Breakdowns in Drug Therapy in the Chronically Ill are Associated with Readmissions

1. HRET/K-HEN Readmissions RaceOffice Hour Building a Multidisciplinary Care Transitions TeamJanuary 25, 2013

2. Breakdowns in Drug Therapy in the Chronically Ill are Associated with Readmissions • 2002 ADHERE registry: 80% of CHF admissions are repeat admissions • 20% in one month; • 50% in 6 months • Why? • 24% Rx non-adherence • 16% Inappropriate Rx • 24% dietary non-adherence • 19% failure to obtain timely care (e.g., report weight gain) • 17% all other Source: Vinson JAGS 1990

3. Poor Outpatient Follow up, Drug Therapy Breakdowns are Associated with Readmissions • Study of 100 consecutive readmitted HF patients at urban medical center • Major causes for readmission: • No outpatient follow up 33% • Medication noncompliance 25% • Fluid noncompliance 22%. • Diet noncompliance 21%, • “Other causes had minor contributions” (Source: Ghali et al, JACC, March 2010)

4. Medication Problems Linked with Readmissions • Study of 998 patients admitted with HF to an urban academic center • 72% of patients reporting non-adherence to their medications were readmitted in the year post discharge vs. 29% adherent patients • Non-adherent patients were 1.7 times more likely to be readmitted ≥ 3 times in the year post discharge (Source: Shenoy et al, JACC, March 2012)

5. Potential Contribution of Pharmacists as a Team Member A randomized trial of 178 patients being discharged home from the general medicine service found pharmacist counseling reduced the number of preventable adverse drug events from 11% in the control group to 1% in the intervention group. • Source: Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. Mar 13 2006;166(5):565-571. 5

6. Potential Contribution of Pharmacists as a Team Member • Pharmacist-Recorded Medication Histories Result in Higher Accuracy and Fewer Medical Errors. • Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. Am J Health Syst Pharm. 2004;61:1689-1695. • Bond CA, Raehl CL, Franke T. Clinical Pharmacy Services, Hospital Pharmacy Staffing and Medication Errors in United States Hospitals. Pharmacotherapy. 2002; 22:134-147. • Nester TM, Hale LS. Effectiveness of a pharmacist-acquired Medication History in Promoting Patient Safety. Am J Health Syst Pharm. 2002;59:2221-25. 6

7. Could Pharmacists help YOU Improve Care Transitions, Reduce Readmissions? Pharmacists could help you by— • Doing admission and discharge medication reconciliation • Teaching patients during hospital stay • Delivering discharge meds to patient before discharge • Making post-discharge phone calls to patients What if you can’t secure the help of your hospital pharmacist? • Community pharmacists can see or make calls to patients and be paid through the Medicare MTM benefit • Pharmacists in outpatient hospital pharmacies could counsel patients and be paid under the Medicare Medication Therapy Management (MTM) program

8. What are Medicare Medication Therapy Management Services? • As defined by the Medicare Modernization Act of 2003 (MMA), MTM services are designed to: • Review patient medication regimen • Counsel patients to enhance understanding and increase adherence • Detect adverse drug events, and patterns of overuse and underuse of prescription medications • Make corrective recommendations to prescriber • Provided at no cost to eligible Medicare Part D (drug benefit) enrollees • Pharmacists are paid by the Part D plan

9. Patients Eligible for the Medicare MTM Program • Patient must meet 3 criteria to be eligible for a Plan’s MTM: • Have multiple chronic diseases (Part D plan can’t require more than 3) • Taking multiple Part D drugs (plan can’t require more than 8 Part D drugs) • Are likely to incur Part D drug costs of at least $3000 • Patients targeted by most hospitals as being at high risk for readmission match these MTM criteria pretty well (e.g., CHF, COPD)

10. Chronic Diseases Targeted by MTM Programs • CMS requires Part D plan to target at least 4 of these 7 conditions: • Bone Disease (e.g., Osteoporosis, Osteoarthritis, or Rheumatoid Arthritis); • Diabetes; • Dyslipidemia; • Heart Failure; • Hypertension; • Mental Health disorders (e.g., Depression, Schizophrenia, Bipolar Disorder); • Respiratory Disease (e.g., Asthma, COPD, or Chronic Lung disorders) 10

11. How Could MTM Services be Coordinated with Hospital Discharge? • Hospital establishes a relationship with pharmacists who will provide MTM services when called by the hospital team with only a day or two of notice • Community pharmacist providing MTM may be in town • Or could be contract pharmacists making telephonic intervention (quite valuable in most cases) • Hospital would target patients who are eligible for MTM, work with pharmacists who are authorized by the patient’s Part D plan to be paid for MTM services. • MTM services would follow the patient after discharge for weeks or months • We are seeking hospitals to pilot test this change model