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Patient Continuity of Care Lapses Linked to Hospital LCF Transitions

Continuity of care suffers during transitions from hospitals to long-term care facilities because 25 % of new patient care recommendations aren’t followed.

As a Journal of Aging Research concludes, both long-term care facilities and hospitals contribute to the break in continuity of care. But financial penalties to hospitals with high readmission rates will likely drive hospital administrators to scrutinize practices on both ends.

transfer to nursing home continuity of careThe study involved 51 patients, 65 and older, that were transitioned to 10 nearby post-acute care facilities after being inpatient at Boston Medical Center. The least likely patient care recommendations to be followed were medication changes and monitoring, lab testing and referrals to sub-specialists.

Hospitals, according to the study report, often provide inadequate or unclear documentation. Long-term care facilities are lax at following up on new patient care recommendations. And no standards or procedures for documentation and accountability exist.

As James M. Berklan wrote in a McKnights article about the study, long-term care facility operators may have valid reasons for not following some recommendations. He says in some instances they may have a better understanding of elderly patient care, or the patient may have been discharged to home or transferred to a different facility.

Continuity of care suffers even more when post-acute care patients are transitioned from LCF to LCF. Higher numbers of transitions and higher numbers of recommendations both mean higher rates of non-compliance to patient care recommendations.

Berklan claims that Electronic Health Records are one part of the solution. Not all of the post-acute care facilities in the study had an EHR system, but the hospitals patient care records were accessible online.

“Perhaps the first thing that should be done — on the ground and in the drawing rooms of electronic health records companies — is to formally add an ‘outstanding issues’ section to every hospital patient’s discharge summary,” suggests Berklan.

Evaluating procedures and policies for patients being transitioned to a post-acute care facility from a hospital or another facility and developing an improvement plan  that includes adherence to follow-up recommendations is another.

The AMDA suggests in its Long-Term Care Practice Guidelines that facilities use the Universal Transfer Form to track recommendations and other important patient care information.

Something needs to be done because hospital readmissions are costly to Medicare and patient care. The current rate is unacceptable and the study authors suggest that non-compliance to follow-up recommendations is a contributing factor.

“It has been estimated that 20%–33% of older patients are rehospitalized within 30 days [12]. Our results are consistent with these figures. However, our sample represents a select, frail population. One may posit that the rate at which subjects were readmitted may have been higher if not for the EHR and the single medical practice within one medical center that cared for these NH residents,” according to the authors of the Journal of Aging Research Article.

General Medicine, The Post Hospitalist Company, provides post-acute care facilities with physicians who are dedicated solely to caring for post-acute care patients. Part of their patient care expertise is ensuring that hospital discharge recommendations are received, clear, followed and monitored.


Tom Prose