Transitions of Care A Pharmacy Approach

March 19, 2019

Disclosures

• I have no actual or potential conflict of interest in relation to this program/presentation.

Objectives

• Identify current healthcare trends, including the need for coordinated and patient-centered transitions of care models

• Identify opportunities for pharmacist intervention within successful transitions of care models

• Describe types of patients who are most likely to benefit from a coordinated and patient-centered transitions of care model

• Explain the financial, quality, and patient safety benefits associated with a medication reconciliation pharmacist on admission and discharge

Transitions of Care

The movement patients make between healthcare practice settings as their condition and care needs change during a chronic or acute illness.

Naylor, M.D., Aiken, L.H., et al. Health Affairs 2011;30(4):746-754.

Transitional Care

• Ensure coordination and continuity of care

• Team Approach MD RN Case Manager/Social Worker Pharmacist PT/OT Dietician Patient & Caregiver

Naylor, M.D., Aiken, L.H., et al. Health Affairs 2011;30(4):746-754.

The Transitional Care Process Begins:

A. When the provider writes the discharge order

B. Upon admission to a healthcare facility

C. As a patient is leaving the hospital setting

D. When the patient arrives at their home

E. At the follow-up appointment one week after discharge

The Reality

• We have all probably seen this Swiss cheese model at some point. In regards to transitions of care, we have hard-working clinical staff with good intentions who try their best to provide a safe transitions of care for patients but this is hindered by the various failed or broken processes within the healthcare system

• Preparing patients for discharge starts at admission, not when a provider writes the order for discharge• Start earlier to identify any points of failure that may lead to adverse events

Modified from Reason J. Human error: models and management. BMJ. 2000;320:768-770.

Scope of the Problem

• Why is there such a huge focus on healthcare, why all these changes??• The US spends most money on healthcare than other countries and also provides less

quality of care• Money is not amounting to better care• Figure 1 – The Commonwealth Fund’s Overall Ranking of Healthcare Systems.

Scope of the Problem

• Americans take 5 or more medications1 in 3• Will leave the hospital with at least 1 new

prescription4 out of 5• Will not see a physician within 30 days of

discharge50%• Of post-discharge adverse events are

medication related72%Alper, E, et al. In: UpToDate, Auerbach AD (Ed), UpToDate, Waltham, MA, 2014.

What is the estimated yearly cost of preventable readmissions?

A. $10 Billion

B. $500 Million

C. $26 Billion

D. $90 Billion

Medicare Beneficiary Statistics• 1 in 5 Medicare beneficiaries are readmitted within 30 days

• CMS recognizes that poor transitions of care lead to preventable readmissions which cost $26 billion per year, which is 17% of total hospital payments

88% of all prescription

medications are filled for Medicare

beneficiaries

Medicare beneficiaries will see an average of 13 different physicians per

year

Medicare beneficiaries will

fill about 50 different

prescriptions per year

1. Jencks SF, et al. N Engl J Med 2009; 360:1418-1428.2. O luga A, et al. Risk Manag Healthc Policy. 2014; 7: 35–44.3. Centers for Medicare and Medicaid Services. Real-Time Reporting of Medicare Readmissions Data. Niall Brennan,

Acting Director, Offices of Enterprise Management. February, 2014

The Joint Commission (TJC)

• National Patient Safety Goal 03.06.01

Maintain and communicate accurate patient medication information

• TJC Core Measures

What Percentage of Medication Errors Occur During Transitions of Care?

A. 10%

B. 66%

C. 90%

D. 25%

The Burden of Medication Errors

• 66% of medication errors occur in transitions of care

20% of these errors result in patient harm

• Serious preventable medication errors occur in 3.8 million inpatients + 3.3 million outpatients

• 7000 deaths annually due to preventable medication errors

1. Forster AJ, Murff HJ, et al. Ann Intern Med. 2003;138(3):161.2. Forster AJ, Clark HD, et al. CMAJ. 2004;170(3):345.

Types of Medication Errors• Inpatient

– Omissions– Incorrect dosing– Incorrect frequency– Wrong formulation– Polypharmacy

• Outpatient– Patient sent home without

prescriptions for necessary medications

– Prescription sent to wrong pharmacy

– Duplicate therapy– Unforeseen drug interactions– Misunderstanding medication

instructions

Which of the following patients are most likely to be readmitted?

A. Patients on high-risk medications including insulin and anticoagulants

B. Patients with low health literacy

C. Patients with heart failure

D. Patients on 5 or more medications

E. All of the above

Predictors of Complicated Care Transitions

Clinical Risk Factors

• Use of high risk medications

• Polypharmacy• More than 6 chronic

conditions• Specific clinical

conditions (COPD, diabetes, stroke, heart failure, cancer, depression)

Demographic and Logistical Risk Factors

• Prior hospitalization• Black race• Low health literacy• Reduced social

network indicators• Lower socioeconomic

status

Alper, E, et al. In: UpToDate, Auerbach AD (Ed),UpToDate, Waltham, MA, 2014. Accessed 30 March 2016.

Common Medication Related Problems

Untreated Indication

Failure to Receive Needed

Medication

Drug Interactions

Improper Drug Selected

Overdosage

Medication Use Without

Indication

Subtherapeutic Dose

Adverse Drug Reaction

Medication Non-Adherence

Bridging the Gap: Pharmacy’s Role

Length of stay and readmission

Obtain complete and accurate medication history

Prevent unnecessary therapy, duplications, dosing errors, adverse events, omissions

Interface with interdisciplinary teamAnticipate medication access issues early onSuggest IV-PO conversionsAssist in pain management

Adverse drug events associated with two-fold increase in mortality and length of stay

Case #1• JM is a 68 yo male with a hx of afib, diabetes, hypertension

admitted for gallstones and is to undergo laparoscopic cholecystectomy.

• His home medications include diltiazem, metoprolol, metformin, sitagliptin, apixaban and atorvastatin.

• When asked about medication history patient reports taking 5 medications: a blue one, a small white one, etc.

• 3 days into hospitalization, JM develops rapid afib and requires IV diltiazem to control heart rate.

Bridging the Gap: Pharmacy’s Role

Patient/Caregiver Education

Case #2

A 68-year-old man is readmitted for heart failure only one week after being discharged following treatment for the same condition. He brought all of his pill bottles in a bag; all of the bottles were full, not one was opened. When questioned why he had not taken his medication, he began to cry, explaining he had never learned to read and couldn’t read the instructions on the bottles.

Bridging the Gap: Pharmacy’s Role

Quality– Ensure core measures are met

Heart failureStrokeMyocardial infarction

Case #3

• PW is a 76 yo female admitted to hospital with acute CVA. She is treated with TPA however her hospitalization is complicated by development of pneumonia. After 10 days in hospital and completion of IV antibiotics, she is ready for discharge home. She has NKDA.

• Discharge medications include: ASA, Metoprolol, Lisinopril, latanoprost eye drops.

• What is missing?

Bridging the Gap: Pharmacy’s Role• Discharge

– Review discharge medication list and address any potential drug interactions with attending

– Review labs and adjust medication doses if needed

– Anticipate any barriers in access to medication

– Educate patient/caregiver in indications, potential side effects, and proper administration of medications

Case #4• A 50 yo Spanish speaking male with PMH hypertension

is admitted to hospital with acute MI, taken to cardiac cath lab and 2 stents are placed.

• On discharge he is given prescriptions for ASA, Ticagrelor (Brilinta), Carvedilol (Coreg), Atorvastatin (Lipitor), SL nitroglycerin

• Patient was in a rush to leave and get back to work. Discharge was rushed and he was not properly educated on medication compliance. Goes to pharmacy, ticagrelor requires prior authorization

• 7 days later, patient readmitted with chest pain due to clotted stent

Bridging the Gap: The Role of the Community Pharmacist

Adverse events estimated to occur in 20% of patients following discharge

Cost of medication non-adherence = $300 billion annually

Key interventions: MTM services

Encourage follow-ups

Patient counseling

Prevention of drug-drug/drug-food interactions

Address medication adherence discrepancies

Reimbursement Opportunities

CPT code for Transitional Care Management (TCM) 99495 (face-to-face visit within 14 days of discharge)

$134.67: facility based settings

$163.91: physician office setting

99496 (face-to-face visit within 7 days of discharge) $197.58: facility based settings

$230.90: physician office setting

Why Pharmacists?

Why Pharmacists?

Study 1, Nestor, et al. Medication history obtained by pharmacist vs RN

Significantly more clinical interventions (34% vs. 16%; p<0.001)

Study 2, Schnipper, et al. Telephone follow-up by pharmacists in 178 discharged patients

Significantly lower rate of preventable adverse events (1% vs. 11%; P=0.01)

Significantly lower rate of medication related ER visits or readmissions (1% vs. 8%; P=0.03)

Why Pharmacists?

• Medication reconciliation reduced discharge medication errors from 90% to 47% on a medical unit of a large academic medical center

• Patients who received follow-up phone calls were 88% less likely to have a preventable medication error resulting in an ED visit or hospitalization

• Preventable adverse events decreased by 78% when pharmacist part of rounding team

Objectives of a TOC Program

• Improve patient safety by avoiding medication errors

• Communicate accurate medication information with patient and involve caregivers

• Initiate care immediately

• Improve medication adherence

• Identify and address potential barriers to adherence

• Reduce readmissions and adverse events

• Decrease length of stay

• Improve HCAHPS scores

Role of the TOC Pharmacist Primary function medication reconciliation

HUMC model Pharmacists work hand in hand with case management, providers,

nursing

Facilitate admission and discharge medication reconciliation

Medication history documented by nursing at triage

Patient designated as admitted

Medicationreconciliation

completed by TOC pharmacist within 24 hr

Medication reconciliation signed

off by provider

Admission Workflow

Goal: to complete admission medication reconciliation within 24 hours of admission

Pharmacist reviews medication history with patient and/or caregiver

Pharmacist reviews labs and notes

Pharmacist reconciles medication list with provider, orders automatically verified

Discharge Workflow

Pharmacist reviews discharge medication reconciliation*ideally admission was also done by Pharmacist

Pharmacist reviews labs and notes

Any discrepancies are addressed with with appropriate provider

Pharmacist counsels patient on new medications and changes, offers meds-to-beds program, addresses any cost/access issues

Medication Reconciliation Process

Medication History

• Typically done at triage

• Best possible medication history Patient, family member, electronic documentation, outpatient pharmacy

• Assess adherence Access

Affordability

Lack of knowledge

• Pharmacy and/or nursing driven

MARQUIS Medication History

• Include Name of each medication

Formulation

Dosage, route, frequency, and time taken

Non-prescription medications

• Use at least 2 sources of information

• Ask open-ended questions

• Utilize EPIC Surescripts, NJPMP

Resources

• Revamp the role of the pharmacist and workflow

• Less pharmacists in main pharmacy Decentralized pharmacists

• Pharmacy extenders Technicians

Students

Residents

• Community Target high-risk populations/medication classes

Effective Models of Transitions of Care

• Project RED (Re-engineered Discharge)

• CTI (Care Transitions Intervention)

• BOOST (Better Outcomes for Older Adults through Safe Transitions)

• TCM (Transitional Care Model)

• GRACE (Geriatric Resources for Assessment and Care of Elders)

APhA/ASHP Medication Management in Care Transitions Project (MMCT)

• Best practices in care transitions

• ~80 institutions submitted and 8 selected as best practice

• Best practice

Impact on patient care

Pharmacy involvement

Potential to implement elsewhere

Barriers

• Financial resources

• Staffing resources

• Electronic transfer of patient information and data to partner groups

• Communication

• Difficulty developing relationships with inpatient or outpatient partners

Elements for Success

• Multidisciplinary support and collaboration

• Effective integration of the pharmacy team

• Data available to justify resources*

• Electronic patient information and data transfer between inpatient and outpatient partners

• Strong partnership network

Data to Justify Resources

• Readmissions

• Length of stay

• Emergency department visits

• Medication-related problems at medication reconciliation

• Disease-specific metrics

• Patient satisfaction or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)- related metrics

HUMC

• Goals

• Prevent medication errors

• Expand pharmacy role

• Improve HCAHPS scores

• Players

• Decentralized pharmacists

• Pharmacy technician

• Pharmacy residents/students

• Components• Attend MDR rounds on cardiac

and diabetes unit• Admission medication

reconciliation• Patient counseling• Prescription filling at

discharge

HUMC Metrics

• Average medications per patient: 7• Average errors per patient: 4• In 24% of patients, at least one change was

made to the current medication list when pharmacist was NOT the FIRST to reconcile

HUMC Metrics

Error Profile

* Incorrect entries include wrong strengths, medications patient is no longer taking, has been discontinued, and completed therapies.

Discharge Involvement

• Discharge medication reconciliation responsibility falls on attending physician

• TOC pharmacists assist when MD unavailable or unable to do discharge med rec

• Common Interventions– Clarify dosing (i.e. renal dosing)

– Call in new medications to pharmacy

– Correct errors on discharge summary

– Educate patient and caregiver on medication changes

Meds-to-Beds Program

• Goal: improve access to medications

• Pharmacy technician works closely with case managers and social workers

• New prescriptions are filled and delivered to patient at bedside

• Prior authorizations, cost and other issues addressed and resolved prior to discharge

Role of the TOC Technician

• Attend MDR rounds on cardiac unit• Interface with nursing, social workers and case managers• Work with orthopedic APNs to provide medications and

supplies for surgical patients• Troubleshoot insurance and medication access issues• Follow-up phone calls within 30 days of discharge

Role of the TOC Technician

• Obtain and input medication history Discrepancies addressed with pharmacist

• Follow-up phone calls Route medication or health related questions

• Ensure patient follow-up Was follow-up appointment made? Did patient

have any issues refilling medication?

• Improve medication adherence by resolving issues

Future Considerations

• Collaborative Practice Agreements• Partner with home care• Partner with local community pharmacies• Transitional Care Management Billing Codes:

99495 and 99496

Where do we stand?

• Currently less than 30% of hospital systems utilize pharmacist services in transitions of care

• In one survey of technicians only about 39% were involved in TOC

• Future of ACA and HRRP is currently unknown

• Navigating the healthcare system is becoming increasingly complex for patients

• Transitions of care services are always beneficial to both health system and patients

Which of the Following Statements is FALSE?

A. Key components of the transitional care process include patient and caregiver education, medication reconciliation, follow-up and transmission of information

B. 60 percent of all medication errors occur during care transitions

C. The cost of medication errors is an estimated $1 million

D. Obtaining a complete and accurate medication history is one of the Joint Commission's patient safety goals

Which of the following are considered transitions of care scenarios?

A. Patient discharged from hospital to home

B. Patient moved from ICU to general medical unit

C. Patient sent from rehab to home

D. A and C

E. All of the above

Who is responsible for the transitions of care process?

A. The attending physician and all the specialists who saw the patient

B. The patient’s nurse during hospitalizations

C. The patient’s primary outpatient physician

D. The case manager or social worker assigned to the patient’s case

E. All members of the healthcare team, including the patient and caregivers

When performing admission medication reconciliation, pharmacists should assess which

of the following?

A. Medication discrepancies

B. Medication compliance issues prior to admission

C. Medications not on hospital formulary

D. All of the above

References

1. ASHP-APhA Medication Management in Care Transitions Best Practices. <http://www.ashp.org/DocLibrary/Policy/Transitions-of-Care/ASHP-APhA-Report.pdf> Accessed November 21, 2017.

2. Naylor, M.D., Aiken, L.H., Kurtzman, E.T., Olds, D.M. & Hirschman, K.B. The importance of transitional care in achieving Health Reform. Health Affairs 2011;30(4):746-754.

3. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003;138(3):161.

4. Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, Khan A, van Walraven C. CMAJ. 2004;170(3):345.

5. Ernst FR, et al. J Am Pharm Assoc (Wash). 2001 Mar-Apr;41(2):192-9.

6. Gil M, Mikaitis DK, Shier G, Johnson TJ, Sims S. Impact of a combined pharmacist and social worker program to reduce hospital readmissions. J of Manag Care Pharm. 2013;19(7):558-563.

7. Kongkaew C, Noyce PR, Ashcroft DM. Hospital admissions associated with adverse drug reactions: a systematic review of prospective observational studies. Ann Pharmacother. 2008;42(7-8):1017-1025.

8. Nestor TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health-Syst Pharm. 2002; 2221-2225.

9. Schnipper JL, Kirwin JL, Cotungo MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006; 166(5):565-571.

10.Kucukarslan SN, Peters M, Mlyrnarek M, et al. Pharmacists on Rounding Teams Reduce Preventable Adverse Drug Events in Hospital General Medicine Units. Arch Intern Med. 2003;163(17):2014-2018.

Thank You!!!

Nilesh Desai, B.S, RPh., MBAAdministrator Pharmacy and Clinical Operations

NileshP.Desai@HackensackMeridian.org551-996-2089