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Transitions of Care Medication Safety


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Presented at the St. Louis College of Pharmacy Medication Safety Forum

Presented at the St. Louis College of Pharmacy Medication Safety Forum

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