Transitions of Care: Using Pharmacists as Part of Team Based CareCare Transformation Collaborative of R.I.TARA HIGGINS, PHARMD, CDOE, CVDOE

CLINICAL PHARMACY DIRECTOR

RHODE ISLAND PRIMARY CARE PHYSICIAN CORPORATION

MAY 5, 2015

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Objectives 1. Explain the importance of medication safety

2. Define medication management and value in care transitions

3. Review medication reconciliation process and ways to improve

4. Explore factors that influence medication adherence

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Medication Safety

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“Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is

enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical

component of improving the national health care system.”

The Institute of Medicine (IOM)1

1The Institute of Medicine, National Academy of Sciences. Informing the future: Critical issues in health. 2007 Fourth edition, page 13. http://www.nap.edu/catalog/12014.html

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of healthcarecosts

75%

Driven by 7chronic

conditions

Taken by 1/3 of all U.S. adults

≥ 5 chronic medications

Drug-related morbidity and mortality costs

annual US cost of drug

mis-adventures

Source: Congressional Budget Office, 2005National Academies Press: Preventing Medication Errors: Quality Chasm Series, 2007 CDC, 2010. http://www.cdc.gov/nccdphp/overview.htmWorld Health Organization, 2003, J Amer Pharm Assoc 2001;41:192–9

Due to prescription painkiller misuse per year

Specialty impact on the

rise

40%of drug spend

due to specialty by 2014

$290B

Major contributor to poor outcomes

The Facts

~500,000

ER visits

~50-60%Adherence

rates

Patient Story #1 72 year old female

Multiple hospitalization for syncope-like events

Kidney transplant 12 years ago

Cognitive issues

Multiple medication issues

Referral to pharmacist for home visit

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Medication Reconciliation

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DefinitionMedication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.”

Roles in Medication Reconciliation

Ideas to Improve Medication Reconciliation

Medication ReconciliationMedication Management Questions

Does the health care provider have enough information to treat the patient?

Does the patient understand what the health care provider wants to know or wants to do?

Does the patient understand their health problem?

Does the patient have the resources to follow a treatment plan?

Does the patient have the support they need to follow a plan?

Is the patient satisfied with the care they are receiving?

Patient Story #2 64 year old male

Knee replacement surgery resulted in pulmonary embolism after discharged home

Re-admission with multiple medication changes

New start warfarin

Meet with patient with NCM

Home visit – care team huddle to coordinate patient needs

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Patient-Centered Medication Therapy Management

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Medication Therapy Management in Ambulatory Care

Clinical Pharmacist

Appropriate, Effective, Safeand Adherent Medication Use

Physicians/Providers Patient

Nurse Care Manager

Patient understands her medications, participates in care plan to improve health

Highest Risk Patients

Pharmacist Collaboration Levels in Primary Care Models

Smith, et.al. Health Affairs 32, No. 11. (2013);1963-1970

Patient Story #3 93 year old female

Eligible for comprehensive medication review

Home visit

Recent hospitalization for COPD

Improper inhaler technique and storage

Pain issues

Coordinated care with MD and NCM

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“The extent to which the patient continues the agreed-upon mode of treatment under limited supervision when faced with conflicting demands”

Medication Adherence

Key Predictors of Medication Persistence

Barriers to Taking Medications

24% forgetfulness

20% side effects

17% medication was too costly

14% decided didn't need the drug

10% difficulties getting prescription

The Hidden Epidemic: Finding a Cure for Unfilled Prescriptions and Missed Doses, December, 2003. The Boston Consulting Group and Harris Interactive. Available at http://www.bcg.com/publications/files/TheHiddenEpidemic_Rpt_HCDec03.pdf.

Challenges with Medication Persistence

Patient Story #4 74 year old female

Recent hospitalization with SNF stay

Lives alone, diabetes, cognitive issues

Multiple medication changes with care transitions

Referred by MD for home visit and comprehensive medication review

Coordinated care with NCM

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Summary

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Medication Related Problems

Health beliefsHealth illiteracyPast medication

experiencesNon-adherence

Gaps in careInappropriate

prescribingIneffective prescribing

Lack of care coordinationInconsistent monitoring

Adapted from Smith, et.al. Health Affairs. 2011;30(4):646-54

Patient Story #5 66 year old male

Eligible for CMR

Diabetes out of control A1C = 9.6

On multiple oral medications

Requesting to start insulin

Referral to NCM for diabetes education

A1C = 7.4 after conversion to insulin, removal of oral medications except metformin

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Questions?

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