Deprescribing Improving Care Transitions Deprescribing

DeprescribingJessica Visco, PharmD, CGP

SeniorPharmAssist

August 24, 2016

Deprescribing

Jessica Visco, PharmD, CGPSeniorPharmAssist

Webinar #1Webinar #2

Improving Care TransitionsLawrence Greenblatt, MDJoan Levitt, RN, CDE

Verification of participation will be noted by signing

in via the Question and Answer box.

No influential financial relationships have been

disclosed by planners or presenters which would

influence the planning of the activity. If any arise, an

announcement will be made at the beginning of the

session.

No commercial support has influenced the planning

of the educational objectives and content of the activity.

Any commercial support will be used for events that are

not CE related.

Disclosures

There is no endorsement of any product by

DUHS associated with the session.

Disclosures

This program is supported by a Geriatric

Workforce Enhancement Program (GWEP)

grant (U1QHP28708) from the U.S.

Bureau of Health Professions Health

Resources and Services Administration

(HRSA).

Objectives

Define the core principles of high

quality transitions of care

Describe a model for improving

transitions in primary care practice

Identify community-based resources

to improve transitions of care

Case

69 year old African American female

Lives alone in a rural area. She has a son

who visits on the weekend and calls

frequently.

Followed at Lincoln Community Health

Center

Case (2) Medical problems

1. Hypertension

2. End Stage Renal Disease – Recently initiated

Hemodialysis.

3. Chronic diastolic congestive heart failure

4. H/o Alcohol Abuse- reports 2-3 drinks per week

now

5. Gout

6. Multifactorial anemia

Case (3)

Medications:

1. Amlodipine 10 mg daily

2. Losartan 100 mg twice daily

3. Metoprolol 100 mg twice daily

4. Hydralazine 75 mg q 8 hours

5. Allopurinol 200 mg daily

Case (4) History of multiple ED visits and hospitalizations

Admitted with pre-syncope and frequent falls

Found to have orthostatic hypotension due to volume

depletion and multiple antihypertensives

Treated with IV fluids and all BP medications held

Noted to have gait instability and poor endurance

Very low health literacy and limited grasp of meds

Hospital Day 4— “ready for discharge”

Case (5)

Concerns at discharge:

Will she take her medicines correctly?

How will her BP be monitored?

How will she manage her ADLs and IADLs

given her functional decline and fall risk?

Who will follow up her medical problems

and medications?

Why Care Transitions Should Be Handled with Care

• Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year.

• Large proportion of re-hospitalizations could be prevented with an improved discharged planning process and coordinated care after discharge.

• In the Medicare population, up to 76% of rehospitalizations occurring within 30 days are potentially avoidable.

• Nearly one in five Medicare patients

discharged from a hospital— approx. 2.6

million seniors —are readmitted within 30

days

• In the Medicare population, up to 76% of

rehospitalizations occurring within 30 days

are potentially avoidable.

Why Care Transitions Should Be

Handled with Care

Potential Hazards of Poor

Transitions

Deterioration of clinical and functional status

Duplication of care

Adverse drug events

Loss of trust and decreased patient satisfaction

Why Older Patients are Vulnerable

During Care Transitions

Possible poor health literacy5

4

3

Types of medical problems2

Coexisting chronic medical problems1

Decreased social support

Functional impairment

Obstacles to Safe and Effective

TransitionsThe Usual Suspects

• Communication Hurdles

• Multiple Maze

• Follow-up Leap of Faith

Courtesy of Dr. Hastings

Communication HurdlesBetween Providers and Patients/Families

• Providers assume that they communicate effectively with patients and families.

• Families report inadequate information about care plan; feel unprepared for the next care setting.

• Why the disconnect?• Failure to recognize the influence of medical

illness & medications, vision/hearing and cognitive impairment

• Failure to provide information to the patient/caregiver as a dyad or family unit

Vom Eigen et al. Med Care 1999;37:33-38; Chugh et al. Front Health Serv Manage 2009;25:11-32.

Communication Hurdles

Between Providers

• Direct communication between providers in different settings is rare (3-20%)

• Discharge summaries or other printed documents are usually the main form of communication.

• Discharge summaries are rarely available at first post-hospital discharge visit (12-34%), and are often missing important information.

Kriplani et al. JAMA 2007;297:831-841

Medication Maze

• Incomplete or incorrect medication information at the time of hospital admission (54-60%)

• Medication discrepancies– Unintentional differences in patient’s

medication regimen following a care transition

– 14% of patients discharged from hospital to home experienced one or more medication discrepancies

• 2/3 of all adverse health events that occur after a transition are due to medications

Coleman et al. Arch Intern Med 2005: 165;1842-47; Cornish et al. Arch Intern Med 2005:165;424-429

Follow-up Leap of Faith

Patients are discharged with “loose ends”…

41% discharged with lab or radiology results

pending

28% discharged with additional outpatient

workup recommended.

…that are frequently not “tied up.”36% of recommended outpatient workups not completed within 6 months.

Roy CL et al. Ann Intern Med 2005: 143: 121-128; Moore et al. Arch Intern Med 2007;167:1305-11

Hospital Readmissions

• 1 in 5 Medicare Beneficiaries readmitted

within 30 Days; 1 in 3 readmitted within

90 Days

• Hospitalizations account for 33% of total

Medicare expenditures

• 50% of patients with no outpatient visit

between discharge and readmission.

Jencks SF et al. N Engl J Med 2009;360:1418-1428

Improving Transitions and Reducing

Readmissions

Transitional Care Teams

• Advanced Practice Nurse-directed discharge planning and home follow up (Naylor)

• Care Transitions Intervention – Transition Coach (Coleman)

• Project RED (Re-Engineered Discharge) –Discharge planning and advocate (Jack)

• Coordinated Transitional Care (C-Trac; Kind) –Nurse care managers, delivered via telephone

Improving Transitions and Reducing

Readmissions

Common Elements:

• Interdisciplinary

• Communication/Collaboration

• Transitional Care Staff

• Patient Activation and Education

• Enhanced Follow-up (by phone and/or home visit)

Improving Transitions in Our

Community

Primary Care Practice:

Duke Outpatient Clinic

Community Care:

DCC/NPCC Home-based Geriatric

Services Program

Inspired by Project BoostCauses of Rehospitalization, Emergency Department

Visits, and other Adverse Events: 8 P’s

• Problem Medications

• Psychological Issues

• Principal Diagnosis

• Polypharmacy

• Poor Health Literacy

• Patient Support

• Prior Hospitalizations in the last 6 months

• Palliative Care

Some Details…

Problem Medication: warfarin, insulin,

digoxin, ASA/Clopidogrel.

Psychological: Depression common in those

with complex medical illness and often

underdiagnosed. Morbidity and self care

concerns.

Principal Diagnosis: Cancers, Stroke,

COPD, Diabetes, Heart Failure

More Details…

Polypharmacy: >5 Concerning

Poor Health Literacy: Huge prevalence at

DOC, under-recognized generally.

(Lack of) Patient Support, Recent Prior

Hospitalization.

(Lack of) Palliative Care: Increasing Data

on impact on both quality of life and

resource utilization.

Duke Outpatient Clinic Approach

Team based

Exploit information systems

Structured given many resident providers

and fairly high staff turnover

Existing system had too much variability

Effort at educating trainees

ADT Notification

We list our patients

Notified when patient is admitted and

discharged

Contact from PSA (front desk staff)

Appt set?

Does it work for you?

Scripted, structured.

Pharmacist

Subsequent call

<2 business days, 2 attempts

Documented in EMR

Structured

Clinical focus

Emphasis on medication

Follow Up Appt. (CMA)

CMA provides structured assessment

& documentation

Depression screening: PHQ-2

Substance abuse screening: AUDIT-

C, single item drug abuse screen

Follow Up Appt. (Provider)

Physician uses highly templated note

Current status r.e. hospital illness

Recheck on obtaining/taking meds

Decline in cognitive or functional status?

Check in on understanding

Check in on self management/strategies to

avoid rehospitalization

Discontinued Meds? Pharmacy notified?

Follow Up Appt (Provider)

Test results not reviewed?

Tests/consults that need to be ordered?

Home Health? Care Management?

Collaboration/communication with PCP,

specialists, non-physician providers

Other issues that need to be addressed

Med changes

To do list for next visit

Results

Adherence to protocol limited by staff

time.

Patients quite receptive.

Provider satisfaction mixed (anecdotal).

Readmissions….

Results

Number of patients not seen within 14

days reduced by 75% (1/4 as many).

Admissions reduced by 22% (separate

effort)

Cost per admission down about 8%

Readmissions reduced by 14%

Lessons Learned

Active Process-don’t wait for patients to call.

Roles defined. Conversation scripted.

Templated notes for admin staff, pharmacists,

and CMA’s.

Highly structured note for providers-directed

thinking and communication. Actively sought out

potential errors and addressed them.

May have improved provider training.

Patients accepting-satisfaction up, cooperative.

Reduced total costs substantially

Huge return on investment (6.7X)

Community Care

Transitions Care – Case Study

• Duke Connected Care/ Northern Piedmont Community Care Home- Based Geriatric Services Program (HBGS Program)

• Program Goals – Address chronic care needs of at risk patients in the community, with Medicare A and B. Link patients with community and Duke resources to improve health outcomes and prevent hospitalizations.

• Services Provided- In-Home Assessments address medication adherence, home safety concerns, cognitive and functional deficits, caregiver stress and patient’s connection with their primary caregiver.

DCC/NPCC Home- Based Geriatric

Services Program provides patient

centered care

• Motivational interviewing skill are used to engage clients, elicit change talk, and evoke motivation to make positive changes

• Interactions focus on patients and caregivers improving or learning self- management skills to meet their health goals.

• Health barriers are addressed and follow-up provided to help resolve problems by linkages to appropriate resources.

What is addressed at a Transitional Care

Home Visit?• Patient/caregivers concerns- pain,

discomfort, fatigue.

• Barriers to care- finances, transportation.

• Patient goals-to promote improved self-management.

• Home safety- mobility issues, home structural barriers, need for Home Health?

• Medication adherence- understanding of medications prescribed, ability to obtain medications and problems with adherence.

• Understanding of Discharge Instructions-Red Flags, Diet or Activity Instructions, Daily weights? Follow-Up Appointment with PCP- preferably occurring in first week post discharge.

• Functional and cognitive status- Is this person safe in their home?

• Self care deficit – ADL needs, meal preparation, food supply

• Advanced Directives

• Patients’ understanding of their medical plan of care and health conditions.

• Community resources needed or already in place?

• Review events and circumstances which occurred prior to hospitalization.

• Depression – coping skills.

• Health literacy.

Home Based Geriatric Services Program

implements Successful past Duke/NPCC program

models to deliver care-

Care Partners- collaborative multidisciplinary team

focused on frequent patient engagement addressing

complex patient needs.

CATCH Program- Care and Transitions to

Community and Home. Based On Eric Coleman’s 4

Pillars ▪Medication Self Management ▪Use of a

Patient Centered Record ▪Primary Care and

Specialist Follow-up ▪Knowledge of Red Flags

Home- Based Geriatric Services Program team is composed of nurses,

(Joan Levitt RN CDE, Donna Fowler LPN) occupational therapist(Carol

Siebert OTD, OTR/L, FAOTA) and social worker (Jonathan Black MSW).

In-Home Assessments are shared with patients PCP’s and referrals are

made to the Just For Us program when appropriate. Communication

and collaboration with patients individual PCP practice, LCSW’s, is

often beneficial in coordinating services and relaying important home

observations.

DukeWELL/Duke Connected Care refer high risk patients for In-Home

Visits.

Jessica Hackett BSW, MHA Administrative Care Specialist (DukeWELL)

sends referrals providing details warranting a home visit.

Referrals are also received from hospital care managers, individual

PCP’s, community partners and NPCC/Duke Hospital Data Feeds.

Prior to our home visit a thorough and invaluable

medication review is completed by Ben Smith, PharmD,

BCACP, CPP, CGP/Duke Connected Care.

Community resources for transportation, medications,

food, housing, caregiver services, long term care planning,

and senior activities are much appreciated and frequently

utilized, to assist in our care delivery. (Senior PharmAssist

Program, DSS In-Home Aide Program, Meals on Wheels, Ship

Programs in other Counties, Durham Center For Senior Life,

Data Access, and many more…).

Continuing Education Credits• 1 hour of CE credit is being offered for this

webinar.

• For the live webinar, to obtain the credit you

must:• Add your name to the Q/A box (to verify

attendance)

• Complete the survey. The survey will open

automatically at the end of the webinar and the

link will be sent in a follow-up email.

• If you did not register for this webinar and

would like CE credit, contact gero@duke.edu

to receive the link for the survey.