June 2022
Difficulties in Care Transitions Between Hospital PALTC and Outpatient Settings

Todd H. Goldberg MD CMD FACP AGSF, Chief of Geriatrics, Abington Jefferson Health and Medical Director, Artman Lutheran Home

As a geriatrician specializing in the care of the elderly, I have found that one of the most interesting as well as challenging aspects of my role is understanding all the different types of care available for seniors, and appropriately advising patients and colleagues. I have repeatedly noticed that not only the public but even many physicians don’t sufficiently appreciate the variety of care settings and services available for seniors. Families need to understand what options are available for loved ones, and health care providers need to understand what options are available for their patients. Too often I have seen, for example, patients discharged from the hospital on the assumption they can get certain types of tests or follow-up care in their “nursing home” when in fact the patient lives in an independent or assisted living facility where no such services are available. Therefore, it is critical for geriatricians as well as all internists, family practitioners, and hospitalists to understand the geriatric continuum of care. I wrote an article summarizing all the different levels of care in the West Virginia Medical Journal in 2014 when I lived and worked in that state Another similar and excellent review of levels of care by the late Robert Kane, MD appeared in JAMA 2011.
“Transitions of Care” is a popular concept in healthcare over the past several years, and in the hospital usually refers to handoffs and transfers of patients from one unit or shift to another – e.g., patient going from ER to floor, floor to and from ICU, day shift to night shift doctors and nurses, etc. Even these transitions “down the hall” are fraught with miscommunication and potential medical errors. However, as a geriatrician I find that the biggest and most problematic transition of care of all is the patient going to and from hospital to and from PALTC settings (nursing home, AL/PC). Too often I see a lack of communication and coordination between these settings, with an even greater potential for miscommunication/ absence of communication, medical errors, lack of appropriate follow-up, and high re-hospitalization rates.
In the office setting, “transitional care management” (TCM) visits are paid for and intended to provide prompt post-hospital outpatient follow-up and coordination of care, but the long-term care space lacks such a formal follow-up mechanism other than an admission/readmission visit upon arrival to the PALTC facility. Further the hospital providers are usually different than the PALTC, with little or no communication between them, and even worse they are on separate EMR’s making obtaining needed information in both directions challenging.
Some examples of problems I have personally experienced or heard about include: ordering medications to be continued from the hospital for unclear reasons and durations; holding blood thinners on return to SNF for tests which never happened; unexplained changes of prior meds on return to SNF; lack of specialist follow-up or PCP follow-up of abnormal labs or radiologic findings; and lack of treatment for osteoporosis after fracture (see below).
Some suggested solutions include: 1) Continuity of providers across settings. Nowadays there is usually a “division of labor” between hospital, SNF, and office practitioners, but ideally, they should follow their patients across settings to assure continuity. 2) Lacking that, closer communication and warm handoffs between providers would help. 3) Access to the same EMR across settings would also be extremely helpful. The problem is compounded even further when patients go from hospital to nursing home to outpatient settings, or from one nursing home or PC facility after being in a hospital then to a different LTCF. Does the final destination receive all the information and DC plans from the initial hospital and all the steps before and in between? Probably not.
Again, a specific example of this problem that I commonly see relates to osteoporosis and fractures. Consider a patient who goes into hospital for a fall and hip fracture at home. In the hospital they are probably seen by both orthopedics and medicine, who may suggest in a consultation that the patient should be tested and treated for osteoporosis. 
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The recommendations contained in the consult rarely are included in the discharge summary and instructions given to the patient and PALTC providers. Then the patient goes to a SNF for several weeks of rehab. Hospital medicines may be continued or changed. Then the patient goes home to outpatient follow-up, with DC instructions from the nursing home and hopefully an appointment with the PCP. But does the PCP also receive a copy of the hospital DC instructions two steps back, or detailed copies of the hospital records? Probably not. If the PCP belongs to the hospital system where the patient was hospitalized, some records may follow the patient back to the outpatient setting and the PCP may read some of the hospital records on the computer, but comments from consults are unlikely to be seen. So, whose job is it to make sure the patient gets tested and treated for osteoporosis after a hip fracture? Primary hospitalist? Hospital medical consultant? Orthopedist or trauma surgeon? SNF doctor? PCP? All share responsibility and should ideally communicate and transmit follow-up instructions. If a DEXA scan is suggested in the hospital, it will probably not be done in the SNF as it is an outpatient procedure, but will the outpatient provider even be aware and get it done later on? Good luck on that.
One thing I have taken to doing is when a patient comes to my nursing home or long-term care facility from another hospital or nursing home, often with limited records, is to spend some time calling the family and prior PCP, and looking up past hospital records in EPIC or whatever EMR the hospital and prior providers used, in order to make sure we know the entire history and are not missing anything. While time consuming, this can avoid future adverse outcomes and lawsuits. This may not be possible when physically at the nursing home which doesn’t have EPIC access, but a hospital-based provider can perhaps spend some time later or the next day filling in the history from the patients seen earlier. Fortunately, Medicare now pays for EXTENDED NON-FACE-TO FACE-SERVICES including record review and coordination of care, thus we can actually get paid for our time doing this if properly documented and billed CPT Codes 99358-99359, non-face to face time supplemental to an in person visit, minimum 30 minutes, are perfect for this scenario.
1. Goldberg TH. The Long-Term and Post-Acute Care Continuum. West Virginia Medical Journal 2014(Nov-Dec);110(6):24-30.
2. Kane RL. Finding the right level of posthospital care. JAMA 2011 (19 Jan.); 305(3):284-293.
Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates, and members.

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JAMDA Issue on Surgery in Older Persons
Over half of surgical procedures today are performed on persons aged 65 and older and collaboration between surgical and geriatric medicine specialists is needed to achieve optimal patient outcomes. To advance this dialogue, the April 2022 issue of JAMDA was entirely devoted to Surgery in Older Persons: Challenges, Considerations, and Interdisciplinary Management. The issue is available online and is free to everyone till June 30. Tell your colleagues!
Submit Proposals for PALTC23 by July 19

AMDA’s Annual Conference will be held March 9-12, 2023 in Tampa, FL. Submissions on all topics pertinent to PALTC medicine and medical direction are welcome, including:
  • Navigating the Healthcare System (effecting change, navigating the hierarchy of the system, role of PALTC in the healthcare system overall)
  • Communication (practical strategies, resolving communication gaps at all levels)
  • COVID-19 (best practices, patient management and treatment, litigation, medical director/facility liability)
  • Dementia (staff training on interacting with residents and managing PBSD behaviors)
  • Infection Control (protocols, PPE, testing, preventing future pandemics)
  • Leadership Skills (effective leadership, nurse leadership training)
  • Medical Director (role and responsibilities, contract negotiations, how to gain administration support)
  • Medication Management (deprescribing, opioids, antibiotics stewardship)
  • QAPI (meetings, implementation)
  • Staffing Issues (retention, competency, recruitment, burnout)
  • Telemedicine (implementation, billing & coding, protocols)
  • Transitions of Care (readmissions, acute care, data transfer)
  • How to apply strategies in other settings (ALF, Home Health, etc.)
  • Change culture in facility with staff and patients (bias, racism, building resilience)
  • Caring for special populations (medically complex needs, younger residents, LGBTQIA+, patients with prior substance abuse/addiction)
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