Transitions of Care

Background: Acute hospitalization has been associated with functional and cognitive decline, particularly in elderly adults. This decline is associated with increased morbidity and mortality.

Patients who received the exercise intervention had significantly higher scores on functional and cognitive assessments at discharge, compared with patients who received standard hospital care alone. Specifically, the study demonstrated a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the Short Physical Performance Battery, 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index, and 1.8 points (95% CI, 1.3-2.3 points) on a cognitive assessment, compared with those who received standard hospital care.

Bottom line: An individualized, multicomponent exercise intervention can help reverse functional and cognitive decline associated with acute hospitalization in elderly patients.

Citation: Martinez-Velilla N et al. Effect of exercise intervention on functional decline in very elderly adults during acute hospitalization. JAMA Intern Med. 2019;179(1):28-36.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: Acute hospitalization has been associated with functional and cognitive decline, particularly in elderly adults. This decline is associated with increased morbidity and mortality.

Patients who received the exercise intervention had significantly higher scores on functional and cognitive assessments at discharge, compared with patients who received standard hospital care alone. Specifically, the study demonstrated a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the Short Physical Performance Battery, 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index, and 1.8 points (95% CI, 1.3-2.3 points) on a cognitive assessment, compared with those who received standard hospital care.

Bottom line: An individualized, multicomponent exercise intervention can help reverse functional and cognitive decline associated with acute hospitalization in elderly patients.

Citation: Martinez-Velilla N et al. Effect of exercise intervention on functional decline in very elderly adults during acute hospitalization. JAMA Intern Med. 2019;179(1):28-36.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: Acute hospitalization has been associated with functional and cognitive decline, particularly in elderly adults. This decline is associated with increased morbidity and mortality.

Patients who received the exercise intervention had significantly higher scores on functional and cognitive assessments at discharge, compared with patients who received standard hospital care alone. Specifically, the study demonstrated a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the Short Physical Performance Battery, 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index, and 1.8 points (95% CI, 1.3-2.3 points) on a cognitive assessment, compared with those who received standard hospital care.

Bottom line: An individualized, multicomponent exercise intervention can help reverse functional and cognitive decline associated with acute hospitalization in elderly patients.

Citation: Martinez-Velilla N et al. Effect of exercise intervention on functional decline in very elderly adults during acute hospitalization. JAMA Intern Med. 2019;179(1):28-36.

Dr. Chace is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: With increased use of anticoagulants, the amount of related ADEs has also increased. ADEs may be preventable through improved communication during transitions of care. The key communication elements are not standardized.

The following items are the 15 RDEs that require documentation: (1) current anticoagulants; (2) indications; (3) new or previous user; (4) if new, start date, (5) short-term or long-term use; (6) if short term, intended duration; (7) last two doses given; (8) next dose due; (9) latest renal function; (10) provision of patient education materials; (11) assessment of patient/caregiver understanding; (12) future anticoagulation provider; and if warfarin, (13) the target range, (14) at least 2-3 consecutive international normalized ratio results, and (15) next INR level.

Bottom line: Standardized communication during transitions of care regarding anticoagulation may reduce anticoagulant ADEs. Objective evidence showing reduction of ADEs after implementation of the list is needed.

Citation: Triller D et al. Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. Jt Comm J Qual Patient Saf. 2018;44(11):630-40.

Dr. Vuong is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: With increased use of anticoagulants, the amount of related ADEs has also increased. ADEs may be preventable through improved communication during transitions of care. The key communication elements are not standardized.

The following items are the 15 RDEs that require documentation: (1) current anticoagulants; (2) indications; (3) new or previous user; (4) if new, start date, (5) short-term or long-term use; (6) if short term, intended duration; (7) last two doses given; (8) next dose due; (9) latest renal function; (10) provision of patient education materials; (11) assessment of patient/caregiver understanding; (12) future anticoagulation provider; and if warfarin, (13) the target range, (14) at least 2-3 consecutive international normalized ratio results, and (15) next INR level.

Bottom line: Standardized communication during transitions of care regarding anticoagulation may reduce anticoagulant ADEs. Objective evidence showing reduction of ADEs after implementation of the list is needed.

Citation: Triller D et al. Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. Jt Comm J Qual Patient Saf. 2018;44(11):630-40.

Dr. Vuong is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: With increased use of anticoagulants, the amount of related ADEs has also increased. ADEs may be preventable through improved communication during transitions of care. The key communication elements are not standardized.

The following items are the 15 RDEs that require documentation: (1) current anticoagulants; (2) indications; (3) new or previous user; (4) if new, start date, (5) short-term or long-term use; (6) if short term, intended duration; (7) last two doses given; (8) next dose due; (9) latest renal function; (10) provision of patient education materials; (11) assessment of patient/caregiver understanding; (12) future anticoagulation provider; and if warfarin, (13) the target range, (14) at least 2-3 consecutive international normalized ratio results, and (15) next INR level.

Bottom line: Standardized communication during transitions of care regarding anticoagulation may reduce anticoagulant ADEs. Objective evidence showing reduction of ADEs after implementation of the list is needed.

Citation: Triller D et al. Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. Jt Comm J Qual Patient Saf. 2018;44(11):630-40.

Dr. Vuong is an associate physician in the division of hospital medicine at the University of California, San Diego.

Background: The optimal quantity of physical therapy provided to hospitalized patients is unknown. It has been hypothesized that the costs of additional physical therapy might be outweighed by a decrease in length of stay. A prior meta-analysis done by the same authors was inconclusive; subsequently, additional large trials were published, prompting the authors to repeat their meta-analysis.

Of note, there was no standard definition of “additional physical therapy” across the heterogeneous group of trials analyzed in this meta-analysis. In all studies, the experimental group received more physical therapy than the control group, either by increased frequency or duration of sessions. Nonetheless, hospitals may consider increasing physical therapy services as a cost-effective means of reducing length of stay.

Bottom line: Additional physical therapy in acute and subacute care settings results in a decreased length of stay and may be cost effective.

Citation: Peiris CL et al. Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and subacute conditions: an updated systematic review and meta-analysis. Arch Phys Med Rehab. 2018;99(11):2299-312.

Dr. Huang is a physician adviser and associate clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: The optimal quantity of physical therapy provided to hospitalized patients is unknown. It has been hypothesized that the costs of additional physical therapy might be outweighed by a decrease in length of stay. A prior meta-analysis done by the same authors was inconclusive; subsequently, additional large trials were published, prompting the authors to repeat their meta-analysis.

Of note, there was no standard definition of “additional physical therapy” across the heterogeneous group of trials analyzed in this meta-analysis. In all studies, the experimental group received more physical therapy than the control group, either by increased frequency or duration of sessions. Nonetheless, hospitals may consider increasing physical therapy services as a cost-effective means of reducing length of stay.

Bottom line: Additional physical therapy in acute and subacute care settings results in a decreased length of stay and may be cost effective.

Citation: Peiris CL et al. Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and subacute conditions: an updated systematic review and meta-analysis. Arch Phys Med Rehab. 2018;99(11):2299-312.

Dr. Huang is a physician adviser and associate clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: The optimal quantity of physical therapy provided to hospitalized patients is unknown. It has been hypothesized that the costs of additional physical therapy might be outweighed by a decrease in length of stay. A prior meta-analysis done by the same authors was inconclusive; subsequently, additional large trials were published, prompting the authors to repeat their meta-analysis.

Of note, there was no standard definition of “additional physical therapy” across the heterogeneous group of trials analyzed in this meta-analysis. In all studies, the experimental group received more physical therapy than the control group, either by increased frequency or duration of sessions. Nonetheless, hospitals may consider increasing physical therapy services as a cost-effective means of reducing length of stay.

Bottom line: Additional physical therapy in acute and subacute care settings results in a decreased length of stay and may be cost effective.

Citation: Peiris CL et al. Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and subacute conditions: an updated systematic review and meta-analysis. Arch Phys Med Rehab. 2018;99(11):2299-312.

Dr. Huang is a physician adviser and associate clinical professor in the division of hospital medicine at the University of California, San Diego.

Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.

The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.

“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”

The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.

Reference

Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .

Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.

The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.

“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”

The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.

Reference

Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .

Hospitalists pay attention to length of stay as a measure of hospital efficiency and resource utilization; outliers on that measure – “long stay patients” – who present complex discharges are a barrier to length of stay reduction. To address this challenge, one institution formed a multidisciplinary Long Stay Committee and described the results in an abstract.

The Long Stay Committee is composed of medical directors, the chief quality officer, directors in nursing, directors of case management/social work, hospitalists, risk management, finance, ethics, psychiatry, and directors of rehabilitation. The most complex patient discharges, identified by case management and social work, are brought to the Long Stay Committee.

“Lack of guardianship is one of the most encountered barriers,” according to the authors. “The Long Stay Committee played an integral part in our institution partnering with the local county to form a guardian service board which facilitates guardianship appointments. Other solutions have included working with the patient and support persons to find appropriate discharge levels of care throughout the United States and other countries as well as guiding them through the process to gain the necessary financial resources.”

The authors conclude that the foundation of the committee’s success in coming up with innovative discharge solutions is the broad range of disciplines that attend this committee and the atmosphere of teamwork it creates.

Reference

Heacock A et al. Long Stay Committee finds innovative discharge plans for difficult discharges. Hospital Medicine 2018, Abstract 312. .

Sanctimonious, self-righteous, discharge saboteurs. These are just a few descriptors I’ve heard hospitalists use to describe my physical therapy (PT) colleagues.

These charged comments come mostly after a hospitalist reads therapy notes and encounters a contradiction to their chosen discharge location for a patient.

I recently met with hospitalists from four different hospitals. They echoed the frustrations of their physician colleagues across the country. The PTs they work with write “the patient requires 24-hour supervision and 3 hours of therapy a day,” or “the patient is unsafe to go home and needs continued therapy at an inpatient rehabilitation center.” The hospitalists in turn want to know “If I discharge the patient home am I liable if the patient falls or has some other negative outcome?” The frustration hospitalists experience is palpable and understandable as their attempts to support a home recovery are often contradicted.
 

Outside the four walls

The transition from fee-for-service to value-based care now calls upon hospitalists to be innovators in managing patients in alternative payment models, such as accountable care organizations, bundled payment programs, and Medicare Advantage plans. Each model looks to support a home recovery whenever possible and prevent readmissions.

Case managers for Medicare Advantage programs routinely review PT notes to inform hospital discharge disposition and post-acute authorization for skilled nursing facility (SNF) admissions and days in SNF. Hospitalists, working with care managers, can follow suit to succeed in alternative payment models. They have the advantage of in-person access to PT colleagues for elaboration and push-back as necessary. For hospitalists, working collaboratively with PTs is crucial to improving the value of care provided as patients transition beyond the four walls of the hospital.
 

The evolution of PT in acute care

Prior to diagnosis-related groups (DRGs), PTs were profit centers for hospitals – rehabilitation departments were well staffed and easily accommodated consults and requests for mobility.

With the advent of DRGs, physical therapy became a cost center, and rehabilitation staffs were reduced. PTs became overextended, were less available for consultations for mobilization, and patients suffered the deleterious effects of immobility. With reduced staffing and a rush to get patients out of the hospital, acute PT practice morphed into evaluating functional status and determining discharge destination.

Now, as members of an aligned health care team, PTs need to facilitate a safe home discharge whenever possible and determine what skilled services a patient needs post-acute stay, not where they should receive them.
 

Discharge disposition and longitudinal recovery

PTs, as experts in function, have a series of “special tests” at their disposal beyond pain, range of motion, and strength assessments. These include: Activity Measure for Post-Acute Care (AM-PAC) or “6-Clicks” Mobility Score, Timed Up and Go, Six-Minute Walk Test, Tinetti, Berg Balance Scale, Modified Barthel Index, Five Times Chair Rise, and Thirty-Second Chair Rise. These are all objective measures of function that can be used to inform discharge disposition and guide longitudinal recovery.

To elaborate on one tool, the 6-Clicks Mobility Score is a validated test that allows PTs to assess basic mobility.^1,2 It rates six functional tasks (hence 6 clicks) that include: turning over in bed, moving from lying to sitting, moving to/from bed to chair, transitioning from sitting to standing from a chair, walking in a hospital room, and climbing three to five steps. These functional tasks are scored based on the amount of assistance needed. The scores, in turn, have been shown to support discharge destination planning.¹ In addition to informing discharge destination decisions, hospitalists and the rest of the health care team can use 6-Clicks to estimate prolonged hospital stays, readmissions, and emergency department (ED) visits.³

Of course, discharge disposition is influenced by many factors in addition to functional status. Hospitalists are the obvious choice to lead the health care team in interpreting relevant data and test results, and to communicate these results to patients and caregivers so together they can decide the most appropriate discharge destination.

I envision a conversation between a fully informed hospitalist and a patient as follows: “Based on your past history, your living situation, all of your test results including labs, x-rays and the functional tests performed by your PT, your potential for a full recovery is good. You have a moderate decline in function with a high likelihood of returning home in the next 7-10 days. I recommend you go to a SNF for high-intensity rehabilitation for 7 days and that the SNF order PT and OT twice a day and walks with nursing every evening.”

This fully informed conversation can only take place if hospitalists are provided clear, concise documentation, including results of objective functional testing, by their physical therapy colleagues.

In conclusion, PTs working in the acute setting need to use validated tests to objectively assess function and educate their hospitalist colleagues on the meaning of these tests. Hospitalists in turn can incorporate these assessments into a discussion of discharge disposition and longitudinal recovery with patients. In this way, hospitalists and physical therapists can work together to achieve patient-centered, high-value care during and following a hospitalization.
 

Ms. Tammany is SVP of clinical strategy & innovation for Remedy Partners, Norwalk, Conn.

References

1. Jette DU et al. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014 Sep;94(9):1252-61.

2. Jette DU et al. Validity of the AM-PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014 Mar;94(3):379-91.

3. Menendez ME et al. Does “6-Clicks” Day 1 Postoperative Mobility Score Predict Discharge Disposition After Total Hip and Knee Arthroplasties?” J Arthroplasty. 2016 Sep;31(9):1916-20.

Sanctimonious, self-righteous, discharge saboteurs. These are just a few descriptors I’ve heard hospitalists use to describe my physical therapy (PT) colleagues.

These charged comments come mostly after a hospitalist reads therapy notes and encounters a contradiction to their chosen discharge location for a patient.

I recently met with hospitalists from four different hospitals. They echoed the frustrations of their physician colleagues across the country. The PTs they work with write “the patient requires 24-hour supervision and 3 hours of therapy a day,” or “the patient is unsafe to go home and needs continued therapy at an inpatient rehabilitation center.” The hospitalists in turn want to know “If I discharge the patient home am I liable if the patient falls or has some other negative outcome?” The frustration hospitalists experience is palpable and understandable as their attempts to support a home recovery are often contradicted.
 

Outside the four walls

The transition from fee-for-service to value-based care now calls upon hospitalists to be innovators in managing patients in alternative payment models, such as accountable care organizations, bundled payment programs, and Medicare Advantage plans. Each model looks to support a home recovery whenever possible and prevent readmissions.

Case managers for Medicare Advantage programs routinely review PT notes to inform hospital discharge disposition and post-acute authorization for skilled nursing facility (SNF) admissions and days in SNF. Hospitalists, working with care managers, can follow suit to succeed in alternative payment models. They have the advantage of in-person access to PT colleagues for elaboration and push-back as necessary. For hospitalists, working collaboratively with PTs is crucial to improving the value of care provided as patients transition beyond the four walls of the hospital.
 

The evolution of PT in acute care

Prior to diagnosis-related groups (DRGs), PTs were profit centers for hospitals – rehabilitation departments were well staffed and easily accommodated consults and requests for mobility.

With the advent of DRGs, physical therapy became a cost center, and rehabilitation staffs were reduced. PTs became overextended, were less available for consultations for mobilization, and patients suffered the deleterious effects of immobility. With reduced staffing and a rush to get patients out of the hospital, acute PT practice morphed into evaluating functional status and determining discharge destination.

Now, as members of an aligned health care team, PTs need to facilitate a safe home discharge whenever possible and determine what skilled services a patient needs post-acute stay, not where they should receive them.
 

Discharge disposition and longitudinal recovery

PTs, as experts in function, have a series of “special tests” at their disposal beyond pain, range of motion, and strength assessments. These include: Activity Measure for Post-Acute Care (AM-PAC) or “6-Clicks” Mobility Score, Timed Up and Go, Six-Minute Walk Test, Tinetti, Berg Balance Scale, Modified Barthel Index, Five Times Chair Rise, and Thirty-Second Chair Rise. These are all objective measures of function that can be used to inform discharge disposition and guide longitudinal recovery.

To elaborate on one tool, the 6-Clicks Mobility Score is a validated test that allows PTs to assess basic mobility.^1,2 It rates six functional tasks (hence 6 clicks) that include: turning over in bed, moving from lying to sitting, moving to/from bed to chair, transitioning from sitting to standing from a chair, walking in a hospital room, and climbing three to five steps. These functional tasks are scored based on the amount of assistance needed. The scores, in turn, have been shown to support discharge destination planning.¹ In addition to informing discharge destination decisions, hospitalists and the rest of the health care team can use 6-Clicks to estimate prolonged hospital stays, readmissions, and emergency department (ED) visits.³

Of course, discharge disposition is influenced by many factors in addition to functional status. Hospitalists are the obvious choice to lead the health care team in interpreting relevant data and test results, and to communicate these results to patients and caregivers so together they can decide the most appropriate discharge destination.

I envision a conversation between a fully informed hospitalist and a patient as follows: “Based on your past history, your living situation, all of your test results including labs, x-rays and the functional tests performed by your PT, your potential for a full recovery is good. You have a moderate decline in function with a high likelihood of returning home in the next 7-10 days. I recommend you go to a SNF for high-intensity rehabilitation for 7 days and that the SNF order PT and OT twice a day and walks with nursing every evening.”

This fully informed conversation can only take place if hospitalists are provided clear, concise documentation, including results of objective functional testing, by their physical therapy colleagues.

In conclusion, PTs working in the acute setting need to use validated tests to objectively assess function and educate their hospitalist colleagues on the meaning of these tests. Hospitalists in turn can incorporate these assessments into a discussion of discharge disposition and longitudinal recovery with patients. In this way, hospitalists and physical therapists can work together to achieve patient-centered, high-value care during and following a hospitalization.
 

Ms. Tammany is SVP of clinical strategy & innovation for Remedy Partners, Norwalk, Conn.

References

1. Jette DU et al. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014 Sep;94(9):1252-61.

2. Jette DU et al. Validity of the AM-PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014 Mar;94(3):379-91.

3. Menendez ME et al. Does “6-Clicks” Day 1 Postoperative Mobility Score Predict Discharge Disposition After Total Hip and Knee Arthroplasties?” J Arthroplasty. 2016 Sep;31(9):1916-20.

Sanctimonious, self-righteous, discharge saboteurs. These are just a few descriptors I’ve heard hospitalists use to describe my physical therapy (PT) colleagues.

These charged comments come mostly after a hospitalist reads therapy notes and encounters a contradiction to their chosen discharge location for a patient.

I recently met with hospitalists from four different hospitals. They echoed the frustrations of their physician colleagues across the country. The PTs they work with write “the patient requires 24-hour supervision and 3 hours of therapy a day,” or “the patient is unsafe to go home and needs continued therapy at an inpatient rehabilitation center.” The hospitalists in turn want to know “If I discharge the patient home am I liable if the patient falls or has some other negative outcome?” The frustration hospitalists experience is palpable and understandable as their attempts to support a home recovery are often contradicted.
 

Outside the four walls

The transition from fee-for-service to value-based care now calls upon hospitalists to be innovators in managing patients in alternative payment models, such as accountable care organizations, bundled payment programs, and Medicare Advantage plans. Each model looks to support a home recovery whenever possible and prevent readmissions.

Case managers for Medicare Advantage programs routinely review PT notes to inform hospital discharge disposition and post-acute authorization for skilled nursing facility (SNF) admissions and days in SNF. Hospitalists, working with care managers, can follow suit to succeed in alternative payment models. They have the advantage of in-person access to PT colleagues for elaboration and push-back as necessary. For hospitalists, working collaboratively with PTs is crucial to improving the value of care provided as patients transition beyond the four walls of the hospital.
 

The evolution of PT in acute care

Prior to diagnosis-related groups (DRGs), PTs were profit centers for hospitals – rehabilitation departments were well staffed and easily accommodated consults and requests for mobility.

With the advent of DRGs, physical therapy became a cost center, and rehabilitation staffs were reduced. PTs became overextended, were less available for consultations for mobilization, and patients suffered the deleterious effects of immobility. With reduced staffing and a rush to get patients out of the hospital, acute PT practice morphed into evaluating functional status and determining discharge destination.

Now, as members of an aligned health care team, PTs need to facilitate a safe home discharge whenever possible and determine what skilled services a patient needs post-acute stay, not where they should receive them.
 

Discharge disposition and longitudinal recovery

PTs, as experts in function, have a series of “special tests” at their disposal beyond pain, range of motion, and strength assessments. These include: Activity Measure for Post-Acute Care (AM-PAC) or “6-Clicks” Mobility Score, Timed Up and Go, Six-Minute Walk Test, Tinetti, Berg Balance Scale, Modified Barthel Index, Five Times Chair Rise, and Thirty-Second Chair Rise. These are all objective measures of function that can be used to inform discharge disposition and guide longitudinal recovery.

To elaborate on one tool, the 6-Clicks Mobility Score is a validated test that allows PTs to assess basic mobility.^1,2 It rates six functional tasks (hence 6 clicks) that include: turning over in bed, moving from lying to sitting, moving to/from bed to chair, transitioning from sitting to standing from a chair, walking in a hospital room, and climbing three to five steps. These functional tasks are scored based on the amount of assistance needed. The scores, in turn, have been shown to support discharge destination planning.¹ In addition to informing discharge destination decisions, hospitalists and the rest of the health care team can use 6-Clicks to estimate prolonged hospital stays, readmissions, and emergency department (ED) visits.³

Of course, discharge disposition is influenced by many factors in addition to functional status. Hospitalists are the obvious choice to lead the health care team in interpreting relevant data and test results, and to communicate these results to patients and caregivers so together they can decide the most appropriate discharge destination.

I envision a conversation between a fully informed hospitalist and a patient as follows: “Based on your past history, your living situation, all of your test results including labs, x-rays and the functional tests performed by your PT, your potential for a full recovery is good. You have a moderate decline in function with a high likelihood of returning home in the next 7-10 days. I recommend you go to a SNF for high-intensity rehabilitation for 7 days and that the SNF order PT and OT twice a day and walks with nursing every evening.”

This fully informed conversation can only take place if hospitalists are provided clear, concise documentation, including results of objective functional testing, by their physical therapy colleagues.

In conclusion, PTs working in the acute setting need to use validated tests to objectively assess function and educate their hospitalist colleagues on the meaning of these tests. Hospitalists in turn can incorporate these assessments into a discussion of discharge disposition and longitudinal recovery with patients. In this way, hospitalists and physical therapists can work together to achieve patient-centered, high-value care during and following a hospitalization.
 

Ms. Tammany is SVP of clinical strategy & innovation for Remedy Partners, Norwalk, Conn.

References

1. Jette DU et al. AM-PAC “6-Clicks” functional assessment scores predict acute care hospital discharge destination. Phys Ther. 2014 Sep;94(9):1252-61.

2. Jette DU et al. Validity of the AM-PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014 Mar;94(3):379-91.

3. Menendez ME et al. Does “6-Clicks” Day 1 Postoperative Mobility Score Predict Discharge Disposition After Total Hip and Knee Arthroplasties?” J Arthroplasty. 2016 Sep;31(9):1916-20.

SAN DIEGO – A nationally representative survey of ICU patients older than age 65 years shows an improvement over time in the frequency of advance care planning (ACP), but one in four have no ACP; the problem is more pronounced among some blacks and Hispanics and those with lower net worth. The study also found that these patients see physicians an average of 20 times in the year preceding the ICU visit, which suggests that there are plenty of opportunities to put ACP in place.

marcosmartinezromero/iStockphoto

“Over two-thirds were seen by a doctor in the last 2 weeks. So they’re seeing doctors, but they’re still not doing advance care planning,” said Brian Block, MD, during a presentation of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. Dr. Block is with the University of California, San Francisco.

Lack of advance planning can put major road blocks in front of patient care in the ICU, as well as complicate communication between physicians and family members. The findings underscore the need to encourage conversations about end-of-life care between physicians and their patients – before the patients wind up in intensive care.

One audience member believes these conversations are already happening. Paul Yodice, MD, chairman of medicine at Saint Barnabas Medical Center in Livingston, N.J., suggested that physicians are attempting to engage older patients and family members in ACP, but many are unready to make decisions. “In my experience, it is happening much more frequently than is captured either in the medical record or in the research that we’ve been publishing. I’ve been a part of those conversations. Those individuals who are faced with those toughest of choices choose to delay making the decision or speaking about it further because it’s just too painful to consider, and they hold out hope of being the one to beat the odds, to have one more day,” said Dr. Yodice.

He called for further research to document whether ACP conversations are happening and to identify barriers to decisions and the means to overcome them. “A next good study would be to send out a respectful survey to the families of those who have lost people they love and ask: Has someone in the past year spoken with you or offered to have a discussion about end-of-life issues? We could get a better handle on [how often] the discussion is being had, and then find a solution,” said Dr. Yodice.

ACP can also be difficult for the provider, he added. Family members and patients, desperate for another treatment option, will often ask if there’s anything else that can be done. “In medicine, the answer almost always is ‘Well, we can try something else even though I know it’s not going to work.’ And people hold on to that, including us,” said Dr. Yodice.

The study analyzed data from a Medicare cohort of 1,109 patients who died during 2000-2013 and had an ICU admission within the last 30 days of their life. Ages were fairly evenly distributed, with 29% aged 65-74 years, 39% aged 75-84, and 32% aged 85 and over. Fifty-four percent were women, 26% were nonwhite, 42% had not completed high school, and 11% were in skilled nursing facilities.

About 35% had no ACP in 2000-2001, and that percentage gradually declined, to about 20% in 2012-2013 (slope, –1.6%/year; P = .009).

Seventeen percent of white participants had no ACP, compared with 51% of blacks and 49% of Hispanics. Net worth was also strongly associated with having ACP: The top quartile had 13% lacking ACP, compared with 43% of the bottom quartile.

The study found that 94% of patients who had no ACP had visited a health care provider in the past year. The average number of visits in the past year was 20, and 83% had seen a provider within the past 30 days.

Dr. Block did not declare a source of funding or potential conflicts. Dr. Yodice had no disclosures.
 

chestphysiciannews@chestnet.org

SOURCE: Block B et al. CCC48, Abstract 401.

SAN DIEGO – A nationally representative survey of ICU patients older than age 65 years shows an improvement over time in the frequency of advance care planning (ACP), but one in four have no ACP; the problem is more pronounced among some blacks and Hispanics and those with lower net worth. The study also found that these patients see physicians an average of 20 times in the year preceding the ICU visit, which suggests that there are plenty of opportunities to put ACP in place.

marcosmartinezromero/iStockphoto

“Over two-thirds were seen by a doctor in the last 2 weeks. So they’re seeing doctors, but they’re still not doing advance care planning,” said Brian Block, MD, during a presentation of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. Dr. Block is with the University of California, San Francisco.

Lack of advance planning can put major road blocks in front of patient care in the ICU, as well as complicate communication between physicians and family members. The findings underscore the need to encourage conversations about end-of-life care between physicians and their patients – before the patients wind up in intensive care.

One audience member believes these conversations are already happening. Paul Yodice, MD, chairman of medicine at Saint Barnabas Medical Center in Livingston, N.J., suggested that physicians are attempting to engage older patients and family members in ACP, but many are unready to make decisions. “In my experience, it is happening much more frequently than is captured either in the medical record or in the research that we’ve been publishing. I’ve been a part of those conversations. Those individuals who are faced with those toughest of choices choose to delay making the decision or speaking about it further because it’s just too painful to consider, and they hold out hope of being the one to beat the odds, to have one more day,” said Dr. Yodice.

He called for further research to document whether ACP conversations are happening and to identify barriers to decisions and the means to overcome them. “A next good study would be to send out a respectful survey to the families of those who have lost people they love and ask: Has someone in the past year spoken with you or offered to have a discussion about end-of-life issues? We could get a better handle on [how often] the discussion is being had, and then find a solution,” said Dr. Yodice.

ACP can also be difficult for the provider, he added. Family members and patients, desperate for another treatment option, will often ask if there’s anything else that can be done. “In medicine, the answer almost always is ‘Well, we can try something else even though I know it’s not going to work.’ And people hold on to that, including us,” said Dr. Yodice.

The study analyzed data from a Medicare cohort of 1,109 patients who died during 2000-2013 and had an ICU admission within the last 30 days of their life. Ages were fairly evenly distributed, with 29% aged 65-74 years, 39% aged 75-84, and 32% aged 85 and over. Fifty-four percent were women, 26% were nonwhite, 42% had not completed high school, and 11% were in skilled nursing facilities.

About 35% had no ACP in 2000-2001, and that percentage gradually declined, to about 20% in 2012-2013 (slope, –1.6%/year; P = .009).

Seventeen percent of white participants had no ACP, compared with 51% of blacks and 49% of Hispanics. Net worth was also strongly associated with having ACP: The top quartile had 13% lacking ACP, compared with 43% of the bottom quartile.

The study found that 94% of patients who had no ACP had visited a health care provider in the past year. The average number of visits in the past year was 20, and 83% had seen a provider within the past 30 days.

Dr. Block did not declare a source of funding or potential conflicts. Dr. Yodice had no disclosures.
 

chestphysiciannews@chestnet.org

SOURCE: Block B et al. CCC48, Abstract 401.

SAN DIEGO – A nationally representative survey of ICU patients older than age 65 years shows an improvement over time in the frequency of advance care planning (ACP), but one in four have no ACP; the problem is more pronounced among some blacks and Hispanics and those with lower net worth. The study also found that these patients see physicians an average of 20 times in the year preceding the ICU visit, which suggests that there are plenty of opportunities to put ACP in place.

marcosmartinezromero/iStockphoto

“Over two-thirds were seen by a doctor in the last 2 weeks. So they’re seeing doctors, but they’re still not doing advance care planning,” said Brian Block, MD, during a presentation of the study at the Critical Care Congress sponsored by the Society of Critical Care Medicine. Dr. Block is with the University of California, San Francisco.

Lack of advance planning can put major road blocks in front of patient care in the ICU, as well as complicate communication between physicians and family members. The findings underscore the need to encourage conversations about end-of-life care between physicians and their patients – before the patients wind up in intensive care.

One audience member believes these conversations are already happening. Paul Yodice, MD, chairman of medicine at Saint Barnabas Medical Center in Livingston, N.J., suggested that physicians are attempting to engage older patients and family members in ACP, but many are unready to make decisions. “In my experience, it is happening much more frequently than is captured either in the medical record or in the research that we’ve been publishing. I’ve been a part of those conversations. Those individuals who are faced with those toughest of choices choose to delay making the decision or speaking about it further because it’s just too painful to consider, and they hold out hope of being the one to beat the odds, to have one more day,” said Dr. Yodice.

He called for further research to document whether ACP conversations are happening and to identify barriers to decisions and the means to overcome them. “A next good study would be to send out a respectful survey to the families of those who have lost people they love and ask: Has someone in the past year spoken with you or offered to have a discussion about end-of-life issues? We could get a better handle on [how often] the discussion is being had, and then find a solution,” said Dr. Yodice.

ACP can also be difficult for the provider, he added. Family members and patients, desperate for another treatment option, will often ask if there’s anything else that can be done. “In medicine, the answer almost always is ‘Well, we can try something else even though I know it’s not going to work.’ And people hold on to that, including us,” said Dr. Yodice.

The study analyzed data from a Medicare cohort of 1,109 patients who died during 2000-2013 and had an ICU admission within the last 30 days of their life. Ages were fairly evenly distributed, with 29% aged 65-74 years, 39% aged 75-84, and 32% aged 85 and over. Fifty-four percent were women, 26% were nonwhite, 42% had not completed high school, and 11% were in skilled nursing facilities.

About 35% had no ACP in 2000-2001, and that percentage gradually declined, to about 20% in 2012-2013 (slope, –1.6%/year; P = .009).

Seventeen percent of white participants had no ACP, compared with 51% of blacks and 49% of Hispanics. Net worth was also strongly associated with having ACP: The top quartile had 13% lacking ACP, compared with 43% of the bottom quartile.

The study found that 94% of patients who had no ACP had visited a health care provider in the past year. The average number of visits in the past year was 20, and 83% had seen a provider within the past 30 days.

Dr. Block did not declare a source of funding or potential conflicts. Dr. Yodice had no disclosures.
 

chestphysiciannews@chestnet.org

SOURCE: Block B et al. CCC48, Abstract 401.

The 2018 State of Hospital Medicine (SoHM) Report provides indispensable data about the scope of clinical services routinely provided by adult and pediatric hospitalists. This year’s SoHM report reveals that a growing number of Hospital Medicine Groups (HMGs) serving adults are involved in roles beyond the inpatient medical wards, including various surgical comanagement programs, outpatient care, and post-acute care services.

The survey also compares services provided by academic and nonacademic HMGs, which remain markedly different in some areas. As the landscape of health care continues to evolve, hospitalists transform their scope of services to meet the needs of the institutions and communities they serve.

In the previous three SoHM reports, it was well established that more than 87% of adult hospital medicine groups play some role in comanaging surgical patients. In this year’s SoHM report, that role was further stratified to capture the various subspecialties represented, and to identify whether the hospitalists generally served as admitting/attending physician or consultant.

Hospitalists’ roles in comanagement are most prominent for care of orthopedic and general surgery patients, but more than 50% of surveyed HMGs reported being involved in comanagement in some capacity with neurosurgery, obstetrics, and cardiovascular surgery. Additionally, almost 95% of surveyed adult HMGs reported that they provided comanagement services for at least one other surgical specialty that was not listed in the survey.

The report also displays comanagement services provided to various medical subspecialties, including neurology, GI/liver, oncology, and more. Of the medical subspecialties represented, adult HMGs comanaged GI/liver (98.2%) and oncology (97.7%) services more often than others.

Interestingly, more HMGs are providing care for patients beyond the walls of the hospital. In the 2018 SoHM report, over 17% of surveyed HMG respondents reported providing care in an outpatient setting, representing an increase of 6.5 percentage points over 2016. Most strikingly, from 2016 to 2018, there was a 12 percentage point increase in adult HMGs reporting services provided to post-acute care facilities (from 13.1% to 24.8%).

These trends were most notable in the Midwest region where nearly 28% of HMGs provide patient care in an outpatient setting and up to 34% in post-acute care facilities. In part, this trend may result from the increased emphasis on improving transitions of care, by providing prehospital preoperative services, postdischarge follow-up encounters, or offering posthospitalization extensivist care.

Within the hospital itself, there remain striking differences in certain services provided by academic and nonacademic HMGs serving adults. Nonacademic HMGs are far more likely to cover patients in an ICU than their academic counterparts (72.0% vs. 34.3%). In contrast, academic hospitalist groups were significantly more inclined to perform procedures. However, the report also showed that there was an overall downtrend of percentage of HMGs that cover patients in an ICU or perform procedures.

As the scope of hospitalist services continues to change over time, should there be concern for scope creep? It depends on how one might view the change. As health care becomes ever more complex, high-functioning HMGs are needed to navigate it, both within and beyond the hospital. Some might consider scope evolution to be a reflection of hospitalists being recognized for their ability to provide high-quality, efficient, and comprehensive care. Hospital medicine groups will likely continue to evolve to meet the needs of an ever-changing health care environment.

Dr. Kurian is chief of the academic division of hospital medicine at Northwell Health in New York. She is a member of the SHM Practice Analysis Committee.

The 2018 State of Hospital Medicine (SoHM) Report provides indispensable data about the scope of clinical services routinely provided by adult and pediatric hospitalists. This year’s SoHM report reveals that a growing number of Hospital Medicine Groups (HMGs) serving adults are involved in roles beyond the inpatient medical wards, including various surgical comanagement programs, outpatient care, and post-acute care services.

The survey also compares services provided by academic and nonacademic HMGs, which remain markedly different in some areas. As the landscape of health care continues to evolve, hospitalists transform their scope of services to meet the needs of the institutions and communities they serve.

In the previous three SoHM reports, it was well established that more than 87% of adult hospital medicine groups play some role in comanaging surgical patients. In this year’s SoHM report, that role was further stratified to capture the various subspecialties represented, and to identify whether the hospitalists generally served as admitting/attending physician or consultant.

Hospitalists’ roles in comanagement are most prominent for care of orthopedic and general surgery patients, but more than 50% of surveyed HMGs reported being involved in comanagement in some capacity with neurosurgery, obstetrics, and cardiovascular surgery. Additionally, almost 95% of surveyed adult HMGs reported that they provided comanagement services for at least one other surgical specialty that was not listed in the survey.

The report also displays comanagement services provided to various medical subspecialties, including neurology, GI/liver, oncology, and more. Of the medical subspecialties represented, adult HMGs comanaged GI/liver (98.2%) and oncology (97.7%) services more often than others.

Interestingly, more HMGs are providing care for patients beyond the walls of the hospital. In the 2018 SoHM report, over 17% of surveyed HMG respondents reported providing care in an outpatient setting, representing an increase of 6.5 percentage points over 2016. Most strikingly, from 2016 to 2018, there was a 12 percentage point increase in adult HMGs reporting services provided to post-acute care facilities (from 13.1% to 24.8%).

These trends were most notable in the Midwest region where nearly 28% of HMGs provide patient care in an outpatient setting and up to 34% in post-acute care facilities. In part, this trend may result from the increased emphasis on improving transitions of care, by providing prehospital preoperative services, postdischarge follow-up encounters, or offering posthospitalization extensivist care.

Within the hospital itself, there remain striking differences in certain services provided by academic and nonacademic HMGs serving adults. Nonacademic HMGs are far more likely to cover patients in an ICU than their academic counterparts (72.0% vs. 34.3%). In contrast, academic hospitalist groups were significantly more inclined to perform procedures. However, the report also showed that there was an overall downtrend of percentage of HMGs that cover patients in an ICU or perform procedures.

As the scope of hospitalist services continues to change over time, should there be concern for scope creep? It depends on how one might view the change. As health care becomes ever more complex, high-functioning HMGs are needed to navigate it, both within and beyond the hospital. Some might consider scope evolution to be a reflection of hospitalists being recognized for their ability to provide high-quality, efficient, and comprehensive care. Hospital medicine groups will likely continue to evolve to meet the needs of an ever-changing health care environment.

Dr. Kurian is chief of the academic division of hospital medicine at Northwell Health in New York. She is a member of the SHM Practice Analysis Committee.

The 2018 State of Hospital Medicine (SoHM) Report provides indispensable data about the scope of clinical services routinely provided by adult and pediatric hospitalists. This year’s SoHM report reveals that a growing number of Hospital Medicine Groups (HMGs) serving adults are involved in roles beyond the inpatient medical wards, including various surgical comanagement programs, outpatient care, and post-acute care services.

The survey also compares services provided by academic and nonacademic HMGs, which remain markedly different in some areas. As the landscape of health care continues to evolve, hospitalists transform their scope of services to meet the needs of the institutions and communities they serve.

In the previous three SoHM reports, it was well established that more than 87% of adult hospital medicine groups play some role in comanaging surgical patients. In this year’s SoHM report, that role was further stratified to capture the various subspecialties represented, and to identify whether the hospitalists generally served as admitting/attending physician or consultant.

Hospitalists’ roles in comanagement are most prominent for care of orthopedic and general surgery patients, but more than 50% of surveyed HMGs reported being involved in comanagement in some capacity with neurosurgery, obstetrics, and cardiovascular surgery. Additionally, almost 95% of surveyed adult HMGs reported that they provided comanagement services for at least one other surgical specialty that was not listed in the survey.

The report also displays comanagement services provided to various medical subspecialties, including neurology, GI/liver, oncology, and more. Of the medical subspecialties represented, adult HMGs comanaged GI/liver (98.2%) and oncology (97.7%) services more often than others.

Interestingly, more HMGs are providing care for patients beyond the walls of the hospital. In the 2018 SoHM report, over 17% of surveyed HMG respondents reported providing care in an outpatient setting, representing an increase of 6.5 percentage points over 2016. Most strikingly, from 2016 to 2018, there was a 12 percentage point increase in adult HMGs reporting services provided to post-acute care facilities (from 13.1% to 24.8%).

These trends were most notable in the Midwest region where nearly 28% of HMGs provide patient care in an outpatient setting and up to 34% in post-acute care facilities. In part, this trend may result from the increased emphasis on improving transitions of care, by providing prehospital preoperative services, postdischarge follow-up encounters, or offering posthospitalization extensivist care.

Within the hospital itself, there remain striking differences in certain services provided by academic and nonacademic HMGs serving adults. Nonacademic HMGs are far more likely to cover patients in an ICU than their academic counterparts (72.0% vs. 34.3%). In contrast, academic hospitalist groups were significantly more inclined to perform procedures. However, the report also showed that there was an overall downtrend of percentage of HMGs that cover patients in an ICU or perform procedures.

As the scope of hospitalist services continues to change over time, should there be concern for scope creep? It depends on how one might view the change. As health care becomes ever more complex, high-functioning HMGs are needed to navigate it, both within and beyond the hospital. Some might consider scope evolution to be a reflection of hospitalists being recognized for their ability to provide high-quality, efficient, and comprehensive care. Hospital medicine groups will likely continue to evolve to meet the needs of an ever-changing health care environment.

Dr. Kurian is chief of the academic division of hospital medicine at Northwell Health in New York. She is a member of the SHM Practice Analysis Committee.

Hospitalists know all too well that a significant source of medical errors is miscommunication during transitions: By interrupting the continuity of care, handoffs can increase the risk of adverse events.

Yet the transfer of patients from the ED to the hospitalist inpatient service has not been well studied, said Carmen Gonzalez, MD, lead author of a recent paper that examined the issue. “The scope of this study was to develop and test a handoff communication tool and a standardized process for transitioning patients from the ED to the hospitalist service at a comprehensive cancer center,” she explained.

In the study, the researchers found that the number of ICU transfers within 24 hours of admission and the number of rapid-response calls decreased after the implementation of a customized handoff tool. “The tool was named DE-PASS (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to), which was a modification of the I-PASS, and adapted to our workflow,” reported Dr. Gonzalez, who is based at the University of Texas MD Anderson Cancer Center, Houston. DE-PASS stratifies patients as stable/urgent/emergent and establishes requirements for communications between providers.

Results from the 1-month pilot revealed that, within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58%, the number of rapid-response team calls by 39%, and time to inpatient order by 31%.

“The standardization of the language and format of the handoff process of admission from the ED to the hospitalist service reduced handoff variations, increased provider satisfaction, and improved patient safety,” she noted.

The hospitalists expressed satisfaction with the tool. “This handoff tool helps stratify newly admitted patients based on their illness acuity, hence, assists the busy admitting hospitalist in prioritizing which patient needs to be attended first,” said study coauthor Norman Brito-Dellan, MD, also of MD Anderson Cancer Center. “In this study, DE-PASS reduced admission-to-evaluation times for unstable patients. These patients tend to be evaluated earlier, improving safety.”
 

Reference

1. Gonzalez CE et al. Handoff tool enabling standardized transitions between the emergency department and the hospitalist inpatient service at a major cancer center. American Journal of Medical Quality. 2018 May 21. doi: 10.1177/1062860618776096.

Hospitalists know all too well that a significant source of medical errors is miscommunication during transitions: By interrupting the continuity of care, handoffs can increase the risk of adverse events.

Yet the transfer of patients from the ED to the hospitalist inpatient service has not been well studied, said Carmen Gonzalez, MD, lead author of a recent paper that examined the issue. “The scope of this study was to develop and test a handoff communication tool and a standardized process for transitioning patients from the ED to the hospitalist service at a comprehensive cancer center,” she explained.

In the study, the researchers found that the number of ICU transfers within 24 hours of admission and the number of rapid-response calls decreased after the implementation of a customized handoff tool. “The tool was named DE-PASS (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to), which was a modification of the I-PASS, and adapted to our workflow,” reported Dr. Gonzalez, who is based at the University of Texas MD Anderson Cancer Center, Houston. DE-PASS stratifies patients as stable/urgent/emergent and establishes requirements for communications between providers.

Results from the 1-month pilot revealed that, within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58%, the number of rapid-response team calls by 39%, and time to inpatient order by 31%.

“The standardization of the language and format of the handoff process of admission from the ED to the hospitalist service reduced handoff variations, increased provider satisfaction, and improved patient safety,” she noted.

The hospitalists expressed satisfaction with the tool. “This handoff tool helps stratify newly admitted patients based on their illness acuity, hence, assists the busy admitting hospitalist in prioritizing which patient needs to be attended first,” said study coauthor Norman Brito-Dellan, MD, also of MD Anderson Cancer Center. “In this study, DE-PASS reduced admission-to-evaluation times for unstable patients. These patients tend to be evaluated earlier, improving safety.”
 

Reference

1. Gonzalez CE et al. Handoff tool enabling standardized transitions between the emergency department and the hospitalist inpatient service at a major cancer center. American Journal of Medical Quality. 2018 May 21. doi: 10.1177/1062860618776096.

Hospitalists know all too well that a significant source of medical errors is miscommunication during transitions: By interrupting the continuity of care, handoffs can increase the risk of adverse events.

Yet the transfer of patients from the ED to the hospitalist inpatient service has not been well studied, said Carmen Gonzalez, MD, lead author of a recent paper that examined the issue. “The scope of this study was to develop and test a handoff communication tool and a standardized process for transitioning patients from the ED to the hospitalist service at a comprehensive cancer center,” she explained.

In the study, the researchers found that the number of ICU transfers within 24 hours of admission and the number of rapid-response calls decreased after the implementation of a customized handoff tool. “The tool was named DE-PASS (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to), which was a modification of the I-PASS, and adapted to our workflow,” reported Dr. Gonzalez, who is based at the University of Texas MD Anderson Cancer Center, Houston. DE-PASS stratifies patients as stable/urgent/emergent and establishes requirements for communications between providers.

Results from the 1-month pilot revealed that, within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58%, the number of rapid-response team calls by 39%, and time to inpatient order by 31%.

“The standardization of the language and format of the handoff process of admission from the ED to the hospitalist service reduced handoff variations, increased provider satisfaction, and improved patient safety,” she noted.

The hospitalists expressed satisfaction with the tool. “This handoff tool helps stratify newly admitted patients based on their illness acuity, hence, assists the busy admitting hospitalist in prioritizing which patient needs to be attended first,” said study coauthor Norman Brito-Dellan, MD, also of MD Anderson Cancer Center. “In this study, DE-PASS reduced admission-to-evaluation times for unstable patients. These patients tend to be evaluated earlier, improving safety.”
 

Reference

1. Gonzalez CE et al. Handoff tool enabling standardized transitions between the emergency department and the hospitalist inpatient service at a major cancer center. American Journal of Medical Quality. 2018 May 21. doi: 10.1177/1062860618776096.

Do food delivery programs reduce the use of costly health services and decrease medical spending in a population of patients dually eligible for Medicare and Medicaid?

Researchers in Massachusetts wanted to determine whether home meal delivery of either medically tailored food or nontailored food reduces the use of selected health care services and medical spending in a sample of adult “dual eligibles.”

“Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program,” the investigators found. “Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending.”
 

Reference

Berkowitz SA et al. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. Health Aff (Millwood). 2018 Apr;37(4):535-42.

Do food delivery programs reduce the use of costly health services and decrease medical spending in a population of patients dually eligible for Medicare and Medicaid?

Researchers in Massachusetts wanted to determine whether home meal delivery of either medically tailored food or nontailored food reduces the use of selected health care services and medical spending in a sample of adult “dual eligibles.”

“Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program,” the investigators found. “Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending.”
 

Reference

Berkowitz SA et al. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. Health Aff (Millwood). 2018 Apr;37(4):535-42.

Do food delivery programs reduce the use of costly health services and decrease medical spending in a population of patients dually eligible for Medicare and Medicaid?

Researchers in Massachusetts wanted to determine whether home meal delivery of either medically tailored food or nontailored food reduces the use of selected health care services and medical spending in a sample of adult “dual eligibles.”

“Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program,” the investigators found. “Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending.”
 

Reference

Berkowitz SA et al. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. Health Aff (Millwood). 2018 Apr;37(4):535-42.

I am going to teach you something you do not know. I am almost sure of it.

Warm handoffs – a term you often hear within the confines of hospital walls when transferring a patient service to service or ward to ward. You do it in-house, but it’s unlikely you make the same connection when you discharge the same patient or transfer them to an outside entity.

But you have to be asleep under a rock not to have heard or read the changes afoot in the skilled nursing facility (SNF) realm, including the rise of the “SNFist”. Too much variation in use and spending; plus, we are learning patients do not need 25 days cooped up in a rehabilitation facility when 15 might do with a segue into home health for another 10 or 14. Patients like being home, and it costs a lot less.

Unfortunately, we do not do SNF handoffs in the same manner as ICUs. Our bad, and inpatient providers better adapt.

As hospitals decant and quality measures get an intimate look in the rehab space, SNFs will notice sicker patients, and the staff there will be more mindful of the sign outs and the data they receive. Know a Centers for Medicare & Medicaid Services value-based program started on October 1 (just like hospitals – penalties and all) and SNFists, whoever they might be – NP/PA/DO/MD – will also require of hospitals a step-up in information transfer, both in quality and timeliness.

Read the full post at hospitalleader.org.

Also on The Hospital Leader

• “Immigration & the Future of Healthcare: Looking to a Greater Good,” by Jordan Messler, MD, SFHM
• “We Must Become Comfortable Talking about Physician Suicide,” by Tracy Cardin, ACNP-BC, SFHM
• “A New Light in the Darkness: Using Hospital-Based Medication-Assisted Treatment to Tackle the Opioid Crisis,” by Richard Bottner, PA-C

I am going to teach you something you do not know. I am almost sure of it.

Warm handoffs – a term you often hear within the confines of hospital walls when transferring a patient service to service or ward to ward. You do it in-house, but it’s unlikely you make the same connection when you discharge the same patient or transfer them to an outside entity.

But you have to be asleep under a rock not to have heard or read the changes afoot in the skilled nursing facility (SNF) realm, including the rise of the “SNFist”. Too much variation in use and spending; plus, we are learning patients do not need 25 days cooped up in a rehabilitation facility when 15 might do with a segue into home health for another 10 or 14. Patients like being home, and it costs a lot less.

Unfortunately, we do not do SNF handoffs in the same manner as ICUs. Our bad, and inpatient providers better adapt.

As hospitals decant and quality measures get an intimate look in the rehab space, SNFs will notice sicker patients, and the staff there will be more mindful of the sign outs and the data they receive. Know a Centers for Medicare & Medicaid Services value-based program started on October 1 (just like hospitals – penalties and all) and SNFists, whoever they might be – NP/PA/DO/MD – will also require of hospitals a step-up in information transfer, both in quality and timeliness.

Read the full post at hospitalleader.org.

Also on The Hospital Leader

• “Immigration & the Future of Healthcare: Looking to a Greater Good,” by Jordan Messler, MD, SFHM
• “We Must Become Comfortable Talking about Physician Suicide,” by Tracy Cardin, ACNP-BC, SFHM
• “A New Light in the Darkness: Using Hospital-Based Medication-Assisted Treatment to Tackle the Opioid Crisis,” by Richard Bottner, PA-C

I am going to teach you something you do not know. I am almost sure of it.

Warm handoffs – a term you often hear within the confines of hospital walls when transferring a patient service to service or ward to ward. You do it in-house, but it’s unlikely you make the same connection when you discharge the same patient or transfer them to an outside entity.

But you have to be asleep under a rock not to have heard or read the changes afoot in the skilled nursing facility (SNF) realm, including the rise of the “SNFist”. Too much variation in use and spending; plus, we are learning patients do not need 25 days cooped up in a rehabilitation facility when 15 might do with a segue into home health for another 10 or 14. Patients like being home, and it costs a lot less.

Unfortunately, we do not do SNF handoffs in the same manner as ICUs. Our bad, and inpatient providers better adapt.

As hospitals decant and quality measures get an intimate look in the rehab space, SNFs will notice sicker patients, and the staff there will be more mindful of the sign outs and the data they receive. Know a Centers for Medicare & Medicaid Services value-based program started on October 1 (just like hospitals – penalties and all) and SNFists, whoever they might be – NP/PA/DO/MD – will also require of hospitals a step-up in information transfer, both in quality and timeliness.

Read the full post at hospitalleader.org.

Also on The Hospital Leader

• “Immigration & the Future of Healthcare: Looking to a Greater Good,” by Jordan Messler, MD, SFHM
• “We Must Become Comfortable Talking about Physician Suicide,” by Tracy Cardin, ACNP-BC, SFHM
• “A New Light in the Darkness: Using Hospital-Based Medication-Assisted Treatment to Tackle the Opioid Crisis,” by Richard Bottner, PA-C