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Risk Management in the Transitions of Care
For the Case Manager
April 21, 2015
Deborah S. Baden, BA, BSN/RN, JD
Director – Risk Management
About AAMC
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Anne Arundel Medical Center (AAMC), a regional health
system headquartered in Annapolis, Md., serves an area
of more than one million people. Founded in 1902,
AAMC includes a 350 bed not for profit hospital, a
medical group, imaging service, substance use
treatment center, and other health enterprises. In
addition to a 57-acre Annapolis campus, AAMC has
outpatient pavilions in Bowie, Kent Island, Pasadena,
Odenton and Waugh Chapel.
AAMC is nationally recognized for its joint replacement
center, emergency heart attack response and cancer
care. A leader in women’s services, AAMC ranks second
in Maryland for number of births annually and has a
Level III neonatal intensive care unit.
AAMC is a Magnet designated hospital for nursing care
and professional nursing practice.
With more than 1,000 medical staff members, 3,900
employees and 750 volunteers, AAMC consistently
receives awards for quality, patient satisfaction and
innovation.
AAMC is patient family centered and is committed to
strengthening the partnership between healthcare
providers and patients and their families. PatientFamily Advisors partner in many hospital initiatives.
• Describe informed consent.
• List areas of risk to the patient at
discharge from the hospital.
• Describe outcomes of patient safety
case studies related to care at
discharge.
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TRANSITIONS OF CARE
INFORMED CONSENT
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INFORMED CONSENT
• Capacity to make informed
decisions
~FACTORS TO CONSIDER
• Interpreter services
• Advanced Directives
• MOLST form
• Health information
confidentiality & privacy
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BUILDING TRUSTING, PROFESSIONAL
PATIENT – CLINICIAN RELATIONSHIPS
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CASE STUDY #1
CONFIDENTIALITY
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• Young female patient presents to
the ED for treatment accompanied
by a young man
• Nurse recognizes patient from
previous visit and asks patient how
her baby is doing
• The young man left
• The hospital received a privacy
complaint for disclosing information
not pertinent to the care being
provided
• The patient had given her child up
for adoption and not discussed her
past history with her fiancé
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The ANA’s 6 Tips to Avoid Problems
with Social Media
1. Remember that standards of professionalism are the
same online as in any other circumstances.
2. Do not share or post information or photos gained
through the nurse-patient relationship.
3. Maintain professional boundaries in the use of
electronic media. Online contact with patients blurs
this boundary.
4. Do not make disparaging remarks about patients,
employers or co-workers, even if they’re not
identified.
5. Do not take photos or videos of patients on personal
devices, including cell phones.
6. Promptly report a breach of confidentiality or
privacy.
Source: The American Nursing Association
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CASE STUDY #2
SOCIAL MEDIA & CONFIDENTIALITY
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• University of Arizona Medical Center ED
employee posted photo on Facebook
with workstation screen in the
background
• Facebook post was removed within 30
minutes. Patient notified of incident
and told to work with credit monitoring
services
• Department of Economic Security
contacted patient 4 months after
incident as someone else was using her
information to qualify for food stamps
• Patient received anonymous calls to her
home and cell phone
• Patient is afraid to be at home and has
retained an attorney
TRANSITIONS OF CARE
DISCHARGE PLANNING
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42 CFR 482.13 (b) (1) and (2)
INFORMED CONSENT
Discharge Planning
• Patient has right to make informed decisions
regarding his/her care
• Patient has the right to participate in the
development and implementation of his/her
plan of care
• Patient or patient’s representative has the
right to be actively involved throughout the
discharge planning process.
• Patient may exercise the right to refuse to
participate in discharge planning or to
implement discharge plan
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Joint Commission
• PC.04.01.01 – “…a process that addresses the patient’s need for
continuing care, treatment, and services after discharge or transfer”.
• PC04.01.03 – “...discharge planning process early in the patient’s
episode of care, treatment”.
• PC.04.01.03 – “… identifies any needs the patient may have for
psychosocial or physical care, treatment, and services after discharge
or transfer”.
• EP 4 – “Prior to discharge, the hospital arranges or assists in arranging
the services required by the patient after discharge in order to meet
his or her ongoing needs for care and services.
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CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
HOSPITAL CONDITIONS OF PARTICIPATION (COP)
42 CFR §482.43: DISCHARGE PLANNING
“TRANSITION PLANNING”
APPROPRIATE DISCHARGE DESTINATION
Screen for risk
of adverse
health
consequences
post discharge
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HEATLHCARE NEEDS
Evaluation of
post discharge
needs
QUALITY
Progress
DISCHARGE
towards careplan goals after Initiate
implementation
discharge
of the
discharge plan
prior to
discharge
Joint Commission:
Transition of Care Portal
Factors that may increase the risk
of readmission
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• Diagnose associated with high
readmission
• Co-morbidities
• The need for numerous
medications
• History of readmissions
• Psychosocial and emotional factors
related to mental health
• Lack of family member, friend or
other caregiver who could provide
support
• Older age
• Financial distress
• Deficient living environment
Patient Care Conferences
PATIENT FAMILY ENGAGEMENT
– Defining the healthcare team.
– Assessment of healthcare literacy.
– Medication management
– Coordination of care
– Discharge planning
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• Poor transitions between different
providers
CAUSES
PREVENTABLE READMISSIONS
• Premature discharge
• Discharge to inappropriate setting
• Lack of information or resources to
ensure continued services
• Poor coordination of care
• Incomplete communication between inpatient and community based providers
• Adverse events following discharge
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TRANSITIONS OF CARE
ADVERSE EVENTS
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Statistics -2003
• 23% of patients over 65 yrs. old are transferred to
skilled nursing facility. 19% of those individuals are
readmitted within 30 days
• Study at 800 bed urban teaching hospital found 20% of
300 patients interviewed at 3 weeks post discharged
had experienced an adverse event.
• 1/3 are preventable.
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Statistics -2004
• Approximately 1 in 5 medical patients
experience an adverse event during the
first several weeks after hospital
discharge.
• 1/3 of them are associated with disability
• 1/2 are associated with use of additional
health services.
• 2/3 of them are adverse drug events.
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Statistics - 2005
• 34% of patients who participated in a
patient survey (2005) reported
experiencing medical mistakes,
medication errors or lab errors.
• The number of patients increased by 14%
if they had 4 or more physicians providing
care.
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Statistics 2007
• Following discharge nearly half (49%) of
hospitalized patients experience 1
medical error in
– Medication continuity
– Diagnostic workup
– Test follow up.
• 19-23% of patients suffer adverse events:
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DISCHARGE SUMMARIES
• At time of patients first follow up with
their PCP after hospitalization, discharge
summaries have not yet arrived about
75% of the time.
• Restricting PCP ability to provide follow
up care in 24% of hospital follow-up
visits.
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• COORDINATION OF CARE BETWEEN FACILITIES
• DISCHARGE INSTRUCTIONS
• MEDICATION RECONCILIATION
• HEALTHCARE TEAM COMMUNICATION
• PERFORMING FINAL PHYSICAL ASSESSMENT
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A woman with jaundice and liver failure was discharged
with instructions to go to a facility 82 miles away by
private automobile. The patient’s car broke down en
route.
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The patient, who was being driven to the second facility
by her son, said she had been “released from hospital..
due to no insurance and was told to follow up at Facility B
and given directions to Facility B to go. Via private
vehicle despite patient weakness and low blood pressure.
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Family states they were driving patient to Facility B when
vehicle broke down and ..was unable to continue and
called 911.
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She arrived jaundiced and in septic shock. The episode
resulted in her death that day.
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Hospital fined $100k
CASE #1
COORDINATION OF CARE interfacility transfer
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CASE #2
DISCHARGE INSTRUCTIONS
• Family member called the nursing unit stating the
discharge instructions were unclear
• The nurse discovered the medication discharge
instructions were not completed.
• The patient had received a coronary artery stent
and the booklet was still with the chart.
• The daughter was also unclear of the pacemaker
instructions
• The daughter was unclear on the length of time
the antibiotic was to be continued.
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• Patient discharged to nursing home.
Case #3
DISCHARGE MEDICATION
RECONCILIATION
• Discharge orders for 50 mcg Fentanyl but was
written for 500 mcg.
• The nursing home did not catch error until patient
became very drowsy.
• Narcan was administered.
• Patient re-admitted to the hospital with change in
level of consciousness- drug induced.
• Patient expired several weeks later, not fully
recovering from medication error.
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CASE #4
HEALTHCARE TEAM
COMMUNICATIONS
• Patient had a brief pause on the cardiac monitor.
The monitor strip was placed on the medical
record but the physician was not notified.
• The patient was discharged the following
morning.
• The patient’s spouse called to report the patient
passed out after leaving the hospital.
• As instructed, they returned to the ED, and the
patient was admitted.
• The patient had a dual chamber pacemaker
inserted the next day.
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Case #5
PENDING TEST RESULT
• Patient was admitted with diagnosis of thrombus
right arm.
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The x-ray of right elbow was ordered.
• Patient was discharged to an extended care facility
via ambulance before right elbow x-ray done.
• Orthopedic doctor notified of x-ray not being done
which would have been the basis for cancelling the
discharge order.
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CASE #6
PERFORMING FINAL PHYSICAL
ASSESSMENT
• Patient was discharged to another facility
with the right femoral triple lumen catheter
still in place.
• The nurse discovered the femoral line and
called the other facility.
• The staff asked how long and how much
pressure to hold on the femoral site when
removing the catheter.
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• Assess
– Patient’s health literacy.
– Screen patients for discharge on
admission;
– Advocate for multidisciplinary
teams to evaluate and implement
discharge needs.
• Finalize the plan with the
patient.
– Communicate with an interpreter, if
needed.
– Request a verbalized understanding
of education and plan
– Document the encounter.
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• Perform final physical assessment
– Attention to removal of items not intended
to continue after discharge
• Provide complete and accurate written
discharge instructions;
– Medication administration instructions- drug
actions & side effects;
– Follow up appointments;
– Diet;
– Signs and symptoms that may develop;
– When to call the MD
– When to seek emergency medical care
• Provide telephone follow up 2 to 3 days
after discharge.
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• Reveal information in the
company of patient’s social
support after patient gives
permission.
• Report adverse events found
upon readmission through your
organization’s reporting channels
of patient safety incidents.
• Know organization’s policies
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Patient privacy
Informed consent.
Hospital discharge planning
Adverse event reporting
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