transionalcare:...
TRANSCRIPT
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Leigh Ann Ross
Associate Dean of Clinical Affairs
UMMC School of Pharmacy
Transitional Care: How Pharmacists Can Impact Outcomes
April 14, 2015
Transi(onal Care:
How Pharmacists Can Impact Outcomes
Leigh Ann Ross, PharmD, BCPS, FCCP, FAPhA Associate Dean for Clinical Affairs
Chair, Department of Pharmacy Prac7ce The University of Mississippi School of Pharmacy
BreB Smith, PharmD Clinical Instructor
The University of Mississippi School of Pharmacy
April 14, 2015
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Objec(ves • Describe transi7ons of care (TOC) in various seCngs • Discuss common medica7on errors seen during TOC • Explain poten7al pharmacist interven7ons during TOC • Analyze implemented TOC programs and their outcomes
• Describe the University of Mississippi School of Pharmacy’s Project: Pharmacist Linkage in Care Transi2ons: From Academic Medical Center to Community
Defining Transi(ons of Care
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Transi(ons of Care
• “Movement of pa7ents between health care loca7ons, providers, or different levels of care within the same loca7on as their condi7ons and care needs change.” • Na7onal Transi7ons of Care Coali7on (NTOCC)
• High risk for readmission, medica7on errors, increased expenses, and overall diminished quality of pa7ent care if transi7ons of care are not handled appropriately.
Types of Transi(ons • Home to hospital
• Preadmission medica7on reconcilia7on • Communica7on with outpa7ent pharmacy
• Hospital to home • Post-‐discharge follow-‐up appointment • Communica7on with primary care providers • Discharge medica7on reconcilia7on • Discharge medica7on educa7on
• Within hospital • Medica7on reconcilia7on and order review • Communica7on with transferring interdisciplinary team
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Goals of Transi(ons of Care • Improve pa7ent care • Prevent all-‐cause readmission post-‐discharge • Avoid medica7on errors • Increase provider communica7on • Provide in depth pa7ent educa7on and ensure pa7ent understanding
• Improve pa7ent adherence and compliance • Maximize Medicare and Medicaid reimbursement rates
Readmission and
Reimbursements
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Readmission Post-‐Discharge
• Nearly 20% of Medicare pa7ents were readmiYed within 30 days of discharge in 2009 • 50% did not see provider post-‐discharge
• 60-‐day readmission rates were 31% • Readmission rate decline in 2012 Jencks SF, et al. Rehospitaliza2ons among Pa2ents in the Medicare Fee-‐for-‐Service Program. NEJM 2009; 360:1418-‐1428. Bellone JM, et al. Postdischarge interven2ons by pharmacists and impact on hospital readmission rates. JAPhA. 2012;52:358-‐62.
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CMS Reimbursement • Hospital Readmissions Reduc7on Program
• Affordable Care Act added to Social Security Act • Centers for Medicare & Medicaid Services (CMS) limit reimbursement based on 30-‐day readmission rates
• Acute Myocardial Infarc7on (AMI), Heart Failure (HF), Pneumonia (PN)
• New applicable condi7ons added in 2014 • Acute exacerba7on of chronic obstruc7ve pulmonary disease (COPD)
• Elec7ve total hip arthroplasty (THA) and total knee arthroplasty (TKA)
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hTp://kaiserhealthnews.org/news/medicare-‐readmissions-‐penal2es-‐by-‐state/
Medica(on Errors
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Medica7on Errors • 60% of medica7on errors occur during transi7ons of care
• Medica7on errors during within hospital transi7ons • 22% during admission • 66% to or from intensive care unity • 12% during discharge
• 80% of serious medical errors are caused by miscommunica7on during a care transi7on
• 19% of Medicare pa7ents had an adverse effect (mostly from drugs) within 3 weeks post-‐discharge
Aronson JK. Medica2on errors: defini2ons and classifica2ons. Br J Clin Pharmacol / 67:6 / 599–604
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Types of Medica7on Errors
• Prescribing error • Error of omission • Duplica7on • Dosing error • Drug interac7on • Compliance error
Pharmacist Interven(ons
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Pharmacist Interven7ons
Pharmacist interven7ons can occur in a(n): • Hospital • Emergency department • Outpa7ent clinic • Skilled nursing facility • Long-‐term Care facility • Retail pharmacy • Home health
Pharmacists Role in TOC • Kern et al. sent survey to pharmacy directors
• Medica7on history on admission completed by nurses (56%) and pharmacy staff (31%)
• Targeted pharmacy service for specific pa7ent popula7on in 25% of facili7es
• 56% reported their pharmacists educated pa7ents on certain medica7ons, and 6% had pharmacists educated on all new medica7ons
• 32% reported that their pharmacists did not provide pa7ent educa7on
• On transi7ons within the hospital, 19% had pharmacists involved with order and drug selec7on, and 43% reported involvement with medica7on reconcilia7on
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Medica(on Reconcilia(on • “Comprehensive evalua7on of a pa7ent’s medica7on regimen any 7me there is a change in therapy in an effort to avoid medica7on errors…” • American Pharmacists Associa7on (APhA) and American Society of Health-‐System Pharmacists (ASHP)
• Comple7ng an accurate and complete medica7on list at every transi7on of care
• A 2010 study showed that upon obtaining a medica7on history, pharmacists iden7fied significantly more pre-‐admission medica7ons than physicians
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Medica(on Reconcilia(on Steps 1. Comprehensive list of current medica7ons
• Prescrip7on, Over-‐the-‐counter medica7ons, Vitamins • Dose, frequency, route • Refill history • Pa7ent adherence
2. Create list of medica7on to be prescribed • Based on acute and chronic condi7on management • Contraindica7ons, allergies, and pa7ent preference considered
Medica(on Reconcilia(on Steps 3. Compare original and updated medica7on lists
• Prevent duplica7on • Ensure each condi7on is addressed
4. Clinically decide which medica7ons should be con7nued, discon7nued, or added
5. Communicate • Provide recommenda7ons to health care team • Educate pa7ent about new regimen
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Inpa(ent Pa(ent Educa(on • Discharge counseling
• Discharge plan review • Disease state educa7on • Medica7on regimen review
• Pa7ent educa7on • Specific medica7on educa7on • Demonstra7on of how to use medica7on (i.e. insulin, asthma inhalers)
Community Pharmacy • Partnership with community hospital • Medica7on delivery to the hospital or pa7ent’s home
• Medica7on management post-‐discharge • Pa7ent follow-‐up within 72 hours post-‐discharge
• Opportunity for Medica7on Therapy Management services • Pa7ent appointment with pharmacist for medica7on review and educa7on
• Transi7ons of Care call centers
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Nursing Facili(es • Consultant pharmacist required by CMS at some long-‐term care facili7es
• Monthly medica7on review • Telephone follow-‐up 1 week post-‐discharge • Communica7on with physicians regarding medica7on discrepancies
• Communica7on with pa7ent and caregivers regarding medica7on regimen
• Transi7ons of Care call centers
Ambulatory Care • Postacute care clinic (PACC) model
• Interdisciplinary team follow-‐up in an outpa7ent seCng post-‐discharge
• Pharmacist reviews medica7on changes, evaluates for appropriate use, and facili7es communica7on between providers
• Scheduling and 7me constraints are barriers
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Pharmacist TOC Interven(on Studies • University of New Mexico Hospital pharmacy-‐driven Care Transi7ons Service (CTS) impact on medica7on related problems
• CTS phases 1. Medica7on reconcilia7on 2. Discharge medica7on review and hospital-‐to-‐community
pharmacist handoff 3. Follow-‐up phone call within 72 hours of discharge 4. Outpa7ent medica7on reconcilia7on at post-‐discharge
appointment
Conklin JR, Togami JC, BurneT A, Dodd MA, Ray GM. Care transi2ons service: a pharmacy-‐driven program for medica2on reconcilia2on through the con2nuum of care. AJHP. 2014;71:802-‐10.
Pharmacist TOC Interven(on Studies cont.
• 1140 MRPs iden7fied during phase 1 aker admiCng team performed medica7on reconcilia7on
• 70% of MRPs were resolved through pharmacy interven7on independent of provider
• Interven7ons involved removal (43%) and addi7on (29%) of medica7ons
Conklin JR, Togami JC, BurneT A, Dodd MA, Ray GM. Care transi2ons service: a pharmacy-‐driven program for medica2on reconcilia2on through the con2nuum of care. AJHP. 2014;71:802-‐10.
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Pharmacist TOC Interven(on Studies • Union Memorial Hospital in Bal7more – Chart Review • Comparing internal medicine pa7ents who received pharmacy discharge counseling versus standard discharge process
• 228 of 1136 discharged pa7ents received counseling • No difference in 30 day readmission rates between groups
• Stra7fied based on readmission risk • Moderate-‐risk group with counseling had significantly lower readmission rate (3.8% vs. 18.9%)
• High-‐risk pa7ents ini7ally targeted for counseling services
S2ll KL, Davis AK, Chilipko AA, Jenkosol A, Norwood DK. Evalua2on of a pharmacy-‐driven inpa2ent discharge counseling service: impact on 30-‐day readmission rates. Consult Pharm. 2013;28(12):775-‐85
Pharmacist TOC Interven(on Studies • Prospec7ve, randomized, pilot study • Effect of pharmacy clinic visit post-‐discharge on readmission, ED visits, and medica7on discrepancy resolu7on
• 54% had medica7on discrepancies iden7fied (n=33) – 50% resolved in interven7on group – 9.5% resolved in usual care group
• Lower 30-‐day rehospitaliza7on and ED visit composite outcome in interven7on vs. usual care group (0% vs. 40.5%)
Hawes EM, Maxwell WD, White SF, Mangun J, Lin FC. Impact of an outpa2ent pharmacist interven2on on medica2on discrepancies and health care resource u2liza2on in posthospitaliza2on care transi2ons. J Prim Care Community Health. 2014;5(1):14-‐8.
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Pharmacist TOC Interven(on Studies • CommUnityCare and Seton University Medical Center at Brackenridge in Aus7n, TX – Retrospec7ve EHR review
• 60 day readmission with pharmacist interven7on within 60 days post-‐discharge (n=67) vs. no interven7on (n=67)
• Pharmacist interven7on • Drug therapy ini7a7on or discon7nua7on • Dosage adjustment (52%) • Pa7ent counseling (88%) • Laboratory monitoring
• Interven7on group had significantly lower 60 day readmission rates compared to control (18% vs. 43%)
Bellone 2012 JAPhA
Pharmacist TOC Interven(on Studies • Medica7on reconcilia7on in a long-‐term care facility
• CroYy et al. inves7gated pharmacist impact on transi7on from hospital to long-‐term care facility • U7lized the Medica7on Appropriateness Index (MAI) score
• Assessment for older adults
– Improvement in medica7on appropriateness when a pharmacist performed a medica7on review (n=56) versus control (n=54)
CroTy M, et al. Does the addi2on of pharmacist transi2on coordinator improve evidence-‐based medica2on management and health outcomes in older adults moving from the hospital to a long-‐term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother 2004;2:257-‐64.
ü Indica7on ü Effec7veness ü Dose ü Direc7ons ü Prac7ce direc7ons ü Drug-‐drug interac7ons ü Drug-‐disease
interac7ons ü Cost ü Unnecessary
duplica7on ü Dura7on of therapy
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Pharmacist TOC Interven(on Studies • Telephone follow-‐up within 48 hours (n=110) versus control group (n=111)
• Discussed hospital stay, follow-‐up appointments, medica7ons – Addressed any problems – Communica7on with inpa7ent medical team if needed
• Significantly less likely to have an emergency department visit within 30 days compared to control (10% vs. 24%)
• 86% of pa7ents reported being very sa7sfied with medica7on instruc7on vs. 61% in the control group
Dudas V, Bookwalter T, Kerr KM, Pan2lat SZ. The impact of follow-‐up telephone calls to pa2ents afer hospitaliza2on. Am J Med. 2001;111:26-‐30S.
Transi(ons of Care Models and Resources
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Re-‐engineered Discharge (RED) • Boston University Medical Center • Clinical pharmacist involvement • Discharge medica7on reconcilia7on • Appointments for follow-‐up • Medical appointments and laboratory tests • Discharge summary transmission to outside provider • Post-‐discharge telephone calls
Re-‐engineered Discharge (RED) • 749 general hospital pa7ents over 18 • Nurse discharge advocate
• Follow-‐up appointment scheduling • Pa7ent educa7on • Medica7on reconcilia7on
• Clinical pharmacist • Telephone follow-‐up within 2-‐4 days post-‐discharge
• Decreased ED visits and hospitaliza7ons within 30 days post-‐discharge with interven7on
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Care Transi(ons Interven(on (CTI) • Self-‐management focus • Transi7ons coach helps pa7ent with communica7on skills, confidence, and behaviors
• Home visit and 3 telephone calls post-‐discharge • Medica7on management, personal health record, follow-‐up with providers, and pa7ent recogni7on of symptoms requiring follow-‐up
Hospital to Home (H2H) • American College of Cardiology and the Ins7tute for Healthcare Improvement
• Quality improvement ini7a7ve • Improve transi7ons of care to reduce readmissions for pa7ents with HF or AMI
• Goal: 20% rela7ve reduc7on in CMS 30-‐day all-‐cause readmission rate
• Clearing house for resources, tools, and strategies for enrolled par7cipants
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BeBer Outcomes for Older Adults through Safe Transi(ons
• Risk assessment tool • 8 Ps (problem medica7on, psychological, principal diagnosis, polypharmacy, poor healthy literacy, pa7ent support, prior hospitaliza7on, pallia7ve care)
• Helps to determine risk of adverse events during transi7ons of care
Pharmacist Linkage in Care Transi(ons Project: From Academic
Medical Center to Community
The National Association of Chain Drug Stores Foundation is gratefully acknowledged for their support
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UM SOP Transi(ons of Care Project • Partnership between University of Mississippi School of Pharmacy, University of Mississippi Medical Center, Walgreens, and the Mississippi Division of Medicaid
UM SOP Transi(ons of Care Project Study Aim
• To improve pa7ent care through integra7on of care by inpa7ent and community-‐based pharmacists and providers during and post-‐discharge
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UM SOP Transi(ons of Care Project Inclusion Criteria
• Pa7ent admiYed with primary diagnosis of • Myocardial infarc7on • Heart failure • Pneumonia • Solid Organ Transplant
• Primary pharmacy • Walgreens within 60 mile radius of Jackson • UMMC outpa7ent pharmacy (Meds & Threads, Pavilion, Jackson Medical Mall)
• Included coun7es: Claiborne, Hinds, Simpson, Madison, Rankin, Yazoo, Copiah, and Warren
UM SOP Transi(ons of Care Project Methods: Inpa(ent
• Medica7on reconcilia7on • In addi7on to usual med history performed by admiCng team and nursing staff
• Discrepancies communicated to primary care area pharmacist, medical team, or social work as necessary
• Discharge educa7on • Medica7on regimen counseling • Follow-‐up appointment schedule
• Bedside delivery of 30 day supply of discharge medica7ons
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UM SOP Transi(ons of Care Project Methods: Outpa(ent
• Walgreens Well-‐Transi7ons • Pharmacists perform follow-‐up phone calls at 48 hours, 10 days, and 25 days post-‐discharge
• Medica7on review • Disease state symptom resolu7on • Based on discharge plan sent from Transi7ons of Care Coordinator
• School of Pharmacy and Walgreens pharmacist Medica7on Therapy Management • Face-‐to-‐face visits at 4-‐7 days, 90 days, and 270 days post-‐discharge
• Telephone follow-‐up at 180 and 365 days post-‐discharge
UM SOP Transi(ons of Care Project Study Outcomes
• Primary outcome: 30 day readmission rates • Secondary outcomes
• 60 and 90 day readmission rates • Medica7on adherence to chronic medica7ons • Humanis7c outcomes
• Pa7ent quality of life • Pa7ent and provider sa7sfac7on
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Transi(onal Care:
How Pharmacists Can Impact Outcomes
Leigh Ann Ross, PharmD, BCPS, FCCP, FASHP Associate Dean for Clinical Affairs
Chair, Department of Pharmacy Prac7ce The University of Mississippi School of Pharmacy
BreB Smith, PharmD Clinical Instructor
The University of Mississippi School of Pharmacy
April 14, 2015
Thank You
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For more information contact your state’s QIN-QIO representative:
This material was presented on behalf of atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 15.SS.MS.02.001C