the ED in the first place.
“That’s going to reduce readmissions,” he predicts. Specific strategies include having the hospital provide checklists and medical decision-making trees, as well as sharing doctors’ phone numbers so each knows who to call.
And Dr. Hilger from Regions points to another innovation that has helped curb readmissions both from post-acute care facilities and among patients discharged home: multidisciplinary rounds. Those take place weekdays for 30 minutes on each unit and include hospitalists, charge nurses, social workers, case managers and pharmacists.
“We spend just 30 to 60 seconds per patient, trying to verbalize who’s at high risk for readmission and how to lower that risk,” Dr. Hilger says. “The rounds have been crucial to decreasing medically unnecessary readmissions from SNFs.”
Timing discharges right
Then there’s the issue of when readmissions from post-acute care settings are likely to occur. Because most readmissions in Illinois occur on Mondays as patients decompensate over the weekend, some hospitals in the state are looking to change the time when patients leave the hospital to avoid late Friday discharges, says Dr. Young. In Delaware, the IPC hospitalists likewise changed their rounding strategies to have a team round earlier in the day to expedite discharges.
Hospitalists should also consider working more closely with another major stakeholder: patients and their families. “There are two or three transitions for a patient who doesn’t go home,” Dr. Jung points out. “All those transitions with different players cause unnecessary readmissions as the instructions get watered down. Only one person is constant throughout all the transitions, and that’s the patient and his or her family.”
Hospitalists can help patients and families be more clear, for instance, on medications so prescriptions don’t go missing in a new facility or new drugs aren’t inadvertently added. Physicians should also send patients with enough medications to get them through the first 24 to 48 hours.
Dr. Jung admits that hospitalists can be torn about doing more. “Productivity is so important,” he says. “Hospitalists think, ‘Should I see one more patient or get involved in discharge?’ ”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.