Hospital discharge risky time for patients
Bad coordination often plagues transition to care of home health agencies
Within two weeks of Joyce Oyler’s discharge from the hospital, sores developed in her mouth and throat, and blood began seeping from her nose and bowels.
Her daughter traced the source to the medicine bottles in Oyler’s home in St. Joseph, Mo. One drug that keeps heart patients like Oyler from retaining fluids was missing. In its place was a toxic drug with a similar name but different purpose, primarily to treat cancer and severe arthritis. The label said to take it daily.
“I gathered all her medicine and as soon as I saw that bottle, I knew she couldn’t come back from this,” said Kristin Sigg, the younger of her two children. “There were many layers and mistakes made after she left the hospital. It should have been caught about five different ways.”
Oyler’s death occurred at one of the most dangerous junctures in medical care: when patients leave the hospital. Bad coordination often plagues patients’ transition to the care of home health agencies, as well as to nursing homes and other professionals charged with helping them recuperate, studies show.
“Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs,” said Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine in Baltimore. “The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”
Medication mistakes like the one in Oyler’s case — which slipped past her pharmacist and home health nurses, according to court records — are one of the most common complications for discharged patients.
The federal government views them as “a major patient safety and public health issue,” and a Kaiser Health News analysis shows such errors are frequently missed by home health agencies.
Between January 2010 and July 2015, the analysis found, inspectors identified 3,016 home health agencies — nearly a quarter of all those examined by Medicare — that had inadequately reviewed or tracked medications for new patients. In some cases, nurses failed to realize that patients were taking potentially dangerous combinations of drugs.
The variety of providers that patients may use after a hospitalization creates fertile ground for error, said Don Goldmann, chief medical and science officer at the nonprofit Institute for Healthcare Improvement.
One factor is the lack of communication among these other parts of the medical system. Of the $30 billion that Congress appropriated to help shift the system to electronic medical records, none went to nursing homes, rehabilitation facilities or providers working with individuals in their homes.
In nursing homes, case management frequently comes up short. A 2013 government report found that more than a third of facilities did not properly assess patients’ needs, devise a plan for their care and then follow through on that.
And at home health agencies, failures to create and execute a care plan are the most common issues government inspectors identify, followed by deficient medication review, according to KHN’s analysis.