30 min Small group activity solving case based scenarios and questions. 30 min Case and answers for each group are discussed in combined classroom

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1 IPE TOC Session Overview 5 min Pre-Session SPICE-R survey min Didactic Transitions of care lecture 20 min Review of CHF evidence based medications 30 min Small group activity solving case based scenarios and questions 30 min Case and answers for each group are discussed in combined classroom setting. 5 min Post-session SPICE-R survey

2 TRANSITIONS OF CARE WHY THEY ARE IMPORTANT AND HOW TO IMPROVE THEM IPE LECTURE JCESOM DEPARTMENT OF INTERNAL MEDICINE AND MUSOP

3 Learning Objectives 1. Definition Transitions of Care. 2. Issues associated with failed transitions. 3. Most common errors in Transition of Care especially at time of discharge from hospital that lead to failed transitions. 4. Ways to improve Transitions of care discharge process.

1. DEFINITION: ANY CHANGE IN LEVEL OF CARE OF THE PATIENT -MOST COMMON ONE WE THINK OF IS BEING DISCHARGED FROM HOSPITAL SETTING TO HOME -OTHER EXAMPLES; HOME TO ER, ER TO HOME, ER TO HOSPITAL

4 1. DEFINITION: ANY CHANGE IN LEVEL OF CARE OF THE PATIENT -MOST COMMON ONE WE THINK OF IS BEING DISCHARGED FROM HOSPITAL SETTING TO HOME -OTHER EXAMPLES; HOME TO ER, ER TO HOME, ER TO HOSPITAL MEDICAL FLOOR, FROM MEDICAL FLOOR TO ICU, FROM HOSPITAL TO A DIFFERENT HEALTH CARE FACILITY. -PATIENTS EXPERIENCE HEIGHTENED LEVEL OF VULNERABILITY DURING THESE TIMES!!!!!! -MULTIPLE COMPLEX ISSUES NEED TO BE ADDRESSED; IS PATIENT READY FOR DISCHARGE AND IF SO TO WHAT LEVEL OF CARE, MEDICATIONS, PATIENT EDUCATION, COMMUNICATION TO PCP OR DISCHARGE FACILITY, LABS, TESTS AND FOLLOW UP APPOINTMENTS -TODAY WE ARE GOING TO FOCUS ON TRANSITIONS OF CARE AFTER HOSPITAL DISCHARGE AND PATIENT BEING SEEN AT HIS PRIMARY CARES OFFICE FOR POST HOSPITAL CARE.

2. ISSUES ASSOCIATED WITH FAILED TRANSITIONS (RELATED TO DISCHARGE PROCESS) -MOST IMPORTANT; QUALITY AND PATIENT SAFETY ARE COMPROMISED DURING TRANSITION PERIODS -RISK OF RE-HOSPITALIZATION -GREATER

5 2. ISSUES ASSOCIATED WITH FAILED TRANSITIONS (RELATED TO DISCHARGE PROCESS) -MOST IMPORTANT; QUALITY AND PATIENT SAFETY ARE COMPROMISED DURING TRANSITION PERIODS -RISK OF RE-HOSPITALIZATION -GREATER USE OF HOSPITAL EMERGENCY, POST-ACUTE AND AMBULATORY SERVICES -PROGRESSIVE FUNCTIONAL DECLINE -PATIENTS EXPERIENCE FUNCTIONAL DEPENDENCY -PERMANENT INSTITUTIONAL -LEADS TO INCREASED HEALTH CARE COSTS

6 2. ISSUES ASSOCIATED WITH FAILED TRANSITIONS, CON T; -IN 2010 AMONG MEDICARE POPULATION 20% OF PATIENTS DISCHARGED FROM HOSPITAL WERE READMITTED WITHIN 30 DAYS. -UNPLANNED READMISSIONS IN 2004 COST MEDICARE $17 BILLION. -OF PATIENTS DISCHARGED TO SNF 19% WERE READMITTED WITHIN 30 DAYS AND 42% WITHIN 24 MONTHS. -49% OF DISCHARGED PATIENTS HAD LAPSES RELATED TO MEDICATIONS, TEST FOLLOWUP, COMPLETION OF A PLANNED WORKUP OR PHYSICIAN VISIT. -19% OF MEDICARE DISCHARGES EXPERIENCED AN ADVERSE EVENT WITHIN 30 DAYS.2/3 ARE DRUG EVENTS, MOST OFTEN JUDGED PREVENTABLE

7 3. MOST COMMON ERRORS THAT LEAD TO FAILED TRANSITIONS; MEDICATION ERRORS, FAILED HANDOFFS, AND ABSENT OR DELAYED FOLLOW-UP. -HIGH RATE OF MEDICATION ERRORS; PATIENT SENT HOME WITHOUT PRESCRIPTION OR WRONG PRESCRIPTION, DUPLICATE PRESCRIPTIONS WITH DIFFERENT LABELING, INADEQUATE MONITORING AND FOLLOW-UP FOR DRUG SIDE EFFECTS -FAILED HANDOFFS; LACK OF SOME TYPE OF DIRECT COMMUNICATIONS TO NEXT HEALTH CARE PROVIDER. 2/3 OF POST CARE PROVIDERS WERE UNAWARE OF TESTS PENDING AT TIME OF DISCHARGE. -ONLY 34% OF DISCHARGE SUMMARIES HAD REACHED AFTERCARE PROVIDERS BY TIME OF THE FIRST POST HOSPITAL VISIT. MANY DISCHARGE SUMMARIES ARE INADEQUATE. -ABSENT OR DELAYED FOLLOW-UP; AMONG MEDICARE BENEFICIARIES REQUIRING RE-ADMISSION WITHIN 30 DAYS OF DISCHARGE, ONLY 50% HAD SEEN A CLINICIAN FOR A FOLLOW-UP VISIT.

8 3. MOST COMMON ERRORS THAT LEAD TO FAILED TRANSITIONS, CON T. -PREMATURE DISCHARGE OR INAPPROPRIATE DISCHARGE SETTING -COMPLICATIONS FOLLOWING PROCEDURES, E.G., PLEURAL EFFUSIONS POST CABG -NOSOCOMIAL INFECTIONS, PRESSURE ULCERS, AND PATIENT FALLS

9 4. WAYS TO IMPROVE TRANSITIONS OF CARE; THE DISCHARGE-HANDOFF PROCESS -PRIMARY GOALS TO PREVENT HARM AND IMPROVE PATIENT SAFETY OUTCOMES -REDUCE RE-ADMISSIONS AND HEALTH CARE COSTS -MEDICATION RECONCILIATION; ALL STARTS WITH MEDIATION HISTORY.GARBAGE IN = GARBAGE OUT STEP 1: VERIFICATION, DOCUMENT MOST ACCURATE LIST OF PATIENTS MEDICATIONS (NAME, DOSAGE AND TYPE) USE ATLEAST TWO SOURCES STEP 2: VALIDATE, COMPARE CURRENT LIST IDENTIFY WHICH MEDICATIONS ARE TO BE CONTINUED, CHANGED, HELD OR DISCONTINUED STEP 3: CLAFICATION, COMPARE THAT LIST WITH NEW MEDICATIONS ORDERED/PRESCRIBED TO ID AND RESOLVE DISCREPENCIES. STEP 4: COMMUNICATE, RELAY THE COMPLETED LIST OF MEDICATIONS TO OTHER PROVIDERS AND TO PATIENT WHEN HE OR SHE IS DISCHARGED

10 4. WAYS TO IMPROVE TRANSITIONS OF CARE; THE DISCHARGE-HANDOFF PROCESS, -MEDICATION RECONCILIATION CON T ESSENTIAL COMPONENTS OF A BEST POSSIBLE MEDICATION HISTORY (BPMH) ASKS PATIENT OPEN-ENDED QUESTIONS ABOUT WHAT MEDICINE S/HE IS TAKING (I.E., DOES NOT READ LISTTO THE PATIENT AND ASK IF IT IS CORRECT) REVIEWS AT LEAST 2 SOURCES OF MEDICATION DATA - MEDICATION LIST THE PATIENT KEEPS - RECENT CLINIC OR HOSPITAL MEDICATION LIST - PILL BOTTLES - FAMILY MEMBERS - PHARMACY LIST OR PHONE NUMBER USES SPECIFIC QUESTIONS TO FIND OUT DOSE AND FREQUENCY OF MEDICATIONS (USES PROBING QUESTIONS TO ELICIT ADDITIONAL INFORMATION) - OVER THE COUNTER MEDS - MEDS TAKEN ONLY AS NEEDED - NON-DAILY MEDS - NON-ORAL MEDS ASKS PATIENT ABOUT ADHERENCE IN AN OPEN, NON-JUDGMENTAL WAY - HOW DOES THE PATIENT ACTUALLY TAKE THE MEDICATION?

11 4. WAYS TO IMPROVE TRANSITIONS OF CARE; THE DISCHARGE-HANDOFF PROCESS -MEDICATION RECONCILIATION CON T RECONCILES VARIOUS SOURCES OF MEDICATION DATA (RECENT CLINIC NOTE, PHARMACY DATA, AND PATIENT REPORT) RETURNS TO PATIENT FOR FINAL CLARIFICATION ATTEMPTS TO IDENTIFY BARRIERS TO MEDICATION ADHERENCE ELICITS PATIENT S SOLUTIONS FOR IMPROVING ADHERENCE -ENSURE ALL LABS AND TESTS ARE ARRANGED FOR PATIENT AT TIME OF DISCHARGE. -TIMELY AND USEFUL DISCHARGE SUMMARY TO NEXT PHYSICIAN RESPONSIBLE FOR NEXT LEVEL OF CARE -POST DISCHARGE FOLLOW UP APPOINTMENT WITHIN 7-14 DAYS.

12 4. WAYS TO IMPROVE TRANSITIONS OF CARE; THE DISCHARGE-HANDOFF PROCESS -TARGET HIGHER RISK PATIENTS (HIGH RISK MEDS, MULTIPLE MEDS, CERTAIN CONDITIONS, PRIOR HOSPITALIZATIONS, RACE, HEALTH LITERACY, SOCIOECONOMIC STATUS, SUPPORT NETWORK) -PATIENT NAVIGATORS IN HOSPITAL, PHARMACIST INVOLVEMENT FOR MEDICATIONS, PATIENT EDUCATION, DISCHARGE CHECK LISTS -USE OF SCREENING TOOLS AS WAY TO IDENTIFY HIGH RISK PATIENTS; LACE INDEX, HOSPITAL SCORE, AND 8P S -OTHER INTERVENTIONS, TELEPHONE CALLS, HOME VISITS, TELE-MONITORING AND MEDICATION MANAGEMENT. -EVIDENCE ON ALL THESE MEASURES WEAK BUT OVERALL TREND THAT TARGETING THE TOP THREE HAVE DECREASED READMISSIONS.

13 SOURCES: -AAMC MED-ED PORTAL EMORY UNIVERSITY TOC MODULE, VANDERBILT UNIVERSITY MEDICATION RECONCILIATION CCE SEMINAR MODULE (PUBLIC DOMAIN EDUCATIONAL MATERIAL) -UP TO DATE ARTICLE HOSPITAL DISCHARGE AND READMISSIONS -USEFUL RESOURCES (REFERENCED FROM UTD ARTICLE) NATIONAL TRANSITIONS OF CARE COALITION: INSTITUTE FOR HEALTHCARE IMPROVEMENT CARE TRANSITIONS PROGRAM PROJECT BOOST PROJECT RED PACT TOOLKIT TRANSITIONAL CARE MODEL

14 MR. ANYONE-CHF PRESENTATION HPI: 82 YEAR OLD WHITE MALE ADMITTED TO SMMC WITH FOUR DAYS OF DYSPNEA, NON PRODUCTIVE COUGH, LEG SWELLING, AND NAUSEA. NO CHEST PAIN, OR PALPITATIONS. HE HAS KNOWN CAD WITH LAST MI TWO YEARS AGO REQUIRING PCI (STENT) TO HIS RCA. HE WAS DIAGNOSED WITH SYSTOLIC HEART FAILURE WITH ECHO SIX MONTHS AGO WITH EJECTION FRACTION OF 30%. SINCE THEN HE S HAD ONE PREVIOUS ADMISSION FOR CHF. GETTING A HISTORY IS DIFFICULT FROM PATIENT BECAUSE HE HAS SIGNIFICANT HEARING LOSS AND LOST HIS HEARING AIDS A COUPLE OF MONTHS AGO. PMH: CAD, CHF, HTN, HLP, DM, DEMENTIA, MACULAR DEGENERATION, DJD MEDICATIONS: FUROSEMIDE 20MG ONCE DAILY CLOPIDOGREL 75MG ONCE DAILY ASPIRIN 325MG ONCE DAILY

15 CHF CASE PRESENTATION CON T MEDICATIONS: SIMVASTATIN 20MG EVERY NIGHT LISINOPRIL 20MG Q DAY CARDIZEM LA 360MG ONCE DAILY GLIPIZIDE XL 10MG ONCE DAILY DONEZEPIL 10MG ONCE DAILY SOCIAL HISTORY: LIVES ALONE AND RECENTLY WIDOWED (WIFE DIED ABOUT SIX MONTHS AGO), DENIES ETOH, DRUG, AND TOBACCO USE. HAS 2 SUPPORTIVE DAUGHTERS THAT CHECK ON HIM FREQUENTLY, USES READING GLASSES AND NEEDS HEARING AIDS.

16 CHF CASE PRESENTATION CON T FUNCTIONAL STATUS: -INDEPENDENT ADL S (BATHING, TOILETING, GROOMIN) -INCREASING USE OF CANE TO GET AROUND HOUSE BUT CAN PREPARE SIMPLE MEALS AND UPKEEP OF HOUSE -WHEN CHF CONTROLLED ACTIVITY LIMITED BY HIS ARTHRITIS ONE OF THE PATIENT S DAUGHTER BROUGHT PATIENT TO HER PCP TO ESTABLISH CARE AFTER HE WAS DISCHARGED FROM THE HOSPITAL.

17 IPE TOC Case #1 care transitions workshop: Patient with CHF Discharge Summary: Primary Diagnosis: Acute Systolic CHF Secondary Diagnosis: CAD s/p PCI 2 years ago HTN HLP DM Dementia Macular degeneration DJD Diet: Low Sodium, 1L fluid restriction Activity: as tolerated Consultants: None Procedures: None Special Instructions: Not discharged on a beta blocker because of patient being acutely decompensated with CHF. Educated on nutrition and importance of compliance with medications and daily weights. Instructed to call PCP if he gained >3lbs. Screening colonoscopy for workup of anemia. Follow-up with PCP 1 week. Brief history and hospital course: This is an 82 year old white male admitted to SMMC with four days of dyspnea, non-productive cough, leg swelling, and nausea. He denied chest pain, or palpitations. He has known CAD with last MI two years ago requiring PCI (stent) to his RCA. He was diagnosed with Systolic Heart Failure with Echo six months ago with Ejection Fraction of 30%. Since then he s had one previous admission for CHF. Getting a history is difficult from patient because he has significant hearing loss and recently widowed. On admission patients Cxr notable for pulmonary edema and cardiomegaly. EKG: NSR no acute changes. On admission he weighed 118 kg, Cxr was significant for pulmonary edema and cardiomegaly. Notable exam findings: T: 37C HR: 100 R: 20 BP: 140/90 O2 Sat on 4L 92%. General: Mild respiratory distress. Cardiac: s1 s2 appreciated,

18 JVD 12cm, Abd: protuberant, BS present in all four quadrants, Ext: 2+ edema. Was given Lasix 80mg IV q 12 hours and over next couple of days he lost 20kg and returned to his dry weight of 98kg. Patient complained of persistent nausea during admission and was started on omeprazole 40mg BID. Patient with Hgb of 10 down 2 points from last admission. Iron studies done were consistent with Iron deficiency anemia and was prescribed Iron sulfate 325mg TID. On day three a repeat Cxr showed patients pulmonary edema had resolved. Vital signs on day of discharge were BP: 106/77, weight 98kg. Labs: K+ 4.0, Na 136 Bun/Cr 15/1.0. His Lasix was changed to 40mg po q daily. Medications on admission: Furosemide 20mg qdaily Clopidogrel 75mg daily Asa 325mg daily Simvistatin 20mg qhs Cardizem 360mg once daily Lisinopril 20mg qdaily Glipizide XL 10mg once daily Donezepil 10mg daily Medications at discharge: Clopidogrel 25mg daily Asa 325mg daily Simvistatin 20mg daily Donepezil 10mg qdaily Lantus 10 Units qdaily Lisinopril 5mg daily Furosemide 40mg daily Ferrous Sulfate 325mg TID Omeprazole 40mg BID Cardizem LA 360MG QDAILY

19 One of Mr. Anyone s daughter wasn t happy with the care he had been receiving from his PCP and has brought him to see her PCP for care. The daughter reports patient is doing just OK. Daughter is extremely supportive. Since you are the daughter s PCP Mr. Anyone is now in your office for his post discharge follow up appointment. You have received and reviewed Mr. Anyone s discharge summary. Remember the three areas identified as problematic for safe handoff at discharge are; medications/medication errors, monitoring/ordering labs and test, and arranging follow-up care. Your goal for this follow up is to fix his medication list, decide if this patient needs labs or other tests. Mr. Anyone s vitals today are: BP 130/80 P: 90 weight 98kg 1. Now reconcile Patients medication from the admission and discharge list provided in the discharge summary. Are there medications you would like to start, stop, change and why? Admission Medications Discharge Medications Reconciled List

20 2. What labs would you order for this patient today and why? 3. What tests or procedures would you recommend and why? 4. What other evaluations or assessments would you consider for this patient?

21 IPE TOC Case #1 care transitions workshop: Patient with CHF Instructors guide Discharge Summary: Primary Diagnosis: Acute Systolic CHF Secondary Diagnosis: CAD s/p PCI 2 years ago HTN HLP DM Dementia Macular degeneration DJD Diet: Low Sodium, 1L fluid restriction Activity: as tolerated Consultants: None Procedures: None Special Instructions: Not discharged on a beta blocker because of patient acutely decompensated with CHF. Educated on nutrition and importance of compliance with medications and daily weights. Instructed to call PCP if he gained >3lbs. Screening colonoscopy for workup of anemia. Follow-up with PCP 1 week. Brief history and hospital course: This is an 82 year old white male admitted to SMMC with four days of dyspnea, non-productive cough, leg swelling, and nausea. He denied chest pain, or palpitations. He has known CAD with last MI two years ago requiring PCI (stent) to his RCA. He was diagnosed with Systolic Heart Failure with Echo six months ago with Ejection Fraction of 30%. Since then he s had one previous admission for CHF. Getting a history is difficult from patient because he has significant hearing loss and recently widowed. On admission patient Cxr notable for pulmonary edema and cardiomegaly. EKG: NSR no acute changes. On admission he weighed 118 kg, Cxr was significant for pulmonary edema and cardiomegaly. Notable exam findings: Vitals: T: 37C HR: 100 R: 20 BP: 140/90 O2 Sat on 4L 92%. General: Mild respiratory distress. Cardiac: s1 s2 appreciated, JVD 12cm, Abd: protuberant, BS present in all four quadrants, Ext: 2+ edema. Was given Lasix 80mg IV q 12 hours and over next couple of days he lost 20kg and returned to his dry weight of

22 98kg. Patient complained of persistent nausea during admission and was started on omeprazole 40mg BID. Patient with Hgb of 10 down from 2 points from last admission. Iron studies were consistent with Iron deficiency anemia and was prescribed Iron sulfate 325mg TID. On day three a repeat Cxr showed patients pulmonary edema had resolved. Vital signs on day of discharge were BP: 106/77, weight 98kg. Labs: K+ 4.0, Na 136 Bun/Cr 15/1.0. His Lasix was changed to 40mg po q daily. Medications on admission: Furosemide 20mg qdaily Clopidogrel 75mg daily Asa 325mg daily Simvistatin 20mg qhs Cardizem 360mg once daily Lisinopril 20mg qdaily Glipizide XL 10mg once daily Donezepil 10mg daily Medications at discharge: Clopidogrel 25mg daily Asa 325mg daily Simvistatin 20mg daily Donepezil 10mg qdaily Lantus 10 Units qdaily Lisinopril 5mg daily Furosemide 40mg daily Ferrous Sulfate 325mg TID Omeprazole 40mg BID Cardizem LA 360MG QDAILY

23 One of Mr. Anyone s daughter wasn t happy with the care he had been receiving from his PCP and has brought him to see her PCP for care. The daughter reports patient is doing just OK. Daughter is extremely supportive. Since you are the daughter s PCP Mr. Anyone is now in your office for his post discharge follow up appointment. You have received and reviewed Mr. Anyone s discharge summary. Remember the three areas identified as problematic for safe handoff at discharge are; medications/medication errors, monitoring/ordering labs and test, and arranging follow-up care. Your goal for this follow up is to fix his medication list, decide if this patient needs labs or other tests. Mr. Anyone s vitals today are: BP 130/80 P: 90 weight 98kg 1. Now reconcile Patients medication from the admission and discharge list provided in the discharge summary. Are there medications you would like to start, stop, change and why? Admission Medications Discharge Medications Reconciled List* Furosemide 20mg qdaily Clopidogrel 25mg daily Aspirin 81mg daily Clopidogrel 75mg daily Aspirin 325mg daily statin Asa 325mg daily Simvistatin 20mg daily lisinopril Simvistatin 20mg qhs Donezipil 10mg daily lasix Cardizem 360mg once daily Lantus 10Units Subq daily Troprol XL or Carvidelol Lisinopril 20mg qdaily Lisinopril 5mg daily Ferrous Sulfate 325mg Glipizide XL 10mg once daily Lasix 40mg daily Diabetic Medication Donezepil 10mg daily Ferrous Sulfate 325mg TID Spironolactone Omeprazole 40mg BID digoxin Cardizem LA 360mg daily

24 *The goal is to get the students to recognize (hopefully the brief review of these & other medications along prior to this will help) at minimum the evidence based medications the patient should be on for his Systolic Congestive Heart Failure. The final list and dosages for each group will vary, but should include an ace/arb, beta or combined beta or alpha blocking agent, a potassium sparing agent. While Lasix doesn t improve mortality it is always a good choice to have on the final discharge medication reconciliation. Digoxin is sometimes chosen by the students for a CHF agent but this isn t a mortality improving agent. Most students get caught up on the Plavix issue wanting to continue it but in this case scenario the patient only needs aspirin and 81mg is recommended dose. Most students choose to optimize this patients statin given the patients history of CAD. Cardizem (contraindicated in CHF) and Donezipil are usually dropped from the list along with omeprazole as there is no indication for the patient to be on one. Where students have the hardest and most problematic decision is in the area of diabetes treatment. Some tables continue lantus, others will choose an oral diabetic medication. There isn t one right answer and students get to decide what medications to continue or discontinue.

25 2. What labs would you order for this patient today and why? -chemistry to monitor bun/creatinine -HgbA1c assess diabetes -cbc anemia -6 minutes walk test to assess if patient qualifies for home oxygen 3. What tests or procedures would you recommend and why? -egd for anemia workup -colonoscopy for anemia workup -could also alternatively defer these measures and reassess at later date 4. What other evaluations or assessments would you consider for this patient? -social work to assess home safety needs -Home PT/OT -Dietary consult

Medication Reconciliation

Medication Reconciliation Define the term medication. Define medication reconciliation. Describe the potential barriers to obtaining an accurate medication list and resolution strategies to overcome these