0. Key Transitions in Care Cincinnati PACT and Ann Arbor Clinical Demonstration Project:
Barbara Robertson, AD
Dena Rattermann, MSN, RN
Christine Cigolle, MD, MPH
Kristin Phillips, PharmD, CGP

1. PACT and Medication Reconciliation Cincinnati VAMC PACT Pilot Team
Barbara Robertson, AD
Dena Rattermann, MSN, RN

2. Teamlet Roles
PSA: Sends letter to patients asking that they bring an updated medication list to their appointment. They also provide patient with a copy of VA medication list to review for accuracy
LPN: performs med reconciliation with patients during intake and notes discrepancies for provider. Also performs med reconciliation during phone visits (including 2 days post discharge calls)
RN: performs med reconciliation with patients at RN visits and phone visits (including 2 days post discharge calls)
Provider: performs med reconciliation with all patients during phone, face to face and sigma visits

3. Letter Sent to Patients:
Dear Patient, Your safety is our number one priority! In order to help us to prevent medication errors, we must know the complete list of medications you are taking. We will cross-check the list against our records during your office visit. Before your next VA clinic visit, review the attached list of medications and follow these steps: Cross out any medications that you no longer take. Add any medications that you take which are not on the list. Include how much you take and when you take it (morning, evening, etc) Include medications prescribed by doctors outside the VA. Include over-the-counter medications such as aspirin or Tylenol. Also include vitamins, herbal remedies, and nutritional supplements. Correct the amount and/or times that you take any medications that are different from the amounts and/or times on the medication list. At your next VA clinic visit: Bring the attached list with you. Be sure to tell us all medication or IV contrast dye allergies that you have. It is often a good idea to bring all of your medications to the clinic visit in order for your health care provider to check them against the list. It is helpful to have a family member or caregiver with you during your visit. A second set of ears to listen to instructions and to ask medication questions can be a big help. At the end of your clinic visit, your provider should update your medication list to reflect any new changes made as part of your treatment plan as a result of your visit. Be sure that you are given a copy of your new updated list to take with you. Destroy all old medicine lists! Protect your identity and private health information. Take your medication list to all medical or dental appointments, whenever you have an outpatient procedure, or when you are being admitted to the hospital. We welcome questions you may have about your medications or medication side effects. It is one of the best ways for you to be an active partner in your health care. For questions about your medications that might arise after your visit, see the back of this handout for phone numbers.

4. Advantages of PACT for Medication Reconciliation
PSA reminds patients to prepare an updated medication list for visits which improves efficiency
Improved accuracy of medication list due to repetition by multiple teamlet members
RN and LPN help reconcile med lists over phone during routine follow-ups and hospital discharge follow-ups which helps us to prevent medication errors in between face to face visits

5. Transitioning from Non VA to VA
DoD
Close ties with the DoD Liaisons
Lots of communication during transitions
New patients
Letters sent to veterans prior to appointment requesting
Outside records, list of prescription and OTC Medications
Reminders calls prior to appointment
Dual Care
Varies with each Primary Care site
Relationships with community providers have been developed
Patient Education
Clear expectations
Dual Care Policy
Responsibility to keep providers informed

6. Patients Post Discharge
From a VA Admission
Nurse Practitioner Discharge Liaison
Ensures Follow-Up Appointment made
Medication Reconciliation
Team to Team Hand-offs
Discharge Notification
Automated list of Discharges sent to Teamlet RN/LPN
From a non VA Admission
Transfer Center Reorganization
Enhancing Medication Reconciliation
Weekly Meeting work out process
Pharmacy to Pharmacy

7. Patients going in between PC and Specialty: New Frontiers
Between Primary Care to Specialty Care
A challenge
Many joint projects with Specialty Care
Specialty imbedded in Primary Care
Audiology, Cardiology, Ophthalmology
Tele-Derm
Education from Specialists for Primary Care
COPD Program
Prevention
Multi-disciplinary
Entire Continuum of Care

8. In between visits Case Management Telehealth Secure Messaging
Diabetic Nurse Practitioner
Training the RN Care Managers
Telehealth
Expanding
CVT, Store and Forward, and CCHT
Secure Messaging
Nurse Line

9. Ann Arbor Bridging the Gap: Care Management Targeting Veterans with Cognitive Impairment at Times of Transition
Christine Cigolle, MD, MPH
Kristin Phillips, PharmD, CGP

10. Bridging the Gap: Care Management Targeting Veterans with Cognitive Impairment at Times of Transition
Clinical Demonstration Project
Innovative Patient Centered Alternatives to Institutional Extended Care
Transformation-21 (T-21) initiative
VA Ann Arbor Healthcare System (VAAAHS)
Team members
Advanced practice nurse (0.5 FTE)
Clinical pharmacist (0.5 FTE)
Social Worker (0.5 FTE)
Geriatricians (0.25 FTE)

11. Project Goals
Goal 1: Provide seamless medical and social services to veterans with cognitive impairment in the transition between hospitalization and the veteran’s return to his medical home.
Goal 2: Improve dementia care by providing diagnostic, medical management, and care management services to veterans with known or suspected cognitive impairment.
Goal 3: Support caregivers/surrogates in their care of veterans with cognitive impairment.
Goal 4: Facilitate the effectiveness of the patient-centered medical home for veterans with cognitive impairment.

12. Project Goals Operationalized
Coordinate with Patient Aligned Care Team (PACT).
Identify levels of patient functional impairment.
Identify levels of caregiver burden.
Identify medication discrepancies, problem medications, etc.
Assist caregivers with coping strategies.
Leverage available VA and outside support services.
Reduce medication errors, polypharmacy, etc.
Increase support staff in existing Geriatrics Clinic.

13. Common Patient Transitions
Home, Assisted Living, Long-Stay Nursing Facility
Emergency Department
Subacute or Long-Stay Nursing Facility
Hospital
Home Assisted Living
Hospital
Subacute Nursing Facility
Home, Assisted Living

14. Project Interventions
Transitional Care Clinic
Embedded in current Geriatrics Clinic.
Flexible, rapidly accessible, and able to accommodate and respond to wide breadth of veterans’ needs in the post-discharge period.
Focus: Coordinate services for and support veteran in immediate post-discharge phase. Emphasis on supporting the caregiver.

15. Project Interventions
Expanded Ongoing Dementia Case Management
Services: Medication management. Accessing VA, Medicare, and community resources (home health care, senior day care). Providing advice and recommendations by phone.
Support the cognitively impaired veteran, his caregiver(s), and his primary health care team (patient-centered medical home).
Sites beyond the VAAAHCS, with an emphasis on outreach to veterans and their caregivers living in rural areas.

16. Target Population Include: 60 years and older
Have (or suspected to have) cognitive impairment
Recent or anticipated transition (e.g., hospital discharge)
Exclude:
Active substance abuse
Primary psychiatric diagnosis

17. “Typical” Patient Seen in Clinic
Mr. R. is a 90 year old male with cognitive impairment and multiple medical problems now having behavioral disturbances for which risperidone had been recently prescribed. He was living in a senior apartment when he presented to the ED with confusion. No sources of infection were found. The patient was referred to our clinic and enrolled in our project.

18. Team Interventions for Mr. R
Performed a complete geriatric and cognitive assessment.
Stopped risperidone and started donepezil.
Educated the family on non-pharmacological methods to deal with behavioral disturbances and ways to improve interaction with the patient.
Identified multiple medication discrepancies and addressed them.
Addressed caregiver stress of his daughter, who was neglecting her own health care.
Educated the family on VA and Medicare coverage.
Explored assisted living options and eventually provided services including Meals on Wheels, home PT, home health aide, respite and HBPC.

19. Pharmacist’s Role General Specific to transitions
Medication adherence and knowledge assessment.
Patient/caregiver goal for medication therapy.
Psychotropic medication use.
Medications contributing to fall risk.
Review for Potentially Inappropriate Medications (PIMS)
Specific to transitions
Instruct patients to bring medication bottles from all sources to each visit.
Obtain MAR from nursing facility prior to patient’s appointment (when applicable).
Ensure each patient leaves the appointment with an accurate medication list.
Follow-up call to patient’s home if discrepancy arises that cannot be resolved.
Call to patient’s home to reconcile medications if transition is known to have occurred.
Provide accurate, complete medication list to nursing facility during transition.

20. Tools Patient-friendly medication list: Note templates: In process:
Easier to use and interpret than usual VA-issued medication list.
Note templates:
Chart review on day prior to clinic appointment.
Assess interim events/medication changes, identify potential problems that need to be addressed.
In process:
Pocket cards/algorithms that address medication issues specific to the older adult.
Consent form for use of antipsychotics in older adults with dementia.

21. Example Medication Reconciliation List
Name: SSN: Date:
Allergies:
Bring ALL medication or a current medication list to every medical appointment.
Medication
Reason
Morning
Noon
Evening
Bedtime
Special Instructions
Aspirin 81mg tablet
Heart
1 tab
Buy at your local pharmacy
Metoprolol 100mg tablet
Heart, Blood pressure
Take about 12 hours apart
Lisinopril 10mg tablet
Blood pressure
Simvastatin 40mg tablet
Cholesterol
Metformin 1000mg tablet
Diabetes
Take with food
Donepezil 10mg tablet
Memory
Memantine (Namenda®) 10mg tablet
Geriatrics Clinic Pharmacist: Kristin Phillips, 734-XXX-XXXX

22. Medication Issues Specific to Older Adults
Physical impairments (vision, hearing, dexterity).
Provide information in more than one format.
Always have patient repeat instructions back.
Be aware of limitations when prescribing medications (e.g., eye drops for patient with Parkinsons).
Cognitive impairment.
Identify reliable caregiver when possible.
Be aware of limitations when prescribing medications (e.g., inhalers).
Potentially inappropriate medications.

23. Success and Challenges
Evaluation of interventions
Post clinic visit phone call
Frequent appointments
Assess patient understanding
Challenge
Cognitively impaired patient self-managing medications
Solutions
Short-term visiting nurse to assist.
Referral to HBPC or other existing VA resources.
Close clinic follow-up.
Social work involvement.

24. Transitional Care Clinic: Value Added to PACT
Dedicated pharmacist for small panel of patients.
Time provided for prep work on the day prior to appointment.
Seamless integration between disciplines.
All in same physical location, discussion occurs while the patient is still there.
True medication reconciliation.
Medication list updated prior to beginning of visit for provider (based on chart review).
Discussion with provider/team after patient is seen for med review.
CPRS orders are updated, discrepancies resolved.
Patient leaves with accurate list.

25. Opportunities to Integrate a Successful Model within PACT – Lessons Learned
Carve out sufficient time for chart review prior to seeing or communicating with the patient.
Develop relationship with providers.
Attempt to coordinate appointment on same day as provider appointment.
Ideal to have face-to-face contact with patient and/or caregiver, including review of medication bottles.
Have patient fill in blank medication sheet while waiting.
Give direct contact information.

26. THE END
Questions?