Hospital to Home Medslink

CoNeCTing medicines care post discharge

Deirdre Criddle ~ Complex Care Coordinator Pharmacist

“Dealing with physical health, mental

health and social care needs separately

makes no sense at a time when people

increasingly depend on all three types of

support.”

Dr Ed Wagner

MacColl Institute for Healthcare Innovation

Group Health Research Institute

Canterbury Clinical Network

~ Coordinated Care after a crisis

http://www.ccnweb.org.nz/

Canterbury Clinical Network

~ Coordinated Care after a crisis

http://www.ccnweb.org.nz/

CoNeCT ~ Complex Needs Coordination Team

Established 2010

An initiative of the Government of Western

Australia’s Friend In Need Emergency

(FINE) scheme, overseen by the

Department of Health of WA and the

metropolitan area health services

Multidisciplinary teams embedded within

several hospitals

CoNeCT Clients are;

High users of hospital services

Multiple presenters to Emergency Departments

People at the higher end of functional decline, in the

later stages of chronic disease and/or those with

multiple co-morbidities

People who are in complex psychosocial

circumstances

Not duplicating or replacing existing care

coordination or case-management services

The CoNeCT Team

Senior Nursing, Physiotherapy, Occupational

Therapy and Social Work in a generic role

Specific Pharmacy role

Common Clinical Competencies

Governance with Primary Care ~unless our

clients are in hospital

Care Coordination Model

6 month pre-post review outcomes

Impact of CoNeCT intervention on ED presentations, admissions and total LoS - all patients [n=45]

(Excludes deceased patients and JHC referrals)

18%13%

18%

22%24%

2%

60% 62%

80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ED Presentations Inpatient Admissions Total LoS

Perc

en

tag

e v

alu

e

Reduced

Unchanged

Increased

Primary health issue

Length of Stay Project Team ~ Respiratory

Project team working with Department representatives

reviewing processes & discussing barriers and

developing solutions to reduce length of stay

CoNeCT identified as enabler to improve care after

discharge

CoNeCT identified as enabler to reduce readmissions

CoNeCT pharmacist identified for role in Early Post

Discharge medication review to “high risk” respiratory

patients, & screen for future CoNeCT Care

coordination if needed

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A problem in parallel

• The period 7 to 10 days following

hospital discharge is a vulnerable

time associated with a significant

risk of medication misadventure,

especially in high-risk patients.

• Studies show ~ 50% of the adults

discharged from hospital

experience a medical error, with

19%-23% suffering an adverse

event, most commonly an

adverse drug event.

Kriplani, Jackson, Schnipper et al, 2007

Journal of Hospital Medicine 2007;2:314 –323).

Perennial problem with transitions of care

Journal of Pharmacy Practice and Research (2015) 45, 208–210

Perennial problem with transitions of care

The Joint Commission currently has standards,

National Patient Safety Goals, survey activities,

and educational services that address transitions

of care, however these mechanisms have limited

utility or reach.

Currently address transition of care concerns

within a healthcare setting, but neither “cross

settings,” nor do they address what happens to

patients after they leave a healthcare setting.

Paving the way for Pathways

“An integrated care pathway (ICP) is a

multidisciplinary outline of anticipated care, placed

in an appropriate timeframe, to help a patient with

a specific condition or set of symptoms move

progressively through a clinical experience to

positive outcomes.”

– Oxford University Medicine

1) Bandolier, Integrated care pathway, http://www.medicine.ox.ac.uk/bandolier/booth/glossary/icp.html

© James Gupta 2012 | james.gupta@hsthpct.nhs.uk

Multidisciplinary

Evidence-based

Anticipated

Local & Specific

Developing a Pathway Approach to COPD

Commissioning

Multidisciplinary Chest physicians

GPs

Practice nurses

COPD / community nurses

Practice managers

Pharmacists

Respiratory physiotherapists

Smoking cessation advisers

Spirometry technicians

Committed

Lead: clinical and managerial experience

1 • Assemble a

team

2 • Design a

pathway

3 • Implement it

© James Gupta 2012 | james.gupta@hsthpct.nhs.uk

What are the benefits of using pathways?

Patients receive care that is not only more

consistent, but also of a higher standard and

more up to date with the latest evidence

Clinicians feel more confident and can get

more done in less time

Resources are used more appropriately

Emergency / non-elective admissions can be

reduced

Rotter et al Cochrane Review 2010

1) Rotter et al, Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006632. DOI: 10.1002/14651858.CD006632.pub2.

2) Campbell H, Hotchkiss R, Bradshaw N, Porteous M, Integrated care pathways. BMJ 1998, 316(7125):133-7.

3) Lowe C, Care pathways: have they a place in ‘the new National Health Service’? J Nurs Manag 1998, 6(5):303-6.

© James Gupta 2012 | james.gupta@hsthpct.nhs.uk

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Medication management solutions?

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Medication management solutions?

• The National Efficient Price is $4,971 per

National Weighted Activity Unit (NWAU).

• Non-admitted price weight Clinical Pharmacy

40.04 = 0.1676

• Price of an outpatient clinic visit = $833.13

STAGE 1

Clinical Pharmacist +/- Ward Clinical Nurse Coordinator

Screens for medication misadventure (using tool)

Safe and appropriate for home visit

Consent from patient for home visit documented in notes

Refers CoNeCT Clinical Pharmacist (CCP) with Estimated Date of Discharge

STAGE 2

CCP contacts patient at home

Requests: Discharge Summary, Medical Record

CCP coordinates: Date and time for Clinical Pharmacy Consult

STAGE 3

CCP conducts Medication Review, reconciles medications from discharge

with medicines at home and resolves medication related problems

CCP ensures; Medication education incl inhaler technique and smoking

cessation, Accurate Medicines List, Outpatient clinic, Pulmonary Rehab, GP

visits booked, vaccination status, ?Action Plan

CCP refers as needed to Community Respiratory Nurse, CoNeCT

Copy of notes from visit, and all correspondence placed in Patients Medical

Record

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The referral

Multidisciplinary

Evidence-based

Anticipated

Local & Specific

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Stratified risk assessment

Adapted from Hospital Outreach in VIC and SA

Risk factors for medication misadventure include: • Lives alone and manages own medicines (3 points).

• Cognitive impairment and manages own medicines (3 points).

• Multiple medications on admission (1.5 points).

• Recurrent admissions to hospital (eg. 2 in 6 months (3 points).

• Changes in medications/dose during the admission (1.5

points.

• Clinical impression of the medical team that a post-discharge

HMR is warranted (5 points).

• Other (1 point). eg. using multiple GPs, English is a second

language, having a low education, or a preference for

alternative/complementary medications).

Patients who score 5 or more on screening assessment

are considered ‘High Risk’ for medication misadventure.

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The screening tool

Validated

Australian

Used in the same setting ~ ie hospital to the home

Excellent way of stratifying risk!

Limits cost by ensuring only those most in need

receive service

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Who are we CoNeCTing Post-discharge?

Patients identified as high risk by screening tool

Having COPD diagnoses & admitted to Respiratory Ward

or Medical Assessment Unit

Deemed appropriate by Senior Clinical Nurse or Clinical

Pharmacist

Can be referred by any member of multidisciplinary team

Triaged for visit within 5 days or 10 days of discharge,

depending upon concerns

Must have signed referral with consent documented in

notes

Recovering heart attack patients fail to adhere to

prescribed medications

Reasons for not taking

medicines are multifactorial,

some reporting financial

hardship because of the

expense of drugs

“Patients who had low adherence cited poor communication of

the need and reasons for each of the discharge medications, as

well as the possible side effects that they may encounter”

Assessing health literacy when disseminating written

patient instructions and educational materials was also

identified as crucial to adherence

Circ Cardiovasc Qual Outcomes.2015;CIRCOUTCOMES.114.001223published

online before print June 2 2015,

Recovering heart attack patients fail to adhere to

prescribed medications

Patients were more likely adherent with medication six

weeks after their heart attack if follow-up appointments

had been made for them before discharge.

“Lack of contact represents a lost opportunity not only for

reinforcing continued treatment goals but also for assessing

medication intolerance and patient knowledge gaps that

might contribute to non-adherence,”

Circ Cardiovasc Qual

Outcomes.2015;CIRCOUTCOMES.114.001223

published online before print June 2 2015,

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What are we collecting & collating?

Measure of risk by screening tool

Language or literacy concerns

No. admissions in past 6 months & Length of Stay

No. of doctors involved in care

Lives alone & managing own medications?

Cognitively impaired & managing own medications?

Regular GP? Community Pharmacist?

Errors on discharge summary?

Booked for GP and Specialist Outpatient Clinic?

Up-to-date Medicines List?

Adherence risk? –McHorney Concerns? Cost?

Commitment? Low/Medium/High

What are we collecting & collating?

Education provided

Action Plan in conjunction with respiratory Nurse/GP

Inhaler technique

Smoking Cessation

On referral ~ Respiratory Nurse, HMR/Medscheck CoNeCT

Care Coordination

Vaccination status

No. Medication Related Problems (MRP)

Resolved by who?

Measures of success

Does clinical pharmacy intervention reduce

readmission rate and LOS 6 months after

intervention?

Did the patient attend Specialist OP

appointment?

Does the patient still have an Up-To-Date

Medicines List 6 months after?

Readmission rate 6 months after?

Patient satisfaction?

GP satisfaction?

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The journey continues ~ the services evolves

Encouraging patient-focussed inside-out thinking;

“Who are you? Where are you from? How did you get to be

here? What failed? How can we stop this happening

again?”

Transitional care, which encompasses both the

sending and the receiving aspects of the transfer, is

essential for persons with complex care needs1.

Improving post hospital medication safety requires

shared care responsibility between acute & primary

care. 1. Russell, L et al National Lead Clinicians Group ~Patient safety – handover of

care between primary and acute care Policy review and analysis March 2013

CoNeCTing medication management post discharge

Take Medications out of the “Background” with

ISOBARM to improve & prioritise handover of

Medication Management on discharge

No “Silver Bullet” but a coordinated collaborative

handover of care to a patient’s usual Medicines

Management Team is likely to come pretty close

Thankyou

COPD Length of Stay Team SCGH

Ms Carolyne Wood ~ CoNeCT Team Lead NMHS

Ms Julie Rennison ~ Area Manager Homelink

NMHS

Dr Fiona Lake ~ Respiratory Physician SCGH

Ms Lynda Cruikshank – CNC G54

Multidisciplinary Team G54 SCGH

Pharmacy Department SCGH

My wonderful NMHS CoNeCT colleagues

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