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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.


Begin with the end in mind: Best practices for transitions of care performed by inpatient pharmacists

Zachary Cox, PharmD, BCPSOctober 20, 2015

2015 ACCP Global Conference on Clinical Pharmacy

Conflict of Interests

Research funding from OtsukaPharmaceuticals

Learning Objectives

Evaluate established inpatient-focused caretransition models

Apply existing quality metrics endorsed byhealthcare quality sponsoring organizationsto track and measure the impact of caretransitions in the inpatient care setting

Develop strategies to incorporate transitionsof care medication reconciliation and patienteducation 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 ensurehealth care continuity, avoid preventable pooroutcomes, and promote safe and timelytransfer

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 arereadmitted within 30 days

Readmission reasons infrequently matchindex 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.


Inside the “Readmission” Metric

Only 16% of readmissions graded aspreventable

30 day readmission rates are heavilyinfluenced 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%

90%

100%

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’ssuccess

Learning Objective

Evaluate established inpatient-focused caretransition models


Audience Response

Which TOC model is validated in multiplehospitals/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/Implementation_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 precipitationfactors 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 communication1. Schedule Follow up appointments and tests

2. Phone call

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

4. Quick and complete written communicationwith 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 medications as instructed

64% - 73% can identify a new medication after discharge

Moser DK et al. Am Heart J. 2005;150:984.e7-e13. Maniaci MJ et al. Mayo Clin Proc. 2008;83:554-558.J Gen Intern Med. 2014;29:1491-1498. Schillinger D et al. Arch Intern Med. 2003;163:83-90.

Teach-back Assessment

Patient teaches concept back

Re-education of

misconceptions

Re-assessment of Understanding

Education of new concept

Schillinger D et al. Arch Intern Med. 2003;163:83-90.


Customization of TOC Models

Root Cause Analysis Disease state prevalence

Population served Resources

Socioeconomic limitations

Education barriers

Institutional system

Learning Objective

Apply existing quality metrics endorsed byhealthcare quality sponsoring organizationsto track and measure the impact of caretransitions in the inpatient care setting

How do you measure TOC success?

Developing Institutional Metrics Outcome

Are you accomplishing your goal?

Process Measure how well the new process is functioning

Structure Measures staff/materials required for process

Balancing Measures new process’ impact on other processes

Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44:Suppl:166-206.

National Standards

JC National Patient Safety Goal 03.06.01 D/C medication reconciliation, education, &

communication

CTM-3 My preferences were considered in my post-D/C health

care needs

I understood my responsibilities post-D/C in my care

I understood the purpose of each medication post-D/C

http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf. Accessed July 2015.http://www.hcahpsonline.org/files/HCAHPS%20V10.0%20Appendix%20A%20-%20HCAHPS%20Mail%20Survey%20Materials%20(English)%20March%202015.pdf. Accessed July 2015.

National Standards

Physician Consortium for PerformanceImprovement

1. Medication List at Discharge New, Continued, Discontinued, & Allergies/Adverse Reactions

2. Transition Record for the Patient

3. Transmission of Transition Record within 24 hours

National Transitions of Care Coalition Framework for Measuring TOC

http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf. Accessed July 2015.http://www.ama-assn.org/ama/pub/physician-resources/physician-consortium-performance-improvement/pcpi-measures.page. Accessed July 2015.

Developing TOC Goals

Define baseline performance Process mapping

Patient discharge knowledge assessment tool

SMART Goals

Establish Data Collection Methods

SpecificMeasurableAchievableRealisticTime defined

Project BOOST. First http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/Boost/Home/Project_Team.aspx.

Accessed July 2015.


TOC Process Mapping

Reprinted with permission. Johnson JK et al. BMJ Qual Saf. 2012;21:i97-i105.

Arrhythmia - AtrialArrhythmia – ventricularHypertensionHF progressionIschemiaKidney dysfunctionLVAD/OHT evaluationMedication / Toxin inducedNew heart failureNoncompliance; dietaryNoncompliance; medicationValvular dysfunctionFree text

Prescribednot prescribed: did not toleratenot prescribed: hypotensionnot prescribed: bleedingnot prescribed: renal functionnot prescribed: hyperkalemianot prescribed: waiting to start as an outpatient not prescribed: not indicatednot prescribed: bradycardianot prescribed: patient unable to perform

Learning Objective

Develop strategies to incorporate transitionsof care medication reconciliation and patienteducation into inpatient pharmacist workflow

Audience Response

What is your primary barrier to performingTOC?

Reimbursement/Institutional Support

Inadequate time from notification

Patient volume


Reimbursement

By 2018, CMS to reimburse with: 50% of payments as alternative payment models

Bundled Payments for Care Improvement

Hospitals bear financial risk

Incentivizes institutional shared-risk partnerships

90% of payments as quality-linked Hospital Value-Based Purchasing Program

Meds to Beds Program

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html. Accessed July 2015.

Too many patients

Risk-based triage of patients Retrospective administrative data models

C statistic range 0.55-0.65

Inpatient data models C statistic range 0.56-0.83

Risk models perform poorly outside ofisolated settings and improvements areneeded for widespread application

Post-acute care inpatient facilities risk

Kanasagara D et al. JAMA. 2011;306:1688-1698.

BOOST Risk Assessment

Problem medications

Psychological/depression

Principle diagnosis

Polypharmacy (> 5 meds)

Poor health literacy

Patient support

Prior hospitalization in 6 months

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

Who is discharging? When?

Multi-disciplinary “huddles”

Case managers

Electronic discharge indicators

Create a discharge culture where pharmacyis integral

More than Meds

MedsMeds

Self Care SkillsSelf Care Skills

Red Flag Symptom

Recognition

Red Flag Symptom

Recognition

Outpatient Follow-upOutpatient Follow-up

Discharge Planning

Discharge Planning

Acknowledgements

Erin Neal, PharmD, BCPS


Hold on, we’re going home: Best Practices for Transitions of Care performed by ambulatory care pharmacistsJulianna Burton, Pharm.D., BCPS, BCACP, FCSHP –Assistant Chief of Pharmacy, UC Davis, Sacramento, CAOctober 20th, 2015

2015 ACCP Global Conference on Clinical Pharmacy

Conflict of Interests

I have no conflicts to disclose

UC Davis Medical Center

Multispecialty, university-affiliated medical center 619 bed tertiary care hospital located in Sacramento, CA

Serves approximately six million residents in the region

3Facts and Figures. http://www.ucdmc.ucdavis.edu/newsroom/facts_figures/index.html. Accessed: April 23, 2014

Learning Objectives

Develop strategies to incorporate transitionsof care medication reconciliation and patienteducation into ambulatory care pharmacistworkflow

Apply existing quality metrics endorsed byhealthcare quality sponsoring organizationsto track and measure the impact of caretransitions in the ambulatory care setting

Evaluate established ambulatory care-focused care transition models

Acronyms

BOOST – Better Outcomes by OptimizingSafe Transitions

Project RED (Re-Engineered Discharge)

NTOCC – National Transitions of CareCoalition

Patient Centered Primary Care Collaborative(PCPCC)

Patient Centered Medical Home (PCMH)

Question 1

Which of the following models could bestincorporate an amcare pharmacists? A. Project Red

B. AHRQ

C. PCPCC

D. BOOST


Question 2

There are several great resources availableonline to start a new TOC service. Which of thefollowing resources would be the best to utilizeto get an in-depth, detailed understanding of theimplementation of TOC services at your site? A. Project RED

B. BOOST

C. AHRQ

D. National Quality Forum

BOOST

Hospitalmedicine.org

1st edition free, 2nd only $65

Proven to decrease readmits

Features: Speaks of accountability

Best Possible Medication History (BPMH)

8P’s including pharmacy component

Has TOC from hospital to SNF

8P’s

Problems with meds

Psych issues

Principal diagnosis

Physical limitations+

Poor health literacy*

Poor social support

Prior hospitalization

Palliative care

Further BOOST features

Provides checklists that can be used by all teammembers

Review to see what the discharge status is for pt

Provides for a medication action plan

Bring to amcare/primary care visit

Pharmacist in primary care can use as a first step

Suggests MARQUIS (Multi-Centered MedicationReconciliation Quality Improvement Study)

Has videos, manual, BPMH pocket cards, andpresentations about med rec

Project RED

Proven to decrease readmits

Free to implement, but not easy

Has several toolkits, including how to implementprogram

Very in depth information

Includes measures to review

MUST have staff and hospital administration onboard to implement

Virtual dc educator Louise

12 components

Language barriers

Make appts for pt

Pending results?

DME/Social

Medications*

Compare to NationalGuidelines

Discharge plan for pt

Educate patient

Assess understanding

Problems arise? Whatto do?

D/C summary to MDw/in 24 hrs

Follow up call -PharmD


Follow up call - PharmD

Three days after discharge

Reviews most of the 12 components again

Script provided on website

Asks open ended questions

Use teach-back method

PCPCC

Patient-Centered Primary Care Collaborative

Website provides broad overview of PatientCentered Medical Home (PCMH) model

For patients, HCP, employers, purchasers,and policy makers

Takes a different approach to readmits –keep patients from being admitted in the firstplace!

PCPCC

Best Amcare Care Coordination/TOCresource

Reviews multiple practice “expert” sites

Asks applicable questions of sites using thePCPCC TOC model

Information provided in Q/A format

Many have a pharmacist embedded into thePCMH for medication management andadherence issues

NTOCC

Wealth of information

TOC checklist – similar to BOOST, moretheory than practice

Supports webinars, conferences and taskforces on TOC with policy groups around thenation

More measures than BOOST or Project Red

Provides sections of the site for patients,HCP, and policy makers

NTOCC

Has section on TOC in primary care Suggests MD, but could be performed by a

PharmD

Uses the Modified Morisky Scale

Has a 3 page medication reconciliationelements document Shows extensive definition of proper way to

perform med rec

Review Metrics - Amcare

NTOCC - Measures Work Group

NQF – HCAHPS CTM-3 questions

Care Coordination Measures Atlas –Measure 18, MUPM


Question 3

Which of the following metrics might be bestincorporated into and amcare TOC program? A. HCAHPS Care Transitions questions

B. Efficiency measures such as reducingduplicative lab tests

C. Pharmacist/Physician contribution metrics

D. Decreasing Length of Stay

NTOCC - Measures

Structural – adequate systems

Process – timeliness/completeness,adequacy of providers

Outcomes - Adverse events

Efficiency – inappropriate resource utilization

Experience – Pt/providers

National Quality Forum

HCAHPS Care Transitions Questions: The hospital staff took my preferences and those of

my family or caregiver into account in deciding whatmy health care needs would be when I left thehospital.

When I left the hospital, I had a good understanding ofthe things I was responsible for in managing my health

When I left the hospital, I clearly understood thepurpose for taking each of my medications.

AHRQ Measures

AHRQ has measures related to pharmacy Measure 18 – MD-PharmD Collaboration

Instrument Measures pharmacist/MD collaboration

Family Medicine Medication Use ProcessesMatrix (MUPM) Measures MD’s perspectives of pharmacist contributions

Incorporation

Barriers of cost, time and culture

Need to develop new role for pharmacist

May need to obtain more credentials, certifications,advanced practice licenses, or even privileging

Studies abound in this area and metrics can help todevelop a sound pilot

Residents/students can help start small initiatives, buteventually a culture shift (and resources) will benecessary for a fully successful program

Question 4

Patient Case: MC is a 78 yo female with hx of AMI, DMand HTN. She is taking Atorvastatin 20mg, ASA 81 mgand insulin. Her MD just saw her for the first time in 4years after she was dc’d from the hospital. Medicationnon-adherence is a probable cause for her admit. Whatwould be the best first step in the PCMH pharmacistvisit? A. Take the patient’s blood pressure

B. Contact the patient’s pharmacy to get prior auths approved

C. Perform a BPMH and medication reconciliation

D. Create a patient specific medication calendar


2012 UC Davis Pilot- CHF

2012 Added 0.5 FTE pharmacist and 0.5 FTE nursein an amcare role (grant funded)486 total Patient encounters 77 Face to face visits (total patients 77) 402 Telephonic education and assessments Seven Email communications (MyChart)

77 Total Patients Medication Adherence Interventions: 81

Patient was either not taking the medication at all or was taking an incorrect dose or frequency 49% of Patients had at least one lack of adherence event(range 1‐14 events)

Most patients had 2‐3 adherence events

Identified Barriers

Type of Barrier Patient Identified Provider Identified

Lack of Info/Understanding 14 29

Functional Limitations 6 9

Cognitive Dysfunction 0 6

Depression/Anxiety 7 7

Financial 5 2

Lack of Psychosocial Support 2 0

Multiple Appointments 1 1

Lack of Transportation 3 4

HF Readmits during 2012 Pilot

14 hospital referred patients followed for at least 30 days after discharge were included in the readmission analysis 1 of 14 (7%) referred from hospital was re‐admittedwithin 30 days of index HF admission• National Average 24%

• Latest Quarter for UC Davis 14%

Clinic patient HF Admits

25 clinic referred patients were followed for at least 30 days after referral from J street PCP 0 of 25 patients (0%) referred from clinic were admitted for HF

Last quarter overall readmit rate for CHF (14%)

PCMH visit

First step is ALWAYS medication reconciliation

Example: Pt with 2 hospitalizations within 30 days

Med rec done at d/c both times

PCMH pharmacist discovered that patient waspicking up old meds at the pharmacy (on 3 beta-blockers)

Patient able to understand better at clinic visit vs.end of hospital stay

Pt stayed out of the hospital for the next 30 days

Medication Access

After Med Rec, Medication Access is the nextimportant step

Example: Pt sent home on covered COPD inhalers

Pharmacist saw patient at discharge and made surethat patient was on formulary approved inhalers

Pt went to the pharmacy, but insurance was in the“doughnut hole” and couldn’t afford

PCMH pharmacist helped patient complete PAPs forinhalers


Health Literacy

Third most important is Health Literacy or LanguageBarriers

Example: Pt was discharged on NOAC for PE

PharmD at d/c got PAP approved for pt

PharmD at retail pharmacy told patient not to take dueto renal dysfunction

Pt went without any anticoagulant x 1 week

Saw PCMH pharmacist and reviewed list, pt wasSpanish speaking and didn’t understand importance ofmed

Question 5

Which of the following was identified as thenumber one barrier to medication non-adherence by both patients and providers atUC Davis, during the CHF pilot study? A. Lack of Transportation

B. Financial Barriers

C. Depression/Anxiety

D. Lack of info/understanding

Medication Calendar

Generic (Brand)/ Name

Dose When to take:

Breakfast Lunch Dinner Bedtime

This medication is for your:

Side Effects

Incorporation

Need to have an amcare place to “catch”d/c’d patients

Utilize learners to help extend reach

Need to work with other disciplines/aspects: Care Coordination – schedule patients/refer

MA’s to room patients

Analysts to review outcomes

Go to MD huddles/meetings to develop trust/getreferrals

Conclusion

Pharmacists can play in important role in catchingpatients after hospitalization

They are uniquely suited for a role with medicationreconciliation and medication access

Since 2003, outpatient visits are up by 12% and inpatientvisits are down by 20% (PWC)

ACO’s make pharmacist costs less important

Now is the time to move pharmacists into the clinics toprovide better patient care, including TOC

References

1. Moore C, Wisnivesky J, Williams S, et al. Medical Errors Related to Discontinuity of Care from an Inpatient to an Outpatient Setting. J Gen Intern Med. 2003; 18:646-651.

2. Kripalani S, Roumie CL, et al. Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge: A RandomizedControlled Trial. Ann Intern Med. 2012; 157(1):1-10.

3. Walker PC, Bernstein SJ, et al. Impact of a Pharmacist-Facilitated Hospital Discharge Program: A Quasi-Experimental Study. Arch Intern Med. 2009; 169(21):2003-2010.

4. Schnipper JL, Kirwin JL, et al. Role of Pharmacist Counseling in Preventing Adverse Drug Events After Hospitalization. Arch Intern Med. 2006; 166:565-571.

5. Sarangarm P, London MS, et al. Impact of Pharmacist Discharge Medication Therapy Counseling and Disease State Education Pharmacist Assisting atRoutine Medical Discharge (Project PhARMD). American Journal of Medical Quality. 2013; 28: 292-299.

6. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006; 565-71. DOI 10.1001/archinte.166.5.565.

7. Centers for Medicare and Medicaid Services. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed: September 25, 2013.

8. University Health System Consortium. University of California, Davis Medical Center Quality Management Dashboard. July 2012.9. UHC Benchmarking Project on Reducing Readmissions 2009. Oakbrook, IL.10. Unpublished data presented at UHC Pharmacy Council, December 2009 and personal communications.

11. ACCP BCPS PSAP module, 2014, TOC chapter.

12. Project Red. Accessed 8/1/15. Internet Citation: https://www.bu.edu/fammed/projectred/

13. NTOCC website. Accessed 8/1/15 Internet Citation: http://www.ntocc.org/

14. AHRQ Care Coordination Atlas. Accessed 8/1/15. Internet Citation: Chapter 1: Background: Care Coordination Measures Atlas Update. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/chapter1.html

15. BOOST Toolkit. Accessed 8/1/15. Internet Citation: http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/BOOST_Intervention/Tools/Medication_Reconciliation.aspx

16. PCPCC Patient Centered Primary Care Collaborative. Accessed 8/1/15. Internet Citation: http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf

17. PWC Health. Accessed 8/1/15. Internet Citation: http://pwchealth.com/cgi-local/hregister.cgi/reg/pwc-hri-medical-cost-trend-2016.pdf


Special Thanks!

Stephanie Roberts, Pharm.D.,BCPS

Stephanie Marin, Pharm.D., BCPS

Pamela Mendoza, Pharm.D.

Jennifer Nguyen, Pharm.D.

Patricia Poole, Pharm.D., BCPS, AAHIVE

Contact info: [email protected]
