Saint Agnes Hospital. Pharmacist utilization of the LACE tool to prevent hospital readmissions. Program/Project Description, including Goals:

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1 Saint Agnes Hospital Pharmacist utilization of the LACE tool to prevent hospital readmissions Program/Project Description, including Goals: Safe transitions of care have always been a frontline patient safety issue. Failure to appropriately transition a patient from the hospital to the community can result in patient injury, death, and hospital readmission. Until recently, there were not any targets or goals for what was an acceptable rate of hospital readmission. In April 2014 the Health Services Cost Review Commission (HSCRC) approved an incentive program which set targets for hospitals all-payer 30-day readmissions starting with the 2014 calendar year. 1 Gaps in the transition of care had to be identified and addressed in order to improve patient safety and outcomes, and to prevent penalties in reimbursement. Studies have shown that adverse drug events make up a large percent of the reason for hospital readmission. 2 An analysis of the adverse drugs events (ADEs) showed that poor medication adherence was a major cause. 2-3 Preventing ADEs needed to be a major component in preventing hospital readmissions. Process: A literature search for transition of care guidelines yields numerous best practices guidelines, core measures, and expert opinions. Hospitals have been using these resources to develop interventions to prevent readmissions. Examples of such interventions include educating the patient regarding their disease state and medication regimen, follow up telephone calls after hospital discharge, and scheduling appropriate discharge follow up. Interventions such as these have well documented outcomes in preventing hospital readmission. 4-5 Originally 3 nurse navigators and 1 social worker were hired to find patients who were either high users and/or were deemed a high risk of readmission. These patients would receive education regarding disease and medication management, make follow up phone calls, provide patient with community resources/patient assistance, and make sure patient had a primary care physician. However, there was a deficiency in the ability to provide that care to every patient. There was no tools or criteria used to identifying high risk patients, and medication education took up a significant time. Solution: A pharmacist was hired in June to address the medication related gaps in the transitions of care. A screening tool was used to find patients at a higher risk for readmission, and they would be followed throughout their hospital stay. The pharmacist would review the discharge medication regimen with the patient and provide medication education on new prescriptions. A patient friendly medication pill card would be created for the patient s record and to assist in compliance. (attachment 1) Patients were identified using the LACE screening tool for readmissions. LACE is an acronym for Length of stay, Acuity of admission, Comorbidities, and Emergency department visits. Patients are scored (see

2 attachment 2), which then correlates to a probability of being readmitted. This tool was implemented at Saint Agnes by using a 3 rd party software that pulled information from our electronic records. It would automatically calculate the LACE score for everyone in the hospital. Regardless of the LACE score, the pharmacist would also provide education to patients on high risk medications such as anticoagulants, antiplatelets, and diabetic agents, as well as assist patients with compliance issues. The LACE tool could also be utilized by the nurse navigators to find out which patients each of the navigators followed were at higher risk. Before, navigators would identify patients that might require an intervention by going through the patient list on the units they covered. The nurse navigator would provide high risk patients would a follow up telephone call after discharge, inpatient education, and ensure follow up appointments were scheduled. Measurable Outcomes: Within 3 months 395 patients were followed by a pharmacist. 351 of them were identified as patients discharged to home with self care. While the goal was to discharge counsel everyone identified, only 180 of these patients actually received counseling. The patient s who did not receive counseling we put into a control group to see if the intervention was working. Table 1 summarizes the characteristics of the two groups. Baseline characteristics of both groups were not statistically different. While there was no difference in patients revisiting a hospital (any ER, observation, or inpatient visit) within 30 days of an inpatient discharge, there was a trend towards a decrease in readmission. Dividing the groups into low risk (LACE score less than 9), high risk (LACE score between 9-12), and very high risk (LACE score greater than 12) showed a significant reduction in readmission in the LACE group between 9 and 12. This might be due to patients with a LACE score less than 9 not being at an enough risk, and those with a score 13 or greater might have advanced disease progression resulting in their readmission. TABLE 1 Intervention (n = Control (n=171) P value 180) Male (%) 91 (50.1) 71 (41.5) p= Average age P= Average LACE Score P= Average # medications P= High risk medications 124 (68.9) 108 (63.2) P= (%) High user patients 8 (4.4) 9(5.0) P= Revisits (%) 49 (27.2) 54 (31.6) P= Readmissions (%) 19 (10.6) 29 (17.0) P= LACE score <9 Readmissions (%) n=38 3 (7.9) n=21 0(0.0) P= LACE score 9-12 Readmissions (%) n=93 5(5.4) n= (22.0) P=.0075* LACE score 13+ n=49 n=50 P=1.0

3 Readmissions 11(22.4) 11(22.4) (%) There did not appear to be any difference in the reason for readmission between the groups. Worsening primary diagnosis was the primary reason for readmission in both groups. However there was a trend towards the control group being at a greater risk of readmissions due to adverse drug events compared to the intervention group (9 readmission in control and 1 in intervention OR % CI to p=0.0302). The most common adverse drug event was non-compliance. This data has been consistent with our hospital data as well. We have noticed a 2% decrease in our intrahopsital readmission rates compared to last year. The interhospital target set by HSCRC is set at 12.52%. We are currently at 12.20% which was 14.09% the same time last year. Significant measures have been made in reducing readmissions from the Medicare five core measures as well. (Table 2) 30- day intrahospital revisits are currently at 19.6%, but are tending down to our target for 18.7%. Together this data suggests that a pharmacist invovlement in discharge counseling and medication reconciliation for an at risk population has a positive impact in readmission prevention. Adding the pharmacist and two additional navigators has allowed for more patients to be followed as well (table 3). Compared to last year, almost five times the number of patients are being followed by eirther a pharmacist or nurse navigator, or both. Medication reconciliation and education takes time. The addition of pharmacist to do those tasks enabled the nurse navigators to focus on other duties and follow more patients. TABLE 2.-Medicare Core Measures Integrated Scorecard (Medicare Cohort) FYTD 14 FYTD 15 Readmits Readmit Readmits Readmit Rate Rate All Cases % % CHF (1) % % AMI (2) % 1 4.3% Pneumonia (3) % % COPD (4) % % Hip/Knee (5) 3 3.8% - 0.0% Subtotal % % Table 3. Patients followed per month CMS PfP FYTD 14 FYTD 15 Readmits Readmit Readmits Readmit Rate Rate All Cases % % CHF (1) % % AMI (2) % 2 4.7% Pneumonia (3) % % COPD (4) % % Hip/Knee (5) 5 4.0% 3 2.6% Subtotal % %

4 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun FY2014 FY2015 Sustainability: There will always be a need for a task force such as this because there will always be patients who need additional resources to remain out of the hospital and it is impossible to give that enhanced care to every patient. The program has expanded since the pharmacist position was created. Two more nurse navigators were added the same time as the pharmacist, and educators for chronic obstructive pulmonary disease and congestive heart failure were added in September. This allows for more patients to be seen as well as opportunity for multiple providers to reinforce medication and disease management education. We are constantly looking for new opportunities and adding people to the readmission prevention efforts as needed. A group that had started off with only 4 members is now at 11. The continued expansion of this group and its documented success will help ensure it is continued in the future. Role of collaboration: This is a multidisciplinary effort with each individual filling a different role. One group alone would not be able to yield the results that collaboration between them has yielded. Nursing, social work, care managers, physicians, and pharmacists are all involved and working together to prevent at risk patients from being readmitted. Some patients may only receive education about their medications from the nurse and/or physician at discharge. Now there is the potential for a nurse, a physician, a nurse navigator, and a pharmacist to all provide education. Having multiple interactions with the patient helps reinforce key concepts and find remaining gaps in a patient s understanding of how to take care of themselves when they go home. A multidisciplinary team ensures that someone in the team can provide the resources the patient requires. Each member provides a unique area of expertise that can help prevent hospital readmission. Often, members of the navigation team collaborate by referring someone to a patient that may be in

5 need of their services. Certain units in the hospital have discharge planning rounds. Nurses, physicians, social workers, a nurse navigator, and the discharge pharmacist would get together and review patients and identify who might be discharged that day, and what resources they may need available to them once they leave. This helped ensure that the patient had a successful transition to home. Executive leadership has been invested in this project since its inception. There is a meeting once a month where the navigator group gets together with executive leadership to go over concerns, discuss what each individual has been doing, and to track our progress. Directors of each of our respective departments have been involved as well and provided the tools necessary for everyone to work together and provide resources needed to help patients. We also have physician champions with expertise is in key areas such as respiratory disease and heart failure facilitating our efforts and consulting as necessary. Innovations: There has not been any published information about a pharmacist using the LACE tool to identify patients that could benefit from additional education about their medication regimen at discharge. This is a new approach, which looked at patients hospital wide, to prevent readmissions due to adverse drug events. Most studies look at a pharmacist providing education to patients in a particular care team, unit, or disease state. Often a screening tool is not used. In this instance, the LACE tool not only benefited the pharmacist, but the nurse navigators also benefited as it allowed them to identify and focus their efforts on high risk patients as well. This is a unique multidisciplinary effort to prevent hospital readmission by providing patients the information and resources to prevent them from coming back to the hospital. Increased communication with the patient as well as better coordination of care and follow up can prevent readmissions when transitioning a patient from the hospital to home. This greatly improves patient safety and helps ensure the continuity of care. References: 1. Final Recommendation for Implementing a Hospital Readmission Reduction Incentive Program for FY Health Services Cost Review Comission (HSCRC). Recommendation-for-Implementing-a-Hospital-Readmission-Reduction-Incentive-Program-for- FY-2016.pdf. April 9, Accessed November 4, McDonnell P, Jacobs M. Hospital Admissions Resulting From Preventable Adverse Drug Reactions. Ann Pharmacother 2002;36: Osterberg L, Blaschke T. Adherence to Medication. N Engl J Med 2005;353: Wilkinson, S, Pal A, Couldry R. Inpacting Readmission Rates and Patient Satisfaction: Results of a Discharge Pharmacist Pilot Program. Hosp Pharm 2011;46(11):

6 5. Dudas et al. The Impact of Follow-up Telephone Calls to patients After Hospitalization. Am J Med.2001;11(9B):26S-30S. Contact Dominick Memoli Clinical Pharmacist Saint Agnes Hospital dmemoli@stagnes.org

7 LACE index scoring tool MR# UNIT DOS Step 1. Length of Stay Length of stay (including day of admission and discharge): days Length of stay (days) Score (circle as appropriate) or more 7 Step 2. Acuity of Admission Was the patient admitted to hospital via the emergency department? If yes, enter 3 in Box A, otherwise enter 0 in Box A Step 3. Comorbidities L A Condition (definitions and notes on reverse) Score (circle as appropriate) Previous myocardial infarction +1 Cerebrovascular disease +1 Peripheral vascular disease +1 Diabetes without complications +1 Congestive heart failure +2 Diabetes with end organ damage +2 Chronic pulmonary disease +2 Mild liver or renal disease +2 Any tumor (including lymphoma or +2 leukemia) Dementia +3 Connective tissue disease +3 AIDS +4 Moderate or severe liver or renal disease +4 Metastatic solid tumor +6 TOTAL If the TOTAL score is between 0 and 3 enter the score into Box C. If the score is 4 or higher, enter 5 into Box C C Step 4. Emergency department visits How many times has the patient visited an emergency department in the six months prior to admission (not including the emergency department visit immediately preceding the current admission)? Enter this number or 4 (whichever is smaller) in Box E E Add numbers in Box L, Box A, Box C, Box E to generate LACE score and enter into box below. If the patient has a LACE score is greater than or equal to 10 the patient can be referred to the virtual ward LACE

8 LACE Score Risk of Readmission: 0-4 Low, 5-8 Moderate, 9-12 High Risk, 13+ Very High Risk

9 Condition Definition and/or notes Previous myocardial infarction Any previous definite or probable myocardial infarction Cerebrovascular disease Any previous stroke or transient ischemic attack (TIA) Peripheral vascular disease Intermittent claudication, previous surgery or stenting, gangrene or acute ischemia, untreated abdominal or thoracic aortic aneurysm Diabetes without microvascular complications No retinopathy, nephropathy or neuropathy Congestive heart failure Any patient with symptomatic CHF whose symptoms have responded to appropriate medications Diabetes with end organ damage Diabetes with retinopathy, nephropathy or neuropathy Chronic pulmonary disease?? Mild liver or renal disease Cirrhosis but no portal hypertension (i.e., no varices, no ascites) OR chronic hepatitis Chronic Renal Disease Any tumor (including lymphoma or leukemia) Solid tumors must have been treated within the last 5 years; includes chronic lymphocytic leukemia (CLL) and polycythemia vera (PV)_ Dementia Any cognitive deficit?? Connective tissue disease Systemic lupus erythematosus (SLE), polymyositis, mixed connective tissue disease, moderate to severe rheumatoid arthritis, and polymyalgia rheumatica AIDS AIDS-defining opportunistic infection or CD4 < 200 Moderate or severe liver or renal disease Cirrhosis with portal hypertension (e.g., ascites or variceal bleeding) Endstage Renal Disease, Hemodialysis or Peritoneal Dialysis Metastatic solid tumor Any metastatic tumour Retrieved from

10 *Bring with you to every doctor s appointment and update as necessary Pill Card Dominick Pharmacist Created: 11/5/2014 Take medications every day as prescribed Name Used For Instructions Morning Afternoon Evening Night Aspirin 81 mg Carvedilol 6.25 mg Furosemide 40 mg Lisinopril 5 mg Potassium Cl 20 meq Pravastatin 40 mg Spironolactone 25 mg Heart Disease Prevention Heart rate Fluid pill Blood pressure Potassium Supplement Cholesterol Blood pressure x

11 Name Used For Instructions Morning Afternoon Evening Night