An interview by Curaspan Health Group with Mark Lachs, MD

Mark Lachs, MD, MPH, geriatrics physician, professor, researcher and author of the new book, Treat Me, Not My Age, says one of the hottest new areas of research is care transitions. He warns that there’s a growing disconnect between hospitals and post-acute providers.

Curaspan: Why is care transition a hot topic?

Mark Lachs: We should be worried about hospital and nursing-home safety, but there is growing evidence that another very dangerous time in health care is the transition between the hospital and the post-acute facility – or when patients move between any two health-care providers or settings. These dangers can even happen in the same institution – such as when you leave the ER to go upstairs to an inpatient bed. Study after study shows that times of care transitions are high-risk times for mishaps.

What can go wrong?

Any number of things. Medication reconciliation is all the rage these days, and it should be: Dosages get miscommunicated, generic names are not recognized so meds are given twice, or the drug is not available in the post-acute formulary when the patient arrives.

Another problem is the clash of hospital and post-acute cultures. Many facilities are still in what I call custodial mode – they’re used to caring for Alzheimer’s patients but not acutely ill folks who need a different kind of attention. Someone may be admitted to a post-acute care facility who had a major surgery just a few days earlier and needs high-tech treatment but instead gets a social history and a dental exam.

Information gets miscommunicated or not conveyed at all. And because health-care environments are so hurried, the prevalence of this problem has been increasing. But things are changing; the physician presence is improving in most post-acute facilities and so is the technology. There are preventative steps for care-transition problems, and they’re both low-tech and high-tech.

What are the high-tech solutions?

EHRs, certainly. Long-term care and sub-acute facilities are slower to adopt electronic health records, but they’re coming around. It’s necessary because there are so many dangling issues with these patients – lots of loose ends from the hospital that need attention. Patients frequently have pending blood tests or imaging studies and these are not always known to the sub-acute facilities. When these are not followed up, patients can clinically decompensate and wind up ping-ponging between the hospital and the nursing home. Previous fee-for-service models actually rewarded this, but new economic disincentives will make this undesirable for both hospitals and post-acute facilities.

And low-tech?

Simple communication. For example, knowing whom to call at the hospital with a question or educating families as to what’s going to happen next in the post-acute facility and under what circumstances someone should come back to the hospital. My colleague Dr. Eric Coleman has created a unique model for managing care transitions involving a care-transition coach, which has been shown to dramatically prevent readmissions to the hospital.

Should physicians be involved in the discharge process?

Absolutely. But it’s probably not feasible to the extent that would be desirable. The hospitalist movement has been a mixed blessing, interrupting patient continuity. In the old days, your primary care physician followed you from the office to the hospital and even into the rehabilitation facility.

How important is the case manager?

A good hospital discharge planner is worth his or her weight in gold. It’s so much more than simply getting patients out the door. It’s a lot like a matchmaker. A good case manager will work closely with her colleagues in social work to understand their patients’ preferences about what kind of facility they would do best in, not only medically, but culturally.

Any thoughts on what’s next?

Acuity will continue to move downstream. Patients in today’s nursing homes are like those in yesterday’s hospitals, and today’s assisted-living patients are as sick as those who were in yesterday’s nursing homes. But at the end of the day, post-acute facilities are in a much better position to care for convalescing patients than are hospitals, which are now dealing with the sickest and most critically ill patients.

This will make long-term and post-acute facilities very important under health-care reform as the potentially high-quality, lower-cost solution. My great hope is that we can “remove the seams” between acute and post-acute providers, with integrated electronic records systems and other innovations.

For so many years, long-term care has been the stepchild of hospital systems – almost an afterthought, really. But long-term care and the sub-acutes have the potential to be the centerpieces of the modern health-care system.

Mark Lachs is a gerontologist at at Weill Cornell Medical College in New York City and author of Treat Me, Not My Age: A Doctor’s Guide to Getting the Best Care as You or a Loved One Gets Older.

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