Transitions From Hospital to Home





Worldwide more than 200 million surgeries are performed each year; in the United States more than 50 million inpatient procedures occur annually. In 2009, the World Health Organization demonstrated that implementation of a relatively simple day-of-surgery checklist was associated with decreased rates of postoperative complications and death. Since that time, numerous evaluations of perioperative checklists and coordinated care efforts have demonstrated significant improvements for patients. In a review of 10 years of Enhanced Recovery programs, length of stay consistently decreased by more than one day moreover, complication rates in these studies on average decreased by 30%.


The focus on perioperative care programs has gained significant attention in the last decade. Enhanced Recovery, The Surgical Home, and Strong for Surgery are among some of the better-known programs. These programs have in common the goal of improving surgical outcomes by preparing for surgery, engaging patients, standardizing interventions, and speeding recovery. As a result, postoperatively patients are going directly from the hospital to home more often and more quickly than ever before. When building perioperative programs, together with focusing on speeding recovery, shortening time to ambulation and return of bowel function, health systems need to be prepared for the next step—the transition from hospital to home.


Paths from Hospital to Home


There are varied paths to home from the hospital ( Fig. 47.1 ). Some patients require continued rehabilitation whether more intensive as found in acute rehabilitation centers, or lower acuity provided in nursing facilities skilled in post-acute care. Some patients may be ready to return home with home-based services; others may be able to return to independent living directly ( Table 47.1 ).




Fig. 47.1


Paths from hospital to home. The path to home postdischarge is not always direct or even linear.


Table 47.1

Discharge disposition options. At the time of discharge, a patient’s current level of function will determine his/her immediate postdischarge needs. Several of these are time limited and would not be available long term.

























Short-term postacute options Long-term living options
Home independently Home independently
Home with family/friend support Home with family/friend support
Home with home health Home with home health
Postacute skilled nursing Assisted living facility
Long-term acute care Long-term care facility
Acute rehabilitation


A major driver of postacute expense in the United States is whether the patient is discharged to a postacute facility compared to home. Postacute facilities have not historically been incentivized to reduce utilization in order to maximize value. However, this pressure is emerging as bundled payment programs become more prevalent.


Currently, the decision to discharge to a postacute facility is widely variable from one institution to another, underscoring a need for improved understanding and coordination of care. For certain populations, discharge to home directly has been demonstrated to be more cost-effective and equally safe when compared with postacute facilities.


Factors Associated with Nonhome Discharge


Studies of discharge location have identified factors associated with nonhome discharge to include higher baseline comorbidity, older age, frailty, non-white race, Medicare recipient, cognitive impairment, poor nutrition, length of stay, and postoperative complications. These factors can be grouped into:



  • 1.

    baseline level of physical function (i.e., frailty, ability to perform activities of daily living [ADLs]),


  • 2.

    baseline cognitive function,


  • 3.

    degree of social support,


  • 4.

    surgical invasiveness, and


  • 5.

    degree of deconditioning that occurs in the acute setting.



Predictive models for nonhome discharge have been developed and several found that preoperative factors alone were adequately predictive (C-statistics 0.87 to 0.88) to merit preoperative initiation of discharge planning. In addition, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Risk Model, which incorporates 22 preoperative variables and was based on an analysis of 1.4 million Americans, also estimates risk of nonhome discharge, among other outcomes.


Planning for Transitions


Identifying the need for postoperative nonhome discharge or the need for home-based services prior to surgery will allow both adequate time to initiate arrangements and to provide better insight into the recovery required as the surgical team and patient discuss care options. Using a predictive model, be it ACS NSQIP or one of the cardiac specific published models, can help identify patients who can begin postdischarge planning prior to surgery.


Discharge planning should begin at the time of the decision to undertake surgery. Multidisciplinary assessments should include: frailty, ability to perform ADLs, cognitive function assessment (i.e., MiniCog assessment), potential home-based social and family-based support. These baseline assessments should be considered along with surgical invasiveness and risk of postoperative complications to inform planning for postoperative postdischarge needs. As a best practice, these assessments could be shared via an electronic medical record with the Case Management or Care Coordination department to assist with discharge planning. Depending on the degree of immobility from the surgical procedure itself, repeat assessment of functional status will probably be essential following surgery to best define the needed resources.


Costs of Failed Transitions


It has been estimated that preventable readmissions cost Medicare $12 billion in 2011. Readmissions are the most notorious measure of transition failure. As a result, increasingly payors are targeting readmission reduction programs across the United States.


When planning for discharge, the team should assess for and mitigate risk of readmission. A look at readmissions among orthopedic patients found that older age, longer length of stay, discharge to skilled nursing facility, higher BMI and ASA greater than 4 were all associated with increased risk. In this analysis, nearly half of readmissions were associated with wound issues, another quarter with medical complications. A multicenter study of 90-day readmissions following major cancer surgeries found type of surgery, number of comorbidities, type of hospital, and discharge to skilled nursing facility all associated with increased risk for readmission. Among patients undergoing vascular surgery, investigators found that preoperative risk factors were not associated with readmission, but open procedures and postoperative pneumonia were. This literature is highly variable and thus provides us general rather than specific guidance; nonetheless, awareness of these factors when planning for discharge could help mitigate readmissions.


Ensuring the Transition


Key components to ensure a smooth transition include a solid communication strategy and patient engagement. In 2003, Eric Coleman published “Falling through the cracks,” calling for systems improvements in transitions of care. Subsequently, Coleman developed and tested a model for improving transitions that reduced readmissions and overall costs. Cornerstones of these interventions include:


“1) tools to promote cross-site communication, 2) encouragement to take a more active role in their care and to assert their preferences, and 3) continuity across settings and guidance from a transition coach.”


Another successful transitions program has been the Society of Hospital Medicine’s BOOST program, which has been implemented in 180 hospitals nationwide. BOOST provides an implementation framework designed to help health systems identify areas of need and offers guidance and tools to address these needs. The key components of BOOST include mentored implementation, data analysis, and the BOOST Toolkit.


The Institute for Health-care Improvement has also designed an implementation toolkit. Key design elements in this work include patient engagement, collaboration, and communication of shared care plans. Foci for interventions include partnering with patients and families to determine needs, effectively educating patients and families, developing appropriate postdischarge follow-up, and providing real-time handoff communication at discharge.


These and other transition programs have two common themes: effective communication and patient and family engagement.


Essentials of effective clinical communication. Standardizing communication to responsible providers in facilities or clinics is as complex as the variation of needs in postdischarge care. Yet, communication failure is the leading cause of medical errors. Programs that commit to ensuring communication between providers at time of a transition have demonstrated superior results. Methods to ensure communication range from utilizing standardized forms, to educating patients, to hiring transition coaches, and to employing care providers who transect clinical locations. In this unique and more recent version of closing the communication chasm, hospitals employ providers to check on their recently discharged patients at postacute facilities, creating a “connected care model.” Many organizations have partnered with longer term skilled facilities to create a preferred care network based on readmission rate performance.


Patient and family engagement. Engaging patients and their families in postdischarge care can be tremendously helpful in ensuring the transition. In the BOOST program, patients are provided with a clear and concise written summary of their hospital care to carry information to their next stage called the Patient PASS. Several programs recommend implementing the technique of TeachBack in discharge counseling to ensure patient and family understanding.


Putting it all Together


In order to develop truly comprehensive and collaborative perioperative care programs, health systems should evaluate the current state of transitions and identify improvements and opportunities in their procedures. Key concepts highlighted in this review include the need to be aware of discharge options, to assess patient needs prior to surgery, to incorporate an assessment of risk for readmission, and to build a process that bridges the inpatient world with the next location through patient engagement and solid communication ( Fig. 47.2 ).


Jun 9, 2021 | Posted by in ANESTHESIA | Comments Off on Transitions From Hospital to Home
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