volunteering as tribute: pharmacists’ role in discharge …...discharge planning 1 christine ji,...

MSHP Annual Meeting 2018 #MASHP18

Discharge Planning 1

Christine Ji, PharmD, BCPS

Clinical Pharmacist, Internal Medicine

Massachusetts General Hospital – Boston, MA

MSHP Annual Meeting May 15th, 2018

Volunteering as Tribute: Pharmacists’ Role in Discharge

Planning

Disclosures

• I have no actual or potential conflicts of interest to disclose



Learning Objectives

• Discuss the pharmacist’s role in reducing medication errors and hospital readmissions

• Describe current practices related to discharge medication reconciliation and bedside delivery

• Apply areas for process improvement to overcome common barriers for effective discharge process

Patient Case

• KM is a 62 year old male with past medical history significant for atrial fibrillation, heart failure (EF=40%), gout, and hypertension admitted with heart failure exacerbation and uncontrolled hypertension SBP ranging 160-170 and DBP 80-90

• Home medications include allopurinol 100mg daily, amiodarone 200mg daily, atorvastatin 20mg daily, metoprolol succinate 200mg daily, furosemide 20mg daily as needed, and warfarin 5mg daily

• During rounds, you make recommendations to add lisinopril 10mg daily and change diuretic to torsemide 20mg daily inpatient and for discharge



Patient Case

Inpatient Medications

• Allopurinol 100mg daily

• Amiodarone 200mg daily

• Lisinopril 10mg daily

• Metoprolol tartrate 50mg Q6h

• Atorvastatin 20mg QHS

• Furosemide 40mg IV daily

• Warfarin 5mg daily

Discharge Medications






• Furosemide 40mg PO daily

Patient Case

• What discrepancies can be seen in this medication reconciliation?

• How would you proceed?



Patient Case

Inpatient Medications



• Lisinopril 10mg daily



• Furosemide 40mg IV daily


Discharge Medications






• Furosemide 40mg PO daily

Metoprolol succinate 200mg daily

Torsemide 20mg PO daily

Lisinopril 10mg daily

Medication Errors and Hospital Readmissions



Medication Errors

• 60% of all medication errors in the hospital occur at admission, in-between hospital transfer, or discharge

• 8% medication access issues occur within 48-72 hours after discharge

• Incorrect or incomplete patient home medication lists

• Transcription errors when creating or reordering from previous lists

J Am Pharm Assoc. 2015;55(4):443-448.

Hospital Readmissions

• Discharging patient from the hospital is a challenging and complex process

• The preventable readmission rate is about 11% across all insured patients, and the readmission cost is $25 billion annually

NEHI. Hospital Readmissions Brief. 2015.



Medicare Beneficiaries

• On average, 1 in 5 Medicare beneficiaries (20%) discharged from the hospital is readmitted in 30 days

• Results in costing the health system $150 billion annually

• 76% of readmissions are preventable

NEHI. Hospital Readmissions Brief. 2015.

Reasons for Readmissions

• Lack of understanding for diagnoses

• Insufficient follow ups/ appointments after discharge

• Failure to relay information to outpatient providers

• Premature discharge from hospitalization

• Confusion about which medications to take

• Inability to fill prescriptions at pharmacy



High Risk Factors for Readmissions

• High risk medications (antibiotics, anticoagulants, narcotics, anticonvulsants, antidepressants, hypoglycemic agents)

• Polypharmacy

• Chronic conditions (COPD, heart failure, diabetes, etc.)

• Prior hospitalization & numerous ED visits

• Low health literacy & socioeconomic status

• Discharge against medical advice

Where do Pharmacists Play a Role?

• Medication reconciliation

• Provider collaboration

• Patient education and communication

• Transitional Care Management (TCM) Billing• Effective January 1, 2013 under Physician Fee Schedule Medicare

• Pharmacist can review discharge medications post discharge

• Ensure that patient understands changes, is adherent, and has resources needed



Pharmacist Interventions

• Initiate new drug therapy

• Change dosage regimen

• Change the drug product

• Discontinue drug therapy

• Institute a monitoring plan

• Patient-specific instructions

• Removal of barriers to obtain medication

Question #1

• Which of the following best represents 30-day readmission rate for Medicare beneficiaries?

A. 5%

B. 10%C. 20%

D. 40%



Current Practices

Medication Reconciliation

• Create the most complete and accurate list possible of home medications

• Use the list when writing inpatient medication orders

• Compare the list to the previous admissions for discrepancies



Admission Medication Reconciliation





Best Practices

• Review admission medication history within 24 hours of admission

• Medication reconciliation at every level of care to avoid discrepancies

• Focus on high risk specialty areas (anticoagulants, transplant meds, etc.)

• Discharge counseling to communicate the important parts of care plan

• Pharmacist-to-pharmacist hand-offs between practice settings

• Include medication reconciliation/ list review on rounds



Medication Knowledge

• Was a proton pump inhibitor initiated for stress ulcer prophylaxis, therefore no long required?

• Was oral hypoglycemic medication held in hospital, and instead insulin sliding scale was used to manage hyperglycemia?

• Was a different agent from the same class as one taken from home, substituted during the hospitalization?

• Was oral antiplatelet or anticoagulant discontinued for discharge or to hold for certain # days prior to procedure?

Question #2

• What is the most important purpose of medication reconciliation?

A. Increase documentation for liability

B. Reduce the cost of hospital careC. Ensure patient’s medications remain accurate during transitions

D. Confirm patient’s drug therapy meets current treatment guidelines



Organizational Background

• Massachusetts General Hospital (MGH)• 1,000 bed academic teaching hospital, outpatient clinics

• Organization-wide electronic medical record EPIC

• Integrated decentralized clinical pharmacist practice model• Daily rounding with multidisciplinary team

• Medication reconciliation and discharge planning

• MGH outpatient pharmacy • Retail pharmacy site located on campus

• Meds to Beds (bedside delivery program) Monday-Friday 9AM-5:30PM

• 7 adult general care floors + 2 pediatrics general care floors

Transitions of Care

High Risk Patients & Admission Medication

Discharge Medication

Reconciliation

Meds to Beds Delivery & Education



Target Population

• Patients being discharged to • Home

• Skilled nursing facility

• Long term acute care

• Acute rehabilitation

• Identify high risk patients • Readmission Risk Total Scores

• Probability of readmission within 30 days of discharge (%) > 27%

• Comorbidities, medication regimens, prior hospitalization histories, etc

Discharge Service

Hospital Admission

• Meet with patients

• Medication modification

Hospital Discharge

• Discuss dispositions in multidisciplinary rounds

• Offer meds to beds delivery service

Fill Prescriptions

• Troubleshoot medication access issues

• Deliver medications and provide discharge counseling



Drug Related Problems

Improper Drug

Selection

Drug Interactions

OverdoseAdverse Drug

Reactions

Untreated Conditions

Suboptimal Therapy

Therapeutic Duplication

Medication Errors

Ineffectiveness Contraindication

Improving Transitions of Care

• Pharmacists’ participation in care team rounds decreases preventable adverse drug events by 66%

• Pharmacists’ involvement in discharge reduces preventable adverse drug events within 30 days post discharge

• Pharmacists’ discharge counseling reduces medication discrepancies and improves medication adherence at 14 and 90 days post discharge

Arch Intern Med. 2006;166:565-71.JAMA. 1999;282:267-70.



Communications with Patients

• At discharge,

• 64% of patients able to say the indications of their medications

• 11% of patients knew their medications’ expected side effects

• 59% of patients able to state their diagnosis and reasons for admission

JAMA Intern Med. 2013.14; 173(18): 10.1001.Mayo Clin Proc. 2008. 83(5):554-8

The Teach Back Method

• New Concept Discharge medication instructions, health information and changes in therapy

Demonstrate new skills (i.e. injections, inhaler techniques)

• Ask patient to demonstrate

• Encourage patient to use own words

Assess Patient Comprehension • Re-assess recall and

understanding

• Ask patient to demonstrate

Clarify and Tailor Explanation

Am J Health Syst Pharm. 2013. 1;70(11):949-55.



Process Improvement

Barriers

• Too many patients to be reviewed by one pharmacist• Staffing AM and PM coverage pharmacists to review and plan discharge

• Attending daily rounds and working with case managers on timely discharge

• Prescribing errors for discharge medications• Pharmacist errors reduce compared to resident physicians

• Examples include prednisone taper, oral vancomycin liquid/capsule, apixaban loading dose followed by maintenance dose

• Accurate and timely communication is critical • Pharmacist and providers / Inpatient and outpatient pharmacy

• Using standardized process to collect and update medication list



Timeline

Admission: Initiate discharge planning

48 Hours Before: Determine authorizations necessary for discharge and address patient education needs

24 Hours Before: Assess clinical readiness and write D/C order for next day and send scripts

Day of Discharge: Complete discharge order, deliver medications, and provide discharge counseling

E-Prescribed

• What medications can be E-prescribed?• Non-narcotics

• Medications with normal designations

• What medications will be printed out?• Scheduled II- V narcotics

• Compounded medications

• What do you do with printed prescriptions?• Physically fax them down to outpatient pharmacy

• Page outpatient pharmacy to inform and keep copy in the chart



Medication Access

Common Scenarios

• Medication is refill too soon• Talk to patient and verify that enough supply

• Ask for insurance override if stolen or lost

• Pharmacy does not have full quantity available• Ask if patient can come in next day or two to pick up the rest

• If they cannot, then fill at home pharmacy with full quantity

• Patient does not have co-pay or no cash/card on hand• Case manager can provide a delayed payment voucher

• Ask family member for payment over the phone



5.5% absolute decrease

19.9% relative decrease

Meds to Beds Intervention

Admit Date

October 1, 2016

– June 25, 2017

statistically significant at p < 0.10 using ChiSq test (p = 0.06)

The Incidence and Severity of Errors in Pharmacist-Written Discharge Medication Orders

Onatade R, Sawieres S, Veck A, et al.

Int J Clin Pharm. 2017. 39:722-28.



Onatade et al.

• Retrospective, observational study

• 1000 bed teaching hospital in London, UK

• Pharmacist write discharge mediation orders • 509 patients with 4258 discharge medication orders, made by 51 pharmacists

• Mean of 8.4 orders per patient

• 10 errors in patients detected giving a 0.2% error (10/509, 95% CI 0.8-3.2%)

• Percentage of medication errors (10/4258, 98% CI 0.1-0.3%)

• Overall, agreement harm vs. no harm between the physician and pharmacist was 90% - none of the errors led to potential harm • Drug omission (9/10) and duplicate therapy (1/10)

Int J Clin Pharm. 2017. 39:722-28.

Pilot Project

• A unit-based pharmacist can proactively assist with discharge medication reconciliation for high risk patients by pending medication orders for prescribers to review and cosign.

• The pilot project will help to develop and implement a process to ensure patient safety during transition from hospital to discharge



Pilot Project

Pilot Project



Moving Forward

• Positive feedback from providers, nursing staffs, patients

• Prevents medication omissions

• Creates a more accurate list by discontinuing duplicates and/or inactive meds

• Expand pharmacist pending orders pilot to different units

• Currently, all floor pharmacists do admission medication reconciliation

• Continue to work collaboratively with outpatient pharmacy

• Continue to collect data on hospital readmissions rate

Discharge Medication List



iVent Documentation

Smart phrase .Meds2Beds

Question #3

• What could be a barrier to successfully implementing pharmacist-driven discharge planning?

A. Using standardized process to collect and update medication list

B. Knowing which medications require prior authorizationsC. Higher risk of errors when discharge orders are written by pharmacists

D. Lack of understanding of workflow amongst health care providers



Tips for Success

• Start preparing for discharge early on admission• Reconcile admission medications

• Identify medication changes throughout patient hospital course

• Measure % of patients who had medication reconciliation within 24 hours

• Reduce last minute discharge prescription changes • Anticipate and encourage team to write discharge prescriptions the day before

• Consolidate medications and minimize excess medication list

• Streamline work into urgent vs. nonurgent • Set up maximum capacity and delivery period

• Coordinate with floor nurses and outpatient (retail) pharmacy

Future Directions

• Current work flow on general care medicine floor • Perform admission medication reconciliation

• Identify high risk patients

• Make recommendations on rounds and prepare discharge

• Ask patient for meds to beds service -> delivery by outpatient pharmacy

• Counsel patients on new and change in medication therapy

• Expansion of meds to beds program to all inpatient units

• Utilization of pharmacy APPE students and PGY-1 residents on rotation



References• Schnipper JL, Kirwin JL, Contugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization.

Arch Intern Med. 2006 Mar 13; 166(5):566-71.

• Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive careunit. JAMA. 1999 Jul 21;282(3):267-70.

• Horwitz LI, Moriarty JP, Chen C, et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013 Oct 14; 173(18): 10.1001.

• Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of medications at discharge. Mayo Clin Proc. 2008 May;83(5):554-8.

• Johnson JL, Moser L, Garwood CL. Health literacy: a primer for pharmacists. Am J Health Syst Pharm. 2013 Jun 1;70(11):949-55.

• Onatade R, Sawieres S, Veck A, et al. The incidence and severity of errors in pharmacist-written discharge medication orders. Int J Clin Pharm. 2017; 39(4): 722–728.

• Kalista T, Lemay V, Cohen L. Postdischarge community pharmacist-provided home services for patients after hospitalization for heart failure. J Am Pharm Assoc. 2015 Jul-Aug;55(4):438-42.

• Phaleen J, Kennedy A, Hubbard TE, et al. Reducing hospital readmissions through medication management and improved patient adherence. The Network for Excellence in Health Innovation. 2015. Available at: https://www.nehi.net/publications/64-reducing-hospital-readmissions-through-medication-management-and-improved-patient-adherence/view. Accessed April 30, 2018.

Christine Ji, PharmD, BCPS

Clinical Pharmacist, Internal Medicine

Massachusetts General Hospital – Boston, MA

MSHP Annual Meeting May 15th, 2018

Volunteering as Tribute: Pharmacists’ Role in Discharge

Planning

https://www.nehi.net/publications/64-reducing-hospital-readmissions-through-medication-management-and-improved-patient-adherence/view

volunteering as tribute: pharmacists’ role in discharge …...discharge planning 1 christine ji,...

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