'Minor' issues at the nursing home can cause disastrous care transitions, expert warns

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James Lett, M.D.
James Lett, M.D.

What may appear to be minor administrative problems in a nursing home – a fax machine locked away at night or no one designated to copy paperwork – can cause major headaches in care transitions, a geriatrician warned in a webinar Thursday.

“The most minute things can ruin a good transition,” said James Lett II, M.D., a geriatrician and past president of the American Medical Directors Association - The Society for Post-Acute and Long-Term Care Medicine. He spoke as part of Irving Levin & Associates' “Transitional Care: Leveling out the Bumps.”

At 2 a.m., a nursing home may not have a ward clerk, he said. That means there's no clear point person for calling the family, updating the records, or copying and sending forms related to a transitioning resident. That's likely part of the reason one study found 10% of skilled nursing residents arrived in an emergency department with no paperwork from the facility, and 90% had inconsistent communication related to patient information. Essential pieces of information conveyed to the hospital should include the patient name, the primary diagnosis for admission, allergies and medication intolerances, vital signs, copies of advance directives, and barriers to communication, including cognitive issues.  

Success in care transitions starts with creating a policy and making sure a procedure is in place. Staff must know who is responsible for transfering necessary information.

“A good form is not going to change a bad process,” Letts warned. “Don't confuse paperwork with communication.”

 Long-term care providers also need to look at their metrics.

“You can't improve what you can't measure,” he said. “In long-term care, we have to learn how to monitor, measure and improve… I can assure you that the payors and the CMS are putting together measures for us.”

Measurements include having the facility's medical director look at each unscheduled departure, and the administrator knowing the 30-day readmission rate. All nursing homes should have a policy around advance directives and end-of-life care, and one to make sure the wishes of the resident are conveyed to the hospital.

“See what they want done at the most crucial time of their lives … You will improve the happiness of the patient and family,” Letts said. One practice guideline is AMDA's “Transitions of Care in the Long-Term Care Continuum.”

In addition to advance directives, correct information around medication is a must for a successful transition, said webinar speaker Kenneth Boockvar, M.D., associate director for research, James J. Peters VA Geriatrics Research Education and Clinical Center.

“Medication reconciliation reduces adverse events,” he said. Additionally, it has to be clear what the baseline is for the patient.

“We want to know what she was like before she went to the hospital,” he noted.

The webinar was sponsored by Regions Bank. 

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