Failure at the transition of care: Challenges in the discharge of the vulnerable elderly patient

Abstract

The case of an elderly patient with mild dementia and severe depression is reviewed including analysis of the barriers to successful transition that led to readmission. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients' cognitive limitations. KEYWORDS: continuity of care and transition and discharge planning, geriatric patients, communication.T he patient is an 86-year-old woman with a history of mild dementia, major depression with psychotic features, congestive heart failure, hypertension, hyperlipidemia, osteoporosis, and hypothyroidism. She presented to her primary care physician (PCP) complaining of 4 days of bilateral lower extremity edema and dyspnea on exertion. She was admitted to the hospitalist service for exacerbation of congestive heart failure. MEDICATIONSDonepezil, olanzapine, mirtazapine, sertraline, spironolactone, triamterene/hydrochlorothizide, simvastatin, alendronate, levothyroxine, multivitamin. SOCIAL HISTORYShe lived alone in an independent-living retirement apartment that provided meals but not medical care, and she was able to function independently in her activities of daily living. Her pharmacy delivered her medications via courier service, whereas visiting home nurses filled her medication box and checked on her status weekly. HOSPITAL COURSEAdmission vitals were: heart rate, 83; blood pressure, 158/84; respiratory rate, 20; temperature, 36.4, and saturation, 95% on

Weekend Discharges and Length of Stay Among Veterans Admitted for Chronic Obstructive Pulmonary Disease

“…Scheduling follow-up appointments, a major reason for delaying discharge, can be challenging on the weekend. 19,21 We found no difference in follow-up visits among patients discharged on the weekend. The transition of care from the inpatient to outpatient setting represents a challenging period and ensuring adequate continuity of care during this time has been shown to reduce readmissions.…”

Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

“…Regarding the former, the healthcare providers in our study may have been more cautious when prescribing medications for cognitively impaired patients, particularly prior to hospital discharge. 27,28 These patients may have had caregivers at home or in facilities who could inform assembly of the discharge medication regimen. Regarding the latter, Hasan et al demonstrated that not being married was protective against hospital readmissions.…”

“…20 Scores range from 0-36 and were categorized as adequate (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36), marginal (17)(18)(19)(20)(21)(22), or inadequate health literacy (0-16). We treated health literacy as a dichotomous variable in our analyses (inadequate/ marginal vs. adequate).…”

Medication Regimens of Frail Older Adults After Discharge From Home Healthcare

“…This highlights the desperate need for systems and structures in place that allow for ongoing medication reconciliation outside of the typical healthcare setting. Interprofessional programs that include pharmacist review in the reconciliation process are demonstrating favorable results in both hospital and community settings (Cumbler, Carter, & Kutner, 2008; Feldman et al, 2012; Reidt et al, 2014; Vogelsmeier, 2013). …”