Care Transitions for Medication Safety in the Community Lauren E. Glaze, PharmD Assistant Professor of Pharmacy Practice UAMS South Family Medical Center

Objectives Define transitional care and its impact on healthcare outcomes and expenditures Describe the development of a Transitions of Care (TOC) service Identify medication-related strategies to decrease hospital readmissions Review examples of pharmacist-led interventions to enhance transitions of care in rural communities

Source: Healthy Transitions Colorado, 2015. Transitions of Care “The movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change.” -National Transitions of Care Coalition, 2008 Source: Healthy Transitions Colorado, 2015.

Barriers to Successful Care Transitions Multiple providers Different EMRs Medication discrepancies Poor communication Lack of patient/family education Inadequate planning and goal setting

Why focus on care transitions? Improve patient safety and health outcomes Reduce readmissions and healthcare costs

2011 Readmission Costs $41.3 billion in hospital costs for 3.3 million adult 30-day readmissions Medicare $4.3 billion Medicaid $839 million Private Insurance $785 million Source: Hines AL, et al. 2014. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf.

Source: New England Journal of Medicine, 2009 Centers for Medicare & Medicaid, 2012

Source: HCUP Statistical Briefs #153 and #154: http://www. hcup-us

Source: HCUP Statistical Briefs #153 and #154: http://www. hcup-us

CMS Data 64% of Medicare patients received no post-acute care between discharge and readmission 76% of readmissions may be preventable Medicare beneficiaries report greater dissatisfaction in discharge-related care than any other aspect of care CMS measures U.S. Department of Health & Human Services. New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. May 7, 2014 .

Hospital Readmission Reduction Program (CMS) YEAR READMISSION DIAGNOSIS PENALTY 2013* Acute MI, CHF 2015 COPD, TKA, THA 2016 CABG surgery 2017 Aspiration pneumonia, sepsis * CMS Transitional Care Billing introduced

The Bottom Line Poorly coordinated care transitions Decreased quality of care Decreased health outcomes Increased hospital readmissions Increased costs

Transitions of Care Service Reduce of adverse drug events Improve quality outcomes Reduce hospital readmission rates

Patient-Centered Medical Home (PCMH) and Rural Health Clinic (RHC) 7 counties in South Arkansas Adult Primary Care, Pediatrics, Senior Care, OB/GYN Family Medicine faculty physicians, residents, and students

Development of TOC Service

Key Players Hospital Physicians Pharmacist Case Managers Nurses Clinic Physicians/APRNs QI Coordinator Care Coordinators Behavioral Therapist Health Educator

UAMS readmission stats

PharmD Impact stats

UAMS South TOC Workflow Inpatient Care/ Discharge DAY 0-1 Follow-up Phone Call DAY 2-3 Follow-up Clinic Visit DAY 7-14 TOC Billing DAY 30

Inpatient Care Medical Team includes attending physician, UAMS medical residents, students, PharmD, and scribe who perform daily rounds PharmD assists in medication selection, duration, and dosing PharmD focuses on UAMS patients medication discrepancies Discuss inpatient care and plans for discharge

Discharge UAMS patients identified by PharmD and hospital case managers Brief discharge counseling and verification of information performed by PharmD or PharmD student Hospital Nurse provides updated medication list to patient and preferred community pharmacy* Hospital Nurse calls UAMS South to schedule Follow-up Clinic Visit

Follow-up Phone Call UAMS South discharged patients emailed to QI Nurse and PharmD daily Led by PharmD or PharmD student within 48 hours of discharge Call to patient’s community pharmacist Call patient or patient caregiver (2 attempts) TOC phone script utilized

Phone Call Script How are you feeling? What appointments do you have ? What imaging/labs/exams are scheduled? Where you able to get your new medication(s)? How are you taking your new medication(s)? What issues/concerns do you have with your new medication(s)? What questions do you have for me? Your provider? Your case coordinator?

Phone Call Documentation TOC Phone Note completed by PharmD or PharmD student Includes discussed appointments, medications, concerns, etc. Hospital discharge note copied to UAMS note Update UAMS EMR to reflect Hospital discharge medication reconciliation Note sent to PCP for review before Follow-up Clinic Visit

Follow-up Clinic Visit Led by PCP within 7 to 10 days of discharge PharmD performs medication education, verifies adherence, and addresses concerns Follow up appointment scheduled for 1-3 months PCP completes clinic visit note with TOC billing code

TOC Billing UAMS coder bills TOC codes at day 30-post hospital discharge for MEDICARE PATIENTS CPT Code 99495 – Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) CPT Code 99496 – Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)

CMS TOC Rules Must include: Date of discharge Date of Interactive Contact (phone call, email, or face to face) with beneficiary or caregiver Non-face to face services* Date of Follow-up Visit (face to face or telemedicine) Complexity of medical decision making (moderate or high)

CMS TOC Rules Discharge from: Inpatient Acute Care Hospital Inpatient Psychiatric Hospital LTAC SNF Inpatient Rehab Hospital Outpatient Observation

CMS TOC Rules Discharge to: Home Nursing Home Assisted Living

CMS TOC Rules Only 1 health professional may report services of 1 billable TOC service per beneficiary within 30 days Same healthcare provider can perform discharge, phone call, and follow-up visit Follow-up visit may not take place the same day as reported discharge May not bill TOC codes and CCM, ESRD, or Care plan oversight services code

Why Involve the Pharmacist? Prevent medication errors Address medication concerns Avoid Adverse Drug Events Provide medication counseling Assess medication adherence and efficacy

Pharmacist Interventions Improper drug selection Subtherapeutic dosages Supratherapeutic dosages Medication non-adherence Therapeutic duplications Therapeutic omissions Drug interactions Drugs with no indications Treatment failures

UAMS Outcomes Completed ___ TOC services since September 2015 (___ weekly discharged patients) Billed 14 Medicare patients Billed Medicaid for ____ patients on EOY reports

Clinical Outcomes QI results

QI Group Benefits ACT Southwest

Partnership Feedback Hospital Home health SNF/Assistant Living Community pharmacists

Patient Success Stories

Future Endeavors Discharge med rec sent to patient’s preferred pharmacy Monthly adherence checks with community pharmacist and at subsequent PCP clinic visits

Future Endeavors

Future Endeavors Expand to other South Arkansas Hospitals Med rec at admission by inpatient pharmacist “Meds to Beds” program Follow-up face to face visits in patient’s home

Question Which of the following is not a barrier to successful care transitions? Different EMRs Multiple providers Medication discrepancies Great communication Lack of patient education

Questions?

TOC Resources

Care Transitions for Medication Safety in the Community Lauren E. Glaze, PharmD Assistant Professor of Pharmacy Practice UAMS South Family Medical Center