CASE A: FROM HOSPITAL TO HOME WITH HOME HEALTH CARE. Claudia M. Chaperon, PhD, APRN, BC-GNP

Transcription

1 CASE A: FROM HOSPITAL TO HOME WITH HOME HEALTH CARE Claudia M. Chaperon, PhD, APRN, BC-GNP

2 CASE A 78-year year-old man with advanced COPD, alcoholism, bipolar is discharged home from hospital late Friday afternoon Hospitalization for pneumonia, COPD Lives alone, son visits twice a month Ice storm prevents nurse visit until Monday Discharge meds not obtained until then

3 CASE A, cont. Home health nurse confused by prednisone taper in D/C papers She calls the hospitalist: Call the primary care doctor. She calls the primary care doctor: The hospitalist should clear this up. Rehospitalized next day for worsening dyspnea,, inability to care for himself

4 SIMILAR EXPERIENCES?

5 As much as 70% of sentinel events occur due to poor communication while handing off responsibility to another professional. Senate Report

6 Transfer of Patient Care Responsibilities through Improved Hand 0ffs of Information 2006 JCAHO Patient Safety Goals Aim to Reduce Variation through Standardization Convey patient complexity and urgency Focus on requiring verbal communication & correcting barriers to achieving this Importance of a Safety Culture that supports Hand- offs as a Priority Barriers include scheduling issues and fatigue The hand-off is more than just transfer of content, also the transfer of professional responsibility

7 SBAR communication model Situation Health care provider name and agency reporting on (patient name and agency) Background Admission diagnosis and date of admission Pertinent medical history for this hospitalization Brief synopsis of treatment to date Patient code status (if applicable) Family/significant other involvement Isolation and type if any Precautions (fall, suicide, seizure, restraints) Medication reconciliation status (JACHO, 2005; Mikos, 2007) Assessment Vital signs Abnormal labs within past 24 hours Mobility (number of staff and lifting device needed) Mental status cognition, mood, delirium Pain assessment/reassessment (last time pain medication was given) Physician orders (received, carried out, pending) Oxygen (yes or no) Changes from prior assessments (vitals, neurological changes, skin, pain) Support for self-management Empowerment to assert preferences Recommendation Preparation of patient and family already Support for self-management Empowerment to assert preferences Items that require follow-up State of patient teaching needs Discharge needs

8 Home Health Regulatory Compliance Safeguarding Safe Transitions Outcome and Assessment Information Set (OASIS, Mandated comprehensive assessment Forms the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).

9 INFORMATION NEEDED BY HOME HEALTH NURSING Situation Transfer Home Name of physician, contact information, preferred mode of communication Patient name, demographics, Name of responsibility emergency contact or caregiver Advance directives, surrogate decision makers For Medicare: Skilled care needs? Homebound justification?

10 INFORMATION NEEDED, cont. Background Patient discharging home with resolving acute illness Past medical history Medications and allergies past medications and changes during hospitalization. The need a reason for every medication how does allergy manifest itself Cognitive function safe to be alone? Medication oversight? Financial oversight? Needs caregiver? Physical function ADLs (walk, talk, self feed, toilet?) Did the patient fall in the past 6 months. IADLs (Can they get their own groceries? Cook their own food? Pay their bills?) Assistive devices (cane? Walker? Eye glasses, hearing aide, communication board?) OT safety evaluation for grab bars, and other home safety issues?

11 INFORMATION NEEDED, cont. Assessment By discharging MD and receiving nurse from Home Health Active Problems last BM? Bladder issues? Pain? Sadness? Unintentional weight loss? Usual diet? Usual sleep pattern? Baseline Exam at time of transition active infection? Resolving infection, CHF, recent pulmonary function tests? Recent pulse oximetry readings? Does this patient desaturate with exercise, at rest? Pressure Ulcers? OASIS by nursing at time of admission to Home Health OASIS

12 INFORMATION NEEDED, cont. Recommendations For Safe Hospital-Home Transition Handoff of responsibility for care clear discharge orders and discharge summary handed off to home health agency and primary MD in anticipation of discharge back to community setting Shared Responsibility for preliminary care plan Issues to monitor and report Anticipated problems - symptoms to report - actions to take and timeline to take those actions Pending Tests or Consults (Date, time, Doctor, Phone) Needed caregiver support, patient teaching and empowerment, durable medical equipment needed at time of arrival back home. Other supplies needed to provide medications, food, heat, clothing, etc.

13 PHARMACISTS, DRUG REGIMENS, AND TRANSITIONS Linda M. Farho, PharmD, BCPS

14 DRUG REGIMENS Need to be reconciled with each change of venue for the patient: Which drugs are new? Which of the old drugs are to be stopped? Which doses of the old drugs have changed? Each drug needs a documented indication Reconciliation is only as good as our knowledge of the original regimen!

15 THE ORIGINAL REGIMEN Must reflect all prescribing providers and pharmacies Includes OTCs, herbals, vitamins, topicals, ophthalmics,. Assess patient adherence (number of doses missed per week) How is regimen managed at home? Pillbox? Help from family?

16 BENEFITS OF CLINCAL PHARMACIST INVOLVEMENT Key role in care transitions, especially from hospital Growing scientific literature supports pharmacist involvement. 3 examples: Medication reconciliation F/U phone calls after hospitalization Counseling at hospital discharge

17 MEDICATION RECONCILIATION Boockvar KS et al. Am J Geriatr Pharmacother 2006 Preintervention-postintervention study Pharmacist-led medication reconciliation and communication with physicians Reduced discrepancy-related related adverse drug events in patients transferred between hospital and nursing home

18 FOLLOW-UP PHONE CALLS AFTER HOSPITALIZATION Dudas V et al. Am J Med 2001 Randomized trial at academic hospital Pharmacists call patients at home 2 days after hospital discharge Patients asked about their meds, if they have been obtained, know how to take Patients receiving the call had fewer ED return visits (and higher satisfaction)

19 PHARMACIST COUNSELING AT HOSPITAL DISCHARGE Schnipper JL et al. Arch Intern Med 2006 Randomized, controlled trial Patients in intervention arm received pharmacist counseling at discharge and phone call days later Intervention reduced rate of preventable adverse drug events within 30 days of hospital discharge