This document discusses a proposal to utilize care management nurses to improve care transitions for high-risk congestive heart failure (CHF) patients in the outpatient setting. It identifies opportunities to improve medication reconciliation and CHF education using teach-back methods. A literature review supports interventions like medication reconciliation, care coordination, CHF education and post-discharge follow up to reduce readmissions. The proposal is to pilot this approach for CHF patients through a microsystem project using a PDSA framework to study workflows and standardized processes for assessments, education and medication reconciliation across care transitions.

1. UTILIZING CARE MANAGEMENT
NURSES TO IMPROVE TRANSITIONS
IN CARE IN THE OUTPATIENT SETTING
FOR HIGH RISK CHF PATIENTS
TANISHA R. DAVIS, BSN, RN, CCRN
UNIVERSITY OF PITTSBURGH/ UPMC HEALTH PLAN
PITTSBURGH, PA

2. Objectives
 Overview of Workflow Analysis
 Review of Quality Improvement Opportunities
 Review of Literature for med rec
 Overview of current recommended tools for med rec
 Review of Literature for care transitions
 Overview of current recommended tools for care transitions
 Review of Literature for CHF
 Review of Literature for CHF education
 Review of Microsystem Proposal
 Review future implementation of microsystem project needed

3. Work Flow Analysis

4. Areas with Quality Improvement
Opportunities
 Medication Reconciliation
 Performed:
 Admission assessment
 Prior to discharge
 24-48 hour post discharge phone call
 Compare to BEERS list
 CHF patient (pilot)specific education using teach back method
 Utilize current CMS approved CHF Fact Sheet
 All Care Managers giving the same education as health coaches to promote patient retention of information
 Address patient concerns for meds and f/u for CHF within IDT rounds weekly to promote transparency
 Work with SNF admin to add “potential discharges” to all daily census sheets to care managers to
promote better time utilization and so patients are not d/c before medication reonciliation is complete
and issues are addressed with IDT

5. Review of the Literature—Med Rec
 Approximately half of hospital related medication errors and 20 percent of adverse drug events are due to poor
communication at transitions. (Stratis Healthcare, 2014)
 As you get older your body changes and the risk of side effects with medication increases. Older adults have more health
problems and take more medication than younger adults. Annually, one in three older adults has an adverse drug reaction
(AGS, 2015).
 Recommendations to prevent errors:
 Implement interventions to assure indications and diagnoses are documented for all prescribed medications.
 Increase pharmacy’s role in medication reconciliation during transitions of care.
 Implement an interdisciplinary approach to medication reconciliation—which includes hospital, nursing home, and pharmacy—
that occurs before or during the care transition
 Prompt and consistent medication reconciliation at every transition point, as well as proper planning to ensure no discrepancies
in administration of medication (American Medical Directors Association, 2010).
 Retention of responsibility for the patient by the sending entity (ACH, SNF/NF, ED) until assumption of care by the receiving
entity, and availability to respond to clinical inquiries from the receiving entity (American Medical Directors Association, 2010).
 Utilize Beer’s List pocket guide or smart phone app to review patient mediations

6. Medication Discrepancy Causes and Contributing Factors
System- and Patient-Level Definitions
Patient-Level Discrepancies System-Level Medication Discrepancies
1. Adverse drug reaction or side effect 1. Prescribed with known allergy/ intolerance
2. Intolerance 2. Discharge instructions incomplete/ inaccurate/illegible
3. Did not fill prescription 3. Duplication (taking multiple drugs with the same action without rationale)
4. Patient feels they do not need prescription 4. Incorrect label
5. Money/financial barriers 5. Incorrect dosage
6. Intentional nonadherence (I was told to take this medication but I choose
not to)
6. Incorrect quantity
7. Nonintentional nonadherence (e.g., knowledge deficit: I don’t under- stand
how to take this medication)
7. Cognitive impairment not recognized
8. Performance deficit (e.g., maybe someone showed me but I can’t
demonstrate that I can)
8. No caregiver/ need for assistance recognized
9. Slight/dexterity limitations not recognized
Source: Coleman Medication DiscrepancyTool (MDT). http://
www.caretransitions.org. Eric Coleman, MD, MPH.

7. Question Motivation Knowledge
1. Do you ever forget to take your medicine? Yes(0) No(1)
2. Are you careless at times about taking your medicine? Yes(0) No(1)
3. When you feel better do you sometimes stop taking your medicine? Yes(0) No(1)
4. Sometimes if you feel worse when you take your medicine, do you stop taking it? Yes(0) No(1)
5. Do you know the long- term benefit of taking your medicine as told to you by your doctor or
pharmacist?
Yes(1) No(0)
6. Sometimes do you forget to refill your prescription medicine on time? Yes(0) No(1)
Table 4. Modified Morisky Scale (1)
Modified Morisky Scale – a validated, evidence-based tool (Morisky 1983)

8. Review of the Literature—transitions in
care
 Initiate and maintain collaboration between the SNF and the local contact agency to support the resident’s
transition to community living, as applicable, including making referrals to community resources under the
State regulations ; and assisting the resident and family/caregivers in coordinating post-discharge services
(CMS, 2014).
 A randomized controlled trial using a collaborative medication management process between a clinical
pharmacist and home healthcare nurses significantly reduced the incidence of therapeutic duplication in the
cohort (Myrka et al., 2002).
 Providing adequate patient education (CMS, 2002).
 Hospital readmissions may result from failures in communication as well as from poor coordination of services,
incomplete treatment, incomplete discharge planning, and/or inadequate access to care(Mansukhani et al.,
2015).
 Boston University Medical Center, ReEngineered Discharge (RED) intervention has 12 components, including establishing
follow-up appointments, confirming medication reconciliation, conducting patient education, and coordinating the care
provided by nurse discharge advocates (Mansukhani et al., 2015).

9. Low Risk Discharge
Independent in ADL’s
⦁ Caregivers in the home and available to
assist
⦁ Lives alone with community support
⦁ Independent with management of chronic
disease/ meds
⦁ Adherent to treatment plan
⦁ Able to direct medical care
⦁ Consistently followed by MD/Practitioner
Moderate Risk Discharge
▪ Lives alone with limited community support
▪ Requires assistance with medications
▪ Issues of health literacy
▪ History of mental illness Polypharmacy (greater than 7 meds)
▪ Requires temporary assistance with IADL’s and ADL’s
▪ Requires assistance in:
• Ambulating
• Transferring
• Wound Care
• Management of oxygen and/ or nebulizer If 2 then refer to home
healthcare agency
▪
High Risk Discharge
▪ Lives alone with no community support
▪ Lives with family that is not actively involved in care
▪ Clinically complex (multiple co-morbidities, repeat hospitalizations or ED visits, needs
considerable assistance to manage or is unable to manage medical needs independently)
▪ History of falls
▪ Acute/chronic wound or pressure ulcer
▪ Incontinent
▪ Cognitive impairment
▪ History of mental illness
▪ CHF and/or COPD and/or diabetes and/or HIV/AIDS
▪ End stage condition
▪ Requires considerable assistance in:
• Transferring
• Ambulating
• Medication management (greater than 7 meds)
• Management of oxygen and/or nebulizer If 4 then refer to home healthcare agency upon
pa- tient admission to hospital
▪
Discharge to Community
Refer to home care services (Including
patients who reside in Adult Home or
Assisted Living Facility)
Refer to home care services for:
Patient received services from home care prior to hospitalization?
■ Yes ■ No If Yes, name of agency:
Skilled Nursing
• Observation and assessment
• Teaching and training
• Performance of skilled treatment or procedure
• Management and evaluation of a client care plan AND/OR
• Physical, occupational and/or speech therapy
• medical social work
• Home healthcare aide service for personal care and/or therapeutic exercises
• Telehealth Care Management
This patient is high risk for
rehospitalization. Refer to home care
services immediately
Source: IPRO for CMS

10. Y N Does the patient/client have a primary care physician? (if appropriate) Send assessment information to PCP – Date
Y N Does the patient/client have a specialty physician, e.g., cardiologist? (if appropriate) Send assessment information – Date
Y N Does the patient/client have a psychiatrist or other mental health provider? (if appropriate) Send assessment information – Date
Y N Does the patient/client have an outpatient case manager who should be notified? Send assessment information – Date
Y N Ensure all transition services and care (medications, equipment, home care, SNF, hospice) are coordinated and documented – Date verified
Y N Ensure patient/client and caregiver understand all information and have a copy of the care plan with them – Date verified
Hand off all assessments to the next level of care coordination
CONTINUITY/COORDINATION OF CARE:
CMAG 2006

11. Literature Review-CHF
 A Randomized controlled trial to determine whether there was a significant difference
within-30-day readmission rates between patients receiving usual care post-discharge
and those receiving intervention from an MSW intern (one home visit and one to two
phone calls) showed over 20% reduction in 30-day hospital readmission rates
(Bronstein et al.,2015).
 A randomized controlled study of CHF patients readmitted to hospitals, factors
associated with an increased risk of hospitalization for CHF were: age, living alone,
those with a sedentary lifestyle and the presence of multiple co-morbid conditions
(Betihavas et al., 2015).
 A study done on automated discharge follow up phone calls, with patients self-rating
their health status indicated 89 patients exhibiting a negative response trend, 37%
were readmitted. By contrast, the 97 patients showing a positive trend and the 329
patients showing a neutral trend were readmitted at rates of 16% and 14%
respectively(Inouye et al., 2015).

12. Literature Review-CHF education
 Low patient oral and aural literacy are associated with poor health outcomes.
 Use of plain language and teach-back, as well as future research, are recommended
(Nouri &Rudd, 2015).
 Meta-analyses completed on disease management programs from 2007-2010 shows
that therapeutic patient education by trained healthcare professionals for CHF patients
appears associated with lower all-cause mortality (Juilliere et al.,2013).
 In a prospective cohort study of CHF patients, the teach-back method was identified as
an effective method used to educate and assess learning. Patients educated longer
retained significantly more information than did patients with briefer teaching and
were associated with reductions in 30-day hospital readmission rates (White et al.,
2013).

13. Microsystem Proposal
 Utilizing a Plan, Do, Study, Act (PDSA) framework, a work flow analysis was
performed and analyzed to assess transitions in care for a large, metropolitan
hospital system’s health plan members in Western PA. The assessment and
discharge processes are standardized within the health plans electronic health
record system. In the pilot study, all CHF patients will have a risk for readmission
assessment, receive disease specific patient education via the teach back method
and will receive multiple medication reconciliation assessments at key care
transitions points. Within the 13 skilled nursing facilities that house health plan
members, the care managers are utilized to the full scope of their abilities to
promote quality care. An in-service, staff education session specific to CHF with
weekly follow up sessions with the CNL were utilized to promote staff compliance.

14. Future implementation of microsystem
project needed
 Staff education
 Risk assessment tool
 CHF education for patients (CHF FACT Sheet recommended with daily weight
form)
 Implementation of project
 Analysis of pilot study results
 Expansion into other high risk disease states: DM, COPD…

15. References:
 American Geriatric Society (2015). Identifying Medications that Older Adults Should Avoid or use with Caution: The 2012 American Geriatrics Society Updated Beers Criteria. Accessed 03 Nov 2015, retrieved from:
http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf
 American Medical Directors Association (2010). Improving Care Transitions between the Nursing Facility and the Acute Care Hospital Setting. Accessed 02 Nov 2015, retrieved from:
https://www.nhqualitycampaign.org/files/Transition_of_Care_Reference.pdf
 Betihavas, V., Frost, S., Newton, P., Macdonald, P., Stewart, S., et al (2015). An Absolute Risk Prediction Model to Determine Unplanned Cardiovascular Readmissions for Adults with Chronic Heart Failure. Heart,
Lung and Circulation. (24)11:1068-1073.
 Bronstein, L., Gould, P., Berkowitz, S., James, G. and Marks, K. (2015). Impact of a Social Work Care Coordination Intervention on Hospital Readmission: A Randomized Controlled Trial. Social Work 60(4)
 Centers for Medicare & Medicaid Services (2014). Discharge Planning. Accessed 02 Nov 2015, retrieved from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/Discharge-Planning-Booklet-ICN908184.pdf
 Inouye, S., Bouras, V,. Shouldis, E., Johnstone, A., Silverweig, Z., Kosuri, P. (2015). Predicting readmission of heart failure patients using automated follow-up calls. BMC Medical Informatics and Decision Making.
(15)22.
 Juillière,Y, Jourdain, P. Suty-Selton, C., Béard, T. , Berder, M., Maître, B. et al. (2013). Therapeutic patient education and all-cause mortality in patients with chronic heart failure: A propensity analysis. International
Journal of Cardiology, (168)1: 388-395.
 Mansukhani ,R. P., Bridgeman, M.B., Candelario, D., Eckert, L.J. (2015). Exploring Transitional Care: Evidence-Based Strategies for Improving Provider Communication and Reducing Readmissions. P T. 2015 Oct;
40(10): 690–694.
 Myrka, A., Butterfield, A., Goss,J., Amin, P., Ambrosy, S., Woellmer, C., and Glock, S. (2011). A System Based Medication Reconciliation Process: with implications for home health care. Wolters Kluwer Health.
Accessed 03 Nov 2015, retrieved from: http://ipro.org/wp-content/uploads/2013/04/sys_based_med_rec_process.pdf
 National Transitions of Care Coalition (2010). Improving transitions of care. Available at: http://www.ntocc.org/Portals/0/PDF/Resources/NTOCCIssueBriefs.pdf. Accessed Nov 9, 2015.
 Nouri,S., and Rudd, R. (2015). Health literacy in the “oral exchange”: An important element of patient–provider communication. 98(5): 565–571.
http://www.sciencedirect.com/science/article/pii/S0738399114005242
 Stratis Healthcare (2014). Understanding and Improving Medication Reconciliation Between Hospitals and Nursing Homes Patient Safety Risk and Cost in Care Transitions Safe Care in Transitions. Accessed 02
Nov 2015, retrieved from: https://www.google.com/search?client=safari&rls=en&q=Stratis-Health-medication-reconciliation-white-paper-2014.pdf&ie=UTF-8&oe=UTF-8
 White, M., Garbez, R., Carroll, M., Brinker, E., Howie-Esquivel, J. (2013). Is “Teach-Back” Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart Failure Patients? Journal of
Cardiovascular Nursing.(28)2: 137–146.