Care transitions: Geriatric medicine offers a roadmap to follow
While an increasing number of hospital systems are creating senior-friendly EDs, one new study suggests that many of the tenets of geriatric medicine are also applicable to the care of patients with complex health problems, especially with respect to care transitions.1
"The main lesson that comes out of geriatrics is the whole idea of taking a holistic approach," explains Alicia Arbaje, MD, MPH, the director of transitional care research at Johns Hopkins Bayview Medical Center, and an assistant professor of medicine at Johns Hopkins School of Medicine in Baltimore, MD. "[With these complex patients] it is not just about a particular disease. It is about how all those diseases interact with each other that makes a patient end up back in the ED."
Arbaje notes that while it is easier to focus on a particular disease, complex patients require providers to consider a bigger picture. "Focusing on disease-specific interventions such as a heart failure clinic or some sort of bridge clinic that is focused on a particular disease is not going to be as helpful to someone who has multiple chronic conditions," she says.
A second lesson from geriatrics is the notion that providers should not just consider the patient, but also their immediate home community and the health system in the region that cares for the patient. "Especially for frail, older people and others with complex needs, there is often a whole team of people who are trying to help," observes Arbaje. "So spouses, children, the primary care practitioner (PCP), specialty physicians, social workers, and case managers also need to be included in interventions to help reduce readmissions."
It is not enough to just notify a PCP that a complex patient has been to the hospital or the ED, notes Arbaje. "As doctors, we often say that as long we keep our patients safe, we have done our job. Our jurisdiction, so to speak, is the patient and maybe their family, but it is really much broader than that," she explains. Consequently, she stresses that it is important to facilitate an exchange of information to all the different receivers of the patient.
Too frequently, home health agencies are left out of the loop, observes Arbaje. "They are often the ones who help manage these complex patients out in their homes and their communities but often times they don’t really get involved until after the fact," she says. "They may not know what changes have been made, and they are often relying on the patients themselves for this kind of information, and we can’t let the patient be the only person providing this information."
As is the case with many geriatric patients, complex patients often have cognitive and/or functional impairments from whatever diseases they have. "Maybe it is diabetes and they can’t walk very well, maybe it is arthritis, or maybe they are a dialysis patient and they have some cognitive issues around dialysis or functional impairments," notes Arbaje. "They can’t move, they can’t think, and they can’t manage their health care. And that is a big driver of what is making people end up back in the ED, or making families frustrated that they can’t handle the patient anymore and therefore the ED is the next place to send them."
Arbaje laments the fact that many of the interventions that have been developed to reduce readmissions and improve transitions of care stem from research on patients who don’t have a very high level of cognitive or functional impairment. "[Interventions] really need to incorporate the fact that many of these patients may not be able to implement a discharge plan that an ED has so carefully put together," she says.
Consequently, Arbaje states that it is important to involve people who can assess the level of cognitive or functional impairment and identify community resources to address these deficits. This could involve referrals to physical or occupational therapists, for example. "In some cases, the solution may be as simple as giving the discharge instructions to someone who isn’t cognitively impaired or functionally impaired, or making sure that the instructions are clear enough to be understood by the patient," she says. "There needs to be follow-up because we know that cognitive and functional impairment can get better over time."
Providers should keep in mind that there is only so much a patient or family can take on at one particular moment. Therefore, spreading the information out to others who can take it and then also having a time frame to follow up when people may be better able to receive the information may make sense in some cases, says Arbaje.
Having ED-based care coordinators who can take on some of these responsibilities is one potential solution. "This can be a case manager or a social worker, but the key is there needs to be those resources for them to coordinate to," says Arbaje. "And there needs to be a sense of accountability around that."
To achieve this accountability, hospitals and EDs may need to work with outside resources to devise new solutions. For example, Arbaje notes that in recent years there has been a big push to make sure that PCPs are notified whenever they have patients who are being discharged from the hospital or the ED so that they can follow up. "That is very good, but the reality is that most PCP offices are not able to handle this information as it is coming in," says Arbaje. "There is usually not a workflow to pick that up. It is just not part of the culture. So you can push the information out, but there is usually not someone who can receive it."
One way to rectify the problem would be to have PCP offices establish a mechanism to receive that information and have someone call those patients, says Arbaje. "Maybe there could be a partnership between the PCP offices and the ED to have certain slots available for people who have just been seen in the ED," she explains. "There isn’t one clear answer because people are still trying to figure this [problem] out."
With the emergence of accountable care organizations, more health care systems are experimenting with ways to get different parts of the health system to work more closely together to improve patient outcomes. With financial incentives behind such changes, more solutions should emerge, notes Arbaje. "The health systems that are going to be the most successful are going to be the ones that figure this out, embrace it, coordinate care, and establish a model that works for them."
- Arbaje A, Kansagara D, Salanitro A, et al. Regardless of age: Incorporating principles from geriatric medicine to improve care transitions for patients with complex needs. Journal of General Internal Medicine 2014 Feb. 21. [Epub ahead of print]
