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49th Annual Meeting

OWNING CHANGE: Taking Charge of Your Profession

Finding the Sweet Spot: Transitions of Care in Diabetes

Adrienne DeBerry, PharmDUF Health Jacksonville

Disclosure

I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation

Objectives

Discuss the developing role of pharmacists in improving transitions of care in diabetic patients.

Identify the keys to success pharmacists have had around implementation of different TOC services in diabetic patients.

Discuss the importance of having criteria for TOC groups.

Recommend TOC quality metrics and role in reimbursement.

Transitions of Care

Barriers to successful transition are multifactorial

Multi-step process

Communication barriers

Potential for patient harm

Approximately 19% of patients experience an adverse event within 5 weeks of discharge

CMS 30-day readmission rate of 17.8% and declining

CMS’s “carrots” and “sticks” approach

Collaborative care practices successful

Reduced costs

Improved outcomesForster AJ, et al. J Gen Intern Med. 2005; 20:317‐323.

Forster AJ, et al. J Gen Intern Med. 2003; 138(3):161‐167.Coleman EA, et al. Arch Intern Med. 2006; 166:1822‐1828

Poor Transitions Are Costly

In 1997, a reported 34,500 patients were discharged and readmitted on the same day Incurred $226 million in medical costs

Reducing preventable unplanned readmissions has the potential to save $17.4 billion annually

Moorman JM. ASHP Summer Meeting Lecture. June 9th 2015. Ambulatory Care Conference, Denver, CO. Jencks SF et al. N Engl J Med 2009;360:1418‐28

Opportunities for Transition Care Management Recognized

Improving Care

Reducing Readmission

Reimbursement in Primary Care

Reimbursement from CMS for acute care

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HCAHPS

Transition of care questions added October 2014

23. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.

24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

25. When I left the hospital, I clearly understood the purpose for taking each of my medications.

http://www.hcahpsonline.org/files/HCAHPS%20V9.0%20Appendix%20A%20-%20Mail%20Survey%20Materials%20%28English%29%20March%202014.pdf

Diabetics Need Help!

Non-adherence Among Diabetics

Medication adherence rates among diabetic patients ranges from 36%-93% for oral agents Approximately 32-86% for patients on insulin

Adherence rates of <80% are associated with 58% increase in hospitalization all-cause mortality: 81% increase

However, 25% increases in adherence make a difference Hospitalization: 17% reduction

All-cause mortality: 25% reduction

Cramer JA. Diabetes Care. 2004;27:1218-1224.Ho PM, et al. Arch Intern Med 2006;166:1836‐41

Diabetes is Everywhere!

Approximately 29.1 million Americans have diabetes

In 2012, $245 billion spent on direct and indirect costs of diabetes Direct medical costs = $174 billion/yr

Diabetes Caucus. Available at <https://diabetescaucus-degette.house.gov/facts-and-figures>

Diabetes in Duval County Diabetes in Florida: Death Rates

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Diabetes in Florida

FloridaCharts.com

Diabetes in Florida: Preventable Hospitalizations

FloridaCharts.com

Risk Factors for Readmission Among Diabetics

Multiple medications

Insulin = high-risk medication

Complications Nephropathy

Cardiovascular disease

Neuropathy

Infection

Few studies have focused on readmissions specific to diabetes patients

What can we do to improve Transitions of Care?

Medication Self-Management

Patient Centered Record

Physician Follow-up

Patient Red Flags

• Medication reconciliation after handoffs• Streamline drug therapy• Patient education

• Facilitate communication and continuity of care• Review and update after handoffs• Encourage patient to take charge of health record

• Primary care or specialist follow-up• Emphasize importance to patient• Practice/role play questions

• Develop an emergency care plan• Reinforce whom to call and when• Emphasize value of prevention

Adapted from http://www.caretranstions.org

Examples of TOC Successes

Current Successes

Better Outcomes for Older Adults Through Safe Transitions (BOOST)

Shands Jacksonville Discharge Transition Program

Care Transition Initiative

Transitional Care Model (TCM)

Project RED (Re-engineered Discharge)

CMS’s Community-Based Care Transitions Program

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BOOST Program

Led by Society of Hospital Medicine

Interdisciplinary initiative

Tools and interventions Comprehensive risk assessment (the 8 P’s) Patient-centered discharge

Follow-up PCP appointment arranged before discharge Teach-back method and checklists

72-hr phone call follow-up Standardized discharge communications

Longitudinal mentorship component

Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.

BOOST Preliminary Results

Overall readmission rates decreased from 13% to 11% in 6 months across all sites

Readmission rates increased by 2% in units not utilizing BOOST

Increased patient satisfaction in some sites

Reductions in LOS and ED visits also seen

Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.Society of Hospital Medicine. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=31576.

Post-discharge Medication Therapy Assessment

Patients identified as high-risk for readmission for Group Health Cooperative in Washington state

Pharmacist telephonic service 72 hours post-discharge Reviewed med changes

Addressed discrepancies

Assessed for medication-related problems

Kilcup M, Schultz D, Carlson J, Wilson B. JAPhA. 2013;53:78-84.

Kilcup et al.

Control,n = 251

Intervention,n = 243

P-value

7-day readmissions 11 (4%) 2 (0.8%) 0.01

14-day readmissions 22 (9%) 11 (4%) 0.04

30-day readmissions 34 (13%) 28 (11%) 0.29

Kilcup M, Schultz D, Carlson J, Wilson B. JAPhA. 2013;53:78-84.

Kilcup et al.

Cost of readmission estimated at approx. $10,000 per patient

NNT of 4 correlates to 25 admissions prevented for every 100 patients receiving pharmacist intervention

Savings of $40,000 per 100 encounters Net labor cost of $4522 for every 100 patients

Savings of $35,478

Kilcup M, Schultz D, Carlson J, Wilson B. JAPhA. 2013;53:78-84.

UF Health Jacksonville Discharge Transition Pilot (2012)

Clinical Pharmacist

Medication Therapy

Management Sessions

Case Manager

Conducts Home Visit

Provider Appointment

Discharge Follow-up

Case Manager Meets Patient At Bedside

UF Health Jacksonville

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Results: UF Health Jacksonville Discharge Transition Pilot

A total of 166 discharges were included in the studyto be followed for 30 days

UF Health Jacksonville

DA19

ResultsImpact of the Collaborative Program

Composite Readmission or ED Visit Rate

p = 0.1167

ResultsImpact of the Collaborative Program

Team Impact on 30-Day Readmissions

p = 0.0468

(N=16)(N=40)

(N=84)

Results

26.0%(n = 40)

53.2%(n = 82)

10.4%(n = 16)

10.4%(n = 16)

Types of Medication-related Problems Identified (n = 154)

Appropriateness andEffectivenessSafety (pADE/ADE)

Nonadherence andPatient VariablesMISC

ResultsAdverse Drug Events

Medication‐related Problem Categories Total

Safety (pADE/ADE) 82

Lab/diagnostic test indicated, not ordered 21

ADR 17

Dose discrepancy between patient use and prescribed therapy 8

Medication overuse or misuse 7

Polypharmacy (Rx not needed)/duplication 5

Drug interaction 5

No indication for medication prescribed 4

Contraindicated 4

Incomplete/improper directions 2

Abnormal lab result not addressed 2

Part II: Focus on Diabetes

Slide 25

DA19 51 by all team members.. add boxDeberry, Adrienne, 5/6/2013

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The CO-CARE Trial

Part II of Discharge Transition Team Pilot

Targeted diabetes patients with A1C >8.5%

Collaborative team impact on: 30-day readmission/ED visit rates

Appropriateness and presence of guideline recommended CHD therapies (e.g. ASA and statin therapy)

Change in lipids, A1C

Included patients discharged between February 2012 and January 2014

UF Health Jacksonville

Results

60 Cases included in Control Group

21 Cases included in Intervention Group

81 Cases Included in the Study

Transition of Care ProgramTraditional

post-discharge follow-up

ResultsBaseline Characteristics

Control Group Intervention Group p-values

Total Discharges (n) 60 21

Demographics

Males, n (%) 29 (48.3%) 12 (57.1%) NS

White, n (%) 20 (33.3%) 9 (42.9%) NS

African American or Hispanic, n (%) 40 (66.7%) 12 (57.1%) NS

Average age, years 47 51 NS

Index admission diabetes-related, n (%) 27 (45.0%) 12 (57.1%) NS

Baseline Health Markers Average Hgb A1C at baseline (%) 11.8 11.0 NS

Average BMI (kg/m2) 31.0 33.2 NS

Charlson Index Score 3.2 3.9 0.03

Baseline Lipid Panel

Average baseline LDL (mg/dL) 99 115 0.03

Average baseline HDL (mg/dL) 39 34 NS

Average baseline TGs (mg/dL) 183 269 0.01

Results

9.8% 11.0% 8.5%11.8%

∆ = - 2.0∆ = - 2.5

ResultsImpact on 30-day Readmissions

Control Group (n = 60)

Intervention Group (n = 21) P-values

Number of Patients

Percentage of Patients

Number of Patients

Percentage of Patients

30-day readmission rates 7 11.7% 3 14.3% NS

30-day ED visit rates 11 18.3% 3 14.3% NS

Composite 30-day readmission or ED Visit rate

16 25.4% 4 19.0% NS

ResultsCHD Preventative Medication

57.1%

80.0%66.7%

100%

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Additional ObservationsImpact of Transition of Care Program on Health Outcomes

19.0%

28.6%

TOC Successes: Discussion

Trends toward improvements in health outcomes seen with Transition of Care (TOC) Program visits

Larger studies are needed in diabetic patients specifically Not currently a disease of focus for Readmission Reduction Program

Less than 2% of hospital discharges annually list a PRIMARY diagnosis of diabetes

However patients with diabetes account for approximately 25% of hospitalizations (+8 million per year)

Rubin DJ. Curr Diab Rep. 2015 Apr;15(4):17.

The Real Deal….

Many discharges in a day

Limited staff members with a multitude of responsibilities

Prospects of additional resources are slim….

The DERRI Tool

Diabetes Early Readmission Risk Index

Based on retrospective cohort of 17,595 adults with diabetes

Reviewed 43 variables Found 13 to be statistically significant predictors of

early readmission

Rubin DJ. Curr Diab Rep. 2015 Apr;15(4):17.

The DERRI Tool

Employment status or disability

Race

Zip code <5 miles from hospital

Private insurance vs none, Medicaid vs private insurance

Urgent/emergent vs elective index admission

Elevated SC

Micro- or macrovascular complications per Dx

Pre-admission glucocorticoid or insulin or statin

Rubin DJ. Curr Diab Rep. 2015 Apr;15(4):17.

Additional High-Risk Markers for Readmission

Acute care utilization in the past 30-60 days

Insulin therapy

Retinopathy

Other high-risk meds (ex anticoagulants)

Multiple chronic conditions

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Transitional Care Management (TCM)

Transition of Care Visits

Effective January 1, 2013 new Healthcare Common Procedure Coding System (HCPCS) codes for

Transitional Care Management (TCM) services may be used to bill physician and “qualified non-physician

providers” care management following discharge from an inpatient hospital setting, observation setting, or

skilled nursing facility.

Transitional Care Management Visits

Visit TypeTiming (calendar

day)CPT Code

Medical Decision Making

ComplexityClaim Date

TransitionalCare

Management

Within 7 days of Discharge*

99496 High30 days from

discharge

TransitionalCare

Management

Within 14 days of Discharge* 99495 Moderate

30 days from discharge

*For face-to-face visits. Communication via either direct, telephone, or electronic to patient or care giver within 2 business days of discharge.

Required Components

Transitional Care Management

Face-to-face Visit

Non-face-to-face Services

Interactive Contact

Visit Requirements: Interactive Contact

Must occur within 2 business days Telephone

E-mail

Face-to-face

Attempts to communicate should continue after the first 2 business days if unsuccessful

Must only bill for successful attempts

Requirements: Specific Non-face-to-face Services

Physicians or non-physician practitioners (NPP) may: Review discharge summaries Review need for follow-up or pending diagnostic

tests/treatments Interact with other health care professionals who will assume

or reassume care of the beneficiary’s system-specific problems

Provide education to beneficiary/family/caregiver Referrals Assist in scheduling required follow-up with community

providers and services

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Licensed Clinical Staff Under the Direction of a Physician or NPP may: Communicate with agencies and community services

used by the beneficiary Provide education to beneficiary/family/caregiver to

support self-management Assess and support treatment regimen adherence and

medication management Identify available community and health resources Assist the beneficiary and/or family in accessing

needed care and services

Requirements: Specific Non-face-to-face Services

Requirements: Face-to-face Visit

Medication reconciliation must be done no later than the face-to-face visit!

Must occur within a certain time frame 7 days for “high medical decision complexity” 14 days for “moderate medical decision complexity”

While non-face-to-face care may be furnished by qualified health care professionals, the patient must be seen face-to-face by the Medicare recognized qualified

provider.

How can pharmacists contribute?

Conduct assessments to identify high-risk patients

Utilize outpatient practitioners within the inpatient units

Facilitate active communication between inpatient and outpatient practitioners

Bedside medication delivery and discharge counseling

Medication reconciliation at admission Utilize pharmacy students/interns

Ease the burden on other healthcare providers through collaboration Collaborative practice agreements

But Is Pharmacist Involvement Billable? It Depends…

http://www.pharmacist.com/cms-tells-family-physicians-pharmacist-provided-services-may-be-billed-incident-8

But Is Pharmacist Involvement Billable? It Depends… Requirements of “incident-to” billing

Conducted under “general” supervision of physician

Initial visit performed by physician

Pharmacist employed by physician practice This does not apply for FQHC and RHCs (1/1/15)

Proper documentation

Physician-based practices

Useful for Chronic Care Management and TCM

http://www.ashp.org/DocLibrary/Advocacy/CCM-Incident-to-Billing-Changes.pdf

Check with your Compliance Officer!

Billing for TCM?

Must meet requirements of TCM codes

Pharmacists cannot independently bill

http://www.ashp.org/DocLibrary/Advocacy/CCM-Incident-to-Billing-Changes.pdf

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Quality Metrics and Assessment

30-day readmission rates CMS standard

Financial impact

ED-visit rates More complete assessment of acute care utilization

Patient satisfaction

Change in HCAHPs scoring

CTM: Care Transition Measure

Developed as part of the Coleman model Care Transitions Intervention

CTM-3 item and CTM-15 item questionnaire to assess the quality of care transitions

Four domains assessed Information transfer

Patient/caregiver preparation

Self-management support

Empowerment to assert preferences

Coleman EA, Smith JD, Eilertsen TB, Frank JC, Thiare JN, Ward A, and Kramer AM. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Journal of Care Integration. 2002:2 April-June

www.caretransitions.org

Efforts to improve transitions of care should be ongoing and implemented as soon as possible

Collaborative transition care models should be expanded

Successful models have a comprehensive proactive approach High-risk patients should take priority

Pharmacists can contribute greatly to improving continuity of care and reducing readmission rates Reductions in medication-related issues

Pharmacist need to continue to strive for provider status to take advantage of billing opportunities

Conclusion

Food for thought…

https://origin.ih.constantcontact.com/fs182/1105304717519/img/136.png

“It takes a village…to make a good transition.” – Kathleen Tong, M.D.

Director of Heart Failure Program, UC Davis Medical Center

References

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005; 20:317-323.

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients following discharge form the hospital. Ann Intern Med. 2003; 138(3):161-167.

Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006; 166:1822-1828.

Moorman JM. Transitions of Care: Best practices and learner experiences. ASHP Summer Meeting Lecture. June 9th 2015. Ambulatory Care Conference, Denver, CO. 

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee‐for‐service program. N Engl J Med 2009;360:1418‐28

Rubin DJ. Hospital readmission of patients with diabetes. Curr Diab Rep. 2015 Apr;15(4):17.

ACCP White Papers. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012; 32(11):e326-e337.

Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27:1218-1224.

Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med 2006;166:1836‐41

Diabetes Caucus. Facts and Figures. Available at https://diabetescaucus-degette.house.gov/facts-and-figures. Accessed May 2015.

The Care Transitions Initiative. Available at www.caretransitions.org. Accessed May 2015.

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Society of Hospital Medicine. Project BOOST: Better Outcomes for Older Adults through Safe Transitions [Internet]. Philadelphia: Society of Hospital Medicine [cited 2012 Aug 17]. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home& Template=/CM/ContentDisplay.cfm&ContentID=31576.

Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: Impact on readmission rates and financial savings. JAPhA. 2013;53:78-84.

Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007; 2:314-323.

Burton R. “Health Policy Brief: Care Transitions” Health Affairs, September 13, 2012.

Center for Medicaid and Medicare Services. Readmissions reduction program. Accessed May 2013. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

Anthony D, Chetty VK, Kartha A., et al. Re-engineering the hospital discharge: an example of a multifaceted process evaluation. In: Henriksen K, Battles JB, Marks ES, et al., eds. Advances in patient safety: from research to implementation. Vol. 2. Rockville, MD: Agency for Healthcare Research and Quality; 2005. p. 379-94

American Pharmacists Association. CMS tells family physicians that pharmacist-provided services may be billed as incident-to. Available at: http://www.pharmacist.com/cms-tells-family-physicians-pharmacist-provided-services-may-be-billed-incident-8. Accessed May 2015.

ASHP. Fact Sheet: Incident-to Billing for Chronic and Transitional Care Management Services. Available at: http://www.ashp.org/DocLibrary/Advocacy/CCM-Incident-to-Billing-Changes.pdf. Accessed May 2015.

References continued