Seizure Management Across Health Care Settings: Health System Perspective

Steve Chung, MD, and Winston Wong, PharmD, discuss the health system perspective on seizure treatment, covering the impact of transitions between health care settings on continuity of care and treatment considerations related to health care resource utilization.

• Speaker: Steven Chung, MD, Executive Director of the Neuroscience Institute, Director of the Epilepsy Residency Program at the Banner Medical Center, Phoenix, AZ
• Moderator: Winston Wong, PharmD, President of W-Squared Group, Longboat Key, FL

This video series is sponsored by Sunovion Pharmaceuticals, Inc and is part of a 4-part series on “Seizure Management Across Health Care Settings.” View the rest of the series here.

Read the full transcript:

Dr Wong: Welcome to an installment of PopHealth Perspective's Seizure Management Across Health Care Settings. We have Dr Steven Chung, who represents the health system perspective. Steve is the chairman of the Neurology, executive director of the Neuroscience Institute and director of the Epilepsy Residency Program at Banner Medical Center in Phoenix, Arizona. His extensive expertise is focused on empowering epilepsy patients through education and comprehensive treatments. Welcome Steve.

Dr Chung: Thanks for having me.

Overview of Seizures

Dr Wong: With respect to antiepileptic drugs, medications that patients may have been on may not be continued in the institution, especially if the reason for the admission is not related to the seizure disorder. If the admission is related to the seizure disorder, the medication doses may be changed, or medications added, or medications discontinued. Which leads to an important safety concern after discharge with patients not fully understanding what medications should be continued or stopped. As high as 50% of the patients are found they have a clinically important medication error after discharge.

Dr Wong: With this brief background, what are the challenges and solutions in supporting patients with seizures during the transition between different care settings?

Challenges and Solutions in Supporting Seizure Patients During Transition of Care

Dr Steven Chung: Yeah, it could be quite challenging transitioning from inpatient to outpatient settings safely. One of the reasons, as you had mentioned, is that it's not the same provider who's going to be seeing the patient inpatient versus outpatient. That alone creates a lot of miscommunication possibilities.

Second, the medication they started on may not be the proper medication for the individual, or maybe they're discharged from the hospital at the lower dosage than the actual target dose that can provide the therapeutic level.

In addition, support system from outpatient versus inpatient could be quite different. There are maybe more ancillary team during the inpatient setting that patients can be provide different types of support. Once they're discharged from the hospital to home, now they're on their own so that they do not know how to administer the medication, maybe they forgot to administer the medication, or following the directions that was given at the time of discharge. Altogether, creates some kind of confusion and miscommunication potentially, and is no wonder that readmission to the hospital after discharge from the hospital for epilepsy patients could be quite high.

Dr Wong: Is there a difference in the challenges to transitions of care between let's say, going back to home or in the community, or versus going into a long-term care facility?

Dr Chung: Most of patients, especially the new onset patients with the seizures, they're discharged home, because they recover fully and do not require a lot of other support. If, initial seizure was due to the underlying neurological disorder, let's say stroke or significant head trauma, then those patients may be discharged to the secondary, the ancillary supporting facilities such as nursing home, sometimes the inpatient rehab or the step-down rehab.

Dr Wong: So, what are some of the possible solutions that these challenges?

Dr Chung: Well, we have to understand that first of all, the seizure could be arise from many different regions. Not everybody who got admitted first time to the hospital due to the new onset seizure has known underlying cause or identifiable brain damage. So, if you do not have those, those patient typically discharge to home and managed through the medications. However, if you ever identify cause or damage to the brain, then other therapy and the support has to be instilled.

Dr Wong: So, are there any particular programs that a health system can implement to try to ease this transition of care?

Dr Chung: Yeah, it is quite difficult to expect that you provide a certain level of instruction to the patient at the time of discharge, what to do, how to increase the medication, how frequently you have to increase the medication and also, obtaining higher dosage medication from the outpatient pharmacy. All that could be lost somewhere. So sometimes programs like ours and many others have a position called the nurse navigators. They're the ones who easing the transition between the inpatient to outpatient and, vice versa as well. They're the ones who's going to be communicating, have a follow up phone call with the patients and, make sure the patients will come back and see the neurologist for further assistance and adjusting the dosage of the medication.

Methods to Decrease Hospital Readmission Rates

Dr Wong: So, is there an integrated communication path from the actual discharge orders to the patient going home and, true follow up for follow up visits, as well as new medications?

Dr Chung: Absolutely. This nurse navigator or equivalent person can make sure the patients are following the directions and, patients are actually doing well with a given medication. Because some people may not take the medication again due to the side effect, along with the simply forgetting to take the medication and, also not increasing the dosage as they directed.

Dr Wong: So, let’s focus in on specifically antiepileptic drug therapy. You talked about the nurse navigator and, I can see where the role of the nurse navigator can have a significant role in trying to reduce medication adverse events during this transition of care. We know that there is one study out there that has reported almost an 11% seizure related readmission rate, a lot of it due to not taking the medications correctly. Is there a resource, such as a pharmacist, that this nurse navigator can also bring in?

Dr Chung: Yes. As a matter of fact, nurse navigator is a single person out of a whole team. The epilepsy team may comprise of many other people who can also communicate with the patient and, also support the physician as well as the nurse navigators.

One important aspect here, as you mentioned, Dr. Wong is how we going to make sure the patients are adhering to the medication. The study shows number one reason that people is not 100% adhering to the medication is simple forgetfulness. This is a relatively new medication given to them and maybe they are taking six or seven other medications at the same time, it can easily be forgotten. So, we have to make sure they understand the purpose of the medication that was given in the hospital. That is to prevent the recurrence seizures, as well as securing the patients can tolerate the medication well. It’s very common the patient comes back to the clinic and they’re already on different dosage of medication, or different frequency medication, let alone not taking the medication at all.

So, we have to transition smoothly by securing and educating patients what the medication is for, how to take it, what kind of side effect may expect and, if the side effect indeed occurs, then who to contact and how to mitigate those kind of side effects. All these kind of things going to be team effort. And along with that is how quickly the physician or neurologist can see the patient. A lot of times if you survey around the country, especially after the COVID era, many people have to wait two, three, even six months to see the neurologist. And if there’s a way we can facilitate to seeing this kind of discharge patients sooner than later, to make sure everything in checked, there will be also quite helpful to transitioning the care.

Dr Wong: So, these activities of this transition care team that you just talked about, are there interactions documented into the EHR as well, or the EMR?

Dr Chung: Yeah. All the conversation, the physician or nurse navigators, or sometimes MAs, the conversation has to be documented in a EHR; and oftentimes the physicians can be intervened, or supervise, what kind of information needs to be conveyed to the patient.

Provider’s Approach to Comorbid Conditions in Patients with Seizures

Dr Wong: So, for our last topic, we know that elderly patients usually don't just have one chronic condition, we usually have any kind of conditions. How should providers approach the comorbid conditions with seizures?

Dr Chung: Well, that is another challenge when patients enter into the emergency department with new onset seizures and, when the medication has to be administered or acutely at that point. All other aspects, or what other health problems a patient has, maybe not the first thing they think about. They want to give some medication quickly, preferably IV medication if it's needed. And also, the medication is readily available in the hospital, as well as medication that ER physicians are familiar with. Those medication may not be the best medications, or the proper medications, for the individual. As you say, Dr. Wong, just because of other comorbid conditions and potential drug to drug interactions.

It does take a lot of effort and consideration to choose a proper medication for every single individual. Seizure types, whether they have a generalized seizures or focal seizures as you mentioned, their age, how about the childbearing potential, drug-drug to interaction other common conditions, their financial situations, and ease of taking medication to secure the adherence to the medication. All of these kind of things should be in consideration when you choose a medication.

So, it is not uncommon when patients were discharged from a medication, that considering every aspect of the choosing the medication, the medication is switched to something else. So, it is actually a very important emphasize that patients who are discharged from the hospital should be followed by the physicians, or neurologists in this case, relatively soon; I propose at least within six weeks.

Dr Wong: Right. And as you mentioned, I think you said most patients usually get discharged to home, which is where the navigator care team really comes into play. For those few patients that do get discharged to long term care facilities, does that navigator team go to that facility as well? Or do you partner with the facility to go and help smooth the transition of care?

Dr Chung: Yeah, first of all, we're very fortunate to have a navigating team in our hospital system, but many other programs do not have that. The patients are followed by different system. Maybe they went into the one hospital, and they're followed by the local neurologist has nothing to do with that system. So, you can imagine the navigation doesn't occur in that kind of scenario. So, it's actually more common not to have this kind of a transition team.

Those patients who are entering to the nursing home, or equivalent facilities, that is also a quite different story because then they have their own team, including physicians and nurses and their own team to provide the care for the patient. So, really the navigating team, navigation RN, their duties kick in when patients actually discharged home in the situation. They had to be an independent person who's going to be taking the medications without much of a help from outside.

Final Remarks

Dr Wong: This concludes this installment of the Pop Health Perspectives. And thank you Steve for your time and this informative discussion.

Dr Chung: Thank you. Thanks for having me.