Transitions of Care


Transitions of Care, Care Transitions, Hospital Transition, Health Care Facility Transition, Hospital Readmission Prevention, Hospital Discharge Planning, Hospital Disposition Planning, Transition to Longterm Care, Nursing Home Admission, Skilled Nursing Facility Admission

  • Definitions
  1. Transitions of Care
    1. Transitions into and out of health care facilities and Longterm Care
    2. Example: Hospital discharge to Nursing Home
  • Indications
  • Transitions of Care
  1. Patient Factors
    1. Failed Activities of Daily Living
    2. Acute illness (debility, intravenous antibiotics, Foley Catheter care, wound care)
    3. Chronic disease progression needing support not available at home
    4. Cognitive Impairment with complications or safety concerns (e.g. Dementia Related Behavior Problems, Psychosis in Dementia)
    5. End of Life Care (e.g. Hospice, respite care)
  2. Social Factors
    1. Family unable to meet patient's needs (Caregiver Burden, no family or support in close proximity)
    2. Inadequate or unsafe living conditions with lack of support services
    3. Financial limitations
    4. Widow or widower with social isolation
  3. Hospital Transition
    1. Post-operative or post-hospital recovery to achieve adequate ADL performance and self care
    2. New or progressive medical conditions requiring additional education, monitoring, medication adjustments
  • Types
  • Options for Transitions of Care
  1. Medicaid Home Waiver Program (State Supported)
    2. Indicated for patients who qualify for Medicaid Longterm Care or Hospice Care
    3. Provides home health aid for up to 20 hours per week
    4. Supervision by primary care physician
  2. Homecare Aid
    1. Median cost $14 per hour ($11 to $18) as of 2022
    2. Private pay
    3. Supervision by primary care physician
  3. Adult Day Center
    1. May offer respite for families and socialization for patients, as well as other services (e.g. medications, dining, transport, recreation)
    2. Indicated in patients with at least 2 ADL deficits
    3. Typically offered 1 to 5 days per week (median cost $78 per day as of 2022)
    4. Supervision by primary care physician
  4. Program of All-Inclusive Care for the Elderly (PACE)
    2. Indicated for medicaid eligible patients, typically over age 65 years who qualify for Longterm Care
    3. Offers adult day center services AND home health and rehabilitation services, on-site primary care, PT/OT, podiatry, dentists
    4. Supervision by PACE provider and contracts with hospitals, specialists, SNF and Nursing Homes for medical care
  5. Group Home
    1. Indicated for young patients with Cognitive Impairment or chronic mental health conditions
    2. Indicated for older patients with Dementia or Frailty
    3. May dispense scheduled medications as well as prn (only if patient requests)
    4. Nursing assistant level care with monthly Vital Signs obtained
    5. Supervision by primary care physician
  6. Independent Living Facility
    1. Indicated in independent patients (often older) who can perform their own ADLs
    2. Additional services are often available at cost (e.g. as needed nursing, monitoring, meals)
  7. Assisted Living Facility
    1. Indicated in patients with difficulty performing Instrumental Activities of Daily Living
    2. Additional services are often available at cost (e.g. as needed nursing, monitoring, meals)
    3. Median cost $4300 per month in 2021
  8. Skilled Nursing Facility (SNF)
    1. Facility offering continuous 24 hour nursing, with medical supervision and adjunctive health and social services
    2. Provides a level of care below acute hospital care and above intermediate care and custodial care
    3. Intended for rehabilitation to greater functional capacity in ADLs and self care (often as a TCU stay after hospitalization)
    4. Tailored services based on patient needs include physical therapy, occupational therapy, speech therapy
    5. SNF in U.S. are typically Medicare certified to provide subacute care and rehabilitation services
  9. Transitional Care Unit (TCU)
    1. Short-term care (typically up to 21-28 days) in a Skilled Nursing Facility
    2. Intended for medically complex patients, typically recovering after hospitalization or surgery
  10. Nursing Home or Longterm Care Facility
    1. Facility offering continuous, Longterm Care to patients unable to perform Activities of Daily Living
    2. Intended for patients with chronic, physical and mental health limitations, not requiring acute or subacute care (>=2 ADL deficits)
    3. Most U.S. Nursing Homes have 24 hour care with nursing assistants and nurse supervision, as well as dining services
    4. Most Nursing Homes also offer additional services, such as physical therapy, occupational therapy, speech therapy
    5. Median cost in $7756 per month in 2021
  • Precautions
  • Transitions of Care
  1. Transitions of Care are high risk periods
  2. Associated with increased medication errors
  3. Associated with 20% re-admission rate within 1 month of hospital discharge
  4. CMS will penalize hospitals and care systems for excess 30 day readmission rates
  1. Selection
    1. Proximity to family and friends
    2. Facility resources (e.g. dining, recreation, fitness)
    3. Cost and Payer (e.g. Medicaid and personal resources)
    4. Perceived Quality (e.g. staffing ratios, patient experience, facility reputation, patient and family confidence in facility)
    5. Language and cultural accommodations
  2. Preparation
    1. Advance Directives including Resuscitation (e.g. POLST)
    2. Medical and financial power of attorney
      1. Identify whether patient has capacity to make decisions and if not, who will perform these duties
  3. Key components to address
    1. Medications (see below)
    2. Mentation and Mood
      1. Cognitive Impairment Screening (e.g. SLUMS, Montreal Cognitive Assessment)
      2. Major Depression Screening (e.g. Geriatric Depression Scale, PHQ-9)
    3. Mobility
      1. Adaptive equipment and nursing support needs (e.g. transfers, mobility, continence)
      2. Assess for Hearing Impairment and Visual Impairment
      3. Assess for Swallowing difficulties
      4. Activities of Daily Living Scale
      5. Instrumental Activities of Daily Living
      6. Advanced activities (e.g. recreation, hobbies)
    4. Multimorbidities (comorbidities)
      1. Comorbidities (e.g. Diabetes Mellitus, COPD, CHF, Vascular Disease, Chronic Kidney Disease)
      2. Communicable disease screening (e.g. Tuberculosis Screening)
  • Approach
  • Medications
  1. Hospital discharge
    1. Discrepancies between pre-admission medications and those during hospitalization and then at discharge
    2. Medications started in the hospital that should have been discontinued at discharge (or with set end-date or taper)
    3. Chronic medications that require re-start after being held during the hospitalization
    4. Changes in medication doses, frequency/schedule or formulation
    5. Scheduled medications are preferred over prn dosing
      1. Patients may be unable to express needs
  2. Chronic medications
    1. See Polypharmacy
    2. See Medication Use in the Elderly (e.g. Beers List, STOPP)
    3. See Drug-Drug Interactions in the Elderly
    4. See Deprescribing
    5. Perform a "brown bag" reconciliation of home medications (home medication bottles including OTC drugs)
    6. Consider Deprescribing medications with low benefit to the patients medical status or goals
  • Approach
  • Labs and Diagnostic common problems
  1. Pending test results following hospital discharge (occurs in 40% of patients discharged)
  2. Important results that change therapy are found in as many as 10% of pending results
  • Billing
  • Evaluation and Management Codes (E&M Codes)
  1. Code 99495: Moderately complex medical decision making
    1. Patient Communication within 2 business days of discharge
    2. Face-to-face patient visit within 14 calendar days
  2. Code 99496: Highly complex medical decision making
    1. Patient Communication within 2 business days of discharge
    2. Face-to-face patient visit within 7 calendar days
  • Prevention
  1. Communication between hospital care team and the clinic care team (sign-offs)
  2. Schedule hospital discharge follow-up prior to the patient leaving the hospital
    1. Clinic staff (e.g. triage RN) to call patient within 2 days of leaving hospital
    2. Provider visit within 7-14 days of leaving the hospital
  3. Give patients their discharge summary from hospital to bring to their follow-up appointment
  4. Educate patients and families on condition-specific home monitoring and measures
    1. Example: Daily weights in Congestive Heart Failure and what abnormalities should prompt a call
    2. Medications
    3. Follow-up visits
  5. Individualized discharge plans result in shorter hospital stays and lower readmission rates in older patients (over age 60 years)
    1. Inpatient assessment of patient needs (e.g. occupational therapy, physical therapy, wound care, Palliative Care)
    2. Medical consultant recommendations
    3. Communication with patients and families (including education as above)
    4. Gonçalves-Bradley (2022) Cochrane Database Syst Rev 2(2):CD000313 +PMID: 35199849 [PubMed]
  • Disposition
  1. Median time to fullow-up after discharge: 12 days
  2. Risk factors for follow-up no-shows and same-day cancellations
    1. Medicaid insurance
    2. Black race
    3. Long admissions >15 days
    4. Discharge to home with services or to facilities
  3. Factors that make follow-up more likely
    1. Age over 65 years
    2. Living more than 40 miles from follow-up clinic
    3. Discharge from subspecialty clinic
    4. Follow-up with subspecialty clinic (in contrast with primary care)
  4. References
    1. (2017) J Hosp Med 12:618-25 [PubMed]