Research

Research Highlights: Geriatric Medicine

Handing Off the Older Patients: Improved Documentation of Geriatrics Assessment in Transitions of Care – Maureen C. Dale, MD

Older adults, particularly frail elders, are at an increased risk for poor health outcomes and avoidable re-hospitalization during transitions of care. Nearly one of five older adults are re-hospitalized within 30 days of

Geriatric QI Curriculum
The Geriatric Medicine Fellowship Continuous Quality Improvement Curriculum allows learners to address meaningful gaps in care and prompts them to address sustainability and next steps as the project passes from one fellowship cohort to the next.
Maureen Dale, MD
Maureen Dale, MD
hospital discharge, and studies have noted that up to 20% of older patients on medicine services have adverse events after discharge, many of which are preventable.

Maureen Dale, MD, and Benjamin Blomberg, MD, along with Geriatric Medicine Fellows Adam Moskowitz, MDSheri Mouw, MD, and Bianca Yoo, MD, have developed a project aimed at reducing 30-day readmissions on the inpatient geriatric service by improving communication between the inpatient team and post-acute care providers.

To do this, they trained residents to use a structured discharge summary template that incorporates documentation of functional assessment, cognitive assessment, and advanced care planning, as well as pharmacy-led discharge medication reconciliation, all of which have been shown to impact readmissions in transitional care interventions. In addition, they have performed root cause analyses on each 30-day readmission during the intervention period, including reaching out to multiple post-acute care providers for feedback on the discharge summary template as well as specific readmissions. Data analysis is ongoing for this year’s project.

This project, supported by the IHQI Improvement Scholars Program, is year two of the new Geriatric Medicine Fellowship’s continuous quality improvement curriculum. This curriculum has allowed teams of Geriatric Medicine fellows to complete meaningful QI projects within their one year fellowship and pass the project to the next class of fellows, ensuring sustainability and continued improvement.

Fellows in the 2016-2017 academic year implemented a discharge summary template that incorporated a geriatric assessment for the inpatient geriatric service, and their work was recently published in The Journal of the American Geriatrics Society.


A Pilot Study Examining the Feasibility of Using a Pharmacogenetic Assay in Mechanically Ventilated Adults in the Medical ICU – Adrian Austin, MD

Adrian Austin, MD
Adrian Austin, MD

Delirium, a form of acute brain dysfunction defined by inattention and a fluctuating course, is a devastating entity that leads to negative patient outcomes. It is seen among critically ill adults: approximately 70% of mechanically ventilated ICU patients are diagnosed with delirium. Each day with delirium in the ICU increases a patient’s relative risk of in-hospital death by an estimated 10%, and continues to increase the risk of death even one year after hospitalization. Delirium also increases patient morbidity and is associated with increases in hospital length of stay, increased functional decline, and long term cognitive impairment. At this time, no pharmacological agents are proven to effectively prevent or treat delirium. Current management strategies for this devastating condition focus on prevention and mitigation of its effects.

Numerous identified risk factors predispose patients to delirium. Non-modifiable, predisposing determinants include mechanical ventilation while potentially modifiable determinants for the critically ill population include sedating medications, metabolic impairments, sepsis, and sleep disturbances. Most mechanically ventilated patients receive sedating medications known to cause delirium, such as opiates (e.g., morphine and fentanyl), as part of routine care.  Genetic variation in drug metabolism of drugs used for analgesosedation may explain the variation seen in the efficacy and side effects of these medications including incidence of delirium.

Pharmacogenomics is the study of genetic variation in the pharmacokinetics and pharmacodynamics of medications. Recent scientific advances in pharmacogenomics provide an avenue to investigate the impact of metabolic variations on delirium in the critically ill. Prior research has examined the genetic basis for inter-individual differences in response to opioids. As a result, the FDA has approved pharmacogenetic information in labeling for some opioids, but no current guidance exists for fentanyl and morphine. A number of genes, including the mu opioid receptor gene, OPRM1, the catchol-O-methyl transferase (COMT) gene, and the cytochrome P450 3A4 (CYP3A4) gene have been identified as important in morphine and fentanyl’s drug efficacy and adverse effect profiles, but the effect of variation of these genes in the critically ill adult population on response to these drugs has not been explored.

Researchers hypothesize that the pharmacogenomics of sedating medications accounts for some of the variability in delirium occurrence observed in mechanically ventilated patients. Delineating the impact of this variability on the incidence and duration of delirium will pave the way for precision medicine in the ICU. The purpose of our pilot feasibility is to demonstrate that pharmacogenomic data can be safely and reliably obtained and analyzed prior to embarking on a larger study. This study is currently being conducted in the Medical ICU at UNC. Researchers anticipate completing enrollment in the pilot phase this fall.


Development and Validation of a Remote, Tablet-based Delirium Assessment Tool – Adrian Austin, MD

Between 12% and 30% of elderly inpatients will suffer from delirium during their hospitalization, and it is associated with at least a two-fold increase in risk of death at one year after hospitalization. In addition to its impact on mortality, it greatly increases patient morbidity. It is associated with increased hospital length of stay, increased functional decline, and long term cognitive impairment. Between 9% and 15% of elderly medical inpatients suffer from delirium that persists to at least time of discharge. Prior research found that patients who were discharged to a post-acute care setting with active delirium had an increased risk of 30-day re-hospitalization, six-month mortality, and one-year mortality. Despite the known negative effects of delirium in the post-acute care population, little is known about the impact of persistent delirium on day-to-day function immediately after discharge to the home setting. The current ability to feasibly evaluate the impact of delirium immediately after discharge is limited by the lack of a quick, reliable delirium assessment that can be performed in the home setting after discharge.

I-DUNC
I-DUNC represents a team of investigators seeking to understand delirium in the elderly, to improve treatment methods and ultimately patient care.
There are no current bio-markers or laboratory-based diagnostic tests for delirium necessitating a clinical diagnosis. Current clinical diagnosis tests require a face-to-face encounter, which limits the ability to feasibly perform frequent delirium assessments in the post-discharge setting. The most commonly used delirium assessment is the Confusion Assessment Method (CAM). It consists of a series of questions and clinical observations, primarily regarding level of consciousness and fluctuations in attentiveness. Given that this screening tool requires observations, the ability to perform the CAM remotely is currently limited. One prior study examined in-home delirium assessments via telephone and found good sensitivity (100%) and specificity (94%). However, this study was limited by its positive predictive value of 50% and its small sample size (n=41). Further, the assessment which consisted of the Delirium Symptom Interview and a version of the Mini-Mental Status Exam takes over fifteen minutes to perform, which has severely limited its practical usage. 

Over the past few years, devices that support videoconferencing such as smart phones, have become commonplace. As of 2015, over 50% of all American adults had smartphones. Concurrently, interest in teleneuropsychology and remote diagnoses of cognitive disorders has grown. Remote cognitive assessments have recently been demonstrated to be valid, reliable, and acceptable to patients. Remote assessments have utilized a wide range of technology ranging from traditional videoconferencing to smartphone assessments. We hypothesize that currently available videoconferencing capabilities can be easily and quickly utilized to perform reliable delirium assessments in elderly adults in the home setting. This project will develop and validate a tablet-based videoconferencing-based delirium assessment tool based on the CAM (Video-CAM). 

This tool will prove invaluable for future researchers and clinicians as it will provide the ability to perform quick, valid, low-cost delirium assessments in the home setting. Information gained from usage of this tool will allow researchers to define the impact of persistent delirium on those patients discharged to the home setting. Further, it will provide a method for clinicians to perform quick, remote delirium assessments of their patients. This could be particularly useful, for example, if a patient’s caregiver has concerns about a change in mental status and wishes to avoid a potentially unnecessary clinic or emergency department visit. We are currently assessing user acceptability of a tablet based CAM in a geriatric population with plans to validate this tool once it is further refined. 


Palliative and Oncology Collaborative Care for Advanced Cancer – Laura C. Hanson, MD, MPH 

Early access to specialty Palliative Care improves outcomes at a lower cost for patients with Stage IV cancer. Patients with advanced cancer who receive concurrent early specialty Palliative Care and Oncology care, report better quality of life, less pain and depression, reduced use of late-life chemotherapy, earlier hospice referral, and are more likely to discuss goals of care. However, medical oncologists lack the time and sufficient skills to consistently deliver palliative care, and concurrent specialty Palliative Care is not feasible for all patients due to limited workforce. Because of these barriers, concurrent care models of early Palliative Care have not been disseminated even in well-resourced NCI Comprehensive Cancer Centers. Delays in addressing palliative care needs and goals of care discussions further limit access.

Laura Hanson, MD, MPH
Laura Hanson, MD, MPH
Collaborative care is a model of outpatient care for patients with complex illness that was originally developed to better manage patients with depression. In the collaborative care approach, outpatient care is made more effective, by systematically tracking high-risk patients and facilitating collaborative care between primary physicians and specialists. It improves outcomes both in solo efforts by a primary physician to manage complex illness, and referral to multiple specialists who may see the patient in parallel with a primary physician but with little care coordination.

With funding from a Tier 2 Clinical/Translational Award from UNC Lineberger Comprehensive Cancer Center, Laura Hanson, MD, MPH and the project team have developed, and are currently implementing and testing, a collaborative palliative care model for patients with Stage IV cancer. The Palliative and Oncology Collaborative Care for Advanced Cancer model offers an innovative approach to support continuity of care between inpatient and outpatient providers and facilitate efficient and targeted use of specialty Palliative Care.

Palliative care diagram
Figure 1: The UNC Palliative and Oncology Collaborative Care Model Diagram

In the Palliative and Oncology Collaborative Care for Advanced Cancer model, the outpatient Medical Oncology and Primary Care physicians are both identified as providing continuity of care, basic management of pain and symptoms, psychiatric distress, communication of prognosis and treatment options, and discussions of goals of care. Specialists in Palliative Care will provide inpatient and outpatient consultation, triggered by complex pain and symptom needs, severe psychiatric distress, or challenging goals of care communication. A nurse navigator with oncology and palliative care training will act as Palliative Care Coordinator, and the Study Coordinator will collect data and maintain the tracking database. (Figure 1)

Phase I of the project involved the creation of a high-risk oncology population tracking database, collection of observational data on the quality of palliative care received during usual care for patients with Stage IV cancer and at least one acute illness admission to E2, and the development of the collaborative palliative care model for patients with Stage IV cancer.

Phase II of the project is comprised of 4 main components: 1) primary palliative care skills training for Medical Oncology; 2) continued systematic tracking and data collection of high risk Stage IV cancer patients; 3) palliative care needs assessment and care plans created by specialty Palliative Care providers and shared with the outpatient Medical Oncologist and Primary Care physician when applicable; and 4) outpatient care coordination to meet ongoing palliative care needs.

Project team members include Laura C. Hanson, MD, MPH, Katherine Aragon, MD, Frances A. Collichio, MD, Darren DeWalt, MD, MPH, Jenny Hanspal, BSN, ONC, Kyle Lavin, MD, MPH, Jennifer McEntee, MD, MPH, Matthew Milowsky, MD, Donald Rosenstein, MD, Gary Winzelberg, MD, MPH, and William Wood, MD.


The Carolina Geriatric Workforce Enhancement Program (CGWEP) – Jan Busby-Whitehead, MD
Jan Busby-Whitehead, MD
Jan Busby-Whitehead, MD

The Carolina Geriatric Workforce Enhancement Program (CGWEP), a four-year $3,457,045 grant funded research and training programs spanning 2015 through 2018 continues to significantly surpass goals, reach and impact. The UNC-CH Center for Aging and Health’s national leadership and success in the CGWEP program has also been rewarded with three added supplemental grant-funded research programs, Alzheimer’s disease and related dementias (ADRD) in 2015, The National American Indian/Alaskan Native Collaborative in 2017 and in 2018 Opioid Addiction in Older Adults. The Center for Aging and Health reported significant patient outcomes, evidence of interprofessional geriatric training at rural and underserved primary care practices. The continuing education programs have reached over 15,800 healthcare providers during the past four years.

The CGWEP research and training has three areas of action. The first action area integrates geriatrics into primary care to transform rural and/or underserved primary care practice, systems and environments and better serve an elderly population by embedding a training program in interprofessional geriatrics team patient care. This approach has resulted in primary care providers in rural and underserved areas increasing the frequency of their geriatric assessments and interventions, and increased the prevalence of Interprofessional teams in primary care practices.

The second action area offers all UNC-CH health sciences students the opportunity to take interprofessional courses in team-based geriatrics care. In the third action area, the CGWEP collaborates with and community partners to provide education and training to patients, families, and direct care workers on geriatric screening and syndromes, especially ADRD, to increase their ability to manage elders' chronic health conditions and improve quality of life.

CGWEP Partners and Site Projects

Partners include 31 rural and/or underserved primary care practices, systems and environments serving elderly populations, greatly exceeding the original proposed 12 primary care sites. In the initial site assessments, no limitations were placed on the geriatric focus topics selected by each primary care practice sites. The majority of the practices chose one of two topics: 1) Advance care planning, or 2) falls risk screenings and interventions around patients at risk for falling. Using a combination of education, workflow redesign and electronic medical record coding for data analysis purposes, CGWEP practice facilitators have been able to make significant changes in falls screening rates. For example, at Jackson Rural Health Group (RHG), a Federally Qualified Health Center (FQHC), falls screening rates improved from 23% of the patients over the age of 65 being screened to 70% screened post intervention. In addition, great strides were made in Advance Care Planning (ACP).

The gold standard for ACP is documentation of a patient's written ACP plan scanned into the electronic health record. The first six of our primary care chose to focus their practice change project on ACP documentation in the medical record. Five of these six showed improvement. ACP is a process that occurs over time with numerous conversations taking place. Thus, after performing the Plan, Do, Study, Act (PDSA) cycle, many of the practices set a new goal of having patient/provider conversations around advance care planning and charting in the electronic medical record (EMR) that these conversations occurred. This was the case for the next eight sites listed on the table. All sites showed improvement (range 1% to 72%). The last five primary care practices chose to use billing for ACP conversations as a marker in the EMR. Results are reported for three of these practices, all of which showed improvement. Two practices will complete this work in 2018 (Senior Care Systems and Patient Center Care). The CGWEP expects that the ACP conversations will increase as more practices become aware that they can bill for this recently developed code. 

Interprofessional Geriatrics Training: Program 1 IPE Geriatric Fellowship

The CGWEP IPE Geriatric Fellowship has trained 9 Fellows including 3 dentists, 3 nurses, 3 physicians. In 2017 the CGWEP designed, initiated and refined an IPE Geriatrics Fellowship that produced a toolkit on unexplained weight loss and an interprofessional, role play-based training in advance care planning (ACP). These published products for rural primary care practices are an important contribution to geriatrics literature. The IPE curriculum and training program on unexplained weight loss was published on MedEdPORTAL

One of the greatest accomplishments of the CGWEP was the integration of the IPE Geriatrics Fellows into the practice change projects. Cohort 2 consisted of two advanced practice nurses, a physician and a community dentist, who provided training to the entire clinic staff of Roxboro Family Medicine, a rural primary care practice, to support the clinic's ACP practice change project. Members of Cohort 2 consulted on ACP at UNC Family Medicine and at a rural family practice clinic in Conetoe, NC. 

Interprofessional Geriatrics Training: Program 2 Pre-professional Interprofessional Geriatrics Curriculum for Graduate Students

The CGWEP exceeded its goal to train graduate students, interprofessionally, in the care of the older adult patient. The number of disciplines participating grew from six disciplines in 2016 to ten in 2017. In 2018 the CGWEP IPE Geriatrics pre-professional training filled to capacity with 250 students. The disciplines included: dentistry, dental hygiene, medicine, nursing, occupational therapy, pharmacy, physical therapy, public health-nutrition, social work and speech and hearing sciences. In addition each group included 16 students from a health and humanities course in the UNC School of Arts and Sciences, Department of English, who assisted with PDSA cycles to improve the experience and communication among disciplines. This program resulted in statistically significant changes in student attitudes, knowledge and beliefs about IPE practice every year. These results were highlighted as an oral podium presentation at the 44th Annual meeting of the National Organization of Nurse Practitioner Faculties meeting in 2018.

The ultimate goal of the CGWEP was to institutionalize interprofessional training in care of the geriatric patient, bridging the gaps between the disciplines and focusing on geriatric care. In 2018 our interprofessional research and training efforts were validated by the UNC-CH University commitment to supporting interprofessional education through the establishment of the Office of Interprofessional Education and Practice. From 2016 through the present our students have increasingly reported that they are having IPE experiences in class and in their field placements. 

Community Outreach to create and deliver community-based programs and educational materials to provide patients, families, and caregivers with the knowledge and skills to improve health outcomes and the quality of care for older adults

From 2016 to the present the CGWEP AHEC partners’ continuing education courses have met the geriatric training needs of 2,177 healthcare providers from all 100 counties in the state. Thirty-four face-to-face courses have been held covering such topics as: Advance care planning, fall prevention, dementia care, dermatology, gerontological nursing, mental illness, end of life care, atherosclerotic peripheral arterial disease, healthy aging, orthopedics, diabetes, gerontological research, opioid management, and transitions of care. The CGWEP, in conjunction with its AHEC partners, offered 13 online courses that have trained 2,438 health care providers to date. 

The UNC School of Medicine offers a special concentration for medical students called Care of the Older Adult Patient. Students from the specialty concentration helped to extend the CGWEP training resources into the rural and underserved communities. The CGWEP trained the medical students to present community based education on Alzheimer's disease and related dementias (ADRD) and deployed them to 3 senior centers. This program will be expanded to 6 additional senior center sites this year.

Across the broader state, two CGWEP coalitions, The North Carolina Falls Prevention Coalition and The North Carolina Mental Health, Substance use and Aging Coalition, provide forums for infrastructure building and sharing best practices. These coalitions meet quarterly at the statewide level and support 11 smaller coalitions that work at the local level.  

Alzheimer's Disease and Related Dementias (ADRD) program provided education and training in Alzheimer's disease and related dementias to patients, families, caregivers, direct care workers, health professions providers, students, residents, Fellows, and faculty

The CGWEP has pushed beyond the bounds of NC in its leadership of the national American Indian/Alaska Native Collaborative (AI/AN), which brings together five total GWEPs (UNC plus Alaska, Arizona, UCLA, and Wyoming) on an ongoing basis to share best practices and educational products for this underserved population on ADRD. The CGWEP received funding from the American Geriatrics Society's GWEP Coordinating Center to host two meetings on the issue in collaboration with national experts from Indian Health Services, The National Council on Indian Aging and the Banner Alzheimer's Institute. 

In North Carolina, the CGWEP focused on producing culturally appropriate content for our in-state tribes. In partnership with the North Carolina American Indian Health Board, East Carolina University and Wake Forest University, the CGWEP is developing a video for Native caregivers related to ADRD. American Indian/Alaska Native (AI/AN) populations have higher rates of diabetes and other risk factors for dementia Rising rates of dementia in this population, and a shortage of culturally competent paid caregivers have led the CGWEP to focus on increasing awareness of ADRD for this group.

The CGWEP and its AHEC partners continue a strong emphasis on ADRD training for all levels of health professionals as well as for family caregivers. CGWEP staff in conjunction with Orange County Cares, funded by the Administration on Community Living, are working to create dementia friendly communities. Since 2017, our AHEC partners included ADRD as a topic in 24% of all face-to-face courses. In these courses, plus four online courses, the CGWEP trained 1,095 health care professionals in 2017.


Geriatrics Workforce Enhancement Program (GWEP) – Coordinating Center: Interprofessional training in geriatrics to promote high quality healthcare services to American Indians and Alaska Natives (AI/AN) - Cristine (Clarke) Henage, MPS, EdD

Summary 

The UNC Center for Aging and Health was awarded a GWEP Coordinating Center Collaborative extension grant in an effort to provide interprofessional training in geriatrics to

GWEP
Back row: Rachel Peterson (AZ), Mindy Fain (AZ), Trena Anastasia (WY), Catherine Carrico (WY), Sheila Shinn (AK), David Fenn (AK), Ronny Bell (NC) Front Row: Blythe Winchester (Indian Health Services), Laura Vitkus (AZ), Lisa O’Neill (AZ), Josea Kramer (UCLA), Nancy Weintraub (UCLA), Donna Galbreath (AK), Cristine Clarke (NC), Ellen Schneider (NC)
promote high quality healthcare services to American Indians and Alaska Natives (AI/AN). Through a partnership with GWEPS in Alaska, Arizona, California and Wyoming and other regional agencies, the AI/AN Coordinating Center has the continued potential to serve 149 recognized federal tribes with a population of over 503,345 rural and underserved older adults. The five AI/AN Coordinating Center GWEPS collaborated at a distance; comparing research, promoting strategies to enhance interprofessional practice, sharing resources, sourcing new grant opportunities and bringing new interested partners to the collaboration.  

Purpose & focus  

The AI/AN CoordinatingCenter (AI/AN Collaborative) advanced knowledge, best practices and innovations for engaging AI/AN elders and their families. They created and deployed culturally appropriate training to healthcare practitioners at primary care clinics utilized by Native peoples will ultimately improve health outcomes. AI/AN’s health is affected by social determinants such as poverty, unemployment, inadequate formal education, etc. Higher rates of diabetes are found across all tribes with higher rates of specific disproportionately illnesses being found regionally for example, dementia mortality rates are 50% higher in North Carolina. This collaboration provided an opportunity to learn about and evaluate existing resources, and share lessons learnedfrom one GWEP to another. 

GWEP Organizations

Each AI/AN Coordinating Center GWEP was engaged in providing continuing education and practice change projects in primary care clinics focusing on the special needs of AI/AN peoples. Some of the GWEPS designed special projects for their service area and some integrated principles of care respectful of AI/AN culture into their activities. Community based partners ranged from think tanks interested in policy around Native American issues in North Carolina to frontline providers in rural Alaska to long term care facilities in Arizona. One example of the kind of best practice that could be replicated as a result of this collaboration is the NUKA system of care developed by Southcentral Foundation in Alaska. This system emphasizes customer ownership, relationship based care and whole system transformation. Similarly, UCLA works in partnership with the Veteran’s Administration (VA) Geriatric Scholars Program making VA Indian Health Service Rural Interprofessional Team Training (IHS-RITT) available to Indian Health Service clinics for all federally recognized Tribes. The VA RITT and VA IHS-RITT programs have been delivered to >100 rural clinics.   

The AI/AN Collaborative met in person twice during 2017. The established CGWEPs also participated in several planning conferences and telecommunication sessions. The first meeting was held in July in San Francisco following the International Association for Gerontology and Geriatrics meeting. The second meeting was held on October 27, 2017 in Tucson Arizona. In addition to the five GWEPs, four experts on AI/AN health and interprofessional training, representing the Banner Alzheimer’s Institute, the National Indian Council on Aging, the Indian Health Service and the Veterans Administration, attended the October meeting in Tucson. The group reviewed the literature on health issues for older AI/AN peoples, explored models of IPE care for these populations, and shared educational products.   

Objectives & Outcomes

The AI/AN Collaborative reviewed and discussed existing best and promising practices used by GWEPs and our consultant experts in healthcare and education to engage American Indian/Alaska Native elders and their families, and improve their care in a culturally relevant manner. This resulted in improved knowledge, access, and intent to utilize educational products and strategies that are culturally appropriate beyond each individual GWEP’s local area. The AI/AN Collaborative developed a list of 48  best practices that was reviewed by the experts in the Collaborative. 

The AI/AN Collaborative examine effective strategies for training American Indian/Alaska Native-serving primary care providers in culturally informed care of elders, such as the VA Indian Health Service Rural Interdisciplinary Team Training (VA IHS RITT), NUKA System of Care and other models. They increased knowledge and intent to use culturally relevant and respectful tools and approaches for preparing primary care providers in meeting the health care needs of American Indian/Alaska Native elders. Two models of culturally appropriate care were presented and discussed at the meetings, the NUKA System of Care and the Veteran’s Administration IHS Rural Interdisciplinary Team Training model. Two AI/AN Collaborative members currently use models, Alaska and UCLA and the others expressed interest in using them in addition to contacts external to the AI/AN Collaborative GWEPs who expressed interest in exploring the models and receiving additional training.  

The AI/AN Collaborative evaluated new and innovative projects targeting American Indian/Alaska Native populations that were currently are being piloted by GWEPs. They evaluated how innovative projects were adapted, implemented, and outcomes evaluated to improve the services of the local population, to build generalizable evidence for these innovations. The AI/AN Collaborative is exploring the feasibility of being included into a national database and listserv of professionals who work on elder and/or palliative care issues in Indian Country being developed by the Indian Health Service.   

Continued Collaboration

These five GWEPs and their Native American consultants continue to collaborate at a distance through comparing research, promoting strategies to enhance interprofessional practice, sharing resources, sourcing new grant opportunities and bringing new interested partners to the collaboration. The AI/AN Collaborative also continues to share information more widely with other interested GWEPs (Montana and Utah) who are not part of the Collaborative and who did not participate in our face-to-face meetings. The Health Resources and Services Administration has recognized the value of this work and will fund an expansion of the project in 2018 adding Hawaii to the Collaborative.

Research Highlights: Hospital Medicine

Faculty in our division of hospital medicine bring clinical excellence to our hospitalized patients. They lead many quality improvement projects intended to optimize patient care while making it more cost-effective. This month we highlight a study led by Dr. Beth Ann Brubaker as to how individual patient care plans (ICPs) can identify issues driving high usage of inpatient resources. Other research includes Dr. Jamison Chang’s team design of a system to identify root causes of hospital acquired venous thromboembolism (VTE). Further, an end-stage liver disease (ESLD) project has created a standardized flow of care for decompensated ESLD patients who are not transplant candidates to tailor care and reduce hospital readmission. Finally, cardiac telemetry in hospitalized patients is a frequently overused resource: Dr. Michael Craig worked with our department’s Value Care Action Group to change cardiac telemetry orders within the Epic EMR, across all of UNC Health Care resulting in overusage.

Janet Rubin, MD
Vice Chair for Research


Complex Care Committee Develops Individualized Care Plans - Beth Ann Brubaker, MD

Five of the highest utilizing patients were compared in 2017 and 2018. After an ICP, a dramatic reduction in ED and hospital days was evident: EC: 68 vs 0; RG: 67 vs 0; MB: 56 vs 2; XW: 74 vs 1; and ECJ: 44 vs 28.
Five of the highest utilizing patients were compared in 2017 and 2018. After an ICP, a dramatic reduction in ED and hospital days was evident: EC: 68 vs 0; RG: 67 vs 0; MB: 56 vs 2; XW: 74 vs 1; and ECJ: 44 vs 28.

Individualized care plans (ICPs) have been created for patients who are high utilizers of inpatient resources. In some cases this high utilization has been due to fractioned/inefficient medical care and in other cases due to social/addiction issues. Most of these patients have chronic medical illnesses, chronic pain issues, and may lack understanding of appropriate utilization of resources. For some patients, it is clear that opioid dependence and addiction issues drive the majority of the frequent hospitalizations. 

Care for these patients is often flawed and ineffective, and providing this type of medical care can be demoralizing for providers and contribute to physician burnout. Additionally, patients who are provided dramatically different management for the same issue from one hospitalization to the next become frustrated and are at high risk of readmission, substance abuse (including overdoses and IVDU related infections), medication errors, and distrust of the medical system. 

Hospitalists are in a unique position to address the issues that contribute to high utilization of the medical system. As a team, they are already familiar with many of these patients, their medical issues, and their social situations. This gives them a strategic advantage, in attempting to help patients overcome destructive, unhealthful, unproductive habits. Hospitalists can have genuine conversations with patients about the actual medical and psychosocial issues. In many instances, these conversations have revealed more focused or detailed problem lists which can then be addressed in the care plan. Sometimes the patients are open to this and sometimes not, but this focus on the real issues at play is the basis of the ICP creation. 

The ICPs seek to identify the real issues driving frequent hospitalizations, and provide the most safe, effective, and high quality care for these patients. This helps providers to be transparent and consistent in communication and approach to management, and allows patients to know what to expect when they come into the hospital. Hopefully, this also improves therapeutic relationships with patients, and reduces burnout in providers. 

Overutilization of hospital resources by this population is not a challenge that is specific to UNC. Many of these patients also frequent Duke, WakeMed, Rex, and other local community hospitals, and this is yet another component of the disjointed and variable care that they receive. Duke and WakeMed have similar complex care committees working in parallel, and UNC has coordinated efforts with these institutions in order to merge patient care into a single, more directed and rational pathway. 

The graph above compares five of the highest utilizing patients in 2017 and 2018. Corresponding values for each patient, pre and post plan, showed a dramatic reduction in ED and hospital days (including partial days). (Care Plans were in place 12/20/2017) 

UNC Medical Center's Complex Care Committee was started by Beth Ann Brubaker, MD, Andy Donohoe, MD, and Kelly Stepanek, NP. To date, nearly 50 ICPs have been created.

Using EMR technology to improve VTE risk assessment and prophylaxis - Jamison Chang, MD, MS

Chang graph
Root causes of hospital-associated venous thromboembolism.
Venous thromboembolism (VTE) remains an important and preventable cause of morbidity and mortality in the United States. It is estimated that 600,000 people per year in the US are diagnosed with VTE and close to 100,000 die as a result (1). One underappreciated fact is that over half of VTEs occur while patients are hospitalized despite the availability of effective prophylaxis (2). In addition to the morbidity and mortality associated with VTE, there are also significant costs associated with these events in terms of penalties or withheld payments to hospitals.  Previous efforts to reduce hospital acquired VTE (HA-VTE) at UNC have used retrospective chart review to try to identify the root causes of HA-VTE at UNC, leading to inconsistent effects.

Jamison Chang, MD, and colleagues have developed a system that identifies HA-VTE in near real time so that the quality and safety teams at UNC are able to better identify the causes underlying these events and intervene in a timely fashion. A seed grant from the Institute for Health Quality Improvement (IHQI) at UNC has allowed his team to begin to tackle this problem using various forms of health information technology, including the novel natural language processing engine, EMERSE, that is being deployed across the UNC healthcare system. This program is able to read free text documents in EPIC including providers notes and radiology reports and accurately identify HA-VTE at UNC.  

Their initial data using these tools revealed three common root-causes of HA-VTE at UNC: (1) incorrect VTE risk stratification at admission (2) a lack of situational awareness ( i.e. a patient’s VTE risk changes during their hospitalization and the treating clinicians do not adjust the prophylaxis--after an unplanned surgery for example) and (3) patients not adhering to the prescribed VTE prophylaxis. Efforts are underway to target all of these causes including the trialing of an evidence-based VTE risk stratification tool (Padua) in EPIC, partnerships with pharmacy to maintain a real-time awareness of a patient’s risk of VTE, and nursing scripting/patient education efforts to increase understanding and compliance with ordered VTE prophylaxis.  

As a result of their efforts, Chang and Carlton Moore, MD, (also in the Division of Hospital Medicine) have been appointed the physician champions for VTE reduction at UNC-CH.   

Decreasing the usage of low-value diagnostic testing and interventions in hospitalized patients - Michael Craig, MD, MPH, FHM

Craig image
The change in protocols was associated with a decrease in the daily number of patients on telemetry monitoring by a mean of 11.4 patients (a 12% drop) and the proportion of patients getting more than two days of daily telemetry monitoring by 7.3%.
Cardiac telemetry in hospitalized patients is an often-overused resource. That overuse is driven both by use outside of accepted clinical indications and by continuing telemetry longer than is clinically indicated. In June of 2017, Michael Craig, MD, worked with the Value Care Action Group and other interested stakeholders across the UNC system to change cardiac telemetry orders within the Epic EMR. Telemetry orders now require both a clinical indication and duration. At UNC Medical Center, this change was associated with a decrease in the daily number of patients on telemetry monitoring by a mean of 11.4 patients (a 12% drop) and the proportion of patients getting more than two days of daily telemetry monitoring by 7.3%. This data was presented at the national Society of Hospital Medicine meeting in April. Dr., Craig is currently examining how this change impacted telemetry usage at other UNC facilities.

Along with co-authors John Stephens, MD, and Andrew Donohoe, MD, (also in the Division of Hospital Medicine), he published the article "Things we do for no reason: Echocardiogram in unselected patients with syncope" in the Journal of Hospital Medicine. This article discussed the low-yield of echocardiogram in syncope patients without pre-existing cardiac disease and a normal EKG.

Dr. Craig's current project is exploring ways to reduce the use of IV antihypertensive medications in hospitalized patients. 

End-stage liver disease project, IHQI funded 2017-18 - Escher Howard-Williams, MD

ESLD
A standardized flow of care for ESLD patients would provide thoughtful and comprehensive care guidance.
End-stage liver disease (ESLD) patients have complex and highly symptomatic disease, and suffer a high rate of morbidity and mortality. Those who are not transplant candidates often have uncontrolled symptoms and frequent readmissions. In fact, this group has the highest readmission rate at UNC. Care typically focuses on short term symptom management while in the hospital, but lacks anticipatory guidance and long term goals of care.

The ESLD QI project aims to create a standardized flow of care for decompensated ESLD patients who are not transplant candidates. The goal is to provide thoughtful and comprehensive care and guidance for these patients, while reducing overutilization of inpatient resources and readmission to the hospital. The flow of care includes creation of a living ACP/ICP note documented in their chart, with specific recommendations detailing goals of care by both Hepatology and Palliative Care consulting services.

Project collaborators include Escher Howard-Williams, MD, Ria Dancel, MD, Allen Liles, MD, Beth Ann Brubaker, MD, Eric Allman, NP, Martha Bausch, NP, and Heather Boykin, NP.