Transitions of Care

last authored: Jan 2010, David LaPierre
last reviewed:

 

get this: CHAMP - care of the hospitalized medical patient

 

 

Introduction

Successful transitions are efficient, include thorough transfer of information

smooth transition

prevent readmission

ensure appropriate follow-up orders

avoid medication errors

avoid duplication of treatments or investigations

avoid medico-legal problems

 

Over 35% of patients admitted to hospital are worse-off re: baseline ADLs on discharge (Covinsky, 2003). This means their discharge will require changes to their previous life.

 

There are many different times during transition

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The Case of Mr RM

Mr RM is being discharged after a three week admission for pneumonia. Her family arrives to pick her up, and are furious with me

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Preparations for Transition

Simulate transition environment while in hosptial.

Documentation

Have good handwriting. Be thorough.

 

To improve effective transition for older adults (Dedhia et al, 2009)

CGA at admission

notification of primary care physician: fax/email a single page with details, asking for comments as appropriate

multidisciplinary team coordination:

medication reconciliation: physician-pharmacist collaboration; ensure you ask the patient

discharge meeting: ensure agreement among staff and patient/caregiver, with easy-to-read written information

 

Active advanced planning

 

be aware and concerned about caregiver burnout

 

Needs to Consider:

housekeeping support

social support: emotional and IADLs

personal care

nursing care

medical care

 

Getting ready to go home checklist

Some places have a PCW that spend a few hours shopping

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Communicating to Receiving Physician

Within one week, only 15% received the document within one week, and only 75% made it ever (Kripalani et al, 2007).

 

 

Choosing a Discharge Destination

Home with services

Recovering ADLs

sufficient and willing caregivers

Nursing Home

Newly impaired ADL

unable to tolerate rehab

 

Requirements

accessible

affordable

temp

maint

safety

social capital

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Additional Resources

Covinsky JAGS, 2003

Dedhia et al, JAGS, 2009

Kripalani et al, JAMA, 2007

 

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