If you are going to change your discharge model for at-risk geriatric patients, there are four elements you are going to need.
Geriatric inpatient care and the transition of patients to postacute care are among the most daunting challenges for health systems and hospitals because of the possibility of patient functionality losses in the inpatient setting and costly readmissions after discharge.
In one effort to rise to these challenges, Philadelphia-based Penn Medicine has launched Supporting Older Adults at Risk, or SOAR. SOAR which served its first patient in January, is modeled after the "flipped" discharge program crafted at Sheffield Teaching Hospitals in the United Kingdom.
Penn Medicine has modified the U.K. approach to "flipped" discharge, which features in-home patient assessments after hospital discharge more prominently than in-hospital assessments at discharge, says Rebecca Trotta, PhD, RN, director, nursing research and science, at the Hospital of the University of Pennsylvania in Philadelphia.
"We tried to adhere to the central tenets of flipped discharge: maintaining a geriatric focus; having comprehensive services, not just medical services; and offering services early and intensively," she says.
SOAR has served 46 patients so far, and the early data is promising, Trotta says. A primary goal of the initiative is decreasing hospital length of stay, which has dropped about 1.5 days for SOAR patients.
Lowering length of stay reduces risks associated with hospital care, she says. "We are thinking about how we can maximize care in the home setting because we know when patients are in the hospital they are at higher risk for falls, functional decline, and delirium."
Flipping the discharge model at Penn Medicine means equipping its SOAR program with the following four elements:
1. Geriatric nurse consultants
Four nurses who serve as geriatric nurse consultants in the inpatient setting are a building block of the SOAR initiative. They are staffed through the department of nursing.
"Their full-time job is to identify older adults upon admission who could benefit from a comprehensive geriatric assessment, to share recommendations and findings with the interprofessional team, to follow up on those recommendations, and to collaborate with caregivers," Trotta says.
The geriatric nurse consultants establish working relationships with patients that underpin the SOAR program, says David Resnick, MEd, MPH, innovation manager for the Acceleration Lab at the Penn Medicine Center for Health Care Innovation in Philadelphia.
"The geriatric nurse consultants spend a lot of time with patients in the hospital conducting assessments and getting to know them and their caregivers, which builds trust. So, we have seen refusals of home care at the door—which happen about 15% of the time with traditional home care—fall to zero with SOAR," he says.
2. Home assessments
SOAR provides home health services through Penn Care at Home, a division of Penn Medicine. When patients return home, a Penn Care at Home staff member conducts an assessment.
The home assessments confirm or revise discharge assessments conducted in the hospital including physical therapy and occupational therapy evaluations, she says. "SOAR verifies what is needed. We often find patients need more or different things than we thought in the hospital."
Home assessments help recovering patients to live at home, Trotta says.
"The goal for our older patients is to maximize their ability to take care of themselves, which includes their daily living and functioning. They need to do things like get to the bathroom, prepare food, do laundry, and keep their house clean. Seeing how that unfolds in their real environment lets us see where they might need help versus seeing it in the hospital," she says.
3. Rigorous handoff
"We do a handoff call with the geriatric nursing consultants that includes highlighting key things they have learned about the family and caregivers. They also work on medication reconciliation jointly with the home care team," Resnick says.
Hospital staff and the home care team work together closely for the first 48 hours after a patient has been discharged, he says.
"For the first two days that a patient is home, the home care team is tethered back to the hospital. The home care team can either call or message the acute care provider and talk with the geriatric nurse consultants for issues that arise in the home such as medication discrepancies and other concerns. They are not on their own," he says.
4. Intensive services
SOAR provides a level of service that is more extensive than traditional home healthcare, Trotta says.
"It is organized differently than standard home care. Typically, across the country the average time to the first home visit is at least two to three days. For an older person leaving a hospital without a connection to their next provider for two or three days, there is a risk of something going wrong in that time," she says.
With SOAR, patients get a same-day visit after discharge. They leave the hospital in the morning, then see a home care nurse that afternoon. They also see that same nurse the next day.
Same-day and next-day visits following hospital discharge allow home care team members to address immediate needs such as questions about medications and usage of durable medical equipment, Trotta says. "There is more immediate attention as patients transition from the hospital to the home."
SOAR provides a level of services, which are reimbursable by Medicare and commercial insurance, that is often not included in traditional home care, she says.
"Our patients are defaulted to receive physical therapy, occupational therapy, and social work. In traditional home care, those services can be delayed or not recognized as needed at all," Trotta says.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Key elements of the 'flipped' discharge model include a geriatric focus, having comprehensive services, and offering services early and intensively.
Penn Medicine's modified 'flipped' discharge initiative has reduced length of stay about 1.5 days for participating patients.
Components of Penn Medicine's initiative include geriatric nurse consultants, home assessments, rigorous handoffs, and intensive services.