1. Michela C.C. Fiori, Pharm.D. PGY1 Pharmacy Resident, Penobscot Community Health Care Outcomes of a Pharmacist-Driven Education Program For Residents Discharged from a Skilled Nursing Facility PHARMACIST-LED DISCHARGE EDUCATION

2. Presentation Overview  Introduce and discuss Maine Veterans’ Home Pharmacies four-step pharmacist-driven discharge counseling program (NavigatoRx)  Review current program data for issues identified by pharmacy during medication reconciliation  Discuss the benefits of pharmacist-led discharge education on quality of patient care

3. Background Each year, patients nationwide are cared for in skilled nursing facilities (SNF) following a hospital stay and subsequently discharged. Many of these patients are readmitted to a hospital within 30 days due to medication-related preventable causes. 1,2 Medicare patient readmission rates have been observed as high as 20 percent with costs nearing $17.4 billion per year. 3 Pharmacists can make a profound impact by identifying risk factors for readmission and making interventions during discharge counseling to help prevent readmissions and reduce costs. 1,2

4. Background There is a paucity of research available specifically regarding pharmacist discharge counseling in SNF settings. 4 Elderly patients are particularly high risk for hospital readmissions resulting from medication- related issues, so the population within the SNF could benefit greatly from pharmacist-driven discharge counseling. 4

5. Maine Veterans’ Home Pharmacies NavigatoRx Program

7. Step 1: Medication Review on Admission  Performed by pharmacist, then documented and communicated to nursing home staff via fax  Immediate issues are communicated via phone to nursing staff and/or MD staff  Documentation: Medication Regimen Review Form

8. Step 2: Medication Reconciliation within 48 hours of Admission  Performed by pharmacists and trained interns  Nursing home provides as much history as possible, ideally one or both of the following:  Home medication list  Hospital discharge summary  MVH Pharmacy in-house staff provides current medication list  Medication reconciliation is performed with any issues raised via phone communicated to nursing staff and/or MD staff  Documentation: Medication Reconciliation Form

9. Step 3: Review and Counseling  Performed by pharmacists/pharmacy residents and trained interns  Home staff provides final/pending discharge medication list  Home staff works with pharmacy team and resident to schedule face-to-face meeting  Widely recognized Indian Health Service medication counseling methodology is used to provide effective and efficient review of medications  Follow-up phone call is arranged and discharge counseling session information is provided to central fill pharmacy  Documentation: Counseling Review Form

10. Step 4: Follow-Up Phone Call within 48-72 hours Post-Discharge  Performed by pharmacist at central fill pharmacy  Recognizing that outpatient care providers are now part of the picture (i.e. PCP and outpatient pharmacist), the purpose of this call is to quickly follow up to be sure that the now discharged resident has no lingering questions or problems with medications.  Review discharge medication list and address discrepancies  Assess for side effects  Answer questions  Triage and recommend (when appropriate) involving additional caregivers. (Example: “Please call your primary care physician about this” or “I think that you should talk to your current pharmacist about this.”)  Documentation: Follow-up Review Form

11. Reducing 30-Day Hospital Readmissions through Pharmacy Intervention

12. Step 2: Medication Reconciliation

13. Step 3: Discharge and Counseling Provide 72-hour follow-up phone call Review important counseling points Assess adherence Clarify discrepancies Facilitate understanding Speak slowly and clearly Utilize teach-back method Involve all members in the discussion Encourage questions Review and counsel with patient/family Provide written, patient-friendly education materials for medications Focus discussion on critical medications (e.g. cardiac, hematologic) and adherence Provide 72-hour follow-up phone call Review important counseling points Assess adherence Clarify discrepancies Facilitate understanding Speak slowly and clearly Utilize teach-back method Involve all members in the discussion Encourage questions Review and counsel with patient/family Provide written, patient-friendly education materials for medications Focus discussion on critical medications (e.g. cardiac, hematologic) and adherence

14. During a post-discharge follow-up phone call, the pharmacist has the opportunity to: A. Correct medication dosing discrepancies which may have occurred post-discharge. B. Review and discuss the discharge medication list with the patient. C. Assess the patient for any medication-related side effects. D. Discuss any concerns/questions the patient may have about their medications. E. All of the above.

15. References 1. Pal A, Babbott S, Wilkinson ST. Can the Targeted Use of a Discharge Pharmacist Significantly Decrease 30-Day Readmissions? Hosp Pharm. 2013; 48(5):380-388. 2. Wilkinson ST, Pal A, Couldry RJ. Impacting Readmission Rates and Patient Satisfaction: Results of a Discharge Pharmacist Pilot Program. Hosp Pharm. 2011;46(11):876-883. 3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in Medicare fee- for-service program. N Engl J Med. 2009;360:1418-1428. 4. Chinthammit C, Armstrong EP, Warholak TL. A Cost-Effectiveness Evaluation of Hospital Discharge Counseling by Pharmacists. J Pharm Pract. 2012;25(2):201-208