Gregg O. Lehman, Ph.D., president and chief executive officer of Health Fitness Corporation and former president and CEO of INSPIRIS, Inc., maps out when and how care transition breakdowns can occur for the Medicare population.
When do breakdowns in care transitions occur? First, breakdowns when moving from a primary care physician (PCP) to a specialty physician are common — often, information is not well documented. And because it’s common for the Medicare population to be cognitively impaired, it can be difficult for them to effectively communicate their symptoms to the physician. Therefore, physicians need to try to gather information such as changes in eating habits or low-grade fever through a brief physical check.
Second, breakdowns can also occur when moving patients within the hospital. For example, when moving a patient from the ER to another department such as surgical or the ICU, things can fall between the cracks. Treatment for one condition may exacerbate another, causing a more serious problem. Recidivism is also common, and patients usually end up back in an acute care setting.
Thirdly, discharges from the hospital to a home setting or an assisted- or skilled-living facility are often a huge challenge. Typically, these patients cannot take on a self-management role and ask the right questions, or they get confused and cannot remember what their PCP told them. It’s a challenge to maintain a consistent database. Many companies have implemented electronic medical records (EMRs) for this population. The database can be maintained on a virtual or real-time basis for the primary caregivers. Our company uses a registered nurse practitioner (RNP) as the lead person triaging care. The EMR helps to effectively disseminate appropriate information on a timely basis during the care transition process.
Fourth, ineffective communications are a huge problem when dealing with the Medicare population. Communication problems can lead to medication errors and delayed treatment. It can also lead to duplicate test results because records were not transferred in real time. In addition, there’s often a misunderstanding of the rules. For example, HIPAA is designated to protect patient information. However, it can work against patients in transition. Despite the fact that HIPAA permits provider-to-provider disclosure without patient authorization, some providers will not do this without prior patient authorization, and sometimes not without actual patient signatures. In many cases, the power of attorney or signature authorization belongs to a family member not even residing in the same state. That compounds the problems you’re already dealing with. A lack of common platforms for sharing data is also a big problem. Using real-time information that is accessible to the caregiver is critical in minimizing the breakdowns that occur.
Finally, for this population, there are problems inherent in the transition itself. If we move a patient out of a familiar setting — where they’re comfortable with the staff — and into an acute-care setting, often they become disoriented. This commonly results in a downward spiral of the individual’s overall health status. The frail elderly are frequently at various stages of cognitive impairment or the early stages of dementia or Alzheimer’s. A low-grade fever can cause a spike in the patient’s confusion. However, it may not get noticed since the caregiver may attribute it to their other cognitive impairments. This lack of treatment can be the beginning of a decline in the patient’s health.
Source: Reducing Readmission Risk for the Elderly through Care Transition Coaching, October 2009
Reducing Readmission Risk for the Elderly through Care Transition Coaching
This resource presents new models of care coordination for the elderly, including an Oxford Health Plan care transition coach program modeled on research from Eric Coleman, M.D., at the University of Colorado. This resource also reports on Inspiris's care team approach to managing care transitions for the frail elderly — adults 65 and older who comprise 40 percent of elderly hospitalizations and who are particularly vulnerable during transitions from one care site to another.
Reducing Readmission Risk for the Elderly through Care Transition Coaching is available from the Healthcare Intelligence Network for $97 by visiting our Online Bookstore or by calling toll-free (888) 446-3530.
