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The Battle Field of Care Transitions Judith Kristeller, PharmD Professor and Chair Wilkes University Department of Pharmacy Practice
The Battle Field of Care Transitions
Judith Kristeller, PharmD
Professor and Chair
Wilkes University
Department of Pharmacy Practice
Objectives
Discuss strategies to gather information from patients to identify opportunities to improve the safety and effectiveness of their medications.
Identify primary causes of medication errors or medication-related problems as patients transition between hospital and home.
Objectives
Describe opportunities for collaboration between pharmacists and physicians as patients transition between hospital and home.
Describe strategies to engage stakeholders in a pharmacy transition of care service.
Learning Objective
Discuss strategies to gather information from patients to identify opportunities to improve the safety
and effectiveness of their medications.
Your strategies to gather information from patients?
Strategies
• Medication Reconciliation • Medication management • Interview / Conversation with patient to
gather information
What does Medication
Reconciliation mean to you?
Definition of Med Rec
• “obtain and maintain accurate and complete medication information”
APhA and ASHP. Improving Care Transitions: Optimizing medication reconciliation. J Am Pharm Assoc. 2012;52:e43-e52.
Definition of Med Rec
• “obtain and maintain accurate and complete medication information”
APhA and ASHP. Improving Care Transitions: Optimizing medication reconciliation. J Am Pharm Assoc. 2012;52:e43-e52.
Purpose of Med Rec
• “obtain and maintain accurate and complete medication information for a patient and use this information within and across the continuum of care to ensure safe and effective medication use”
APhA and ASHP. Improving Care Transitions: Optimizing medication reconciliation. J Am Pharm Assoc. 2012;52:e43-e52.
Med Rec → Med Management
• Med rec alone is insufficient in preventing medication-related problems
• Use as a first step in assessment of medication management
– Appropriateness
– Safety
– Efficacy
– Consistent with patient goals/needs
Goals of Medication Management
• Improve adherence
• Prevent medication-related problems
• Prevent medication errors
• Reduce hospitalization / readmissions
Accuracy of Med Rec
• Med rec is a Joint Commission National Patient Safety Goal…so everybody’s doing it
• BUT, it’s often inaccurate and/or incomplete
• Errors with home med list are transferred to inpatient and discharge lists
• Care transitions are vulnerable moments for medication errors and problems
Our Experience (N=238)
Case
• HPI: 79 yo Male admitted for stroke
• PMH: CAD, HTN, Hyperlipidemia, Anxiety, BPH
• SH: No EtOh or tobacco
• Management of stroke – Acute
– Chronic (secondary prev’n) • Start clopidogrel 75mg daily
• Switch to intensive dose statin
Categorize Home and Hospital Meds
Indication Home Medication Hospital Medication
CAD (stent ‘2002)
Aspirin 81mg Daily
Continue
HTN Metoprolol Succ 25mg Daily
Continue
Hyperlipidemia Pravastatin 40mg Daily Simvastatin
BPH Finasteride 5mg Daily Continue
Anxiety Alprazolam 0.25mg BID PRN
Continue
CVA -- Clopidogrel 75mg Daily
Medication Reconciliation and
Medication Management
What do we want to talk to the patient about?
Interviewing Techniques
• What medications do you take for your BP?
– Assess knowledge of medications
– Verifies med list
• What does your BP normally run at home?
– Assess patient engagement
– Assess med efficacy and safety
• Have you fallen in the past?
– Consider medication-related causes
What we learned from the patient…
• Hasn’t used alprazolam in > 1 year
• Understood indication for medications
• No myalgias with statins
• BP usually 160/90
• Using OTC Claritin D
Any medication-related problems for follow-up?
Medication Management Problem List
• CVA – Clarify Aspirin + Clopidogrel…add or switch?
– Statin…discharge on intensive dose?
• HTN – Consider switch beta-blockers to ACEI +/- Thiazide
– Educate patient to avoid decongestants
• Anxiety – Patient not using alprazolam - D/C?
Discuss with Physicians
• Hospital Prescriber
– Clarify discharge statin
– Verify aspirin + clopidogrel
– D/C hospital order for alprazolam?
• PCP - Chronic Issues
– Discuss intensive dose statin
– D/C alprazolam
– Consider switching to ACEI for HTN
Discuss with Patient
• How to prevent another stroke
• Clopidogrel + Aspirin
• Change in statin
• Avoid decongestants
• Goal BP
Patient Interview / Discussion • Develop a rapport with patient to understand
their goals, preferences, concerns
• Assess health literacy and information needs
• Provide patient-specific education
• Clarify medications
• Probe further to identify MRPs based on patient responses and body language
• Probe further to identify adherence barriers / opportunities
Evidence shows benefits of a conversation…
• Medication reconciliation without patient conversation ≈ 2.7 interventions/pt.
• With patient conversation ≈ 5.3 interventions/pt.
• Counseling is necessary to identify: – Continuous need for drug therapy – Starting new drug therapy – Inappropriate dosing – Drug-drug interactions – Side effects – Omitted OTCs
Ann of Pharmacother 2009; 43:1001-10
Examples of MRPs Uncovered through conversation with patients
Hypertensive emergency + weight loss drugs
AKI + OTC NSAIDS
ACEI cough…ARB
Spiriva / Advair PRN use
Tizanidine + sedation…switch to baclofen
Insomnia + Amitriptyline= constipation + dry eyes
Learning Objective
Identify primary causes of medication errors or medication-
related problems as patients transition between hospital and
home.
What do you see?
Errors with Admission Medication Reconciliation
Errors with Discharge Medication
Reconciliation
Common Errors with Admission Med Rec
Multiple dose units Metoprolol 25mg 2 tabs BID
PRN Alprazolam TID PRN Alprazolam TID
Recent dose changes Diuretics, etc.
Recently discontinued Omissions Psych OTC (analgesics, decongestants) Combination products
Lisinopril / HCTZ
Common Errors at Discharge Med adjustments for temporary problems
DM, BP, psyche meds New meds for temporary problems
Prescribed at d/c (insulin, PPI, antiarrhythmics) Omission of chronic medications held during hospitalization Therapeutic interchange becomes therapeutic duplication
Learning Objective
Describe opportunities for collaboration between pharmacists and physicians as patients transition
between hospital and home.
First, Consider Barriers • Reflect on our culture of collaboration
– Between HC disciplines (and within disciplines)
– Between HC providers
– Outside of a HC system
• Perceived HIPAA barrier – Even though communication between providers
about the care of the patient is ok!
• Lack of structure to facilitate communication
• Risk of interrupting work flow / causing medical errors
From our case: Discuss with Physicians
• Hospital Prescriber
– Clarify discharge statin
– Verify aspirin + clopidogrel
– D/C hospital order for alprazolam?
• PCP - Chronic Issues
– Discuss intensive dose statin
– D/C alprazolam
– Consider switching to ACEI for HTN
…and, the patient’s community pharmacist is an untapped resource
that can have a positive impact in promoting the safe and effective
use of medications…through collaboration
Hand-off with the Community Pharmacist
• Medication indications
• Reasons for medication changes
• Follow-up on education started in hospital
– Information overload
• Actual or potential medication-related problems
– Indication for PPI / H2RI
– BP monitoring
Community Pharmacist F/U on...
Lifestyle modifications (diet, exercise, weight)
DM monitoring
Assess BP
Assess inhaler technique and use (PRN)
OTC use - analgesics, etc
Smoking cessation
Assess efficacy of new meds
Assess safety of new meds
Assess adherence - cost?
Learning Objective
Describe strategies to engage stakeholders in a pharmacy transition of care service.
Engaging Stakeholders Who are they?
Patient
Family
Hospital providers
Community providers - PCP, pharmacists
Health system administration
Tell Your Story for System Support
Quantitative
Qualitative
Quantitative Outcomes
• Medication discrepancies identified with admission home med list
• Medication errors identified / prevented
• Interventions for improving medication management
• Adherence
• Readmissions
Qualitative Outcomes can Tell your Story
Counselled about warfarin non-adherence in patient with dose increase due to subtherapeutic INR
Synthroid dose increased to 200mcg/day in patient who was taking it with food; Counselled patient and let PCP know that dose may need to be adjusted if taken on empty stomach.
Qualitative Outcomes can Tell your Story
Recommend high intensity statin for stroke prevention
Recommend alternative analgesic in patient taking aspirin 325mg BID and rivaroxaban
Counselled patient to discontinue naproxen after GIB
Recommend statin in patient with CAD
Recommend ACEI in patient with HTN and DM
Conclusion
Pharmacist’s Role in Care Transitions
Improve the safe and effective med use
Medication Reconciliation
Medication Management
Conversation with patient
Identify common problems during transitions
Collaborate with physicians and pharmacists
Engage our stakeholders to highlight our role and gain support
