Charles A. Crecelius, MD, of Saint Louis, has experienced best- and worst-case scenarios when his frail elderly patients have been admitted and discharged by local hospitalists.
Best case, he says: “My patient is admitted. I get a call. I’m told what is going on. I’m notified of meaningful changes, and at discharge, I get another call [from the hospitalist].”
But there are wide variations in hospitalist/nursing home relationships, notes Dr. Crecelius, a long-term care physician and president-elect of the American Medical Director’s Association (AMDA).
This was brought home by the case of a patient with a well-documented history of dystonic reaction to toxic lithium levels. The patient was later misdiagnosed as having tardive dyskinesia, a movement disorder. Her much-needed medication was discontinued, and the hospital transferred the patient back to the nursing home in worse condition than before.
“We wasted an entire hospitalization,” Dr. Crecelius recalls ruefully.
The above scenario underscores the importance of a thorough transfer of information when elderly patients move from facility to facility. Interaction between hospitalists and nursing home staff will become increasingly important in light of the growing frail elderly population and the Joint Commission on Accreditation of Health Care Organization’s (JCAHO) push for improved discharge communications.1
By applying a customer service model and continually upgrading transfer documentation, hospital medicine groups can “keep the level of communication where it needs to be,” says Susan S. Cumming, MD, associate medical director of Marin Hospitalist Medical Group at Marin General Hospital in Greenbrae, Calif.
Running a Risk
Dan Osterweil, MD, CMD, is familiar with the hospitalist model through his medical training in Israel during the late 1970s and early 1980s. Hospitalists there routinely handled inpatient care.
Dr. Osterweil, a clinical professor of medicine/geriatric medicine at UCLA, research associate with the UCLA Borun Center for Gerontological Research, and former medical director of the Jewish Home for the Aging in Reseda, Calif., has the opportunity to observe hospitalists deal with nursing homes in his current capacity as a consultant for managed care corporations in Southern California.
“Hospitalists have an excellent understanding of acute care management,” he says. “They do a good on-site job of dealing with immediate problems of the individual, and they’re very efficient and very responsive. But while hospitalists are providing higher competency in the management of intra-hospital care, I think that those I’ve interfaced with fall short on the transitions of care, which is so critical with the nursing home patient.”
Dr. Osterweil recalls one patient who had in place do not resuscitate (DNR) and do not intubate (DNI) orders. But when he was hospitalized, the patient was intubated. “If [the hospitalist] had asked one question of the individual or the caregiver—‘What is the goal of care?’—they would have been able to plan a much smoother transition for that person back to the facility.”
At Lower Bucks Hospital in Bristol, Pa., where long-term care physician Daniel Haimowitz, MD, CMD serves as chairman of internal medicine and chairs the utilization committee, the surrounding community of physicians has responded in a mostly positive way to a new hospitalist program.
However, Dr. Haimowitz has concerns that transitioning admissions of nursing home patients to hospitalists can hinder continuity of care.
Different hospitalists work each shift, and unless the patient has been on the hospitalist service in the past, the admitting hospitalist may know nothing about the patient—and most probably has no relationship with the patient’s family (as the primary care physician would have).
“The family doctor has seen the patient for 20 or 30 years and knows what he or she wants,” Dr. Haimowitz says. “But this patient is brand new to the hospitalist. Unless the hospitalist is really good with communication and takes the extra step to call the physician at the nursing home, I think you run the real risk of duplicating workup or actually not doing what is in the best interest of the patient.”
“While demonstrating improved quality of care for the acutely ill hospitalized patient, hospital medicine has struggled with the fact that it inherently adds more patient hand-offs into the mix,” says Bryce Gartland, MD, medical director for care coordination and director of hospital medicine for Emory University Hospital in Atlanta. “We experience this internally, within our facility and externally when transferring patients into or out of the hospital.”
There is always a potential for what has been called the “voltage drop” when hand-offs occur, agrees Dr. Cumming, whether they’re between hospitalists in the same facility or from hospitalist back to the primary care provider. “We function in a healthcare system that is very individualized,” she says. “When you’re dealing with many different community hospitals that may not be part of the same system, it’s very hard to standardize [transfer processes].”
The standard of care for transferring patients from Marin General Hospital to subacute rehabilitation facilities or to skilled nursing facilities entails a detailed inter-facility transfer form. The form includes a thorough discharge summary, with a separate medication reconciliation form, photocopies of any relevant consultations, and a list of pending lab tests. In concert with the hospital’s case managers, Dr. Cumming and hospitalists on her team also make every effort to speak with patients’ receiving providers to relay a synopsis of what has occurred during their patients’ stay in the hospital.
—Daniel Haimowitz, MD, CMD, chairman of internal medicine, Lower Bucks Hospital, Bristol, Pa.
Especially in the case of patients with dementia or severe illness prohibiting communication about their condition, a thorough transfer sheet or discharge summary—arriving with the patient or faxed in a timely manner—can help reduce errors and contribute to more seamless resumption of care at the next facility.
Without access to a patient’s history, the opportunity for errors increases. One of Dr. Crecelius’ pet peeves is seeing “history not obtainable” on the hospital’s patient transfer sheet. “A history is always obtainable,” Dr. Crecelius asserts. “You can call the nursing home, the family, or the patient’s physician. That phrase equals, ‘We didn’t bother to take the time.’ There is no such thing as ‘history not obtainable,’ and legally, that will not fly in a court of law.”
Missing or incomplete records necessitate communication between facilities. Dr. Crecelius has also found that hospitalists may not understand the nuances of medication prescription for the elderly—a situation that can be rectified with a phone call.
A case in point: Dr. Crecelius once prescribed theophylline for a bradycardic patient who refused a pacemaker but frequently lost consciousness when his pulse and blood pressure dropped. Although this was an obscure use of the drug, which is primarily a bronchodilator, “it worked to keep the patient’s pulse up so he was not passing out. When he went to the hospital, they stopped the drug, and it took forever to get him discharged. The patient came back to the nursing home in horrible shape. I assume the providers at the hospital thought I was crazy for prescribing theophylline to a frail old person!”
Dr. Crecelius’ prescription for avoiding the above scenario: “If you think the medicine is an odd choice, ask the prescriber why the patient is on it. We need to respect each other and get the information when there is a question.”
Cornerstones of Continuity
Medical directors have addressed continuity of care issues in their own ways. Whenever possible, Dr. Crecelius sees his patients in the hospital. He has also been working as a representative of the Missouri Association of Long-Term Care Physicians with a statewide transition planning committee. The committee is drafting new transfer forms for hospitals and post-acute care facilities.
The Asheville Hospitalist Group, PA has “gone to extraordinary lengths to address the issue of inter-facility transfers,” says Marc Westle, DO, FACP, president and managing partner for the large private group in N.C. His group has coordinated efforts with another group of hospitalists who specialize in managing patients in the Asheville area’s 20-plus nursing homes.
To facilitate transfers to a hospital, the nursing homes send paperwork (including history, physical, and medication records) with patients to the emergency department. When patients are ready for discharge, discharge summaries are dictated stat and faxed to the nursing home. Hospitalists discharging patients pre-order diagnostic tests that will be necessary when the patient returns to the nursing home by noting those tests on discharge orders. In addition, “The nursing home group has a list of all our beeper numbers for direct contact should a question arise,” says Dr. Westle.
Every patient transferred to another facility from Emory University Hospital in Atlanta is accompanied by a three-page transfer form, says Dr. Gartland. Included is a one-page summary of detailed nursing care; a second page listing hospitalization events, including pertinent consults, procedures, diagnoses, pending lab tests, and recommended follow-up; and a detailed medication sheet with discontinuation dates for such medication as antibiotics.
During his time as medical director at the Jewish Home for the Aging, Dr. Osterweil created what he calls his own “pseudo-hospitalist arrangement” to ensure continuity of care. He identified multiphysician groups comprising internists and nephrologists who, between them, could offer 24 hours on-call coverage.
When patients were transported to a local community hospital, Dr. Osterweil or his staff would call one of these physicians, who would take care of the patients when they were admitted to the floor. That arrangement is still in place.
“Any major decisions that are made, we are kept in the loop,” says Dr. Osterweil. “Twenty-four hours before readmission back to the skilled nursing facility, we receive a call letting us know the patient is coming back and his or her issues. The physician group executes a ‘stat’ dictated discharge summary, and the patient leaves the hospital with those orders. This ensures the continuity of care when the patient goes back to the nursing home or the board and care facility.”
Beef Up Communication
Dr. Crecelius concedes that certified medical directors (CMDs) are also often guilty of dropping the ball when it comes to communicating with inpatient provider colleagues.
Care of nursing home patients can be improved if hospitalists and medical directors of nursing homes talk directly on the phone, he says. “I met one wonderful hospitalist who actually showed up at the nursing home to see how the patients that he’d been sending out of the hospital were doing,’’ he recalls. “It was so nice to see the face behind the voice. You can’t get mad at a face!”
However, again demonstrating the range of practice techniques, another hospitalist group in Dr. Crecelius’ area does not do anything beyond faxing him the patient’s diagnosis. “Well, I knew the diagnosis, so that fax is not telling me anything,’’ he says. “And unfortunately, that is their idea of communication.”
The Marin Hospitalist Medical Group makes every effort to ensure communications with receiving facilities are timely and thorough. According to Dr. Cumming, the group has surveyed—and will continue to survey—its referring primary care physicians, whether office or facility-based, for feedback on their performance. Hospital case managers also relay feedback to the hospitalist group, she notes. “We’ve tried to use the customer service model across all the groups of physicians who transfer patients to us and to whom we transfer patients, to keep that level of communication where it needs to be,” she says. Some of the questions they ask of their facilities:
- Are we sending the information you need?
- Do you want to receive all documents with the patient when he or she is transferred, or just a small subset of documents?
- How do you want information delivered? Do you want forms, discharge summaries and other documents faxed to you? Would you prefer a phone call?
- What can we do better?
Dr. Haimowitz’s advice to hospitalists might parallel the advice he recently gave to local a hospital administrators who were considering starting an intensivist program. “If you’re going to do this right, you must have physicians who are sensitive to older patients and what they want,” he says. Quality of life, DNR orders, and goals of care take on subtle gradations when applied to the elderly, he emphasizes.
Absent the time to visit the area nursing homes, hospitalists can always at least call, Dr. Crecelius notes.
Just as a hospitalist or emergency department physician would contact the family to corroborate patient history, they should also call the nursing home. “Speaking with the nurse at the skilled nursing facility, you can access a wealth of information—and save time and effort,” he says.
Dr. Haimowitz believes communication—on a form or by phone—is essential. He sees even more opportunity for miscommunication between hospitals and nursing homes because of different recordkeeping systems.
Hospitals are moving increasingly to electronic health records, while nursing homes still rely on paper documentation. “How do you foster communication?” Dr. Haimowitz asks. “How do you get the right people on the same bus? The best transfer sheet in the world is no good if one, it’s not filled out, and two, if it’s not read.”
Disparate systems can be a barrier, but it does not mean you should not try to optimize communication within whatever system you have, says Dr. Cumming.
The Marin Hospitalist Medical Group is setting up a communication system to alert all primary care physicians of pending lab results so such tests do not fall through the cracks after patients are discharged.
In another initiative, the hospital will set up a system to note that any pneumonia or influenza vaccinations performed while the patient was hospitalized are communicated either to PCP or outside facility. The group is also working to urge all local nursing facilities to include records of patients’ recent vaccinations when they are transferred to the hospital.
It’s clear that effective transfers of elderly patients require a concerted effort by all involved. “If you perform a root cause analysis of [transfer] errors, most occur not because of any negligence, but because communication—written or verbal—was not handled as best as it could have been,” Dr. Gartland notes. “Oftentimes, we are just as frustrated as they [nursing facilities] are when patients return to the emergency room unable to communicate their medical conditions, wishes, and the like,” he says. As medical director of care coordination at Emory, he has worked to improve relationships with administrators and physicians in nursing facilities used most often by the hospital. “If people have a vested interest in a relationship, they are more likely to be diligent about the transfer of patients,” he asserts.
Above all, emphasizes Dr. Cumming, “it important to always solicit feedback from your primary care physician ‘clientele.’ They are your clients, much as your patients are, and your hospital is. We’re providing services to all these various groups. Quality patient care is the most important thing that we do, and part of that means that we have to have good transfer of information. Our group recognizes that we are far from perfect; we know we can always do better; and we always have to reassess to make sure that we’re on the right track.” TH
Gretchen Henkel is a frequent contributor to The Hospitalist.
- Ouslander JG, Osterweil D, Morley J. Medical Care in the Nursing Home. 2nd ed. New York, New York: McGraw-Hill Publishers;1997.