Transition of Care Practices Nancy MacDonald, PharmD, BCPS, FASHP Henry Ford Hospital Detroit, MI
Objectives Pharmacist 1. Describe transition of care opportunities 2. Explain ways to use pharmacist extenders in transition of care 3. Describe novel pharmacy practices in transition of care hand-off Technician 1. Describe transition of care opportunities 2. Describe novel pharmacy practices in transition of care hand-off
Transition of Care
Transition of Care The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/carecoordination/carecoord-measures. Accessed April 10, 2018
Transition of Care: Admission to Hospital Admission Home Med List Created/Verified Inpatient Home Meds Continued or Held & New Meds Added Discharge New Med List Created (inpatient meds + home meds)
Transition of Care: Ambulatory Care Arrival Home Med List Created/Verified Provider Evaluation Home Meds Continued or Held & New Meds Added Discharge New Med List Created (inpatient meds + home meds)
The Many TOC Components Med History Caregiver Lack of Follow Up Non-adherence Access to Med Education Others
2014 National Survey 393 respondents (31.5% response rate) Results Admission med history 27% pharmacists 5% indicated technicians Most respondents pharmacists do not routinely or consistently provide patients with tools to facilitate medication adherence before hospital discharge pharmacists do not routinely or consistently follow up with patients after discharge Kern K, Kalus J, Bush C, et al. AJHP 2014; 71:648-56
2014 National Survey Most respondents either agreed or strongly agreed that it is important for pharmacists to be involved in TOC activities for hospitalized patients. Few respondents indicated that student pharmacists are involved with TOC activities Kern K, Kalus J, Bush C, et al. AJHP 2014; 71:648-56
ASHP Forecast Recommendations Increase pharmacist involvement on services that facilitate patient empowerment and where medication adherence is clearly linked to outcomes ASHP Pharmacy Forecast 2016-2020
Henry Ford Hospital Pharmacy Transitions of Care Services
Henry Ford Hospital (HFH) 1 of 5 Henry Ford Health System (HFHS) hospitals 802 bed tertiary care, teaching hospital Level 1 trauma center, Detroit Inpatient Pharmacy Services Ambulatory Care Pharmacy Services Bone Marrow Transplant Hem Onc HIV Pulmonary Solid Organ Transplant
HFH Pharmacy Training Programs Training Program Number of Participants Longitudinal Advanced Pharmacy Practice (LAPP) Students PGY1 Residents 10 Pharmacotherapy 1 PGY2 Residents 12 2 Hem Onc 1 Critical Care 1 Pharmacotherapy 1 Infectious Disease
HFH Transition of Care (TOC) Services General Practice Unit Introduction to Pharmacy Services TOC Consults Intensive Care Unit Access to Therapy Consults Diabetes Medications Pulmonary Hypertension Medications All Units Electronic Referral for Am Care Pharmacist Follow-Up Outpatient Parenteral Antimicrobial Therapy Consults
Introduction to HFH Pharmacy Services Inpatient Pharmacy Services Introduce Pharmacy services Provide HFHS medication safety brochure Update preferred discharge pharmacy May identify need for targeted pharmacy services or education
Introduction to Pharmacy Services 842
Henry Ford Hospital Pharmacy Transitions of Care Consults
Types of Inpatient Pharmacy TOC Consults General Practice Unit (GPU) TOC Consults Medication History & Adherence Disease Specific Acute Exacerbation of COPD Acute Exacerbation of Heart Failure ICU TOC Planning Consults Diabetes Mellitus (DM) Transition of Care Planning Pulmonary Arterial Hypertension TOC planning
GPU TOC Consult Goals Provide adherence counseling Provide avenue to document pharmacy services Build ambulatory care pharmacy services
GPU TOC Consults Medication History & Adherence Verify & update med history Discuss discrepancies Identify non-adherence Provide tools & strategies to improve adherence Educate If possible, refer to am care pharmacist Disease Specific Consults Additional components Optimize disease specific meds
Target Patients & Populations High Risk Readmissions Program of All-Inclusive Care for the Elderly (PACE) patients Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT) Those with non-adherence or med access barriers Plan to be discharged on new medicine
Resident TOC Requirements Goal R1.2: Ensure continuity of care during patient transitions between care settings 2015-2016 HFH Residents Implemented minimal TOC consults for PGY1s 2017-2018 HFH Residents Increased total TOC consult requirements Added quarterly targets Progress discussed monthly Added consult requirements for PGY2 hem/onc
GPU TOC Consults 1126 1113
ICU TOC Consults DM Ensure Access to DM Meds for Discharge DKA or A1C >9% in the last 6 months on an insulin drip PAH Ensure Access to PAH and CTEPH Meds for Discharge PAH or CTEPH therapy
ICU Encounters with a PAH TOC Consult
Henry Ford Hospital Using Pharmacy Technicians as Pharmacist Extenders
HFH Bedside Transition of Care Pilot program October 2017 Cardiac general practice unit Leverages relationships & skills Outpatient pharmacy technician Access to electronic medical record Access to outpatient prescription records Attends progressive rounds
Bedside TOC Technician Obtain an accurate medication history Update the EMR medication history & preferred pharmacy Identify medication access barriers, including the need for discharge medication prior authorization Begin resolution of medication access barriers medication test claims prior authorization Document Standard note template Med history, prior auth status, test claim results Co-signed by unit-based pharmacist Enroll patients in Pharmacy Advantage
HFH Bedside Transition of Care 160 Number of Patients 140 120 100 80 60 71 121 122 138 40 20 0 Oct-17 Nov-17 Dec-17 Jan-18 Month-Year
Outpatient Parenteral Antimicrobial Therapy (OPAT)
OPAT Used to treat invasive infections or to contain inpatient hospital costs Requires a thorough assessment patient s medical condition, especially infection medical needs inpatient antimicrobial regimen clinical parameters insurance coverage access to follow-up monitoring
HFH Detroit OPAT Process Implemented May 2015 Pharmacy OPAT Consult Case Management ID - Approves OPAT - Line placement, if required - Optimizes OPAT regimen - Educates patient/caregiver - Documents discharge safety labs - Places information in the patient s EMR - Determines eligibility - Sets up home infusion or placement -Uses pharmacy consult to obtain medication prior auth OPAT Discharge
Pharmacist Checklist for OPAT Consult Checklist Comments Is the patient likely to require outpatient IV therapy? Has infectious diseases consult evaluated the patient? Is the case manager aware? Has the regimen and monitoring plan been optimized and simplified for the infection? Has the patient been educated on their discharge antimicrobial regimen? Has the OPAT referral for the ID am care clinical pharmacist been placed? Was Pharmacy OPAT note placed in the patient s record? -Disease state that requires long term IV (e.g. osteomyelitis, endocarditis, MRSA bacteremia) -No oral switch options (PO switch preferred for CAP and pyelonephritis) -ID approval required before PICC insertion or discharge for OPAT -Yes, ID approval required for dialysis patients -Case manager will evaluate insurance eligibility, capability to perform home infusion -Minimize the number of doses per day where possible -Document if steady state has been achieved for PK drugs/ when steady state anticipated -Provide written and verbal instructions about the antimicrobial therapy (use Clin Pharm Pt Education) -Place discharge order if they are going to K10 for an in-clinic infusion - Regimen and monitoring parameters
OPAT Practice Models Pharmacist OPAT Consult (HFH) n=50 Standard of Care (HFWB) n=44 OPAT Team HFH ID Physician Unit-based Pharmacist (Non-ID trained) Case Management Nursing Home Infusion Service OPAT Team HFH ID Physician Case Management Nursing Home Infusion Service Pharmacy OPAT Consult Service began May 1, 2015 No Pharmacy OPAT Consult
Patient Education P < 0.001 P < 0.001 P < 0.001 P < 0.001
Discharge Safety Labs 91% Percent
Pharmacist Interventions
Henry Ford Hospital Transition of Care Hand-Off
TOC Consult Hand-off EMR note Standard note template Alert for next pharmacist Follow up on prior authorizations More targeted review or education Enrollment in home med delivery Referral to am care pharmacist
Electronic Referrals Hand-off to clinician after discharge Referral order placed in EMR By pharmacist or technician Goes to designated In-Basket Two Types Referral to Ambulatory Care Pharmacist Follow up on adherence Optimize disease therapy Work through access barriers Referral for Pharmacy Advantage Enrollment in home delivery of meds
Bedside TOC Program
Summary There are many opportunities to improve TOC for patients prior to discharge Pharmacist extenders can increase documentation in the EMR The EMR can serve as a means for hand-off to another pharmacist for follow up after discharge
Questions?
Self Assessment Question #1 Which of the following can lead to poor outcomes upon transition from the hospital? a) Medication non-adherence b) Affordable prescription co-payments c) An accurate medication history d) Good follow up after discharge
Self-Assessment Question #2 Which of the following is TRUE about pharmacist extenders: a) Technicians can document patient education in the medical record b) Technicians cannot identify patients who want home delivery of medications c) Technicians can document pharmacy services in the medical record d) Residents should not provide transition of care pharmacy services as part of training
Self Assessment Question #3 A novel way to provide TOC hand-off includes: a) Pharmacy documented notes in the EMR b) Having pharmacy technicians call the patient s provider after discharge c) Working in two different electronic medical records d) Having each pharmacist develop a unique note template