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Presented at the St. Louis College of Pharmacy Medication Safety Forum
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Transitions of Care and Medication Safety
H. Edward Davidson, PharmD, MPH
Assistant Professor, Internal MedicineEastern Virginia Medical School
Partner, Insight Therapeutics, LLC
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
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 transitionColeman E, et al. J Am Geriatr Soc 2003;51:556-7.
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
Responsibilities of Health Professionals For Patients in
Transition •Stable
for transfer
•Patient/caregiver understand and are prepared
•Transfer information is complete
•Contact person’s name and number
Sending health care
team
•Review transfer information promptly and clarify
•Incorporate patient’s goals/preferences in care plan
•Document contact information
Receiving health care
team
(c) Eric A. Coleman, MD, MPH
Fundamental Disconnect…
Rehabilitation
HospiceHome
Ambulatory CareHospital
Nursing Facility
Patient
Outpatient Behavioral
Health Services
Transition Issues Dramatically Impact Patient
Care
PatientPatient
ERER ICUICU
In-PatientIn-Patient
PatientPatient
OUTPATIENT:• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver
OUTPATIENT:• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver
SNFSNF ALFALF
Transition Issues Dramatically Impact Patient
Care
Patient
ER ICU
In-Patient
Patient
OUTPATIENT:• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver
SNF ALF
NOMedication
Reconciliation
NOPersonal
Medicine List
NO Coordinated
Care Plan
NODischargeCare Plan
NO Care Plan
NO Medication Reconciliation
NO Personal Medicine List
NO Care Plan
NO Medication Reconciliation
NO Personal Medicine List
Barriers to Care Coordination
System level
barriers
Practitioner level barriers
Patient level
barriers
(c) Eric A. Coleman, MD, MPH
System Level Barriers
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
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
The Epidemiology of Transitions of Care
Care Transitions Following Acute Care
Hospital
Home64%
77%13%
11%
Nursing
Facility
Hospital or TCU
16% 10%
74%
TCU = Transitional Care UnitColeman EA et al. Health Svcs Research 2004;37:1423-40
Predictors of Complicated Care Transitions
Heart disease Diabetes # of prior
hospitalizations Visual impairment Medicaid recipient Prior stroke
Coleman EA et al. Health Svcs Research 2004;37:1423-40.
Incr
easi
ng
Ris
k
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
Cornish PL et al. Arch Intern Med 2005;165:424-9.
*Discrepancy defined as error between admission medication orders and patient interview of medication history.
Hospital Discharge
On discharge from the hospital
with possible or probable patient discomfort or clinical deterioration
* Most common discrepancy is incomplete prescription requiring clarification.
Wong JD, et al. Ann Pharmacother 2008;42:1373-9.
30% of patients have at least one medication discrepancy *
AHRQ Hospital Survey on Patient Safety Culture: 2007
Report
Hospital to Home
40% of patients experienced at least 1 medical error
Moore C et al. J Gen Intern Med 2003;18:646-51.
*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).
Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 months
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
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.
The infant was discharged to home with Mom in car seat
Independent Risk Factors for Having a Preventable ADE in
NFs
Risk FactorOdds Ratio 95% CI
Male 0.55 0.30 - 0.99No. regularly scheduled meds
0-45-67-8>=9
1.01.73.22.9
Referent0.83 - 3.51.4 - 6.91.3 - 6.8
New resident+ 2.9 1.5 -5.7
+within 60 days of admission
Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.
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 eventBoockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.
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.
Patient-Level Contributing Factors
Non-intentional nonadherence 34%
Money/financial barriers 6%
Intentional nonadherence 5%
Didn’t fill prescription 5%
Other 1%
Subtotal 51%
Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.
System-Level Contributing Factors
D/C instructions incomplete/illegible
16%
Conflicting info from different sources
15%
Duplicative prescribing 8%
Incorrect label 4%
Other 7%
Subtotal 49%
Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.
Examples of Duplicative Prescribing
Institute for Safe Medication Practices
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
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.
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
Medication Errors Involving Reconciliation Failure
September 2004 – July 2005 MEDMARX Data (N=2022)
Site of Error
Admission Transition Discharge
Total 23% 67% 12%
U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
Medication Error Type by Transition Category
Transition Category
Error Type AdmissionTransitio
nDischarg
e
Improper Dose/Quantity
55% 73% 62%
Prescribing Error 49% 36% 27%
Omission Error 35% 36% 76%
U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
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.
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.
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.
Study Outcomes: Pharmacist Intervention vs Usual Care
Outcome*
Pharmacist Intervention
(n=92)
Usual Care
(n=84) P ValueAdverse drug events, No. (%)
All 14/79 (18) 12/73 (16) >.99
Preventable 1/79 (1) 8/73 (11) .01
Health Care Utilization, No. (%)
ED visit or readmission 28/92 (30) 25/84 (30) >.99
Medication-related 4/92 (4) 8/84 (8) .36
Preventable medication-related
1/92 (1) 7/84 (8) .03
*Outcomes 30 days postdischarge
Schnipper JL et al. Arch Intern Med 2006;166:565-71.
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)
NTOCC: Barriers and Gaps in Supporting Transitions of Care
Lack of Connectivity
Lack of Shared Goals
Misaligned Incentives
Consumer Knowledge
Issues of Trust
The Leapfrog Group Study: CPOE
Hospital Type
# of medication
orders processed
% of medication orders that did not
receive an appropriate warning
Adult Hospitals (n=187) 8,716 52%
Pediatric Hospitals (n=37) 1,731 42.1%
Survey Period: June 2008-January 2010
http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf
The Leapfrog Group (cont.)
Hospital Type
# of potentially fatal errors processed
% of potentially fatal orders that did not
receive an appropriate warning
Adult Hospitals (n=187) 311 32.8%
Pediatric Hospitals (n=37) 62 33.9
Survey Period: June 2008-January 2010
http://www.leapfroggroup.org/media/file/NewCPOEEvaluationToolResultsReport.pdf
Snow V et al. J Gen Intern Med 2009;24:971-6.
“Ideal Transition Record”(ACP, SGIM, SHM, AGS, ACEP, and
SAEM)
1. Primary, secondary diagnoses and problems list2. Medication list (reconciliation) including
OTC/other 3. Treatment and diagnostic plan 4. Clearly identifiable medical home/coordinating
and transferring MD/institution and contact information
5. Prognosis and outcome goals 6. Test results (available and pending)7. Patient cognitive status8. Advance directives, power of attorney, consent9. Planned interventions, med equipment, wound
care10. Emergency plan, contact information 11. Assessment of caregiver status
National Efforts
A Report from the HMO Care Management Workgroup
Supported by the Robert Wood Johnson Foundation
One Patient, Many Places:Managing Health Care
Transitions
Medication List Toolkit
CMS 9th Scope of Work
Care Coordination (3 measures)1) Global re-hospitalization rate2) Patient assessment of hospital discharge
performance (H-CAHPS items 17, 19, 20)3) Physician visit postdischarge, before re-
admission (within 30 days)
The Care Transitions Theme focuses on improving coordination across the continuum of care.
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
Working to Address the Issues
www.ntocc.org
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
www.ntocc.org
Other Organizations at Work
Society of Hospital Medicine (Boost)
Boston Medical Center (Project
RED)
Centers for Medicare & Medicaid Services
American Medical
Directors Association
American College of Physicians
RAND – ACOVE measures
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