Why are we involved? Transitions of Care: The Financial Burden and Impact on Delivery of Care .
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Why are we involved?
Transitions of Care: Transitions of Care: The Financial Burden The Financial Burden
and Impact on and Impact on Delivery of CareDelivery of Care
www.ntocc.orgwww.ntocc.org
Current State of HealthcareCurrent State of Healthcare
Care is complexCare is complex Care is uncoordinatedCare is uncoordinated Information is often not available to those who Information is often not available to those who
need it when they need itneed it when they need it As a result patients often do not get care they As a result patients often do not get care they
need or do get care they don’t needneed or do get care they don’t need
IOM, Crossing the Quality Chasm
What is “Transition of Care”What is “Transition of Care”
The The movement of patientsmovement of patients from one health care from one health care practitioner or setting to another as their condition and practitioner or setting to another as their condition and care needs changecare needs change
Occurs at multiple levelsOccurs at multiple levels– Within SettingsWithin Settings
Primary care Primary care Specialty care Specialty care ICU ICU Ward Ward
– Between SettingsBetween Settings Hospital Hospital Sub-acute facility Sub-acute facility Ambulatory clinic Ambulatory clinic Senior center Senior center Hospital Hospital Home Home
– Across health statesAcross health states Curative care Curative care Palliative care/Hospice Palliative care/Hospice Personal residence Personal residence Assisted living Assisted living
(c) Eric A. Coleman, MD, MPH
What is “Transitional Care?”What is “Transitional Care?”
A set of actions designed to ensure the coordination and A set of actions designed to ensure the coordination and continuity of health care as patients transfer between continuity of health care as patients transfer between different locations or different levels of care within the same different locations or different levels of care within the same locationlocation
Based on a comprehensive care plan and availability of well-Based on a comprehensive care plan and availability of well-trained practitioners that have current information about the trained practitioners that have current information about the patient's goals, preferences, and clinical status.patient's goals, preferences, and clinical status.
Includes:Includes:– Logistical arrangementsLogistical arrangements– Education of the patient and familyEducation of the patient and family– Coordination among the health professionals involved in Coordination among the health professionals involved in
the transitionthe transition
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
Ineffective Transitions Ineffective Transitions Lead to Poor OutcomesLead to Poor Outcomes
Wrong treatmentWrong treatment Delay in diagnosisDelay in diagnosis Severe adverse eventsSevere adverse events Patient complaintsPatient complaints Increased healthcare costsIncreased healthcare costs Increased length of stayIncreased 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
PatientPatientPatientPatient
ERERERER ICUICUICUICU
In-PatientIn-PatientIn-PatientIn-Patient
PatientPatientPatientPatient
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
SNFSNFSNFSNF ALFALFALFALF
Transition Issues Dramatically Transition Issues Dramatically Impact Patient CareImpact Patient Care
Transition Issues Dramatically Impact Transition Issues Dramatically Impact Patient CarePatient Care
Patient
ER ICU
In-Patient
Patient
OUTPATIENT:• Home• PCP• Specialty• Pharmacy• Case Mgr.• Care Giver
SNF ALF
NOMedication
Reconciliation
NOPersonal
Medicine List
NO Coordinated
Care Plan
NODischargeCare Plan
NO Care Plan
NO Medication Reconciliation
NO Personal Medicine List
NO Care Plan
NO Medication Reconciliation
NO Personal Medicine List
Barriers to Improving Barriers to Improving Transitions of CareTransitions of Care
We Need To Understand Them First!We Need To Understand Them First!
Barriers to Care CoordinationBarriers to Care Coordination
System level barriersSystem level barriers Practitioner level barriersPractitioner level barriers Patient level barriersPatient level barriers
(c) Eric A. Coleman, MD, MPH
(c) Eric A. Coleman, MD, MPH
System Level BarriersSystem Level Barriers
Practitioner Level BarriersPractitioner Level Barriers
Practitioners often have not practiced in settings Practitioners often have not practiced in settings where they transfer patientswhere they transfer patients
Sending practitioners may not communicate Sending practitioners may not communicate critical information to receiving practitionerscritical information to receiving practitioners
Practitioners may not know the patient and his Practitioners may not know the patient and his or her preferences for careor her preferences for care
Practitioners have no accountabilityPractitioners have no accountability
(c) Eric A. Coleman, MD, MPH
Patient Level BarriersPatient Level Barriers
Patients assume that someone is in charge of Patients assume that someone is in charge of coordinating carecoordinating care
Patients (and caregivers) are often the only Patients (and caregivers) are often the only common thread weaving between care sites common thread weaving between care sites
Yet they navigate the system with few tools or Yet they navigate the system with few tools or training to manage in this roletraining to manage in this role
(c) Eric A. Coleman, MD, MPH
Problems that Illustrate Problems that Illustrate Inadequacies of Care TransitionsInadequacies of Care Transitions
Medication errorsMedication errors Increased health care utilizationIncreased health care utilization Inefficient/duplicative careInefficient/duplicative care Inadequate patient/caregiver preparationInadequate patient/caregiver preparation Inadequate follow-up careInadequate follow-up care DissatisfactionDissatisfaction Litigation/Bad publicityLitigation/Bad publicity
(c) Eric A. Coleman, MD, MPH
The Facts…The Facts…
Hospital AdmissionHospital Admission
On hospital admission, more than 50% of On hospital admission, more than 50% of patients have at least one medication patients have at least one medication discrepancy*discrepancy*
– Approximately 40% of those have potential to Approximately 40% of those have potential to cause harmcause harm
Cornish PL et al. Arch Intern Med 2005;165:424-9.
*Discrepancy defined as error between admission medication orders and patient interview of medication history.
Hospital DischargeHospital Discharge
On discharge from the hospital, 30% of On discharge from the hospital, 30% of patients have at least one medication patients have at least one medication discrepancy* with the potential to cause discrepancy* with the potential to cause possible or probable harmpossible or probable harm
Kwan Y et al. Arch Intern Med 2007;167:1034-40.
*Most common discrepancy is omission of pre-admit medication.
AHRQ Hospital Survey on Patient AHRQ Hospital Survey on Patient Safety Culture: 2007 ReportSafety Culture: 2007 Report
Hospital to HomeHospital to Home
40% of patients experienced at least 1 40% of patients experienced at least 1 medical errormedical error
– Those with a “work-up” error* were 6 times Those with a “work-up” error* were 6 times more likely to be rehospitalized within 3 more likely to be rehospitalized within 3 monthsmonths
Moore C et al. J Gen Intern Med 2003;18:646-51.
*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).
Hospital to PCP transferHospital to PCP transfer
Meta-analysisMeta-analysis Direct communication between hospital Direct communication between hospital
physicians and primary care physicians physicians and primary care physicians occurred infrequently occurred infrequently
Discharge summary Discharge summary – Availability at first postdischarge visit low (12%-34%) Availability at first postdischarge visit low (12%-34%) – Remained poor at 4 weeks (51%-77%)Remained poor at 4 weeks (51%-77%)– Affected quality of care in ~25% of follow-up visitsAffected quality of care in ~25% of follow-up visits– Often lacked important information (e.g., lab results, Often lacked important information (e.g., lab results,
discharge medications, treatment, follow-up plan)discharge medications, treatment, follow-up plan)
Kripalani S, et al. JAMA 2007;297:831-41.
Completing Recommended Completing Recommended Outpatient WorkupsOutpatient Workups
TotalTotal
No. (%)No. (%)
CompletedCompleted
Workup TypeWorkup Type YesYes NoNo
Diagnostic procedureDiagnostic procedure 115 (47.9)115 (47.9) 50.450.4 49.649.6
Subspecialty referralSubspecialty referral 85 (35.4)85 (35.4) 72.672.6 27.427.4
Laboratory testLaboratory test 40 (16.7)40 (16.7) 85.085.0 15.015.0
TotalTotal 240 (100)240 (100) 64.164.1 35.935.9
Moore C et al. Arch Intern Med 2007.
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.
Hospital to Nursing HomeHospital to Nursing Home
Transfers and Adverse EventsTransfers and Adverse Events
Adverse drug events (ADEs) attributable to Adverse drug events (ADEs) attributable to medication changes occurred in 20% of bi-medication changes occurred in 20% of bi-directional transfersdirectional transfers
– 50% of ADEs were caused by 50% of ADEs were caused by discontinuation of medications during discontinuation of medications during hospital stayhospital stay
Boockvar K et al. Arch Intern Med 2004;164:545-50.
Independent Risk Factors for Independent Risk Factors for Having a Preventable ADEHaving a Preventable ADE
Risk FactorRisk Factor Odds RatioOdds Ratio 95% CI95% CI
MaleMale 0.550.55 0.30 - 0.990.30 - 0.99
No. regularly scheduled medsNo. regularly scheduled meds
0-40-4
5-65-6
7-87-8
>=9>=9
1.01.0
1.71.7
3.23.2
2.92.9
ReferentReferent
0.83 - 3.50.83 - 3.5
1.4 - 6.91.4 - 6.9
1.3 - 6.81.3 - 6.8
New residentNew resident++ 2.92.9 1.5 -5.71.5 -5.7
+within 60 days of admission
Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.
Adverse Events in Nursing Home Adverse Events in Nursing Home Residents Transferred to the HospitalResidents Transferred to the Hospital
122 nursing home to hospital transfers122 nursing home to hospital transfers 98% returned to the nursing home98% returned to the nursing home In 86% of transfers, at least one medication In 86% of transfers, at least one medication
order was altered (mean 1.4)order was altered (mean 1.4)– 65% - discontinued65% - discontinued– 19% - dose changes19% - dose changes– 10% - substitutions 10% - substitutions
20% of changes resulted in an adverse event20% 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 ‘07OIG Report – June ‘07
Consecutive Medicare stays involving inpatient Consecutive Medicare stays involving inpatient and skilled nursing facilitiesand skilled nursing facilities
Key findings …Key findings …– 35% of consecutive stays were associated with 35% of consecutive stays were associated with
quality-of-care problems and/or fragmentation of quality-of-care problems and/or fragmentation of servicesservices
– 11% of individual stays within consecutive stay 11% of individual stays within consecutive stay sequences involved problems with quality-of-care, sequences involved problems with quality-of-care, admission, treatments or dischargesadmission, treatments or discharges
DHHS; OIG, June 2007; OEI-07-05-00340
Cost of Morbidity Due to Cost of Morbidity Due to Medication ErrorsMedication Errors
Estimates:Estimates:– Hospital care: $3.5 billion (2006 dollars) (Bates et al., 1997)Hospital care: $3.5 billion (2006 dollars) (Bates et al., 1997)– Outpatient Medicare: $887 million (2000 dollars) (Field et al., Outpatient Medicare: $887 million (2000 dollars) (Field et al.,
2005)2005)
Many major costs are excluded, for example:Many major costs are excluded, for example:– Failure to receive drugs that should have been prescribedFailure to receive drugs that should have been prescribed– Patient non-compliance with prescribed drug regimensPatient non-compliance with prescribed drug regimens– Lost earnings and inability to perform household tasksLost earnings and inability to perform household tasks– Errors that do not result in harm, but create extra workErrors that do not result in harm, but create extra work
Costs of Adverse Drug EventsCosts of Adverse Drug Events
Bates et al, 1997Bates et al, 1997– Additional length of stay associated with ADE = 2.2 daysAdditional length of stay associated with ADE = 2.2 days– Increased cost associated with ADE = $3244Increased cost associated with ADE = $3244– For preventable ADEs, increased length of stay = 4.6 days; For preventable ADEs, increased length of stay = 4.6 days;
increased cost = $5857increased cost = $5857
Classen et al, 1997Classen et al, 1997– 91, 574 admissions over 4 years (1990-1993) in LDS hospital 91, 574 admissions over 4 years (1990-1993) in LDS hospital
(tertiary care facility)(tertiary care facility)– 2227 patients developed an ADE2227 patients developed an ADE– ADEs complicated 2.43 of 100 admissionsADEs complicated 2.43 of 100 admissions– Excess cost associated with ADE was $2013Excess cost associated with ADE was $2013
Data on Safety and QualityData on Safety and Quality
44,000-98,000 deaths/year in hospitals as a 44,000-98,000 deaths/year in hospitals as a result of adverse drug eventsresult of adverse drug events– Over 1,000,000 injuriesOver 1,000,000 injuries
Enormous practice variationEnormous practice variation– Estimated $450 billion unnecessary spendingEstimated $450 billion unnecessary spending
Slow translation of research to practiceSlow translation of research to practice– One estimate 17 yearsOne estimate 17 years
IOM, Crossing the Quality Chasm
Medication Errors Involving Medication Errors Involving Reconciliation FailureReconciliation Failure
September 2004 – July 2005 September 2004 – July 2005
MEDMARX Data (N=2022)MEDMARX Data (N=2022)
Site of ErrorSite of Error
AdmissionAdmission TransitionTransition DischargeDischarge
TotalTotal 23%23% 67%67% 12%12%
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
Medication Error Type by Medication Error Type by Transition CategoryTransition Category
Transition CategoryTransition Category
Error TypeError Type AdmissionAdmission TransitionTransition DischargeDischarge
Improper Improper Dose/QuantityDose/Quantity 55%55% 73%73% 62%62%
Prescribing ErrorPrescribing Error 49%49% 36%36% 27%27%
Omission ErrorOmission Error 35%35% 36%36% 76%76%
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
Case Examples of Medication Case Examples of Medication Errors on AdmissionErrors on Admission
Patient’s home medication recorded as CoregPatient’s home medication recorded as Coreg®® 25 mg 25 mg twice daily on admissiontwice daily on admission– Patient actually taking 6.25 mg twice daily at homePatient actually taking 6.25 mg twice daily at home– Patient received 4 doses of excessive strength and developed Patient received 4 doses of excessive strength and developed
leg edemaleg edema– Error was not discovered until after leg ultrasound test to rule Error was not discovered until after leg ultrasound test to rule
out DVTout DVT Nursing home patient receiving propranolol 20 mg/5mL Nursing home patient receiving propranolol 20 mg/5mL
twice dailytwice daily– Admitting orders written as propranolol 20 mg/mL give 5 mL Admitting orders written as propranolol 20 mg/mL give 5 mL
(which equates to 100 mg) twice daily(which equates to 100 mg) twice daily– Patient received 5 doses of 100 mg strength before error was Patient received 5 doses of 100 mg strength before error was
discovereddiscovered
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
Case Examples of Medication Case Examples of Medication Errors on Transition/TransferErrors on Transition/Transfer
Patient with prior history of several arterial stent Patient with prior history of several arterial stent replacementsreplacements– Receiving aspirin, enoxaparin, clopidogrelReceiving aspirin, enoxaparin, clopidogrel– Meds placed on hold prior to surgery for removal of toe; Meds placed on hold prior to surgery for removal of toe;
Physician did not reordered after surgeryPhysician did not reordered after surgery– 2 of patient’s coronary arteries with stents became 100% 2 of patient’s coronary arteries with stents became 100%
occluded; patient expiredoccluded; patient expired
Patient transferred from ICU to step-down unitPatient transferred from ICU to step-down unit– Prior to transfer, patient received morning doses of scheduled Prior to transfer, patient received morning doses of scheduled
meds meds – Administration of same meds repeated upon arrival to new unit Administration of same meds repeated upon arrival to new unit
due to unclear documentation and communicationdue to unclear documentation and communication
Source: U.S. Pharmacopeia Patient Safety CAPSLinkTM 2005.
National EffortsNational Efforts
The Joint Commission The Joint Commission National Patient Safety GoalsNational Patient Safety Goals
Goal 8: Accurately and completely reconcile Goal 8: Accurately and completely reconcile medications across the continuum of caremedications across the continuum of care– 8A: There is a process for comparing the patient/resident’s 8A: There is a process for comparing the patient/resident’s
current medications with those ordered for the patient/resident current medications with those ordered for the patient/resident while under the care of the organizationwhile under the care of the organization
– 8B A complete list of the resident’s medications is 8B A complete list of the resident’s medications is communicated to the next provider of service when a resident is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete level of care within or outside the organization. The complete list of medications is also provided to the patient/resident on list of medications is also provided to the patient/resident on discharge from the facilitydischarge from the facility
The Joint Commission National Patient Safety Goals. Available at htt://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm
A Report from the HMO Care Management Workgroup
Supported by the Robert Wood Johnson FoundationSupported by the Robert Wood Johnson Foundation
One Patient, Many Places:One Patient, Many Places:Managing Health Care TransitionsManaging Health Care Transitions
AGS Position StatementAGS Position Statement
Position 1Position 1::
Clinical professionals must prepare patients and their Clinical professionals must prepare patients and their caregivers to receive care in the next setting and caregivers to receive care in the next setting and actively involve them in decisions related to the actively involve them in decisions related to the formulation and execution of the transitional care formulation and execution of the transitional care planplan
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
AGS Position StatementAGS Position Statement
Position 2Position 2::
Bidirectional communication between clinical Bidirectional communication between clinical professionals is essential to ensuring high quality professionals is essential to ensuring high quality transition caretransition care
Position 3:Position 3:
Develop policies that promote high quality transitional Develop policies that promote high quality transitional carecare
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
AGS Position StatementAGS Position Statement
Position 4Position 4::
Education in transitional care should be provided to Education in transitional care should be provided to all health professionals involved in the transfer of all health professionals involved in the transfer of patients across settingspatients across settings
Position 5:Position 5:
Research should be conducted to improve the Research should be conducted to improve the process of transitional careprocess of transitional care
Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.
What Can We Do …What Can We Do …
The Care Transitions InterventionThe Care Transitions Intervention
Does encouraging Does encouraging older patients and older patients and their caregivers to their caregivers to assert a more assert a more active role in their active role in their care transition care transition reduce rates of reduce rates of rehospitalization?rehospitalization?
Coleman EA et al. Arch Intern Med 2006
Utilization OutcomesUtilization Outcomes
GroupGroup
Adj. Adj.
p-value*p-value*
OR OR
(95% CI)(95% CI)VariableVariable
InterventionIntervention
(n=379)(n=379)
ControlControl
(n=371)(n=371)
RehospitalizationRehospitalization
Within 30 dWithin 30 d 8.3%8.3% 11.9%11.9% .048.048 0.59 (0.35-1.00)0.59 (0.35-1.00)
Within 90 dWithin 90 d 16.7%16.7% 22.5%22.5% .04.04 0.64 (0.42-0.99)0.64 (0.42-0.99)
Rehospitalization for same dx as index hospitalizationRehospitalization for same dx as index hospitalization
Within 30 dWithin 30 d 2.8%2.8% 4.6%4.6% .18.18 0.56 (0.24-1.31)0.56 (0.24-1.31)
Within 90 dWithin 90 d 5.3%5.3% 9.8%9.8% .04.04 0.40 (0.26-0.96)0.40 (0.26-0.96)
Within 180 dWithin 180 d 8.6%8.6% 13.9%13.9% .046.046 0.55 (0.30-0.99)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 Follow-up of Hospitalized Elders with Heart FailureElders with Heart Failure
An advanced practice nurse home follow-up An advanced practice nurse home follow-up program reduced 1 year hospitalization rates by program reduced 1 year hospitalization rates by over 60% with a mean cost savings of $4,845 per over 60% with a mean cost savings of $4,845 per patientpatient
Naylor MD et al. J Am Geriatr Soc 2004;52:675-84.
Role of Pharmacist Counseling in Role of Pharmacist Counseling in Preventing ADEs After HospitalizationPreventing ADEs After Hospitalization
Does pharmacist counseling before discharge Does pharmacist counseling before discharge reduce the rate of preventable ADEs?reduce the rate of preventable ADEs?
Randomized controlled trial of pharmacist Randomized controlled trial of pharmacist intervention (n=92) vs usual care (n=84)intervention (n=92) vs usual care (n=84)
Intervention on day of dischargeIntervention on day of discharge– Medication reconciliationMedication reconciliation– Screening for nonadherence, previous drug-related Screening for nonadherence, previous drug-related
problems, lack of drug efficacy, and side effectsproblems, lack of drug efficacy, and side effects– Review of indications, directions for use, and Review of indications, directions for use, and
potential side effects with patient potential side effects with patient
Schnipper JL et al. Arch Intern Med 2006;166:565-71.
Study Outcomes: Pharmacist Study Outcomes: Pharmacist Intervention vs Usual CareIntervention vs Usual Care
Outcome*Outcome*
Pharmacist Pharmacist Intervention Intervention
(n=92)(n=92)
Usual Care Usual Care
(n=84)(n=84) P ValueP Value
Adverse drug events, No. (%)Adverse drug events, No. (%)
AllAll 14/79 (18)14/79 (18) 12/73 (16)12/73 (16) >.99>.99
Preventable Preventable 1/79 (1)1/79 (1) 8/73 (11)8/73 (11) .01.01
Health Care Utilization, No. (%)Health Care Utilization, No. (%)
ED visit or readmissionED visit or readmission 28/92 (30)28/92 (30) 25/84 (30)25/84 (30) >.99>.99
Medication-related Medication-related 4/92 (4)4/92 (4) 8/84 (8)8/84 (8) .36.36
Preventable medication-relatedPreventable medication-related 1/92 (1)1/92 (1) 7/84 (8)7/84 (8) .03.03
*Outcome 30 days postdischarge
Schnipper JL et al. Arch Intern Med 2006;166:565-71.
Readmission Rates with Comprehensive Readmission Rates with Comprehensive Discharge Planning + Postdischarge Support Discharge Planning + Postdischarge Support
Phillips CO et al. JAMA 2004;291:1358-67.
0.5 1.0 2Intervention Control
Relative RiskStrategyStrategy
InterventionIntervention
Events/Events/
Total Total
ControlControl
Events/Events/
TotalTotal
RRRR
(95% CI)(95% CI)
Single home Single home visitvisit 95/23395/233 129/243129/243 0.76 (0.63-0.93)0.76 (0.63-0.93)
Clinic follow-Clinic follow-up +/- phone up +/- phone 151/370151/370 161/395161/395 0.64 (0.32-1.28)0.64 (0.32-1.28)
Home visit +/- Home visit +/- phonephone 168/437168/437 262/533262/533 0.79 (0.69-0.91)0.79 (0.69-0.91)
Extended Extended home carehome care 132/438132/438 152/421152/421 0.82 (0.68-1.00)0.82 (0.68-1.00)
TotalTotal 555/1590555/1590 741/1714741/1714 0.75 (0.64-0.88)0.75 (0.64-0.88)
Transitions of CareTransitions of CareA National CrisisA National Crisis
Why are we involved?Why are we involved?
Sanofi aventis ChairmanSanofi aventis Chairman“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 non-adherence. 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.”
Tim Rothwell, Chairman, sanofi-aventis U.S.
The Case Management Society of America willThe Case Management Society of America willpositively impact and improve patient well positively impact and improve patient well being and patient health care outcomesbeing and patient health care outcomes
We envision case managers as pioneers of health care We envision case managers as pioneers of health care change: nursing case managers, disease managers, change: nursing case managers, disease managers, health care coaches, social workers, pharmacists, health care coaches, social workers, pharmacists, physicians and others who are key initiators of and physicians and others who are key initiators of and participants in the health care team as patient care participants in the health care team as patient care managers.managers.
The Statistics are StaggeringThe Statistics are Staggering
Despite wide distribution, evidencebased clinical practice guidelineshave not changed physician behaviors3
Medication Reconciliation across care settings is a Joint CommissionNational Patient Safety Goal
National Quality Forum (NQF) endorsed 3-Item Care CoordinationMeasures to expand voluntary hospital consensus standards incare transitions4,5
Mobilize sanofi-aventis resources to optimize appropriate medication use across all channels
Convene experts and apply evidence based clinical practice guidelines
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
COALITION LAUNCH October 18, 2006 - National Transitions of Care Coalition – Chicago
Collaboration with CMSA to lead multidisciplinary coalition of expertsEmployers – JCAHO - NQF – SHM – ACHE – ASHP – ASCP – ASA – AGS - IHI – NASW - URAC
Closing gaps across the continuum
4949
2008 Advisory Task Force2008 Advisory Task Force
These groups represent over 200,000 health care professionals, 11,000 employers and These groups represent over 200,000 health care professionals, 11,000 employers and 30,000,000 consumers throughout the United States.30,000,000 consumers throughout the United States.
Working to Address the Issues?Working to Address the Issues?
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 Motivation Knowledge 1. Do you ever forget to take your medicine?
Yes(0) No(1)
2. Are you careless at times about taking your medicine?
Yes(0) No(1)
3. When you feel better do you sometimes stop taking your medicine?
Yes(0) No(1)
4. Sometimes if you feel worse when you take your medicine, do you stop taking it?
Yes(0) No(1)
5. Do you know the long-term benefit of taking your medicine as told to you by your doctor or pharmacist?
Yes(1) No(0)
Draft NTOCC ToolsDraft NTOCC Tools
Raise NTOCC AwarenessRaise NTOCC Awareness Information and tools available by stakeholderInformation and tools available by stakeholder
Consumer Professional Policy Maker Media
SNFSNFSNFSNF ALFALFALFALF
ERERERER ICUICUICUICU In-PatientIn-PatientIn-PatientIn-Patient
The NTOCC Tools Make it PossibleThe NTOCC Tools Make it Possibleto Address the Transition Issuesto Address the Transition Issues
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
OUTPATIENT:OUTPATIENT:• HomeHome• PCPPCP• SpecialtySpecialty• PharmacyPharmacy• Case Mgr.Case Mgr.• Care GiverCare Giver
PatientPatientPatientPatient
My
Med List
Medication ReconciliationData Elements
+Care / Case
Transition Process
Working GroupsWorking Groups
Education & Education & AwarenessAwareness
Metrics & Metrics & OutcomesOutcomes
Policy & Policy & AdvocacyAdvocacy
Tools & Tools & ResourcesResources NTOCCNTOCC
We Can & Will Make A Difference!We Can & Will Make A Difference!
Case Studies for Case Studies for DiscussionDiscussion
Case 1Case 1
During a patient’s monthly follow-up During a patient’s monthly follow-up appointment with the cardiologist, he informed appointment with the cardiologist, he informed the doctor that he was having trouble with one the doctor that he was having trouble with one of his medications. The doctor asked which one. of his medications. The doctor asked which one. The patient said “The patch, the nurse told me The patient said “The patch, the nurse told me to put on a new one every day and now I’m to put on a new one every day and now I’m running out of places to put it!” The physician running out of places to put it!” The physician had him undress and discovered that the man had him undress and discovered that the man had over a two dozen patches on his body. had over a two dozen patches on his body.
Case 2Case 2
An older man with atrial fibrillation who takes An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. reduced to his usual dose prior to discharge. The new dose turned out to be double his usual The new dose turned out to be double his usual dose and within two days he was rehospitalized dose and within two days he was rehospitalized with uncontrollable bleeding. with uncontrollable bleeding.
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