Clinical Update: Role of Pharmacists in Transitions of Care. Objectives

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1 Clinical Update: Role of Pharmacists in Transitions of Care Meredith T. Moorman, PharmD, BCOP, CPP Duke University Hospital NCOP Annual Meeting August 8, 2015 Objectives Summarize why improving transitions of care is important Identify populations most at risk for adverse drug events associated with care transitions List interventions that have been proposed to decrease errors across transitions of care Describe examples of pharmacist involvement in transitions of care in oncology-specific settings 1

2 Why Are Transitions Of Care Important? Care transitions have potential for + or impact on patient care First study to identify errors found 54% of hospital medication errors made by prescribers when ordering meds on admission Inpatient outpatient is most studied transition 20% patients readmitted within 30 days 34% patients readmitted within 90 days Jencks SF, et al. N Engl J Med 2009;360(14): Medication Errors During Transitions of Care Hospital admission time when most errors arise 2/3 patients affected by discrepancies in medication history Up to 70% patients may have unintentional medication discrepancy at discharge During the first few weeks after discharge: 50% patients have clinically important medication error 20% experience an adverse event, most commonly an adverse drug event Sponsler KC, et al. Cleve Clin J Med 2015;82(6):

3 JCAHO National Patient Safety Goal for 2015 NPSG Maintain and communicate accurate patient medication information Obtain info on patient medications when he/she is admitted to hospital or seen in outpatient setting Define info to be collected in non-24-hour settings (emergency department, ambulatory surgery) Compare medication info brought to hospital with medications ordered and resolve discrepancies Provide patient with written information on medications Explain importance of managing medications upon discharge The Joint Commission National Patient Safety Goals. Available from: AHRQ 4 Goals To Decrease Preventable Readmissions 1. Know what medications you are taking and how to take it 2. Know signs of danger and whom to call if they occur 3. Have prompt follow-up scheduled and be able to keep it 4. Understand and be able to follow selfcare instructions AHRQ Agency for Healthcare Research and Quality 3

4 Financial Implications To Transitions Of Care Section 3025 of Affordable Care Act established Hospital Readmissions Reduction Program Requires CMS to reduce payments to IPPS hospitals with excess readmissions Includes readmissions for: acute myocardial infarction, pneumonia, heart failure, COPD, total hip and knee arthroplasty Hospitals with higher readmission rates than national average risk loss of CMS reimbursements IPPS inpatient prospective payment system Challenges Associated With Transitions of Care Poor communication between providers Lack of effective infrastructure to facilitate effective communication Communication between IP and OP providers occurs in 3-20% of discharges Discharge summary available to OP provider at time of follow-up in 12-34% of cases Kripalani S, et al. J Am Med Assoc 2007;297(8): IP inpatient, OP outpatient 4

5 Opportunities To Improve Transitions Of Care Improve communication Use of standardized forms Patient awareness of plan Stress need for outpatient follow-up Use variety of healthcare provider disciplines to facilitate process What Populations Are Most At Risk For Medication Errors? Elderly Limited health literacy End of life Children with special healthcare needs Taking 5 10 maintenance medications/day Cognitive impairment Complex medical or behavioral conditions Coexisting disabilities Lower income Newly admitted Move frequently / homeless 5

6 Project RED Overview Study examining a designed package of services to minimize discharge failures reengineered discharge (RED) 2 group, randomized, controlled trial of adult patients admitted to medical teaching service at large, urban hospital All in-hospital activities carried out by nurse discharge advocates (DAs) Clinical pharmacist participated in postdischarge activities Jack BW, et al. Ann Intern Med 2009;150: Project RED Components DAs develop after-hospital care plan (AHCP) Educate patient about relevant diagnoses Make appointments for follow-up Discuss pending results/studies Organize post-discharge services Confirm medication plan Reconcile discharge plan with guidelines Review what to do if problem arises Transmit discharge summary to physicians Assess degree of patient understanding Pharmacist call 2-4 days post-discharge 6

7 Project RED Results Total of 3873 patients assessed In intervention group (n=373): Discharged with PCP appointment 94% Left with an AHCP 83% Had medications reconciled 53% Pharmacist activities Reached 62% of intervention group patients Completed medication review 53% Identified 65% that had at least 1 med problem Needed corrective action by pharmacist 53% Rate of hospital utilization in intervention arm AHCP after hospital care plan Can Pharmacists Help Bridge The Gap? Advantages We are the medication specialists! Additional certifications that allow us to provide patient education about disease states Board Certification (BCOP, BCPS, geriatrics) Certified Diabetes Educator Disadvantages Physical location Are we accessible? Has patient information been adequately communicated? IT system communication (between EHR and dispensing systems) EHR = electronic health record 7

8 Models of Pharmacist Participation in TOC Philadelphia College of Pharmacy Pharmacy technician-centered MR Group visits pharmacist station Anticoagulant management program in VA Post-Acute Care Clinic (PACC) SunRay Drugs program Sen S, et al. Pharm Pract 2014;12(2):439. MR medication reconciliation Qualitative Data on Managing Medications During TOC Qualitative, descriptive study using in-depth interviews of health professionals in 2 Australian hospitals One metropolitan, public, teaching hospital One suburban, community, public, teaching hospital Study aim to determine how health professionals, patients and family members communicate about managing medications across TOC ED discharge, ED medical ward discharge Manias E, et al. J Clin Nurs 2014; 24:

9 Qualitative Data on TOC Four Primary Themes Health Professionals Patients/Families Contextual environment of care Competing responsibilities of care Awareness of responsibility for safety Interdisciplinary communication Frequent interruptions Need to stabilize critically ill patients Reactive environment in ED vs. proactive on wards Delay in obtaining meds Inability to contact outside providers to complete list Everything urgent for doctors Understanding roles Aware of overwhelming chaos in ED lack of effective communication Appreciate structure of ward rounds & staff handoffs Educating patient allows for active participation N/A Apart from big medications like anticoagulants checking medications is otherwise not out there in the front of your mind. You are so in a rush to do other things So you just often leave the odd one out. Oncology Specific Examples Stem Cell Transplant Eligible patients received allogeneic transplant and then discharged to ambulatory clinic (MWF visits) Clinical pharmacist undertook 20 minute consultation visit with each patient x 6 Visit 1 at 2 weeks post-discharge, then q7-10 days Conducted medication reconciliation, evaluated pillboxes Interventions categorized and assigned risk rating Chieng R, et al. Support Care Cancer 2013;21:

10 Oncology Specific Examples Stem Cell Transplant Results 23 eligible patients consented over 1 year 73% (n=17) completed 6 pharmacist visits Total of 109 clinical pharmacist visits Average time per visit was 18 minutes 161 total interventions recorded: 51 - TDM of immunosuppressants/antifungals 24 wrong dose (renal dosing, steroid tapers) 20 omitted medication (prophylactic antibiotics) 19 unnecessary medication (ursodiol continuation) 15 ADR 3 drug interaction TDM therapeutic drug monitoring ADR adverse drug reaction Challenges To Increase Pharmacist Participation in TOC Resources Need systematic evaluation and documentation regarding benefit of pharmacist participation Can we better utilize technicians, students, residents? Provide education to other disciplines participating in TOC and MR Maximize potential of EHR and IT systems to facilitate communication 10

11 Conclusions Transitions of care continue to be a challenge for many health care settings Pharmacists have multitude of skills that can aid in TOC process to decrease errors and increase patient safety Documentation of outcomes specifically related to oncology pharmacist participation can justify future resources Assessment Question #1 1. By refining and improving transitions of care, healthcare providers aim to: A. Decrease adverse drug events B. Decrease patient satisfaction scores C. Decrease reimbursement rates D. All of the above 11

12 Assessment Question #2 2. These populations have been identified as being high risk for adverse drug events during transitions of care: A. Older adults B. Limited health literacy C. Lower income D. All of the above Assessment Question #3 3. The following items have been suggested to decrease errors across transitions of care: A. More timely availability of discharge summaries to PCP/outpatient providers B. Development of standardized discharge forms across settings C. Ongoing patient education about diagnoses and medications D. All of the above 12

13 Assessment Question #4 4. The most common pharmacist interventions for allogeneic stem cell transplant patients transitioning to an outpatient clinic included therapeutic drug monitoring of: A. Antihypertensive medications B. Antiviral medications C. Immunosuppressant medications D. All of the above Clinical Update: Role of Pharmacists in Transitions of Care Meredith T. Moorman, PharmD, BCOP, CPP Duke University Hospital NCOP Annual Meeting August 8,

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