Maryland Patient Safety Center s Annual MEDSAFE Conference: Taking Charge of Your Medication Safety Challenges November 3, 2011 The Conference Center at the Maritime Institute
Pharmacy-Driven Inpatient Discharge Counseling Service: Impact on 30-day hospital readmission rate Azizza K. Davis, Pharm.D. Clinical Specialist, Internal Medicine Daryn K. Norwood, Pharm.D., BCPP, BCPS, CGP Clinical Specialist, Internal Medicine Program Director, PGY-2 Pharmacy Residency in Internal Medicine
Objectives At the end of this presentation the audience will able be to: Identify potential risk factors for patients at risk for frequent readmissions Describe a process for addressing readmission prevention in a community teaching hospital
Background 2015 ASHP initiative Objective 1.4: Hospital inpatients discharged with complex and highrisk medication regimens will receive discharge medication counseling managed by a pharmacist in 75% of hospitals. Objective 1.6: In 90% of hospitals, pharmacists will ensure that effective medication reconciliation occurs during transitions across the continuum of care. Link: http://www.ashp.org/s_ashp/docs/files/2015_goals_objectives_0508.pdf Am J Health-Syst Pharm. 2008(65):1451-57.
Background Drug-Related Problems Treatment failures due to possible noncompliance with medication regimen Total estimated cost is $100 billion annually Approximately 2 million hospital readmissions each year can be traced to noncompliance Approximately 125,000 Americans die each year because of noncompliance Arch Intern Med. 2008(116):565-71. Am J Health-Syst Pharm. 1998(55)1:1127-33.
Background Drug-Related Problems Adverse drug reactions (ADRs) 12-17% of general medicine patients experience ADRs after hospital discharge 6-12% of ADRs result in emergency department visits ~ 5% result in hospital readmissions Arch Intern Med. 2008(116):565-71. Am J Health-Syst Pharm. 1998(55)1:1127-33.
Pilot Impact on 30 day all cause hospital readmission rates
Hospital Union Memorial Hospital Baltimore, Maryland Approximately 220 bed community hospital 80,000 visits per year General Medicine Service 4 Internal Medicine Teams Approximately 10-15 patients per Medicine Team
Pharmacy Discharge Counseling Pilot Service Overview Hours: 0900-1600 (Monday-Friday) Limited to General Medicine Service Pharmacy discharge counseling has been shown to improve readmission rates and improve utilization costs Ann Intern Med 2009; 150: 178-87
Pilot Goals and Objectives Identifying High Risk patients Providing extra support for High Risk patients Improve dialogue about discharge planning across the various disciplines Referral to a transitional care clinic for High Risk patients on the general medicine service Coordination of transitional care or primary care visits prior to discharge Pharmacy discharge counseling for High Risk patients on the General Medicine Teams
Criteria for identifying High Risk patients? Each item = 2 points, Score > 10 = high risk Admitted to the hospital/visited ER > 3 times within past year Age > 65 years Taking anticoagulant therapy Taking > 5 medications Comorbidities 2 or more comorbidities (i.e. HTN, HIV, DM, etc.) (= 2 points) OR Core measure disease (PNA, MI, CHF) regardless of other comorbidities (= 4 points) Homeless / No available transportation Substance abuse (active or past history) Unable to afford medications/non-compliance No identified PCP Dependent with difficulty performing activities of daily living
Role of Pharmacy Each Medicine team has a dedicated pharmacist for daily rounds The pharmacist screens patients to determine those at High Risk status during daily rounds If the pharmacist identifies the patient as High Risk The pharmacist does the following Works with team on discharge medications Obtains an order for Pharmacy Discharge Counseling
Pharmacy Discharge Medication List Reviewed with the Medicine team prior to discharge Medication list signed by prescriber and pharmacist Signed by patient to reflect understanding after counseling session General Pharmacy Discharge Counseling Form and copy of Pharmacy Discharge Medication List are placed in patient s chart
Discharge Medication List Discharge Counseling Form
Making a Difference? What have we seen? High Risk vs. Non-High Risk Approximately 20% higher rate of comorbid disease states in the High Risk group About twice as many patients in the High Risk group were discharged on > 5 medications Comparable rate of core measure disease states between the two groups Comparable lengths of stay between groups
Impact of Pharmacy Counseling on Readmission Rates 30-Day readmission rates (May August 2011) High Risk: 14 % Non-High Risk: 26% Agency for Healthcare Research and Quality (AHRQ) Another pharmacy initiative evaluating the discharge process Higher rate of Accurate Discharge Instructions in the High Risk group
Proposed Goals Improve patient compliance and adherence to medication regimen Optimize and streamline medications on discharge Optimize affordability of medications Prevent or minimize adverse events post discharge Improve 30-day readmission rates
Ideas on the Horizon Dependent on additional FTE support Consideration for expanding service to the hospitalist service Developing a role for a medication management pharmacist in the transitional care clinic Evaluating impact on Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) Survey Improving Hospital discharge process overall
Acknowledgements Lieser Mayo, RPh, PhD. Pharmacy Director Marybeth Kazanas, Pharm.D., BCPS Pharmacy Clinical Coordinator Allison Chilipko, Pharm.D., BCPS Clinical Specialist, Internal Medicine Aroonjit Anne Jenkosol, Pharm.D., BCPS Clinical Specialist, Internal Medicine Kimberly Still, Pharm.D. PGY-2 Pharmacy Resident in Internal Medicine Pharmacy Chris Price, MD, Ph.D Chief Medical Informatics Officer Rohit Gulati, MD, MBA Medical Director, Utilization and Quality
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