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49th Annual Meeting
OWNING CHANGE: Taking Charge of Your Profession
Finding the Sweet Spot: Transitions of Care in Diabetes
Adrienne DeBerry, PharmDUF Health Jacksonville
Disclosure
I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation
Objectives
Discuss the developing role of pharmacists in improving transitions of care in diabetic patients.
Identify the keys to success pharmacists have had around implementation of different TOC services in diabetic patients.
Discuss the importance of having criteria for TOC groups.
Recommend TOC quality metrics and role in reimbursement.
Transitions of Care
Barriers to successful transition are multifactorial
Multi-step process
Communication barriers
Potential for patient harm
Approximately 19% of patients experience an adverse event within 5 weeks of discharge
CMS 30-day readmission rate of 17.8% and declining
CMS’s “carrots” and “sticks” approach
Collaborative care practices successful
Reduced costs
Improved outcomesForster AJ, et al. J Gen Intern Med. 2005; 20:317‐323.
Forster AJ, et al. J Gen Intern Med. 2003; 138(3):161‐167.Coleman EA, et al. Arch Intern Med. 2006; 166:1822‐1828
Poor Transitions Are Costly
In 1997, a reported 34,500 patients were discharged and readmitted on the same day Incurred $226 million in medical costs
Reducing preventable unplanned readmissions has the potential to save $17.4 billion annually
Moorman JM. ASHP Summer Meeting Lecture. June 9th 2015. Ambulatory Care Conference, Denver, CO. Jencks SF et al. N Engl J Med 2009;360:1418‐28
Opportunities for Transition Care Management Recognized
Improving Care
Reducing Readmission
Reimbursement in Primary Care
Reimbursement from CMS for acute care
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HCAHPS
Transition of care questions added October 2014
23. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
25. When I left the hospital, I clearly understood the purpose for taking each of my medications.
http://www.hcahpsonline.org/files/HCAHPS%20V9.0%20Appendix%20A%20-%20Mail%20Survey%20Materials%20%28English%29%20March%202014.pdf
Diabetics Need Help!
Non-adherence Among Diabetics
Medication adherence rates among diabetic patients ranges from 36%-93% for oral agents Approximately 32-86% for patients on insulin
Adherence rates of <80% are associated with 58% increase in hospitalization all-cause mortality: 81% increase
However, 25% increases in adherence make a difference Hospitalization: 17% reduction
All-cause mortality: 25% reduction
Cramer JA. Diabetes Care. 2004;27:1218-1224.Ho PM, et al. Arch Intern Med 2006;166:1836‐41
Diabetes is Everywhere!
Approximately 29.1 million Americans have diabetes
In 2012, $245 billion spent on direct and indirect costs of diabetes Direct medical costs = $174 billion/yr
Diabetes Caucus. Available at <https://diabetescaucus-degette.house.gov/facts-and-figures>
Diabetes in Duval County Diabetes in Florida: Death Rates
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Diabetes in Florida
FloridaCharts.com
Diabetes in Florida: Preventable Hospitalizations
FloridaCharts.com
Risk Factors for Readmission Among Diabetics
Multiple medications
Insulin = high-risk medication
Complications Nephropathy
Cardiovascular disease
Neuropathy
Infection
Few studies have focused on readmissions specific to diabetes patients
What can we do to improve Transitions of Care?
Medication Self-Management
Patient Centered Record
Physician Follow-up
Patient Red Flags
• Medication reconciliation after handoffs• Streamline drug therapy• Patient education
• Facilitate communication and continuity of care• Review and update after handoffs• Encourage patient to take charge of health record
• Primary care or specialist follow-up• Emphasize importance to patient• Practice/role play questions
• Develop an emergency care plan• Reinforce whom to call and when• Emphasize value of prevention
Adapted from http://www.caretranstions.org
Examples of TOC Successes
Current Successes
Better Outcomes for Older Adults Through Safe Transitions (BOOST)
Shands Jacksonville Discharge Transition Program
Care Transition Initiative
Transitional Care Model (TCM)
Project RED (Re-engineered Discharge)
CMS’s Community-Based Care Transitions Program
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BOOST Program
Led by Society of Hospital Medicine
Interdisciplinary initiative
Tools and interventions Comprehensive risk assessment (the 8 P’s) Patient-centered discharge
Follow-up PCP appointment arranged before discharge Teach-back method and checklists
72-hr phone call follow-up Standardized discharge communications
Longitudinal mentorship component
Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.
BOOST Preliminary Results
Overall readmission rates decreased from 13% to 11% in 6 months across all sites
Readmission rates increased by 2% in units not utilizing BOOST
Increased patient satisfaction in some sites
Reductions in LOS and ED visits also seen
Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.
Post-discharge Medication Therapy Assessment
Patients identified as high-risk for readmission for Group Health Cooperative in Washington state
Pharmacist telephonic service 72 hours post-discharge Reviewed med changes
Addressed discrepancies
Assessed for medication-related problems
Kilcup M, Schultz D, Carlson J, Wilson B. JAPhA. 2013;53:78-84.
Kilcup et al.
Control,n = 251
Intervention,n = 243
P-value
7-day readmissions 11 (4%) 2 (0.8%) 0.01
14-day readmissions 22 (9%) 11 (4%) 0.04
30-day readmissions 34 (13%) 28 (11%) 0.29
Kilcup M, Schultz D, Carlson J, Wilson B. JAPhA. 2013;53:78-84.
Kilcup et al.
Cost of readmission estimated at approx. $10,000 per patient
NNT of 4 correlates to 25 admissions prevented for every 100 patients receiving pharmacist intervention
Savings of $40,000 per 100 encounters Net labor cost of $4522 for every 100 patients
Savings of $35,478
Kilcup M, Schultz D, Carlson J, Wilson B. JAPhA. 2013;53:78-84.
UF Health Jacksonville Discharge Transition Pilot (2012)
Clinical Pharmacist
Medication Therapy
Management Sessions
Case Manager
Conducts Home Visit
Provider Appointment
Discharge Follow-up
Case Manager Meets Patient At Bedside
UF Health Jacksonville
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Results: UF Health Jacksonville Discharge Transition Pilot
A total of 166 discharges were included in the studyto be followed for 30 days
UF Health Jacksonville
DA19
ResultsImpact of the Collaborative Program
Composite Readmission or ED Visit Rate
p = 0.1167
ResultsImpact of the Collaborative Program
Team Impact on 30-Day Readmissions
p = 0.0468
(N=16)(N=40)
(N=84)
Results
26.0%(n = 40)
53.2%(n = 82)
10.4%(n = 16)
10.4%(n = 16)
Types of Medication-related Problems Identified (n = 154)
Appropriateness andEffectivenessSafety (pADE/ADE)
Nonadherence andPatient VariablesMISC
ResultsAdverse Drug Events
Medication‐related Problem Categories Total
Safety (pADE/ADE) 82
Lab/diagnostic test indicated, not ordered 21
ADR 17
Dose discrepancy between patient use and prescribed therapy 8
Medication overuse or misuse 7
Polypharmacy (Rx not needed)/duplication 5
Drug interaction 5
No indication for medication prescribed 4
Contraindicated 4
Incomplete/improper directions 2
Abnormal lab result not addressed 2
Part II: Focus on Diabetes
Slide 25
DA19 51 by all team members.. add boxDeberry, Adrienne, 5/6/2013
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The CO-CARE Trial
Part II of Discharge Transition Team Pilot
Targeted diabetes patients with A1C >8.5%
Collaborative team impact on: 30-day readmission/ED visit rates
Appropriateness and presence of guideline recommended CHD therapies (e.g. ASA and statin therapy)
Change in lipids, A1C
Included patients discharged between February 2012 and January 2014
UF Health Jacksonville
Results
60 Cases included in Control Group
21 Cases included in Intervention Group
81 Cases Included in the Study
Transition of Care ProgramTraditional
post-discharge follow-up
ResultsBaseline Characteristics
Control Group Intervention Group p-values
Total Discharges (n) 60 21
Demographics
Males, n (%) 29 (48.3%) 12 (57.1%) NS
White, n (%) 20 (33.3%) 9 (42.9%) NS
African American or Hispanic, n (%) 40 (66.7%) 12 (57.1%) NS
Average age, years 47 51 NS
Index admission diabetes-related, n (%) 27 (45.0%) 12 (57.1%) NS
Baseline Health Markers Average Hgb A1C at baseline (%) 11.8 11.0 NS
Average BMI (kg/m2) 31.0 33.2 NS
Charlson Index Score 3.2 3.9 0.03
Baseline Lipid Panel
Average baseline LDL (mg/dL) 99 115 0.03
Average baseline HDL (mg/dL) 39 34 NS
Average baseline TGs (mg/dL) 183 269 0.01
Results
9.8% 11.0% 8.5%11.8%
∆ = - 2.0∆ = - 2.5
ResultsImpact on 30-day Readmissions
Control Group (n = 60)
Intervention Group (n = 21) P-values
Number of Patients
Percentage of Patients
Number of Patients
Percentage of Patients
30-day readmission rates 7 11.7% 3 14.3% NS
30-day ED visit rates 11 18.3% 3 14.3% NS
Composite 30-day readmission or ED Visit rate
16 25.4% 4 19.0% NS
ResultsCHD Preventative Medication
57.1%
80.0%66.7%
100%
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Additional ObservationsImpact of Transition of Care Program on Health Outcomes
19.0%
28.6%
TOC Successes: Discussion
Trends toward improvements in health outcomes seen with Transition of Care (TOC) Program visits
Larger studies are needed in diabetic patients specifically Not currently a disease of focus for Readmission Reduction Program
Less than 2% of hospital discharges annually list a PRIMARY diagnosis of diabetes
However patients with diabetes account for approximately 25% of hospitalizations (+8 million per year)
Rubin DJ. Curr Diab Rep. 2015 Apr;15(4):17.
The Real Deal….
Many discharges in a day
Limited staff members with a multitude of responsibilities
Prospects of additional resources are slim….
The DERRI Tool
Diabetes Early Readmission Risk Index
Based on retrospective cohort of 17,595 adults with diabetes
Reviewed 43 variables Found 13 to be statistically significant predictors of
early readmission
Rubin DJ. Curr Diab Rep. 2015 Apr;15(4):17.
The DERRI Tool
Employment status or disability
Race
Zip code <5 miles from hospital
Private insurance vs none, Medicaid vs private insurance
Urgent/emergent vs elective index admission
Elevated SC
Micro- or macrovascular complications per Dx
Pre-admission glucocorticoid or insulin or statin
Rubin DJ. Curr Diab Rep. 2015 Apr;15(4):17.
Additional High-Risk Markers for Readmission
Acute care utilization in the past 30-60 days
Insulin therapy
Retinopathy
Other high-risk meds (ex anticoagulants)
Multiple chronic conditions
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Transitional Care Management (TCM)
Transition of Care Visits
Effective January 1, 2013 new Healthcare Common Procedure Coding System (HCPCS) codes for
Transitional Care Management (TCM) services may be used to bill physician and “qualified non-physician
providers” care management following discharge from an inpatient hospital setting, observation setting, or
skilled nursing facility.
Transitional Care Management Visits
Visit TypeTiming (calendar
day)CPT Code
Medical Decision Making
ComplexityClaim Date
TransitionalCare
Management
Within 7 days of Discharge*
99496 High30 days from
discharge
TransitionalCare
Management
Within 14 days of Discharge* 99495 Moderate
30 days from discharge
*For face-to-face visits. Communication via either direct, telephone, or electronic to patient or care giver within 2 business days of discharge.
Required Components
Transitional Care Management
Face-to-face Visit
Non-face-to-face Services
Interactive Contact
Visit Requirements: Interactive Contact
Must occur within 2 business days Telephone
Face-to-face
Attempts to communicate should continue after the first 2 business days if unsuccessful
Must only bill for successful attempts
Requirements: Specific Non-face-to-face Services
Physicians or non-physician practitioners (NPP) may: Review discharge summaries Review need for follow-up or pending diagnostic
tests/treatments Interact with other health care professionals who will assume
or reassume care of the beneficiary’s system-specific problems
Provide education to beneficiary/family/caregiver Referrals Assist in scheduling required follow-up with community
providers and services
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Licensed Clinical Staff Under the Direction of a Physician or NPP may: Communicate with agencies and community services
used by the beneficiary Provide education to beneficiary/family/caregiver to
support self-management Assess and support treatment regimen adherence and
medication management Identify available community and health resources Assist the beneficiary and/or family in accessing
needed care and services
Requirements: Specific Non-face-to-face Services
Requirements: Face-to-face Visit
Medication reconciliation must be done no later than the face-to-face visit!
Must occur within a certain time frame 7 days for “high medical decision complexity” 14 days for “moderate medical decision complexity”
While non-face-to-face care may be furnished by qualified health care professionals, the patient must be seen face-to-face by the Medicare recognized qualified
provider.
How can pharmacists contribute?
Conduct assessments to identify high-risk patients
Utilize outpatient practitioners within the inpatient units
Facilitate active communication between inpatient and outpatient practitioners
Bedside medication delivery and discharge counseling
Medication reconciliation at admission Utilize pharmacy students/interns
Ease the burden on other healthcare providers through collaboration Collaborative practice agreements
But Is Pharmacist Involvement Billable? It Depends…
http://www.pharmacist.com/cms-tells-family-physicians-pharmacist-provided-services-may-be-billed-incident-8
But Is Pharmacist Involvement Billable? It Depends… Requirements of “incident-to” billing
Conducted under “general” supervision of physician
Initial visit performed by physician
Pharmacist employed by physician practice This does not apply for FQHC and RHCs (1/1/15)
Proper documentation
Physician-based practices
Useful for Chronic Care Management and TCM
http://www.ashp.org/DocLibrary/Advocacy/CCM-Incident-to-Billing-Changes.pdf
Check with your Compliance Officer!
Billing for TCM?
Must meet requirements of TCM codes
Pharmacists cannot independently bill
http://www.ashp.org/DocLibrary/Advocacy/CCM-Incident-to-Billing-Changes.pdf
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Quality Metrics and Assessment
30-day readmission rates CMS standard
Financial impact
ED-visit rates More complete assessment of acute care utilization
Patient satisfaction
Change in HCAHPs scoring
CTM: Care Transition Measure
Developed as part of the Coleman model Care Transitions Intervention
CTM-3 item and CTM-15 item questionnaire to assess the quality of care transitions
Four domains assessed Information transfer
Patient/caregiver preparation
Self-management support
Empowerment to assert preferences
Coleman EA, Smith JD, Eilertsen TB, Frank JC, Thiare JN, Ward A, and Kramer AM. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Journal of Care Integration. 2002:2 April-June
www.caretransitions.org
Efforts to improve transitions of care should be ongoing and implemented as soon as possible
Collaborative transition care models should be expanded
Successful models have a comprehensive proactive approach High-risk patients should take priority
Pharmacists can contribute greatly to improving continuity of care and reducing readmission rates Reductions in medication-related issues
Pharmacist need to continue to strive for provider status to take advantage of billing opportunities
Conclusion
Food for thought…
https://origin.ih.constantcontact.com/fs182/1105304717519/img/136.png
“It takes a village…to make a good transition.” – Kathleen Tong, M.D.
Director of Heart Failure Program, UC Davis Medical Center
References
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005; 20:317-323.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients following discharge form the hospital. Ann Intern Med. 2003; 138(3):161-167.
Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006; 166:1822-1828.
Moorman JM. Transitions of Care: Best practices and learner experiences. ASHP Summer Meeting Lecture. June 9th 2015. Ambulatory Care Conference, Denver, CO.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee‐for‐service program. N Engl J Med 2009;360:1418‐28
Rubin DJ. Hospital readmission of patients with diabetes. Curr Diab Rep. 2015 Apr;15(4):17.
ACCP White Papers. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012; 32(11):e326-e337.
Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27:1218-1224.
Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med 2006;166:1836‐41
Diabetes Caucus. Facts and Figures. Available at https://diabetescaucus-degette.house.gov/facts-and-figures. Accessed May 2015.
The Care Transitions Initiative. Available at www.caretransitions.org. Accessed May 2015.
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Society of Hospital Medicine. Project BOOST: Better Outcomes for Older Adults through Safe Transitions [Internet]. Philadelphia: Society of Hospital Medicine [cited 2012 Aug 17]. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home& Template=/CM/ContentDisplay.cfm&ContentID=31576.
Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: Impact on readmission rates and financial savings. JAPhA. 2013;53:78-84.
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007; 2:314-323.
Burton R. “Health Policy Brief: Care Transitions” Health Affairs, September 13, 2012.
Center for Medicaid and Medicare Services. Readmissions reduction program. Accessed May 2013. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
Anthony D, Chetty VK, Kartha A., et al. Re-engineering the hospital discharge: an example of a multifaceted process evaluation. In: Henriksen K, Battles JB, Marks ES, et al., eds. Advances in patient safety: from research to implementation. Vol. 2. Rockville, MD: Agency for Healthcare Research and Quality; 2005. p. 379-94
American Pharmacists Association. CMS tells family physicians that pharmacist-provided services may be billed as incident-to. Available at: http://www.pharmacist.com/cms-tells-family-physicians-pharmacist-provided-services-may-be-billed-incident-8. Accessed May 2015.
ASHP. Fact Sheet: Incident-to Billing for Chronic and Transitional Care Management Services. Available at: http://www.ashp.org/DocLibrary/Advocacy/CCM-Incident-to-Billing-Changes.pdf. Accessed May 2015.
References continued