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

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 Includes: 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 www.safetyandquality.org/internet/safety/publishing.nsf/Content/ 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 Hospital Patient Hospice Home Rehabilitation Outpatient Behavioral Health Services

8. PCP

9. Specialty

10. Pharmacy

11. Case Mgr.

12. Care GiverPatient ER ICU In-Patient SNF ALF Patient

14. PCP

15. Specialty

16. Pharmacy

17. Case Mgr.

18. Care GiverPatient ER ICU In-Patient SNF ALF Patient

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 Hospital 11% 16% 10% Nursing Facility Hospital or TCU 74% 77% 13% 64% Home TCU = Transitional Care Unit Coleman EA et al. Health Svcs Research 2004;37:1423-40

25. Predictors of Complicated Care Transitions Heart disease Diabetes # 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

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) Results: 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 Meta-analysis 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 Results 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)

50. NTOCC: Barriers and Gaps in Supporting Transitions of Care

51. The Leapfrog Group Study: CPOE Survey Period: June 2008-January 2010 http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf

52. The Leapfrog Group (cont.) Survey Period: June 2008-January 2010 http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf

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://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm

59. Working to Address the Issues www.ntocc.org

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. www.ntocc.org

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