Transcript Successful Discharge - Society of Hospital Medicine

Medication
Non-Adherence:
The Hidden Epidemic
Managing Medication Adherence & A Safe Hospital
Discharge
Incidence of Medication
Noncompliance
50% of the 1.8 billion prescription
medications dispensed annually
in the United States are not taken
correctly by patients
Adherence to Long-Term Therapies: Evidence for Action. WHO 2003
Smith DL - Med Interface 1993; 74-84
U.S. Patients Do Not Take
Medications as Prescribed
-12%
-12%
-29%
100%
88%
76%*
47%*
Rx prescribed
Rx filled
Rx taken
Rx continued
* 22% of U.S. patients take less of the medication than is prescribed
American Heart Association: Statistics you need to know. http://216.185.102.50/CAP/pro/prof_statistics2.html. Accessed July 27,
2002.
Impact of Medication Adherence on
Hospitalization Risk
60
50
40
30
20
10
0
1-19*
2039*
4059*
6079*
80100
Medication Possession Ratio
Diabetes
Hypertension
*P<0.05 when compared to the 80-100% group
Sokol etal. Med Care 2005;43: 521-530
Hypercholesterolemia
Healthcare Cost
Impact of Medication Adherence on AllCause Healthcare Costs
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Diabetes
1-19*
20-39*
Hypertension
40-59*
60-79+
80-100
Hypercholesterolemia
*P<0.05 when compared to the 80-100% group
+ P<0.05 when compared to the 80-100% group in Diabetes and Hypercholesterolemia Patients
Sokol etal. Med Care 2005;43: 521-530
Potential Barriers to
Improving Adherence
 Poor attitude
 Denial
 Memory deficits
 Fear or
 Language
 Literacy
 Cultural beliefs
 Alternative health
beliefs
 Poor support
 Pride
Vermiere E, et al. J Clin Pharm Ther. 2001;26:331-342.
embarrassment
 Side effects
 Religious beliefs
 Unable to “see”
results of drug
therapy
 Lack of choices
 Cost
What is CMAG?
 Developed from concepts presented by the World
Health Organization (WHO)

Case Management Adherence Guidelines or
CMAG provides an interaction and management
algorithm to assess and improve the patient's
knowledge and his/her motivation to take
medications as they are prescribed.
 The guidelines provide great flexibility in that
individual patient needs can be taken into
account.
WHO White Paper on
Adherence
 The World Health Organization has made a strong case
that medication adherence is based on three pillars:
patient information, motivation, and behavioral skill
requirements.
Adherence to Long-Term Therapies: Evidence for Action. WHO 2003
CMAG Algorithm
Case Management Adherence Guidelines. Copyright© 2004. CMSA
CMAG Assessment Tools
Tools to assess patient knowledge
 Health Literacy – RealmR
 Medication Knowledge Survey
 Modified Morisky Scale
Health Literacy
 Health literacy is defined as the ability to
read, understand, and act on health
information.
 Poor health literacy results in medication
errors, impaired ability to remember and
follow treatment recommendations, and
reduced ability to navigate within the
healthcare system.
 The Rapid Estimate of Adult Literacy in
Medicine-Revised (REALM-R), a brief
eight-item screening test
Bass Pf, Wilson JF, Griffith, CH. J Gen Intern Med.2003;18:1036-1038.
Medication Knowledge
Survey
Assesses knowledge of various
medications to be taken, their dosing
schedule, benefits and storage
Useful as part of the knowledge
assessment for CMAG to determine
if the patient is in the high or low
knowledge domain
CMAG Assessment Tools
Tools to assess patient motivation
 Readiness Ruler
 Duke-UNC Functional Social
Support Questionnaire
Readiness Ruler
 Assess willingness to change behavior
Zimmerman GL, Olsen CG, Bosworth MF. Am Fam Physician.2000:61;1409-1416
Social Support
 Family or social support is a significant
predictor of adherence to long-term
medical therapy
 Duke-UNC Functional Social Support
Questionnaire
 Eight-item, self-administered,
multidimensional instrument
Broadhead WE, et al. Med Care.1989:27;221-223.
Modified Morisky Scale
 Patients on existing therapy
 Morisky 4 item validated adherence predictor
scale
 Two new items to recognize patient
understanding of medication benefits as well as
refill behavior
 Allows patients to be categorized as either High
or Low on Knowledge and Motivation domains
Morisky DE, Green LW, Levine DM. Med Care. 1986;24:67-74.
New to CMAG
Revision
Recognize unique needs of those working with inpatients
Hospital Discharge
The Hospitalized Patient
 Acknowledges patients higher level of
acuity
 Case managers may only be involved
with a small percent of inpatients
 Case managers & Nurses have a
decreased period of time to interact
and plan interventions with patients
Successful Discharge
 Collaboration with other healthcare
providers both within and outside
the inpatient setting is extremely
important to ensure a Successful
Discharge
Steps to Ensure a
Successful Discharge
 Educate the patient and ensure patient
understanding on their diabetes disease process
and factors that can influence their condition
 Ensure the patient has the resources to manage
their diabetes after discharge from the hospital
 Make certain that the discharge will be “safe” for
the individual patient
 Ensure that the patient understands the plan for
transition of care into the post discharge setting
 Make certain that the patient has access to the
follow up care and therapy
Information for Patients to Ensure
a Successful Discharge
 Patients that are educated regarding their
diabetes and treatments are more likely to
remain adherent to treatment recommendations
 Many patients discharged from the hospital will
leave on new medications or different routes of
administration
Information for Patients to Ensure
a Successful Discharge
 Medications that are newly started during
hospitalization need to be reconciled with other
medications
 Patients need to know how to monitor their
diabetes and treatment in an outpatient setting.
Questions Addressed With Patients
Prior To Discharge
 What is wrong with me and what will this
condition mean to my long-term health?
 What do I need to do when I get home to treat
my condition?
 Who should I contact if I have questions
regarding my treatment after I am discharged?
 What are things that I need to watch for to know
if my condition is getting worse and what should
I do if these occur?
 How will I pay for my outpatient medical
supplies or services?
Why discharge counseling and adherence
messaging are important for the hospital?
 Maintain Accreditation
 JCAHO, NCQA, CMS
 Successfully compete with other hospitals in the
community
 Patient satisfaction
 Publicly available quality rankings
 Financial
 Prevent readmissions
 Promote timely patient discharges
Competitive Advantage for Hospital
Discharge Planning
 Hospitals seek to be viewed as providing an
outstanding level of care
 Hospitals work to maintain a high level of
patient satisfaction
 Discharge counseling is one of the last points of
contact with the patient
 Patients and payers can now easily compare
quality indicators on hospitals in their
community
 www.hospitalcompare.hhs.gov
 www.jcaho.org/quality+check/home.htm
Current State of Hospital Discharge
Counseling and Adherence Messaging
Studies of patients recently discharged from
the hospital have found that:
 < 50% of patients could state their
diagnosis
 < 50% of patients could list all their
medications
 < 25% of patients could state common side
effects and what to expect from their
medications,
 Patients taking three or more medications
were more likely to have problems with
medication knowledge
King, 1998; Makaryus, 2005
Key Elements of Successful
Discharge Planning
 Recruit a champion
 Build a multidisciplinary hospital team
 Review baseline data
 Develop protocols and order sets that include




appropriate evidence-based therapies
Conduct hospital staff conferences to introduce
process and gain buy in
Continue data analysis and report results back to
hospital staff on a regular basis
Evaluate data and look for opportunities for
improvement
Create an adherence program
AHA, Get with the Guidelines
Coordination of Care and Transition
of Care Outside the Hospital
Transition of Care to the
Outpatient Setting
 Involve family and caregivers in patient
education
 Ensure that patient has a plan for outpatient
follow up
 Facilitate referral for outpatient services and
healthcare providers
 Assist patients with resolving issues relating
to the cost of outpatient services and
treatments
 Evaluate Adherence Intention prior to
discharge using CMAG tools