DISCHARGE PLANNING

Bill Lyons, MD

BACKGROUND
Surging interest from professional societies, payers, Joint Commission Among reasons for the challenge
Aging, increasingly complex population More, and more specialized, venues Providers defining practice by location

CASE 1
Mrs. G, a 96-year-old woman is seen by 96-yearher physician at a home visit Progressive shortness of breath over 2-3 2day period No fever, chills, cough, chest pain Was discharged from hospital one week before

CASE 2
68 yo man transferred from acute hospital to distant suburban SNF after uneventful valve replacement On warfarin + enoxaparin until INR 2.5-3.5 2.5 Progressively less ambulatory INR rises to 17, even after warfarin held and vitamin K administered Cardiac arrest

BOUNCEBACKS

FACTORS ASSOCIATED WITH POOR DISCHARGE OUTCOMES

Age>80 Fair-to-poor selfFair-toselfrating of health Recent and frequent hospitalizations Inadequate social support Multiple, active chronic health problems Depression history Chronic disability and functional impairment History of nonadherence to therapeutic regimen Lack of documented patient/family education

INFORMATION TRANSFER

INFORMATION TRANSFER
Discharge summary not for Med Records Discharge diagnoses should include: functional, cognitive, behavioral, affective Discharge instructions must include red flags, and whom to call Explicitly list follow-up studies, appts follow-

INFO TRANSFER, cont.

Functional status: baseline, transfer The Big Picture
Global goals of care Preferred intensity of care Advance directives

MEDICATIONS
Reconciliation = (New List) (Old List) Tapering and stop schedules Document drug indications Target symptoms for psychiatric drugs

OTHER PEARLS
Early involvement of PT and SW Dispo daily in thought, speech, prose Discuss discharge by goals, not schedule Avoid discharge to SNF or home with HHC on weekends Involve primary care provider Involve clinical pharmacist

PLACES PATIENTS GO

POSSIBLE DISCHARGE LOCATIONS

Home with family support Home with HHC SNF Nursing home, ALF, custodial care Acute rehab LTAC Hospice

HOME WITH HOME HEALTH CARE

Medicare qualifiers
Reasonable and necessary Skilled services (RN, PT, or ST) needed If above needed, can bring in OT, SW, HHA Home bound: Leaving home is infrequent,
requires great, taxing effort requires supportive devices, transportation, help of others medically contraindicated

HOME HEALTH CARE FINANCING

Medicare A: RN, PT, OT, ST, HHA Medicare B: MD home visits, DME, labs but with 20% co-payment co Homemaker services: no Medicare or Medicaid coverage

SKILLED NURSING FACILITIES

Patient requires skilled care: IV therapy, artificial nutrition and hydration, complex wound care, ostomy care, rehab Medicare pays 100% for first 20 days, then 80% for remaining 80 days Coverage stops when goals met or patient stops improving Infrequent provider visits (~monthly)

ACUTE REHAB HOSPITAL

Medicare criteria:
Close medical supervision by physiatrist Needs 24h rehab nursing care Multidisciplinary needs, coordinated program Reasonable expectation of gain Able to participate in 3 hr/d of intense therapy

Typical patients: head/spine injuries, youngish-old after stroke youngish-

LONGLONG-TERM ACUTE CARE (LTAC)

For complex, potentially unstable patients requiring ongoing hospital-level care hospital Specialty Select in Omaha Chronic ventilator patients, multiple IV medications, extensive wound care, TPN Medicare qualifiers
Frequent physician monitoring Need for highly-skilled care highly Expected LOS 25+ days

NURSING HOME (CUSTODIAL)

Home with HHC < Care Needs < SNF Medicare does NOT cover Financing via private pay, Medicaid, longlongterm care insurance

CASE 1 FOLLOW-UP FOLLOW Hospitalization had been for viral gastroenteritis Furosemide held during hospitalization Not resumed (or mentioned) at discharge Result: pulmonary edema

CASE 2 FOLLOW-UP FOLLOW Autopsy: 1500 mL grossly bloody fluid in pericardium, hepatic congestion Positive feedback loop initiated No communication between SNF MD and CT Surgery re significance of climbing INR values