Cedars Sinai Medical Center (CSMC) Learning Objectives. Why Medication Reconciliation?

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1 Management Case Study: Transitions Trifecta Calibrating the Severity of Drug Related Problems, dherence, and Literacy in a High Risk Population Tuesday, December 10, :00 p.m. 2:30 p.m. Management Case Study: Transitions Trifecta Calibrating the Severity of Drug Related Problems, dherence, and Literacy in a High Risk Population Olga Zaitseva, Pharm.D. Clinical Pharmacist, Department of Pharmacy Services Rita Shane, Pharm.D., FSHP, FCSHP Director, Pharmacy Services radley T. Rosen, MD, M, FHM Director, Care Transitions and Complex Medical Management Cedars Sinai Medical Center Los ngeles, C Learning Objectives Describe the elements of a comprehensive care transitions program. Determine the value of a medication adherence and literacy algorithm. Identify metrics to evaluate the impact of the pharmacist on transitions of care. Cedars Sinai Medical Center (CSMC) Nonprofit, academic hospital 896 licensed beds Level I trauma center Comprehensive stroke center Over 100 intensive care unit beds Pharmacy Department o Decentralized clinical pharmacy services o mbulatory care clinics o Outpatient pharmacy services o Two outpatient cancer centers o Care transitions programs Why Reconciliation? Inadequate medication reconciliation during care transitions can result in adverse drug events or near misses Inpatient Specialty Program (ISP) 29 Hospitalists 10 Care Managers 9 Nurse Practitioners 1 Social Worker 1 Home Health Liaison 1 Physical Therapist Pharmacy Department 1 Clinical Pharmacist 1 Pharmacy Technician Up to 67% of admitted patients have medication discrepancies which can be clinically significant¹ Comprehensive Care Transitions 1. Kwan J, Lo L, Sampson M, Shojania K. reconciliation during transitions of care as a patient safety strategy. nn Intern Med. 2013;158: merican Society of Health-System Pharmacists 1

2 Pharmacist Performing Comprehensive Care Transitions Identification of High Risk Patients Identify highrisk patients Validate medication history ssess adherence and literacy Educate patient Notify MD about any problems identified along with recommendations Post Discharge follow Up within 72 Hrs: Med rec dherence & literacy reinforcement Education dditional calls up to 30 days based on risk assessment Criteria for high risk patients ge over 65 More than 10 chronic medications Therapeutic duplicates Congestive Heart Failure (CHF) Decentralized pharmacists referrals based on clinical judgment Referrals by hospitalist Reconciliation Taking an accurate preadmission medication history may be the single most important step to improving medication safety during transitions in care. It can also be the most difficult.² Validation of History Name of Frequency each medication Dosage Route Nonprescription medications Formulation 2. MRQUIS Implementation Manual Guide for Mediation Reconciliation Quality Improvement. Society of Hospital Medicine. 2011;5:49. ccurate PT medication list Sources of Information Transfer orders form other facilities Discharge med list from previous admissions Dialysis Centers Providers Pharmacies Pill bottles Med list Caregiver Patient Communication of Discrepancies Identified & Pharmacist Recommendations Enter the PT medication list into the patient s electronic medical record (EMR) Compare validated PT medication list vs. patient medication administration record (MR) Perform comprehensive evaluation of medication regimen Provide Hospitalist with an itemized list of discrepancies, along with pharmacist recommendations 2013 merican Society of Health-System Pharmacists 2

3 Literacy and dherence Increase medication literacy Increase medication adherence Measurement of dherence dherence (MMS 4) ⁴ 1. Do you ever forget to take your medicine? 2. re you careless at times about taking your medicine? 3. When you feel better do you sometimes stop taking your medicine? 4. Sometimes if you feel worse when you take the medicine, do you stop taking it? Improve clinical outcomes Lower health care spending Scoring: 1 point for every YES answer 0 High adherence 1 2 Intermediate adherence 3 4 Low adherence 3. ruce Stuart, F. Ellen Loh, Pamela Roberto and Laura M. Miller. Increasing Medicare Part D Enrollment in Therapy Management Could Improve Health and Lower Cost. Health ffairs. 2013; 32(7) Morisky D, Green L, Levine D. Concurrent and predictive validity of a self reported measure of medication adherence. Med Care. 1986;24: Measurement of Literacy Literacy 1. Name all of your medications? 2. Explain the indications for all of your medications? 3. What are the doses for all of your medications? 4. What are the frequencies for all of your medications? Scoring: 1 point for each category that patients could not answer about all of their medications 0 High literacy 1 2 Intermediate literacy 3 4 Low literacy Literacy dherence High Intermediate Low lgorithm to Determine Need for Post Discharge Follow Up High Intermediate Low No post DC f/u Educate pt. No post DC f/u Educate pt. No post DC f/u Educate pt. No post DC f/u? vs.? Use clinical judgment Patient Education Goals of therapy s Educate patient on the importance of adherence Use teach back method Use language at a 6 th grade level or below sk patient/family if any further questions Use interpreter, if necessary Post Discharge Follow Up within 72 Hours Patient discharged HOME Provide education regarding the discharge medication regimen Instruct patient to pick up new medications as soon as possible Instruct patient to take all meds as was directed at discharge Re educate patient on the importance of adherence Evaluate if patients further follow up 2013 merican Society of Health-System Pharmacists 3

4 Categorizing Interventions CSMC Derived Severity Ratings NCC MERP Index for Categorizing Errors⁵ NCC MERP Index for Categorizing Errors⁵ Life Threatening Low Capacity for Harm Serious/ Significant 5. dapted with permission: Copyright 2001 National Coordinating Council for Error Reporting and Prevention. ll Rights Reserved pdf 5. dapted with permission: Copyright 2001 National Coordinating Council for Error Reporting and Prevention. ll Rights Reserved pdf Resolution of PT List Drug Related Problems (DRPs) PT Reconciliation November 2011 March 2013 DRPs Resolved: 6,184 (803 patients) verage 7.7 DRPs/patient 54% of resolved DRPs were classified as life threatening or serious/significant 35% of inpatient orders were changed due to PT DRPs ased on risk stratification algorithm only 25% of patients had both high medication adherence and literacy Examples of PT Drug Related Problems (DRPs) Drug Related Problem DRP Type Flecainide Prednisone Mycophenolate PT List: Med not listed Finding: Pt reports taking flecainide PT List: Prednisone 20 mg daily Finding: Pt reports med was discontinued by 6 months ago PT List: Mycophenolate 360 mg ID Finding: Pt reports taking 720 mg ID Omission Extraneous Wrong Dose Capacity for Harm Life Threatening Serious/ Significant Serious/ Significant Resolution of Post discharge Drug Related Problems (DRPs) Post discharge Reconciliation January 2013 June 2013 DRPs Resolved: 601 (207 patients) verage 2.9 DRPs/patient 58% of patients had discrepancies between their discharge medication list and what they were taking 33% of patients were taking more medications than were prescribed* Estimated 16 % of patients would have been readmitted base on physician evaluation** *Excludes vitamins, herbals, OTC supplements **Validated by ISP physicians Examples of Post Discharge Follow up Reason for dmission 63 y/o F w/ h/o CHF presented with dizziness and palpations (Digoxin level 0.3 mcg/l on digoxin 125 mcg daily) 78 y/o M w/ h/o afib, HTN, HLD, DM DRPs Identified Post Discharge and Pharmacist Intervention Issue discovered: Patient did not fill prescription and resumed her old dose of digoxin 125 mcg daily and furosemide 40 mg daily Intervention: Instructed patient to take digoxin 250 mcg daily and furosemide 60 mg daily as it was prescribed at discharge Issue discovered: Patient was not receiving warfarin at SNF Intervention: Notified physician. Warfarin was restarted dverse Outcome Prevented voided potential readmission for worsening symptoms of CHF voided potential incidence of stoke 2013 merican Society of Health-System Pharmacists 4

5 Conclusions Tackling the transitions trifecta in a comprehensive manner can improve outcomes for high risk patients There is opportunity to better fine tune the process for efficiently identifying high risk patients Data collection and analytics are important to ensure the program is achieving goals Multi disciplinary, team based approach is essential, including the role of pharmacy technicians The care of the patient does not end at discharge history validation, assessment and risk stratification of the patients medication adherence and literacy, patient education, post discharge follow up, and inter professional collaboration are essential elements of a comprehensive care transitions program. history validation, assessment and risk stratification of the patients medication adherence and literacy, patient education, post discharge follow up, and inter professional collaboration are essential elements of a comprehensive care transitions program. The use of an algorithm to risk stratify patients for post discharge follow up may help to effectively deploy limited resources. The use of an algorithm to risk stratify patients for post discharge follow up may help to effectively deploy limited resources Measuring the number of drug related problems resolved and potential readmissions prevented is not important to determine the impact of pharmacists on care transitions merican Society of Health-System Pharmacists 5

6 Questions Measuring the number of drug related problems resolved and potential readmissions prevented is not important to determine the impact of pharmacists on care transitions 2013 merican Society of Health-System Pharmacists 6

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