TAMPA – Consistently safe and effective transfers of patients from hospitals to nursing homes take effort and planning that health care facilities and professionals typically do not focused on, according to two medical directors with more than 2 decades of hospital and nursing home experience in South Dakota.
"The hospital’s job until now, and the job of the hospitalist as well, is to treat the acute illness, keep patients safe during hospitalization, and discharge patients as soon as possible," Dr. David Sandvik said at the annual meeting of AMDA – Dedicated to Long Term Care Medicine. "There have been no incentives so far regarding safe transfers."
Moving patients safely means overcoming numerous physician and institutional barriers, said Dr. Sandvik, professor of internal and family medicine at the University of South Dakota, Sioux Falls. "Hospital discharge is viewed as the least important part of the stay."
Dr. David Sandvik
"In the hospital, you should start working on discharge planning on day 1," Dr. Priscilla Bade said. Where she practices, the sole tertiary care hospital, Rapid City (South Dakota) Regional Hospital, and eight community nursing homes have created standardized discharge checklists that facilitate safe transfers, said Dr. Bade, who is an attending physician at the hospital and director of hospice care and a member of the internal medicine faculty at the University. Regular, ongoing meetings of a work group on transfers have been instrumental as well, she said.
Dr. Bade advised others to assemble groups of people with common interests in improving patient transfers, including clinicians at the hospital and the skilled nursing facilities. "This will help hospital administrators see we all need to work together or we will hang separately."
Dr. Sandvik said that administration participation is a natural. "It’s not hard to get [because] you end up with messes if you don’t have a good transfer system." Others important to include in meetings on better transfers are members of hospital and nursing home departments of nursing, social services, information systems, medical records, and pharmacy, he said, "and this is just in the planning."
Designate a meeting coordinator and find appropriate space to meet, Dr. Bade advised. Involve everyone present and "get input from those people on what to change" about the current transfer procedures, she said. "At each meeting, set practical goals for the next meeting and assign people to work on them."
Several talking points can start the conversation, Dr. Bade said. They include: Optimal transfers maintain patient safety, improve patient satisfaction, improve facility and physician workflow, reduce delays and the number of transfers, and lower readmission rates.
Transitions are not only logistically challenging but also one of the most cognitively challenging tasks for a physician, Dr. Sandvik said. For an effective transfer, doctors on both ends need to know, for example, events that occurred during hospitalization; the capabilities and needs of the receiving facility; the patient’s medication list at discharge and possible drug interactions; the need for rehabilitation; the potential for reimbursements through Medicare, Medicaid, private insurance, and private payments; and what appropriate physician follow-up can be arranged.
"This is a daunting list," Dr. Sandvik said, and payment for all that work can be challenging. "The more complex the patient or transfer, the lower physician reimbursement per time unit," Dr. Sandvik said. "Current charges for extended time require patient face-to-face time ... which is often the least productive time to spend arranging a transfer with a confused, older patient."
Many transfer problems result from poor communication, Dr. Sandvik said, so improving information exchange is crucial. He said he has witnessed the transfer of a hospital patient on a day other than what a nursing home had been told and the transfer of a hypoxic patient without any oxygen.
"The reality is we all have to migrate to a technologic solution," Dr. Sandvik said. Electronic medical records and other technologies could end cases of incomplete information accompanying a transferred patient. "I can’t get a fishing license unless all the required fields are filled in," yet patients often come to nursing homes without important information, Dr. Sandvik said.
"Hospitalists do not start out to do a bad job," he added. "We have to figure out why those forms are not getting filled out." "Sometimes, we spend days in the nursing home trying to figure out why an order was given or not given." In some cases, that’s made harder when the hospitalist who took care of a patient and wrote the discharge orders is off-duty at the time of the transfer.