Fasten Your Seatbelts Dr. Paul declares that she has no - PDF document

1/24/2018 Disclosures • Amy Paul, PharmD Fasten Your Seatbelts • Dr. Paul declares that she has no relationships pertinent to this activity Utilizing Transitions of Care to Avoid a Med Wreck Amy Paul, PharmD Tiffany Rudisill, CPhT Clinical Pharmacist Pharmacy Technician • Tiffany Rudisill, CPhT Providence Primary Care Providence Primary Care amy.paul@providence.org tiffany.Rudisill@providence.org • Ms. Rudisill declares that she has no relationships pertinent to this activity Alaska Pharmacists Association 52 nd Annual Convention and Tradeshow February 11, 2018 Providence Patient Centered Objectives Medical Home Model • Define transitions of care (TOC) • Discuss the significance of TOC • Identify fundamental components of a TOC encounter and opportunities for pharmacist and technician interventions https://pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care Prescription Drug Use in the U.S. NCHS, Health, United States, 2016 , Figure 15. Data from the National Health and Nutrition Examination Survey (NHANES) 1

1/24/2018 Risk Factors for Medication Consequences of Errors Medication Errors Patient Associated Provider Associated Inpatient • Low health literacy • Poor communication Errors • Polypharmacy • Inadequate perception Hospitalizations of risk • Language barriers • Inadequate knowledge • Age of the patient ED Visits • Multiple comorbidities • Provider fatigue Ambulatory Events Budnitz et al. JAMA. 2006;296:1858-1866 www.who.int/patientsafety Gandhi et al. N Engl J Med. 2003;348:1556-1564 https://psnet.ahrq.gov/primers/primer/23/medication-errors Brake Check What is Transitions of Care? • The term “transitions of care” refers exclusively to • The movement of a patient from one setting of care the movement of patients from the hospital to an to another ambulatory setting. • Hospital • Ambulatory primary care practice • Ambulatory specialty care practice A. True • Long-term care B. False • Home health • Rehabilitation facility • Pharmacy to pharmacy? www.cms.gov www.ahrq.gov www.jointcommission.org What is Transitions of Care Why Does it Matter? to You? Improving health and patient safety • How many of you currently perform transitions of care activities in your practice setting? • What are some barriers to performing transitions of Reducing healthcare costs care in your practice setting? 2

1/24/2018 Why Does it Matter? Why Does It Matter? • Quality Metrics Health Care Reform • Joint Commission • Centers for Medicare & Medicaid • HCAHPS Survey Accountable Care Organizations Medicare Shared Savings Program • NCQA Healthcare Effectiveness Data & Information Set • Plan All-Cause Readmissions Fee for Service Meaningful Use • Medication Reconciliation Measure vs. • Physician Consortium for Performance Improvement Pay for Performance Federal Readmissions Reduction Program www.medicare.gov https://www.ahrq.gov/topics/hospital-readmissions.html HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems NCQA: National Committee for Quality Assurance Brake Check • Which of the following patients are appropriate for a transitions of care encounter? A. A woman with dementia transferred from a skilled nursing facility to the hospital Building a Strong Foundation B. A man seeking specialty treatment from a neurologist C. A patient being transferred from the ICU to the floor Medication Reconciliation D. A patient being discharged from home health services E. All of the above Medication Reconciliation Medication Reconciliation • Definition • The process of identifying the most accurate list possible of all medications a patient is taking – including: • Drug name This includes over the counter supplements and • Dosage nonprescription products! • Frequency • Route • Indication? by comparing the medical record to an external list obtained from a patient, transfer, or discharge orders. • This process should occur any time there is a change in therapy or patient status www.cms.gov Voss et al. Arch Intern Med. 2011;171:1232-7. http://www.ihi.org/Topics/ADEsMedicationReconciliation/Pages/default.aspx 3

1/24/2018 Medication Reconciliation Medication Reconciliation • Goal • To use the information obtained within and across the continuum of care to ensure safe and effective medication use, avoiding: • Omissions • Duplications • Dosing errors Develop a • Drug interactions list of current as well as to observe compliance and adherence patterns. medications www.cms.gov Voss et al. Arch Intern Med. 2011;171:1232-7. www.jointcommission.org http://www.ihi.org/Topics/ADEsMedicationReconciliation/Pages/default.aspx Ask the right questions Medication Reconciliation Closed-Ended Open-Ended • Do you take this for… • What do you take for… • You take this 2 times • How do you take… per day, right? • How often do you… • Do you ever… • What questions do you Develop a list Develop a list Compare the of current of medications medications • Do you have any have for me? medications to be on the two prescribed lists questions? www.jointcommission.org Develop and Compare Medication Reconciliation • Prescribed vs. Taking • Medications held • Temporary or as needed orders Develop a list Develop a list Compare the Make clinical of current of medications medications decisions medications to be on the two based on the prescribed lists comparison • Anticipate needs www.jointcommission.org 4

1/24/2018 Make Clinical Decisions Medication Reconciliation • Duplications in therapy • Sub or supra-therapeutic doses • Therapeutic substitutions Develop a list Develop a list Compare the Make clinical Communicate of current of medications medications decisions the new list to medications to be on the two based on the appropriate prescribed lists comparison caregivers and • Patient education the patient www.jointcommission.org Communication Brake Check • Which of the following is an open-ended question? Provider Patient A. Do you take this medication twice daily? • Medication Action Plan • Chart note B. Do you ever miss a dose of medication? • Pharmacy Communication • Personal Medication Record C. What questions do you have for me? • Curbside D. Are you taking this for diabetes? E. None of the above Sorry I missed you, but here’s a note of important things from my visit! Patient Name: Medication Concerns: Refills Needed: Time: Patient seen by: Patient is: Back in the Lobby or Exam Rm TOC Opportunities for Pharmacy Medication Education Chronic Therapeutic Disease State Interchange Management Making Meaningful Pharmacists & Interventions Pharmacy Technicians Lab Targeted Monitoring Services Screening 5

1/24/2018 Medication Education Medication Education • JW is a 52 year old male who is a regular at your • Medication timing pharmacy. He complains of constant fatigue due to lack of restful sleep. He has never had an issue with • Medication indication insomnia in the past. He is up three to four times per night to use the bathroom. When prompted as to what time of day he takes his furosemide, he • Inhaler technique states that he takes ALL of his medications before bed. • Insulin administration TOC Opportunities for Chronic Disease State Pharmacy Management Medication • RP is a 29 year old male with a history of type 2 Education diabetes mellitus who presents to your clinic to Chronic establish care. He does not check his blood sugars Therapeutic Disease State Interchange Management regularly at home. When asked how often he takes Pharmacists his metformin, he states that he only takes it when & he “feels” that his blood sugars are high or he eats Pharmacy a meal that is high in protein. Technicians Lab Targeted Monitoring Services Screening TOC Opportunities for Chronic Disease State Pharmacy Management Medication • Diabetes • COPD/Asthma Education Chronic Therapeutic Disease State Interchange Management • Hypertension • Anticoagulation Pharmacists & • Depression • Congestive heart Pharmacy Technicians failure Lab Targeted Monitoring Services Screening 6

1/24/2018 Lab Monitoring Lab Monitoring • Therapeutic drug levels • AV is a 28 year old female presenting to your clinic to establish care with the psychiatric nurse practitioner. She has been taking lithium for three • Renal function years. She states that over the past few months she has developed some visual disturbance and • Liver function difficulty maintaining her balance. • Electrolytes • Hemoglobin A1c TOC Opportunities for Screening & Targeted Services Pharmacy Medication • SS is a 21 year old female who is admitted to your Education facility for suicidal ideation. She states she has Chronic been prescribed venlafaxine for her depression, Therapeutic Disease State Interchange Management but has not been taking it for the past month due Pharmacists to the fact that she lost her job and no longer & receives prescription benefits. Pharmacy Technicians Lab Targeted Monitoring Services Screening TOC Opportunities for Screening & Targeted Services Pharmacy • PHQ-9 Medication Education Chronic Therapeutic Disease State • Financial services Interchange Management Pharmacists & • Nurse Case Management Pharmacy Technicians Lab • Social Work Targeted Monitoring Services Screening 7