Healthcare transition.pptx
- 1. Rafael A. Ríos Rivera, M.D University of Puerto Rico, Medical Science Campus Fellow in training Rheumatology, PGY-5
- 2. People are vulnerable when they move between different parts of the health care system. Care transitions threaten patient safety as they can increase the possibility of losing critical clinical information and require an increased degree of coordination. Primary care has a central role to play in improving transitions of care, which requires a multifaceted approach.
- 3. The movement of patients from one health care practitioner or setting to another as their condition and care needs change Occurs at multiple levels Within Settings Primary care Specialty care ICU Ward Between Settings Hospital Sub-acute facility Ambulatory clinic Senior center Hospital Home Across health states Curative care Palliative care/Hospice Personal residence Assisted living (c) Eric A. Coleman, MD, MPH
- 4. Each transition of care creates and opportunity for information to be lost or distorted Handoffs are a major contributing factor in trainee- related malpractice cases Malpractice is more frequent when trainees are involved in care as compared to attending-only cases (19% vs 13%, p- 0.02) Scoglietti VC, et al. Am Surg. 2010;76(7):682-686. Arora V, et al. J Gen Intern Med. 2007;22(12):1751-1755 Singh H et al. Arch Intern Med. 2007;167(19):2030-2036
- 5. Transitions between hospitals and primary care settings are recognized as high- risk scenarios for patient safety: Delay in diagnosis Wrong or delays in receiving appropriate treatment Increase adverse events Patient complaints Increased healthcare costs Increased length of stay Additional primary care or emergency department visits Increased readmissions Additional or duplicated tests or tests lost to follow-up Increase in mortality Increase in morbidity (temporary or permanent injury or disability) Emotional and physical pain and suffering for service users, careers, and families Patient and provider dissatisfaction with care coordination Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. World Health Organization. "Transitions of care." (2016).
- 6. Patient ER ICU In-Patient Patient OUTPATIENT: • Home • PCP • Specialty • Pharmacy • Case Mgr. • Care Giver SNF ALF NO Medication Reconciliation NO Personal Medicine List NO Coordinated Care Plan NO Discharge Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Care Plan NO Medication Reconciliation NO Personal Medicine List
- 8. System level barriers Practitioner level barriers Patient level barriers (c) Eric A. Coleman, MD, MPH
- 9. (c) Eric A. Coleman, MD, MPH
- 10. Practitioners often have not practiced in settings where they transfer patients Sending practitioners may not communicate critical information to receiving practitioners Practitioners may not know the patient and his or her preferences for care Practitioners have no accountability (c) Eric A. Coleman, MD, MPH
- 11. Patients assume that someone is in charge of coordinating care Patients (and caregivers) are often the only common thread weaving between care sites Yet they navigate the system with few tools or training to manage in this role (c) Eric A. Coleman, MD, MPH
- 12. Medication errors Increased health care utilization Inefficient/duplicative care Inadequate patient/caregiver preparation Inadequate follow-up care Dissatisfaction Litigation/Bad publicity (c) Eric A. Coleman, MD, MPH
- 14. On hospital admission, more than 30% to 80% of patients have at least one medication discrepancy Approximately 19 % and 2 % were classified as significant and serious, respectively. Giannini O, Rizza N, Pironi M, Parlato S, et al. A. Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward. BMJ Open. 2019 May 27;9(5):e026259.
- 15. On discharge from the hospital, 30% of patients have at least one medication discrepancy with the potential to cause possible or probable harm The most common discrepancy is the omission of pre- admit medication. Kwan Y et al. Arch Intern Med 2007;167:1034-40.
- 16. Agency for Healthcare Research and Quality. Hospital Survey on Patient Safety Culture. https://www.ahrq.gov/sops/surveys/hospital/index.html. Accessed September 25, 2022.
- 17. 40% of patients experienced at least 1 medical error Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 months Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to disontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646-51. *Work-up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart).
- 18. Observational Studies Direct communication between hospital physicians and primary care physicians occurred infrequently (3-20%) Discharge summary Completed discharge summaries within 48 hrs with a mean of 67%. Availability at first post-discharge summary to PCP (55%) Often lacked important information (e.g., lab results, discharge medications, treatment, follow-up plan) Information was limited to pending results (25%) Diagnostic test performed (60%) Postdischarge medications (78%) Affected quality of care in ~25% of follow-up visits Delayed or insufficient transfer of discharge information between hospital-based providers and PCPs remains common. Creation of electronic discharge summaries seems to improve timeliness and availability but does not consistently improve quality. Kattel, Sharma MD; Manning, Dennis M. MD; Erwin, Patricia J. Et.al. Information Transfer at Hospital Discharge: A Systematic Review. Journal of Patient Safety 16(1):p e25-e33, March 2020.
- 19. Total No. (%) Completed Workup Type Yes No Diagnostic procedure 115 (47.9) 50.4 49.6 Subspecialty referral 85 (35.4) 72.6 27.4 Laboratory test 40 (16.7) 85.0 15.0 Total 240 (100) 64.1 35.9 Moore C et al. Arch Intern Med 2007. • Workup Type is the outpatient workup recommended upon discharge from the hospital. • Completed indicates whether the recommended workup was done within 6 months after discharge. • 240 workups recommended in 191 discharges.
- 20. Transfers and Adverse Events Adverse drug events (ADEs) attributable to medication changes occurred in 20% of bi-directional transfers 50% of ADEs were caused by discontinuation of medications during hospital stay Boockvar K, Fishman E, Kyriacou CK et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004;164:545-50.
- 21. 44,000-98,000 deaths/year in hospitals as a result of adverse drug events Over 1,000,000 injuries Enormous practice variation Estimated $450 billion unnecessary spending Slow translation of research to practice One estimate 17 years IOM, Crossing the Quality Chasm
- 22. Patient cognitive status Patient activity level and functional status Suitability of the patient’s home (e.g. cleanliness, stairways, location) Availability of support from careers and family Availability to obtain medications and health care and social services availability of appropriate transportation
- 24. There is no easy solution to providing safer care transitions. Interventions that may be beneficial include: Complying with nationally agreed guidelines Standardizing documentation and agreeing on which information should be included in referral and discharge documents Irrespective of where they were generated or who is to receive them). Robust discharge planning with agreed criteria and protocols Establishing tracking systems for diagnostic and follow-up tests, referrals, and appointments Improving the quality and timeliness of discharge documentation Implementing effective medication reconciliation practices Conducting timely and appropriate patient follow-ups telephone calls and home visits
- 25. Improving the effectiveness and timeliness of clinical handovers between clinicians Establishing primary care hotline to hospital emergency departments Assigning care coordinators or case managers to people with complex needs Increasing the involvement of primary care physicians Educating and supporting patients, families and careers
- 26. 1. Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. 2. World Health Organization. "Transitions of care." (2016). 3. Giannini O, Rizza N, Pironi M, Parlato S, et al. A. Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward. BMJ Open. 2019 May 27;9(5):e026259. 4. Kwan Y et al. Arch Intern Med 2007;167:1034-40. 5. Agency for Healthcare Research and Quality. Hospital Survey on Patient Safety Culture. https://www.ahrq.gov/sops/surveys/hospital/index.html. Accessed September 25, 2022. 6. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to disontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646-51. 7. Kattel, Sharma MD; Manning, Dennis M. MD; Erwin, Patricia J. Et.al. Information Transfer at Hospital Discharge: A Systematic Review. Journal of Patient Safety 16(1):p e25-e33, March 2020. 8. Boockvar K, Fishman E, Kyriacou CK et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004;164:545-50.