Geriatric Medicine Book


Transitions of Care

Aka: Transitions of Care, Hospital Transition, Health Care Facility Transition, Hospital Readmission Prevention
  1. Definitions
    1. Transitions of Care
      1. Transitions into and out of health care facilities
      2. Example: Hospital discharge to Nursing Home
  2. 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
  3. Approach: Medication reconciliation common problems
    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
  4. 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
  5. 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
  6. 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
  7. 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]
  8. References
    1. (2015) Presc Lett 22(3): 17
    2. Abrashkin (2012) Mt Sinai J Med 79:535–44 [PubMed]
    3. Hesselink (2012) Ann Intern Med 157(6):417-28 [PubMed]

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