HRET/K-HEN Readmissions Race Office Hour Building a Multidisciplinary Care Transitions Team January 25, 2013

Breakdowns in Drug Therapy in the Chronically Ill are Associated with Readmissions 2002 ADHERE registry: 80% of CHF admissions are repeat admissions  20% in one month;  50% in 6 months Why?  24% Rx non-adherence  16% Inappropriate Rx  24% dietary non-adherence  19% failure to obtain timely care (e.g., report weight gain)  17% all other Source: Vinson JAGS

Poor Outpatient Follow up, Drug Therapy Breakdowns are Associated with Readmissions Study of 100 consecutive readmitted HF patients at urban medical center Major causes for readmission:  No outpatient follow up 33%  Medication noncompliance 25%  Fluid noncompliance 22%.  Diet noncompliance 21%,  “Other causes had minor contributions” (Source: Ghali et al, JACC, March 2010) 3

Medication Problems Linked with Readmissions Study of 998 patients admitted with HF to an urban academic center 72% of patients reporting non-adherence to their medications were readmitted in the year post discharge vs. 29% adherent patients Non-adherent patients were 1.7 times more likely to be readmitted ≥ 3 times in the year post discharge (Source: Shenoy et al, JACC, March 2012) 4

Potential Contribution of Pharmacists as a Team Member A randomized trial of 178 patients being discharged home from the general medicine service found pharmacist counseling reduced the number of preventable adverse drug events from 11% in the control group to 1% in the intervention group. – Source: Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. Mar ;166(5):

Potential Contribution of Pharmacists as a Team Member Pharmacist-Recorded Medication Histories Result in Higher Accuracy and Fewer Medical Errors. – Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. Am J Health Syst Pharm. 2004;61: – Bond CA, Raehl CL, Franke T. Clinical Pharmacy Services, Hospital Pharmacy Staffing and Medication Errors in United States Hospitals. Pharmacotherapy. 2002; 22: – Nester TM, Hale LS. Effectiveness of a pharmacist- acquired Medication History in Promoting Patient Safety. Am J Health Syst Pharm. 2002;59:

Could Pharmacists help YOU Improve Care Transitions, Reduce Readmissions? Pharmacists could help you by— – Doing admission and discharge medication reconciliation – Teaching patients during hospital stay – Delivering discharge meds to patient before discharge – Making post-discharge phone calls to patients What if you can’t secure the help of your hospital pharmacist? Community pharmacists can see or make calls to patients and be paid through the Medicare MTM benefit Pharmacists in outpatient hospital pharmacies could counsel patients and be paid under the Medicare Medication Therapy Management (MTM) program 7

What are Medicare Medication Therapy Management Services? As defined by the Medicare Modernization Act of 2003 (MMA), MTM services are designed to: Review patient medication regimen Counsel patients to enhance understanding and increase adherence Detect adverse drug events, and patterns of overuse and underuse of prescription medications Make corrective recommendations to prescriber Provided at no cost to eligible Medicare Part D (drug benefit) enrollees Pharmacists are paid by the Part D plan 8

Patients Eligible for the Medicare MTM Program Patient must meet 3 criteria to be eligible for a Plan’s MTM: – Have multiple chronic diseases (Part D plan can’t require more than 3) – Taking multiple Part D drugs (plan can’t require more than 8 Part D drugs) – Are likely to incur Part D drug costs of at least $3000 Patients targeted by most hospitals as being at high risk for readmission match these MTM criteria pretty well (e.g., CHF, COPD)

Chronic Diseases Targeted by MTM Programs CMS requires Part D plan to target at least 4 of these 7 conditions: – Bone Disease (e.g., Osteoporosis, Osteoarthritis, or Rheumatoid Arthritis); – Diabetes; – Dyslipidemia; – Heart Failure; – Hypertension; – Mental Health disorders (e.g., Depression, Schizophrenia, Bipolar Disorder); – Respiratory Disease (e.g., Asthma, COPD, or Chronic Lung disorders) 10

How Could MTM Services be Coordinated with Hospital Discharge? Hospital establishes a relationship with pharmacists who will provide MTM services when called by the hospital team with only a day or two of notice – Community pharmacist providing MTM may be in town – Or could be contract pharmacists making telephonic intervention (quite valuable in most cases) Hospital would target patients who are eligible for MTM, work with pharmacists who are authorized by the patient’s Part D plan to be paid for MTM services. MTM services would follow the patient after discharge for weeks or months We are seeking hospitals to pilot test this change model 11