4/22/2013. Transitions Handoffs Vulnerable exchange points Adverse clinical events Unmet needs Poor patient satisfaction

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Agatha Patrick
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1 Objectives Transitions of Care and the Pharmacy Practice Model Initiative Emily Bennett, PharmD Melody Hartzler, PharmD, AE-C Describe the Affordable Care Act and it s implications on current healthcare and practice Discuss the impact of transitions of care on continuity of patient care Identify innovative practice models to improve the transition of care process Apply the current and potential roles of pharmacists during transitions of care to current practice Affordable Care Act Affordable Care Act: Improving the Quality & Efficiency Transforming the Health Care Delivery System Linking Payment to Quality Outcomes Under the Medicare Program National Strategy to Improve Health Care Quality Encouraging Development of New Patient Care Models Critical Point Transitions Handoffs Vulnerable exchange points Adverse clinical events Unmet needs Poor patient satisfaction Level of Access Effect on Readmission Level of Access Influence Low access Higher/lower readmission rates? High access Higher readmission rates Socioeconomic status Needs evaluated! Health Affairs 2011; 30(4) JAMA 2011;306(16) 1

potential roles of pharmacists during transitions of care to current practice Affordable Care Act Affordable Care Act: Improving the Quality & Efficiency Transforming the Health Care Delivery System

2 Transitional Care Avoid preventable poor outcomes in high risk populations Identify early! Multidisciplinary Patient advocates Patient/caregiver goal setting Pharmacist discharge counseling Post-discharge follow-up POP Quiz Which of the following is a diagnosis that is part of the Hospital Readmissions Reduction Program under the ACA as of October 2012? a. COPD b. CHF c. CABG d. Asthma Health Affairs 2011; 30(4) & JAPHA 2011;51(4) Hospital Readmissions Reduction Program Started October 1, 2012 Heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PN). Future Expansions likely in 2015 include: Atrial fibrillation COPD CABG PCTA Definition of Readmission as occurring when a patient is discharged from an applicable hospital and then admitted to the same or another acute care hospital, that is, another applicable hospital, within a specified time period (30 days) from the date of discharge from the initial index hospitalization. ACA Sec , MedPac June 2007 Report FY 2012 IPPS/LTCH PPS final rule (76 FR 51666) E1 Medicare Hospital Readmission Rates Potentially Preventable MedPac June 2007 Report MedPac June 2007 Report 2

Readmissions Reduction Program under the ACA as of October 2012? a. COPD b. CHF c. CABG d.

3 Slide 12 E1 I have always been wondering this, and I don't know how I ever got this far without knowing the answer...but does ANY readmission count against the hospital? If the patient is sent home after CHF exac but comes back in 2 weeks with DKA, is the hospital penalized? Emily, 4/16/2013

..but does ANY readmission count against the hospital?

4 Potential Economic Impact COPD Example Preventing any exacerbations in patients with both severe and moderate exacerbations could save $13,296/patient/year Reducing the severity of exacerbations from severe to moderate could save $9409/patient/year Direct costs 18 billion in billion in 2010 Community-Based Care Transitions Program Goals Improve transitions of care Improve quality of care Reduce readmissions for high risk beneficiaries Document measurable savings to the Medicare program Pasquale MK, et al. International Journal of COPD 2012: OrnekT, et al. Int J Med Sci. 2012;9(4): Sec Community-Based Care Transitions Program Requirements Transition services that begin no later than 24 hours prior to discharge Timely and culturally and linguistically competent post-discharge education Timely interactions between patients and post-acute and outpatient providers Patient-centered self-management support and information specific to the beneficiary s condition A comprehensive medication review and management Community-Based Care Transitions Program Proposals Identify community-specific root causes of readmissions, define the target population, and strategies for identifying high risk patients Specify care transition interventions and services that will address readmissions, including strategies for improving provider communications and improving patient activation Be culturally appropriate, beneficiary-centric Describe prior experience with managing care transition services and reducing readmissions Other Programs Section 3021 CMS Innovation Center offers grant money for innovative care delivery and payment models ( ) Section 2602 Federal Coordinated Health Care Office Designed to foster integration of Medicaid/Medicare Section 3022 Medicare Shared Savings Program Accountable Care Organizations/PCMH/Transitions of Care Emily Bennett, PharmD INNOVATION Health Affairs 2011; 30(4) 3

5 billion in 2010 Community-Based Care Transitions Program Goals Improve transitions of care Improve quality of care Reduce readmissions for high risk beneficiaries Document measurable savings to the

5 Transitions of Care and Innovation Critical to discover new ways to keep patients out of the hospital From here: PPMI Studies Future directions Activity PPMI Goal: Significantly advance the health and well being of patients by developing and disseminating a futuristic practice model that supports the most effective use of pharmacists as direct patient care providers Transitions of care Coleman, et al. Personal Health Record Patient-centered document with important core elements Transition coach (RN) Tools to promote cross-site communication Encouragement to take a more active role in their care and to assert their preferences Continuity across settings and guidance Coleman, et al. Arch Intern Med. 2006;166: Balaban, et al. Intervention Patient Discharge Form Telephone outreach from a nurse Four undesirable outcomes were measured after hospital discharge Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls Balaban RB, et al. J Gen Intern Med 2008;23(8): Jack, et al. Nurse discharge advocate Create After Hospital Care Plan Arrange follow-up appointments Confirm medication reconciliation Conduct patient education Clinical pharmacist Called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications Hospital to Home (H2H) Initiative Nationwide quality campaign led by the American College of Cardiology (ACC) and the Institute for Healthcare Improvement Wiggins, et al. Principles in discharge medication counseling Transitions of care and pharmacist role Individualization Jack BW, et al. Ann Intern Med. 2009;150: Schnipper JL, et al. Arch Intern Med. 2006;166:

http://www.ashpmedia.org/ppmi/rationale.html Coleman, et al.

6 Ongoing research Discharge medication counseling and its correlation with reducing readmission rates in patients with chronic obstructive pulmonary disease exacerbations Funded by the ASHP Foundation through the Pharmacy Resident Practice-Based Research Grant Design and Methods Results? Group Discussion Groups of 5 Brainstorm changes you can implement at your own practice site Write them out on the provided sheet and hang around the room Share ideas References The Affordable Care Act, Section by Section. Department of Health and Human Services. Available from: Accessed 5 April Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med 2008;23(8): Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention. Arch Intern Med. 2006;166: Community based care transitions program. Center for Medicaid and Medicare Innovation. Available from: Accessed 4 April Cutler TW. The pharmacy profession and health care reform: Opportunities and challenges during the next decade. J Am Pharm Assoc (2003). 2011;51(4): References Jack BW, ChettyVK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med. 2009;150: Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for medicare beneficiaries by race and site of care. JAMA. 2011;305(7): The health reform law section by section. Bricker and Eckler Attorney's at Law. Available from : Accessed 3 April Kangovi S, Grande D. Hospital Readmissions-not just a measure of quality. JAMA. 2011;306(16): Medicare hospital readmissions. Center for Medicare Advocacy, Inc. Available from: Accessed 15 April Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4): References Örnek T, Tor M, Altın R, Atalay F, Geredeli E, Soylu O, et al. Clinical factors affecting the direct cost of patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Int J Med Sci. 2012;9(4): Pasquale MK, Sun SX, Song F, Hartnett HJ, Stemkowski SA. Impact of exacerbations on health care cost and resource utilization in chronic obstructive pulmonary disease patients with chronic bronchitis from a predominantly Medicare population. International Journal of COPD 2012: Report to congress: promoting greater efficiency in medicare. Medicare Payment Advisory Commission. Available from: Accessed 15 April Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166: Wiggins BS, Rodgers JE, DiDomenico RJ, Cook AM, Page RL. Discharge Counseling for Patients with Heart Failure or Myocardial Infarction: A Best Practices Model Developed by Members of the American College of Clinical Pharmacy s Cardiology Practice and Research Network Based on the Hospital to Home (H2H) Initiative. Pharmacotherapy Questions? 5

Group Discussion Groups of 5 Brainstorm changes you can implement at your own practice site Write them out on the provided sheet and hang around the room Share ideas References The Affordable Care

Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION

Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION At the end of this session, you will be able to: Identify ways RT skills can be utilized for