Small group, but sometimes that makes for the best learning, right? So I'll start with a little bit of icebreaker, because we are going to force some participation here. So just want to see a show of hands. Has anybody made it through midnight yet? I'm only halfway through. You listened to the whole thing? You listened to the whole album already? Oh, no, no, I'm sorry, but we still have something. Oh, gotcha. That's probably much more important. Gotcha. Well, being an Aeronator and not a Swifty, we called this talk Switching Up Transitions for You, which is a course of play on her song. And we're going to try and take you through some things that we've learned collectively in our different settings about how to help patients transition from one level of care to the next. So when we talk about a transition of care, we're really talking about patients transitioning from one level of care to the next. And I think being physiatrists, we get pretty, sometimes we can be a little bit narrow-minded and think about that transition from acute care to rehab or from rehab home. But as we're going to talk about today, patients often go through multiple transitions of care. And they're really, it's fraught with peril at every step. And so there's a role for a physiatrist in each one of those transitions to help it make it go smoother and to minimize the risk and the injury to the patient that's potentially there. CMS, as you know, is insanely focused on this transition from the acute care hospital, short-term acute care hospital stack, if you're not familiar with the acronym, to home. But as I mentioned, there's lots of other transitions. So why are we talking about this? Well, I'm probably preaching to the choir and I don't want to spend too much time on this. But this is an area where there are a high number of medical errors and patients experience morbidity and mortality because of that. It's also, if you're a clinical person, you know there's a tremendous amount of emotional stress associated with that transition from the families, from the patients, from everybody involved. And so helping to be a calming influence in that can be very helpful. You know, they make up lots of numbers and this is no exception, but the number that you will find in the literature is 33 million adults have some kind of readmission or problem after they're discharged from an acute care hospital. And again, the made-up number is 41.3 billion, which would be a good profit year for Cigna, but we won't go there. So transitions of care, CMS is really cracking down on this, as I mentioned, October 1st of 2012 is when this program started and they find new and exciting ways to penalize all of us for mishaps for that. In particular, they're very hyper-concerned on the congestive heart failure, pneumonia, and myocardial infarction patients, many of which will probably cross paths with the people in this room. So it does affect you and it does affect your payment, your institutions, and your reputation as a physician. So they have come up with some generalized advice and things that we support. Things like asking for home medications, reconciling the medication upon discharge, ensuring that the patient has access to their medications, right? And some of these seem kind of menial tasks and often delegated maybe to other care providers, but there's something that as a physiatrist you should be aware of and many times be involved with. You need to make sure that the provider has access to the complete care plan, although that's never really well-defined, but as physiatrists I think we can do that and probably better than anyone else. And then patient education always is a key feature. So my numbers came from this particular study, but you'll find similar numbers out there, not to belate the fact. But without further ado, I'm gonna turn it over to Dr. Murtaugh. She's gonna tell us a little bit about her experiences and some data on transitions of care. Good morning. So I come from a unique perspective, I think, as an OT in an inpatient rehabilitation facility that also has LTCH, inpatient rehab, and outpatient. So this is one thing in working with, I manage the brain injury and burn programs at Madonna Rehabilitation Hospitals. So I'm looking at patients and assessing them before they come in when they're in acute care or ICU, but then I'm also thinking of what happens next when they leave our facility, when they leave either LTCH, when they leave inpatient acute rehab, what does that look like and how do we make that transition as smooth as possible, decrease risks, and help the patient and the family be successful? I don't have any disclosures. So I'm gonna kind of give a broad overview of kind of those transitions that we all look at depending on, as physiatrists, if you're doing consults in acute care, if you're in an inpatient rehab facility, or down the stream in SNF long-term care or seeing patients as an outpatient. So when you're in acute care, some things that you need to be talking to your teams about and thinking, and I feel like sometimes in acute care, who's taking the lead on this? It can be quite fractured in some organizations, and so having that holistic view of the patient and their social situation as well as their medical needs, what do we need to be thinking about? So of course, what's gonna be the most appropriate next step for them after acute care? Most patients with polytrauma, neurological injury or illness aren't gonna be ready to go home once they're medically stable in acute care. So what is their primary diagnosis? Is it appropriate for inpatient rehab, LTAC, or do they need a lower level of care? And of course then, as Craig alluded to, what's their payer source? That's always the next question. Do they have benefits and resources that make those transitions and next levels of care available to them? What is their medical need? That's important because certain facilities aren't able to take a high complexity. What are the patient and family goals? It's always important to involve the families of what is that social situation, and we have to be good prognosticators. Regardless of the diagnosis, we have to be able to have in mind what does that trajectory of recovery look like? What is gonna be that end game? Because that's gonna help us start to predict what are they gonna need when they're no longer in a hospital or medical-based facility? What are the supports that they're going to need? Are you already in conversations if you're thinking that they're going to go to an institution such as an inpatient rehabilitation facility? Are you already in conversations with that team and that admissions team? Being in Nebraska, rural area, what's available? How far is that patient and family going to have to travel to get the most appropriate services that they need for their recovery? Breaking down those post-acute care options. Long-term acute care, so complex medical need. Do they have still chest tubes? Are they on the vent? Do they need TPN? Are they really medically complex and deconditioned in critical care illness syndrome where they can't tolerate that three plus hours of therapy? Wounds, Medicare A tends to get increased time in LTAC versus inpatient rehab facility. Also dialysis, things that may be barriers to participating in a more intense level of rehabilitation. Then of course, kind of my wheelhouse and IRF. Are they medically stable to where they can tolerate that increased intensity of rehabilitation? Do they have that 24-hour nursing and PMNR need? Can they physically tolerate and physiologically tolerate that three plus hours of therapy, which again, is an arbitrary CMS number. And then I'm always looking at, because our goal as an inpatient rehab facility, one of the things that we are evaluated on is discharge to community. Because that's what we want. If they weren't able to discharge to community, why do we send them to an IRF in the first place? So kind of how we're judged. So I'm always looking at what is the possibility? What are the barriers that we need to be addressing to make sure that we can get that home and community discharge? So what if that patient either doesn't meet the criteria for LTAC or inpatient rehab facility, or they don't have the payer source or resources, or family decides like, hey, we don't wanna go six hours away. We wanna stay local. And there's more SNFs than long-term care in their local area. So what does that look like in things that we need to consider? Again, SNF, medical stability. They're not gonna have the ability to manage anything complex, or anything that may be unstable or become unstable. Again, that return to acute care that we're looking at and wanna try and prevent. Most don't take trachs or vents unless they're a specialty facility. Brain injury world. If they have a one-on-one, if they have neurobehavioral sequelae, that's a no-go. So that's something we're always looking at and trying to manage. Doesn't require that daily physician's visit. You know, what is their age? Sometimes, you know, we'll see a patient with brain injury, spinal cord injury that does not have the resources, but they're 25 or 32. Some SNFs because of their age, because they want to, you know, have people quote-unquote institutionalized of similar age. That can be a barrier as well. And then long-term care. What's their long-term prognosis? Do they require long-term placement? Do they not have skilled needs? And they're really just considered custodial. Again, one-to-one, no-go. They don't require that physician's visit daily, but they still have that 24-hour care need from nursing or nurse aides. And then the one I'm most passionate about is how do we get them home? The things that we need to be thinking about, especially in inpatient rehabilitation, to get them home. And why home? Why is that so important? You know, there's so much research out there, and I just, you know, referenced four, but, you know, patients do better at home. You know, they have less morbidity and mortality, less complications. They're more engaged. Quality of life reports and subjective reports increase. They're able to engage and participate in community. They're with their family and support systems. And so there's a lot of supporting evidence that, you know, home is beneficial for patients to be in and get them back to community. So when I look at a patient and working with our admissions teams, it's a whole team, you know, from admissions directors, our nurse clinical liaisons, our PM and our admitting physician, families. What does the referring acute care team, how are they involved? You know, external payers, are they work comp, Medicaid, Medicare? You know, those are all the things that we're looking at even prior and having those discussions before they come in because we want to have all the I's dotted and T's crossed because successful admission, smooth and seamless, will promote, in my opinion, a more successful discharge. So other factors to consider prior to admission. So as a physiatrist and a team lead in inpatient rehabilitation facility, what things should you be thinking about? You know, again, being a good prognosticator, being able to have an accurate idea how that injury or illness is going to rehabilitate, what the trajectory of recovery is gonna look like, not only length of time, but what's that end outcome going to look like? And how do we plan for that and put the supports in place? Involving the patient and family in those goals and those discussions. And what, with that family, is gonna be that support system, especially if you're predicting that that patient, when they leave your facility in 20 days, 30 days, are they gonna need that 24-hour care? Because in today's age when, you know, the spouse has to work or there's children to care for or it's an adult with elderly parents, you know, that 24-hour care burden can be a significant barrier. So getting family involved early is so crucial. And what is gonna be their ongoing medical needs at home? And their resource availability to manage those. So it's an interdisciplinary discussion, of course, preaching to the choir on that. I'll keep going. Pitfalls. So what are the things that trip us up as teams to get that patient home? Medicare A wants, I wanna pull my hair out, because somebody with a severe stroke or brain injury or spinal cord injury, if they're Med A, may get 14 days. If we're lucky, what the heck are we supposed to do in that amount of time? So yes, we're looking then at, you know, how many in their buckets, if they're private insurance, Medicaid, what are their buckets of resources at each level of care? And how can we be the best stewards of those resources as we plan and transition them through the continuum of care? I work a lot with disorders of consciousness, so I wanna make sure that those patients have a guardian, because it's gonna be the surrogate that's gonna be making those transitions of care decisions. And then what's gonna be their medical team, or medical needs when they go home? Are they gonna go home with a trach, a G-tube, spinal cord injury? Do they have neurogenic bowel and bladder management programs that we need to train the patient and family on? What medications are they going home with? That's a question our case manager and social worker they do a great job of working with our physicians, like, hey, what medications are they on, and what are the cost of those medications? Especially if they're new medications that they weren't on before the illness or injury, because is it going to be cost prohibitive for that patient to be able to manage certain medications if they're incredibly expensive? So those are things to keep in mind as well. Other challenges that we run into is when there's a lack of care providers, there's waiting lists for Medicaid waiver programs that can get nursing or nurse aides into the home. What are transportation needs, especially if they're going home at a wheelchair level? Are we concerned about patient and family isolation, because we know that can create a lot of stress, anxiety, depression, and impact overall quality of life. Do they need long-term neurobehavioral health services? Making sure families have support groups and that we're helping them set up long-term financial resources, especially if it's going to be an individual who will live with long-term disability. And all this is so dependent upon family involvement and education. Again, if I'm thinking of high-level spinal cord injury, disorders of consciousness, burns, another area of mine where, what does family need to be involved in to help? And so this is a question to be asking your teams. How do you support your families? And how does the team do training? Do they get families involved on day one? How available are families able to be there during the rehabilitation process? And already talking, you know, upon the day of admission, as you're doing your evaluations with your multidisciplinary teams, you know, what are some potential barriers for home discharge that we can start addressing right away in those first days after admission? How do you integrate families into training? Do you have caregiver checklists? You know, think of a patient who may go home in a chronic state of DOC. All the things that a family would need training on with positioning, equipment, bowel and bladder management. Are they going home with a trach? So really immersing them in that 24-hour nursing care so that they can manage that. Or a patient with neurobehavioral, you're sending somebody home as a Rancho 5-6. You know, how do they manage those behaviors, confusion, intermittent agitation, so that they feel that they're skilled and can manage those if something comes up at home? Looking at home and community resources in your area is, you know, what are the stroke associations, brain injury associations? What are the spinal cord injury supports, cancer supports? Again, because we may treat these diagnoses all day long, but if we haven't lived it, we really can't understand what the patient and family's going through. So sometimes those supports are very, very helpful for that transition and adjustment to a new life and maybe a new disability. What if your patient can't go home? So what are those alternative transition settings? You know, we have skilled nursing facilities, we went through all of that. I think in my world, the most challenging non-home discharge are, we have a patient with chronic neurobehavioral changes, they're agitated, they're confused, they're a high elopement risk. There's few inpatient neurobehavioral programs in the country, and that is a huge barrier. We just had a gentleman with us in and out of our lockdown unit from March to September, because that's what we were challenged with, is we couldn't, he didn't have the right resources to match up with an available neurobehavioral program. Advanced pulmonary needs, are they vent dependent? Or do they have a trach that may not ever be removed? Hopefully not, but that can definitely be a situation for complex patients that can be a barrier if they can't go home. I'll just keep going so we have enough time. And then I just wanted to touch base on these special populations. So I've mentioned disorders of consciousness. Again, if they're chronic and they are moving towards emergence, how do we get them home? And it can be challenging. These patients can go home. That's a bias that I try and overcome with our teams every day is this patient can go home. It's gonna take a lot of work from the team, but we can get them home in a chronic DOC state. So that specialized family training, making sure you're setting up respite services, DME of the home, hospital bed lift system, wheelchair, what does that all look like? And those are things that we can be working on right away. And then high-level spinal cord and ventilator-dependent patients. What are their power mobility wheelchair needs? That can take a while to get the right wheelchair, especially for somebody who's C3, C4. What are their transportation needs? We know these patients are gonna need a 24-hour caregiver, so looking at that right away. Emergency preparedness. We just had a big hurricane down in the southeast. What do you do if you have to evacuate and you're on a vent or you're in a power wheelchair? How do you prepare for that? And then making sure, again, with ventilators, what you're using in the hospital may not be available in the community. So working with your DME and respiratory community providers on what is a vent that you can issue in the community? Because you wanna train that patient and family on that specific ventilator. And then pediatric populations. Always a consideration, I think, with PEDS. They tend to have a higher discharge to community, but working with the school systems, depending on their age and development, working, are they gonna need a new IEP? How do we make sure they're following up with long-term care specialists and supporting the family, especially siblings and their peers? Thank you. Excellent. Good morning. Thanks for being here. We're looking forward to some more conversation after we get through our core slides here. So I'm Jen Zumsteg, and I'm at Valley Medical Center outside of Seattle. It's an acute care hospital. We're licensed for about 340 beds. It's a level three trauma center, big stroke center, thrombectomy capable. And I'm the only PMNR doctor now. So I do acute care consults, and I want to broaden our perspective after our great overviews to also think about what we can do or what tools we can use for decision making as physiatrists when there are resource limitations. Because that happens to us as physiatrists every day, I would argue. But COVID and the surge, especially in January of 2022, really brought out how extreme this can get for us during times of crisis and then helps look for places for innovation. So trying to give us a framework for that in the perspective of COVID, which thankfully has eased a bit since that time, but of course still has ongoing considerations. So also want to bring in just some of our more objective reasons that we can say that PMNR has expertise in this area, including our milestones for our training. Just bringing out briefly, moral distress, because there's a lot of this around these crisis situations. But for any individual patient where you can't get them what you know they need, there's some moral distress there that I think we want to make sure we're supporting each other and as teams to think about. And then two of the tools that I think many people are familiar with but want to remind us or give you other resources to use for these times of resource limitation and decision making are the four box model for ethical clinical decision-making. And just a reminder about the structure of ICF and how useful that can be, especially in teams that maybe are not as used to thinking through detailed impairments and participation restrictions and trying to think about home and transitions of care. And then to invite you all to think a little bit about some of the challenges you've had in your practice or region, especially during COVID, again, just because that brought out so much, to really look at what opportunities for innovation there might be. I think we're in a difficult time in healthcare and it's been just a joy of this meeting to be able to reconnect and support each other, but those times of resource limitation are often great opportunities for innovation and creativity and so I want to make sure our specialty takes advantage of that. So we've talked a lot about transitions of care just to add some additional perspectives or resources. I think when there's lots of lots of slightly different resources out there, it tells me a little bit that maybe we're not in 100% agreement or that we've got lots of stakeholders, lots of people kind of thinking about this. So here's another set of key elements from the Agency for Healthcare Research and Quality with seven things to think about as essential for safe and seamless transitions. These are pretty focused on acute care transitions, but of course could be relevant in any setting and I don't know that any of us would disagree. I think this is also a lot to ask of healthcare teams for something like a four-day pneumonia admission or trying to get someone out of the hospital quickly after a hip fracture or just then really complicated and maybe our core rehab populations, whether that's burn or severe TBI or stroke, this turns into a really long checklist. So these are really, really important things that are not always easy to optimize as a team. This also fits really well into our efforts as a specialty through PMNR BOLD to have us as physiatrists be the essential medical experts across the continuum of care to define impairments and drive the rehab plan and think about how to help patients optimize their function and participation throughout the continuum of care. So again, just reminding us about our strategic vision and how well these things can fit into us being leaders as physiatry. And again, just this is not quite as clear as I'd hoped it'd be, but there's the link, will be in the slides if you're interested. Also IHI has guides and efforts for improving transitions and I think has tried to really push thinking more about continuum across the entire post-acute care spectrum as well as considerations for transitions of care for folks with more chronic conditions and trying to improve that quality of care. Very process oriented, but need to then think about that in our individual systems, geographic variability, and how to individualize care for the patient in front of us that day with their family or whoever they have to support them. So I think we've, I've heard a lot of excitement at this meeting, which is great, about our expertise as physiatrists and I think we know it and it's, myself included, it's just not as easy to share with others sometimes as I would like, right? That pitch of trying to explain PMNR for your whole career, including maybe to your parents and your family, let alone everybody that you're working with. And so I just want to remind everybody that we have our newer PMNR milestones that actually have a lot of language of our core training in PMNR. You know, some of what's listed here are those level four milestones that we expect most people to achieve upon graduation, which includes not only being able to navigate our complex healthcare system, but really to be able to role model that to other people on the team. And again, to really be the experts in this area. We have training that's different from other healthcare providers and we've got a structure and evaluation and certification system that supports this. It's not just hand-waving that we like to do this in our spare time, right? We are trained to do this in ways that other people are not. And so if that helps you support metrics, support your role on the team, list the kinds of skills that you've been evaluated, even if you're like us and came through before Milestones 2.0, this is still the core part of your training to say that I am the medical expert in this area. Let me be your champion. Let me use this expertise. Let my other colleagues do their expertise. But you've got a foundation here that you can use as well. So in January of 2022, Washington State got, my understanding is very close, like maybe a couple beds away at the state level from going into crisis standards of care. And I say this just for context. I wanna definitely recognize that we did have states that had to go into crisis standards of care, certainly places that had even more resource limitation than I was seeing and that this was stressful for everyone, regardless of the numbers or conditions that we put in. I'm just curious, was anybody participating in planning for crisis of standards of care for their hospital or like part of those conversations? So, and if you're willing to share your experience later, we'd be happy to hear. It was an interesting process for us. At the time I had one other PM&R amazing leader provider, and the two of us were very involved because of the PM&R expertise and trying to think about the many things that came up with crisis standards of care. And I think Washington State tried really hard to come up with good resources, thinking about fairness and equity and good decision-making. But I think everyone was also aware that this would probably freak everyone out. So a lot of the conversations and planning happened confidentially behind the scenes. So if for us anyway, so if you were in those conversations with the hospital about what are we gonna do? How are we gonna manage this? If we go into crisis standards of care, meaning we don't think our hospital has enough ventilators for the number of people going to be admitted who need ventilators, how do we decide who gets a ventilator or not? Who's going to go tell the family that your family doesn't get a ventilator today? Those kinds of conversations, very, very intense of course, right? And needs to be planned in order to be done appropriately. But there was, I think for many organizations, kind of this split between what was planned behind the scenes, hoping we'd never have to do it versus what other people were seeing was in the planning. Sorry, that's a little circular, but. One piece that I wanna bring out is, this is kind of the definitions from our Washington State resources, which were consistent with national guidelines and crisis standards of care go to this crisis capacity, which I think the heart of this is, we're basically saying that we're changing the standard of care, right? Usually it's pretty straightforward from a medical indication that if you come into a hospital in the United States and you have a respiratory condition where you need ventilatory support, as long as it's consistent with your values and your goals of care, you get put on the ventilator, right? And so this is a change in the standard of care where maybe we say we are in a situation where sometimes that doesn't happen, okay? And one thing that I thought was really interesting and really a barrier at the time that I'm hoping we can develop in the future is that understandably this was institution specific, right? So this is just for each hospital. And there was a lot of good coordination, but we were just doing our Valley Medical Center crisis standards of care. What are we going to do inside our physical hospital space? And it doesn't consider anything related to rehab needs, right? There's no conversation about what's the crisis capacity for IRF beds in our region, right? Because it's too fluid, there's not enough of kind of the brick and mortar connection to talk about that. So in a good way, I think this brought out some of the gaps of what we need to think about for resources. And again, incredibly grateful that we didn't get to this point and did not have to alter our standard of care, but it got a little wacky in January of 2022. So these are helpful resources to just know are out there. If you or your community are facing real resource limitation, there are Institute of Medicine reports, high level expert reports that have thought about how do you try to approach this in an organization to even if things are unacceptable, really to adjust in as equitable way as possible. So with that, just again, offering this definition of moral distress and moral injury. Really, I think it's just helpful to think about it day to day as a healthcare provider knowing what is clinically indicated for your patient and not being able to get it. And I feel like practicing as a physiatrist, there's a little bit of this every day and dealing with it as part of our practice. It also means that we're usually really well equipped to help our teams and our organizations think about it. I've popped in here just some resources so that if you need to think about this or help people debrief that you can. All right, so like I said, in our surge in January of 2022, basically what happened is all SNFs and IRFs closed. So we went from 40 plus discharges a week to SNFs to just dwindling. I know these are tiny numbers, but as of January, that bottom table is by day, but we had multiple days a week where we could not get anyone discharged. And this was for a variety of reasons. SNFs had their own COVID infections and they were closed by the Department of Health, staff had COVID and were staying home, so they were understaffed. Our acute inpatient rehab beds were just full with their own hospital-based rehab patients and could not take outside admissions, but that resource just went away, right? We talk about transitions of care. What do you do when you have no place to send people for your normal rehab resources? So now what do we do? So again, we're really well equipped to try to think about these difficult decisions, even when it's not this extreme. So just reviewing those tools. So four box model is an ethical decision-making model that can work in any clinical setting that was largely developed between the University of Washington and the University of Chicago, where you look at medical indications, quality of life, patient preferences, and contextual features. And this is the link if you wanna, you get together with your team and you write out these four boxes and just make sure you've called out all the areas to try to think about what decision you can make and just to get everything in a structured way kind of out there. What I'll highlight is that contextual features is longer than any other box. So it's interesting to me that that's longer than the medical indication box. And even under usual times, number five is, are there problems of allocation of scarce health resources that might affect clinical decisions? Okay, so this is something we can routinely think about and is good for individualized patient care. So if that's something you're interested in or would be useful for you, there's great resources from the University of Washington that are public. And then this is a busy slide just to remind us that we can use the ICF and this classification of function and health and disability, looking at impairments, activity limitations, participation restrictions, barriers and facilitators especially for something that seems so simple to many people, right? Like walking outside after a stroke. That's what this model is, is outdoor walking after stroke. And maybe the many things to think about for that. You can ask the question about what does it look like to get this patient with fill in the blank and these resource limitations home or to some sort of facility or what are our options? And so we have a framework to help us walk through this that we can offer to our teams. So what we ended up doing with our care managers is asking this urgent clinical question about, okay, we don't have post-acute care facilities to send right now, probably for at least two weeks if not longer. Can we get them home? Why can't they go home? And so basically we looked at, this flowchart is a typical discharge for somebody that might be best served at a SNF for next site of care, meaning that we think they're gonna gain function and return to baseline and not be a long-term care placement, but do have complex rehab or medical needs sufficient to need to go to a SNF, including, for example, nursing needs, right? And so do we expect clinically that that person could recover at home, for example, like pneumonia, but medically stable and on the right meds with access to that, expect to return to their baseline, have sufficient caregivers, and that potentially if we had resource limitations for equipment, is recovery at bed level viable and acceptable or is that gonna cause increased harm? And if the answer to that was yes, that maybe we could do that, we would proceed with the team to trying to get them home. The important part here for me as a physiatrist was if the answer to any of those questions was no, we were done and they stayed with us. You stayed with us until you were safe, and we had another safe discharge plan. And it made it tangible enough that we could focus on what was actually actionable. During this time, I was taking care of a gentleman that had a C3 Asia A spinal cord injury from an idiopathic cord infarction. We do not do a lot of spinal cord injury acute care, spinal cord injury, especially cervical level on the unit. And I just said, we're keeping this gentleman here until we have an appropriate IRF discharge. And everybody said, great, thanks. We know what his plan is. Let's focus on other folks. And I had no pressure to discharge him to home, which would have just been unacceptable. So there was a lot of potential here. And the ability to think through things like medical risk, really needing the collaborative decision making, highlighting everybody's strengths on the team, needed to do frequent communication. The care managers set up additional steps to do warm handoffs and make sure we knew kind of where this person was gonna be seen next for their care, and do all those considerations like you've heard in our discharge plan. I'll highlight one strength of our system, which is connection with community resources. I work for a county system that's a safety net hospital for a specific health district. And we have lots of interesting programs. FD Cares is fire department cares. Our Renton Fire Department, where the hospital is located, has basically a home visit nurse care manager through the fire department that will come and check on you, do daily visits. And that was really a big part of us saying, can we get home, and then pairing with the fire department where if something had happened and you were not mobile, that the fire department could come and help carry you out down your stairs, get you back to Valley to get more care. So setting this up as part of that specific discharge plan. So just an invitation for you to reflect in your own area, in your own practice, what some of the barriers or facilitators were during the COVID surge, and if there's other opportunities for you to do innovation in your practice. So for us, some things that came through. So Dr. Jill Williams, who has recently retired, is a PM&R doc that hired me, and really is great at creating clinical tools at the bedside. So this led us to really write out a pretty complicated, but one-sided sheet about decisions that go into next side of care. So many of the things that you've heard talked about, including do they have mobility impairments, do they have cognitive impairments, do they have the right caregivers for that, where do they need to go next, to try to deepen the conversations, but increase the speed of decision-making for next side of care. We hired a outpatient MA who had worked in a rehab clinic for several years as an inpatient discharge coordinator, who now takes a structured, basically PM&R, psychosocial functional history for me, that increases my ability to see patients. And so she's meeting patients and telling them about PM&R and asking them about, do you have any military service, do you have VA benefits, who's involved in your life, do you have caregivers, are you working, were you driving, do you need a disability permit, what were you needing help with before you came in, which just makes us more effective. And I think this whole resource limitation piece allowed us to develop the team and be more specific in our plans, not just that you needed PT, OT, and speech, but what exactly are we trying to do, what's the trajectory of recovery, what are the goals, really bring out that expertise and find those folks that actually would be better served at home, even under usual times, and to start some of that process improvement, what data do we need to follow, what's helpful for our communities, so that we can make better decisions under times of usual resource limitation. Because as we know, a lot of our patients do not have resources in terms of payer coverage or caregivers to actually get what we would ideally want for them in their recovery. So we have to do this a lot in physiatry. Thank you. Thank you. Good morning. I'm Cherry Jun. I'm also at Seattle, at University of Washington. I'm mostly at Harborview Medical Center, which is a level one trauma center in the region of all five states, Wyoming region, Washington, Wyoming, Alaska, and I have to count, Idaho, right? And then something else, Montana, I forget. It was one of those facilities that Dr. Zomstek mentioned that closed for inpatient rehab during that time of surge, and what I'm gonna talk about is a little bit about how do we transition people from acute care after we've seen them as a consult, and then also some of the ideas that we've tried in terms of how do you then improve transition to care after inpatient rehab as well. Mainly, what I wanna do is share the challenges that we faced, and probably all of you guys faced as well, and things that we're trying to see if it will help. So one of them is the difficulty of transitioning to skilled nursing facility itself. One of the things that we faced during that time was a lot of patients were in the hospital even though they no longer needed acute medical need. Like, they were there because they didn't have a safe disposition, they didn't have a facility that was accepting, they had cognitive deficit that needed somebody to supervise them for, or they just couldn't access the home itself. So when that happened, you just could not get them to a skilled nursing facility even though they needed some of that care. So as a hospital-wide system, this was an interesting solution that developed even before COVID, actually. In 2018, they developed this program called Bed Readiness Program. It's a post-acute care network that is contracted with the hospital for certain skilled nursing facility beds. So it's two skilled nursing facilities within Seattle, and our hospital contracted 62 beds to say, these are for us, and then we want to make sure that we can transition people through. And they are also planning to expand it to potentially up to 100 beds because it actually has been helpful financially and also timeline-wise for our system. So that's what's coming. So the hospital really piloted this and saw that it was working, and it is staffed by hospitalists that are within our system. So it makes it easier for us to collaborate as well. And then this one really is to help those who just cannot go elsewhere. So again, those people who had that architectural problem or supervision limitations, but also some other groups that I think we definitely need to think about when we're helping. So those who are undocumented or do not have insurance, and then therefore they do not have anywhere to go. And then they also needed specialty treatments that were too expensive for the lot of skilled nursing facility to provide, and therefore they couldn't be moved there. And the other ones that I think we also think about who are difficult to get placed into skilled nursing facility also includes those who've had criminal history, whether they're currently or previously incarcerated, or those who've had unhoused and they do not have a place to go, whether it be lack of shelter availability or whether you discharge them to the streets. So the hospital decides to pay daily rates. So one, if you have insurance, or if you do not have insurance, you needed to divide them into two groups. One group that needed continued care in terms of whether they needed still need rehab or any medical issues, then they are gonna cover that. And whatever the cost insurance doesn't cover, the hospital was supporting. And then there was that kind of what we talk about, that custodial care, a person who really just needs a place to be because they cannot be safe or cannot access a home. So that place gets like a lower daily rate, but they do get paid for additional social work that needs them to find a place to go to. So this was one of the systems that they're working on and has been incredibly helpful in moving people. One of the things that it is frustrating though is that even these beds get sort of filled and they don't have a place to go. And the saying is, if we expanded it to 100, we're gonna need it to be 200. And what is the end limit? So it's not a solution to everything, but it has been helping. And that was one of the more different approach that the hospital took. So once the patient then did transition to skilled nursing facility from acute care that we saw as a consult provider, was that a lot of them had trouble coming back to seeing us whether we thought they needed to come back to the inpatient rehab or other rehab needs, but they just couldn't come. So we looked at our own numbers. Of all the people who were recommended to come back within about two months of timeframe, only, well, not two months, but 20% of people who were recommended to follow up completed the visit when we looked at it. And the number was even more dismal, but zero patients came back within the timeframe that we recommended, usually like one to three months timeframe. That was horrible. So we decided to figure out, hey, why is it so hard for these follow-ups to happen? You've probably heard it from, if you see people in clinic or if you've seen people at a skilled nursing facility, you've probably seen this as well. Some of it was a little bit easier for us to act on. So there wasn't a clear follow-up recommendation when the consult was done and many appointments, unfortunately, do not get scheduled at the time of discharge. So if you think about it, hospital does not want to schedule a clinic visit because you're not exactly sure when the discharge is gonna happen. And so when the discharge actually happens, then you're scheduling them. That delays how quickly they can come. And then once they leave the hospital system, it's so much harder for them to figure out how to come back. And then some of them just didn't even have referrals. And what I found out from talking to people from the SNF and also the patient care coordinators was that it takes an exorbitant amount of effort to get these people scheduled. So in the skilled nursing facility side, the coordinators are calling, but they only can call the usual contact center line. Have you ever called your hospital's contact center lines and how long have you been on hold to talk to anybody and get scheduled? So it gets really hard for them to schedule that way because they're not allowed to call the back line. And then our patient care coordinators, when they've received the referral, are calling the patients and trying to figure out, hey, can you come in? And sometimes they have incorrect contact information. Their cell phone potentially was lost or broken during a car accident or whatever it may be, and they are not to be answered. And they didn't even know that the person was at a skilled nursing facility. Those people who are helping with those scheduling, there is a huge staff turnover. You kind of go through this and then go through the kind of the rubric of, hey, this is how you schedule, and then they leave. And the other staff turnover probably everybody has experienced is the nursing shortage and how stretched thin they are, and patient burden too. It's costly for them to come back to the hospital and clinic from skilled nursing facility. Anybody have any idea how much they can cost? Any thoughts? Yeah. I've seen it more than $600. Yeah, a cabulance can be 500, $600. And if they need an ambulance to come, that can cost thousands of dollars. That's a lot of money to pay when you need all these visits to come back and forth. And lack of escort. So they can't just come, some people, behaviorally or medically. And the escort themselves are usually non-clinical staff from skilled nursing facility. So they don't know the patient, they don't know much to tell you, but somebody needed to come. So that is a lot of those challenges and more. So what we did in terms of kind of simple things, we thought, okay, how can we fix this a little bit? So things that we could do was that consult team was placing orders, making sure we were tracking that they were followed, and then making sure that the actual recommendations were in there. And that did improve our numbers from zero to 50 at one point in these follow-ups. Continuing the effort, though, is what it takes a lot of difficulty. Like then the new residents come in, and then the attending switch, and then these kind of fluctuate. But we were able to show that, hey, if you are working on it, it does improve, and it is able to help people when they transition. So the other efforts that are also ongoing, this was actually from one of the skilled nursing facilities that have really great therapy team leaders. And what they did is that they had the patient be seen via telemedicine visit from their gym with a therapist that they've been working with, which has been incredibly valuable. So kind of making sure that that can be maybe potentially done elsewhere. And then this also gave us opportunities to connect with those, our kind of the hospitalist and geriatricians who are going out to the skilled nursing facilities to build bridges there and say, hey, I'm still gonna see this patient. Do you have any questions, any updates? And then kind of that back and forth communication has been really helpful. All right, so how do we transition from inpatient rehab and what is gonna be done there? I just wanted to give a plug out to this study that's gonna be coming up. It's called the BRIGHT Study, funded by PCORI. Six participating centers, UW was one of them, as well as a lot of different representatives with Indiana, Ohio, New York, Pennsylvania, and Texas. So what this study is looking at, this is focusing on traumatic brain injury patients and how they're discharging from inpatient rehab. So some are going to get the typical discharge plan as recommended by CARF. Which is current plan. And then the other one that they're trying to see in terms of comparing the efficacy was transition plan, modeled after the VA system one. And then see how they are doing in terms of trajectory with participation and also how their quality of life is when they check up one year after discharge. And then you're also wanting to see if that changes healthcare utilization, as well as the caregivers. How are they doing? What's happening there? So this is a reminder what a typical rehabilitation discharge plan looks like. They're getting TBI education, families getting family training, and then they have a written discharge plan that they go home with, usually a huge packet, and depending on who's writing, longer than others. And then they get a call within three days. Whereas the transition plan includes that, plus up to 12 contacts over six months from a trained clinician, whether it be a social worker or a case manager. And then caregivers are also contacted separately because brain injury patients may or may not always have the best insight. And then also they get a follow-up letter if they had that kind of visit to summarize, so they have that additional info. And then also a helpline that they could call. So we're currently almost done with collecting that 12-month mark, actually. The six months have all happened, so we're excited that this is gonna be coming out, hoping we don't have the data to really fully analyze how effective it was. But nonetheless, some of these kind of transition models are available and possible there. And then that's it for me. Thank you. So in case you hadn't figured out, this is the opposite of a mantle. We have three women who are leading the charge and much more qualified. And I just used to be the token guy, so that's a nice change in the normal setup. So we're gonna take you through a case study now. And I'm gonna force you all to get up and get on the microphone. I know it's early, but hopefully you've all had your coffee. And we'll talk through some of the issues and things we talked about today. So we're all friends. It's a small group. This isn't being recorded. Don't worry about it. All right, so our case study starts with a gentleman named Henry Hill. He's a 49-year-old man who presented to the hospital emergency room with shortness of breath. They acutely diagnosed him with a bacterial and viral pneumonia. I'm sure there were CAT scans involved. He required intubation, IV antibiotics, and pressers. He was very sick. He had the normal ICU rigamarole and then eventually was extubated. However, upon being extubated, the interesting things were that he was very confused and he was weak on the right side per everyone's encounter. All right, so I need one brave soul to break the ice. It's okay if you're a swifty. I won't make fun of you. Just one person, come up and tell me what are the things you'd wanna know about this case? Come on, it's a softball question. One person, please. I'm not gonna move on. Somebody's gotta come up. Come on. Thank you, brave sir in the purple shirt. Sure, I think those are all great things to know, absolutely. Okay, um, and if I was concerned... You don't have to order stuff? It's just an exercise in your thought process. This is uncomfortable. I like to talk and touch. I like those things for your first meal, so do you want to know? Mm-hmm. Right? Yeah. If you want your physical exam, you want, yeah, we're on the same time and thing for it. It's all good. Yes. Kudos to the gentleman in purple short. Thank you. Excellent job, and thank you for breaking the ice. All right, so Mr. Hill then downgrades to the IMU. He's tolerating a high-flow nasal cannula most of the time, but he does use his BiPAP at night. His communication remains pretty limited. His behavior is erratic, and the patient is, of course, if your institution is like mine, on high-dose antipsychotics. All right, let's pretend that we didn't get any of that information, and you are now consulted at this point. Are you making any recommendations or orders or questions that you would want the team to answer? Come on. A different brave soul. You can do it. We'll walk you through it. It's not meant to be that stressful. All right. Thank you. I mean, this is extremely common from what we see. We're a level one trauma institution, so this is pretty much three or four consults every day that I see that are exactly like this. So recommendations would be dropping in the dot phrase that we have for TBI or encephalopathy, so appropriate sleep-wake cycles, melatonin or some other appropriate medication for sleep, not what they're doing, enough activity during the day, but low STEM environment, and then looking through the medication, saying you might consider altering or changing these specific medication treatments. Prognosis, I would be hedging a fair amount, but on the positive side rather than the negative side. This was very short-lived. I was a healthy, active, functional person beforehand. I think a more positive prognosis than a negative. And I said we would be anxious to look toward this person coming to acute rehab when we have some of these recommendations put into place. So maybe hurry up and consider putting these recommendations into place. Excellent. Thank you very much. That was succinct, articulate, very good. All right. So you still don't have much information, but suddenly Mr. Hill's sister arrives. She's able to inform you that he has been in the truck driver's union for years, but he has very few close friends. He is estranged from his wife, and they have a daughter and a son, but they are not in the picture. His parents are deceased, and he has a brother who has triplegic cerebral palsy. This sister lives out of state, and she kind of lets you know that she is not going to be holding the bag on this one. And of course, he does have a interesting history of cocaine abuse. All right. One more brave soul. Let's close this out strong. Who's up? Sure. So tell me, you have this sister in front of you now, the patient's still confused, not answering. What kind of things would you want to know from them? Sure, I think that's fantastic. Are you making any further recommendations at this point? Yeah, absolutely right. What barriers are sticking out to you at this point? What seem to be the biggest concerns in your mind? I think that's a huge one. I think his history of substance abuse, as someone mentioned, the skilled nursing facilities are often very judgmental on patients, if I can use such a strong word. The young age and the history of cocaine abuse oftentimes becomes a big barrier. So that's something else to consider, especially if it's already in his medical record. And then to the point, we still haven't talked about diagnosis. There are, unfortunately, particular diagnoses that make it a little bit more difficult. Or on the opposite side, I've seen, especially with what I presume to be anoxic brain injuries, no one ever quite making the appropriate diagnosis. Just something happens, often cardiac, and then the patient wakes up and they're very confused. They have some focal weakness that's unexplained. And the imaging is rather benign, to be honest. And the assumption is that there's been an anoxic, but there's not always something to put your finger on in those cases. And so that makes getting the discharge tough, especially if you have one of the private insurers will say, you haven't explained this confusion. What's the diagnosis that you're admitting this patient to your rehab or your skilled nursing facility for? And you don't have an MRI or a CT to point to and say, ah, look, there's the ischemic injury right there, or there's the traumatic brain injury. It remains a bit of a mystery, so that can be a barrier as well. OK? Thank you very much. That was excellent. All right, so the story progresses. LTAC is refusing this gentleman, if that's what you were thinking, because they're saying that his medical complexity at this point does not meet the criteria. Your neighbor rehab also does not want to admit him, as they feel that they can't handle the erratic behavior. And the therapy notes reflect that he does not consistently engage with the therapist in acute care. And the insurance companies love to see that, of course. And your skilled nursing facility is denying for the reasons we mentioned earlier. Unstable insurance as he was working, but now he's not, right? So is he going to be able to afford the COBRA? Probably not. Is he going to kick over to Medicare? No, he's too young. Is he going to get disability? Perhaps, but in two years. So that's another common barrier. And then again, the complexity of care, and like I said, the stigma against substance abuse. All right, I lied. One more person. Come on. We're all friends now. We feel like family, right? We spent our morning together? Dr. Smith, this has got to be your real house. Can I call you out? This is where you've got to get creative. And I guess the first thing I'd want to know is when PT, OT, and speech see him, what is the level of supervision needed? So you'd want to know where his cognition is. If he hasn't had his sleep-wake cycles restored, I would get him sleeping properly to see if that improves his cognition, his agitation. I'd identify if there are any other sources of pain or things that are making him agitated. Easy fixes. Get him on a bladder training program so he's not maybe agitated because he's always needing to urinate because he's in a promoter bladder. I'd also want to know his level of assistance for mobility. Because if he's max assist or mod assist, that limits our options in the community. If he's just mostly touching assistance, supervision, that's easier. And if he is still mod or max, what I'd want to see is if there's any change in his ability to participate in therapy once you get his sleep-wake cycles appropriately done. I also would want to see if he is on Medicaid. Some communities in Texas are kind of in bad shape. In Austin, Texas, you're really in bad shape. What you'd have to work with then is some of the faith-based communities or what happens in some places is skilled nursing facilities that are part of the ACF network, the bundle, may be required to take a certain number of patients that are high risk like this with the agreement that there would be some sort of adult family home or some sort of community setting that this person would go to after that. So that would be, I think, really important if there is some sort of collaborative agreement. If you have a place like Harris County or San Antonio, they do have a healthcare district and they do have inpatient funded rehab units and they might be able to do the same thing as short scholarship, presuming that he can participate and presuming that we ultimately will have a disposition. And those are the things that I would be looking for. You know, the other options, I think, would be, again, faith-based community. We've had patients that have to be discharged to a place called Mary's Home and they are very good. They're used to these types of patients amazingly, do a really great work. But that's pretty much what you got to work with until he has Medicare. Can I add one more thing from my OT brain? On assisting with placement, so this individual is still in acute care. Not only with therapies, but environmental modification. Acute care isn't the most peaceful, restful place. It's overstimulating that can also be exacerbating the confusion. And so, you know, promoting and empowering your team, you know, not only from therapy, but nursing and like really taking a whole look at the environment and how can we decrease that peripheral stimulation to see if that helps with his confusion as well. Because then those are ideas you can give to, you know, the next level of care of like, hey, these things really help, which then helps them feel that this is a much more manageable. that could work on Medicaid for him, if and when you spend down to that, or trying to get him on Medicare, which will take a while. Thank you very much. That's very intelligent. So that's the end of our talk today. I thank you all for getting up so early and bearing with us and being so brave to come up and answer questions. We hope that this was helpful to you in some way and that you can take it home and use it in your practice. Thank you. Are there any other questions before we finish up from the content that we shared? What was that? Yeah, so this is actually Jen's patient. She can fill you in on the story. Yeah, pretty close. This is a great opportunity to combine things. Interestingly, this gentleman was an attorney and worked as a self-employed contractor and so had purchased a Medicaid plan on the market, on the open market. So was employed, but had a Medicaid plan in place, which we have a really robust waiver system and process in Washington State, which we're incredibly grateful for, that has a home and community services program where you can either... Our particular patient had a slightly more robust social support system and actually his wife really wanted him to come back home. pretty much opted us out of every sniff. It's sort of shocking, actually. He also had COVID as part of his admission, which was an interesting part of that. And we were hoping that we could get to acute inpatient rehab, but we still have quite restricted resources in our area. And he had an anoxic what ended up happening was we did get a actually post-acute care network contracted SNF bed that has more than average rehab services that said they could take him. We got his home and community services application going for caregiver payment with the goal that once he, his behavior improved significantly on valproic acid and once he was more mobile, his wife was One of the great facilitators for us on acute care was that Washington State added an incentive for adult family homes to take patients from acute care over other settings. And so I feel bad about that in some ways because people need adult family homes regardless of setting. However, we are in such a contingency push status for acute care beds in the entire region that we really needed to, from a public health perspective, really needed to move people through acute care. And so there was like an extra $3,000 for adult family homes to take people direct from acute care, which made a huge difference. And we're just about out of time, so I apologize. If there are other questions or concerns, we're happy to meet with you outside. But I think we have to get the room flipped over. Thank you all for attending. Thank you. Give a round of applause.

smooth transitions of care

physiatrists

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CMS guidelines

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ethical decision-making

social determinants of health