93
HRET-Foundation for Healthy Communities Readmissions Workshop Building an Enduring Care Transitions Team Concord, New Hampshire July 19, 2013
HRET-Foundation for Healthy Communities Readmissions Workshop
Building an Enduring
Care Transitions Team Concord, New Hampshire
July 19, 2013
Aims of Today’s Workshop
• Review relationship of public policy on readmissions and value-based purchasing to your hospital care transitions work
• Learn how to talk to the C-Suite to earn resources and attention
• Share practical approaches based in evidence and experience
• Support interdisciplinary and cross setting improvement teams in reducing hospital readmissions 2
1,548 Hospitals in the HRET HEN
3
AHA-HRET HEN
• All 26 HENs are committed contractually to reduce harm by 40%, reduce readmissions by 20%
• Nationally, AHA-HRET HEN hospitals have met initial CMS target on 8 of 11 topics
• 1175 of 1414 (83%) of hospitals in our HEN are reporting readmissions data, have reduced readmissions by 19.15%
• The HEN hospitals must sustain these gains to win another year of support for our progress
• But New Hampshire hospitals have not yet met the minimum 15% reduction CMS requires in readmissions--it is too soon to focus on sustaining the gains here!
4
Is Your Hospital Team Configured for Success? PPACA Readmission Policy
Medicare Readmissions Penalty in Year One • 67% of Hospitals had a penalty (including 8 in
New Hampshire); 33% had no penalty • Average hospital penalty: $125,000. • 9% of hospitals were at the maximum penalty
cap of 1% In October 2013 the maximum penalty
doubles to 2% More DRGs are to be added to the original set
of HF, CAP, and AMI 5
Is Your Hospital Team Configured for Success? Medicare Value-based Purchasing (VBP)
• DRG payments for hospitals are initially reduced by 1% in FY2013 to create a pool of money to be reallocated based on performance Reduction rises by 0.25% each year, ending with a total
of 2% reduction in FY2017 • Payments are adjusted based on performance on
HCAHPS (30%) and clinical process measures (70%) • All HCAHPS questions, other than willingness to
recommend and, for now, the 3 new care transitions questions, are factored into VBP performance
• Clean/quiet are combined into one category 6
HCAHPS In a Nutshell 7 of 21 Questions Pertain to Care Transitions
• HCAHPS is a standardized national survey of recently hospitalized patients
• Hospitals often add their own vendor’s questions to the standard 32 questions 21 substantive
questions 4 screening questions 7 demographic
questions
7
HCAHPS Topics (# of questions)
• Physician Communication (3) • Nurse Communication (3) • Medication Communication (2) • Discharge Information (2) • Care Transitions (3) • Pain Management (2) • Responsiveness (2) • Clean/Quiet (2) • Willingness to Recommend (1) • Overall Rating (1)
New Care Transitions Questions in HCAHPS
• On top of two domains (4 questions) re: Communication about Medications and Discharge Information, CMS has added 3 new questions on care transitions: “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.“
“When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.”
“When I left the hospital, I clearly understood the purpose for taking each of my medications.”
• The new questions were developed by Eric Coleman’s team at the U of CO; they predict the likelihood of readmissions
8
• “Higher patient satisfaction with inpatient care and discharge planning is associated with lower 30-day readmission rates even after controlling for hospital adherence to evidence-based practice guidelines.”
• For some conditions (e.g., HF) HCAHPS performance is more predictive of readmission rates than clinical performance measures
Source: Am J Manag Care. 2011; 17(1): 41-48.
9
Breakdowns in Drug Therapy Lead to Readmissions in a Chronically Ill Population
• 2002 ADHERE registry: 80% of CHF admissions are repeat admissions 20% in one month; 50% in 6 months
• Why? 24% Medication non-adherence 16% Inappropriate medication 24% dietary non-adherence 19% failure to obtain timely care (e.g., report
weight gain) 17% all other Source: Aghababian RV. Rev Cardiovasc Med. 2002; 3(suppl 4):S3-S9.
10
Breakdowns in Drug Therapy in a Chronically Ill Population Persist
• Study of 100 consecutive readmitted HF patients at urban medical center
• Major causes for readmission: No outpatient follow up 33% Medication “noncompliance” 25% Fluid noncompliance 22%. Diet noncompliance 21%, “Other causes had minor contributions”
(Source: Ghali et al, JACC, March 2010)
11
Drug Therapy, Poor Hospital-PCP Coordination Linked with Readmissions
• Study of 998 patients admitted with HF to an urban academic center
• 72% of patients reporting non-adherence to their medications were readmitted in the year post discharge vs. 29% of adherent patients
• Non-adherent patients were 1.7 times more likely to be readmitted ≥ 3 times in the year post discharge
(Source: Shenoy et al, JACC, March 2012)
12
Your Care Transitions Improvement Faculty
• New Hampshire hospital and non-hospital innovators • Resource people
David Schulke, HRET staff with experience working on care transitions and readmissions since 1985
Matthew Schreiber, M.D., Lead facilitator
• Dr. Schreiber Combined Internal Medicine/Pediatrics training at UCSD Primary Care MD in rural setting, hospitalist at small and
large facilities Fmr. CMO for 500 bed hospital, VP Safety in 1100 bed system In August will be VP for Safety & Quality at 6 hospital system
13
Matt Schreiber: Disclosures
• I am supported by HRET for my time • I have no financial relationships with industry
or research partners
14
A Syllogism to Remember
• If You Don’t Meet Someone’s Needs or Expectations, There Is No Chance They Will Be Satisfied
• Providing What People Need Is Often Different From What We Naturally Want To Do
• Process Improvement Is About Bridging The Gap Between What We Do and What We Need By Demonstrating the Value of the Proposed Change
Evidence of Reality • One in five general medicine patients
experiences an adverse event (resulting from medical management) within two weeks of hospital discharge
• 66% of these events are adverse drug events • 17% are related to procedures
– 33% of these events lead to disability – Two-thirds of these events are preventable or
ameliorable The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Forster AJ. Ann Intern Med. 2003;138:161-167
16
The Big Picture
• The cost of readmissions to Medicare was as high as $17.4 B in 2004
Medicare & Medicaid statistical supplement. Baltimore: Centers for Medicare & Medicaid Services, 2007.
• 195,000 people in the USA died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002, according to HealthGrades
Health Grades Quality Study. Patient Safety In American Hospitals. July 2004.
• If the CDC’s annual list of leading causes of death included medical errors, it would show up as number six, ahead of diabetes, pneumonia, Alzheimer's disease and renal disease
• Preventable readmissions are seen as medical mistakes by the government and by the public 17
Barriers to Safe Discharges
• Health (Il)Literacy’: Nearly half of adults have trouble understanding simple health information (procedure consent, prescriptions, oral instructions)
Vastag, B. Low health literacy called a major problem. JAMA. May 12 2004;291(18):2181-82
• Less than half of patients discharged from academic general medicine know their diagnoses, treatment plan or side effects of prescribed medications
Powell, CK. Resident recognition of low literacy as a risk factor in hospital readmission. JGIM 20(11):1042-4, 2005 Nov.
• Post-hospitalization patients typically identified multiple concerns including understanding their progress, activity, insurance, medications, and pain control
Makaryus, AN. Patients’ Understanding of Their Treatment Plans and diagnosis at discharge. Mayo Clin Proc. August 2005;80(8):991-994
18
It’s a Process Thing
• Forster et al., using a survey of patient recollection of the discharge preparations among 400 discharged patients showed that discussion of potential side effects was associated with a reduction in frequency of adverse drug events (adjusted OR 0.4 [95% CI 0.2 to 0.7]). There was no evidence that these discussions increased the likelihood of reported side effects. Unfortunately, only 62% of patients could recall having been told about potential medication side effects at time of discharge.
The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Forster AJ. Ann Intern Med. 2003;138:161-167
19
Typical Discharge Process
• *Complex process involving multiple disciplines • *Discharges can be urgent & unplanned with pressure to cut length of stay • *Time constraints on clinicians who educate, prepare patients for transition • Poor Communication with PCPs:
• Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%).
• availability of a discharge summary at the first post-discharge visit was low (12%-34%) • Discharge summaries often lacked important information such as diagnostic test results
(missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%)
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297:831-41.
• *Unsafe discharges are an under-recognized significant issue that has heretofore received almost no attention from health care providers
*Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care. Coleman EA. Ann Intern Med. 2004;140:533
20
Not My Father’s Medicine • Patients need to be sicker than ever to get into the hospital • Hospital lengths of stay are getting shorter • Patients are not well when they are discharged—they are
“well enough. . . .” • Patient understanding and participation is key to successful
health maintenance • As a general rule, “case management” and education are not
recognized by the reimbursement system • Increasing sub-specialization of care and fewer “general
practitioners” available—especially for the Medicare population
• Dichotomy between inpatient and outpatient care provision
21
The Space Between Hospital Care the Next Provider
Pending test results:
• Many patients (41%) are discharged with test results still pending.
• Many of these results (10%) can change management • Physicians are often (61%) unaware of test results
returning after discharge that may change management Roy, CL. Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge. Ann Intern Med. 2005;143:121-128.
• Poor communication between hospital and ambulatory providers
Coleman, EA. Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care. Ann Intern Med. 2004;140:533
22
Good Reasons to Work on Care Transitions
• Patient Safety • Good Quality Clinical Care • Improves Public Trust • Financial [penalty] • It is precisely the work you came to health
care to do
23
What I Know
• Your Front-Line Staff isn’t the barrier to reducing readmissions—This is a leadership issue and you are the leadership
• You aren’t the ones that are going to come up with the ideas that change the world—that’s going to come from the people that do the work.
• Genius tends to be elegant • Don’t succumb to analysis paralysis • Innovation is successful implementation
24
Results: Two Years of Readmission Work Across 40 Beds at Piedmont Hospital
Volume CMI LOS Readmit Rate
Mortality Rate
Before <70
1088 1.26 5.34 13% 0.46 %
After < 70
3103 1.48 5.58 7% 0.64%
Before >/=70
434 1.30 5.93 15.9% 1.84%
After >/= 70
1526 1.49 6.13 8.7% 1.9%
25
Flipsides of the Same Coin
• Length of Stay [LOS] and Readmissions are intimately related
• You can’t have great success with one without also focusing on the other
• LOS represents an accepted metric associated with substantial financial value
• Readmissions is the quality/safety counterbalance • Quality/Safety is the product made by the process of
operations
26
$50 White Board with the $1 Million Impact
• Main Whiteboard in RN Station
• Pt Room Whiteboard
Rm# Name Transitions DOA LOS* Age Dx PCP Symbols
Day/Date RN for shift and station #
Charge RN Name
How to Call into RM
Key Fam Contact and #
IMS MD/# Consulting MDs
How to Call Dietary
Plans for Day: Dx, tests, results
Dispo info PCP name & f/u
27
Drivers of Success: Key Elements of Proven and Promising Models
• This Workshop focuses on these practical priorities: Build effective teams inside the hospital and between the
hospital and other providers, “transparent” relationships Hospital takes responsibility for the “accountability moment” Data Development and Tracking Medication Reconciliation—Issues and Solutions Patient Friendly Discharge Form/Teachback Setting Up Post-Discharge Appointments 72 hr clinical follow up calls to patients after discharge Risk Identification Process triggering prescribed responses
28
Top 10 Evidence Based Interventions Reducing Readmissions Top Ten Checklist can be found at www.HRET-HEN.org
1. Enhanced admission assessment of discharge needs /begin discharge planning on admission 2. Formal assessment of risk of readmission – align interventions to patient’s needs and risk stratification level 3. Accurate medication reconciliation at admission, at any change in level of care and at discharge 4. Patient education – culturally sensitive, incorporate health literacy concepts, include information on diagnosis and symptom management, medication and post-discharge care needs 5. Identify primary caregiver, if not the patient, and include in education and discharge planning 6. Use teach-back to validate patient and caregiver’s understanding
7. Send discharge summary and after-hospital care plan to primary care provider (PCP) within 24 to 48 hours of discharge 8. Collaborate with post-acute care and community based providers including skilled nursing facilities, rehabilitation facilities, long-term acute care hospitals, home care agencies, palliative care teams, hospice, medical homes, and pharmacist 9. Before discharge, schedule follow-up medical appointments and post-discharge tests / labs. For patients without a PCP, work with health plans, Medicaid agencies and other safety-net programs to identify and link patient to a PCP. 10. Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of after-hospital care plan using teach-back and identify any unmet needs such as access to medication, transportation to follow-up appointments, etc.
Evidence-based Change Packages
• Five change packages (bundles of interventions) have been shown to work in controlled trials—
1) Coleman’s Care Transitions Intervention 2) Jack’s Reengineered Hospital Discharge (Project RED) 3) Evans’ early, systematic discharge planning 4) Koehler’s pharmacist patient education, medication
reconciliation, phone follow-up 5) Naylor’s Transitional Care Model
• Individual parts of these change packages have not yet been proven to work by themselves—to increase likelihood of a beneficial effect, implement the whole bundle (Source: Hansen et al, Ann Intern Med. Oct 2011;155:520-528)
30
On-line Care Transitions Resources
• Project RED • http://www.ahrq.gov/professionals/systems/hospital/red/index.html
• BOOST • http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/
CM/HTMLDisplay.cfm&CONTENTID=27659
• Eric Coleman • http://www.caretransitions.org/
• STAAR • http://www.patientcarelink.org/Improving-Patient-Care/ReAdmissions/STate-
Action-on-Avoidable-Rehospitalizations-Initiative-STAAR.aspx
• Mary Naylor • http://www.innovations.ahrq.gov/content.aspx?id=2674
• INTERACT • http://www.interact2.net/
31
Generating Productive Teams
The Only Problem with MY Department is YOUR Department
32
Team Building
• Have you ever thought the world would be a better place if only everyone would let you call the shots?
• Have you ever thought why am I doing job x when person y is really expert in that? Or why is person y doing what I could really do best?
• Have you ever had the experience that no one completed the task that was everyone’s job?
• Have you ever found out the hard way that no one was responsible for something important?
• Have you ever felt that the patient was getting in the way of our care process?
• Have you ever felt the rhetorical questions would never end?
33
Setting the Tone
• We’re not making incremental change, we’re redesigning the care experience from the patient’s perspective
• You have to try something 7 times before you decide you don’t like it
• Roles not Ranks • Can only say what you can contribute to the solution, no matter
how small that might be • Weekly mtgs to ask what’s going well, who should be recognized,
what are the barriers, homework follow up • Accountability belongs to all of us • Homework should flow uphill • No IT requests
34
Rocket Science?? • Geographically designated personnel including hospitalist MD—LEAN
Advantage • Ward organized around attending MD instead of disease state • Name in the Box* • Right person, right job***(eg pharmacy) • Centralized Communication—d/c criteria, what’s next, patient out of
room on “public” whiteboard • Automation/Standardization—data retrieval results in predictable
responses • Detailed Risk Assessments translate into proactive care—medications,
functional assessments • “Specialized testing triage” • Create “the Pull” • Charge RN in Charge of being in charge • BOOST toolkit
35
Perfect Partners in an Imperfect World
• Home Health is both over and under-utilized at the same time
• Find the landmines by developing relationships whose continuation is predicated upon transparency, MUTUAL benefit, understanding, communication and commitment.
• Be aggressive about inviting post-acute care providers into your team
36
Pearls of Wisdom
• Likely that < 1/3 of pts admitted 4 or more times to your hospital in the last 12 mos left the hospital with home health
• Medicare is the best payer for home health and hospice
• Probably only 25% of your patients are getting what was ordered exactly as ordered at d/c
• High rate of bounce back to hospital after inpatient rehab/SNF stays
37
More Pearls
• Understand how LTACs and SNF make and lose money so you can be a better partner
• Shared Care Protocols translate to better outcomes • Accessibility is a key issue that can be overcome by
flexibility and technology. Referral to the ER is a failure of “the system”
• Post-Acute providers have an army of people to get orders signed
• Pharmacy is a HUGE opportunity for shared wins
38
Palliative Care Pearls
• Palliative care is the difference between asking “what’s the matter” and asking “what matters most.”
• Palliative care is a matter for the entire care continuum to address.
• Palliative care often translates to providing skilled service cost at hospice pay rates.
• Do not attempt to change the entire culture—compartmentalize into something practical for slow, steady change.
• Deciding how someone will spend the time they have left is not our decision to make.
39
Palliative Care: The Right Thing To Do
• Meeting Patients’ needs with a side-effect of improved quality of life at a lower cost which improves satisfaction.
• Maximizes quality of life vs quantity of life (and there’s some evidence it extends life)
• Aggressive symptom management vs curative management
• Multi-disciplinary team with adaptable plan vs physician dependent treatment protocol
40
Palliative Care
• What Patients Want: • Majority of Americans prefer to die at home
(Hays et al., 2001; Gallup, 2000)
• Pain-Free Passing
• What Patients Get: • 33.5% die at home (2009; Teno et al., 2013)
• Patients continue to die in pain (Meier, 2006) • 46% of Do Not Resuscitate orders written within 2 days
of death 41
Palliative Care: The Value Proposition
The Piedmont Experience • Reduced total hospital LOS • Reduced ICU LOS • Reduced ICU Cost per Case [CRRT, Vent, drips]
Reduced Readmission Rates • Enguidanos, Vesper, & Lorenz (2012). 30 day readmissions among Seriously Ill Older
Adults. Journal of Palliative Medicine, 1-6.
Reduced daily cost per case on Palliative Care Status in hospital • Ciemins, Blum, Nunley, Lasher, Newman, Journal of Palliative Medicine 2007
Improved Satisfaction—Palliative Care patients more likely to die at home • Townsend, Frank, Fermont, et al., 1990; Karlsen & Addington-Hall, 1998; Hays et al.,
2001
42
HRET - FHC Readmissions Race Workshop
LUNCH
43
HRET-FHC Readmissions Race Workshop
Medication Reconciliation The Importance of Getting Hospital and
Community Pharmacists on the Team
44
• “Medication errors and preventable adverse drug events (ADEs) [are] a very serious cause for concern….defined as any injury due to medication, [ADEs] are common…at least 1.5 million preventable ADEs occur each year”
• Hospital: 380,000-450,000 preventable ADEs/year “These are likely underestimates”
• Ambulatory Care: 530,000 preventable ADEs per year among Medicare enrollees Over 180,000 life-threatening or fatal ADEs per year, of which more than
50% may be preventable • Long Term Care: 800,000 preventable ADEs/year.
This is “likely an underestimate”
• Does not include errors of omission
NAS Institute of Medicine (IOM): Preventing Medication Errors, July 2006
45
Who? What? Where? When? How?
• There are certain points of care where medication errors occur more frequently
• Approximately 60% of errors occur when patients are admitted, transferred to another unit or discharged.
Rozich JD, Resar RK. Medication Safety: One Organization’s Approach to the Challenge. J Clin Outcomes Manag. 2001; 8:27-34.
46
Part I—The Admission
• 22% of Discrepancies could have resulted in patient harm during their hospitalization.
• 59% of Discrepancies could have resulted in patient harm if the discrepancy had continued as ordered after discharge.
• 27% of ALL prescribing errors that occur in the hospital result from incomplete medication histories at the time of admission.
Sullivan C, Gleason KM, et al. Medication Reconciliation in the Acute Care Setting: Opportunity and Challenge for Nursing. J Nurs Care Qual 2005 Vol 20, No2: 95-98
47
Summary of the Literature: Hospital Medication Reconciliation
• Errors in inpatient prescription medication histories occurred in up to 67% of all cases [on admission]
• Up to 60% had at least one omission error, about 20% had an error of commission (addition of a drug not used pre-admit)
• When non-prescription drugs were included in reconciliations, the error rate was as high as 80s%
• When info regarding drug allergies or prior adverse drug reactions were added, the frequency of errors reached as high as 95%
48
Reinventing the Wheel
• 160 patients admitted to 6N were reviewed by a pharmacist within 24 hrs of admission
• 95% of the patient med lists had been entered by an RN, MD, or PA
• 60% of these lists were completed in the ER • Average of 26 min per patient by pharmacist [17 min
if pharmacist was first person to touch the MRR] • Total of 1153 Meds were reviewed • 478 of these were entered correctly [41% accurate]
49
My Own Backyard
• 678/1153 [59%] were either omitted or incorrect
• 306 Meds were Omitted [45% of errors] • 92 incorrect doses [14% of errors] • 83 incorrect frequencies [12%] • 43 Incorrect Drugs [6%] • 154 Other Errors [23%]—incomplete, wrong
dosage form, etc.
50
Real Patient Example
51
Patient Actually Taking • Dilantin 300 mg po qhs • Dilantin 125 mg
suspension po BID • Acyclovir/Viroptic Eye
drops • Warfarin • Lovenox
Entered on Med Rec Form • Omitted • Omitted
• Omitted
• Omitted • Omitted
Real Patient Example
52
Patient Actually Taking Coreg 25 mg po BID Primidone 100 mg po
TID Metformin 500 mg po
daily Verapamil ER 360 mg po
daily
Entered on Med Rec Form Coreg 6.25 mg po BID Primidone 50 mg po TID
Metformin 500 mg po
BID Verapamil 80 mg po BID
My Own Backyard
• 89% of Medication Reconciliations At Piedmont Hospital had at least one Error
• 100% of patients with more than 5 Meds had an error • Average # of discrepancies between pharmacist and MD
MRR was 5.21 • The Error rate did not change significantly if the MRR was
reviewed either before OR after the MD had reconciled and ordered the patient’s medications
• Approx 20% of discovered errors had already reached the patient by time of pharmacist’s review (done within 24hrs)
53
Part II – The Importance of Discharge Medication Reconciliation
Coleman et al found that hospital readmission rates for patients with identified medication discrepancies were 14.3% among the 375 study patients. This contrasted with a 6.1% readmission rate among patients with no identified medication discrepancy. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. Sep 12 2005;165(16):1842-1847.
54
Part III—The Outpatient Environment
• In the outpatient setting, Only 14.4% of the physician/patient med recs demonstrated complete congruence. Peyton, Lauren. Evaluation of medication reconciliation in an ambulatory setting before and after pharmacist intervention. J Am Pharm Assoc. Aug 2010;50:490–495.
55
Breakdowns in Drug Therapy in a Chronically Ill Population Persist
• Study of 100 consecutive readmitted HF patients at urban medical center
• Major causes for readmission: No outpatient follow up 33% Medication noncompliance 25% Fluid noncompliance 22%. Diet noncompliance 21%, “Other causes had minor contributions”
(Source: Ghali et al, JACC, March 2010)
56
Drug Therapy, Poor Hospital-PCP Coordination Linked with Readmissions
• Study of 998 patients admitted with HF to an urban academic center
• 72% of patients reporting non-adherence to their medications were readmitted in the year post discharge vs. 29% of adherent patients
• Non-adherent patients were 1.7 times more likely to be readmitted ≥ 3 times in the year post discharge
(Source: Shenoy et al, JACC, March 2012)
57
No Reason to Change?
The Only Problem with My Patient Care is My Patients
58
Common Barriers to Accurate Medication Reconciliation—Patient Factors
• Health Literacy • Patient illness [intubated] • Lack of Availability of Medication Bottles • Language Barriers • Current Health Status • Specific knowledge about medications and disease
process • Memory impairment, psychiatric disease • OTCs, Vitamins and Supplements are not always
considered “Medications”
59
Common Barriers to Medication Reconciliation—Physician Factors
• Interview skills of the clinician • Specific knowledge about medications, expected dosage
and utilization • TIME • Discrepancies between multiple sources conducting med
interviews not compared/rectified. • OTCs, vitamins and supplements are not always
considered “Medications” • Drug interactions from herbals are not always known or
appreciated • Lack of access to community pharmacy records
60
A Little Help Please?
Schnipper et al showed in a randomized trial of 178 patients being discharged home from the general medicine service that pharmacist counseling reduced the number of preventable adverse drug events from 11% in the control group to 1% in the intervention group.
• Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. Mar 13 2006;166(5):565-571.
61
61
An Excellent Place to Begin • Studies Show That Pharmacist-Recorded Medication
Histories Result in Higher Accuracy and Fewer Medical Errors.
– Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. Am J Health Syst Pharm. 2004;61:1689-1695.
– Bond CA, Raehl CL, Franke T. Clinical Pharmacy Services, Hospital Pharmacy Staffing and Medication Errors in United States Hospitals. Pharmacotherapy. 2002; 22:134-147.
– Nester TM, Hale LS. Effectiveness of a pharmacist-acquired Medication History in Promoting Patient Safety. Am J Health Syst Pharm. 2002;59:2221-25.
• Yet, pharmacists conduct the medication history only 5% of the time in most US hospitals. – Bond CA, Raehl CL, Franke T. Clinical Pharmacy Services, Hospital Pharmacy
Staffing and Medication Errors in United States Hospitals. Pharmacotherapy. 2002; 22:134-147.
62
62
Med Rec Expert Tips • Take care in the way you ask your questions. Ask patient about
typical day and what meds they take in a.m., p.m., evening, bedtime • Link Meds to medical conditions. Probe for other commonly
prescribed meds, e.g., diuretics in patient with heart failure on a typical “cocktail,” short-acting insulin in patients on Lantus, etc
• Pay attention to Med Suffixes, especially ER, XR, CD etc. • Clarify all Dosages. Don’t assume that the instructions on the bottle
reflect the dose or frequency the patient is actually taking them. • Even if you have all the correct meds, doses, and frequency, the
patient may ACTUALLY be taking them differently either due to confusion, memory impairment, dependence. They may actually take PRN meds in a scheduled fashion and vice-versa. Home health records and description of meds found in the home can be invaluable.
63
Med Rec Expert Tips, continued
• Ask specifically about OTCs, Herbals, Vitamins, and Supplements • Record the name, number, and location of the pt’s pharmacy and
use their info to help ensure accurate reconciliation • Focus on particular “problem meds” like digoxin, coumadin, insulin,
theophylline, antihistamines to guide important follow-up questions about diet, drug interactions.
• Ask the patient which physician prescribes which Meds • Stress the importance of maintaining an accurate list of
medications AND request they bring that list to every interaction they may have with ANY and EVERY physician.
• Ask about medications that were recently stopped and the reason why.
• Never ever trust someone else’s history always do a primary verification
64
If You Want A Puppy, Sometimes It is Better to Ask for A Pony
That Way, The Puppy Doesn’t
Seem So Bad
65
Med Rec—A Burning Financial Platform?
66
All Patients • Ave # Med Errors per Admitted Pt
= 5.21 • # Inpatient Admissions = 26,286 • Potential for error reduction =
5.21 x 26,286 = 136,950 • Literature range of % errors that
result in significant cost is anywhere from 1 – 10%
Only ER Patients • Ave # Med Errors per Admitted Pt
= 5.21 • # ER Admits = 9,384 • Potential for Error reduction =
5.21 x 9,384 = 48,891 • Literature range of % errors that
result in significant cost is anywhere from 1 – 10%
Med Rec—A Burning Financial Platform?
67
All Patients • 1% of 136,950 is 1,370
“costly errors” [very conservative]
• Most Conservative figure from literature of average “cost of these errors” is $6,600
• Conservative Savings opportunity is $9,042,000
Only ER Patients • 1% of 48,891 is 489 “costly
Errors” • Average price of a “costly
error” is $6,600 • Conservative Savings
Opportunity is $3,227,400
Med Rec—A Burning Financial Platform?
68
All Patients • Average time required per
admission = 22 min • Hrs of Pharm time needed =
9, 638 hrs • Number of pharm FTEs to
provide 9,638 hrs per year = 6.0
• Incremental cost of 6.0 Pharm FTEs = $756,984
Only ER Patients • Average time required per
admission = 22 min • Hrs of Pharm time needed =
3,440 hrs • Number of Pharm FTEs to
provide 3,440 hrs per year = 2.2
• Incremental Cost of 2.2 Pharm FTEs = $268,813
The Final Analysis • The Most Conservative Estimated Cost of Medical Errors at
Piedmont Hospital is $9,042,000 • The Potential Savings is $8,285,016 if 6.0 pharm FTEs were
deployed to handle Med Rec for the whole house • The Potential Savings if 2.2 FTEs are deployed to handle Med
Rec in the ER alone is $2,958,587 • It is not a question of IF the Government will decide not to
pay for costs attributable to all med errors, it is a question of WHEN.
• Decision to NO Longer Reimburse for Anticoagulation complications and 30 day readmissions is more than a Credible Threat.
69
Pearls of Wisdom
• Deal with the secret staffing standard tension • Under-promise and over-deliver in terms of quality benefit • What would Baldrige do? • Consider a consultant • Find novel ways to reduce cost
• Use students, residents, techs—its not the credentials, it is the focus • Reorganize pharmacy work-flow • Couple med rec issues with believable medical utilization savings, include MEC • Surescripts data to reduce pharm time needed
• Find novel ways to get funding • Grants • Philanthropy • Work with community pharms in new ways, consider relationships like Walgreen’s • Discharge pharmacy/insource employee pharm benefit if self-insured??
70
HRET-FHC Readmissions Race Workshop
Community Pharmacist Contribution to the Team
71
Community Pharmacist Contribution to Hospital Efforts
What if you can’t secure the help of your hospital pharmacist in medication reconciliation, medication education, and post-discharge follow up? Consider:
• Pharmacists in outpatient hospital pharmacies and hospital clinics could counsel patients
• Community pharmacists can make calls to patients and be paid through the Medicare Medication Therapy Management (MTM) benefit
• Richer benefits than Medicare MTM, but rare: – Walgreens “Well Transitions” program – Home Health/Pharmacist combination
72
Benefits of Bedside Delivery of Medications Before Discharge
• Ensures patients are actually able to receive their medications. Prior authorization Exorbitant co-pays Unusual drug not routinely on shelf-stock
• Provides opportunities to reduce cost to patient Can ensure most preferred tier in class of drug selected Can access prescription savings/co-pay assistance from
vendor/partners $6,389 prescription savings with co-pay assistance and coupons.
For 369 pts that received a total of 921 prescriptions through Walgreen’s bedside delivery in July 2011
• Patient Satisfier/High Touch Experience
73
What are Medicare Medication Therapy Management Services?
• As defined by the Medicare Modernization Act of 2003 (MMA), MTM services are designed to: • Review patient medication regimen • Counsel patients to enhance understanding and
increase adherence • Detect adverse drug events, and patterns of overuse
and underuse of prescription medications • Make corrective recommendations to prescriber
• Provided at no cost to eligible Medicare Part D (drug benefit) enrollees
• Pharmacists are paid by the Part D plan 74
75
Wise Words from as Wise Man
If you want to change the outcome, you have to change the
conversation
76
Talking to the C-Suite
• Five Minutes of Fame • CEOs will only attend to 2 slides • Print the slides/handout • You have to speak their language • Connect to Work Already Happening and
Previously Established Organizational Goals • Must address quality and cost at the same
time and be prepared to present an ROI that the CFO will believe
77
The Value Proposition • Readmissions Penalty Prevention • Length of Stay • Medication Reconciliation • Meaningful Use • Cost per Case Reductions
» Palliative Care » Medical Utilization Patterns [pharm, protocols] » Move Inpatient Testing to Outpatient Environment [send out labs, imaging]
• Value Based Purchasing • Revenue through Higher accuracy DRG Documentation
» Higher blended rate with higher CMI » Risk Adjusted Mortality Improvement
• Employee/Med Staff Satisfaction » Reduced Turnover/Recruitment » Physician/Volume Retention » Physician-Administration Team Building [supply chain, leadership, utilization] » HCAHPS » Outcomes » Process » Efficiency
HRET-FHC Readmissions Race Workshop
Discharge/Handover Process
79
Simple, Useful Discharge Tactics
• Patient-Friendly Discharge Form • Teach Back • Discharge Appointments • Follow-up Phone Calls
80
Patient Friendly Discharge Form
• If you want to see what organizational inertia looks like, try changing your hospital discharge form
• This is a good hill to die on if you are committed to reducing readmissions
• Teach Back to patient AND their key contact is mission critical
• Nursing will balk big-time, and only direct observation and talking to patients will tell you if it is happening the way it should.
81
BOOST PASS FORM
82
Teach Back Process
Step 1: Using simple language, explain the concept/process to the pt/caregiver.
Step 2: Ask the pt/caregiver to repeat in his or her own words how s/he understands the concept.
Step 3: Identify and correct misunderstandings
Step 4: Ask the pt/caregiver to demonstrate understanding again to ensure the misunderstandings are corrected.
Step 5: Repeat Steps 4 and 5 until the clinician is convinced of Comprehension.
Dean Schillinger, MD Associate Professor of Clinical Medicine
University of California, San Francisco
83
Pearls of Wisdom About Discharge Appointments
• Must have confirmed next physician appointment date and time before discharge
• Clearly established single person responsible with a back up if primary is out/at lunch
• Get direct access to MD office schedule with your aligned docs/key practices
• Train the [midlevels working for] specialists to leave appointment times for the discharging hospitalist
• Within 1 week is ideal, sooner for patients with key pending tests, later for sophisticated, stable patients
• Set appointments on Friday for next week for patients whose discharge is likely in next few days 84
Pearls of Wisdom on Follow-Up Calls
• 48 – 72 hrs is the sweetspot • Must be a clinical call by a fairly sophisticated person • Caller should have access to PASS/Discharge form and key info
when making the call • Use Teachback when making the call • Document the results of the call in the PCP’s electronic
medical record and copy for hospital record • Track connect rates to figure out best times to call and high
risk patients you are unable to reach • Track main issues that arise and interventions used to fix them • Establish a clear escalation procedure for the caller to use
when he/she cannot immediately solve the issue
85
HRET-FHC Readmissions Race Workshop
Closing Comments
Summary Statements • Adverse events after hospital discharge are:
Common and often preventable Often involve medications and pending test results Result in significant morbidity and increased health care
utilization • Medicine has focused on episodes and domains of care
and responsibility • We need to focus less on how well we did “our job”
rather on patient outcome • We are all responsible for the whole shebang, though
we choose to subdivide responsibility for our own convenience
87
A Deceptively Simple Formula
Hospital Staff, Patient, and Family/Friend Must: • Know the diagnosis • Know key tests and treatments performed • Know what the treatment plan [meds, appts] • Know red flag symptoms, common side
Effects/Failure points. • Know who/how to contact if something is not going
well
88
Solving the Formula for “x”
• Assume anything that can go wrong will go wrong and act accordingly
• If it isn’t written down, the plan didn’t happen • If teachback wasn’t used, the plan wasn’t effective • If you don’t assess the physical, mental, social, and financial
status of the patient, the plan can’t get executed • If you don’t improve medication reconciliation/education,
have follow-up appoinments, and do a follow-up call at 48-72 hours, then the plan will get derailed.
• Shared care protocols with post-acute providers ensure consistent, quality outcomes and common expectations
89
Name In the Box • Pt Friendly D/C form: CNO • Teachback Process: Nursing Education Leader • Med Rec Process: Pharmacy Director • Treatment Plan: Attending MD • Functional Status Assessment:
• Physical—PT • Mental/social—Social Work [ID key friend/family] • Financial—Case Management
• F/U Appt, home health arrangements: Case Management • F/U Clinical Call: Nursing • PCP Contact: Hospital Attending MD • Code Status/DPA/Living Will: Nursing [Palliative/case
management] 90
Reaching Across the Aisles
• 90% of health care is delivered in the ambulatory environment, but we must make the most of the “Inpatient Moment”
• Integration and communication is key • Achieving a single truth about medications will take
everyone every time • Managing “the Space Between” will require a
redefinition of your relationship with community providers
• We already have all the help we need—it’s sitting in this room
91
Table Activity
• Talk amongst your hospital/community partner team members and decide what you will do next to improve care transitions.
• Set a deadline: we will revisit in office hours • Be prepared to report out a few sentences
when we reconvene in 10 minutes
92
QUESTIONS?
93
