Directly Speaking - Transition of Care: A View From the Other Side

Transition of care is not a new term – it’s been around for many years. It’s not a catch phrase, buzzwords or marketing term. It is something we’ve been talking about for a long time and unfortunately that’s about all. I think part of the problem could be that we don’t appreciate the real meaning until we’ve lived it from the other side.

Well in the two short months of nice weather we’ve had this year, I’ve lived it on the other side with two different family members. Both entered the hospital through the emergency department of their respective hospitals. One because it was a true emergency and the other because the primary care physician involved did not have admitting privileges. The latter, taking two attempts for admission with what turned out to be a nasty case of C. Diff!

Both family members spent about a week in the hospital and then both, who were elderly and severely compromised by their initial problems, ended up in two different nursing homes to rehab before going home. In the case of the patient with C.Diff., there was good communication in advance, and the nursing home was prepared with the necessary doses of vancomycin. However, medications for GERD, sleep and anxiety were not there at the onset, and at least one day was lost for each. The other patient, who went home without antibiotics did, however, have to wait a full day for diabetes, blood pressure and pain medications.

In all the above mentioned cases, life and death was not imminently in the balance, but certainly missing a couple of doses of vancomycin could lead to resistance and additional unnecessary treatments. In addition, the medication reconciliation process from hospital to nursing home was less than desirable. The patient with blood pressure medications was sent to the nursing home on a different regime than he had been on at home, and to be honest, it was probably better than what he had been taking prior to admission.

Which brings me back to the hospital admission transition. When admitted, the patient was NPO for several days and because of that, no meds were administered. When the patient returned from surgery and was experiencing significantly elevated blood pressure, there were no orders for any meds and more importantly any records of the previous regime. Seems to me that that transition wasn’t very smooth either.

These experiences have left me with a new appreciation of the hurdles the regular patient and their family have to face when navigating our health care system. Care is fragmented, communications are poor at best even within the hospital or the nursing home. Without a strong understanding of the processes and their intricacies, patients and their families are lost…wandering through a system that has so much to offer but does a really bad job of coordinating it.

Is it because we have become so “siloed”, or are we too focused on our particular part?  These problems may not occur in every hospital with every transition, but I’m sure they happen much more often than we see. And in many cases, no one even realizes that it’s happening.  

I believe it is time to review and revise our current transition processes. At a recent Clinical Specialist and Research Network meeting, this was a topic of discussion. There, the presenter asked hospital pharmacists in the group to encourage their administrators to allow the supply of 24 hours of medications to patients at the time of discharge to a nursing home. This would allow ample time for the nursing home pharmacy to provide the needed medications. The problem with this request is that most third party insurers won’t pay for those medications. So working within the hospitals and nursing homes will not solve the problem by itself. But the discussions must escalate to a level that brings in all involved parties.

We need to make sure that medication reconciliation is done efficiently and effectively at both ends of the stays and work to provide solid discharge planning and counseling. These processes may not even be in the circle of influence of some pharmacy departments, but they should be. The pharmacy department should work with discharge planners and the nursing home pharmacy providers and reach out to insurers to convince them to reimburse for the 24-hour supply for transfer patients. That way, no patient goes without needed medications when they leave our facilities. We need to look at these transitions of care from the patient’s side just to make sure we’re not missing anything. It looks a lot different from there!