​Transitioning patients between settings has always been a bit of a roller coaster: improving, then facing challenges, then put on the back burner. The COVID pandemic brought the issue front and center, and many hope this is the start of a smooth ride. The need for clear, real-time communication between settings became a priority, and many organizations developed new systems and processes. However, while we’ve made strides, there are still gaps that need to be filled and opportunities for improvement.

“We’ve made progress in understanding this is a collaborative effort between settings. We are talking to each other more and using electronic health records (EHRs) to our advantage,” said Manisha Parulekar, MD, FACP, AGSF, CMD, director of the division of geriatrics at Hackensack University Medical Center and associate professor at the Hackensack Meridian School of Medicine. During the pandemic, she added, “we created different models where hospitals extended teleservices to nursing homes for videoconferences and consultations.” However, she stressed that we still need to look at ways to make transitions more efficient.

Arif Nazir, MD, CMD, chief medical officer at BrightSpring Health Services, noted, “one issue has been that discharge planning usually doesn’t get addressed until a few days before the patient is due to leave the facility. This is the wrong approach. Discharge planning needs to start on admission. Then we need to continue to gain information about the patient/family and where they are going when they are discharged.” He added, “we need to be proactive. If you don’t start addressing these issues early on, you’re already missing the boat.”

Dispelling Fear and Falsehoods

Communication with residents and families is key to smooth transitions, so it is important to include them in conversations and listen to them. “A common issue is that their expectations are different from that of the health care team’s. Information needs to be communicated in a way they understand. We need to create multiple opportunities for advance care planning and conversations about their goals and expectations. Then we need to address these in the care plan,” said Nazir. “We need to emphasize and re-emphasize things, such as the need for some home health care services.” At the same time, when they express goals that are impractical or unrealistic, the team needs to work with them to arrive at an acceptable compromise.

“People are often intimidated by difficult terms and messages, an abundance of paperwork, and lots of information coming at one time. They may not understand things but hesitate to ask questions, or they are so overwhelmed, they don’t know what to ask. They also may have a fear of the unknown—such as there is a diagnosis on the chart that no one has discussed with them. Or they don’t know who to trust,” said Nazir. “We can address a lot of this by opening conversations sooner rather than later. We need to take the time to explain their illnesses and issues. Then we need to work as a team to manage their care and build trust.”

It’s a simple formula of person-centered care. “We need to make sure we ask patients and their families for their preferences. Quality is in the eye of the beholder. The patient, along with their family, can tell us about what is essential to quality of life for them,” said Nazir. He added the need to engage family. “We really need to think of families as a part, if not the leader, of the team. We need to put our assessments on the table and talk openly. If family members seem difficult or intrusive, it’s often because we aren’t committing the time to talk with them. We need to be humble and collaborative.”

The Hospital Connection

Communication between the hospital and nursing home has always been challenging and a source of gaps and missed information. During the pandemic, Parulekar said, “hospitals acknowledged the importance of partnerships and the need to work with nursing homes and subacute care facilities and look at ways to improve transitions. We started working closer together, sharing resources and protocols with each other.” This was especially useful in places where hospitals had more resources and could help share personal protective equipment, daily care rounds, and consultations.

While long term care facilities had greater access to hospital EHRs, Parulekar said, “interoperability is still a bucket where we need to make progress. It is time-consuming to go from one platform to another, and it requires extra steps. We need to make it easy to move between platforms without sacrificing security.”

While hospital partnerships improved during the pandemic, Parulekar suggested, so did the appropriate use of hospitalizations. “There has been an increased understanding and utilization of palliative care and when a patient can be treated in the nursing home. We need more focus on having a palliative care team, addressing care planning, and making sure we are transferring only those patients who need to be hospitalized.” She added, “I’m hopeful that the focus on advance care planning will remain, and we will continue to build on the momentum we’ve gained. We can use the example of the pandemic to emphasize why it’s important.”

T is for Trust and Team

Nazir said, “the pandemic showed that many things could be done differently and better. We were able to show that we can come together and use our knowledge as a team to improve transitions and outcomes, as we did for many patients with COVID-19.” We realized, he observed, that “we have more power than we thought, just by being more communicative. It gave me hope that we can improve outcomes if we put our minds to it.” Long term care facilities have realized that they need to assign people to ensure transitions, establish processes, and communicate with the hospital to secure information. Often, nurse practitioners and other clinical team members are taking on this role.

Targeting Medication Management

“Medication management on discharge from the nursing home is the number one issue, in my opinion,” said Nazir. “That is an area where we need to continue to make an impact.” Facilities can work with their pharmacy partners to take the lead on this, helping to make sure people know what medications to take when and to discard those they were taking before they went into the hospital.

“A partnership between the pharmacy and the facility care team can focus on polypharmacy,” said Jeremy Colvin, senior vice president of growth and market development at BrightSpring Health Services. “We can work together to ensure an integrated workflow that augments the team and provides needed educational pieces.

Then there need to be milestones identified along the way to bring clarity to the system.” Virtual case management is another element that enables an opportunity to triage, ask questions, and make sure gaps are addressed promptly.

Even when we’re not in the midst of a pandemic, facility teams are overburdened and turnover presents additional challenges, Colvin said. “A case manager can provide consistency and gets to know the patient and their families. Having that layer enables easy integration with the prescriber and pharmacist to promptly identify and address medication-related problems, such as duplicate prescriptions, missed dosages, and prescriptions that go unfilled.”

Beyond medications, a case manager can work with a social worker and community resources to provide needed help with things like cleaning, cooking, and transportation. “This creates continuity and consistency, so if unforeseen roadblocks arise, there will be a safety net,” said Colvin.

Out of the Box, Into Their Homes

Looking ahead, Nazir suggested, “we have some out-of-the-box thinking to do. There are some great models out there, such as value-based environments where practitioners have more ownership of the patient, and there is a value of connections through transitions.”

Parulekar said, “it is all our responsibility not to go back to the status quo. We have learned how critical communication is, and we need to keep the dialogue going.” This should include events such as quarterly meetings or breakfasts with hospital leaders and practitioners. Establishing relationships and getting to know each other can make a significant difference when someone has a question or needs information. This can mean the difference between a smooth transition home and a trip back to the hospital or emergency room.