Transcript Slide 1

Transitions of Care:
The Financial Burden
and
on
Why
areImpact
we involved?
Delivery of Care
www.ntocc.org
Current State of Healthcare
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Care is complex
Care is uncoordinated
Information is often not available to those who
need it when they need it
As a result patients often do not get care they
need or do get care they don’t need
IOM, Crossing the Quality Chasm
What is “Transition of Care”
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The movement of patients from one health care
practitioner or setting to another as their condition and
care needs change
Occurs at multiple levels
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Within Settings
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Between Settings
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Primary care  Specialty care
ICU  Ward
Hospital  Sub-acute facility
Ambulatory clinic  Senior center
Hospital  Home
Across health states
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Curative care  Palliative care/Hospice
Personal residence  Assisted living
(c) Eric A. Coleman, MD, MPH
What is “Transitional Care?”
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A set of actions designed to ensure the coordination and
continuity of health care as patients transfer between
different locations or different levels of care within the same
location
Based on a comprehensive care plan and availability of welltrained practitioners that have current information about the
patient's goals, preferences, and clinical status.
Includes:
– Logistical arrangements
– Education of the patient and family
– Coordination among the health professionals involved in
the transition
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
Ineffective Transitions
Lead to Poor Outcomes
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Wrong treatment
Delay in diagnosis
Severe adverse events
Patient complaints
Increased healthcare costs
Increased length of stay
Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature
Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/
AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf
Transition Issues Dramatically
Impact Patient Care
Patient
ER
ICU
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Care Giver
In-Patient
SNF
Patient
ALF
Transition Issues Dramatically Impact
Patient Care
NO
Discharge
Care Plan
Patient
ER
ICU
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Care Giver
NO
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
NO
Medication
Reconciliation
NO
Personal
Medicine List
NO
Coordinated
Care Plan
In-Patient
SNF
Patient
ALF
NO
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
Barriers to Improving
Transitions of Care
We Need To Understand Them First!
Barriers to Care Coordination
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System level barriers
Practitioner level barriers
Patient level barriers
(c) Eric A. Coleman, MD, MPH
System Level Barriers
(c) Eric A. Coleman, MD, MPH
Practitioner Level Barriers
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Practitioners often have not practiced in settings
where they transfer patients
Sending practitioners may not communicate
critical information to receiving practitioners
Practitioners may not know the patient and his
or her preferences for care
Practitioners have no accountability
(c) Eric A. Coleman, MD, MPH
Patient Level Barriers
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Patients assume that someone is in charge of
coordinating care
Patients (and caregivers) are often the only
common thread weaving between care sites
Yet they navigate the system with few tools or
training to manage in this role
(c) Eric A. Coleman, MD, MPH
Problems that Illustrate
Inadequacies of Care Transitions
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Medication errors
Increased health care utilization
Inefficient/duplicative care
Inadequate patient/caregiver preparation
Inadequate follow-up care
Dissatisfaction
Litigation/Bad publicity
(c) Eric A. Coleman, MD, MPH
The Facts…
Hospital Admission
On hospital admission, more than 50% of
patients have at least one medication
discrepancy*
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Approximately 40% of those have potential to
cause harm
*Discrepancy defined as error between admission medication orders and
patient interview of medication history.
Cornish PL et al. Arch Intern Med 2005;165:424-9.
Hospital Discharge
On discharge from the hospital, 30% of
patients have at least one medication
discrepancy* with the potential to cause
possible or probable harm
*Most common discrepancy is omission of pre-admit medication.
Kwan Y et al. Arch Intern Med 2007;167:1034-40.
AHRQ Hospital Survey on Patient
Safety Culture: 2007 Report
Hospital to Home
40% of patients experienced at least 1
medical error
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Those with a “work-up” error* were 6 times
more likely to be rehospitalized within 3
months
*Work-up error occurred if an outpatient test or procedure suggested or
scheduled by the inpatient provider was not adequately followed up by the
outpatient provider (e.g., colonoscopy for positive fecal occult blood test
scheduled at discharge but not documented in outpatient chart).
Moore C et al. J Gen Intern Med 2003;18:646-51.
Hospital to PCP transfer
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Meta-analysis
Direct communication between hospital
physicians and primary care physicians
occurred infrequently
Discharge summary
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Availability at first postdischarge visit low (12%-34%)
Remained poor at 4 weeks (51%-77%)
Affected quality of care in ~25% of follow-up visits
Often lacked important information (e.g., lab results,
discharge medications, treatment, follow-up plan)
Kripalani S, et al. JAMA 2007;297:831-41.
Completing Recommended
Outpatient Workups
Total
No. (%)
Yes
No
Diagnostic procedure
115 (47.9)
50.4
49.6
Subspecialty referral
85 (35.4)
72.6
27.4
Laboratory test
40 (16.7)
85.0
15.0
Total
240 (100)
64.1
35.9
Workup Type
Completed
Workup Type is the outpatient workup recommended upon discharge from
the hospital. Completed indicates whether the recommended workup was
done within 6 months after discharge. 240 workups recommended in 191
discharges.
Moore C et al. Arch Intern Med 2007.
Hospital to Nursing Home
Transfers and Adverse Events
Adverse drug events (ADEs) attributable to
medication changes occurred in 20% of bidirectional transfers
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50% of ADEs were caused by
discontinuation of medications during
hospital stay
Boockvar K et al. Arch Intern Med 2004;164:545-50.
Independent Risk Factors for
Having a Preventable ADE
Risk Factor
Odds Ratio
95% CI
0.55
0.30 - 0.99
1.0
1.7
3.2
2.9
Referent
0.83 - 3.5
1.4 - 6.9
1.3 - 6.8
2.9
1.5 -5.7
Male
No. regularly scheduled meds
0-4
5-6
7-8
>=9
New resident+
+within
60 days of admission
Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.
Adverse Events in Nursing Home
Residents Transferred to the Hospital
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122 nursing home to hospital transfers
98% returned to the nursing home
In 86% of transfers, at least one medication
order was altered (mean 1.4)
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65% - discontinued
19% - dose changes
10% - substitutions
20% of changes resulted in an adverse event
Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.
OIG Report – June ‘07
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Consecutive Medicare stays involving inpatient
and skilled nursing facilities
Key findings …
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35% of consecutive stays were associated with
quality-of-care problems and/or fragmentation of
services
11% of individual stays within consecutive stay
sequences involved problems with quality-of-care,
admission, treatments or discharges
DHHS; OIG, June 2007; OEI-07-05-00340
Cost of Morbidity Due to
Medication Errors
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Estimates:
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Hospital care: $3.5 billion (2006 dollars) (Bates et al., 1997)
Outpatient Medicare: $887 million (2000 dollars) (Field et al.,
2005)
Many major costs are excluded, for example:
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Failure to receive drugs that should have been prescribed
Patient non-compliance with prescribed drug regimens
Lost earnings and inability to perform household tasks
Errors that do not result in harm, but create extra work
Costs of Adverse Drug Events
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Bates et al, 1997
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Additional length of stay associated with ADE = 2.2 days
Increased cost associated with ADE = $3244
For preventable ADEs, increased length of stay = 4.6 days;
increased cost = $5857
Classen et al, 1997
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91, 574 admissions over 4 years (1990-1993) in LDS hospital
(tertiary care facility)
2227 patients developed an ADE
ADEs complicated 2.43 of 100 admissions
Excess cost associated with ADE was $2013
Data on Safety and Quality
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44,000-98,000 deaths/year in hospitals as a
result of adverse drug events
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Enormous practice variation
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Over 1,000,000 injuries
Estimated $450 billion unnecessary spending
Slow translation of research to practice
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One estimate 17 years
IOM, Crossing the Quality Chasm
Medication Errors Involving
Reconciliation Failure
September 2004 – July 2005
MEDMARX Data (N=2022)
Site of Error
Total
Admission
Transition
Discharge
23%
67%
12%
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
Medication Error Type by
Transition Category
Transition Category
Error Type
Admission
Transition
Discharge
Improper
Dose/Quantity
55%
73%
62%
Prescribing Error
49%
36%
27%
Omission Error
35%
36%
76%
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
Case Examples of Medication
Errors on Admission
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Patient’s home medication recorded as Coreg® 25 mg
twice daily on admission
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Patient actually taking 6.25 mg twice daily at home
Patient received 4 doses of excessive strength and developed
leg edema
Error was not discovered until after leg ultrasound test to rule
out DVT
Nursing home patient receiving propranolol 20 mg/5mL
twice daily
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Admitting orders written as propranolol 20 mg/mL give 5 mL
(which equates to 100 mg) twice daily
Patient received 5 doses of 100 mg strength before error was
discovered
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
Case Examples of Medication
Errors on Transition/Transfer
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Patient with prior history of several arterial stent
replacements
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Receiving aspirin, enoxaparin, clopidogrel
Meds placed on hold prior to surgery for removal of toe;
Physician did not reordered after surgery
2 of patient’s coronary arteries with stents became 100%
occluded; patient expired
Patient transferred from ICU to step-down unit
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Prior to transfer, patient received morning doses of scheduled
meds
Administration of same meds repeated upon arrival to new unit
due to unclear documentation and communication
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
National Efforts
The Joint Commission
National Patient Safety Goals
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Goal 8: Accurately and completely reconcile
medications across the continuum of care
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8A: There is a process for comparing the patient/resident’s
current medications with those ordered for the patient/resident
while under the care of the organization
8B A complete list of the resident’s medications is
communicated to the next provider of service when a resident is
referred or transferred to another setting, service, practitioner or
level of care within or outside the organization. The complete list
of medications is also provided to the patient/resident on
discharge from the facility
The Joint Commission National Patient Safety Goals. Available at
htt://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm
One Patient, Many Places:
Managing Health Care Transitions
A Report from the HMO Care
Management Workgroup
Supported by the Robert Wood Johnson Foundation
AGS Position Statement
Position 1:
Clinical professionals must prepare patients and their
caregivers to receive care in the next setting and
actively involve them in decisions related to the
formulation and execution of the transitional care
plan
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
AGS Position Statement
Position 2:
Bidirectional communication between clinical
professionals is essential to ensuring high quality
transition care
Position 3:
Develop policies that promote high quality transitional
care
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
AGS Position Statement
Position 4:
Education in transitional care should be provided to
all health professionals involved in the transfer of
patients across settings
Position 5:
Research should be conducted to improve the
process of transitional care
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
What Can We Do …
The Care Transitions Intervention
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Does encouraging
older patients and
their caregivers to
assert a more
active role in their
care transition
reduce rates of
rehospitalization?
Coleman EA et al. Arch Intern Med 2006
Utilization Outcomes
Group
Variable
Intervention
(n=379)
Control
(n=371)
Adj.
p-value*
OR
(95% CI)
Rehospitalization
Within 30 d
8.3%
11.9%
.048
0.59 (0.35-1.00)
Within 90 d
16.7%
22.5%
.04
0.64 (0.42-0.99)
Rehospitalization for same dx as index hospitalization
Within 30 d
2.8%
4.6%
.18
0.56 (0.24-1.31)
Within 90 d
5.3%
9.8%
.04
0.40 (0.26-0.96)
Within 180 d
8.6%
13.9%
.046
0.55 (0.30-0.99)
*Adjusted for age, sex, education, race, self-reported health status, chronic disease score, prior
hospitalization and ED utilization and discharge diagnosis
Coleman EA et al. Arch Intern Med 2006
Follow-up of Hospitalized
Elders with Heart Failure
An advanced practice nurse home follow-up
program reduced 1 year hospitalization rates by
over 60% with a mean cost savings of $4,845 per
patient
Naylor MD et al. J Am Geriatr Soc 2004;52:675-84.
Role of Pharmacist Counseling in
Preventing ADEs After Hospitalization
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Does pharmacist counseling before discharge
reduce the rate of preventable ADEs?
Randomized controlled trial of pharmacist
intervention (n=92) vs usual care (n=84)
Intervention on day of discharge
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Medication reconciliation
Screening for nonadherence, previous drug-related
problems, lack of drug efficacy, and side effects
Review of indications, directions for use, and
potential side effects with patient
Schnipper JL et al. Arch Intern Med 2006;166:565-71.
Study Outcomes: Pharmacist
Intervention vs Usual Care
Outcome*
Pharmacist
Intervention
(n=92)
Usual Care
(n=84)
P Value
Adverse drug events, No. (%)
All
14/79 (18)
12/73 (16)
>.99
1/79 (1)
8/73 (11)
.01
ED visit or readmission
28/92 (30)
25/84 (30)
>.99
Medication-related
4/92 (4)
8/84 (8)
.36
Preventable medication-related
1/92 (1)
7/84 (8)
.03
Preventable
Health Care Utilization, No. (%)
*Outcome 30 days postdischarge
Schnipper JL et al. Arch Intern Med 2006;166:565-71.
Readmission Rates with Comprehensive
Discharge Planning + Postdischarge Support
Intervention
Control
Events/
Total
Events/
Total
(95% CI)
Single home
visit
95/233
129/243
0.76 (0.63-0.93)
Clinic followup +/- phone
151/370
161/395
0.64 (0.32-1.28)
Home visit +/phone
168/437
262/533
0.79 (0.69-0.91)
Extended
home care
132/438
152/421
0.82 (0.68-1.00)
Total
555/1590
741/1714
0.75 (0.64-0.88)
Strategy
RR
Relative Risk
0.5
1.0
Intervention
Phillips CO et al. JAMA 2004;291:1358-67.
2
Control
Transitions of Care
A National Crisis
Why are we involved?
Sanofi aventis Chairman
Tim Rothwell,
Chairman, sanofi-aventis U.S.
“Sanofi-aventis is supporting the National Transitions
of Care Coalition (NTOCC) and its multidisciplinary
team of health care leaders to address complex
issues like health literacy, patient safety and nonadherence. At sanofi-aventis, patients are at the
center of all we do. Our mission is to fight for
patient’s health and well being - because health
matters. If we fail to help patients understand why
they need to take medications, or how to take them, it
can lead to non-adherence. Non-adherence can lead
to increased emergency room visits, admittance or
re-admittance to hospitals, longer hospital stays,
higher health care costs and even life-threatening
situations. We believe the work of this Coalition will
play a vital role for health care professionals,
patients, caregivers, and payers.”
The Case Management Society of America will
positively impact and improve patient well
being and patient health care outcomes
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We envision case managers as pioneers of health care
change: nursing case managers, disease managers,
health care coaches, social workers, pharmacists,
physicians and others who are key initiators of and
participants in the health care team as patient care
managers.
The Statistics are Staggering
Non-adherence statistics:
•45% of hospital NRxes or Rx
changes are never documented
in out-patient medical records1
•12% of NRxes are never filled2
•29% don’t complete LOT2
•22% take < than prescribed2
•Average hospital LOS due to
medication non-compliance is
4.2 days2
Closing gaps across the continuum
Convene experts and apply
evidence based clinical practice
guidelines
Despite wide distribution, evidence
based clinical practice guidelines
have not changed physician behaviors3
Medication Reconciliation across
care settings is a Joint Commission
National Patient Safety Goal
Mobilize sanofi-aventis
resources to optimize
appropriate medication use
across all channels
National Quality Forum (NQF)
endorsed 3-Item Care Coordination
Measures to expand voluntary
hospital consensus standards in
care transitions4,5
COALITION LAUNCH
October 18, 2006 - National Transitions of Care Coalition – Chicago
Collaboration with CMSA to lead multidisciplinary coalition of experts
Employers – JCAHO - NQF – SHM – ACHE – ASHP – ASCP – ASA – AGS - IHI – NASW - URAC
2008 Advisory Task Force
These groups represent over 200,000 health care professionals, 11,000 employers and
30,000,000 consumers throughout the United States.
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Working to Address the Issues?
Draft NTOCC Tools
Medication
Reconciliation
Transitions of Care List
Example of Assessment & Coordination of Care Communication Check
List
MEDICATION Assessment:
 Be sure you cover all prescribed meds, over-the-counter medications and
health/nutritional supplements
Name of Medication
Dose
Route
Frequency
Next Refill
Can the patient tell you:
Reason they are taking medication
Positive Effects of taking medication
Symptoms or side effects of taking medication
Where does the patient keep their medication at home
When is the next refill date for their medication
How long will the patient need to remain on the medication
Question
1. Do you ever forget to
take your medicine?
2. Are you careless at times
about taking your
medicine?
3. When you feel better do
you sometimes stop taking
your medicine?
4. Sometimes if you feel
worse when you take your
medicine, do you stop
taking it?
5. Do you know the longterm benefit of taking your
medicine as told to you by
your doctor or pharmacist?
Motivation
Yes(0) No(1)
Yes(0)
Knowledge
No(1)
Yes(0)
No(1)
Yes(0) No(1)
Yes(1) No(0)
Raise NTOCC Awareness
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Information and tools available by stakeholder
Consumer
Professional
Policy Maker
Media
The NTOCC Tools Make it Possible
to Address the Transition Issues
Medication
Reconciliation
Data Elements
+
Care / Case
Transition Process
My
Med List
ER
ICU
In-Patient
OUTPATIENT:
• Home
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Care Giver
Patient
SNF
ALF
Working Groups
Education &
Awareness
Tools &
Resources
NTOCC
Metrics &
Outcomes
Policy &
Advocacy
We Can & Will Make A Difference!
Case Studies for
Discussion
Case 1
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During a patient’s monthly follow-up
appointment with the cardiologist, he informed
the doctor that he was having trouble with one
of his medications. The doctor asked which one.
The patient said “The patch, the nurse told me
to put on a new one every day and now I’m
running out of places to put it!” The physician
had him undress and discovered that the man
had over a two dozen patches on his body.
Case 2
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An older man with atrial fibrillation who takes
warfarin for stroke prophylaxis was hospitalized
for pneumonia. His dose of warfarin was
adjusted during the hospital stay and was not
reduced to his usual dose prior to discharge.
The new dose turned out to be double his usual
dose and within two days he was rehospitalized
with uncontrollable bleeding.