“Can I get a Med Rec?”

Heath Denmark, PA-SIISouth University c/o 2013May 10, 2012

And then what?

Patient Care Doesn’t End at Discharge

Alper E, O’Malley TA, Greenwald J. Hospital Discharge. UpToDate.com. Dec 19, 2011

Time for DischargeDischarge planning is a mandatory complex

process that seeks to determine the appropriate level of services required by the patient and then match the patient to an appropriate site of care.

This process ideally begins at the start of the hospitalization

Discharge Process ElementsDischarge planning

Medication reconciliation

Discharge summary

Patient instructions

Discharge checklist

Post-Discharge Site of CareWhen it has been determined that a patient is

medically ready for discharge, the health care team must determine the most appropriate setting for ongoing care.

Need to consider: Medical Functional Social

Home?Must consider these factors first:

Patient cognitive status Patient activity level and functional status The nature of the patient's current home and

suitability for the patient's conditions (eg, presence of stairways, cleanliness)

Availability of family or companion support Ability to obtain medications and services Availability of transportation from hospital to home

and for follow-up visits Availability of services in the community to assist

the patient with ongoing care

Medication ReconciliationAccurate list of home meds

Needs to be updated

Accurate list of medications being taken at time of discharge

Indications for each medication changes or initiation of new meds

In Sweden, patients 80 years or older who were randomly assigned to receive a medication reconciliation intervention by unit-based pharmacists had 16 percent fewer visits to the hospital and 47 percent fewer emergency department visits than controls. Medication-related readmissions were reduced by 80 percent.

Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reducemorbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med 2009;169:894

Unresolved Issues with Med Recs Who should perform medication reconciliation (eg, nurse,

pharmacist, physician)?

How can resources (personnel, systems) be most effectively allocated to perform medication reconciliation, and reimbursement attached to safety-oriented, time-consuming tasks such as medication reconciliation?

How should one determine the "gold standard" list of medications for individual patients, to use as the basis for reconciliation?

How can aftercare providers reliably be informed of medication changes in a timely and accurate fashion?

How can patients and family/caregivers be engaged in understanding the importance of medication reconciliation?

Important Elements ofDischarge SummaryThe outcome of the hospitalization

The disposition of the patient

Provisions for follow-up care including appointments, statements of how care needs will be met, and plans for additional services (eg, hospice, home health assistance, skilled nursing)

Patient InstructionsOne model for patient materials, developed by

the National Patient Safety Foundation, is called Ask Me 3.1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Discharge instructions, both written and verbal, should be reviewed with the patient/family caregivers with an emphasis on assessing and ensuring comprehension.

Discharge Checklist

Factors Contributing toRehospitalizationMany rehospitalizations are unavoidable

Progression of disease process Separate problem unrelated to initial admission Patient not following through with initial discharge

plan

However, many are also preventable Systemic review of 34 studies found that the

median proportion of readmissions deemed avoidable was 27% but what was deemed “preventable” was varied between the studies.

van Walraven C, Bennett C, Jennings A, et al. Proportion of hospital readmissions deemedavoidable: a systematic review. CMAJ 2011; 183:E391.

Modifiable Factors of RehospitalizationSeveral factors that increase the likelihood of

rehospitalization may be modifiable Premature discharge or inadequate post-discharge

support Insufficient follow-up Therapeutic errors Adverse drug events and other medication related

issues Failed handoffs Complications following procedures Nosocomial infections, pressure ulcers, and patient

falls.

Therapeutic ErrorMedication error occurs in approximately 20%

of patients post-discharge

Examples of these types of errors include: Patients sent home without prescriptions for

necessary medications Patients receiving duplicate prescriptions for

medications they have at home labeled with different name (eg, generic and proprietary names)

Inadequate monitoring and follow-up for drug side effects

Failed HandoffsPoor information transfer from hospital-based

providers to primary care providers occurs commonly Tests that are pending at discharge often fail to be

communicated to providers responsible for their follow-up

Failed Handoff cont. In one study, 41 percent of discharged patients

had a test pending at discharge. Almost one in ten patients potentially required an intervention, but almost two-thirds of responsible aftercare providers were unaware that a test was outstanding.

A meta-analysis revealed that only 12 to 34 percent of discharge summaries had reached aftercare providers by the time of the first post hospitalization appointment

Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that returnafter hospital discharge. Ann Intern Med 2005; 143:121

Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transferbetween hospital-based and primary care physicians: implications for patient safety and continuityof care. JAMA 2007; 297:831.

Absent or Delayed Follow UpMost studies affirm that patients who are

scheduled or seen for post hospital follow-up are less likely to be readmitted

High Risk PatientsScreening for increased risk may help

healthcare providers and organizations target resources to patients most likely to be rehospitalized.

Clinical factors to consider for risk assessment Use of high risk medication

antibiotics, glucocorticoids, anticoagulants, narcotics, antiepileptic medications, antipsychotics, antidepressants, and hypoglycemic agents

Polypharmacy (five or more medications)

Specific clinical conditions eg, advanced COPD, diabetes, heart failure,

stroke, cancer, weight loss, and depression

Demographic factors to consider for risk assessmentPrior hospitalization, typically including

unplanned hospitalizations within the last 6 to 12 months

Black race

Low health literacy

Reduced social network i.e. Living alone with little or no contacts

Post Discharge InterventionsFollow-up

Phone call

Communication with ambulatory provider

Home visits

Phone CallCalls have been moderately effective at

reducing emergency department visits and improving follow-up with providers, but demonstrated a trend towards reduced hospital readmissions in only one study

Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patientsafter hospitalization. Am J Med 2001; 111:26S.

Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospitaldischarge to enhance patient care: a randomized controlled study. J Gen Intern Med 2008; 23:1228

Home VisitsOne trial illustrated that a single home visit by

a nurse and pharmacist to patients discharged with a diagnosis of heart failure, with a goal of optimizing medication management, showed a trend towards almost a 50 percent reduced risk of unplanned readmission

Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients withcongestive heart failure discharged from acute hospital care. Arch Intern Med 1998; 158:1067.

TelemonitoringUsing an integrated telephonic stethoscope in

conjunction with follow-up nursing calls in patients with heart failure reduced emergency department visits in one small study, and demonstrated a trend toward reduced readmissions and overall costs. blood pressure heart rate weight Oxygen saturation

Multidisciplinary Team EffortA nurse discharge advocate to assist with

discharge planning and preparation

A clinical pharmacist to call the patient 2-4 days following hospital discharge, to review the medication list, address any medication questions or concerns, reinforce the plan, and assess for adverse effects related to medications

Follow-up appointments scheduled at times convenient to the patient

Medication reconciliation

A low literacy discharge instruction booklet for patients, also provided to the primary care clinician

H2HA new quality improvement initiative by the

American College of Cardiology (ACC) and the Institute for Healthcare Improvement (IHI) called Hospital to Home (H2H) was developed to help in this endeavor. The program was designed to improve patient outcomes and decrease readmission rates for cardiovascular patients, specifically heart failure (HF) and acute myocardial infarction (AMI) patients. The goal of the H2H initiative is to decrease HF and AMI readmission rates by 20% by the year 2012

SummarySeveral systems initiatives have shown

promise in minimizing rehospitalizations. These interventions include improved collaboration between the care team, patient, and aftercare provider prior to discharge; medication reconciliation; enhanced patient education and empowerment; home visits or telephone calls by clinical providers; remote monitoring; and early post-discharge follow up. Patient instructions should take into account the patient's cognitive status, health literacy, and other barriers to self-care. Multiple concurrent interventions may be more effective than single components.