Post Discharge Pharmacy Phone Calls. Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist

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1 Post Discharge Pharmacy Phone Calls Don Julian, RPh Pharmacy Director Deon Neal, Pharm D, Pharmacy Safety Specialist

2 St. Mary s Medical Center Member of Ascension Health Number of Available Beds: 509 Admissions: 16,880 Outpatient visits: 646,767 (includes Outpatient Surgery) Number of Births: 1,411 Emergency Room Visits: 55,656 Surgical visits: 4,528 (inpatient only) Employees: 3,685

3 Care Transitions Goal: Reduce All Cause Readmissions for patients with a principle diagnosis of heart failure by 2% Steering Committee Approve and facilitate change; provide thought leadership; ensure connections among work groups. Team Members: Cardiac Telemetry, Home Health, OVHC, Case Management, Pharmacy, Social Work, Quality, Priority Care, Medical Nursing, Cardiac Rehab Focus Area Follow Up Care Cindy Whittinghill Focus Area Medication Education/ Compliance Don Julian Focus Area Early Discharge Planning Tracy MacGregor Focus Area Patient/Family Engagement/ Education Dawn Worman Improve home health screening and referral process Update home health plan of care for HF Ensure timely physician follow up appt in 5-7 days Improve coordination of care with SNF and LTC Test coaching methodology using pharmacy students Conduct pre discharge visit for medication reconciliation & education Conduct post DC phone call Identify anticipated DC date & post on whiteboard Trial rounding with physicians Interview Readmissions and intensify DC planning process Implement teach back methodology across CV services: Educate staff using scenarios and modeling Update DC Phone Call Tool Update patient education materials

4 Assemble Team Safety Coordinator (Pharmacy) Clinical Manager (Pharmacy) Student Preceptor Coordinator (Pharmacy) Cardiac Rehab Staff Nurse (Nursing) Director of Cardiac Unit (Nursing) Exec Director Pharmacy / Patient Flow Pharmacy Student

5 Team Education (Understanding Care Transitions & GWTG Models) Define Ideal State Hospital Visit (introduction to program and personal heath record) Follow-up home visit within hours of discharge Three follow-up phone calls (2, 7, and 14 days post discharge) Personal Heath Record Four pillars (patient fills out during home visit) Medication self-management Dynamic patient centered record Follow-up Red flags Coaching patient to take charge of their own healthcare Help smooth the transition from Hospital to home Empower patients to manage their own health care and contact health care providers when needed Support for patient and source of information NOT the care provider Help develop questions and concerns

6 Team Education Barriers to Ideal State Resources, Resources, Resources Define Available Resources Clinical Pharmacists Students Determine Qualifiers Cardiac Unit Patients Only Patients Discharged M TH Only (No Weekend Discharges will be Covered, unless already visited) No nursing home patients or those that are unable to communicate through a phone Current post discharge follow-up process used by Cardiac Rehab Team will not change

7 Develop Pilot Goals Decrease Readmissions (overarching) Calls Made Within 72 hours of Discharge Review Patient Discharge Home Medications Review Follow-up Appointment with Primary Care Physician (date/time) Portability between students (easy training / start-up) Team Meetings Meet regularly to discuss problems identified and ways to improve overall process

8 Tool Kit Concept Two copies Contents Process Overview Forms Scripting Tools Additional Resources

9 Process Review (Identification and Review) Patient Identification Cardiac Rehab Census List Patient Tracking Form Chart Review (15 minutes) Face Sheet H&P Home Medication List Active Pharmacy Drug Profile

10 Process Review In Hospital Visit (15 minutes) Ideally Done on First Full Day of Admission Introduction Purpose of Meeting / Call (prevent readmission) Use of Medication Profile Card Verify Best Time to Call Ask Patient to Gather Lists and Bottles When They Are At Home Commitment to Call

11 Process Review Phone Call (30 Minutes) Ask Patient to Gather Med Related Items Medication Card Prescription Bottles Discharge Summary Info Blank Piece of Paper (for questions) Review Discharge Med List Open Ended Questions Indication How They Take Special Instructions

12 Process Review Phone Call (30 Minutes) General Question and Answer (Counseling if needed) Did They Have Prescriptions Filled, Any Barriers (cost, transportation, etc) Verify Follow-up Physician Appointments Verify Patient checking on weight and what to do for increases When should they call a doctor? Encourage Use of Medication Profile Card

13 Pilot Results Number Of Patients Visited In Hospital: 42 Number of successful calls after discharge: 29 Number of interventions: 40 Number of interventions per patient: 1.37 Follow-up physician appt. made: 15 Patient satisfied with phone call: 27 Readmission within 30 days: 1

14 Pharmacy Related Interventions Missing Prescriptions Discrepancies in Med Start Date and Dose Patient Continuing To Take Contraindicated Medication Counseling on Smoking Cessation Encouraging Use of Weekly Pill Planner Counseling on importance diet (low salt, diabetic) Encouraging Patients to Contact Physician for Issues Potentially Related to Medications (Fatigue, Continuing Specific Meds)

15 Pilot Findings Most benefit when comparing Rx bottles to new home med list Lack of new medication prescribed (either due to cost or lack of prescription) Still taking medication that was discontinued in the hospital either due to name confusion or because still with all other bottles Different doses from hospital to prescription bottles Patients are unaware of indication for medication and need counseling on many home medications Patients may not have scales at home Patients are not making their follow-up appointments

16 Looking Forward Make a continual process to reach more HF patients Include both 6th year pharmacy students and pharmacists (pharmacists to provide gap coverage when no student) Dedicated pharmacy student rotation (Purdue) for three months of the year for Care Transitions (discharge medication management) Expand Program Other Disease States All Patients > 65 yo All Patients (any age) taking > 10 home medications

17 Care Transitions Results Care Transitions Heart Failure Performance Measurement Outcome Measures: Source data: Premier Quality Manager Target Benc hmark s-qio or CMS Jan- Jun 2009 Jul- 09 Aug- 09 Sep- 09 Oct- 09 Nov- 09 Dec- 09 Jan day Readmissions- all dx, all cause, all payor < 8.1% 10.4 % 10.3% 10.3% 8.7% 9.1% 8.8% 9.7% 9.4% 30 day Readmissions- all dx, all cause, Medicare <13.5 % 17.6 % 14.5 % 16.8% 16.3% 10.5% 13.7% 13.1% 14.0% 12.4% Number of Patients dc'd with Principal Dx of HF (Premier- pt details) d Readmissions- 1st Adm HF, Readmit all cause, all payor 30d Readmission- 1st Adm HF, Readmit all cause, Medicare <19% 24.5% 23.8 % 25.7% 28.1% 8.7% 36.1% 25.0% 14.0% 18.4% 22.3 % 30.8% 33.3% 11.8% 42.9% 25.0% 14.3% 21.4%

18 Revised Med Rec Forms Implemented New Reconciliation Form on 4/13/10. Designed to be used internally and given to patient Avoids potential errors related to transcription Larger Font, Plain Language replaces Medical Terminology Incorporates Discharge Instruction Forms that were given to patient apart from med reconciliation

19 Revised Med Rec Forms Patient and pharmacy student caller have same form and can discuss specific changes and annotations

20 SMMC Post Discharge Rx Calls Questions?

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