Student transitions in care information

Hospitalized Adult Care-Transitions/Home visits *Do you ever wonder what happens to a patient after discharge from the hospital? *Are you ever confused about what medications a patient is actually taking? *Have you ever seen a patient in clinic who informs that he/she was hospitalized and you have no idea what for and what was done? Physicians are currently poorly trained in several important aspects of the discharge process and have limited understanding of the transition to the next site of care Patients are also poor at negotiating these processes and may be rehospitalized, experience a medication error, or miss much needed follow up due to the confusion that surrounds this time During this educational experience, you will receive this much needed education and learn about some of the barriers in a quality transition from both the medical and patient perspectives Additionally, it is our hope that you will develop skills in interprovider communication and patient hand-offs Objectives: Students will identify the critical components of care transitions and the common obstacles to quality of care in transitions from the inpatient setting Students will identify and describe the important role of healthcare providers in assuring quality of care during transitions of care from the inpatient setting Students will perform thorough medication reconciliation between hospital discharge and home/assisted living/skilled nursing facility Students will gain confidence and skills in inter-provider communication necessary for quality care in transitions from the inpatient setting Student expectations: Project: Students will perform at least one NON-MEDICAL post-discharge visit to a patient they cared for while in the hospital The visit will be at a patient's home, in the nursing home, in hospice, or in an assisted living facility Students are encouraged to make this visit with another student, a resident or a faculty member Participating hospitals: • AIP/University of Colorado Hospital (UCH) • • • • • Veteran’s Administration Hospital (VA) Denver Health (DH) Rose Medical Center (RMC) Presbyterian Saint Luke’s Medical Center (PSL) Exempla Saint Joseph’s Hospital (ESJH) Timeframe: • Home/nursing home/assisted living visit MUST BE COMPLETEDshould be completed or scheduled within the first weeks of clerkship • A small group session discussion regarding issues of transitions in care will occur on the Thursday afternoon of Intrasession Safety issues: Take a functioning cell phone and only visit during daylight hours Be sure to tell your team where you are going, when you are going and that you may need to call them (the attending or resident) if any problems arise Follow your gut reaction, if you need to leave, leave If you are uncomfortable with going to a home, consider a nursing home visit Consider going with another student If the patient is unstable, call 911 Carry your attending’s and resident’s pager number with you as well as the phone number for the primary care provider or other transition provider (i.e nursing home or hospice physician) if you have other questions Patient selection recommendations: Patient admitted and discharged during Hospitalized Adult Care clerkship within the first four weeks, AND At least one prior admission in the last year OR One or more of the following diagnoses: a cardiac arrhythmia b heart failure c acute coronary syndrome (unstable angina or acute myocardial infarction) d diabetes mellitus which is poorly controlled or has complications e acute exacerbation of chronic obstructive pulmonary disease f hip fracture within the last year g HIV disease h active lung, breast, or colon cancer i chronic liver disease AND Lives within the local Denver area (30 mile radius) Discharged to home, assisted living, nursing home, hospice, rehabilitation facility, or skilled nursing facility Cooperative primary care provider OR does not have a primary care provider Age 65 years or older OR low literacy Has a telephone to confirm home visit follow-up Home visit goals: • Compare the medications the patient was discharged with to those patient is actually taking (medication reconciliation) • See how the illness has progressed in the patient (education only) • See how the patient negotiates obstacles despite any disabilities • Encourage the patient to make/keep follow-up appointment with PCP • Relay (NOT ANSWER) patient questions to follow-up provider Items to complete (see attachments for templates): Read attached article (Coleman, The Care Transitions Intervention) This article will help you understand the key issues you are likely to encounter on your home visit Patient log Discharge phone call to PCP (you should this for all patients you care for, not just the home visit patient) Discharge phone call to patient (you should consider doing this for all patients you care for as well) Home visit form (use as a guideline for visit) Medication reconciliation form (turn in) Follow-up form/phone call for provider (turn in) Debriefing small group: • Thursday during intrasession, small group format with clinicians • Discuss visit findings, surprises, problems, interactions, etc • Discuss EBM article, Coleman, The Care Transitions Intervention Telephone call to PCP post-discharge: This is , a third year medical student at hospital I am contacting Dr to discuss his/her patient, _, who is being discharged from the hospital Patient name: _ Admission date: _ Admission diagnoses: Discharge diagnoses: Problem Status Follow-Up Plan Procedures: Pending studies: _ Discharge to: □ Home □ Skilled nursing facility _ □ Hospice □ assisted living facility □ other _ He/She needs a follow-up appointment in days May I schedule it now or can your office give the patient a call at (phone number)? [If you are planning to visit…] Because I followed Mr /Ms in the hospital, I would like to visit him/her at home/nursing home/assisted living This would allow me to better medication reconciliation, find out how the patient lives, and reinforce follow-up plans Would that be okay with you? I will communicate my findings of the visit with you If you have any further questions, I can be reached at: _ (pager) Patient follow-up phone call: This is , the medical student who helped care for you while you were at _ (hospital) I am calling to see how you are managing since discharge *Overall, how are you feeling? *Medications -did you have any trouble getting your medications? -do you have any trouble taking your medications? -are you having any side effects of medications? *Are you able to function at home adequately to care for yourself? (Or can your caregiver help well enough?) -Are you eating okay? -Are you having trouble getting around? -Have you fallen recently? -Are you able to go to work (if appropriate)? [Things to think about: toileting, bathing, falls, sleeping, eating, driving, shopping, cooking, cleaning.] *Do you have a follow-up appointment scheduled? With whom? When? **Are there any particular questions I can relay to your provider (Not answer)? -Have you written down the questions so you not forget? *Remember to bring your discharge paperwork and medicines to your follow-up appointment! (If you are hoping to a home visit…) I would like to come and see you at your home (nursing home/assisted living) to learn about how medical problems change and improve over time It will also give me a chance to see how you function in your own environment This is not to replace your hospital follow-up with your provider Would that be okay with you? Can we set up a time that is convenient? Note: It is best to approach this subject in the hospital and then call to confirm a time and date Note: If the patient asks you a question you are unable to answer, let him/her know that you would be happy to relay that question to the PCP or ask your supervisors Please not try to answer medical questions Home visit: Reminders: 911 if pt is unstable Safety issues: Consider going in pairs, bring a cell phone, tell others where you are going, only go during daytime hours If your gut reaction tells you this is dangerous, not proceed Bring the phone numbers of: Attending: Resident: _ Primary Care Provider: _ It is often helpful to discuss the reason for the visit: Hospital diagnosis-reiterate for patient if he/she is not sure Transition back to health-explain that this visit is NOT a medical visit It is to help you understand how he/she lives despite medical illness and to ensure that he/she has appropriate medical follow-up planned Current health concerns: Do you understand why you were hospitalized? Do you feel like you have improved? Do you have any questions about your medical issues for your doctor? (If they ask you a specific medical question, please tell them that you will communicate it to their doctor, or your team and get back to them.) Have you written down these questions? Do you need to role play in order to be able to ask your questions? Function: Activities of Daily Living/Instrumental Activities of Daily Living (ADL/IADL) These ultimately determine how a patient will be able to live It will determine his/her independence and it might have changed since the acute illness Observe how patient performs: ADLs: Transferring- see how pt gets up out of chair or bed Walking- how does pt get around? Does he/she use any gait aides? Can he/she go up down the stairs if needed? Dressing- get pt to take off his/her socks and shoes and put them back on Caregiver might be able to shed light if unable to assess directly Toileting- can pt walk to bathroom? Have patient sit down on closed toilet and get back up What does he/she use to help rise (grabs towel bar, uses bathtub or sink, unsteady)? Bathing- can pt get into the tub/shower on own? Pt/caregiver report is helpful Ask frequency of bathing (some people bathe less than once a week) IADLs (will need to ask most): Cooking- safety, ability to stand up to cook Shopping- planning, memory, stamina to go to store/get around Driving- prior to illness and since discharge Medication Management- who sets up the medications, who is in charge of remembering medications? 10 Money Management- who pays the bills, balances the checkbook How long has it been that way? 11 Cleaning- who does it and how? Medications: There is an absolute need to have a clear, concise list for the patient on hospital discharge and at home It is crucial to take a list from the hospital discharge (discharge summary or pharmacy profile) and reconcile what is in the home It is not enough to ask the patient what they take It is worthwhile to look at their medication bottles, medication box, in their medicine cabinet, in their bedside drawer, and wherever else you might find meds It is important to see the over the counter medicines and ask patients about how they take them Look for expired medications and document them If there is a medication compliance issue, count pills and try to guess or deduce whether meds are being taken appropriately It is sometimes appropriate to document when the last fill on the medication bottle was Look in medicine bottles to make sure the pills all look the same If you have any questions, you can always call the pharmacy, describe the shape, color and markings and they should be able to identify the pill for you Document everything you find carefully Encourage pt to discard expired medicines It might be helpful to make a list for the pt to take to the follow-up appointment Home environment: Steps into home? How many levels in the home? Where does the patient sleep? How does the patient get around the house? Any gait aides? Significant hazards for getting around the home (e.g oxygen tubing, clutter, cords, loose carpeting/rugs, pets…)? Where does the patient spend most of the day? Is the bathroom accessible for the patient’s needs? Does he/she use the towel bar to pull self up? Is the patient safe in the tub/getting in and out? Fire safety, including smoke detectors and fire extinguishers? Smoking safety? Smoking with oxygen on? Evacuation routes? Physical Exam: YOU ARE NOT EXPECTED TO BE THE DOCTOR!! As appropriate for your learning ONLY It might be helpful to assess physical changes since the hospitalization if there was any significant finding when the patient was hospitalized Examples include changes in wheezing or crackles in lungs, edema, ascites, jugular venous distention, extra heart sounds, wound healing, or mental status It is very helpful to assess how the patient gets around in the home Wrap-up: Review with the patient diagnosis, medication confusion, questions, follow-up plan Does the patient have a personal health record with their medical problems, medications, allergies, physician name and phone number, written questions? Can you help develop one? Follow-up letter to primary care provider: Dear Dr _, I am writing to provide feedback about your patient, _ I was privileged to see him/her on _ (date) He/she is currently at home/ assisted living/ nursing home Your patient, _, was discharged on (date) recovering from (diagnosis) At the home visit, Mr /Ms Understood/did not understand his/her medical problems Functioned well/poorly in the current environment Needed help with _ (ADLs/IADLs) Had/did not have medication confusion Medications that were not accounted for include Had questions about _ Concerns or questions that I have about the current situation are (This includes medication clarification of dose or schedule, safety issues, concerns about abuse or neglect, personal care, etc.) He/she has a follow-up visit with you on _ (date) The tests that are still pending are _ If you have any further questions, I can be reached at: _ (pager) Thank you for your time, ... appropriate)? [Things to think about: toileting, bathing, falls, sleeping, eating, driving, shopping, cooking, cleaning.] *Do you have a follow-up appointment scheduled? With whom? When? **Are... reconciliation form (turn in) Follow-up form/phone call for provider (turn in) Debriefing small group: • Thursday during intrasession, small group format with clinicians • Discuss visit findings, surprises,... bar to pull self up? Is the patient safe in the tub/getting in and out? Fire safety, including smoke detectors and fire extinguishers? Smoking safety? Smoking with oxygen on? Evacuation routes?