Transitions of Care

1. Transitions of Care Sarah Saxer Todd, PharmD Clinical Pharmacy Coordinator Solid Organ Transplantation Emory University Hospital Atlanta, Georgia

2. Learning Objectives • Describe the role of the transplant PharmD in the continuum of care • Medication history, recommendations, adherence, monitoring, documentation, optimization of regimen • Medication reconciliation • Discuss transition models and their impact on medication safety and patient care outcomes • Barriers and solutions to models • Impact of patient transitions – medical errors, medication errors, ADEs, readmissions, admissions, patient outcomes • Incorporating new medication into patient care

3. Transitions of Care • Within Setting • ICU/OR to inpatient transplant floor • Between Settings • Referring physician and transplant center • Outpatient and inpatient care • Discharge to home • Readmission • Across Health States • Rehabilitation • Home health care • End of life care • Hospice • Between Providers • Surgery • Medicine • PCP • Referring physician • Multidisciplinary team

4. Impact of Transitions • Medication errors • 1 in 5 patients experience an adverse event in transition from hospital to home • 33% are considered preventable • 33% could have been less severe with intervention • Prevention • Improve communication • Follow up with MD • Follow up with pharmacist Forster Ann IM 2003

5. Adverse Effects Post Discharge Forster Ann IM 2003

6. Adverse Effects After Discharge Forster Ann IM 2003

7. The Care Transitions Intervention • RCT • N= 750 • Age > 65 yo • Intervention vs usual care • Intervention • Tools to promote cross-site communication • Encouragement to take active role in health • Continuity across setting with “continuity coach” Coleman Arch Int Med 2006

8. Rehospitalization Coleman Arch Int Med 2006

9. Medication Discrepancies on Hospital Admission Class 1 = no potential for discomfort or clinical deterioration Class 2 = potential for moderate discomfort or clinical deterioration Class 3 = potential for severe discomfort or clinic deterioration Cornish Arch Intern Med 2005

10. Goals of Transition of Care • Improve patient outcomes • Graft survival • Decrease readmission rates and hospitalizations • Reduce ADRs • Improve patient quality of life • Improve patient experience • Improve patient safety

11. Multidisciplinary Care Teams • Physicians • Fellows • Mid-level practitioners • Nurses and coordinators • Pharmacists • Social workers • Dietitians • Financial coordinators • Residents • Students

12. Patient-Centered Care Comprehensive Care Plan Accountability

13. Goals During Transitions of Care • Coordination • Continuity • Comprehensive Care Plan • Accountable Provider(s)

14. Transplant Pharmacy Transitions

15. Pharmacist Roles

16. Medication History • Process varies within and among institutions • Standardization critical • Policy about critical information to obtain • Inaccuracies can follow patient throughout continuum of care • Omission is the most common discrepancy • Adverse effects • Readmissions Schnipper Arch Int Med 2009 DeWinterQual Safe HealthCare 2010

17. Pharmacists and Medication Histories • Uniquely qualified – training and education • Completeness • Accuracy • Follow up Dewinter 2010

18. Barriers to Accurate Med History • Lack of knowledge of provider • Lack of knowledge of the patient • Lack of unified documentation system • Within system • Among health care systems • Among pharmacies

19. Improving Medication Histories • Patient brings actual medications versus medication list to encounter (“Brown Bag”) • Only clinical (RN, PharmD, etc) obtain medication list vs clerical staff • Interview patient versus list • Provide updated medication list at each encounter/transition • Make medication list available to all providers across continuum of care

20. Creative Solutions – Med History Outpatient • PharmD Student Project • Limited resources, limited time • Outpatient clinic • 18 PharmD volunteer students from Mercer University • Phoned or in person interview to obtain med history • Results: • Updated medication histories for over 2500 liver and kidney patients • Nurses reported less errors and less need to update medication history in clinic

21. Medication History: CPOE

22. Medication Reconciliation • The Joint Commission defines medication reconciliation as “the process of comparing a patient's medication orders to all of the medications that the patient has been taking. […] It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. […] http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_35.htm.

23. National Patient Safety Goal: TJC http://www.jointcommission.org/assets/1/6/NPSG_Chapter_Jan2012_BHC.pdf

24. Elements of Performance of NPSG 03.06.01 • Obtain information on medications the patient is currently taking (“good faith” effort) • Define the types of medication information needed in a non 24-hour setting (name, dose, strength, etc) • Compare medication information from the pt/family with the hospital list • Resolve discrepancies: omissions, duplications, contraindications, unclear orders and changes by a “qualified individual • Provide patient with written information on meds • Explain the importance of managing medication information to the patient at end of encounter

25. Med Rec Process

26. Med Rec in CPOE

27. Hurdles to Med Reconciliation • Patient/caregiver knowledge of medication regimen • Multiple providers • Lack of communication • Multiple pharmacies and health care access points • Knowledge of provider • Medications • Electronic documentation • Multiple steps in documentation • Multiple time-points for failure • Lack of policy/procedures

28. Potential Solutions: PharmD • Improve patient knowledge of medication list • Provide updated medication list at each encounter • Patient education • Improve knowledge of provider obtaining medication history • Dedicate personnel • Educate providers participating in med rec • Increase technology use to decrease errors • Promote use of centralized system • External Rx history Schnipper 2009

29. Medication Recommendations • Participation in rounds reduces errors and ADEs • Preventable ADEs 11% vs 1% in Pharmvs control • Reduce ADEs by 66% in ICU • Dedicated transplant PharmD • UNOS Bylaws • Develop individualized care plan • Continuity of Care • Inpatient/Outpatient PharmD Alloway AJT 2011, Kaboli Arch Int Med 2006, Leape JAMA 1999, Schnipper Arch Int Med 2006

30. Optimizing Regimens • Assess drug therapy prescribing, appropriateness, effectiveness and safety • Pharmacokinetics, pharmacodynamics • Drug interactions • Drug administration and delivery • Drug costs • Discharge planning • Pre transplant review Alloway AJT 2011

31. Challenges to PharmD Recommendations • Limited resources • Optimal staffing levels • Multiple departments with “ownership” • Collaborative practice agreements insufficient • Acceptance by team

32. PharmD Solutions • Billing for pharmacy services • Pre-transplant/CMS • Expand transplant residencies and fellowships • Expand services beyond kidney transplant • Conduct research validating role in SOT • Develop collaborative practice agreements

33. Monitoring • Pharmacokinetics and pharmacodynamics • Drug levels, drug effect • Patient outcomes • Acute cellular rejection • Graft and patient survival • Adherence • Outpatient • Quality of Life • ADEs • Research

34. Patient and Caregiver Education • Pre-transplant and Post-Transplant • 1:1 teaching sessions • Group teaching session • Electronic teaching/web based resources (EMMI) • Videos/TV sessions • Provider • PharmD – Medications • CCTC – Life after transplant, follow-up care • Multi-D Team

35. Delivering Education • Written materials • Booklet • Handouts • Discharge list • Medication list • Electronic media • Internet • DVD • Apps • CCTV • Verbal communication • MultiD team

36. PharmD Providing Medication Education • Medication expert • 1:1 patient/pharmacist education • Medication list/reconciliation • www.medactionplan.com • Content reviewer • Policies and procedures • Educational materials • Educate staff • In-services, new employee education

37. Medication Ed Tool Survey

38. Barriers to Delivering Education • Limited resources • Decreased LOS (inpatient) • Patient readiness to receive education • Financial • Psychosocial • Clinical • Knowledge of educator • Lack of consistency of information provided to patient

39. Patient Interviews on Med Facts

40. Improvements to Patient Education • MultiD involvement • Develop educational materials • Ensure protocols and education are consistent • Provide educational in-services to all staff • Streamline educational tools • All transplant service lines • Improve patient access to materials • Reinforce education at each encounter • Document educational needs of patient

41. Adherence • Lack of adherence correlated with graft loss • Non-adherence rate 20-50% in SOT • Responsible for up to 50% of rejections • Pharmacist may impact adherence • 96% vs 82% adherence rate in outpatient setting (pharmvs control) • More likely to obtain target level • Improved BP control Chisholm ClinTranspl 2001, Chisholm Eth Dis 2002, Nevins Transpl 2004, Butler Transpl 2004

42. Adherence and the PharmD • Promote adherence • Non-punitive environment • Strong, open relationship with patient • Monitor adherence • Interviews, pill count • Many portals to miss adherence • Difficult to quantify

43. Documentation • Improve communication among MultiD team (Handoffs) • Regulatory compliance, billing • Barriers to documentation • Limited resource/time • Lack of full utilization of electronic resources • Knowledge of providers documenting • Lack of availability to all providers

44. Documentation: Checklists • Enhance communication • Patient assessment, care plan and essential clinical information • Assessment and interventions for • Physiological • Psychosocial • Cultural • Health literacy • Financial • Spiritual • Environmental • Physical safety • Family support • Handoff checklist

45. Documentation • Multidisciplinary team note • Multidisciplinary team discharge planning • Individual provider note • Patient education documentation