Transcript Pharmacists Role in Prevention of Hospital Readmissions

Preventing Hospital
Readmissions:
Pharmacists’ Role in
Transitions of Care
JENNIFER SHANNON, PHARMD, BCPS
SHARON F. CLACKUM, PHARMD, CGP, CDM, FASCP
Objectives
After completing the session learners will understand…
the literature that describes post-hospital medication discrepancies that
result in adverse events
changes in the hospital, facility and physician payment structure that make
transitions of care programs more attractive to health systems
the appropriate target within a hospital or facility for a proposal and how to
pitch your pharmacy services
the IMPACT Act of 2014
specific ways to target patients discharging from hospitals to long-term care
facilities to ALC or home
Transition of Care
The movement patients make between health care practitioners
and settings as their condition and care needs change during the
course of a chronic or acute illness
Coleman EA, Boult CE. Improving the Quality of Transitional Care for Persons with
Complex Care Needs. J of the Amer Ger Society. 2003; 52(4): 556-557
Barriers to Successful Care Transitions
Number of providers involved in patient’s care
Inaccurate documentation during hospital stay
Prescribing errors
Inaccurate medication profile at discharge
Polypharmacy
Inadequate patient education on discharge medications
Failure to provide patient follow-up
Medication errors remain the core of
hospital readmission problems
60% of all medication errors in the hospital occur at admission, intra-hospital
transfer, or discharge
Approximately 20% of patients discharged from hospital to home will
experience an adverse event during transition
◦ 65% to 70% of these events are associated with medications
◦ 77% of these patients receive inadequate medication instructions
Anticoagulants, antiplatelet agents, insulin, and oral hypoglycemic agents
account for the majority of medication-related hospitalizations
Institute of Medicine. Washington DC: National Academies Press; 2000
Butterfield S, et al. www.psqh.com/mayjune-2011/838-understanding care transitions.
Just in case you missed it….
60% of hospital medication errors occur
during care transitions!
A brief review of the literature can demonstrate why and how
pharmacists should be part of the care transition team
Deficits in communication and
information transfer between hospitalbased and primary care physicians:
implications for patient safety and
continuity of care
Sunil Kripalani, MD, MSc; Frank LeFevre, MD; et al
JAMA. 2007;297(8):831-841
Kripalani, et al
Objective was to evaluate communication deficits during
transfers of care and post hospital discharge between hospital
and primary care physicians
A review of 55 observational studies demonstrated was
conducted
Study demonstrated that information related to medications was
missing from discharge summaries 40% of the time
The availability of the discharge summary for outside providers
to view remained low, leading to increased prescribing errors
following discharge
Emergency hospitalizations for
adverse drug events in older
Americans
Budnitz DS, Lovegrove MC, Shehab N, et al
N Engl J Med. 2011;365:2002-12
Budnitz, DS et al
identified the medications involved in 88.3% of emergency
department admissions of older adults by adverse drug events
◦ 2/3 were due to accidental drug overdoses
◦ Medications identified were: hematologic, endocrine,
cardiovascular, central nervous system, and anti-infectives
◦ Warfarin, oral hypoglycemics, insulins, and oral antiplatelet
drugs were responsible for 7 out of 10 readmissions
What does the aforementioned literature support?
Readmission rates among Medicare
Beneficiaries
On average, 1 in 5 Medicare beneficiaries discharged from the
hospital is readmitted in 30 days costing the health system $150
billion annually
76% of hospital readmissions are preventable
Jencks, Stephen F., Mark V. Williams, and Eric A. Coleman. “Rehospitalizations among
Patients in the Medicare Fee-for-Service Program.” NEJM 2009; 360:1418-28
The Regulatory and Financial
Impact on Hospitals
The Patient Protection and
Affordable Care Act
2012: Penalties enacted on hospitals with high
readmission rates for heart failure, myocardial
infarction, and pneumonia
2015: Expanded to total hip and knee replacements
and chronic obstructive pulmonary disease (COPD)
exacerbations
2017: Coronary artery bypass graft (CABG) to be added
to readmission penalties list
Centers for Medicare and Medicaid
Initiated penalization for hospital readmissions beginning FY 2013
CMS estimates approximately 2/3 of US hospitals did receive penalties of up
to 1% of their reimbursement from Medicare during the 2013 fiscal year
CMS increased penalties to 3% in FY 2015 for
Incremental increase in penalties will continue to occur after FY 2015
CMS expected to recoup $280 million from the 2,217 hospitals who care for
patients with Medicare coverage with high readmission rates
.
http://www.jointcommission.org/core_measure_sets.aspx
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
Centers for Medicare and Medicaid
It is estimated that CMS will recoup from FY 2015
roughly $424 million dollars from over 2600 hospitals
An average penalty of $160,000 per hospital in the US
The Joint Commission (JCAHO)
National Patient Safety Goal 03.06.01
◦ Maintain and communicate accurate patient medication
information
Core Measures
◦ Stroke
◦ VTE
◦ Heart failure
◦ AMI
◦ Pneumonia
◦ Tobacco treatment
Where do Pharmacists Play a Role?
Provider collaboration
Patient education and communication
Medication reconciliation
Transitional Care Management Billing Codes: 99495 and 99496
◦
◦
◦
◦
◦
Used to report qualified physician or qualified non-physician management services
Services must be performed during the first 30 days following patient discharge
Provider accepts responsibility for patient’s care following discharge without a gap
The patient has medical or psychosocial problems that require high or complex decision
making
Pharmacists, alone, are incapable of billing for these codes – requires a medical director
willing to perform face-to-face follow up visits.
Postdischarge pharmacist
medication reconciliation: Impact
on Readmission Rates and
Financial Savings
Kilcup M, et al. J Am Pharm Assoc. 2013;53:78-84
Kilcup M, et al
Ad hoc retrospective comparison and quality improvement analysis from September 2009-February
2010 on 494 patients (243 in med review group and 251 in comparison group)
Evaluated patients discharged who were at higher risk for readmission at 7 days, 14 days, and 30 days
readmission
Patients with the following factors were considered high risk:
◦ Current hospitalization was a readmission
◦ Patients with complex care plans
◦ Primary diagnosis of chronic disease
◦ Major medication changes during hospital stay
◦ Concern for patients ability to self manage
Study Methods
Clinical pharmacists contacted patients 72 hours post discharge
Comprehensive medication reviews were performed
◦ Pharmacist reviewed unexplained discrepancies
◦ Discussed changes with the patient
◦ Pharmacists documented encounter and was sent to patient’s primary
care provider
◦ Also documented medication omissions, therapeutic duplicates, dose
changes, discontinued medications, and drug-drug interactions
Primary Outcomes
Rate of hospital readmission and health system financial savings
Rate of medication discrepancies for patients who receive clinical pharmacist medication
reconciliation
Cost-Savings Calculations:
Estimated cost of readmission for medical admits: $10,000
Estimated cost for clinical pharmacist labor required for assessment: $73.33/hour (including
benefits)
Estimated time required of clinical pharmacist: 37 minutes
Readmission rates
At 7 days postdischarge, 2 patients in the med review group and 11 patients
in the comparison group were readmitted (p = 0.01)
At 14 days postdischarge, 11 patients in the med review group and 22
patients in the comparison group were readmitted (P=0.04)
At 30 days postdischarge, 28 patients in the medication review group and 34
patients in the comparison group were readmitted (P=0.29)
80% of patients had at least one medication discrepancy after discharge, with
many patients having multiple discrepancies
Evidence to support the pharmacists’ role
Author/Journal
Title
Pharmacist
Intervention
Primary outcome
Results
Jack BM, et al.
A Reengineered
hospital discharge
program to
decrease
hospitalization
(Project RED)
Clinical Pharmacist
at 2-4 days
following
discharge
Rate of
rehospitalization in
30 days in 749
patients.
Decreased 30 day discharge by 30% in
intervention group
Avg cost savings per discharge:$412
Medication
Reconciliation at
Hospital Discharge:
Evaluating
Discrepancies
Clinical
pharmacists
performed at
discharge
Rate of medication
discrepancy at
discharge and
clinical impact on
patients
106 of 170 pts had medication
discrepancy at discharge
Role of pharmacist
counseling in
preventing adverse
drug events after
hospitalization
Clinical
Rate of preventable
pharmacists
ADEs within 30
performed at
days of discharge
discharge, then 3-5
days later
Annals of Internal
Medicine
Wong, et al.
Annals of
Pharmacotherapy
Schnippner JL, et al.
Archives of Internal
Medicine
At 30 days, 1 patient in intervention group
had a preventable ADE vs 8 patients in the
control group
The Core of Transition
of Care Programs
Establish the relationship
Establish point of contact responsible for quality improvement
for the hospital
Discuss a potential meeting about value-added services
Develop a transition of care team in conjunction with the
hospital
Transition of Care Program
Goals
Provide enhanced patient care services
Provide a continuum of care from the hospital to home through
community pharmacy care
Reduce readmission and adverse events
Reduce cost to the health system and patients
Ensure regulatory compliance
Interventions performed by
pharmacists during care transitions
Contact patient within 24 hours of hospital discharge to establish follow-up
consult
Detailed review and reconciliation of drug orders between hospital and PCP
Analysis of prescription, OTC, vitamins, supplements, herbal remedies
Comparison of patient’s preadmission and discharge medication lists
◦ Omissions, discontinued medications, dose changes, therapeutic
duplicates, drug-drug interactions
◦ Discussion of unintended medication discrepancies with providers for
resolution
Medication reconciliation during consult
Perform comprehensive medication history
Verify patient’s current medication list
Provide updated medication list to patient
Provide patient/caregiver medication education
◦ Indications for use and importance of adherence to therapy
◦ Proper administration (self-injection technique, inhaler technique, etc)
◦ Goals of therapy (A1C, BG, BP, Cholesterol, INR, etc)
◦ Disease state monitoring
◦ Potential adverse effects
Provide interpretive tools to assist patients with barriers to taking medication
Ensure patient access to medications – including lower cost alternatives and
insurance formularies
Additional resources
APhA and ASHP have developed a resource center
◦ http://www.ashp.org/menu/practicepolicy/resourcecenters/t
ransitions-of-care
ASHP-APhA constructed a manual on best practices
management
◦ http://media.pharmacist.com/practice/ASHP_APhA_Medicati
onManagementinCareTransitionsBestPracticesReport2_2013.
pdf
Closing thoughts
Determine a hospital to develop a transition of care relationship
Schedule meeting to demonstrate the result of pharmacist intervention
Enhance your credentials and certifications to perform direct patient care in your
pharmacy setting (consider hiring a clinical pharmacist with residency training)
Collect performance improvement data (errors, omissions, etc)
Implementation of a program is worth the community relationship!
◦ Offer the program for free at first to prove your worth (and pick up the patient referrals)
IMPACT ACT OF 2014
https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Post-Acute-Care-QualityInitiatives/IMPACT-Act-of-2014-and-Cross-SettingMeasures.html
LTPAC = Long Term Post Acute Care
Affects the 4 major areas of LTPAC
◦ Long Term Care Hospitals (LTCHs)
Skilled Nursing Facilities (SNFs)
Inpatient Rehabilitation Facilities (IRFs)
Home Health Agencies (HHAs)
◦ Goal : To standardize reporting of key domains to
improve interoperability and cost
IMPACT ACT OF 2014
4 areas currently report using different tools
Long Term Care Hospitals (LTCHs) LTCH Care Data Set
Skilled Nursing Facilities (SNFs)
MDS-minimum data set
Inpatient Rehabilitation Facilities (IRFs) PAI-Patient
Assessment Instrument
Home Health Agencies (HHAs)
OASIS- Outcome and
Assessment Information Set
Goal is to create one data set that contains the
information in a consistent manner. Current
workaround is to complete individual data tools PLUS
additional data collection ---time consuming and
duplicative
IMPACT ACT OF 2014
Measure Domains to be standardized:
Skin integrity and changes in skin integrity;
Functional status, cognitive function, and changes in function and cognitive
function;
Medication reconciliation;
Incidence of major falls;
Transfer of health information and care preferences when an individual
transitions;
Resource use measures, including total estimated Medicare spending per
beneficiary;
Discharge to community; and
All-condition risk-adjusted potentially preventable hospital readmissions rates.
IMPACT ACT of 2014
WHY does this matter to me ??
New opportunities for business
◦ Transitions of Care
◦ Consulting for Home Health Agencies & Hospice
◦ Ability to pick up new customers
◦ Collaborative Practice Agreements
◦ ACO/PCMH Practice Agreements
◦ Self Insured Employers
Transitions of Care
Hospital to Home
Hospital to Assisted Living Community (ALC)
Hospital to Home Health Agency (HHA)
Hospital to Skilled Nursing Facility (SNF)
Hospital to LTC Hospital
Hospital to IRF (Inpatient Rehab Facility)
SNF to Home
SNF to ALC
SNF to HHA
PAIN POINT –Each institution does a fair job of medication
reconciliation during the stay –Problem: NO coordination with
home or community pharmacy –primary care provider
Transitions of Care
Hospitals / Home Health Agencies / Skilled Nursing Facilities /
Accountable Care Organizations (ACO)
Agreements with Hospitals to be part of Preferred Network or
contracting to become an ACO
GOALS: 1) to prevent rehospitalizations (negatively affects
hospital reimbursement)
2) Participate in New Medicare Billing Models based on
outcomes
Ways for Pharmacist to Participate
1. Transitions of Care Programs
2. Annual Wellness Visit
3. Ongoing Disease State Management
Transitions of Care Program
3 requirements:
1. Phone call within 48 hours of hospital discharge
◦ Requires Medication Reconciliation
◦ Care Coordination
◦ Adverse Side Effects
2. MD/Hospital Clinic follow-up –Face to Face Visit (location
of visit not specified)
◦ High Risk –within 7 days CPT Code 99496
◦ Medium Risk – within 14 days CPT Code 99495
3. PRN Visits
MD/Clinic can charge $115-$250 per visit –the pharmacist
negotiates how much of that amount they should receive for
care provided
Transitions of Care Visit
Clinical staff (under the supervision of a physician or
other qualified clinician) may include:
•communicate with the patient or caregiver (by phone, email, or in person),
•communicate with a home health agency or other
community service that the patient needs,
•educate the patient and/or caregiver to support selfmanagement and activities of daily living,
•provide assessment and support for treatment
adherence and medication management,
Transitions of Care Visit (cont)
Clinical staff (under the supervision of a physician or
other qualified clinician) may include:
•identify available community and health resources, and
facilitate access to services needed by the patient and/or
caregivers.
•interact with other clinicians who will assume or resume care of
the patient's system-specific conditions,
•educate the patient and/or caregiver,
•establish or re-establish referrals for specialized care, and
•assist in scheduling follow-up with other health services.
Home Health Agencies (HHA)
Required to perform Medication
Reconciliation
List of medications – historically –
nothing else ..not really reconciled
Need pharmacist input –review of medication lists –
especially high risk patients
Study shows 86% reduction in readmission of Level 1
patients with telephonic intervention
Zillich AJ, Snyder ME, Frail CK, et al. A randomized, controlled pragmatic trial of telephonic medication
therapy management to reduce hospitalization in home health patients. Health Serv Res. 2014 Apr 9
Home Health Agencies (HHA)
Patients needs:
◦ Current medication list – what do I take ? -- why can’t I
use what I already have?
◦ Do they actually have the medications prescribed on
discharge ?
◦ Do they have all the equipment needed to take
medications (nebulizer, insulin pen needles, glucose
monitoring strips, blood pressure monitor, spirometer)
Skilled Nursing Facility (SNF)
If you haven’t visited one lately
(within last 6 months) –GO VISIT
Big change from old concept of nursing home
Subacute Rehabilitation Beds (10-50% or higher of
capacity)
Length of stay in Rehab = 10-21 days
Transition to Home or ALF –frequently with Home
Health
Skilled Nursing Facility (SNF)
Need coordinated care to prevent rehospitalizations or
readmission to SNF – Transitions of Care CPT cover SNF
Discharge
Hospital/SNF/Home Health on the hook for 90 days—
decreased reimbursement if rehospitalization occurs -up to 3% of TOTAL Medicare billing ($428 million
annually for 2015) http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turnsthe-medicare-hospital-readmission-reduction-program/
Readmission Target Categories
Heart Failure
Heart Attack (AMI)
Pneumonia
COPD
TKR (total Knee replacement)
THR (total Hip replacement)
Coming Soon for 2017 – CABG (coronary artery bypass
graft)
ACO-PCMH Opportunities
What is PCHM ?
Patient Centered Medical Home --coordinates care
across all elements of the broader health care system,
including specialty care, hospitals, home health care,
and community services and supports.
33 Quality measures ---Pharmacist can affect 23 of
those QA measures
Annual Wellness Visit –The pharmacist can bill directly
to ACO/PCMH.
ACO-PCMH Opportunities
Don’t have to meet the “incident to” billing
requirements
Billed under MD NPI –approximately $183 per
evaluation, negotiate your reimbursement PLUS
potential of Chronic Care Management
Comprehensive medication reconciliation, medication
action plan, and adherence review
Disease Management and
Collaborative Practice Agreements
Opportunities for Pharmacists – Do you need a specialty ??
◦
◦
http://www.pharmacycredentialing.org/files/certificationprogra
ms.pdf
Specialty Certifications
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Anticoagulation
Asthma
COPD
Diabetes
Heart Failure
HIV/AIDS
Infectious Diseases
Oncology
Pain
Psychiatric
Poisons/Toxicology
Nutrition Support
Geriatrics
Nuclear Pharmacy
Psychiatry
Ambulatory Care
Pharmacotherapy
Critical Care
Pediatrics
Disease Management and
Collaborative Practice Agreements
Disease State Management (DSM) & Collaborative Practice Agreements
(CPA) can be set up in a multitude of ways –must be compliant with
state board rules and Medicare billing rules (if applicable)
Chronic Care Management CPT® Code 99490 – minimum of 20
minutes/month –billed at $42 pmpm (per member / per month) No MD
supervision** required –visit not required to be face to face
Disease State Management agreements with Self Insured Employers –
negotiated rates –generally pmpm
Collaborative Practice Agreements with specific physicians for targeted
patient group
Discharge planning agreements with Hospitals, Home Health Agencies,
Skilled Nursing Facilities
Opportunities Abound –Take
Advantage
With constantly changing reimbursement rules, opportunities to
expand your pharmacy practice are endless, but you MUST know
the rules and present your case effectively to gain new business.
1. Research the rules and billing requirements
2. Determine your costs to provide the service – Maximize Technology
3. Are they interested ?? Start with the Medical Director or Administrator
4. Be willing to entertain risk sharing ---UNDERSTAND the risks (90 day trial)
5. Negotiate a fair price for services
6. Bill and Collect ---DON’T give your services away !!!
7. Measure your outcomes --- this is the key to gaining more business!
8. Start small and DO IT WELL !!!!
Resources
Hospital Readmission Program
https://www.medicare.gov/hospitalcompare/readmissionreduction-program.html
ACO Quality Measures
https://https://www.medicwww.cms.gov/Medicare/Medicare-Feefor-Service-Payment/sharedsavingsprogram/Downloads/MSSPQM-Benchmarks-2015.pdf
Nursing Home Compare
are.gov/nursinghomecompare/search.html
Home Health Compare
https://www.medicare.gov/homehealthcompare
QUESTIONS ?