We know that older people do not fare well in the hospital. In recent years, researchers coined the term “post-hospital syndrome” to describe the bundle of issues that put older adults at an elevated risk of adverse events after they’ve been hospitalized. What if we could shorten hospital length of stay and, potentially, reduce the number of older adults who experience post-hospital syndrome?
Close to one-fifth of a patient’s time in the hospital may be unnecessary and avoidable. This time is often spent in the hospital planning for discharge. This means a longer length of stay and a missed opportunity for rehabilitative assessment in the home, where it is more likely to align care with the life of the older adult: How many reaches and how much strength does it take to make a cup of tea at home? How many steps on a flat floor or on raised stairs does it take to get to the bedroom?
Penn Medicine was inspired to improve the length of stay and the transition home for older adults when they participated in the IHI International Innovations Network and saw “flipped" discharge in action in Sheffield, England. The model involves “flipping” the traditional approach to discharge. Instead of using the “assess to discharge” approach, providers in Sheffield follow the “discharge to assess” model. This means that — rather than hold patients in the hospital to assess needs before they leave — providers discharge patients as soon as they are medically ready and assess their needs at home. This process not only reduced length of stay, but — more importantly — improved the accuracy of determining patients’ true post-acute needs.
While the concept of flipped discharge was exactly what Penn needed for their patients, it was daunting to implement a complete reimagining of care delivery across settings. The Penn team applied the Model for Improvement and Penn’s Center for Health Care Innovation invested in this opportunity, and the SOAR (Supporting Older Adults at Risk) Program was born.
3 Phases of Continuous Care
SOAR promotes seamless continuity of care across settings in three phases: prepare, transition, and support.
Prepare — Preparation of an older adult to safely return home after an acute illness requires significant coordination among the hospital-based care team and between the hospital and home-based teams. At Penn, this was designed with geriatric considerations at the center. As treatment is unfolding for the acute illness, a geriatric nurse consultant (GNC) supports the interprofessional team to address concerns such as delirium, cognitive impairment, difficulty with chewing and swallowing, and prevention of excess disability. The GNC works with caregivers to understand the support in place at home. Using customized dashboards and secure group messaging, the GNC ensures everyone is on the same page regarding the patient’s hospital discharge, and that home care is scheduled to unfold immediately.
One of the biggest gaps in the traditional approach to transition is the inability for providers from different settings to directly communicate with one another. The SOAR team designed a day-of-discharge hand-off call between the interdisciplinary providers involved in the older adult’s care to have a collaborative discussion about the patient’s needs. This communication enables a morning discharge from the hospital which is key to the transition.
Transition — SOAR completely redesigned the transitional phase of care by focusing on a few key elements: 1) communication between hospital and home-based providers; 2) elimination of barriers for the patient and family by providing transportation, lunch, and medication delivery; and 3) seamless transition in care with same-day and next-day nursing visits.
- Transportation: older adults in the SOAR Program receive transportation home, timed to align with loved ones’ availability to receive them. Scheduling transportation also helps ensure a timely discharge.
- Nutrition: Malnutrition is a major issue for older adult patients, and it’s especially challenging when patients return home from the hospital to empty fridges or spoiled food. With SOAR, patients and their caregivers receive lunch delivered to their home upon return from the hospital, and a case of nutritional shakes to bridge the gap to stocking the cabinets.
- Transition to Home Care: SOAR patients are discharged from the hospital in the morning and are seen at home by a nurse on the same day of discharge. The home nurse reviews the post-acute care plan, focusing on the medication and treatment instructions. The nurse has direct phone access to the hospital-based provider who discharged the patient that morning to review and confirm the treatment plan. Next, the patient’s medications are delivered to the home that evening. The home care nurse also visits the day after discharge to finalize medication reconciliation and ensure the next steps in care are unfolding as planned.
Support — This phase focuses on early, intensive, interdisciplinary care in the home, coupled with ongoing outpatient care and connection to community resources. Hospitalization can leave older adults at high risk for permanent functional and cognitive disability upon return home. They may also struggle to regain losses in nutritional status. Early, intensive rehabilitation provides the best opportunity for functional, cognitive, and nutritional recovery, so Penn Medicine’s SOAR Program defaults patients to receive physical and occupational therapy in the home within two days of discharge. This continues until the patient’s rehabilitative goals are met. Patients also receive speech therapy, if warranted.
A social worker provides home visits and supports the patient and family in managing outpatient care. They help with scheduling appointments, arranging transportation, and connecting patients to community resources for services like home health aides, meal delivery, and adult day care services.
The future of geriatric medicine demands that we provide high-quality, high-value care to older adults that transcends barriers to continuity of care across settings. SOAR, Penn Medicine’s adaptation of the flipped discharge, is one way we strive to do this every day.
Leslie Pelton is a senior director at IHI. Rebecca Trotta is Director of Nursing Research and Science at Penn Medicine. David Resnick is Innovation Manager at Penn Medicine’s Center for Health Care Innovation. They will share more during session C11: QI Meets Design Thinking at the 2018 IHI National Forum (December 9-12 in Orlando, Florida, US).
You may also be interested in:
Innovation case study: Discharge to Assess: “Flipping” Discharge Assessment from Hospital to Home
Editor’s note: SOAR is supported by the Rita and Alex Hillman Foundation.