transitions of care - njha · cpt code for transitional care management (tcm) 99495 (face-to-face...
TRANSCRIPT
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Transitions of Care A Pharmacy Approach
March 19, 2019
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Disclosures
• I have no actual or potential conflict of interest in relation to this program/presentation.
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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
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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.
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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.
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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
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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.
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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.
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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.
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What is the estimated yearly cost of preventable readmissions?
A. $10 Billion
B. $500 Million
C. $26 Billion
D. $90 Billion
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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
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The Joint Commission (TJC)
• National Patient Safety Goal 03.06.01
Maintain and communicate accurate patient medication information
• TJC Core Measures
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What Percentage of Medication Errors Occur During Transitions of Care?
A. 10%
B. 66%
C. 90%
D. 25%
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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.
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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
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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
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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.
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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
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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
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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.
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Bridging the Gap: Pharmacy’s Role
Patient/Caregiver Education
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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.
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Bridging the Gap: Pharmacy’s Role
Quality– Ensure core measures are met
Heart failureStrokeMyocardial infarction
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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?
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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
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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
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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
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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
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Why Pharmacists?
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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)
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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
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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
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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
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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
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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
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Medication Reconciliation Process
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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
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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
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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
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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)
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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
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Barriers
• Financial resources
• Staffing resources
• Electronic transfer of patient information and data to partner groups
• Communication
• Difficulty developing relationships with inpatient or outpatient partners
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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
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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
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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
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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
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HUMC Metrics
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Error Profile
* Incorrect entries include wrong strengths, medications patient is no longer taking, has been discontinued, and completed therapies.
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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
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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
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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
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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
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Future Considerations
• Collaborative Practice Agreements• Partner with home care• Partner with local community pharmacies• Transitional Care Management Billing Codes:
99495 and 99496
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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
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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
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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
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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
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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
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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.
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Thank You!!!
Nilesh Desai, B.S, RPh., MBAAdministrator Pharmacy and Clinical Operations