Transitions of Care: Using Pharmacists as Part of Team Based Care Care Transformation Collaborative of R.I. TARA HIGGINS, PHARMD, CDOE, CVDOE CLINICAL PHARMACY DIRECTOR RHODE ISLAND PRIMARY CARE PHYSICIAN CORPORATION MAY 5,

Objectives 1. Explain the importance of medication safety 2. Define medication management and value in care transitions 3. Review medication reconciliation process and ways to improve 4. Explore factors that influence medication adherence 2

Medication Safety 3

4 “ Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system. ” The Institute of Medicine (IOM) 1 1 The Institute of Medicine, National Academy of Sciences. Informing the future: Critical issues in health Fourth edition, page 13.

5 of healthcare costs 75 % Driven by 7 chronic conditions Taken by 1/3 of all U.S. adults ≥ 5 chronic medications Drug-related morbidity and mortality costs annual US cost of drug mis- adventures Source: Congressional Budget Office, 2005 National Academies Press: Preventing Medication Errors: Quality Chasm Series, 2007 CDC, World Health Organization, 2003, J Amer Pharm Assoc 2001;41:192–9 Due to prescription painkiller misuse per year Specialty impact on the rise 40% of drug spend due to specialty by 2014 $ 290B Major contributor to poor outcomes The Facts ~500,000 ER visits ~50-60% Adherence rates

Patient Story #1 72 year old female Multiple hospitalization for syncope-like events Kidney transplant 12 years ago Cognitive issues Multiple medication issues Referral to pharmacist for home visit 6

Medication Reconciliation 7

Definition Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.”

Roles in Medication Reconciliation

Ideas to Improve Medication Reconciliation

Medication Reconciliation Medication Management Questions Does the health care provider have enough information to treat the patient? Does the patient understand what the health care provider wants to know or wants to do? Does the patient understand their health problem? Does the patient have the resources to follow a treatment plan? Does the patient have the support they need to follow a plan? Is the patient satisfied with the care they are receiving?

Patient Story #2 64 year old male Knee replacement surgery resulted in pulmonary embolism after discharged home Re-admission with multiple medication changes New start warfarin Meet with patient with NCM Home visit – care team huddle to coordinate patient needs 12

Patient-Centered Medication Therapy Management 13

Medication Therapy Management in Ambulatory Care Clinical Pharmacist Appropriate, Effective, Safe and Adherent Medication Use Physicians/Providers Patient Nurse Care Manager Patient understands her medications, participates in care plan to improve health

Highest Risk Patients

Pharmacist Collaboration Levels in Primary Care Models Smith, et.al. Health Affairs 32, No. 11. (2013);

Patient Story #3 93 year old female Eligible for comprehensive medication review Home visit Recent hospitalization for COPD Improper inhaler technique and storage Pain issues Coordinated care with MD and NCM 17

“The extent to which the patient continues the agreed-upon mode of treatment under limited supervision when faced with conflicting demands” Medication Adherence

Key Predictors of Medication Persistence

Barriers to Taking Medications 24% forgetfulness 20% side effects 17% medication was too costly 14% decided didn't need the drug 10% difficulties getting prescription The Hidden Epidemic: Finding a Cure for Unfilled Prescriptions and Missed Doses, December, The Boston Consulting Group and Harris Interactive. Available at

Challenges with Medication Persistence

Patient Story #4 74 year old female Recent hospitalization with SNF stay Lives alone, diabetes, cognitive issues Multiple medication changes with care transitions Referred by MD for home visit and comprehensive medication review Coordinated care with NCM 22

Summary 23

Medication Related Problems Health beliefs Health illiteracy Past medication experiences Non-adherence Gaps in care Inappropriate prescribing Ineffective prescribing Lack of care coordination Inconsistent monitoring Adapted from Smith, et.al. Health Affairs. 2011;30(4):646-54

Patient Story #5 66 year old male Eligible for CMR Diabetes out of control A1C = 9.6 On multiple oral medications Requesting to start insulin Referral to NCM for diabetes education A1C = 7.4 after conversion to insulin, removal of oral medications except metformin 25

Questions? 26