Transition of Care

Define a transition of care and explain the need for managing transitions of care

• Movement of a patient from one setting of care to another

• Ex settings: 

  • hospital

  • ambulatory care/primary care

  • ambulatory specialty care practice

  • long-term care facility

  • home health

  • rehabilitation facility 

Identify and define quality measures that track transitional care management activities 

• Examples

  • Hospitalized adult patient with eart failure who were given complete written discharge instructions

  • Communicate about discharge information 

  • Median hospital 30-day risk standardized readmission rate 

HF discharge instructions

• Data from CMS

• Tracked data from 2005-13

• Sex, race/ethnicity 

• Achieved benchmark by 5 states

Discharge Communication 

• Measure: pt who did not receive good communication about discharge information

  • Lower number = better  

• Data from 2009-14

• Disparities 

  • “In all years, Black and Asian patients were less likely than White patients to receive good communication about discharge information”

  • “In all years except 2012, AI/AN patients were less likely than White patients to receive good communication about discharge information”

Readmission 

• Readmission refers to an unplanned admission to a hospital for any condition or procedure 30 days after discharge 

• Hospital readmission shortly after discharge is a marker of inpatient quality of care and a significant contributor to rising health care cost 

• 2013 - 2/3 of US hospitals faced financial penalities from CMS because of excessively high 30-day readmission rates for acute MI, HF, and pneumonia 

• Lower rates = better 

• Readmission rate show if hospital is doing best to deliver quality care, preventing complications, and making sure pt has smooth transition where ever they are going 

Describe roles for pharmacists and pharmacy technicians in managing transitions of care

• Risk of adverse event can possible be from medication errors that may be preventable 

• Ex of transitions of care programs run by pharmacist:

  • Heart failure education on discharge from hospital admission with heart failure

    • Outcome: 30-day readmission

  • Medication reconciliation 

    • Outcome: prevent adverse drug events 

  • Primary care transitional care management 

    • Outcome: (looking for medication discrepancies from discharge;) prevent adverse drug events

Identify and describe key components in the medication reconciliation process

Comprehensive list should include

• All rx meds, herbal supplements, vitamins, OTCs
  
  

Best Possible Medication History

• No perfect list

• Taken by anyone in the health field. Histories taken by pharmacist or pharm techs are more complete than those taken by other healthcare professionals

• Started in the ED if that is where pt entered

Process 

• Before EMRs, most health systems → paper forms for med recs

• With EMRs → med rec section

  • Different health professions are responsible for different things

    • Nurse in ED gets initial list from pt. Sometimes there is a pharm tech that is with a pharm 

    • Pt admitted in inpatient floor, provider receives list and reconciles what should be continued, stopped, changed or started