Recently, an outstanding junior year nursing student intervened in what could have been a tragic situation. Her patient, a frail 98 year-old woman, could not stand and was challenged by a poorly healing leg wound. Malnourished and suffering from chronic congestive heart failure with 2+ pitting edema in her legs, she was hospitalized with cellulitis. To the student's surprise (and her clinical instructor), the physician came in and perfunctorily announced that he was discharging her home that day. The woman lived alone and had 26 stairs up to her house.
The student recognized that sending the patient home was most likely not appropriate and came to me, her nursing instructor, to seek guidance. The student knew that an occupational therapy/physical therapy evaluation had been ordered. She had, in fact, been talking about her patient with the case manager the day before. We sleuthed our way through the chart, first looking at the occupational therapy/physical therapy notes. The brief therapist's notes concluded that the woman could function well enough to go home. But, the patient stated that no one had worked with her. The student then went to the case manager and explained her concern. The case manager asked the therapist to reassess the patient. The therapist agreed that she was barely able to ambulate, she was very weak and that she required PT and OT in a Skilled Nursing Facility for several weeks to assure that she would be safe going home. Given her poor functional status and social situation, Mrs. M. was at risk for many geriatric syndromes, most notably falls. This alone placed her at risk for readmission in this transition of care.
Another junior 2 student, attentive yet somewhat reticent early in the semester, accompanied her 42 year-old patient with diagnosis of lupus and cancer in an ambulance to a Magnetic Resonance Imaging (MRI) testing center. The patient's cognition was altered by medications. She presented with several central line ports extending from her body. Given her mastectomy she had strict orders to not take blood pressure on the affected arm.
Apparently the paramedics/transporters were not aware of the patient's condition. When the transporters began to take her blood pressure on her arm, the student jumped in and pointed out that it should be taken on the patient's leg. Next, at the MRI center, the technician was about to administer a contrast medium in the incorrect central line port-a potentially fatal error. Again, the student was keenly observant and responded assertively to stop them. This situation highlights a significant system issue. Communication, falling short, potentially leads to hazards and harm.
Such scenarios can occur in the best of institutions. In both of these situations the students' good judgment and courage may have, in fact, saved these women's lives. Each took place during a "transition of care." Such transitions occur commonly in health care as patients move between health care practitioners and settings as their condition and care needs change during the course of an acute or chronic illness. For example, in the course of an acute exacerbation of an illness, the patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to hospital inpatient care and be discharged out to a Skilled Nursing Facility, back to home, with or within support of home health services (Transition of care: Why Is This Important to Me? Retrieved from blog, November 5, 2011). As the first scenario indicates, it may be worse yet for some patients to be transitioned back to home, if they are going alone and without the support to manage.
In a perfect world the individual or the family would be the advocate for appropriate transition. They would ask intelligent questions, take notes, research issues, keep a file of the names, contact information, dates, issues discussed, persevere and call on a daily basis. However, the complexity of health care places most patients at a disadvantage raveling through and across the health care system requires translation and interpretation even within the English language. For those who lack basic health literacy or cognitive agility it is easy to stumble. Navigation of the system may require not only an understanding of basic math, but also statistics to weigh treatment options and insurance companies' reimbursement.
This is particularly the case with older patients who may face complications upon complications, resulting in fragmentation of care. The result is a disjointed team of multiple practitioners, albeit delivering high quality care, who, more often than not, fail to communicate and/or coordinate the care. The drive to shorten hospital stays has compounded the problems with inefficient systems for transferring medical information. The consequence is a readmission rate in Medicare beneficiaries from 15 to 25 per cent.
The costs of rough transitions in care are high. Patients and their families suffer. The cost to the health care system is on the rise. Changes in Medicare are curtailing payments for "rebound" admissions. Innovations are underway to improve the quality of care, from the development of electronic medical records to hospital to home follow-up programs. An example of a promising attempt to improve transition of care is the Coleman Care Transition Intervention program in Denver, Colorado. After hospital discharge, a registered nurse working as a "Transition Coach" develops a "personal health record" and works with the family for the following month. Coleman states that "patients go from being confused and overwhelmed to confident, active participants in their own healing." In a 2004 study, 50% were less likely to return to the hospital. In 2006, funded by the Hartford Foundation, findings also revealed lower re-hospitalization rates. Cost was reduced and the estimate is that hospitals, health plans, or clinics employing the coaches could save $295,000 across 350 patients. (Care Transitions Intervention model retrieved from CTI website on November 8, 2011). In a recent State of California randomized controlled trial, that the use of CTI not only resulted in lowered readmission rates, but also that those who have used the model rate their hospital discharge experience as very good to excellent (Archives of Internal Medicine, September 2006).
Multiple organizations in the United States are attempting to improve care transitions. From the Centers for Medicare and Medicaid Services to the National Transitions of Care Coalition efforts at change are underway. Fundamental to smooth transitions is advocacy. Patient advocacy is a primary ethical responsibility of the nurse. From our novice nursing students to our expert clinicians, we need to support patient advocates who are intellectually curious, passionate and persistent in seeking and speaking truth to the powers of health care systems.