1. Preventing Hospital Readmissions: Pharmacists’ Role in Transitions of Care JENNIFER SHANNON, PHARMD, BCPS SHARON F. CLACKUM, PHARMD, CGP, CDM, FASCP

2. 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

3. 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

4. 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

5. 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.

6. 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

7. Deficits in communication and information transfer between hospital- based 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

8. 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

9. 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

10. 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

11. What does the aforementioned literature support?

12. 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

13. The Regulatory and Financial Impact on Hospitals

14. 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

15. 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

16. 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

17. 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

18. 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.

19. Postdischarge pharmacist medication reconciliation: Impact on Readmission Rates and Financial Savings Kilcup M, et al. J Am Pharm Assoc. 2013;53:78-84

20. 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

21. 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

22. 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

23. 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

24. Evidence to support the pharmacists’ role Author/JournalTitlePharmacist Intervention Primary outcomeResults Jack BM, et al. Annals of Internal Medicine 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 Wong, et al. Annals of Pharmacotherapy 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 Schnippner JL, et al. Archives of Internal Medicine Role of pharmacist counseling in preventing adverse drug events after hospitalization Clinical pharmacists performed at discharge, then 3-5 days later Rate of preventable ADEs within 30 days of discharge At 30 days, 1 patient in intervention group had a preventable ADE vs 8 patients in the control group

25. The Core of Transition of Care Programs

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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)

32. IMPACT ACT OF 2014 https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/Post-Acute-Care-Quality- Initiatives/IMPACT-Act-of-2014-and-Cross-Setting- Measures.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)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

33. 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 SetLong Term Care Hospitals (LTCHs)Skilled Nursing Facilities (SNFs)Inpatient Rehabilitation Facilities (IRFs)Home Health Agencies (HHAs) 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

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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, e- mail, 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 self- management and activities of daily living, provide assessment and support for treatment adherence and medication management,

40. 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.

41. 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

42. 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)

43. 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

44. 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-turns- the-medicare-hospital-readmission-reduction-program/

45. 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)

46. 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.

47. 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

48. Disease Management and Collaborative Practice Agreements Opportunities for Pharmacists – Do you need a specialty ?? ◦http://www.pharmacycredentialing.org/files/certificationprogra ms.pdfhttp://www.pharmacycredentialing.org/files/certificationprogra ms.pdf ◦Specialty Certifications ◦AnticoagulationNutrition Support ◦AsthmaGeriatrics ◦COPDNuclear Pharmacy ◦DiabetesPsychiatry ◦Heart FailureAmbulatory Care ◦HIV/AIDSPharmacotherapy ◦Infectious DiseasesCritical Care ◦OncologyPediatrics ◦Pain ◦Psychiatric ◦Poisons/Toxicology

49. 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

50. 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 !!!!

51. Resources Hospital Readmission Program https://www.medicare.gov/hospitalcompare/readmission- reduction-program.html ACO Quality Measures https://https://www.medicwww.cms.gov/Medicare/Medicare-Fee- for-Service-Payment/sharedsavingsprogram/Downloads/MSSP- QM-Benchmarks-2015.pdf Nursing Home Compare are.gov/nursinghomecompare/search.html Home Health Compare https://www.medicare.gov/homehealthcompare

52. QUESTIONS ?