Transition from Hospital to Home: Importance of Medication Education and Reconciliation

Transcription

1 Transition from Hospital to Home: Importance of Medication Education and Reconciliation Julie Baron, PharmD, CGP, BCACP/Clinical Pharmacy Specialist/Kaiser Permanente Lindsay Salsburg, PharmD, BCACP/Clinical Pharmacy Specialist/Kaiser Permanente Jodie Fink, Pharm.D. BCPS/Clinical Pharmacy Specialist/Cleveland Clinic

2 Disclosure Presenters reported no financial interest relevant to this presentation

3 Objectives Identify strategies to improve medication reconciliation during a care transition so that patients can remain at home following a hospitalization Discuss a multidisciplinary transitional care program at Kaiser Permanent of the Ohio Region implemented to prevent hospital readmission Describe methods to overcome challenges encountered by pharmacists during implementation of transitional care programs for heart failure patients

4 Kaiser Permanente Clinical Pharmacy Primary Care Support IM OPMG providers at the 15 facilities within the region 8 Decentralized Clinical Pharmacists (7.5 FTEs) 2 Centralized Clinical Pharmacists (2 FTEs) 2 Pharmacy Practice Residents (2 FTEs) Support regional & national clinical initiatives Care Management Institute initiatives, NCQA standards, & HEDIS measures Telephonic care

5 Model Influences Care Transitions Intervention Program Eric A. Coleman, MD, MPH The Four Pillars Medication self-management Patient-centered record Follow-up Red flags

6 High Risk Qualifiers Category 1- Medications Category 2- Medical history Category 3- Past year care history Category 4- Potential candidate Observation for High Risk For Readmission High risk readmission score If 2 of the above categories are positive, the patient is a candidate for the High Risk Transition Program

7 TOC Workflow Patient meets high risk readmission score. Patient discharged from hospital to home. Patient has an OPMG PCP. IPCC Places PharmD Referral PharmD TOC Medication Review Standard SOAP template. Update EMR. 3 call attempts to all listed numbers + letter. Chart review after patient hospital follow up appointment with provider. PharmD TOC Follow Up

8 Medication Reconciliation Strategies Assess patient s understanding of treatment plan Bring medication list and bottles to visit/call Identify caretaker (as appropriate) Describe medication Evaluate medication refill history Use open-ended questions Patient initiate next medication to be discussed Ask about common OTC products Allow patient to take their time Making Strides in Safety Program

9 Discrepancy Examples No hospital discharge prescriptions provided Prescription bottle directions different than hospital discharge instructions Incomplete discharge list Patient has multiple medication lists Nonformulary medications

10 Successes Referrals placed through EMR Discharging provider and pager number in IPCC notes IPCC informing patients of PharmD call Pharmacy participating in weekly chart reviews Two pharmacists responsible for TOC referrals each day

11 Areas for Opportunity Accurate admission list Including OTC and herbals Clear indication of new, changed, or discontinued medications Ensuring patient is given prescriptions at discharge Identifying responsible physician

12 Kaiser s Numbers TOC referrals Q4 2011: ~ 350 Jan 2012: ~ 110 PharmD has 5-6 days per month Two PharmDs per day

13 Heart Failure Medication Counseling Initiative Medication counseling by a pharmacist to heart failure patients across the Cleveland Clinic enterprise Full initiative began November 1, 2011 Goals Improve patient education Reduce heart failure readmissions Improve patient satisfaction scores Target Patients Primary diagnosis of heart failure Age > 65 years Heart & Vascular Institute and Medicine Institute

14 Pharmacy Team Involvement Inpatient Pharmacy Nursing-unit based Pharmacists Clinical Specialists Decentralized Technicians Ambulatory Pharmacy Pharmacists Technicians

15 Pharmacist Preparation Heart Failure Modules Didactic teaching Medication counseling competency Uniform documentation of HF counseling

16 Pharmacy Workflow Pharmacy survey Questions to address medication access, understanding and compliance Prescription delivery program introduced and patient interest assessed Administered by decentralized pharmacy technician once on nursing floor Survey results are entered into Pharmacy s EPIC Heart Failure Report Heart failure medication education by pharmacists Communication with team regarding disposition Delivery of prescription medications to bedside Individualized discharge counseling

17 Pharmacy Workflow Pharmacy survey Heart failure medication education by pharmacists Review survey to personalize education provided Medication counseling session Handout: Medication Guidelines for Heart Failure Documentation: RX Heart Failure Medication Counseling Communication with team regarding disposition Delivery of prescription medications to bedside Individualized discharge counseling

18 Medication Education EPIC Inpatient Note Patient education note RX Heart Failure Medication Education Counseling components Readiness to learn Learning response Teach back documentation

19 Pharmacy survey Pharmacy Workflow Heart failure medication education by pharmacists Communication with team regarding disposition Delivery of prescription medications to bedside Offer for discharge prescription delivery at bedside from Cleveland Clinic Ambulatory Pharmacy Hours: Monday - Friday: 8 am - 6 pm; Saturday - Sunday: 9 am - 1 pm Delivery to bedside within 4 hours Patient s insurance (if applicable) will be billed Payment/Co-pay will be accepted at the bedside (cash or credit card) Offer to fax prescriptions to patient s pharmacy of choice if patient does not choose to use Cleveland Clinic Ambulatory Pharmacy Individualized discharge counseling

20 Pharmacy Workflow Pharmacy survey Heart failure medication education by pharmacists Communication with team regarding disposition Delivery of prescription medications to bedside Individualized discharge counseling Triggered via completion of physician s medication reconciliation Documentation: RX Heart Failure Medication Counseling List MAR-type medication list provided to patient

21 Discharge Medication List Generated from discharge medication reconciliation Counseling tool for pharmacists Accurate, user-friendly format for patients to keep a record of medications

22 Patients Encountered Nov-11 Dec-11 Jan Number of Patients

23 Challenges Timely identification of patients to be discharged Discharge counseling Bedside delivery Clarification from primary team about discrepancies in discharge medication list Program expansion to all heart failure patients

24 Successes Increased direct patient care activities by pharmacists Education of pharmacists Education of patients and increased understanding of medications Increasing patient access to medications at discharge Positive feedback from patients, nursing, and physicians

25 Thank You Questions?