1. Why are we involved? Transitions of Care: The Financial Burden and Impact on Delivery of Care www.ntocc.org

2. Current State of Healthcare  Care is complex  Care is uncoordinated  Information is often not available to those who need it when they need it  As a result patients often do not get care they need or do get care they don’t need IOM, Crossing the Quality Chasm

3. What is “Transition of Care”  The movement of patients from one health care practitioner or setting to another as their condition and care needs change  Occurs at multiple levels – Within Settings Primary care  Specialty care Primary care  Specialty care ICU  Ward ICU  Ward – Between Settings Hospital  Sub-acute facility Hospital  Sub-acute facility Ambulatory clinic  Senior center Ambulatory clinic  Senior center Hospital  Home Hospital  Home – Across health states Curative care  Palliative care/Hospice Curative care  Palliative care/Hospice Personal residence  Assisted living Personal residence  Assisted living (c) Eric A. Coleman, MD, MPH

4. What is “Transitional Care?”  A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location  Based on a comprehensive care plan and availability of well- trained practitioners that have current information about the patient's goals, preferences, and clinical status.  Includes: – Logistical arrangements – Education of the patient and family – Coordination among the health professionals involved in the transition Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

5. Ineffective Transitions Lead to Poor Outcomes  Wrong treatment  Delay in diagnosis  Severe adverse events  Patient complaints  Increased healthcare costs  Increased length of stay Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

6. PatientPatient ERERICUICU In-PatientIn-Patient PatientPatient OUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care GiverOUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care Giver SNFSNFALFALF Transition Issues Dramatically Impact Patient Care

7. Patient ERICU In-Patient Patient OUTPATIENT: Home PCP Specialty Pharmacy Case Mgr. Care Giver SNFALF NO Medication Reconciliation NO Personal Medicine List NO Coordinated Care Plan NO Discharge Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Care Plan NO Medication Reconciliation NO Personal Medicine List

8. Barriers to Improving Transitions of Care We Need To Understand Them First!

9. Barriers to Care Coordination  System level barriers  Practitioner level barriers  Patient level barriers (c) Eric A. Coleman, MD, MPH

10. System Level Barriers

11. Practitioner Level Barriers  Practitioners often have not practiced in settings where they transfer patients  Sending practitioners may not communicate critical information to receiving practitioners  Practitioners may not know the patient and his or her preferences for care  Practitioners have no accountability (c) Eric A. Coleman, MD, MPH

12. Patient Level Barriers  Patients assume that someone is in charge of coordinating care  Patients (and caregivers) are often the only common thread weaving between care sites  Yet they navigate the system with few tools or training to manage in this role (c) Eric A. Coleman, MD, MPH

13. Problems that Illustrate Inadequacies of Care Transitions  Medication errors  Increased health care utilization  Inefficient/duplicative care  Inadequate patient/caregiver preparation  Inadequate follow-up care  Dissatisfaction  Litigation/Bad publicity (c) Eric A. Coleman, MD, MPH

14. The Facts…

15. Hospital Admission On hospital admission, more than 50% of patients have at least one medication discrepancy* – Approximately 40% of those have potential to cause harm Cornish PL et al. Arch Intern Med 2005;165:424-9. *Discrepancy defined as error between admission medication orders and patient interview of medication history.

16. Hospital Discharge On discharge from the hospital, 30% of patients have at least one medication discrepancy* with the potential to cause possible or probable harm Kwan Y et al. Arch Intern Med 2007;167:1034-40. *Most common discrepancy is omission of pre-admit medication.

17. AHRQ Hospital Survey on Patient Safety Culture: 2007 Report

18. Hospital to Home 40% of patients experienced at least 1 medical error – Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 months Moore C et al. J Gen Intern Med 2003;18:646-51. *Work-up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart).

19. Hospital to PCP transfer  Meta-analysis  Direct communication between hospital physicians and primary care physicians occurred infrequently  Discharge summary – Availability at first postdischarge visit low (12%-34%) – Remained poor at 4 weeks (51%-77%) – Affected quality of care in ~25% of follow-up visits – Often lacked important information (e.g., lab results, discharge medications, treatment, follow-up plan) Kripalani S, et al. JAMA 2007;297:831-41.

20. Completing Recommended Outpatient Workups Total No. (%) Completed Workup Type YesNo Diagnostic procedure 115 (47.9) 50.449.6 Subspecialty referral 85 (35.4) 72.627.4 Laboratory test 40 (16.7) 85.015.0 Total 240 (100) 64.135.9 Moore C et al. Arch Intern Med 2007. Workup Type is the outpatient workup recommended upon discharge from the hospital. Completed indicates whether the recommended workup was done within 6 months after discharge. 240 workups recommended in 191 discharges.

21. Hospital to Nursing Home Transfers and Adverse Events Adverse drug events (ADEs) attributable to medication changes occurred in 20% of bi- directional transfers – 50% of ADEs were caused by discontinuation of medications during hospital stay Boockvar K et al. Arch Intern Med 2004;164:545-50.

22. Independent Risk Factors for Having a Preventable ADE Risk Factor Odds Ratio 95% CI Male0.55 0.30 - 0.99 No. regularly scheduled meds 0-45-67-8>=91.01.73.22.9Referent 0.83 - 3.5 1.4 - 6.9 1.3 - 6.8 New resident + 2.9 1.5 -5.7 + within 60 days of admission Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.

23. Adverse Events in Nursing Home Residents Transferred to the Hospital  122 nursing home to hospital transfers  98% returned to the nursing home  In 86% of transfers, at least one medication order was altered (mean 1.4) – 65% - discontinued – 19% - dose changes – 10% - substitutions  20% of changes resulted in an adverse event Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.

24. OIG Report – June ‘07  Consecutive Medicare stays involving inpatient and skilled nursing facilities  Key findings … – 35% of consecutive stays were associated with quality-of-care problems and/or fragmentation of services – 11% of individual stays within consecutive stay sequences involved problems with quality-of-care, admission, treatments or discharges DHHS; OIG, June 2007; OEI-07-05-00340

25. Cost of Morbidity Due to Medication Errors  Estimates: – Hospital care: $3.5 billion (2006 dollars) (Bates et al., 1997) – Outpatient Medicare: $887 million (2000 dollars) (Field et al., 2005)  Many major costs are excluded, for example: – Failure to receive drugs that should have been prescribed – Patient non-compliance with prescribed drug regimens – Lost earnings and inability to perform household tasks – Errors that do not result in harm, but create extra work

26. Costs of Adverse Drug Events  Bates et al, 1997 – Additional length of stay associated with ADE = 2.2 days – Increased cost associated with ADE = $3244 – For preventable ADEs, increased length of stay = 4.6 days; increased cost = $5857  Classen et al, 1997 – 91, 574 admissions over 4 years (1990-1993) in LDS hospital (tertiary care facility) – 2227 patients developed an ADE – ADEs complicated 2.43 of 100 admissions – Excess cost associated with ADE was $2013

27. Data on Safety and Quality  44,000-98,000 deaths/year in hospitals as a result of adverse drug events – Over 1,000,000 injuries  Enormous practice variation – Estimated $450 billion unnecessary spending  Slow translation of research to practice – One estimate 17 years IOM, Crossing the Quality Chasm

28. Medication Errors Involving Reconciliation Failure September 2004 – July 2005 MEDMARX Data (N=2022) Site of Error AdmissionTransitionDischarge Total23%67%12% Source: U.S. Pharmacopeia Patient Safety CAPSLink TM 2005.

29. Medication Error Type by Transition Category Transition Category Error Type AdmissionTransitionDischarge Improper Dose/Quantity 55%73%62% Prescribing Error 49%36%27% Omission Error 35%36%76% Source: U.S. Pharmacopeia Patient Safety CAPSLink TM 2005.

30. Case Examples of Medication Errors on Admission  Patient’s home medication recorded as Coreg ® 25 mg twice daily on admission – Patient actually taking 6.25 mg twice daily at home – Patient received 4 doses of excessive strength and developed leg edema – Error was not discovered until after leg ultrasound test to rule out DVT  Nursing home patient receiving propranolol 20 mg/5mL twice daily – Admitting orders written as propranolol 20 mg/mL give 5 mL (which equates to 100 mg) twice daily – Patient received 5 doses of 100 mg strength before error was discovered Source: U.S. Pharmacopeia Patient Safety CAPSLink TM 2005.

31. Case Examples of Medication Errors on Transition/Transfer  Patient with prior history of several arterial stent replacements – Receiving aspirin, enoxaparin, clopidogrel – Meds placed on hold prior to surgery for removal of toe; Physician did not reordered after surgery – 2 of patient’s coronary arteries with stents became 100% occluded; patient expired  Patient transferred from ICU to step-down unit – Prior to transfer, patient received morning doses of scheduled meds – Administration of same meds repeated upon arrival to new unit due to unclear documentation and communication Source: U.S. Pharmacopeia Patient Safety CAPSLink TM 2005.

32. National Efforts

33. The Joint Commission National Patient Safety Goals  Goal 8: Accurately and completely reconcile medications across the continuum of care – 8A: There is a process for comparing the patient/resident’s current medications with those ordered for the patient/resident while under the care of the organization – 8B A complete list of the resident’s medications is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient/resident on discharge from the facility The Joint Commission National Patient Safety Goals. Available at htt://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm

34. A Report from the HMO Care Management Workgroup Supported by the Robert Wood Johnson Foundation One Patient, Many Places: Managing Health Care Transitions

35. AGS Position Statement Position 1: Clinical professionals must prepare patients and their caregivers to receive care in the next setting and actively involve them in decisions related to the formulation and execution of the transitional care plan Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

36. AGS Position Statement Position 2: Bidirectional communication between clinical professionals is essential to ensuring high quality transition care Position 3: Develop policies that promote high quality transitional care Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

37. AGS Position Statement Position 4: Education in transitional care should be provided to all health professionals involved in the transfer of patients across settings Position 5: Research should be conducted to improve the process of transitional care Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

38. What Can We Do …

39. The Care Transitions Intervention  Does encouraging older patients and their caregivers to assert a more active role in their care transition reduce rates of rehospitalization? Coleman EA et al. Arch Intern Med 2006

40. Utilization Outcomes Group Adj.p-value*OR (95% CI) VariableIntervention(n=379)Control(n=371) Rehospitalization Within 30 d Within 30 d8.3%11.9%.048 0.59 (0.35-1.00) Within 90 d Within 90 d16.7%22.5%.04 0.64 (0.42-0.99) Rehospitalization for same dx as index hospitalization Within 30 d Within 30 d2.8%4.6%.18 0.56 (0.24-1.31) Within 90 d Within 90 d5.3%9.8%.04 0.40 (0.26-0.96) Within 180 d Within 180 d8.6%13.9%.046 0.55 (0.30-0.99) *Adjusted for age, sex, education, race, self-reported health status, chronic disease score, prior hospitalization and ED utilization and discharge diagnosis Coleman EA et al. Arch Intern Med 2006

41. Follow-up of Hospitalized Elders with Heart Failure An advanced practice nurse home follow-up program reduced 1 year hospitalization rates by over 60% with a mean cost savings of $4,845 per patient Naylor MD et al. J Am Geriatr Soc 2004;52:675-84.

42. Role of Pharmacist Counseling in Preventing ADEs After Hospitalization  Does pharmacist counseling before discharge reduce the rate of preventable ADEs?  Randomized controlled trial of pharmacist intervention (n=92) vs usual care (n=84)  Intervention on day of discharge – Medication reconciliation – Screening for nonadherence, previous drug-related problems, lack of drug efficacy, and side effects – Review of indications, directions for use, and potential side effects with patient Schnipper JL et al. Arch Intern Med 2006;166:565-71.

43. Study Outcomes: Pharmacist Intervention vs Usual Care Outcome* Pharmacist Intervention (n=92) Usual Care (n=84) P Value Adverse drug events, No. (%) All All 14/79 (18) 12/73 (16) >.99 Preventable Preventable 1/79 (1) 8/73 (11).01 Health Care Utilization, No. (%) ED visit or readmission 28/92 (30) 25/84 (30) >.99 Medication-related 4/92 (4) 8/84 (8).36 Preventable medication-related 1/92 (1) 7/84 (8).03 *Outcome 30 days postdischarge Schnipper JL et al. Arch Intern Med 2006;166:565-71.

44. Readmission Rates with Comprehensive Discharge Planning + Postdischarge Support Phillips CO et al. JAMA 2004;291:1358-67. 0.5 1.0 2 InterventionControl Relative Risk StrategyInterventionEvents/TotalControlEvents/TotalRR (95% CI) Single home visit 95/233129/243 0.76 (0.63-0.93) Clinic follow- up +/- phone 151/370161/395 0.64 (0.32-1.28) Home visit +/- phone 168/437262/533 0.79 (0.69-0.91) Extended home care 132/438152/421 0.82 (0.68-1.00) Total555/1590741/1714 0.75 (0.64-0.88)

45. Transitions of Care A National Crisis Why are we involved?

46. Sanofi aventis Chairman “Sanofi-aventis is supporting the National Transitions of Care Coalition (NTOCC) and its multidisciplinary team of health care leaders to address complex issues like health literacy, patient safety and non- adherence. At sanofi-aventis, patients are at the center of all we do. Our mission is to fight for patient’s health and well being - because health matters. If we fail to help patients understand why they need to take medications, or how to take them, it can lead to non-adherence. Non-adherence can lead to increased emergency room visits, admittance or re-admittance to hospitals, longer hospital stays, higher health care costs and even life-threatening situations. We believe the work of this Coalition will play a vital role for health care professionals, patients, caregivers, and payers.” Tim Rothwell, Chairman, sanofi-aventis U.S.

47. The Case Management Society of America will positively impact and improve patient well being and patient health care outcomes  We envision case managers as pioneers of health care change: nursing case managers, disease managers, health care coaches, social workers, pharmacists, physicians and others who are key initiators of and participants in the health care team as patient care managers.

48. The Statistics are Staggering Despite wide distribution, evidence based clinical practice guidelines have not changed physician behaviors 3 Medication Reconciliation across care settings is a Joint Commission National Patient Safety Goal National Quality Forum (NQF) endorsed 3-Item Care Coordination Measures to expand voluntary hospital consensus standards in care transitions 4,5 Mobilize sanofi-aventis resources to optimize appropriate medication use across all channels Convene experts and apply evidence based clinical practice guidelines Non-adherence statistics: 45% of hospital NRxes or Rx changes are never documented in out-patient medical records 1 12% of NRxes are never filled 2 29% don’t complete LOT 2 22% take < than prescribed 2 Average hospital LOS due to medication non-compliance is 4.2 days 2 COALITION LAUNCH October 18, 2006 - National Transitions of Care Coalition – Chicago Collaboration with CMSA to lead multidisciplinary coalition of experts Employers – JCAHO - NQF – SHM – ACHE – ASHP – ASCP – ASA – AGS - IHI – NASW - URAC Closing gaps across the continuum

49. 49 2008 Advisory Task Force These groups represent over 200,000 health care professionals, 11,000 employers and 30,000,000 consumers throughout the United States.

50. Working to Address the Issues?

51. Medication Reconciliation Transitions of Care List Draft NTOCC Tools

55. Raise NTOCC Awareness  Information and tools available by stakeholder Consumer Professional Policy Maker Media

56. SNFSNFALFALF ERERICUICUIn-PatientIn-Patient The NTOCC Tools Make it Possible to Address the Transition Issues OUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care GiverOUTPATIENT: Home Home PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care Giver PatientPatient My Med List Medication Reconciliation Data Elements + Care / Case Transition Process

57. Working Groups Education & Awareness Metrics & Outcomes Policy & Advocacy Tools & Resources NTOCC

58. We Can & Will Make A Difference!

59. Case Studies for Discussion

60. Case 1  During a patient’s monthly follow-up appointment with the cardiologist, he informed the doctor that he was having trouble with one of his medications. The doctor asked which one. The patient said “The patch, the nurse told me to put on a new one every day and now I’m running out of places to put it!” The physician had him undress and discovered that the man had over a two dozen patches on his body.

61. Case 2  An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose and within two days he was rehospitalized with uncontrollable bleeding.