Tara Higgins, pharmd , cdoe , cvdoe Clinical pharmacy director

1. 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

2. 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

3. Medication Safety

4. “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

5. The Facts 75% ~500,000 ER visits 40% annual US cost of drug mis-adventures of drug spend due to specialty by 2014 ≥ 5 chronic medications Driven by 7chronic conditions Due to prescription painkiller misuse per year Taken by 1/3 of all U.S. adults of healthcarecosts $290B ~50-60% Adherence rates Specialty impact on the rise Major contributor to poor outcomes Drug-related morbidity and mortality costs Source: Congressional Budget Office, 2005 National 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

6. 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

7. Medication Reconciliation

8. Definition Medication 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.”

9. Roles in Medication Reconciliation

10. Ideas to Improve Medication Reconciliation

11. 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?

12. 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

13. Patient-Centered Medication Therapy Management

14. Medication Therapy Management in Ambulatory Care Patient understands her medications, participates in care plan to improve health Appropriate, Effective, Safe and Adherent Medication Use Clinical Pharmacist Physicians/Providers Patient Nurse Care Manager

15. Highest Risk Patients

16. Pharmacist Collaboration Levels in Primary Care Models Smith, et.al. Health Affairs 32, No. 11. (2013);1963-1970

17. 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

18. Medication Adherence “The extent to which the patient continues the agreed-upon mode of treatment under limited supervision when faced with conflicting demands” Compliance Adherence Commitment Persistence Consistency

19. Key Predictors of Medication Persistence

20. 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.

21. Challenges with Medication Persistence

22. 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

23. Summary

24. Medication Related Problems Lack of care coordination Inconsistent monitoring Health beliefs Health illiteracy Past medication experiences Non-adherence Gaps in care Inappropriate prescribing Ineffective prescribing Adapted from Smith, et.al. Health Affairs. 2011;30(4):646-54

25. 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

26. Questions?