Text of Deprescribing Improving Care Transitions Deprescribing
DeprescribingJessica Visco, PharmD, CGP
August 24, 2016
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
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.
There is no endorsement of any product by
DUHS associated with the session.
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
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
69 year old African American female
Lives alone in a rural area. She has a son
who visits on the weekend and calls
Followed at Lincoln Community Health
Case (2) Medical problems
2. End Stage Renal Disease – Recently initiated
3. Chronic diastolic congestive heart failure
4. H/o Alcohol Abuse- reports 2-3 drinks per week
6. Multifactorial anemia
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”
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
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
• 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
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
Types of medical problems2
Coexisting chronic medical problems1
Decreased social support
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.
• 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
• 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
28% discharged with additional outpatient
…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
• 1 in 5 Medicare Beneficiaries readmitted
within 30 Days; 1 in 3 readmitted within
• Hospitalizations account for 33% of total
• 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
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
• Transitional Care Staff
• Patient Activation and Education
• Enhanced Follow-up (by phone and/or home visit)
Improving Transitions in Our
Primary Care Practice:
Duke Outpatient Clinic
DCC/NPCC Home-based Geriatric
Inspired by Project BoostCauses of Rehospitalization, Emergency Department
Visits, and other Adverse Events: 8 P’s
• Problem Medications
• Psychological Issues
• Principal Diagnosis
• Poor Health Literacy
• Patient Support
• Prior Hospitalizations in the last 6 months
• Palliative Care
Problem Medication: warfarin, insulin,
Psychological: Depression common in those
with complex medical illness and often
underdiagnosed. Morbidity and self care
Principal Diagnosis: Cancers, Stroke,
COPD, Diabetes, Heart Failure
Polypharmacy: >5 Concerning
Poor Health Literacy: Huge prevalence at
DOC, under-recognized generally.
(Lack of) Patient Support, Recent Prior
(Lack of) Palliative Care: Increasing Data
on impact on both quality of life and
Duke Outpatient Clinic Approach
Exploit information systems
Structured given many resident providers
and fairly high staff turnover
Existing system had too much variability
Effort at educating trainees
We list our patients
Notified when patient is admitted and
Contact from PSA (front desk staff)
Does it work for you?
<2 business days, 2 attempts
Documented in EMR
Emphasis on medication
Follow Up Appt. (CMA)
CMA provides structured assessment
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
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
To do list for next visit
Adherence to protocol limited by staff
Patients quite receptive.
Provider satisfaction mixed (anecdotal).
Number of patients not seen within 14
days reduced by 75% (1/4 as many).
Admissions reduced by 22% (separate
Cost per admission down about 8%
Readmissions reduced by 14%
Active Process-don’t wait for patients to call.
Roles defined. Conversation scripted.
Templated notes for admin staff, pharmacists,
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)
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
• 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.