Why are we involved? Transitions of Care: The Financial Burden and Impact on Delivery of Care

Why are we involved?

Transitions of Care: Transitions of Care: The Financial Burden The Financial Burden

and Impact on and Impact on Delivery of CareDelivery of Care

www.ntocc.orgwww.ntocc.org

Current State of HealthcareCurrent State of Healthcare

Care is complexCare is complex Care is uncoordinatedCare is uncoordinated Information is often not available to those who Information is often not available to those who

need it when they need itneed it when they need it As a result patients often do not get care they As a result patients often do not get care they

need or do get care they don’t needneed or do get care they don’t need

IOM, Crossing the Quality Chasm

What is “Transition of Care”What is “Transition of Care”

The The movement of patientsmovement of patients from one health care from one health care practitioner or setting to another as their condition and practitioner or setting to another as their condition and care needs changecare needs change

Occurs at multiple levelsOccurs at multiple levels– Within SettingsWithin Settings

Primary care Primary care Specialty care Specialty care ICU ICU Ward Ward

– Between SettingsBetween Settings Hospital Hospital Sub-acute facility Sub-acute facility Ambulatory clinic Ambulatory clinic Senior center Senior center Hospital Hospital Home Home

– Across health statesAcross health states Curative care Curative care Palliative care/Hospice Palliative care/Hospice Personal residence Personal residence Assisted living Assisted living

(c) Eric A. Coleman, MD, MPH

What is “Transitional Care?”What is “Transitional Care?”

A set of actions designed to ensure the coordination and A set of actions designed to ensure the coordination and continuity of health care as patients transfer between continuity of health care as patients transfer between different locations or different levels of care within the same different locations or different levels of care within the same locationlocation

Based on a comprehensive care plan and availability of well-Based on a comprehensive care plan and availability of well-trained practitioners that have current information about the trained practitioners that have current information about the patient's goals, preferences, and clinical status.patient's goals, preferences, and clinical status.

Includes:Includes:– Logistical arrangementsLogistical arrangements– Education of the patient and familyEducation of the patient and family– Coordination among the health professionals involved in Coordination among the health professionals involved in

the transitionthe transition

Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

Ineffective Transitions Ineffective Transitions Lead to Poor OutcomesLead to Poor Outcomes

Wrong treatmentWrong treatment Delay in diagnosisDelay in diagnosis Severe adverse eventsSevere adverse events Patient complaintsPatient complaints Increased healthcare costsIncreased healthcare costs Increased length of stayIncreased 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

PatientPatientPatientPatient

ERERERER ICUICUICUICU

In-PatientIn-PatientIn-PatientIn-Patient


OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver


SNFSNFSNFSNF ALFALFALFALF

Transition Issues Dramatically Transition Issues Dramatically Impact Patient CareImpact Patient Care

Transition Issues Dramatically Impact Transition Issues Dramatically Impact Patient CarePatient 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 Improving Barriers to Improving Transitions of CareTransitions of Care

We Need To Understand Them First!We Need To Understand Them First!

Barriers to Care CoordinationBarriers to Care Coordination

System level barriersSystem level barriers Practitioner level barriersPractitioner level barriers Patient level barriersPatient level barriers



System Level BarriersSystem Level Barriers

Practitioner Level BarriersPractitioner Level Barriers

Practitioners often have not practiced in settings Practitioners often have not practiced in settings where they transfer patientswhere they transfer patients

Sending practitioners may not communicate Sending practitioners may not communicate critical information to receiving practitionerscritical information to receiving practitioners

Practitioners may not know the patient and his Practitioners may not know the patient and his or her preferences for careor her preferences for care

Practitioners have no accountabilityPractitioners have no accountability


Patient Level BarriersPatient Level Barriers

Patients assume that someone is in charge of Patients assume that someone is in charge of coordinating carecoordinating care

Patients (and caregivers) are often the only Patients (and caregivers) are often the only common thread weaving between care sites common thread weaving between care sites

Yet they navigate the system with few tools or Yet they navigate the system with few tools or training to manage in this roletraining to manage in this role


Problems that Illustrate Problems that Illustrate Inadequacies of Care TransitionsInadequacies of Care Transitions

Medication errorsMedication errors Increased health care utilizationIncreased health care utilization Inefficient/duplicative careInefficient/duplicative care Inadequate patient/caregiver preparationInadequate patient/caregiver preparation Inadequate follow-up careInadequate follow-up care DissatisfactionDissatisfaction Litigation/Bad publicityLitigation/Bad publicity


The Facts…The Facts…

Hospital AdmissionHospital Admission

On hospital admission, more than 50% of On hospital admission, more than 50% of patients have at least one medication patients have at least one medication discrepancy*discrepancy*

– Approximately 40% of those have potential to Approximately 40% of those have potential to cause harmcause 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 DischargeHospital Discharge

On discharge from the hospital, 30% of On discharge from the hospital, 30% of patients have at least one medication patients have at least one medication discrepancy* with the potential to cause discrepancy* with the potential to cause possible or probable harmpossible or probable harm

Kwan Y et al. Arch Intern Med 2007;167:1034-40.

*Most common discrepancy is omission of pre-admit medication.

AHRQ Hospital Survey on Patient AHRQ Hospital Survey on Patient Safety Culture: 2007 ReportSafety Culture: 2007 Report

Hospital to HomeHospital to Home

40% of patients experienced at least 1 40% of patients experienced at least 1 medical errormedical error

– Those with a “work-up” error* were 6 times Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 more likely to be rehospitalized within 3 monthsmonths

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).

Hospital to PCP transferHospital to PCP transfer

Meta-analysisMeta-analysis Direct communication between hospital Direct communication between hospital

physicians and primary care physicians physicians and primary care physicians occurred infrequently occurred infrequently

Discharge summary Discharge summary – Availability at first postdischarge visit low (12%-34%) Availability at first postdischarge visit low (12%-34%) – Remained poor at 4 weeks (51%-77%)Remained poor at 4 weeks (51%-77%)– Affected quality of care in ~25% of follow-up visitsAffected quality of care in ~25% of follow-up visits– Often lacked important information (e.g., lab results, Often lacked important information (e.g., lab results,

discharge medications, treatment, follow-up plan)discharge medications, treatment, follow-up plan)

Kripalani S, et al. JAMA 2007;297:831-41.

Completing Recommended Completing Recommended Outpatient WorkupsOutpatient Workups

TotalTotal

No. (%)No. (%)

CompletedCompleted

Workup TypeWorkup Type YesYes NoNo

Diagnostic procedureDiagnostic procedure 115 (47.9)115 (47.9) 50.450.4 49.649.6

Subspecialty referralSubspecialty referral 85 (35.4)85 (35.4) 72.672.6 27.427.4

Laboratory testLaboratory test 40 (16.7)40 (16.7) 85.085.0 15.015.0

TotalTotal 240 (100)240 (100) 64.164.1 35.935.9

Moore C et al. Arch Intern Med 2007.

Workup Type is the outpatient workup recommended upon discharge from the hospital. Completed indicates whether the recommended workup was done within 6 months after discharge. 240 workups recommended in 191 discharges.

Hospital to Nursing HomeHospital to Nursing Home

Transfers and Adverse EventsTransfers and Adverse Events

Adverse drug events (ADEs) attributable to Adverse drug events (ADEs) attributable to medication changes occurred in 20% of bi-medication changes occurred in 20% of bi-directional transfersdirectional transfers

– 50% of ADEs were caused by 50% of ADEs were caused by discontinuation of medications during discontinuation of medications during hospital stayhospital stay

Boockvar K et al. Arch Intern Med 2004;164:545-50.

Independent Risk Factors for Independent Risk Factors for Having a Preventable ADEHaving a Preventable ADE

Risk FactorRisk Factor Odds RatioOdds Ratio 95% CI95% CI

MaleMale 0.550.55 0.30 - 0.990.30 - 0.99

No. regularly scheduled medsNo. regularly scheduled meds

0-40-4

5-65-6

7-87-8

>=9>=9

1.01.0

1.71.7

3.23.2

2.92.9

ReferentReferent

0.83 - 3.50.83 - 3.5

1.4 - 6.91.4 - 6.9

1.3 - 6.81.3 - 6.8

New residentNew resident++ 2.92.9 1.5 -5.71.5 -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 Adverse Events in Nursing Home Residents Transferred to the HospitalResidents Transferred to the Hospital

122 nursing home to hospital transfers122 nursing home to hospital transfers 98% returned to the nursing home98% returned to the nursing home In 86% of transfers, at least one medication In 86% of transfers, at least one medication

order was altered (mean 1.4)order was altered (mean 1.4)– 65% - discontinued65% - discontinued– 19% - dose changes19% - dose changes– 10% - substitutions 10% - substitutions

20% of changes resulted in an adverse event20% of changes resulted in an adverse event

Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.

OIG Report – June ‘07OIG Report – June ‘07

Consecutive Medicare stays involving inpatient Consecutive Medicare stays involving inpatient and skilled nursing facilitiesand skilled nursing facilities

Key findings …Key findings …– 35% of consecutive stays were associated with 35% of consecutive stays were associated with

quality-of-care problems and/or fragmentation of quality-of-care problems and/or fragmentation of servicesservices

– 11% of individual stays within consecutive stay 11% of individual stays within consecutive stay sequences involved problems with quality-of-care, sequences involved problems with quality-of-care, admission, treatments or dischargesadmission, treatments or discharges

DHHS; OIG, June 2007; OEI-07-05-00340

Cost of Morbidity Due to Cost of Morbidity Due to Medication ErrorsMedication Errors

Estimates:Estimates:– Hospital care: $3.5 billion (2006 dollars) (Bates et al., 1997)Hospital care: $3.5 billion (2006 dollars) (Bates et al., 1997)– Outpatient Medicare: $887 million (2000 dollars) (Field et al., Outpatient Medicare: $887 million (2000 dollars) (Field et al.,

2005)2005)

Many major costs are excluded, for example:Many major costs are excluded, for example:– Failure to receive drugs that should have been prescribedFailure to receive drugs that should have been prescribed– Patient non-compliance with prescribed drug regimensPatient non-compliance with prescribed drug regimens– Lost earnings and inability to perform household tasksLost earnings and inability to perform household tasks– Errors that do not result in harm, but create extra workErrors that do not result in harm, but create extra work

Costs of Adverse Drug EventsCosts of Adverse Drug Events

Bates et al, 1997Bates et al, 1997– Additional length of stay associated with ADE = 2.2 daysAdditional length of stay associated with ADE = 2.2 days– Increased cost associated with ADE = $3244Increased cost associated with ADE = $3244– For preventable ADEs, increased length of stay = 4.6 days; For preventable ADEs, increased length of stay = 4.6 days;

increased cost = $5857increased cost = $5857

Classen et al, 1997Classen et al, 1997– 91, 574 admissions over 4 years (1990-1993) in LDS hospital 91, 574 admissions over 4 years (1990-1993) in LDS hospital

(tertiary care facility)(tertiary care facility)– 2227 patients developed an ADE2227 patients developed an ADE– ADEs complicated 2.43 of 100 admissionsADEs complicated 2.43 of 100 admissions– Excess cost associated with ADE was $2013Excess cost associated with ADE was $2013

Data on Safety and QualityData on Safety and Quality

44,000-98,000 deaths/year in hospitals as a 44,000-98,000 deaths/year in hospitals as a result of adverse drug eventsresult of adverse drug events– Over 1,000,000 injuriesOver 1,000,000 injuries

Enormous practice variationEnormous practice variation– Estimated $450 billion unnecessary spendingEstimated $450 billion unnecessary spending

Slow translation of research to practiceSlow translation of research to practice– One estimate 17 yearsOne estimate 17 years

IOM, Crossing the Quality Chasm

Medication Errors Involving Medication Errors Involving Reconciliation FailureReconciliation Failure

September 2004 – July 2005 September 2004 – July 2005

MEDMARX Data (N=2022)MEDMARX Data (N=2022)

Site of ErrorSite of Error

AdmissionAdmission TransitionTransition DischargeDischarge

TotalTotal 23%23% 67%67% 12%12%

Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.

Medication Error Type by Medication Error Type by Transition CategoryTransition Category

Transition CategoryTransition Category

Error TypeError Type AdmissionAdmission TransitionTransition DischargeDischarge

Improper Improper Dose/QuantityDose/Quantity 55%55% 73%73% 62%62%

Prescribing ErrorPrescribing Error 49%49% 36%36% 27%27%

Omission ErrorOmission Error 35%35% 36%36% 76%76%


Case Examples of Medication Case Examples of Medication Errors on AdmissionErrors on Admission

Patient’s home medication recorded as CoregPatient’s home medication recorded as Coreg®® 25 mg 25 mg twice daily on admissiontwice daily on admission– Patient actually taking 6.25 mg twice daily at homePatient actually taking 6.25 mg twice daily at home– Patient received 4 doses of excessive strength and developed Patient received 4 doses of excessive strength and developed

leg edemaleg edema– Error was not discovered until after leg ultrasound test to rule Error was not discovered until after leg ultrasound test to rule

out DVTout DVT Nursing home patient receiving propranolol 20 mg/5mL Nursing home patient receiving propranolol 20 mg/5mL

twice dailytwice daily– Admitting orders written as propranolol 20 mg/mL give 5 mL Admitting orders written as propranolol 20 mg/mL give 5 mL

(which equates to 100 mg) twice daily(which equates to 100 mg) twice daily– Patient received 5 doses of 100 mg strength before error was Patient received 5 doses of 100 mg strength before error was

discovereddiscovered


Case Examples of Medication Case Examples of Medication Errors on Transition/TransferErrors on Transition/Transfer

Patient with prior history of several arterial stent Patient with prior history of several arterial stent replacementsreplacements– Receiving aspirin, enoxaparin, clopidogrelReceiving aspirin, enoxaparin, clopidogrel– Meds placed on hold prior to surgery for removal of toe; Meds placed on hold prior to surgery for removal of toe;

Physician did not reordered after surgeryPhysician did not reordered after surgery– 2 of patient’s coronary arteries with stents became 100% 2 of patient’s coronary arteries with stents became 100%

occluded; patient expiredoccluded; patient expired

Patient transferred from ICU to step-down unitPatient transferred from ICU to step-down unit– Prior to transfer, patient received morning doses of scheduled Prior to transfer, patient received morning doses of scheduled

meds meds – Administration of same meds repeated upon arrival to new unit Administration of same meds repeated upon arrival to new unit

due to unclear documentation and communicationdue to unclear documentation and communication


National EffortsNational Efforts

The Joint Commission The Joint Commission National Patient Safety GoalsNational Patient Safety Goals

Goal 8: Accurately and completely reconcile Goal 8: Accurately and completely reconcile medications across the continuum of caremedications across the continuum of care– 8A: There is a process for comparing the patient/resident’s 8A: There is a process for comparing the patient/resident’s

current medications with those ordered for the patient/resident current medications with those ordered for the patient/resident while under the care of the organizationwhile under the care of the organization

– 8B A complete list of the resident’s medications is 8B A complete list of the resident’s medications is communicated to the next provider of service when a resident is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete level of care within or outside the organization. The complete list of medications is also provided to the patient/resident on list of medications is also provided to the patient/resident on discharge from the facilitydischarge from the facility

The Joint Commission National Patient Safety Goals. Available at htt://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm

A Report from the HMO Care Management Workgroup

Supported by the Robert Wood Johnson FoundationSupported by the Robert Wood Johnson Foundation

One Patient, Many Places:One Patient, Many Places:Managing Health Care TransitionsManaging Health Care Transitions

AGS Position StatementAGS Position Statement

Position 1Position 1::

Clinical professionals must prepare patients and their Clinical professionals must prepare patients and their caregivers to receive care in the next setting and caregivers to receive care in the next setting and actively involve them in decisions related to the actively involve them in decisions related to the formulation and execution of the transitional care formulation and execution of the transitional care planplan




Bidirectional communication between clinical Bidirectional communication between clinical professionals is essential to ensuring high quality professionals is essential to ensuring high quality transition caretransition care

Position 3:Position 3:

Develop policies that promote high quality transitional Develop policies that promote high quality transitional carecare




Education in transitional care should be provided to Education in transitional care should be provided to all health professionals involved in the transfer of all health professionals involved in the transfer of patients across settingspatients across settings

Position 5:Position 5:

Research should be conducted to improve the Research should be conducted to improve the process of transitional careprocess of transitional care


What Can We Do …What Can We Do …

The Care Transitions InterventionThe Care Transitions Intervention

Does encouraging Does encouraging older patients and older patients and their caregivers to their caregivers to assert a more assert a more active role in their active role in their care transition care transition reduce rates of reduce rates of rehospitalization?rehospitalization?

Coleman EA et al. Arch Intern Med 2006

Utilization OutcomesUtilization Outcomes

GroupGroup

Adj. Adj.

p-value*p-value*

OR OR

(95% CI)(95% CI)VariableVariable

InterventionIntervention

(n=379)(n=379)

ControlControl

(n=371)(n=371)

RehospitalizationRehospitalization

Within 30 dWithin 30 d 8.3%8.3% 11.9%11.9% .048.048 0.59 (0.35-1.00)0.59 (0.35-1.00)

Within 90 dWithin 90 d 16.7%16.7% 22.5%22.5% .04.04 0.64 (0.42-0.99)0.64 (0.42-0.99)

Rehospitalization for same dx as index hospitalizationRehospitalization for same dx as index hospitalization

Within 30 dWithin 30 d 2.8%2.8% 4.6%4.6% .18.18 0.56 (0.24-1.31)0.56 (0.24-1.31)

Within 90 dWithin 90 d 5.3%5.3% 9.8%9.8% .04.04 0.40 (0.26-0.96)0.40 (0.26-0.96)

Within 180 dWithin 180 d 8.6%8.6% 13.9%13.9% .046.046 0.55 (0.30-0.99)0.55 (0.30-0.99)

*Adjusted for age, sex, education, race, self-reported health status, chronic disease score, prior hospitalization and ED utilization and discharge diagnosis

Coleman EA et al. Arch Intern Med 2006

Follow-up of Hospitalized Follow-up of Hospitalized Elders with Heart FailureElders with Heart Failure

An advanced practice nurse home follow-up An advanced practice nurse home follow-up program reduced 1 year hospitalization rates by program reduced 1 year hospitalization rates by over 60% with a mean cost savings of $4,845 per over 60% with a mean cost savings of $4,845 per patientpatient

Naylor MD et al. J Am Geriatr Soc 2004;52:675-84.

Role of Pharmacist Counseling in Role of Pharmacist Counseling in Preventing ADEs After HospitalizationPreventing ADEs After Hospitalization

Does pharmacist counseling before discharge Does pharmacist counseling before discharge reduce the rate of preventable ADEs?reduce the rate of preventable ADEs?

Randomized controlled trial of pharmacist Randomized controlled trial of pharmacist intervention (n=92) vs usual care (n=84)intervention (n=92) vs usual care (n=84)

Intervention on day of dischargeIntervention on day of discharge– Medication reconciliationMedication reconciliation– Screening for nonadherence, previous drug-related Screening for nonadherence, previous drug-related

problems, lack of drug efficacy, and side effectsproblems, lack of drug efficacy, and side effects– Review of indications, directions for use, and Review of indications, directions for use, and

potential side effects with patient potential side effects with patient

Schnipper JL et al. Arch Intern Med 2006;166:565-71.

Study Outcomes: Pharmacist Study Outcomes: Pharmacist Intervention vs Usual CareIntervention vs Usual Care

Outcome*Outcome*

Pharmacist Pharmacist Intervention Intervention

(n=92)(n=92)

Usual Care Usual Care

(n=84)(n=84) P ValueP Value

Adverse drug events, No. (%)Adverse drug events, No. (%)

AllAll 14/79 (18)14/79 (18) 12/73 (16)12/73 (16) >.99>.99

Preventable Preventable 1/79 (1)1/79 (1) 8/73 (11)8/73 (11) .01.01

Health Care Utilization, No. (%)Health Care Utilization, No. (%)

ED visit or readmissionED visit or readmission 28/92 (30)28/92 (30) 25/84 (30)25/84 (30) >.99>.99

Medication-related Medication-related 4/92 (4)4/92 (4) 8/84 (8)8/84 (8) .36.36

Preventable medication-relatedPreventable medication-related 1/92 (1)1/92 (1) 7/84 (8)7/84 (8) .03.03

*Outcome 30 days postdischarge

Schnipper JL et al. Arch Intern Med 2006;166:565-71.

Readmission Rates with Comprehensive Readmission Rates with Comprehensive Discharge Planning + Postdischarge Support Discharge Planning + Postdischarge Support

Phillips CO et al. JAMA 2004;291:1358-67.

0.5 1.0 2Intervention Control

Relative RiskStrategyStrategy

InterventionIntervention

Events/Events/

Total Total

ControlControl

Events/Events/

TotalTotal

RRRR

(95% CI)(95% CI)

Single home Single home visitvisit 95/23395/233 129/243129/243 0.76 (0.63-0.93)0.76 (0.63-0.93)

Clinic follow-Clinic follow-up +/- phone up +/- phone 151/370151/370 161/395161/395 0.64 (0.32-1.28)0.64 (0.32-1.28)

Home visit +/- Home visit +/- phonephone 168/437168/437 262/533262/533 0.79 (0.69-0.91)0.79 (0.69-0.91)

Extended Extended home carehome care 132/438132/438 152/421152/421 0.82 (0.68-1.00)0.82 (0.68-1.00)

TotalTotal 555/1590555/1590 741/1714741/1714 0.75 (0.64-0.88)0.75 (0.64-0.88)

Transitions of CareTransitions of CareA National CrisisA National Crisis

Why are we involved?Why are we involved?

Sanofi aventis ChairmanSanofi aventis Chairman“Sanofi-aventis is supporting the National Transitions of Care Coalition (NTOCC) and its multidisciplinary team of health care leaders to address complex issues like health literacy, patient safety and non-adherence. At sanofi-aventis, patients are at the center of all we do. Our mission is to fight for patient’s health and well being - because health matters. If we fail to help patients understand why they need to take medications, or how to take them, it can lead to non-adherence. Non-adherence can lead to increased emergency room visits, admittance or re-admittance to hospitals, longer hospital stays, higher health care costs and even life-threatening situations. We believe the work of this Coalition will play a vital role for health care professionals, patients, caregivers, and payers.”

Tim Rothwell, Chairman, sanofi-aventis U.S.

The Case Management Society of America willThe Case Management Society of America willpositively impact and improve patient well positively impact and improve patient well being and patient health care outcomesbeing and patient health care outcomes

We envision case managers as pioneers of health care We envision case managers as pioneers of health care change: nursing case managers, disease managers, change: nursing case managers, disease managers, health care coaches, social workers, pharmacists, health care coaches, social workers, pharmacists, physicians and others who are key initiators of and physicians and others who are key initiators of and participants in the health care team as patient care participants in the health care team as patient care managers.managers.

The Statistics are StaggeringThe Statistics are Staggering

Despite wide distribution, evidencebased clinical practice guidelineshave not changed physician behaviors3

Medication Reconciliation across care settings is a Joint CommissionNational Patient Safety Goal

National Quality Forum (NQF) endorsed 3-Item Care CoordinationMeasures to expand voluntary hospital consensus standards incare transitions4,5

Mobilize sanofi-aventis resources to optimize appropriate medication use across all channels

Convene experts and apply evidence based clinical practice guidelines

Non-adherence statistics:•45% of hospital NRxes or Rx changes are never documented in out-patient medical records1

•12% of NRxes are never filled2

•29% don’t complete LOT2

•22% take < than prescribed2

•Average hospital LOS due to medication non-compliance is 4.2 days2

COALITION LAUNCH October 18, 2006 - National Transitions of Care Coalition – Chicago

Collaboration with CMSA to lead multidisciplinary coalition of expertsEmployers – JCAHO - NQF – SHM – ACHE – ASHP – ASCP – ASA – AGS - IHI – NASW - URAC

Closing gaps across the continuum

4949

2008 Advisory Task Force2008 Advisory Task Force

These groups represent over 200,000 health care professionals, 11,000 employers and These groups represent over 200,000 health care professionals, 11,000 employers and 30,000,000 consumers throughout the United States.30,000,000 consumers throughout the United States.

Working to Address the Issues?Working to Address the Issues?

Medication Reconciliation

Transitions of Care List

Example of Assessment & Coordination of Care Communication Check List MEDICATION Assessment:

Be sure you cover all prescribed meds, over-the-counter medications and health/nutritional supplements

Name of Medication Dose Route Frequency Next Refill Can the patient tell you: Reason they are taking medication Positive Effects of taking medication Symptoms or side effects of taking medication Where does the patient keep their medication at home When is the next refill date for their medication How long will the patient need to remain on the medication 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)

Draft NTOCC ToolsDraft NTOCC Tools

Raise NTOCC AwarenessRaise NTOCC Awareness Information and tools available by stakeholderInformation and tools available by stakeholder

Consumer Professional Policy Maker Media

SNFSNFSNFSNF ALFALFALFALF

ERERERER ICUICUICUICU In-PatientIn-PatientIn-PatientIn-Patient

The NTOCC Tools Make it PossibleThe NTOCC Tools Make it Possibleto Address the Transition Issuesto Address the Transition Issues




My

Med List

Medication ReconciliationData Elements

+Care / Case

Transition Process

Working GroupsWorking Groups

Education & Education & AwarenessAwareness

Metrics & Metrics & OutcomesOutcomes

Policy & Policy & AdvocacyAdvocacy

Tools & Tools & ResourcesResources NTOCCNTOCC

We Can & Will Make A Difference!We Can & Will Make A Difference!

Case Studies for Case Studies for DiscussionDiscussion

Case 1Case 1

During a patient’s monthly follow-up During a patient’s monthly follow-up appointment with the cardiologist, he informed appointment with the cardiologist, he informed the doctor that he was having trouble with one the doctor that he was having trouble with one of his medications. The doctor asked which one. of his medications. The doctor asked which one. The patient said “The patch, the nurse told me The patient said “The patch, the nurse told me to put on a new one every day and now I’m to put on a new one every day and now I’m running out of places to put it!” The physician running out of places to put it!” The physician had him undress and discovered that the man had him undress and discovered that the man had over a two dozen patches on his body. had over a two dozen patches on his body.

Case 2Case 2

An older man with atrial fibrillation who takes An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. reduced to his usual dose prior to discharge. The new dose turned out to be double his usual The new dose turned out to be double his usual dose and within two days he was rehospitalized dose and within two days he was rehospitalized with uncontrollable bleeding. with uncontrollable bleeding.

Documents

Why are we involved? Transitions of Care: The Financial Burden and Impact on Delivery of Care