MIRROR-TCM: Eileen Brinker
Q: What do you think are the major challenges affecting the care of complex older adults as they transition from hospital to home?
A: Aside from the ongoing COVID pandemic, I think one major challenge is the complexity of patients’ medical conditions. Oftentimes, patients in the hospital don’t know what they’re even being treated for or what is happening. Making sure that there’s good communication with the older adult and the family while in the hospital is essential. That they know that they have heart failure and what that really means and starting some of the disease management education so that it can empower them, and they can advocate for themselves and importantly, so they know what to look for and know how to take care of themselves when they get home. So I always think that’s number one: do they know what’s going on in their bodies? Why they’re not feeling well, and what they can do at home to look for signs and symptoms of worsening or improvement, as well as the importance and role of each medication. Patients can come in saying they’re on 25, but do they know what each one does and why?
The other huge piece to complexity is psychosocial, such as do they live alone. We have a lot of older adults in San Francisco living alone, and what supports do they really have available to them. Do they have an IHSS [In-Home Supportive Services] caregiver, do they have any friends or neighbors or church coming in? Before COVID, these were great sources of support and now with COVID, it’s very isolating. We’re finding even more isolation within our older adults, and we know that there’s a higher risk for older adults not doing as well or coming back to the hospital when they live alone. And then, are they able to get to their appointments? You know it’s a simple question but if we’re setting up all these appointments for them when they leave the hospital, and then they have no transportation or aren’t able to get down the stairs to get to that paratransit or taxi or to the bus, what good does that do? Other things that encompass risks when at-home, such as are they able to get food, or can they get their medications when they get home, as well as other factors that we know affect health, like smoking or alcohol use.
I think another important piece is Advance Care Planning [ACP]. It’s been a huge initiative for us. We can see whether a patient has an advance directive, a POLST or an ACP note [in the patient record]. And, knowing that an ACP note is in there…[patient’s] decisions are there for care teams to understand what matters most to this patient. We really know what patients want and what their goals are and what they hope for and what worries them. We have Dr. Rebecca Sudore’s PREPARETM for your care, that uses videos and tools geared to patient and caregivers in multiple languages. It’s a great resource and it’s what we’re using as a basis to facilitate standardization of these important conversations. We’re also doing particular outreach to our Latinx community because we saw that there’s a disparity around ACP with that group.
Q: What impact has COVID-19 had on the care transitions among at-risk older adults?
A: I think the biggest impact on patients is the isolation. Not having all their usual social supports, and possibly even home agencies are coming in less. I would also say the disparity of technology is a big issue with patients not having the same access or devices. We quickly pivoted to telehealth when COVID began, but some older adults don’t even have a computer or they have only a home-phone (landline), so that disparity, inequity quickly appeared for us at the start of the pandemic. I also think there’s been a trend in patients waiting to go to the hospital and maybe not receiving the care that they need in a timely manner. We’re just seeing a higher acuity at admission. We know that the patients coming in are sicker than prior to COVID, who are not COVID-positive. People are waiting to come to the hospital. They don’t want to be in the hospital and are just trying to avoid it, as well as primary care to a less extent. So I think the isolation, the inequities around technology and overall delays in seeking and/or receiving care, further complicates the complexity of at-risk patients.
Q: What other strategies have been implemented to bridge the physical gap during this pandemic?
A: There’s been a lot of outreach with telephone, and just meeting the patient where they are. Although we may not be able to see the patient, there was a lot of telephone calls and checking in and tremendous outreach by our Population Health team and other teams, to patients that hadn’t been seen by their primary care doctor or we [inpatient side] hadn’t had an outreach from since the pandemic emerged in our community. We also work with the Institute on Aging in San Francisco that has buddy lines—a friendly call to patients to help with isolation. We also know that our Behavioral Health team is working overtime, so there’s a lot of outreach being done. And our Home-Based Primary Care program piloted “grand pads” that they can do games on, or they can hit one button and know to call their family. They have one button that’s their direct telehealth. It’s a really simple interface and they’ve had some great success with it.
One other thing that I thought of in regard to the initial part of the question was the visitor policy. It ebbs and flows, but for a long time there were no visitors allowed at the bedside while in the acute care hospital. We saw this firsthand when we initially started the MIRROR-TCM study, because at that time we were still surging and there were no visitors allowed, and just the impact that it made on patients but mostly their cognitive disorientation, and the struggle of patients’ families and caregivers trying to get information and communicate with the team. It’s just an ongoing lesson for all. Currently, we are able to have visitors back at the bedside and our team has really seen a huge difference. For example, we were interviewing a patient and they were a little disoriented and not as clear. When the spouse walked back into the room, the patient was like a completely different person. With the family by the bedside there is a comfort, there is a knowing, a reorientation to their sense of familiar while in a strange unknown setting. It truly makes a world of difference.
Q: What about home visits?
A: We have not had any hesitancy from any patient about us coming into their homes. I don’t know if these patients are so sick or what, but we’re finding that people see the value of this, and say, ‘no, I need this’. Not to say that every situation has been perfect as home situations also has challenges. For example, working with a patient in a very big multi-generational household in a small physical space. So we have a lot of discussions around how many people may be present during the home visit and we have a policy that only one caregiver can be with the patient in the room but they have very limited space. We need to think outside the box, to keep the transitional care nurse as safe as possible in the community while still working with the patient. It’s threefold safety: do we have all the personal protective equipment to go into the home; does the patient feel comfortable and safe with it; and does the provider feel comfortable and safe with it. We do the screenings but screenings are really around symptoms and exposure, not necessarily around who else we may encounter during the visit, and is this a private space that we can meet in, and not everyone has that. We’re continuing to learn how to meet patients and caregivers where they are for each situation, and we’ve been very pleased that we’re having such success with getting in patient’s homes. We’ve also been able to vaccinate our team, so that they also feel a level of protection as well.
Q: How do you think the Transitional Care Model [TCM] can help to address these challenges?
A: I think the most exciting thing to me about TCM—because I’ve worked inpatient for so long and collaborated with patient post-acute collab partnerships—is that there’s one person on a team that has the continuity from hospital-to-home. They see the challenges in the hospital, they optimize the discharge, they work with the medical team, the case managers, the family, to advocate for that patient, and then they continue with the patient home. Then they see that patient’s progression from the hospital to home, and then over the next two to three months, whether it’s a decline or it’s an improvement. Having one person do all of that is the game changer. I’ve followed patients remotely but to have this 1 person…to have a nurse-led program and this advanced practice nurse follow the patient from hospital-to-home to identify all these risks to work on, to advocate for more resources and programs and optimization and then to also advocate if re-admitted back again and to continue those services in the outpatient setting. That is the difference. To be able to continue to close that loop and to have one person see that whole picture and to develop that trust and rapport with the patient is just incredible. It’s been a huge gap for us and that’s what we’re really most excited about and has proven to be so beneficial already. It’s [also] bringing nurses to the table which we continue to advocate so much for at UCSF and it’s the perspective that they bring to the team—an interdisciplinary team, and it’s a perspective of someone over time and in different environments. And in different settings.
Q: How will the TCM advance the mission and capitalize on the strengths of your health system or hospital?
A: We’re looking at that daily. We share our P.R.I.D.E. at UCSF in the work we do, that is we have overarching values we call ‘pride’: Professionalism, Respect, Integrity, Diversity, Excellence. There are many aspects of each one of those words that make our pride to be a UCSF patient, employee, and care team member, and I think that the TCM represents every piece of that. The interaction, positively and collaboratively, with patients and visitors and to hold each other accountable and responsible comes with that professionalism. The respect of being courteous, kind, and really acting in the best interest of the patient and their goals and treating others as we would want to be treated and trying to also engage the family and bringing them into the center of this. The integrity, there’s a lot of pieces of complex decision making in this model, but always being ethical, doing the right thing for the patient with a lot of quick decisions at the moment. There’s high integrity in this model. Then the diversity, like all the different patients that we’re seeing and that the homes and the values and the environments and really being inclusive of all the opportunities for each patient that that brings. And then the excellence, I think staying really dedicated to the high standards of care that we have at UCSF and trying to excel at the model, the integrity and the fidelity of the protocol this model, and integrating all of the high standards of care that we have at UCSF.
Q: What impact do you hope the TCM will have on your patients and on your health care system?
A: One impact we’re really hoping for is more awareness for nursing research and nursing-led programs which this opportunity has provided. We’ve gotten some great exposure but more importantly, some incredible support for this work that’s been amazing. For example, there’s a lot of heart failure research being done with our patients and they’re all physician-driven and they’re all med and device, and so, to have a nurse lead intervention that’s around care transitions that everyone’s very excited about it and wants to partner with us to help patients. In the end, I still think the biggest impact this effort will have is to fill the gap in the care continuum and meet the needs of high-risk, medically complex patients.
Q: If successful in improving the health outcomes of patients while reducing cost of care, how do you envision future use of this model?
A: 100% implementation! I think the exciting thing so far is that we are already receiving referrals from case managers from other medical teams. We have increased exposure with the home health agencies and SNFs that we’re working with, and just their support but also their referrals show that everyone has a good understanding of this model, supports it and wants it for every patient. We’re trying to get some data around our current limitations as we have just one advanced practice nurse and many, many eligible patients. So how we grow this and sustain it and also work with other existing programs at UCSF, whether it be Home-Based Primary Care or a possible hospital-to-home program or our care transitions outreach program that does calls with our patients, after the trial is completed is something we are actively working on. There may be a lot more opportunities for integration. 100% implementation is what my goal is and what I’m hoping for, and we’re already seeing a lot of support and success around that.
Eileen Brinker, RN, MSN, Clinical Coordinator for the MIROR-TCM study has worked at UCSF Medical Center for over 17 years. She worked as a bedside nurse on the cardiovascular unit for 5 years and as Heart Failure Program Coordinator/ Care Transitions Inpatient Program Manager for 12 years. Brinker developed and implemented an evidence-based Heart Failure Program that includes thorough patient education, follow up calls, discharge planning, and advocacy and support roles for the patient, family and caregivers. This program has resulted in a reduction of readmissions for their patients. It was chosen by the Institute of Healthcare Improvement (IHI) to be featured at the National Forum and included in IHI’s “How-to-guide: Creating an ideal Transition Home”. Brinker enjoys spending time with her husband and their four children in the Bay area. She received her Bachelor’s at Santa Clara University and Master’s in Nursing from Samuel Merritt University.