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  • Global Conference

    Adult Medicine PRN and Ambulatory Care PRN Focus Session—Transitions of Care Management: Best Practices Activity Number: 0217-0000-15-136-L01-P, 1.50 hours of CPE credit; Activity Type: An Application-Based Activity

    Tuesday, October 20, 2015 1:30 p.m. to 3:00 p.m. Continental Ballroom 4

    Moderator: Sarah L. Anderson, Pharm.D., BCPS Assistant Professor, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, Colorado

    Agenda

    1:30 p.m. Begin with the End in Mind: Best Practices for Transitions of Care Performed by Inpatient Pharmacists Zachary Lane Cox, Pharm.D., BCPS Associate Professor, Lipscomb University College of Pharmacy, Nashville, Tennessee; Heart Failure Clinical Pharmacist, Vanderbilt University Medical Center, Nashville, Tennessee

    2:00 p.m. Hold On, We’re Going Home: Best Practices for Transitions of Care Performed by Ambulatory Care Pharmacists Julianna L. Burton, Pharm.D., BCPS, BCACP, FCSHP Assistant Chief of Pharmacy, Director of PGY2 Ambulatory Care, Pharmacy Department, UC Davis Medical Center, Sacramento, California

    2:30 p.m. Lessons from the Trenches: Expanding Transition of Care Services Through Expansion of Student and Resident Roles Julianna L. Burton, Pharm.D., BCPS, BCACP, FCSHP Assistant Chief of Pharmacy, Director of PGY2 Ambulatory Care, Pharmacy Department, UC Davis Medical Center, Sacramento, California

    Zachary Lane Cox, Pharm.D., BCPS Associate Professor, Lipscomb University College of Pharmacy, Nashville, Tennessee; Heart Failure Clinical Pharmacist, Vanderbilt University Medical Center, Nashville, Tennessee

    Conflict of Interest Disclosures Sarah L. Anderson: no conflicts to disclose. Julianna L. Burton: no conflicts to disclose. Zachary Lane Cox: Received grant funding from Otsuka Pharmaceuticals and Cumberland Pharmaceuticals.

    © American College of Clinical Pharmacy 1

  • Global Conference

    Learning Objectives

    1. Develop strategies to incorporate transitions of care medication reconciliation and patient education into inpatient pharmacist workflow.

    2. Apply existing quality metrics endorsed by healthcare quality sponsoring organizations to track and measure the impact of care transitions in the inpatient care setting.

    3. Evaluate established inpatient-focused care transition models. 4. Develop strategies to incorporate transitions of care medication reconciliation and patient education

    into ambulatory care pharmacist workflow. 5. Apply existing quality metrics endorsed by healthcare quality sponsoring organizations to track and

    measure the impact of care transitions in the ambulatory care setting. 6. Evaluate established ambulatory care-focused care transition models. 7. Identify successes and challenges encountered when integrating students and residents into transitions

    of care services. 8. Describe a student-driven medication reconciliation process. 9. Given a case scenario, determine how to incorporate a learner into the transition of care process.

    Self-Assessment Questions

    Self-assessment questions are available online at www.accp.com/gc15.

    © American College of Clinical Pharmacy 2

  • Begin with the end in mind: Best practices for transitions of care performed by inpatient pharmacists Zachary Cox, PharmD, BCPS October 20, 2015

    2015 ACCP Global Conference on Clinical Pharmacy

    Conflict of Interests

     Research funding from Otsuka Pharmaceuticals

    Learning Objectives

     Evaluate established inpatient-focused care transition models

     Apply existing quality metrics endorsed by healthcare quality sponsoring organizations to track and measure the impact of care transitions in the inpatient care setting

     Develop strategies to incorporate transitions of care medication reconciliation and patient education into inpatient pharmacist workflow

    Transitions of Care (TOC) Definition  Movement of patients between healthcare

    locations, providers, or different levels of care within the same location as their conditions and care needs change

     Time-limited services designed to ensure health care continuity, avoid preventable poor outcomes, and promote safe and timely transfer

    National Transitions of Care Coalition. Transitions of Care Measures. 2008.http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. Accessed July 2015. Naylor MD, Aiken LH, Kurtzman ET, et al.Health Aff (Millwood). 2011;30(4):746-54.

    0%

    5%

    10%

    15%

    20%

    25%

    30%

    Hospital A Hospital B Hospital C

    30 Day Readmission rates

    Post-Hospital Syndrome

     19.6% of Medicare beneficiaries are readmitted within 30 days

     Readmission reasons infrequently match index hospitalization reasons

     HF: 65% AMI: 90%  Pneumonia: 78% COPD: 64%

     Younger patients are also vulnerable  11% readmitted within 30 days  42% unrelated to index admission

    Krumholz HM. N Engl J Med 2013;368(2):100-102. Dharmarajan K et al. JAMA. 2013;309:355-363. Jencks SF et al. N Engl J Med. 2009;360:1418-1428. Dreyer RP et al. Circulation. 2015;132:158-166.

    © American College of Clinical Pharmacy 3

  • Inside the “Readmission” Metric

     Only 16% of readmissions graded as preventable

     30 day readmission rates are heavily influenced by the patient population

     Race: 13% increase  High minority populations: 23% increase for all races  Safety net hospitals 60% more likely to be penalized

     ED Treat-and-release visits within 30 days:  7.5% of discharges

    Van Walraven C et al. CMAJ. 2011;183;E1067-1072. Vashi AA et al. JAMA. 2013;309:L364-371. Joynt KE et al. JAMA. 2011;305:375-681. Epstein AM et al. N Engl J Med. 2011;365:3387-2295. Boozary AS et al. JAMA. 2015;314:347-348.

    Hospital A 30 Day Readmissions

    0%

    10%

    20%

    30%

    40%

    50%

    60%

    70%

    80%

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    Related to Index Admission

    25%

    75%

    Non- Preventable

    Preventable

    Hospital A

    Home

    Hospital B

    Hospital C

    PCP

    Specialist

    Fragmentation & Conflict of Care  Medicare beneficiaries:  See median of 2 PCPs in a 2 year window  See median of 5 specialists

     Medicare beneficiaries with Heart Failure:  See mean of 15 providers a year  17% report conflicting advice from providers  44% prescribed 3 or more diet restrictions

    Riegel B et al. Circulation. 2009;120:1141-1163. Pham HH et al. N Engl J Med. 2007. 356;1130-1139.

    Summarizing TOC Barriers

     30 Day readmissions:  Reflective of a patient’s global health more than quality

    performance on a disease state  Not all preventable  Vary in incidence with the population served  Enhanced by our system’s fragmentation

     Not the only metric that defines a TOC model’s success

    Learning Objective

     Evaluate established inpatient-focused care transition models

    © American College of Clinical Pharmacy 4

  • Audience Response

     Which TOC model is validated in multiple hospitals/populations in rigorous, outcome- based trials?

     Coleman Care Transitions

     Project RED

     PROJECT BOOST

    Rennke S, et al. Ann Intern Med. 2013;158:433-440. Herner SJ et al. PSAP Transitions of Care. 2014. Chronic Illness. Book 2:79-97.

    Components of TOC Models

    1. Secure institutional support 2. Define multidisciplinary team

     Engage key community stakeholders outside institution

    3. Develop specific goals  Define metrics of success for each goal

    4. Collect baseline data of current performance  Root cause analysis

    5. Create intervention

    Project BOOST Implementation Guide to Improve Care Transitions. First Edition. 2008. http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Imp lementation_Toolkit/Boost/First_Steps/Implementation_Guide.aspx. Accessed July 2015.

    Readmission Root Cause Analysis

    “It is clear that there are multiple factors along the care continuum that impact readmissions, and identifying the

    key drivers of readmissions for a hospital and its downstream providers is the first step towards

    implementing the appropriate interventions necessary for reducing readmissions.”

     Interview all 30 day readmissions for 1 month  Quantify and characterize precipitation

    factors in an institution’s population CMS Community-Based Care Transition Program. http://innovation.cms.gov/initiatives/CCTP/. Accessed July 2015. CMS Community-Based Care Transition Program. http://innovation.cms.gov/resources/CCTP_HowtoApply.html. Accessed July 2015.

    Components of TOC Models

    1. Education on medication and self-care skills 2. Early post-discharge patient communication

    1. Schedule Follow up appointments and tests 2. Phone call

    3. Identification of and action for “Red Flag” symptoms

    4. Quick and complete written communication with outpatient providers

    Paper ≠ Education

     Written and Verbal discharge instructions  ~50% of all instructions are able to be recalled or

    understood  14-50% understood self care instructions  ~1/3 could not name 1 symptom of an acute

    exacerbation  ~1/3 take all medicati

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