Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions
Restricted accessResearch articleFirst published online September, 2021
Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies During Hospital to Skilled Nursing Facility Transitions
Provided the complexity of managing dementia-related neuropsychiatric symptoms (NPS), accurate communication about these symptoms at hospital discharge is critical to facilitating safe and effective transitions, particularly transitions from hospitals to skilled nursing facilities (SNF), which are often poorly managed. Skilled nursing facilities providers have cited undercommunication regarding NPS as a major challenge that contributes to poor outcomes including rehospitalization. This multisite retrospective cohort study identified omission rates for NPS and associated management strategies in discharge communication as compared to medical record documentation in the 72 hours preceding discharge among hospitalized patients with dementia. High rates of omission were found across NPS and management strategies: anxiety (94%), agitation/aggression (77%), hallucinations (85%), 1:1 supervision (90%), high fall risk (89%), use of restraints (91%). Omission rate for new or modified antipsychotic medication was 12.9%. Findings underscore the need for additional research on cross-setting communication regarding care needs of patients with dementia—who often cannot communicate these needs on their own—in facilitating high-quality transitions.
FortinskyRHDownsM. Optimizing person-centered transitions in the dementia journey: a comparison of national dementia strategies. Health Aff (Millwood). 2014;33(4):566–573.
2.
ColemanEA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549–555.
3.
CallahanCMArlingGTuW, et al.Transitions in care for older adults with and without dementia. J Am Geriatr Soc. 2012;60(5):813–820.
4.
GauglerJEYuFDavilaHWShippeeT. Alzheimer’s disease and nursing homes. Health Aff (Millwood). 2014;33(4):650–657.
5.
PorockDClissettPHarwoodRHGladmanJR. Disruption, control and coping: responses of and to the person with dementia in hospital. Ageing Soc. 2015;35(1):37–63.
6.
KalesHCGitlinLNLyketsosCG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350:h369.
7.
SmithMGerdnerLAHallGRBuckwalterKC. History, development, and future of the progressively lowered stress threshold: a conceptual model for dementia care. J Am Geriatr. 2004;52(10):1755–1760.
8.
KolanowskiABoltzMGalikE, et al.Determinants of behavioral and psychological symptoms of dementia: a scoping review of the evidence. Nurs Outlook. 2017;65(5):515–529.
SchneiderLSDagermanKSInselP. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934–1943.
11.
KwokTBaiXChuiMYP, et al.Effect of physical restraint reduction on older patients’ hospital length of stay. J Am Med Dir Assoc. 2012;13(7):645–650.
12.
MöhlerRNürnbergerCAbrahamJKöpkeSMeyerG. Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings. Cochrane Database Syst Rev. 2016;2016(12):CD012476. The Cochrane Collaboration. John Wiley & Sons, Ltd.
13.
AmjadHCarmichaelDAustinAMChangCHBynumJP. Continuity of care and health care utilization in older adults with dementia in fee-for-service Medicare. JAMA Intern Med. 2016;176(9):1371–1378.
14.
CallahanCMTuWUnroeKTLaMantiaMAStumpTEClarkDO. Transitions in care in a nationally representative sample of older Americans with dementia. J Am Geriatr Soc. 2015;63(8):1495–1502.
15.
FengZCootsLAKaganovaYWienerJM. Hospital and ED use among Medicare beneficiaries with dementia varies by setting and proximity to death. Health Aff (Millwood). 2014;33(4):683–690.
16.
GoodwinJSHowreyBZhangDDKuoYF. Risk of continued institutionalization after hospitalization in older adults. J Gerontol A Biol Sci Med Sci. 2011;66(12):1321–1327.
17.
LaMantiaMAStumpTEMessinaFCMillerDKCallahanCM. Emergency department use among older adults with dementia. Alzheimer Dis Assoc Disord. 2016;30(1):35–40.
18.
MorVIntratorOFengZGrabowskiDC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57–64.
19.
PhelanEABorsonSGrothausLBalchSLarsonEB. Association of incident dementia with hospitalizations. JAMA. 2012;307(2):165–172.
20.
SakataNOkumuraYFushimiKNakanishiMOgawaA. Dementia and risk of 30-day readmission in older adults after discharge from acute care hospitals. J Am Geriatr Soc. 2018;66(5):871–878.
21.
LaurilaJVPitkalaKHStrandbergTETilvisRS. Detection and documentation of dementia and delirium in acute geriatric wards. Gen Hosp Psychiatry. 2004;26(1):31–35.
22.
LeggettANPolenickCAMaustDTKalesHC. Falls and hospitalizations among persons with dementia and associated caregiver emotional difficulties. Gerontologist. 2018;58(2):e78–e86.
23.
LinPJFillitHMCohenJTNeumannPJ. Potentially avoidable hospitalizations among Medicare beneficiaries with Alzheimer’s disease and related disorders. Alzheimers Dement. 2013;9(1):30–38.
24.
Gilmore-BykovskyiALRobertsTJKingBJKenneltyKAKindAJH. Transitions from hospitals to skilled nursing facilities for persons with dementia: a challenging convergence of patient and system-level needs. Gerontologist. 2017;57(5):867–879.
25.
KingBJGilmore-BykovskyiALRoilandRAPolnaszekBEBowersBJKindAJ. The consequences of poor communication during transitions from hospital to skilled nursing facility: a qualitative study. J Am Geriatr Soc. 2013;61(7):1095–1102.
26.
MockfordC. A review of family carers’ experiences of hospital discharge for people with dementia, and the rationale for involving service users in health research. J Healthc Leadersh. 2015;7:21–28.
27.
RichardsonABlenkinsoppADownsMLordK. Stakeholder perspectives of care for people living with dementia moving from hospital to care facilities in the community: a systematic review. BMC Geriatrics. 2019;19(1):202.
28.
TjiaJBonnerABriesacherBAMcGeeSTerrillEMillerK. Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med. 2009;24(5):630–635.
29.
BowblisJRLucasJABruntCS. The effects of antipsychotic quality reporting on antipsychotic and psychoactive medication use. Health Serv Res. 2015;50(4):1069–1087.
30.
KirkhamJShermanCVelkersC, et al.Antipsychotic use in dementia. Can J Psychiatry. 2017;62(3):170–181.
31.
KindAJHSmithMA. Advances in patient safety documentation of mandated discharge summary components in transitions from acute to subacute care. In: HenriksenKBattlesJBKeyesMAGradyML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Agency for Healthcare Research and Quality (US); 2008.
32.
DimantJ. Roles and responsibilities of attending physicians in skilled nursing facilities. J Am Med Dir Assoc. 2003;4(4):231–243.
33.
MerlaCWickson-GriffithsAKaasalainenS, et al.Perspective of family members of transitions to alternative levels of care in Anglo-Saxon countries. Curr Gerontol Geriatr Res. 2018;2018:4892438.
34.
GibsonMJKellyKAKaplanAK. Family Caregiving and Transitional Care: A Critical Review. Final report. National Center on Caregiving, Family Caregiver Alliance; 2012.
35.
JacobsenJMLSchnelleJFSarafAA, et al.Preventability of hospital readmissions from skilled nursing facilities: a consumer perspective. Gerontologist. 2017;57(6):1123–1132.
36.
HovermanCShugarmanLRSalibaDBuntinMB. Use of postacute care by nursing home residents hospitalized for stroke or hip fracture: how prevalent and to what end?J Am Geriatr Soc. 2008;56(8):1490–1496.
37.
CreditorMC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219–223.
38.
OstwaldSKGodwinKMYeFCronSG. Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation. Rehabil Nurs. 2013;38(5):254–263.
39.
TaylorDHJrØstbyeTLangaKMWeirDPlassmanBL. The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited. J Alzheimers Dis. 2009;17(4):807–815.
40.
Gilmore-BykovskyiALBlockLHovanesMMirrJKolanowskiA. Analgesic use patterns among patients with dementia during transitions from hospitals to skilled nursing facilities. Res Gerontol Nurs. 2019;12(2):61–69.
41.
PolnaszekBGilmore-BykovskyiAHovanesM, et al.Overcoming the challenges of unstructured data in multisite, electronic medical record-based abstraction. Med Care. 2016;54(10):e65–e72.
42.
CummingsJLMegaMGrayKRosenberg-ThompsonSCarusiDAGornbeinJ. The neuropsychiatric inventory. Neurology. 1994;44(12):2308–2314.
43.
KindAJSmithMALiouJIPandhiNFrytakJRFinchMD. The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs. J Am Geriatr Soc. 2008;56(6):999–1005.
44.
AnathhanamSPowisRACracknellALRobsonJ. Impact of prescribed medications on patient safety in older people. Ther Adv Drug Saf. 2012;3(4):165–174.
45.
TampiRRTampiDJBalachandranSSrinivasanS. Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Ther Adv Chronic Dis. 2016;7(5):229–245.
46.
KripalaniSLeFevreFPhillipsCOWilliamsMVBasaviahPBakerDW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–841.
47.
NewnhamHBarkerARitchieEHitchcockKGibbsHHoltonS. Discharge communication practices and healthcare provider and patient preferences, satisfaction and comprehension: a systematic review. Int J Qual Health Care. 2017;29(6):752–768.
48.
DykesPCSamalLDonahueM, et al.A patient-centered longitudinal care plan: vision versus reality. J Am Med Inform Assoc. 2014;21(6):1082–1090.
49.
DeanSMGilmore-BykovskyiABuchananJEhlenfeldtBKindAJ. Design and hospitalwide implementation of a standardized discharge summary in an electronic health record. Jt Comm J Qual Patient Saf. 2016;42(12):555–511.
50.
CallenJLAldertonMMcIntoshJ. Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries. Int J Med Inform. 2008;77(9):613–620.
51.
HorwitzLIJenqGYBrewsterUC, et al.Comprehensive quality of discharge summaries at an academic medical center. J Hosp Med. 2013;8(8):436–443.
52.
KingBJGilmore-BykovskyiALRobertsTJ, et al.Impact of hospital context on transitioning patients from hospital to skilled nursing facility: a grounded theory study. Gerontologist. 2018;58(3):521–529.
53.
BurkeRELawrenceELadebueA, et al.How hospital clinicians select patients for skilled nursing facilities. J Am Geriatr Soc. 2017;65(11):2466–2472.
54.
KindAJThorpeCTSattinJAWalzSESmithMA. Provider characteristics, clinical-work processes and their relationship to discharge summary quality for sub-acute care patients. J Gen Intern Med. 2012;27(1):78–84.
55.
GitlinLNKalesHCLyketsosCG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA. 2012;308(19):2020–2029.
56.
KimSKParkM. Effectiveness of person-centered care on people with dementia: a systematic review and meta-analysis. Clin Interv Aging. 2017;12:381–397.
57.
WhitlatchCJOrsulic-JerasS. Meeting the informational, educational, and psychosocial support needs of persons living with dementia and their family caregivers. Gerontologist. 2018;58(suppl_1):S58–S73.
58.
GitlinLNMaslowKKhillanR. National research summit on care, services, and supports for persons with dementia and their caregivers. Report to the National Advisory Council on Alzheimer’s Research, Care, and Services. 2018.
59.
Gilmore-BykovskyiAJensenLKindAJ. Development and implementation of the coordinated-transitional care (C-TraC) program. Fed Pract. 2014;31(2):30–34.
60.
KindAJBrenny-FitzpatrickMLeahy-GrossK, et al.Harnessing protocolized adaptation in dissemination: successful implementation and sustainment of the veterans affairs coordinated-transitional care program in a non-veterans affairs hospital. J Am Geriatr Soc. 2016;64(2):409–416.
61.
CrowtherGJBennettMIHolmesJD. How well are the diagnosis and symptoms of dementia recorded in older patients admitted to hospital?Age Ageing. 2017;46(1):112–118.
62.
NaylorMDBrootenDACampbellRLMaislinGMcCauleyKMSchwartzJS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675–684.
63.
NaylorMDBrootenDCampbellR, et al.Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620.
64.
RantzMJPopejoyLVogelsmeierA, et al.Successfully reducing hospitalizations of nursing home residents: results of the Missouri quality initiative. J Am Med Dir Assoc. 2017;18(11):960–966.
65.
HuckfeldtPJKaneRLYangZ, et al.Degree of implementation of the interventions to reduce acute care transfers (INTERACT) quality improvement program associated with number of hospitalizations. J Am Geriatr Soc. 2018;66(9):1830–1837.
66.
PirainoEHeckmanGGlennyCStoleeP. Transitional care programs: who is left behind? A systematic review. Int J Integr Care. 2012;12:e132.
Centers for Medicare and Medicaid Services. Hospital Readmissions Reduction Program (HRRP): Department of Health and Human Services, Centers for Medicare & Medicaid. 2019.
CrossDAMcCulloughJSAdler-MilsteinJ. Drivers of health information exchange use during postacute care transitions. Am J Manag Care. 2019;25(1):e7–e13.
71.
DeversKLallemandNNapolesASpillmanBBlavenFOzanichG. Health information exchange in long-term and post-acute care settings. U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation Office of Disability, Aging and Long-Term Care Policy. 2015.https://aspe.hhs.gov/system/files/pdf/205271/LTPACsetting.pdf
72.
KamermayerAKLeasureARAndersonL. The effectiveness of transitions-of-care interventions in reducing hospital readmissions and mortality: a systematic review. Dimens Crit Care Nurs. 2017;36(6):311–316.
73.
KattelSManningDMErwinPJWoodHKashiwagiDTMuradMH. Information transfer at hospital discharge: a systematic review. J Patient Saf. 2020;16(1):e25–e33.
74.
GitlinLNMarxKAStanleyIHHansenBRVan HaitsmaKS. Assessing neuropsychiatric symptoms in people with dementia: a systematic review of measures. Int Psychogeriatr. 2014;26(11):1805–1848.
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