Transitions of Care · transitions of care Discuss potential pharmacists’ and pharmacy...

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Transitions of Care: Policy, Regulation, Opportunities, & Challenges for Pharmacy AIMON C. MIRANDA, PHARMD, BCPS RADHA V. PATEL, PHARMD, MPH, BCACP, CPH ERINI SERAG-BOLOS, PHARMD

Transcript of Transitions of Care · transitions of care Discuss potential pharmacists’ and pharmacy...

Transitions of Care: Policy, Regulation, Opportunities,

& Challenges for Pharmacy

AIMON C. MIRANDA, PHARMD, BCPS

RADHA V. PATEL, PHARMD, MPH, BCACP, CPH

ERINI SERAG-BOLOS, PHARMD

Objectives

Interpret policies and regulations involving

transitions of care

Discuss potential pharmacists’ and pharmacy

technicians’ roles and opportunities in

transitions of care

Describe challenges associated with

implementation of a transitions of care program

Introduction

Efficient care coordination leads to:

Improved clinical outcomes

Reduced hospital readmissions

Reduction in adverse drug events

Prudent use of resources

Cost savings

Certain populations are at higher risk

Geriatric patients

End-of-life care

Patients with limited health literacy

Adults and children with special needs

Homeless patients

Polypharmacy (>5 drugs)

Importance of Proper Care Transitions

20% of readmissions occur due to a medication error

Study found 36% of patients had medication errors at admission

85% originated from the patient’s medication history

Unintended medication discrepancies at the time of hospital

admission range from 30% to 70%

60% of all medication errors occur during times of care transitions

1.5 million preventable adverse drug events/year accounts for

> $3 BILLION/year in health care dollars

Think & Share

How are you implementing transitions of care in your practice setting?

What specific outcomes are most pertinent in your area?

Setting the Landscape:

Transitions of Care Policy

Transitions of Care: Policy Inpatient

Section 3025 Affordable Care Act

Hospital Readmissions Reduction Program (HHRP)

Centers for Medicare and Medicaid Services (CMS) reimbursement penalties

30 day hospital readmission

Calculation of excess readmission ratio for each applicable condition

Compared to national average

FY 2015-2016 Fiscal Year (FY)

54% of hospitals penalized

38 hospitals received the maximum 3% reimbursement penalty

Florida

154 hospitals penalized

Conditions under HRRP

FY 2012

•Acute myocardial infarction (AMI)

•Heart failure (HF)

•Pneumonia (PN)

FY 2014

•Chronic Obstructive Pulmonary DIsease

•Total hip arthroplasty(THA)

•Total knee arthroplasty(TKA)

FY 2016

•Expanded pneumonia diagnosis

•Aspiration pneumonia

•Sepsis patients coded with pneumonia

FY 2017

•Coronary artery bypass graft (CABG) surgery

Transitions of Care: Post-acute & Long-term

Care Policy

Protecting Access to Medicare Act (PAMA) of 2014

Improving Post-Acute Care Transformation (IMPACT) Act

Value-based purchasing programs for Skilled Nursing Facilities

(SNFs)

Beginning in 2018

Incentives and penalties for SNFs failing to meet all-cause, all-

condition hospital 30-day preventable readmission

Transitions of Care Billing Codes

Transitional Care Management Services (TCM)

Healthcare professional accepts are for beneficiary post-discharge from the facility without a gap

30-day begins on day of discharge from

Inpatient acute care hospital

Inpatient psychiatric hospital

Long term care

Post acute care

Observation or partial hospitalization

Transitions of Care Billing Codes

Services billed by:

Physicians

Clinical nurse specialists

Nurse practitioners

Physician assistants

Where are the pharmacists?

Transitions of Care Billing Codes

TCM with moderate medical decision complexity

Face-to-face visit within 14 days of discharge

CPT Code 99495

TCM with highmedical decision complexity

Face-to-face visit within 7 days of discharge

CPT Code 99496

Key Organizations & Resources

Centers for Medicare and Medicaid Services

Community-based Care Transitions Program

The Joint Commission

Transitions of Care Portal

Agency for Healthcare Research and Quality

Project RED (Re-Engineered Discharge) Training Program

National Transition of Care Coalition (NTOCC)

NTOCC’s Transitions of Care Evaluation

TOC Compendium

Opportunities for Implementation

Opportunities

Increased pharmacist involvement in development of TOC initiatives

Advocate for pharmacist involvement

Advancement of health information technology

Interprofessional approach to patient care

Accountable Care Organizations

Patient Centered Medical Home

Patient-centered care

Cost-effectiveness/savings

TOC billing codes

Accountable Care Organizations

Pharmacists’ Roles in Care

Transitions

Best Practices – Institutional Settings

Prompt admission medication history

Medication reconciliation at every level of care to avoid discrepancies

Discharge counseling to communicate vital components of the care plan with

patients/caregivers

Assess health literacy

Promote adherence and importance of timely follow up

Focus on high risk specialty areas (transplant, HIV, etc.)

Pharmacist-to-pharmacist hand-offs between practice settings

Interprofessional practice

Pharmacist involvement in medical rounds to anticipate and resolve medication problems

Ensuring adequate and timely follow up

Best Practices – Ambulatory Care Settings

Medication reconciliation upon discharge to avoid discrepancies

“Medication reconciliation is not an event, but an enduring activity.” -

American Medical Directors Association

Direct communication among healthcare providers between settings

Discharge notes and proper hand-offs

Discontinuation of old medication regimen from community pharmacies

Evaluation of patient ability and caregiver availability

Discontinuation of old medication regimen from community pharmacies

Pharmacist-run clinics within interprofessional settings

Chronic disease state management

Best Practices –

Community Pharmacy Settings

Patient empowerment through counseling and education

Reiterate importance of care coordination

Patient advocacy in seeking clarification from clinics as necessary

Vital role in providing accurate information for proper medication

reconciliation

Best Practices – Telemedicine

Post-discharge follow up

Reiterate key counseling points

Ensure timely follow-up appointments made

Chronic disease monitoring

Beneficial for patients who have limited transportation or live in rural areas

Includes three main distinctions:

Asynchronous shared EMRs

Remote patient monitoring

Real-time, interactive services

Opportunities for Pharmacy Technicians &

Interns

Pharmacy technicians

Medication reconciliation

Meds-to-beds programs

Assistance with prior authorizations and referrals

Pharmacy interns

Extend pharmacist services while enhancing competence

Pharmacy Residency Programs

ASHP accreditation for PGY2 residencies - potential for new areas of

post-graduate training opportunities

Example daily activities:

Attending multidisciplinary rounds and ambulatory clinics

Making post-discharge telephone calls

Performing medication reconciliation

Participating in patient education and counseling

Collaborating with other HCPs

Transitions of Care Models

Better Outcomes for Older Adults

through Safe Transitions (BOOST)

Aim to establish a national standard for discharge processes

Multidisciplinary team focuses on discharge education

Currently offer an implementation toolkit for various disease

states

Care Transitions Intervention

Self-management program for patients with complex needs and their

caregivers

Four week period

Focus on

Medication self-management

Use of dynamic personal health record

Timely follow up after discharge

Knowledge of red flags indicating worsened condition and next steps

Guided Care Model

Led by a guided care nurse in primary care office

Works with patients, caregivers, and physician

Focus on care of chronic diseases:

Assessing patient/caregiver in home environment

Create evidence-based care plan

Monthly monitoring of patients

Promote self management

Care coordination among providers

Transition support between care sites

Caregiver support

Transitional Care Model

Led by transitional care nurse

Focus on high risk, geriatric patients with chronic disease

hospitalized for medical or surgical conditions

Involves inpatient planning and home follow-up

Think – Pair – Share

What types of transitions of care initiatives

have you developed at your sites?

What challenges have you encountered?

What are your future plans for enhancement?

Challenges with Program

Implementation

Barriers to Implementation

Lack of interface and interoperability among health information technology systems

Various electronic medical record programs

Hospital to hospital

Hospital to long-term care facility

Hospital to ambulatory care clinic

Multiple pharmacy dispensing systems

Lack of standardized processes among institutions

Insufficient coordination and communication

Inadequate financial resources

Inadequate staffing resources (time allocation)

Misaligned incentives for stakeholders

Barriers to Implementation (cont.)

Limited patient knowledge leading to reduced demand for

a care plan

Lack of a single clinician or team with definitive responsibility

for care continuation

Student Preparation at the

USF College of Pharmacy

Didactic Curriculum

P2 Year• Pharmaceutical Skills

series• Medication

reconciliation• Interprofessional

education

• Medical Informatics course

• Transitions of care simulation

• Medication reconciliation simulation

P3 Year• Pharmaceutical Skills

series• Transitions of care and

medication

reconciliation lecture

• Transitions of care

simulations

• Interprofessional

education (special

populations)

• Cardiology elective• Transitions of care

simulation

P4 Year

• Advanced Pharmacy

Practice Education

(APPE)

• Adult medicine

• Cardiology

• Long term care

Transitions of Care Simulations

Two simulations in the P3 year and conducted at the Center for Advanced Clinical Learning & Simulation (CAMLS)

Patient case involved atrial fibrillation and anticoagulation

Objectives

Identify pharmacist roles in various practice settings

Clinic, ER, ICU, IV room, inpatient pharmacy, medical floor, long term care facility

Discuss pharmacist involvement in care transitions

Assessment categories were based on various concepts regarding pharmacist roles in:

Medication reconciliation

Reduction of medication errors and readmissions

Interprofessional involvement

Information technology utilization

Our Endeavors in Transitions

of Care

Erini Serag-Bolos, PharmD

Practice site at Tampa General Hospital

Medication reconciliation at admission

Rounds on the inpatient medicine service

Discharge counseling

Clarification of discharge orders and communication with

ambulatory care clinics for follow up

Academic endeavors

Curricular development and enhancement

Aimon Miranda, PharmD, BCPS

Practice Site at Morsani Center – Cardiology

Pharmacotherapy Clinic (focus is on anticoagulation)

Student-led medication reconciliation for high-risk patients (general

cardiology patients)

Practice Site of Florida Hospital – Tampa

Interdisciplinary rounds in CCU/CSU

Outpatient Heart Failure Transitions Program

Heart failure/MI discharge counseling

Future opportunities

Radha V. Patel, PharmD, MPH, BCACP,

CPH, CPh

Former Practice Site: University of Pennsylvania Health System

Interprofessional Post-Acute Care Clinic

Referral for continuity of care to pharmacist-run clinic

Project: The clinical and economic outcomes of utilizing pharmacist

interventions associated with an outpatient post-acute care clinic

Former Practice Site: Fletcher Health and Rehabilitation Center

USF Health Interprofessional initiative

Project: A Pilot Interprofessional Transfer Triage Protocol in Post-Acute Care

Transitions of Care Elective Course

Questions?

References

American Medical Directors Association. Transitions of care in the long term care continuum. Clinical Practice Guideline. 2010.

American Medical Directors Association. Policy resolution H10 - improving care transitions between the nursing facility and the acute-care hospital settings. 2010.

American Pharmacists Association and American Society of Health-System Pharmacists. Improving Care Transitions: Optimizing Medication Reconciliation. Retrieved from: http://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspx. Accessed September 12, 2015.

American Society of Health-Systems Pharmacists. PGY2 Competency Areas, Goals and Objectives. Accessed October 18, 2016. Available: www.ashp.org/menu/residency/residency-program-directors/pgy2-competenc-areas-goals-and-objectives.aspx

American Society of Health-Systems Pharmacists and American Pharmacists Association. Medication Management in Care Transitions Best Practices. Retrieved from: http://www.ashp.org/DocLibrary/Policy/Transitions-of-Care/ASHP-APhA-Report.pdf. Accessed October 18, 2016.

Arya V. Telemedicine: new technologies, new normal. Pharmacy Today. 2013. Retrieved from https://www.pharmacist.com/telemedicine-new-technologies-new-normal. Accessed October 18, 2016.

Centers for Medicare and Medicaid Services. Readmissions Reduction Program (HRRP). Retrieved from: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed October 18, 2016.

Centers for Medicare and Medicaid Services. Transitional Care Management Services. Retrieved from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Accessed October 18, 2016.

Ensing HT, Stuijt CCM, Van Den Bemt BJF. Identifying the optimal role for pharmacists in care transitions: a systematic review. J Manag Care Spec Pharm. 2015;21(8):614-38.

Hume AL, Kirwin J, Bieber HL, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012; 32(11):e326-e337.

Jeffs L., Lyons R, Merkley J, Bell, C. Clinicians’ views on improving inter-organizational care transitions. BMC H Svc Res. 2013; 13:289.

Malakos K. Pharmacy technicians in transitions of care. Pharmacy Today. 2016. Retrieved from http://www.pharmacytimes.com/publications/issue/2016/may2016/pharmacy-technicians-in-transitions-of-care. Accessed October 18, 2016.

National Conference of State Legislatures. Protecting Access to Medicare Act of 2014. Retrieved from: http://www.ncsl.org/research/health/protecting-access-to-medicare-act-of-2014.aspx Accessed October 18, 2016.

Rau, Jordan. Half Of Nation’s Hospitals Fail Again To Escape Medicare’s Readmission Penalties.. Retrieved from: http://khn.org/news/half-of-nations-hospitals-fail-again-to-escape-medicares-readmission-penalties/. Accessed October 18, 2016.