Oh the places you may go: Transitions of care

1. Oh the places you may go: Transitions of care Rachel A. Stephens, PharmD Kristen G. Belew, PharmD Practice Plus/Arkansas Health Group

2. We have no financial or personal relationships with commercial entities that may have direct or indirect interest in the subject matter of this presentation.

3. Objectives • Define the need for transitions of care (TOC). • Define the goals for TOC. • Describe the TOC model and the participating team members. • Describe the role of pharmacists in the TOC model. • Discuss the challenges of effective TOC.

4. Patient Case • TH is a 78 year old female recently diagnosed with heart failure. She receives three new prescriptions when discharged from the hospital: sacubitril/valsartan, metoprolol succinate and furosemide. Discharge summary instructs her to stop taking lisinopril. When she presents to her primary care physician 2 weeks later, she complains of lip swelling, dizziness, falls and palpitations. Her blood pressure is 95/72 and potassium 5.9. • What could have been done to help prevent this medication error?

5. Transitions of Care • Movement of a patient from one care setting to another • Also called Transitional Care Management (TCM) AHRQ, 2018.

6. Pathways of TOC

7. Why is TOC needed? Jencks SF et al. NEJM 2009.

8. Why is TOC needed? Jencks SF et al. NEJM 2009.

9. Why is TOC needed? • Cumulative 30-day rehospitalization without physician follow-up: ~50% • 30-day rehospitalization without physician follow-up: ~25% Jencks SF et al. NEJM 2009.

10. Why is TOC needed? Jencks SF et al. NEJM 2009.

11. Why is TOC needed? • Conclusions • 30-day readmission rates: 20% • 90-day readmission rates: 34% • 2004 Financial Impact: $17.4 billion Jencks SF et al. NEJM 2009.

12. How do readmissions look today? KFF, 2017.

13. Audience Response #1 Which of the following represents when transitions of care occurs? • Admission into the hospital • Discharge out of the hospital • Admission into a skilled nursing faculty • Discharge tohome • All of the above

14. Audience Response #1 Which of the following represents when transitions of care occurs? • Admission into the hospital • Discharge out of the hospital • Admission into a skilled nursing faculty • Discharge tohome • All of the above

15. Root causes of ineffective TOC • Communication breakdowns • Patient education breakdowns • Accountability breakdowns TJC, Last accessed September 2018.

16. Root causes of ineffective TOC • Communication Breakdown • Occurs between providers, patients and caregivers • Lack of teamwork and respect • Inadequate hand-off TJC, Last accessed September 2018.

17. Root causes of ineffective TOC • Patient education breakdown • Conflicting information • Unclear instructions • Confusing medication regimens • Education level of patient TJC, Last accessed September 2018.

18. Root causes of ineffective TOC • Accountability breakdowns • No responsible party ensuring coordinated health care • Failure to coordinate and communicate between specialists • Failure to coordinate discharge resources TJC, Last accessed September 2018.

19. Goals of TOC • Prevent medical errors • Identify problems for early intervention • Prevent unnecessary and costly hospitalization and readmission • Improve patient engagement in healthcare • Improve interprofessional communication CMS, Last accessed September 2018.

20. Audience Response #2 What was the root causeor causesfor ineffective TOC for TH? • Communication breakdown • Patient education breakdown • Accountability breakdown • 1 only • 2 only • 1 and 2 • 1, 2 and 3

21. Audience Response #2 What was the root causeor causesfor ineffective TOC for TH? • Communication breakdown • Patient education breakdown • Accountability breakdown • 1 only • 2 only • 1 and 2 • 1, 2 and 3

22. How do we provide effective TOC?

23. MLN, 2016.

24. CMS Transitional Care Management (TCM) Model • Requirements for eligibility • Transitioning from inpatient to community • Provider accepts responsibility for care • Moderate to high complexity medical decision making MLN, 2016.

25. TCM Model within 2 business days within 7-14 days of discharge 30 days after discharge MLN, 2016.

26. TCM Model: Interactive Contact • Can occur via telephone, email or face-to-face visit • Performedwithin 2 business days of discharge • Services rendered: • Review of discharge information, provide education to patient/caregiver, establish referrals and community resources, assist in scheduling appointments MLN, 2016.

27. TCM Model: Face-to-Face Visit • Performed by a provider (MD, PA, APRN) • Must occur within 7-14 days based on complexity of medical decisions • CPT 99495 - moderate complexity - 14 day follow-up • CPT 99496 - high complexity - 7 day follow-up • Can be done via telehealth • Medication reconciliation and management must be done no later thantheface-to-face visit MLN, 2016.

28. TCM Model: Billing Services • Can only be done by one provider • Bill cannot be place prior to day 30 post-discharge • Patient cannot be readmitted within 30-days post-discharge MLN, 2016.

29. TCM Model: Documentation Requirements • Date of discharge • Date of interactive contact • Date of face-to-face visit • Complexity of medical decision making MLN, 2016.

30. Audience Response #3 Which of the following is true in regards to TCM services? • Interactive contact must be made within 2 days of discharge • High medical complexity patients must be seen within 14 days • TCM services can be billed as they are completed • Medication reconcilation must be completed no later than the face-to-face visit

31. Audience Response #3 Which of the following is true in regards to TCM services? • Interactive contact must be made within 2 days of discharge • High medical complexity patients must be seen within 14 days • TCM services can be billed as they are completed • Medication reconcilation must be completed no later than the face-to-face visit

32. Current trends in performing TOC • Multidisciplinary communication, collaboration and coordination • Comprehensive planning and risk assessment • Standardized transition plans, procedures and forms • Standardized training • Timely follow-up support and coordination after discharge TJC, Last accessed September 2018.

33. Interprofessional TCM Team

34. Interprofessional TCM Team Roles

35. Interprofessional TCM Team Roles • Pharmacists… • Review medication changes or discrepancies • Counsel on proper medication use and side effects • Identify need for additional or follow-up lab work • Identify medication related problems • Provide cost effective alternatives or patient assistance programs

36. TCM Challenges • Complete information to make informed clinical decisions • Access to medical records • Relationships between inpatient/outpatient

37. TCM Challenges • Billing for services • Multiple providers billing for TCM • Dropping bill at 30 days

38. TCM Challenges • Patient access • Unable to contact • Lack of transportation

39. Goals of TOC • Prevent medical errors • Identify problems for early intervention • Prevent unnecessary and costly hospitalization and readmission • Improve patient engagement in healthcare • Improve interprofessional communication CMS, Last accessed September 2018.

40. TCM Successes

41. TCM Successes

42. Interprofessional TCM Team

43. TCM Successes “They don’t care how much you know until they know how much you care.”

44. Audience Response #4 Who should be involved in TCM? • Physician • RN • Pharmacist • Social Worker • All of the above

45. Audience Response #4 Who should be involved in TCM? • Physician • RN • Pharmacist • Social Worker • All of the above

46. Audience Response #5 Which of the following is NOT a goal of TCM? • Prevent medication errors • Extinguish Medicaid slots • Improve patient engagement • Reduce hospital readmission

47. Audience Response #5 Which of the following is NOT a goal of TCM? • Prevent medication errors • Extinguish Medicaid slots • Improve patient engagement • Reduce hospital readmission

48. References • Transitions of Care. Content last reviewed June 2018. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html • Jencks SF, Williams MV, Coleman EA. “Rehospitalizations among patients in the Medicare fee-for-service program.” NEJM 2009;360:1418-28. • Aiming for fewer hospital u-turns: the Medicare hospital readmission reduction program. Content last reviewed May 2017. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/

49. References • Transitions of Care: The need for a more effective approach to continuing patient care. The Joint Commission. Accessed September 2018. https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf. • Improving Care Transitions. Centers for Medicare and Medicaid Services. Accessed September 2018. https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/care-transitions/index.html • Transitional Care Management Services. Content last review December 2016. Medicare Learning Network. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

50. Questions Contact Information Rachel A. Stephens, PharmD rastephens@practice-plus.com 501-812-7579 Kristen G. Belew, PharmD kgbelew@practice-plus.com 870-674-4136