The Pharmacist’s Role in Transitions of Care

Successes, Barriers, and Opportunities

Karsen Duncan, PharmD

Clinical Pharmacist Bryan Medical Center

Karsen Duncan, PharmD, has no relevant financial relationships that would be considered a conflict of interest for the purposes of this program. This CPE program will include a discussion of the pharmacist’s role in transition of care.

Objectives

• Describe the former transition of care process between hospital and long-term care/community.

• Identify Bryan Medical Center’s process for transitions of care (primarily hospital to long term care/community).

• Evaluate barriers to implementing a pharmacist led transition service.

• Define the need for collaboration between pharmacists in all areas of care to ensure medication compliance.

Why is transition of care so important?

• Seamless patient care • Maintain health status

• Reduce errors

• Increase efficiency

• Insurance/Medicare Reimbursement • CMS mandate for admission medication reconciliation and discharge

planning2,5

• Hospital Readmissions Reduction Program (enacted under the Affordable Care Act) • Affects all hospital readmissions within 30 days of initial admission 14, 15, 16

Historical Transition of Care(Outpatient – Inpatient – Outpatient)

• Physician/mid-level driven • Admission

• Incomplete home medication list

• Incorrect therapy ordered during hospital stay

• Discharge • Missing prescriptions

• Resumption of inaccurate home medications

• Confusing discharge instructions

Utilizing historical Care Transition Processes: Medication errors represent the most common patient safety error

• More than 40% believed to result from poor handoff at care transition (admission, transfer, discharge)3

• About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation.

• It is estimated preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings.

Who is responsible for correcting these errors? The Bryan Medical Center Pharmacy Approach

• Admission Medication Reconciliation

• Discharge Medication Reconciliation

• Ambulatory Pharmacist Follow-up (collaboration with Bryan Physician Network)

Bryan Medical Center Admission Medication Reconciliation Process • Utilizes pharmacy technicians

• Training • Interview questions

• Maintenance of competency (Top 200 drugs guidance document, Vitamin/Supplement dosing handout)• Periodic pharmacist evaluation

• Implements pharmacy procedures/safeguards• Supplement Hold Procedure

• Bisphosphonate Hold Procedure

• Anti-hypertensive parameters

Bryan Medical Center Admission Medication Reconciliation Process • Target specific admitting services (hospitalist [internal medicine],

cardiology, and trauma) • However, all inpatient admission (including overnight surgery) undergo pharmacy

review

• Medication history technicians collect data for targeted services upon hospital admission

• Technician process –• PDMP• Call retail pharmacy/fax VA/obtain facility MAR/TAR• Interview patient/caregiver/family• Contact PCP or prescribing physician office • Pass off information to the pharmacist

Bryan Medical Center Admission Medication Reconciliation Process • Pharmacist Process

• Review technician obtained information

• Collaborate with physician/provider to order home medications while inpatient (goal completion within 24hrs from time of admission)• Review admitting diagnosis

• Review labs and clinical picture

• Hold supplements

• Provide recommendations• Provider or pharmacist orders home medications for use while inpatient

• Continue to follow during hospital course

Bryan Medical Center Admission Medication Reconciliation Process: Benefits• Generation of a complete and accurate home medication list

• Reduced drug errors

• Faster restart of home medications during hospital stay

• Reduced drug costs

• Smoother transition of care from outpatient to inpatient• Clinically relevant dose adjustments

Bryan Medical Center Discharge Medication Reconciliation Process • Provider(s) complete hospital discharge

• Pharmacist at discharge: • Validates prescription requirements depending on discharge destination

• Can include generation of non-CS prescriptions via ePrescribing• Ensures accuracy of medication dosing at discharge (authorization to adjust medications per

BMC procedure) • Safeguards changes made to medication therapy during hospital stay are continued at

discharge • Promotes safe opioid prescribing • Reduces poly-pharmacy • Audits medication orders for confusing or misleading information • Collaborates with care management to make sure patient has access to medications at

hospital discharge• Releases discharge prescriptions for transmission • Provides ad hoc counseling for discharge medication therapy

Bryan Medical Center Discharge Medication Reconciliation Process : Benefits• Increased utilization of patient friendly language

• Improved patient and caregiver education

• Reduced medication errors

• Lowered cost of discharge medication therapy

• Fewer missing prescriptions/medication orders at hospital discharge

• Collaboration with all members of the healthcare team

Bryan Medical Center Ambulatory Care Pharmacy Program• Transitional Care Management

• Pharmacist works with Care Navigator • Pharmacist Role:

• Assess Compliance • Identify barriers

• Evaluate disease states• Add indications to outpatient medications (Collaborative Practice Agreement) • Confirm patient receives education regarding drug administration technique• Give recommendations regarding lab monitoring or follow-up• Facilitate prescription transmission if needed• Provide a quick synopsis of what occurred during hospital stay

• Identify potential issues resulting from or potentially resolved by medication therapy

• Ultimate goal = reduce readmissions7 and costs8

Audience Activity

What do you believe to be potential barriers to implementing a Pharmacist led Care Transition Service?

Barriers to Implementing a Pharmacist Led Transition Service

• Staffing

• Pharmacist to patient ratio (patient load)

• Timing of admissions and discharges (what are the service hours?)

• Willingness of patient/family to participate• Compliance• Retention of information

• Provider buy-in (potentially pulling FTEs from other services)

• Cost of pharmacy services (must justify a benefit to increased pharmacy staffing)

• Socio-economic disparity

• Staff training and competency

• Networking

• Sacrificing speed for accuracy

• Flow of information across healthcare systems (e.g. Bryan to non-Bryan facility)

• Access to medications on discharge • Affordability • Transportation

Collaboration between pharmacists in all areas of care can ensure medication compliance

• Pharmacists are medication experts – each area of practice can contribute

• Increased Communication• Collaboration between inpatient – outpatient – skilled nursing care• Creation of a more universal and consistent transmission of data between levels of care• Formation of workgroups• Process Improvement

• Medication indications • Streamlining home medication lists and MARs/TARs

• Consistent medication lists across levels of care• Reduction of inappropriate prescribing

• Increased Education• Patient/caregiver awareness regarding medication changes and drug indications18

• Continued evaluation of competency • Pharmacist • Patient/caregiver

Resources

1. Gleason, K., Groszek, J., et al. (2004). Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients[Electronic version]. American Journal of Health System Pharmacists, 61. 1689-1695.

2. Aspden, P., Wolcott, J., et al. (2006).Reporting Brief: Preventing Medication Errors. Institute of Medicine of the National Academies. 1-4.

3. Preventing Medication Errors. National Institute of Medicine. Accessed April 9, 2019 from https://psnet.ahrq.gov/resources/resource/4053/Preventing-Medication-Errors-Quality-Chasm-Series--.

4. Nester, T., Hale, L., Effectiveness of a pharmacist-acquired medication history in promoting patient safety [Electronic version]. American Journal of Health System Pharmacists, 59. 2221-2225.

5. CMS Updates Guidance for Hospital Discharge Planning. Accessed May 10, 2019 from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-cert-Letter-13-32.pdf.

7. CMS Hospital Readmissions Reduction Program (HRRP). Accessed April 9, 2019 from https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hrrp/hospital-readmission-reduction-program.html.

8. Ni, W., Colayco, D., et al. (2018). Budget Impact Analysis of a Pharmacist-Provided Transition of Care Program [Electronic version]. Journal of Managed Care & Specialty Pharmacy, 24 (2). 91-96a.

9. Shull, M., Braitman, L., et al. (2018). Effects of a pharmacist-driven intervention program on hospital readmissions Center [Electronic version]. American Journal of Health System Pharmacy, 75 (9), e221-230.

10. Jack, B., Chetty, V., et al. (2009). A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial [Electronic version]. Annals of Internal Medicine, 150 (3). 178-187.

11. Sawyer, R., Odom, J., et al. (2016). Discharge Medication reconciliation by Pharmacists to improves Transitions following Hospitalization (DEPTH) [Electronic version]. Greenville Health System Procedures, 1(1). 32-37.

12. Walker, S., Lo, J., et al. (2014). Identifying Barriers to Medication Discharge Counselling by Pharmacists [Electronic version]. Canadian Journal of Hospital Pharmacy. 67 (3). 203-212.

Resources

13. Longstreth, K. Implementation and Evaluation of Pharmacist-Optimized Education and Transition (POET) Service at a Community Teaching Hospital. Retrieved May 10, 2019, from www.ashpmedia.org/pai/docs/casestudy-implementation-and-evaluation-of-a-poet-service.pdf

14. McIlvennan, C., Eapen, Z., et al. (2015). Hospital Readmissions Reduction Program [Electronic version]. Circulation. 131(20). 1796-1803.

15. Rottman-Sagebiel, R., Cupples, N., et al. (2018). A Pharmacist-Led Transitional Care Program to Reduce Hospital Readmissions in Older Adults [Electronic version]. Federal Practitioner, 42-50.

16. Joynt, K., Figueroa, J., et al. (2016). Opinions on the Hospital Readmission Reduction Program: Results of a National Survey of Hospital Leaders Center [Electronic version]. The American Journal of Managed Care, 22 (8), e287-e294.

17. Phatak, A., Prusi, R., et al. (2016). Impact of Pharmacist Involvement in the Transitional Care of High-Risk Patients Through Medication Reconciliation, Medication Education, and Postdischarge Call-Backs (IPITCH Study) [Electronic version]. Journal of Hospital Medicine, 11(1). 39-44.

18. Hawes, E., Maxwell, W., et al. (2014). Impact of an Outpatient Pharmacist Intervention on Medication Discrepancies and Health Care Resource Utilization in Posthospitalization Care Transitions [Electronic version]. Journal of Primary Care & Community Health, 5(1). 14-18.

19. Hawes, E., Misita, C., et al. (2016). Prescribing pharmacists in the ambulatory care setting: Experience at the University of North Carolina Medical Center [Electronic version]. American Journal of Health System Pharmacy, 73 (18), 1425-1433.

20. Keeys, C., Kalejaiye, B., et al. (2014). Pharmacist-managed inpatient discharge medication reconciliation: A combined onsite and telepharmacy mode [Electronic version]. American Journal of Health System Pharmacy, 71, 2159-2166.

21. Woodall, T., Landis, S., et al. (2017). Provision of annual wellness visits with comprehensive medication management by a clinical pharmacist practitioner [Electronic version]. American Journal of Health System Pharmacy, 74 (4), 218-223.

22. Arnold, M., Buys, L. et al. (2015). Impact of pharmacist intervention in conjunction with outpatient physician follow-up visits after hospital discharge on readmission rate [Electronic version]. American Journal of Health System Pharmacy, 72 (1), 536-542.

Learning Assessment

Question 1

Historically, efforts to improve care transitions have been led primarily by:

a) Patients

b) Pharmacists

c) Nurses

d) Physicians

e) C and D

Question 2

Care transitions void of pharmacy/pharmacist intervention often require extensive clarification of medication therapies and place the patient at an increased risk for medication related adverse events.

• True

• False

Question 3

By utilizing pharmacy technicians to collect home medication data upon transfer from the outpatient to hospital setting, Bryan Medical Center is able to obtain a complete medication list which contains the following:

a) Prescription medications

b) Supplements/Herbals

c) Eyes drops/nasal sprays/inhalers

d) Injectables

e) All of the above

Question 4

What percentage of medication errors are believed to result from poor handoff at care transition (admission, transfer, discharge)?

a) >15%

b) >30%

c) >40%

d) >50%

Question 5

Ambulatory Care pharmacists can provide assistance in understanding the events of a hospital course, reducing medication cost, increasing adherence/compliance, and medication management of disease states.

• True

• False

Question 6

Adequate staffing is not a barrier to implementing a pharmacist led care transition service.

• True

• False

Question 7

Collaboration of pharmacists from different areas of practice can provide which of the following:

a) Greater efficiency, reduced medication errors, enhanced flow of information, and improved patient education

b) Greater efficiency, reduced medication errors, enhanced flow of information, and reduced patient education

c) Reduced efficiency, reduced medication errors, enhanced flow of information, and improved patient education

d) Greater efficiency, reduced medication errors, non-existent flow of information, and improved patient education

Question 8

Pharmacists at different levels of care can collaborate to make sure a patient is initiated on affordable medication therapy.

• True

• False