2019 ANNUAL SCIENTIFIC SESSION Saturday Workshops: Handouts · 2019 ANNUAL SCIENTIFIC SESSION Saturday Workshops: Handouts February 22-23, 2019 Raleigh Marriott Crabtree Valley Hotel

2019 ANNUAL SCIENTIFIC SESSION Saturday Workshops: Handouts

February 22-23, 2019 Raleigh Marriott Crabtree Valley Hotel • Raleigh, NC

This continuing medical education activity is sponsored by the American College of Physicians

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Techniques for MusculoskeletalJoint Injection Ryan Jessee, MD, RhMSUS

Lisa Criscione, MD, MEd

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Acknowledgements

• RheumTutor.com

• Kenneth S. O’Rourke, MD

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Overview

• Injection and Arthrocentesis Supplies

• Injectable Agents

• Arthrocentesis Results

• Potential Complications

• Contraindications

• Techniques for Common Joints• Shoulder, Elbow, Wrist, Knee, Ankle

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Arthrocentesis Supplies

• Chlorhexadine or povidone-iodine• Alcohol swabs• Syringe and needle

• 3 - 5 cc syringe• 18g-21 g needle on ≥ 20 cc syringe • 25g needle for most injections

• Gauze, bandages• Gloves• Pen• Purple top, red top, black top (sterile container)• Assistant• Consider procedural videos before doing (NEJM)

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Injectable Agents(What Goes In)

• Corticosteroids

• Anesthetic

• Saline

• Viscosupplements

• Platelet‐rich plasma

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What Goes In

• Corticosteroids• Fluorinated‐ Less soluble (Triamcinolone, Dexamethasone)

• Non‐fluorinated‐ More soluble (Methylprednisolone)

• Anesthetic

• Saline

• Viscosupplements• ‐Hyaluronic Acid preparations

• Platelet‐rich plasma

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Arthrocentesis Results(What Comes Out)

• Synovial/bursal fluid

• Send for:• Gram Stain

• Culture

• Cell Count

• Crystals

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Predictive value of synovial fluid analysis for diagnosing non-gonococcal septic arthritis

Study Sens% Spec% +LR -LR

WBC >100K 29 99 28 0.71

WBC >50K 62 92 7.7 0.42

WBC >25K 77 73 2.9 0.32

Polys >90% 73 79 3.4 0.34

Low glucose

51 85 3.4 0.58

Prot >3gm/dL

48 46 0.90 1.1

LDH >250 U/L

100 51 1.9 0.1

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Rule of 2’s

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Potential Complications

• Infection• Bleeding• Nerve damage• Pain• Inflammation• Pseudoseptic joint• Localized atrophy• Loss of skin pigmentation• Temporary increase in blood sugar• Tendon rupture

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Relative Contraindications

• Recent Injection

• Cellulitis

• Psoriatic Plaque

• Bleeding Diathesis

• Periarticular Fracture

• Artificial Joints

• Planned Upcoming Joint Replacement

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Techniques for Common Joints

• Shoulder

• Elbow

• Wrist

• Knee

• Ankle

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Shoulder: Subacromial and Glenohumeral

• Injectate

• Anatomy

• Techniques

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Shoulder Injectate

• 20‐40mg methylprednisolone or triamcinolone

• 1‐2 ml lidocaine

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Shoulder Anatomy

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Subacromial

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Glenohumeral Joint

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Elbow

• Injectate

• Anatomy

• Techniques

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Elbow Injectate



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Elbow Anatomy

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Wrist

• Injectate

• Anatomy

• Techniques

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Wrist Injectate

• 20mg methylprednisolone or triamcinolone


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Dorsal Wrist Anatomy

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Knee

• Injectate

• Anatomy

• Techniques

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Knee Injectate

• 40‐80 methylprednisolone or triamcinolone


• Hyaluronic Acid derivatives

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Knee Anatomy

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Ankle

• Injectate

• Anatomy

• Techniques

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Ankle Injectate



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Ankle Anatomy

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Any Questions?

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All Rights Reserved, Duke Medicine 2007

Lost in Transition: Improving Hospital to SNF Transitions

Aubrey Jolly Graham, MDHeidi White, MDNC ACP Session

February 23, 2019

Additional credit for slide content: Dr. Juliessa Pavon and Dr. Michael Krol


Objectives

1. Describe the care environment at SNF’s

2. Share key tenants of quality hospital to SNF transitional care

3. Overview of payment models for SNF care

4. Highlight local work on transitions through the HOPE program

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Starting Points

• Introductions

• Disclosures

• Get to know our audience

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Case Introduction

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Aging Population and Evolution of Nursing Facilities

• Aging Baby Boomers, Rapidly growing Population of >85 year olds

– Double by 2036, Triple by 2049

– Anticipate Alzheimers dementia to triple by 2050

• Nursing Home Needs Increasing

– 75% increase from 2010 to 2030

• Nursing Facilities shifting to focus on Post-Acute care and rehab vs Long term care

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Who lives (and dies) in Nursing homes?

• 2004 – 1.5 million nursing home residents

– 88% aged 65 years and older

– 45% aged 85 years and older

– 71% female, 86% white

• Projected that by 2030 >3 million Americans will reside in institutional long‐term care

• 25% Americans die in nursing homes

• By 2020, death in hospitals is expected to decrease, but death in nursing is expected to rise to 40%.

www.capc.org

http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf 6

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The Skilled Nursing Facility Environment

• 24% of Hospitalized Medicare Beneficiaries discharged from Hospital to Post‐Acute Care (PAC) – largely occurs in Skilled Nursing Facilities (SNF)

• Provide 24/7 skilled nursing care and rehabilitation services to people with illnesses, injuries or functional disabilities

• Now provide much of the nursing care that was previously provided in a hospital setting a decade ago.

• Most focused on rehab (as opposed to long‐term care) to allow patients to transition back home.

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Skilled Nursing Facility Environment- Clinical Care

• MD on call, rounds weekly but not on all patients. Most local facilities have an APP on site on weekdays. 1 MD visit per 30 days required, within 7 days of admission.

• After hours, no one on site, calls to covering provider for orders, recommendations

• PT, OT, speech services daily on weekdays, prn coverage on weekends

• Staff pharmacist (rare) or consulting pharmacist (monthly)

• Bedside care by CNA’s, LPN’s, RN’s

• Within 1 week of arrival- care plan meetings with team members, patient and family for those on rehab side (doesn’t include MD)

• Many have paper charts. None have Epic. Most do not have Duke doctors.

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The SNF Environment- available services

• Available consults: Psychiatry, Podiatry

• Hospice services available in most SNF’s through contracts

• Chaplains not available in most SNF’s

• SNF’s do not offer bereavement services (hospice does)

• Most offer wound care nurse expertise

• No other in-facility medical consultations usually available

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Both philosophies conflict with the needs of dying people.

Can lead to mismanaged pain, poor symptom control, limited spiritual and emotional support, “revolving door”

25% Readmission Rate (30-day)

$4.34 Billion (in 2006)

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SNF focus is on rehabilitation

• MD is no longer front and center, nor readily available

• PT/OT/ST/nursing care become front and center

• Potential for rehab and barriers to successful rehab become the focus

• Patients and families have hard time adjusting from “medical” environment to “rehab” environment

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Care Transitions to SNF

• Nursing home residents are highly vulnerable to harm from poorly executed care transitions

• Examples include:

– inadequate communication of critical information

– medication errors/delays

– omissions or delays in follow‐up diagnostic tests and treatments

– Bed availability at nursing homes

• Leading to repeat hospitalizations/adverse events

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Breakout #1:

Discussion Questions:

1. Where have you seen care transition errors occur in SNF patients?

2. What are potential areas for errors to occur?

Hint- Think practically! Think about your day-to-day workflows

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Upon Arrival to SNF

• Review of hospital discharge orders/instructions with the accepting MD over the phone

– MD usually does not know patient or details of hospitalization, so would only make changes if something is obviously wrong with orders

– These come from the Orders (DTOF), often d/c summary not read until MD visit a few days later

• Initial nursing assessment

• Initial assessment by all therapy services that have been ordered

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Patient discharged to

SNF

Arrives to SNF, Med Rx faxed to LTC

pharmacy

Med may not arrive to SNF

until after 5pm

Medications for new admits are not immediately available.

If medication needed urgently…SNF uses a back up pharmacy, or emergency supply2-4 hrs for medication arrival = urgentlyBest way, have medication sent with them from hospital or send orders ahead of time

How do they get their meds?

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- High risk patients- Multiple care providers- Changes in: medication,

function, nutrition, and/or cognition.

- Unprepared for discharge- Poor pt/family engagement- Goals of care often not

discussed

Hospital Stay

- Limited knowledge of patient’s baseline function

- Medication discrepancies- Family/patient unsure how

to advocate for care- Expectation mismatch- Goals of care not

reassessed

Post Acute Care

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Improving the transition: Proven strategies

• Hospital med rec pharmacist review (at discharge)

• Post discharge Advocate nurses vs Physician/APP post-hospital visit

– Ensure proper care plans made and orders written

• Better coordination with specialists (ex. Neurology via telehealth)

• Readmission Reviews (RCA)

• Limiting discharges to SNF after 2PM

• Discharge checklist, standardized communication

Mileski et al. Clinical Interventions in Aging. 25 Jan 2017 17


Improving the Transition: Prior to Discharge Agenda

• Stabilize all active medical issues and consolidate medication regimens

• Think about ongoing “geriatric syndromes” or rehab barriers and include plans/orders for management

– Pain, Nausea

– Constipation

– Delirium

– Falls Risk

– Nutrition18

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Improving the Transition: Follow-up items

• Make sure BOTH orders and discharge summary convey key follow-up items that are indicated, this could include:

– Labs – include date needed

– Vital sign orders (for med titration such as weights, BP’s)

– Blood sugar monitoring

– Wound/line care

• Note that most labs won’t return or be reviewed same day

• Discharge summary often not references, SNF’s rely on the “orders”

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Improving the Transition: Medications

• Indicate when the last dose was given at the hospital

• List specific stop dates and indications for antibiotics

• Send hard scripts for controlled substances (benzo, opiod, lyrica)

– If not, delay in getting hard script from SNF MD who is not on‐site

• Review list for high risk meds in elderly‐ consider deprescribing!

• Continuous Subq and IV administration is not routinely done at nursing homes (i.e. IV pain meds, ativan drip), SL and IM dosing OK.

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Improving the Transition: Medications

• Ensure Accurate admission med rec!

• Excellent Discharge med rec is essential!

• Caution when “continuing” home meds- make sure requisite details are included and meds are appropriate

• Be sure SNF is updated of last minute changes (orders have often already been sent and submitted hours prior to discharge)

• Can be helpful to continue home durable medical equipment orders if they will need to be continued after SNF stay upon sending pt home

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Key Med Related Issues for SNF

• Pain Meds & Anxiolytics

– Require paper scripts

– Strict DEA enforcement

• Anti‐psychotics – Max 14 day limit with end date for prn, Can re‐write order after 14 days

• Anti‐emetics

– Expense (i.e., Zofran)

– Antipsychotics should be limited for this indication

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Improving the Transition: Follow-up appointments

• Include in your “orders” all relevant rehab services that need to see patient in the facility: PT, OT, speech, dietician

• Include “referral to psychiatry, podiatry, etc” for appropriate patients

• NO NEED to make a PCP appointment, this will be scheduled post-SNF discharge

• Patients can still see subspecialists for outpatient visits, preferable not for first 1-2 weeks in the facility, and preferably not for routine things that can be rescheduled until post-rehab

• Make referrals for future subspecialty consultations as these are hard for SNF’s to facilitate

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Improving the Transition: Goals of Care

• Be clear about any goals of care conversations you’ve had with the patient and document these in the discharge summary

• Update Code status on Discharge summary, send yellow DNAR

• Consider filling out “MOST” form, these are used by many SNF’s

• For patients with poor rehab potential, consider addressing this in the hospital, or be willing to recognize the “revolving door” cycle and try to move this conversation forward

– Palliative care or geriatrics consults, Engage the facility or community teams who know the patient

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Palliative Care in Nursing Homes

Models of Palliative Care Delivery in NHs

Traditional Hospice

Non-Hospice Palliative Care Consultation

Services

Integrated Palliative Care

Programs developed by the NH “Home

Grown”

Challenges of Integrated Palliative Care Programs:•Chaplain and bereavement services??•Skilled hospice nursing ??•Financial viability is challenging 25


Breakout #2:

Article review and Discussion

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What is HOPE?• “Health Optimization Program for Elders”

• Began as a multidisciplinary workgroup, grew into a clinical consult program, and now also a HOPE SNF Collaborative

• Transitional care model designed to prevent avoidable readmissions and other adverse outcomes during and after transition from the acute inpatient care setting to the post-acute care setting for adult patients age 55 and older at Duke University Hospital

Acute HOPE SNF

SYSTEM LEVEL

PATIENT LEVEL 27

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What is a HOPE Consult?

• Inpatient Consult staffed by Geriatrics Nurse Practitioner, and Geriatrics Attending (introduce Colette Allen, NP)

• Targets transition from hospital to facility

• See patient as inpatient, AND within 1 week of discharge

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What does HOPE Consult help with?

• Patient and family engagement in rehab process

• Goal clarification toward achievable progress

• Optimization for Rehab

• Geriatric Syndromes

• Discharge Follow-up in Facility

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Duke HOPE program

Patient Identification

Age ≥ 55 year old on internal medicine service

Sources of Consults

• Attendings/ Residents

• Epic hip fracture order‐set

• Nursing Manager Rounds

Inpatient Interventions (APP ) Chart review

High risk medication review

Patient/Family discussion regarding prognosis and expectations

Connect patient to Duke resources

Recommendations to primary team and family

SNF Interventions Review high risk

medication

Assess participation in rehabilitation

Confirm follow‐up appointment scheduled

Confirm follow‐up labs are ordered

Communicate patient’s stated goals of care

Discuss outstanding symptoms not yet resolved

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Who should have a HOPE Consult?

• All patients admitted with hip fracture

• All patients going to SNF rehab for first time (age >55)

• All patients seen in past by HOPE consult

• Patients with recent readmission from SNF or home

• Patients with complex issues to follow-up in facility

• NOT limited to local SNF, can be anywhere, even out of state (follow-up visit done via phone)

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HOPE Consult Program

n Age (avg) LOS CMI Severity of Illness Risk of Mortality 7 Days (%,n) 14 Days (%,n) 30 Days(%,n)

Hope 248 80.1 9.7 1.97 3.0 2.8 5.0% 12 7.4% 18 11.2% 27

Non-Hope 996 76.8 8.2 1.82 3.1 2.9 4.4% 42 8.9% 86 16.3% 157

IM Patients in Redcap: All Patients No Readmissions14-Day Readmission

Age 80 80 83

CMI 1.94 1.90 2.52

LOS 9.88 9.83 11.64

ROM 2.83 2.82 3.08

SOI 2.95 2.93 3.15

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What is a SNF Collaborative?

• A SNF Collaborative is a group of facilities that meet certain quality standards and engage in preferred partnerships with an ACO.

• By establishing a SNF Collaborative, Duke Health and DCC seek to advance its engagement with local SNFs as partners.

Informal Engagement

Formal Collaboration

Contracted or Employed

• Interaction between ACO providers and SNF (e.g., HOPE program, PHMO coordinators, CJR)

• Advise development of protocols to ease transitions of care

• Designate SNF partners to accelerate collaboration

• Mutually designed standards and protocols (e.g., MedLink expectations, PCP communications)

• Share utilization and performance information

• Standard agreements identifying shared expectations

• Broader patient and provider-level data sharing (e.g., MSSP data)

• May include financial risk/gain potential

• Providers may be employed or owned by ACO Participant

Table adapted from Tu, Tianna, Ike Bennion, and Michelle Templin. (2014, Sept). The Right Care for the Right Cost: Post-Acute Care and the Triple Aim. Retrieved from: https://www.mhainc.com/uploadedFiles/Content/Resources/MHA_Leavitt%20Partners%20White%20Paper%20091814.pdf

ACO – PAC Engagement Spectrum

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Duke HOPE SNF Collaborative

• Collaborative with 22+ local SNF’s (none Duke owned)

• Engaged with ongoing QI projects to improve care, quality metrics, data sharing, educational sessions, feedback

• Initial Goals and Focuses:

– Improve PCP communication (appt scheduling)

– Improve Epic MedLink usage for accurate Hospital d/c summaries and uploading SNF d/c summaries

– Utilize resource center for questions on discharged patients

– Utilize transfer center to notify ED of expectants and convey clinical information

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SNF Participants FY2019

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Questions?

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Documents

2019 ANNUAL SCIENTIFIC SESSION Saturday Workshops: Handouts · 2019 ANNUAL SCIENTIFIC SESSION Saturday Workshops: Handouts February 22-23, 2019 Raleigh Marriott Crabtree Valley Hotel