{"id":4768,"date":"2016-05-25T00:00:00","date_gmt":"2016-05-25T06:00:00","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/2016\/05\/25\/teamwork-eases-transitions-of-care-for-the-elderly\/"},"modified":"2026-04-02T15:25:52","modified_gmt":"2026-04-02T21:25:52","slug":"teamwork-eases-transitions-of-care-for-the-elderly","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/teamwork-eases-transitions-of-care-for-the-elderly\/","title":{"rendered":"Teamwork eases transitions of care for the elderly"},"content":{"rendered":"
<\/div>
\"Lisa
Lisa Schilling, MD, directs Ambulatory Health Promotion, a program that assists the Seniors Clinic in coordinating the care of elderly patients discharged from UCH.<\/figcaption><\/figure>\n

The transition from the hospital to another facility or even home can be challenging for patients under the best of circumstances, but it\u2019s often especially difficult for the elderly. Many of them have complex medical conditions and medication regimens that put them at higher risk of readmission. The Seniors Clinic at University of Colorado Hospital is part of an initiative to support its patients after discharge by marrying technology with old-fashioned communication.<\/p>\n

The initiative is a joint effort between the clinic and Ambulatory Health Promotion (AHP) \u2013 a patient outreach program that is part of the University of Colorado School of Medicine\u2019s Office of Value-Based Performance<\/a>. The overall goal of AHP is to provide preventive care and chronic disease management to UCH patients through a variety of strategies.<\/p>\n

The AHP-Seniors Clinic initiative aims to coordinate care for elderly patients discharged from UCH to go home or to a community provider. The foundation is the Epic electronic health record (EHR), which AHP uses to identify the patients, said Lisa Schilling, MD, MSPH<\/a>, director of the program.<\/p>\n

\"Bennett
Collaborative care has helped decrease hospital readmissions for Seniors Clinic patients, says Seniors Clinic Medical Director Bennett Parnes, MD.<\/figcaption><\/figure>\n

With that information, AHP staff make \u201cinteractive contact\u201d with each patient within 48 business hours of their discharge to help set up clinic follow-up visits that happen within seven days of discharge for complex patients or 14 days for those with less-complex needs. They also identify patients\u2019 current needs, and triage them to the Seniors Clinic team for further care coordination. Patients get their medications reviewed and reconciled by a pharmacist before their clinic visit.<\/p>\n

Necessary steps<\/strong><\/p>\n

Patient contact, medication reconciliation and scheduling of a timely clinic visit are all necessary to bill the Centers for Medicare and Medicaid Services (CMS) for managing transitions of care, Schilling said. That provides an incentive for the real goal: establishing regular communication with patients and helping them avoid unnecessary readmissions and trips to the emergency department. That, in turn, benefits the patient and the hospital, which can receive penalties from CMS if its 30-day readmission rates for patients with specific conditions, such as heart failure, are too high.<\/p>\n

The work has tightened the Seniors Clinic\u2019s connections with hospitalized patients, said Medical Director Bennett Parnes, MD<\/a>. Since the program launched in August 2014, it\u2019s covered more than 500 discharges of Seniors Clinic patients. More recently, the clinic has used AHP information to sharpen its scrutiny of the roughly 30 percent of patients discharged to skilled nursing facilities (SNFs). They have long been higher-than-average readmission risks, Parnes said.<\/p>\n

\u201cThey are often complicated patients,\u201d Parnes said. \u201cIt\u2019s a harder nut to crack to manage SNF patients who are discharged to home.\u201d<\/p>\n

The social network<\/strong><\/p>\n

The problem is fragmented communication between the hospital and the large number of SNFs scattered around the Denver metro area, the state and the region. To close those gaps, Kirbie Knutsen, LSW, social worker for the Seniors Clinic, uses AHP notifications in the Epic EHR to identify clinic patients discharged to a SNF and contacts the facility to make contact with a social worker or discharge planner. Knutsen reviews the patient\u2019s needs, such as transportation, durable medical equipment, and home health care, and requests that the SNF fax her a copy of the discharge summary and medication list when the patient leaves the facility. At that point, Knutsen lets the patient\u2019s clinic provider and the AHP team know that the patient has been discharged and can be scheduled for a follow-up visit.<\/p>\n

Knutsen, who began the SNF project about two months ago, said that as of mid-May she had closed eight cases and was working on another seven. The biggest challenge, she said, was getting SNFs to call her back. \u201cIt\u2019s not always their highest priority,\u201d she said. \u201cBut I\u2019m developing relationships with them. It will improve with time.\u201d<\/p>\n

There are additional incentives for SNFs to work closely with hospital providers like Knutsen. CMS has proposed a rule<\/a> to withhold 2 percent of Medicare payments to SNFs. The facilities could earn the money back by keeping their 30-day hospital readmission rates at or below average.<\/p>\n

The measure puts tightening coordination of care and preventing unnecessary readmissions \u201chigh on everyone\u2019s list,\u201d Parnes said.<\/p>\n

Rx for care management<\/strong><\/p>\n

The AHP-Seniors Clinic project also brings clinical pharmacy into the transitions-of-care cycle. Data show the importance of that decision. In an analysis of the medication lists of nearly 300 Seniors Clinic patients discharged from UCH between August 2014 and August 2015, clinical pharmacists identified at least one \u201cdiscrepancy\u201d \u2013 a medication that should have been stopped but was left on the discharge summary, for example \u2013 in 78 percent of the cases, said Danielle Rhyne, PharmD.<\/p>\n

That\u2019s not surprising, Rhyne said. Most elderly patients take at least five medications, but the analysis put the average at 14. Those with chronic disease and complex medical conditions may take two dozen or more, Rhyne said.<\/p>\n

\u201cThe more medications they are on, the more problems they can have,\u201d she said. Medication-related issues such as low blood pressure or blood sugar, dizziness, and electrolyte imbalances can land a patient back in the hospital unnecessarily.<\/p>\n

\"Kirbie
Kirbie Knutsen, social worker with the Seniors Clinic, works with skilled nursing facilities to make sure the clinic stays up to date on patients\u2019 transitions of care.<\/figcaption><\/figure>\n

The medication management work has had a positive effect. The patients discharged from UCH during the August 2014-August 2015 period \u2013 average age 81 \u2013 had a 14.8 percent 30-day readmission rate compared with an overall readmission rate for UCH Medicare patients of 15.6 percent. From Dec. 1, 2015 to Feb. 29, 2016, the readmission rate for Seniors Clinic patients managed by the program fell to 10.6 percent.<\/p>\n

Drug detectives<\/strong><\/p>\n

That kind of success requires commitment. Rhyne and pharmacy colleague Sunny Linnebur, PharmD, sort through patients\u2019 medication lists and head off potential issues. They are in the Seniors Clinic five days a week, contacting patients identified by AHP. They ask them or their caregivers to retrieve their medication bottles and read them so they can reconcile the patients\u2019 actual meds with those listed on the discharge summary from the hospital or SNF.<\/p>\n

\u201cWe act as investigators,\u201d Rhyne said.<\/p>\n

She and Linnebur correct discrepancies, collect medication questions to ask the provider, and start notes in Epic to document any changes in dose, start and stop dates.<\/p>\n

The work requires patience \u2013 the calls typically take 45 minutes, but they can run much longer \u2013 as well as precision. It\u2019s important that patients take the medications as prescribed, but it\u2019s also important to weed out those they don\u2019t need.<\/p>\n

\u201cWe try to identify medications that are of no benefit to patients,\u201d Rhyne said. Benadryl and Advil, for example, are \u201cno-no\u2019s\u201d for elderly patients because of their potentially harmful side effects.<\/p>\n

The pharmacists also act as conduits to care whenever they can. If patients have trouble paying for medications, for example, they try to find low-cost options. If transportation is an issue, they assist with setting up mail-order accounts. They give patients on Warfarin the number for UCH\u2019s Anticoagulation Clinic and route their medication notes to providers in specialty clinics to ensure they are aware of the medications their patients are taking.<\/p>\n

The benefits of such efforts of the Seniors Clinic and AHP go beyond clinical confines, Parnes said.<\/p>\n

\u201cWe\u2019ve had extremely favorable reviews from patients,\u201d he said. \u201cMany have said they were surprised that we knew they had been in the hospital. Patient satisfaction has been huge.\u201d<\/p>\n

\"Danielle
Medication management and reconciliation is a vital part of care for Seniors Clinic patients, notes clinical pharmacist Danielle Rhyne, PharmD.<\/figcaption><\/figure>\n

The outreach work continues. Schilling said AHP also receives daily data feeds from the Colorado Regional Health Information Organization<\/a> (CORHIO) about UCH primary care patients discharged from other hospitals. Staff pull information from CORHIO PatientCare 360<\/a>, a web-based portal that allows users to view medical records from Colorado hospitals. They view the available details of each hospitalization, including the discharge summary, enter the information into the Epic EHR, and start the outreach process. They also send the information to his or her primary care provider at UCH. In the future, Schilling said she hopes in the future to see data from CORHIO flow straight into Epic.<\/p>\n

Similarly, Schilling envisions a system that automatically alerts AHP when a SNF discharges a UCH patient. That would free a social worker like Knutsen from having to make phone inquiries.<\/p>\n

Overall, however, Schilling said the transitions-of-care progress made thus far is encouraging. \u201cWe are striving to optimize data exchanges and the use of data to drive more personalized, right-person, right-time team-based care that focuses on value rather than volume,\u201d she said.<\/p>\n","protected":false},"excerpt":{"rendered":"

The transition from the hospital to another facility or even home can be challenging for patients under the best of circumstances, but it\u2019s often especially difficult for the elderly. Many of them have complex medical conditions and medication regimens that put them at higher risk of readmission. The Seniors Clinic at University of Colorado Hospital […]<\/p>\n","protected":false},"author":2143,"featured_media":2690,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[5],"tags":[9171],"class_list":["post-4768","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-innovative-care","tag-senior-care"],"acf":[],"yoast_head":"\nTeamwork eases transitions of care for the elderly - UCHealth Today<\/title>\n<meta name=\"description\" content=\"The transition from the hospital to another facility or even home can be challenging for patients under the best of circumstances, but it\u2019s often especially difficult for the elderly. 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