Transitions of Care Medication Safety

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Transitions of Care Medication Safety

  1. 1. Transitions of Care and Medication Safety<br />H. Edward Davidson, PharmD, MPH<br />Assistant Professor, Internal Medicine<br />Eastern Virginia Medical School<br />Partner, Insight Therapeutics, LLC<br />
  2. 2. Current State of Healthcare<br />Care is complex<br />Care is uncoordinated<br />Information is often not available to those who need it when they need it<br />As a result patients often do not get care they need or do get care they don’t need<br />IOM, Crossing the Quality Chasm<br />
  3. 3. Transition of Care vs Transitional Care<br />The movement of patients from one practitioner or setting to another<br />Multiple levels<br />Within Settings<br />Primary care  Specialty care<br />Between Settings<br />Hospital  Home<br />Across health states<br />Curative care  Palliative care/Hospice<br />A set of actions ensuring the coordination and continuity of care as patients transfer between locations or levels of care<br />Includes:<br />Logistical arrangements<br />Education of the patient and family<br />Coordination among the health professionals involved in the transition<br />Coleman E, et al. J Am Geriatr Soc 2003;51:556-7.<br />
  4. 4. Ineffective Transitions Lead to Poor Outcomes<br />Wrong treatment<br />Delay in diagnosis<br />Severe adverse events<br />Patient complaints<br />Increased healthcare costs<br />Increased length of stay<br />Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf<br />
  5. 5. Responsibilities of Health Professionals For Patients in Transition <br />(c) Eric A. Coleman, MD, MPH<br />
  6. 6. Fundamental Disconnect…<br />Nursing Facility<br />Ambulatory Care<br />Hospital<br />Patient<br />Hospice<br />Home<br />Rehabilitation<br />Outpatient <br />Behavioral<br />Health Services<br />
  7. 7. Transition Issues Dramatically Impact Patient Care<br />OUTPATIENT:<br /><ul><li> Home
  8. 8. PCP
  9. 9. Specialty
  10. 10. Pharmacy
  11. 11. Case Mgr.
  12. 12. Care Giver</li></ul>Patient<br />ER<br />ICU<br />In-Patient<br />SNF<br />ALF<br />Patient<br />
  13. 13. Transition Issues Dramatically Impact Patient Care<br />NODischargeCare Plan<br />NO Care Plan<br /> NO Medication Reconciliation<br /> NO Personal Medicine List<br />NOMedication Reconciliation<br />NOPersonal Medicine List <br />NO Coordinated Care Plan<br />NO Care Plan<br /> NO Medication Reconciliation<br /> NO Personal Medicine List<br />OUTPATIENT:<br /><ul><li> Home
  14. 14. PCP
  15. 15. Specialty
  16. 16. Pharmacy
  17. 17. Case Mgr.
  18. 18. Care Giver</li></ul>Patient<br />ER<br />ICU<br />In-Patient<br />SNF<br />ALF<br />Patient<br />
  19. 19. Barriers to Care Coordination<br />(c) Eric A. Coleman, MD, MPH<br />
  20. 20. System Level Barriers<br />
  21. 21. Practitioner Level Barriers<br />Practitioners often have not practiced in settings where they transfer patients<br />Sending practitioners may not communicate critical information to receiving practitioners<br />Practitioners may not know the patient and his or her preferences for care<br />Practitioners have no accountability<br />(c) Eric A. Coleman, MD, MPH<br />
  22. 22. Patient Level Barriers<br />Patients assume that someone is in charge of coordinating care<br />Patients (and caregivers) are often the only common thread weaving between care sites <br />Yet they navigate the system with few tools or training to manage in this role<br />(c) Eric A. Coleman, MD, MPH<br />
  23. 23. The Epidemiology of Transitions of Care<br />
  24. 24. Care Transitions Following Acute Care<br />Hospital<br />11%<br />16%<br />10%<br />Nursing Facility<br />Hospital or TCU<br />74%<br />77%<br />13%<br />64%<br />Home<br />TCU = Transitional Care Unit<br />Coleman EA et al. Health Svcs Research 2004;37:1423-40<br />
  25. 25. Predictors of Complicated Care Transitions<br />Heart disease<br />Diabetes<br /># of prior hospitalizations<br />Visual impairment<br />Medicaid recipient<br />Prior stroke<br />Increasing Risk<br />Coleman EA et al. Health Svcs Research 2004;37:1423-40.<br />
  26. 26. Hospital Admission<br />On hospital admission, more than 50% of patients have at least one medication discrepancy*<br />Approximately 40% of those have potential to cause harm<br />*Discrepancy defined as error between admission medication orders and patient interview of medication history.<br />Cornish PL et al. Arch Intern Med 2005;165:424-9.<br />
  27. 27. Hospital Discharge<br />On discharge from the hospital<br />with possible or probable <br />patient discomfort or <br />clinical deterioration<br />* Most common discrepancy is incomplete prescription requiring clarification.<br />30% of patients have at least one medication discrepancy * <br />Wong JD, et al. Ann Pharmacother 2008;42:1373-9.<br />
  28. 28. AHRQ Hospital Survey on Patient Safety Culture: 2007 Report<br />
  29. 29.
  30. 30. Hospital to Home<br />40% of patients experienced at least 1 medical error<br />Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 months<br />*Work-up error occurred if an outpatient test or procedure suggested or scheduled by the inpatient provider was not adequately followed up by the outpatient provider (e.g., colonoscopy for positive fecal occult blood test scheduled at discharge but not documented in outpatient chart).<br />Moore C et al. J Gen Intern Med 2003;18:646-51.<br />
  31. 31. Medication Discrepancies: Hospital to SNFs Transitions<br />Tija et al. J Gen Intern Medicine 2009.<br />Cross-sectional study of patients admitted to SNF for subacute care (N=199, 2319 meds)<br />Results: <br />21.3% of medication orders had a discrepancy<br />At least one discrepancy in 71.4% of patients<br />CV agents, opioid analgesics, neuropsychiatric agents, hypoglycemics, antibiotics, and anticoagulants accounted for > 50% of all discrepancies<br />SNF=Skilled nursing facility<br />
  32. 32. Hospital to PCP transfer<br />Meta-analysis<br />Direct communication between hospital physicians and primary care physicians occurred infrequently <br />Discharge summary<br />Availability at first postdischarge visit low (12%-34%) <br />Remained poor at 4 weeks (51%-77%)<br />Affected quality of care in ~25% of follow-up visits<br />Often lacked important information (e.g., lab results, discharge medications, treatment, follow-up plan)<br />Kripalani S et al. JAMA 2007;297:831-41.<br />
  33. 33. The infant was discharged to home with Mom in car seat<br />
  34. 34. Independent Risk Factors for Having a Preventable ADE in NFs<br />+within 60 days of admission<br />Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.<br />
  35. 35. Adverse Events in Nursing Home Residents Transferred to the Hospital<br />122 nursing home to hospital transfers<br />98% returned to the nursing home<br />In 86% of transfers, at least one medication order was altered (mean 1.4)<br />65% - discontinued<br />19% - dose changes<br />10% - substitutions <br />20% of changes resulted in an adverse event<br />Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.<br />
  36. 36. Post-hospital Medication Discrepancies<br />Post-hospital medication review<br />Compare what hospital told patient to take versus what patient was actually taking<br />One MDE completed for each discrepancy<br />Results<br />Of the 375 patients, 14.1% experienced one or more medication discrepancies<br />Patients who experienced a discrepancy averaged 9 medications compared to 7 for those without a discrepancy (p<.001)<br />Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.<br />
  37. 37. Patient-Level Contributing Factors<br />Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.<br />
  38. 38. System-Level Contributing Factors<br />Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.<br />
  39. 39. Examples of Duplicative Prescribing<br />Therapeutic duplication with the same drug<br />Enalapril 10 mg daily; Vasotec 5 mg daily<br />Lopressor 50 mg one tablet twice a day; Toprol XL 50 mg one tablet twice a day <br />Adalat 10 mg three times a day; Procardia XL 30 mg daily<br />Therapeutic duplication within a drug class<br />Pravachol 10 mg daily; Lipitor 10 mg daily<br />Hytrin 1 mg orally at bedtime; Cardura 1 mg daily<br />Therapeutic duplication with components of combination products<br />Enalapril 5 mg daily; Vaseretic one tablet daily<br />Hydrochlorothiazide 50 mg daily; Maxzide one capsule daily<br />Institute for Safe Medication Practices<br />
  40. 40. Clinical Practice Guidelines, the Elderly, and Multiple Comorbid Conditions<br />Hypothetical 79 yr old woman with COPD, Type 2 DM, osteoarthritis, hypertension, and osteoporosis<br />If followed published CPGs would<br />Be prescribed 12 routine medications<br />Cost of $406/month<br />Implications in pay-for-performance initiatives<br />Increase risk of medication related problems<br />Different settings, different goals<br />Potential for diminished quality of care<br />Boyd CM et al. JAMA 2005;295:716-24.<br />
  41. 41. OIG Report – June ‘07<br />Consecutive Medicare stays involving inpatient and skilled nursing facilities in CY 2004<br />Key findings …<br />35% of consecutive stays were associated with quality-of-care problems and/or fragmentation of services<br />11% of individual stays within consecutive stay sequences involved problems with quality-of-care, admission, treatments or discharges<br />DHHS; OIG, June 2007; OEI-07-05-00340<br />
  42. 42. Medication Errors Involving Reconciliation Failure<br />U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.<br />
  43. 43. Medication Error Type by Transition Category<br />U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.<br />
  44. 44. Case Examples of Medication Errors on Admission<br />Patient’s home medication recorded as Coreg® 25 mg twice daily on admission<br />Patient taking 6.25 mg twice daily at home<br />Patient received 4 doses of excessive strength and developed leg edema<br />Error not discovered until after leg ultrasound test to rule out DVT<br />Nursing home patient receiving propranolol 20 mg/5mL twice daily<br />Admitting orders written as propranolol 20 mg/mL give 5 mL (which equates to 100 mg) twice daily<br />Patient received 5 doses of 100 mg strength before error was discovered<br />U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.<br />
  45. 45. Case Examples of Medication Errors on Transition/Transfer<br />Patient with prior history of several arterial stent placements<br />Receiving aspirin, enoxaparin, clopidogrel<br />Meds placed on hold prior to surgery for removal of toe; Physician did not reorder after surgery<br />2 of patient’s coronary arteries with stents became 100% occluded; patient died<br />Patient transferred from ICU to step-down unit<br />Prior to transfer, patient received morning doses of scheduled meds <br />Administration of same meds repeated upon arrival to new unit due to unclear documentation and communication<br />U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.<br />
  46. 46. Role of Pharmacist Counseling in Preventing ADEs After Hospitalization<br />Does pharmacist counseling before discharge reduce the rate of preventable ADEs?<br />Randomized controlled trial of pharmacist intervention (n=92) vs usual care (n=84)<br />Intervention on day of discharge<br />Medication reconciliation<br />Screening for nonadherence, previous drug-related problems, lack of drug efficacy, and side effects<br />Review of indications, directions for use, and potential side effects with patient <br />Schnipper JL et al. Arch Intern Med 2006;166:565-71.<br />
  47. 47. Study Outcomes: Pharmacist Intervention vs Usual Care<br />*Outcomes 30 days postdischarge<br />Schnipper JL et al. Arch Intern Med 2006;166:565-71.<br />
  48. 48. Health Information Technology<br />Health Information Technology for Economic and Clinical Health Act (HITECH)<br />Part of the American Recovery and Reinvestment Act of 2009<br />Electronic Health Record (EHR) and Meaningful Use Criteria <br />Health Information Exchange (HIE)<br />Continuity of Care Document (CCD)<br />
  49. 49.
  50. 50. NTOCC: Barriers and Gaps in Supporting Transitions of Care<br />
  51. 51. The Leapfrog Group Study: CPOE<br />Survey Period: June 2008-January 2010<br />http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf<br />
  52. 52. The Leapfrog Group (cont.)<br />Survey Period: June 2008-January 2010<br />http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf<br />
  53. 53. Primary, secondary diagnoses and problems list<br />Medication list (reconciliation) including OTC/other <br />Treatment and diagnostic plan <br />Clearly identifiable medical home/coordinating and transferring MD/institution and contact information<br />Prognosis and outcome goals <br />Test results (available and pending)<br />Patient cognitive status<br />Advance directives, power of attorney, consent<br />Planned interventions, med equipment, wound care<br />Emergency plan, contact information <br />Assessment of caregiver status<br />Snow V et al. J Gen Intern Med 2009;24:971-6.<br />“Ideal Transition Record”(ACP, SGIM, SHM, AGS, ACEP, and SAEM)<br />
  54. 54. National Efforts<br />
  55. 55. A Report from the HMO Care Management Workgroup<br />Supported by the Robert Wood Johnson Foundation<br />One Patient, Many Places:Managing Health Care Transitions<br />
  56. 56. Medication List Toolkit<br />
  57. 57. CMS 9th Scope of Work<br />Care Coordination (3 measures)<br />Global re-hospitalization rate<br />Patient assessment of hospital discharge performance (H-CAHPS items 17, 19, 20)<br />Physician visit postdischarge, before re-admission (within 30 days)<br />
  58. 58. The Joint Commission National Patient Safety Goals<br />Goal 8: Accurately and completely reconcile medications across the continuum of care<br />8A: There is a process for comparing the patient/resident’s current medications with those ordered for the patient/resident while under the care of the organization<br />8B: A complete list of the resident’s medications is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient/resident on discharge from the facility<br />The Joint Commission National Patient Safety Goals. Available at htt://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm<br />
  59. 59. Working to Address the Issues<br />www.ntocc.org<br />
  60. 60. Transition of Care Evaluation:Identifying Process Nodes<br />Case study: In a nursing home to hospital bi-directional transfer, you may consider that there are six exchanges<br />Exchange 1: Preparation in nursing home to transfer patient to hospital (nursing home handover)<br />Exchange 2: EMS/Ambulance transport<br />Exchange 3: Hospital receipt of patient<br />Exchange 4: Preparation in hospital to transfer patient back to nursing home (hospital handover )<br />Exchange 5: EMS/Ambulance transport<br />Exchange 6: Nursing home receipt of patient <br />
  61. 61. www.ntocc.org<br />
  62. 62. Other Organizations at Work<br />
  63. 63. Role of the Pharmacist<br />Play a key leadership role in medication reconciliation<br />Be involved in the design and implementation of emerging medication safety technologies<br />Assist in evaluating your practice<br />Can it be improved with regard to transitions of care issues?<br />Pay special attention to patients in transition – this is a vulnerable population<br />

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