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

2. 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

3. 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.

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

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

7. 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

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

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

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

11. 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,

12. 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

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

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

15. 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

17. Development of TOC Service

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

19. UAMS readmission stats

20. PharmD Impact
stats

21. 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

22. 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

23. 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

24. Follow-up Phone Call
UAMS South discharged patients ed 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

25. 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?

26. 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

27. 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

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

29. CMS TOC Rules Must include: Date of discharge
Date of Interactive Contact (phone call, , 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)

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

31. CMS TOC Rules
Discharge to:
Home
Nursing Home
Assisted Living

32. 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

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

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

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

36. Clinical Outcomes
QI results

37. QI Group Benefits
ACT Southwest

38. Partnership Feedback Hospital Home health SNF/Assistant Living
Community pharmacists

39. Patient Success Stories

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

41. Future Endeavors

42. 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

43. 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

44. Questions?

45. TOC Resources

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