Post-acute care discharge delays for neurology inpatients

Roberts, Debra; Holloway, Robert G.; George, Benjamin P.

doi:10.1212/cpj.0000000000000492

Cited by 13 publications

(9 citation statements)

References 25 publications

(29 reference statements)

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“…This is a small single-center retrospective review and results may vary by institution, especially since different health-care systems may own a greater or lesser number of SNF beds, have prior arrangements with post-acute care facilities, or have established post-acute care networks to ameliorate the burden of suboptimal discharges. 9 Therefore, our results may not be generalizable. However, similar medication cost issues have been described previously for patients on other pharmaceuticals in fields such as rheumatology and oncology.…”

Section: Discussionmentioning

confidence: 82%

“…Patient advocate groups, neurologists, administrators, and policymakers should be aware of the misaligned incentives that may result in discharge difficulties, 9 where patients with MS must sometimes choose between rehabilitation or their medications. This consequence of existing health policy poses an unnecessary barrier to MS medications within many US rehabilitation facilities.…”

Section: Discussionmentioning

confidence: 99%

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Difficult Discharges to Skilled Nursing Facilities Attributed to Multiple Sclerosis Medications: An Observational Study

Munger

George

Samkoff

et al. 2019

The Neurohospitalist

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Background: The costs of multiple sclerosis (MS) disease-modifying therapies (DMTs) and certain symptomatic treatments (ie, dalfampridine [DFP]) are high. Consolidated billing models require that medication costs be covered by skilled nursing facilities (SNFs) after hospitalization. As a result, patients may experience suboptimal discharge, off of medication or without rehabilitation. Methods: To characterize the frequency with which MS pharmaceutical costs lead to suboptimal discharge, we performed a retrospective chart review of admissions to a large academic medical center from January 2013 to December 2017 among patients with MS on DMT and/or DFP with SNF rehabilitation recommendations. We quantified the burden of suboptimal discharge due to medication discontinuation, limited medication supplies, or forgone rehabilitation. Results: Among 169 admissions of patients with MS with discharge recommendations for SNF rehabilitation, there were 57 (33.7%) admissions across 49 patients with MS on DMT/DFP. Overall, 39 (68%) of 57 admissions (71% of patients) experienced a suboptimal discharge. Overall, 29 (65%) discontinued DMT/DFP, 9 (16%) took their remaining home supply of medications during rehabilitation (including 5 admissions also affected by a discontinuation), and 6 (11%) were discharged home to remain on DMT. Among those discharged to rehabilitation, discharge to a hospital-owned SNF was associated with a routine discharge with no lapse in medication (n = 11/15 vs 7/36, P < .001). Conclusions: High costs of MS medications in conjunction with SNF consolidated payment models result in misaligned incentives and often lead to medication discontinuation or other suboptimal discharge for patients with MS.

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Section: Discussionmentioning

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Difficult Discharges to Skilled Nursing Facilities Attributed to Multiple Sclerosis Medications: An Observational Study

Munger

George

Samkoff

et al. 2019

The Neurohospitalist

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“…In a study of 100 patients discharged from an academic inpatient neurology service, ten patients discharging to hospice stayed an average of 5.4 days in excess after medical readiness to discharge. 21 This not only is a significant cost to the medical system, but also has a large impact on the quality of care provided to patients and their families, increasing the risk of dying in the hospital and therefore lowering concordance between preferred and actual location of death. Prioritizing expanding hospice-eligible beds and streamlining the discharge process to a facility for hospice must be a key priority for hospitals.…”

Section: Discussionmentioning

confidence: 99%

Inpatient Neurology Deaths and Factors Associated With Discharge to Hospice

Dujari

Wei

Kraler

et al. 2023

The Neurohospitalist

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Background and Purpose The Neurology Mortality Review Committee at our institution identified variability in location of death for patients on our inpatient neurology services. Hospice may increase the number of patients dying in their preferred locations. This study aimed to characterize patients who die on inpatient neurology services and explore barriers to discharge to hospice. Methods This retrospective study was completed at a single, quaternary care medical center that is a Level I Trauma Center and Comprehensive Stroke Center. Patients discharged by an inpatient neurology service between 6/2019-1/2021 were identified and electronic medical record review was performed on patients who died in the hospital and who were discharged to hospice. Results 69 inpatient deaths and 74 discharges to hospice occurred during the study period. Of the 69 deaths, 54 occurred following withdrawal of life sustaining treatment (WLST), of which 14 had a referral to hospice placed. There were 88 “hospice-referred” patients and 40 “hospice-eligible” patients. Hospice-referred patients were less likely to require the intensive care unit than hospice-eligible patients. Hospice-referred patients had their code status changed to Do Not Intubate earlier and were more likely to have advanced directives available. Conclusion Our data highlight opportunities for further research to improve discharge to hospice including interhospital transfers, advanced directives, earlier goals of care discussions, palliative care consultations, and increased hospice bed availability. Importantly, it highlights the limitations of using in-hospital mortality as a quality indicator in this patient population.

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“…Discharge planning in the hospital is often delayed because clinicians fail to recognize impaired mobility until after resolution of acute medical/surgical issues. 13 The use of routinely collected mobility measurements, such as step count, to inform decisions around care coordination and discharge planning may ultimately prove helpful for hospital throughput.…”

mentioning

confidence: 99%