MEDS TO BEDS AND CARE MANAGEMENT MEDICATION ASSESSMENT TOOLKIT: FOR HOSPITAL TEAM AND PHARMACISTS

MEDS TO BEDS AND CARE MANAGEMENT MEDICATION ASSESSMENT TOOLKIT: FOR HOSPITAL TEAM AND PHARMACISTS Implementation Toolkit Last Updated: 02/2018 OneCity Health Services 199 Water Street, 31st Floor, New York, NY 10038 onecityhealth.org

TABLE OF CONTENTS How to use this Implementation Toolkit... 4 Setting up the Pharmacy Projects... 4 Meds to Beds... 4 Care Management Medication Assessment... 4 Overview of OneCity Health Pharmacy Projects... 5 Project Objective... 5 Meds to Beds... 5 Care Management Medication Assessment... 5 Target Patient Population... 6 Meds to Beds... 6 Care Management Medication Assessment... 6 Role and Responsibilites of the Hospital Team... 7 Meds to Beds... 7 Identifying Patients and Making Referrals... 7 Follow-Up with Acute Care Inpatient Unit... 8 Care Management Medication Assessment... 8 Identifying Patients and Making Referrals... 8 Follow-Up with Care Team... 8 Role and Responsibilities of Pharmacists... 9 Meds to Beds... 9 Accepting Referrals... 9 Medication Delivery... 9 Medication Reconciliation... 9 Follow-Up with Patient... 10 Care Management Medication Assessment... 10 Accepting Referrals... 10 Medication Reconciliation... 10 Follow-Up with Patient and/or Care Team... 11

APPENDIX A: Care Management Medication Assessment Referral Pathway... 12 APPENDIX B: Care Management Medication Assessement Workflow... 15 APPENDIX C: Meds to Beds Referral Pathway... 16 APPENDIX D: Meds to Beds Workflow... 19 APPENDIX E: Personal Medication list... 20

HOW TO USE THIS IMPLEMENTATION TOOLKIT This Toolkit was developed by OneCity Health to assist partners in launching projects and overseeing project performance. This Toolkit is intended for use by partner organizations that are participating in Meds to Beds and Care Management Medication Assessment programs as part of OneCity Health s Pharmacy Project. ONECITY HEALTH SUPPORT DESK If you have any questions, please contact the OneCity Health support desk: Phone Number: 646-694-7090 Email: ochsupportdesk@nychhc.org, with the subject line Pharmacy Question Hours of Operation: Monday through Friday from 9am to 5pm ET SETTING UP THE PHARMACY PROJECTS The main steps for this preparation stage are: Meds to Beds 1. Conduct introduction kick-off meeting, facilitated by OneCity Health, between OneCity Health PPS Pharmacy partner and acute care inpatient unit 2. OneCity Health PPS Pharmacy partner and acute care inpatient unit to establish delivery schedule of medications to be delivered to the inpatient unit 3. Acute care inpatient unit to identify contact person in inpatient unit for Pharmacy to escalate medication related issues or concerns 4. OneCity Health PPS Pharmacy partner to satisfy facility onboarding requirements for any staff that will be delivering medications to the inpatient unit Care Management Medication Assessment 1. Conduct introduction kick-off meeting, facilitated by OneCity Health, between OneCity Health PPS Pharmacy partner and The OneCity Health Partner Transition Management Teams (TMTs)

2. The OneCity Health Partner Transition Management Teams (TMTs) to identify contact person on team for Pharmacy to escalate medication related issues or concerns OVERVIEW OF ONECITY HEALTH PHARMACY PROJECTS Project Objective The objective of the OneCity Health Performing Provider System (PPS) Pharmacy project is to reduce hospital re-admissions and Emergency Department utilization by providing medication delivery pre-discharge and medication reconciliation post-discharge under the Meds to Beds program and medication reconciliation/adherence consultation for high risk patients identified by Care Management under the Care Management Medication Assessment program. Meds to Beds The acute care inpatient unit will: 1. Identify all insured patients with one of the indicated Chronic Diseases (Asthma/COPD, CHF, Diabetes, Hypertension, Schizophrenia, Bipolar disorder and Depression) 2. Request permission from the patient to have prescriptions delivered bedside predischarge 3. Electronically prescribe medications to OneCity Health PPS Pharmacy partner for medication delivery The OneCity Health PPS Pharmacy partner will: 1. Fill patient s prescriptions pre-discharge or post-discharge 2. Deliver medications to patient in the inpatient unit or to patient s home if discharged 3. Conduct medication reconciliation and distribute to patient post-discharge Care Management Medication Assessment The OneCity Health Partner Transition Management Teams (TMTs) will: 1. Identify patients who do not display medication adherence or have one of the indicated Chronic Diseases (Asthma/COPD, CHF, Diabetes, Hypertension, Schizophrenia, Bipolar disorder and Depression) 2. Refer patient to Pharmacist for medication reconciliation and 3 month assessment of medication adherence

The OneCity Health PPS Pharmacy partner will: 1. Contact patient within 3 days of discharge to conduct medication reconciliation and counsel patient on importance of medication adherence 2. Distribute updated medication reconciliation section of the care plan to patient and care manager within 7 days 3. Conduct a 3 month assessment of medication adherence and counsel patient on importance of medication adherence TARGET PATIENT POPULATION Meds to Beds The Meds to Beds program targets insured adult and pediatric patients who have a high risk chronic condition that may lead to repeat hospital admissions. The acute care inpatient unit is responsible for identifying patients who are being discharged and have at least one of the following chronic conditions: Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Diabetes Hypertension Schizophrenia Bipolar Disorder Depression Care Management Medication Assessment The Care Management Medication Assessment program targets insured or uninsured adult patients enrolled in the OneCity Health Care Transitions program who either do not display medication adherence or have a high risk chronic condition that may lead to repeat Emergency Department utilization or hospital admissions. Medication adherence can be defined as the extent to which patients are able to follow the recommendations for prescribed treatments. Causes of nonadherence can include limitations in health literacy, social determinants, mental capacity, etc. The OneCity Health Partner Transition Management Teams (TMTs) are responsible for identifying patients who do not display medication adherence and/or have at least one of the following chronic conditions:

Asthma Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Diabetes Hypertension Schizophrenia Bipolar Disorder Depression ROLE AND RESPONSIBILITES OF THE HOSPITAL TEAM Meds to Beds Identifying Patients and Making Referrals As a participant of the Meds to Beds Pharmacy project, an acute care inpatient facility has been matched to a OneCity Health Pharmacy Partner to make referrals into the program. The acute care inpatient unit, which may consist of the discharge physician, discharge planning team or any team member responsible for electronically prescribing the patient s medications to a pharmacy, will identify patients eligible for the program and recommend participation to receive delivery of his/her discharge medications prior to discharge. The discharge team member will advise the patient medication delivery is free of charge but patient will be responsible for all applicable copays. If patient refuses, acute care inpatient unit will send prescriptions to patient s pharmacy of choice If patient accepts, acute care inpatient unit will electronically prescribe medications to matched Pharmacy Partner and include the following in the notes section of each prescription: Meds to Beds Principal diagnosis at discharge Patient s RX insurance coverage information which includes: o Bin # o PCN # o ID # o Group # (if indicated)

Follow-Up with Acute Care Inpatient Unit The identified point of contact in acute care inpatient unit to escalate any medication related issues or concerns, identified by the Pharmacy, to the patient s discharge team. Care Management Medication Assessment Identifying Patients and Making Referrals As a participant of the Care Management Medication Assessment Pharmacy project, each Care Management/Transition Management Team (TMT) has been matched to a OneCity Health Pharmacy Partner to make referrals into the program. The OneCity Health Partner Transition Management Teams (TMTs), an interdisciplinary team comprised of a Registered Nurse (RN), Licensed Social Workers and nonclinical workers who serve as transition management assistants, will identify patients eligible for the program and recommend an initial medication review and 3 month assessment of medication adherence with a Pharmacist. If patient agrees, TMT to send referral email, via secure file transfer, to matched Pharmacist. Referral should include: Referring Care Management Team/TMT information (Name, contact information, facility, etc.) Patient Name Patient Date of Birth Patient Gender Patient Diagnosis Patient Discharge Date from Emergency Department or Inpatient setting Copy of Discharge summary (if available) Copy of Discharge medication list (if available) Follow-Up with Care Team Care Management Team/TMT to escalate any medication related issues or concerns, identified by the Pharmacy, to the patient s clinical Care Team.

ROLE AND RESPONSIBILITIES OF PHARMACISTS Meds to Beds Accepting Referrals As a participant of the Meds to Beds Pharmacy project, each OneCity Health Pharmacy Partner has been matched to an acute care inpatient facility to accept referrals into the program. The acute care inpatient discharging team will refer eligible patients to Pharmacy by issuing an electronic prescription. Pharmacy will acknowledge referral if notes section in each electronic prescription include the following: Medication Delivery Meds to Beds Principal diagnosis at discharge Patient s RX insurance coverage information which includes: o Bin # o PCN # o ID # o Group # (if indicated) Following acceptance of referral, pharmacy will adjudicate claims for all prescriptions and deliver medications to the inpatient unit prior to patient discharge or to patient s home within 48 hours if patient has already been discharged. Pharmacy to escalate any medication related issues or concerns to the identified point of contact in the acute care inpatient unit. Medication Reconciliation During or following delivery of patient s medication, within 48 hours, Pharmacist to conduct medication reconciliation via completed personal medication list. Medication reconciliation should identify: a. New medication b. Discontinued medication c. Adjusted medication d. Unchanged medication e. Any medication withheld in hospital

f. Over the counter medication g. Supplements, herbals Follow-Up with Patient Pharmacy will distribute updated medication reconciliation section of the care plan to the patient within 7 days post-discharge. Care Management Medication Assessment Accepting Referrals As a participant of the Care Management Medication Assessment Pharmacy project, each OneCity Health Pharmacy Partner has been matched to Care Management/Transition Management Team (TMT) to accept referrals into the program. The Care Management/Transition Management Team (TMT) will refer eligible patients to Pharmacy by email, via secure file transfer. Pharmacy will acknowledge referral if email includes the following: Referring Care Management Team/TMT information (Name, contact information, facility, etc.) Patient Name Patient Date of Birth Patient Gender Patient Diagnosis Patient Discharge Date from Emergency Department or Inpatient setting Copy of Discharge summary (if available) Copy of Discharge medication list (if available) Medication Reconciliation Upon acceptance of referral, Pharmacist will contact patient, conduct medication reconciliation within 3 days via completed personal medication list, and counsel patient on importance of medication adherence. If the patient is not reached at the first attempt, the Pharmacist must make a minimum of three attempts to contact the patient at different times of the day and days of the week.

Medication reconciliation should identify: a. New medication b. Discontinued medication c. Adjusted medication d. Unchanged medication e. Any medication withheld in hospital f. Over the counter medication g. Supplements, herbals Pharmacist must conduct a 3 month follow-up, at one month intervals, to assess medication adherence and counsel patient on importance of medication adherence. Follow-Up with Patient and/or Care Team Pharmacy will distribute updated medication reconciliation section of the care plan to patient and TMT team within 7 days of referral, and will notify TMT team of any medication related issues or concerns to be escalated to the patient s clinical Care Team.

APPENDIX A: CARE MANAGEMENT MEDICATION ASSESSMENT REFERRAL PATHWAY Transition Management Teams (TMT)/Care Management Care Team This pathway is designed for referrals into the OneCity Health Care Management Medication Assessment DSRIP program. Care Manager in the Emergency Department or Inpatient setting should utilize this referral pathway for enrolling eligible patients for this program. 1. Care Manager is managing a patient being discharged from the Emergency Department or Inpatient setting. 2. Decision Tree Referral Criteria a. Care Manager performs eligibility assessment. Does this patient meet referral criteria? Patient is being discharged from ED or Inpatient setting Care Management Referral Criteria 1. Adult 2. Insured or Uninsured 3. Patient displays Medication Nonadherence OR 4. Patient has at least one of the following Chronic Conditions: - Asthma/COPD - Diabetes - Congestive Heart Failure - Hypertension - Mental Illness (Schizophrenia, Bipolar, Depression) i. Yes, Patient is an Adult AND 1. Displays medication nonadherence. Medication adherence can be defined as the extent to which patients are able to follow the recommendations for prescribed treatments. Causes of nonadherence can include limitations in health literacy, social determinants, mental capacity, etc. a. Proceed to 3 OR ii. No 2. Has at least one of the indicated chronic conditions a. Proceed to 3 1. Patient is a child a. Continue with Care Management services 2. Patient does not have at least one of the indicated Chronic Conditions a. Continue with Care Management services 3. Patient displays medication adherence a. Continue with Care Management services 3. Upon identification, Care Manager recommends medication review with a Pharmacist. a. Decision Tree Does patient agree? i. Yes 1. Proceed to 4 ii. No 1. Continue with Care Management Services

4. Send referral email, via secure file transfer, to Pharmacy. Content should include: a. Referring Care Team information (Name, contact information, facility, etc.) b. Patient Name c. Patient Date of Birth d. Patient Gender e. Patient Diagnosis f. Patient Discharge Date from Emergency Department or Inpatient setting g. Copy of Discharge Summary (If available) h. Copy of Discharge Medication List (If available) 5. Escalate any medication related issues or concerns, identified by the Pharmacist, to the patient s clinical care team

Pharmacy This pathway is designed for Pharmacies accepting referrals for patients enrolled in the Care Management Medication Adherence DSRIP program. Pharmacies should utilize this pathway to perform medication reconciliation and 3 month follow-up contact to assess medication adherence. 1. Patient is referred to Pharmacy by means of email via secure file transfer. 2. Pharmacy receives referral email which includes the following items: a. Referring Care Team information (Name, contact information, facility, etc.) b. Patient Name c. Patient Date of Birth d. Patient Gender e. Patient Diagnosis f. Patient Discharge Date from Emergency Department or Inpatient setting g. Copy of Discharge Summary (If available) h. Copy of Discharge Medication List (If available) 3. Decision Tree Are all elements necessary for referral present? a. Yes i. Proceed to 4 b. No i. Pharmacy will contact Care Team member to gather all required information 4. Contact patient to conduct Medication Reconciliation via Personal Medication List within 3 days of referral. Medication Reconciliation should identify: a. New medication b. Discontinued medication c. Adjusted medication d. Unchanged medication e. Any medication withheld in hospital f. Over the Counter medication g. Supplements, herbals 5. Were any medication related concerns found? a. Yes i. Contact Care Manager to resolve b. No i. Proceed to 6 6. Distribute Personal Medication List to Patient and Care Manager within 7 days of referral. 7. Conduct 3 month follow-up, at one month intervals, to assess medication adherence a. Decision Tree Does patient demonstrate medication adherence? i. Yes 1. Counsel patient on importance of medication adherence ii. No 1. Counsel patient on importance of medication adherence and contact Care Manager

APPENDIX B: CARE MANAGEMENT MEDICATION ASSESSEMENT WORKFLOW

APPENDIX C: MEDS TO BEDS REFERRAL PATHWAY Acute Care Inpatient Unit - Discharge Planning Team/Physician This pathway is designed for referrals into the OneCity Health Meds to Beds program. Discharging Planning Team/Physicians in the Inpatient setting should utilize this referral pathway for enrolling eligible patients for this program. 6. Discharge Planning Team/Physician is ready to electronically prescribe patient s discharge medications from the inpatient setting during designated Meds to Beds hours. 7. Decision Tree Referral Criteria a. Discharging Planning Team/Physician performs eligibility assessment. Does this patient meet referral criteria? Patient is being discharged from Inpatient setting Meds to Beds Referral Criteria 1. Adult or Child 2. Insured 3. Patient has at least one of the following Chronic Conditions: - Asthma/COPD - Diabetes - Congestive Heart Failure - Hypertension - Mental Illness (Schizophrenia, Bipolar, Depression) i. Yes ii. No 1. Proceed to 3 1. Uninsured a. Advise patient to utilize Health + Hospitals Pharmacy or send prescriptions to patient s pharmacy of choice 2. Insured patient without Chronic Condition a. Send prescriptions to patient s pharmacy of choice 8. Upon identification, Discharge Planning Team/Physician offers patient to participate in Meds to Beds program to have participating DSRIP Pharmacy deliver discharge medications bedside prior to discharge. (Delivery is free, Patient is responsible for all copays) 9. Decision Tree Does patient agree to program enrollment? a. Yes i. Discharge Planning Team/Physician electronically prescribes prescriptions to participating DSRIP Pharmacy and includes the following items in the notes section of each prescription: 1. Meds to Beds 2. Principal diagnosis at discharge 3. Patient s RX insurance coverage information which includes: a. BIN # b. PCN # c. ID # d. Group # (if indicated) b. No i. Send prescriptions to patient s pharmacy of choice

10. Identified contact person in acute care inpatient unit to escalate any medication related issues or concerns, identified by the Pharmacy, to the patient s discharge team. Pharmacy This pathway is designed for Pharmacies accepting referrals for patients enrolled in the Meds to Beds program. Pharmacies should utilize this pathway to adjudicate claims for participating patients prescriptions and deliver medication bedside to patient prior to discharge. 8. Patient is referred to Pharmacy by means of indication on electronic prescription 9. Pharmacy receives prescription(s) from the Inpatient Discharge Planning Team/Physician which includes the following items in the notes section of each prescription: 1. Meds to Beds 2. Principal diagnosis at discharge 3. Patient s RX insurance coverage information which includes: a. BIN # b. PCN # c. ID # d. Group # (if indicated) 10. Decision Tree Are all elements necessary for referral present? a. Yes i. Adjudicate claims for prescriptions 1. Decision Tree Were all prescriptions covered by health insurance plan? a. Yes i. Proceed to 4 b. No i. Pharmacy will outreach identified contact person from inpatient unit to adjust prescriptions b. No i. Pharmacy will outreach patient or identified contact person from inpatient unit to obtain information necessary to accept the referral 11. Decision Tree Was patient discharged from Hospital i. Yes 1. Contact patient to deliver medications to patient s home and collect appropriate copay. ii. No 1. Deliver medications to inpatient unit in facility during designated hours and collect appropriate copay. 12. Conduct Medication Reconciliation via Personal Medication List within 48 hours post-discharge. Medication Reconciliation should identify: a. New medication b. Discontinued medication c. Adjusted medication d. Unchanged medication e. Any medication withheld in hospital f. Over the Counter medication g. Supplements, herbals

13. Distribute Personal Medication List to patient within 7 days post-discharge.

APPENDIX D: MEDS TO BEDS WORKFLOW

APPENDIX E: PERSONAL MEDICATION LIST < PHARMACY/PHARMACIST NAME> PERSONAL MEDICATION LIST FOR < Insert Patient s name, DOB: mm/dd/yyyy > This medication list was made for you after we talked. Use blank rows to add new medications. Then fill in the dates you started using them. Cross out medications when you no use them. Then write the date and why you stopped using them. Ask your doctors, pharmacists, and other healthcare providers to update this list at every visit. Keep this list up-to-date with: prescription medications over the counter drugs longer herbals vitamins minerals If you go to the hospital or emergency room, take this list with you. Share this with your family or caregivers too. DATE PREP ARED: < Insert date > Allergies or side effects: < Insert patient s allergies and adverse drug reactions including the medications and their effects > Medication: < Insert generic name and brand name, strength, and dosage form for current/active medications. > How I use it: < Insert regimen, including strength, dose and frequency (e.g., 1 tablet (20 mg) by mouth daily), use of related devices and supplemental instructions as appropriate > Why I use it: < Insert indication or Prescriber: < Insert prescriber s name intended medical use > > < Insert other title(s) or delete this field >: < Use for optional product-related information, such as additional instructions, product image/identifiers, goals of therapy, pharmacy, etc., and change field title accordingly. This field may be expanded or divided. Delete this field if not used. > Date I started using it: < May be Entered by pharmacy or entered based upon patient-reported data, or leave blank for beneficiary to enter start date> Why I stopped using it: < Leave blank for patient s notes > Date I stopped using it: < Leave blank for patient to enter stop date >

PERSONAL MEDICATION LIST FOR < Insert Patient s name, DOB: mm/dd/yyyy > (Continued) Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it: Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it: Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it: Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it: Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it:

PERSONAL MEDICATION LIST FOR < Insert Patient s name, DOB: mm/dd/yyyy > (Continued) Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it: Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it: Medication: How I use it: Why I use it: Prescriber: < Insert other title(s) or delete this field >: Date I started using it: Date I stopped using it: Why I stopped using it: Other Information: If you have any questions about your medication list, call < insert Pharmacist contact information, phone numbers, days/times, etc. >.