Sarah H. Lee, Pharm.D. PGY-1 Pharmacy Practice Resident Jersey Shore University Medical Center The speaker has no actual or potential conflict of interest in relation to this presentation. Community-Acquired Pneumonia and the Effect of a Transitional Care Program on 30-Day Readmission Rates

Jersey Shore University Medical Center  Meridian Health System  Tertiary care, teaching hospital in Neptune, NJ  643 beds  Care Transition Center (CTC)  Centralized interdisciplinary discharge unit  Discharge order (electronic medical record) “High risk for readmission send patient to the Care Transition Center on discharge”  Provide transitional care services  Goals of the CTC: Reduce readmission rates Improve patient flow 2

Interdisciplinary Team in the CTC 3  Hours:  Monday – Friday  9AM – 7PM  Staff:  1 pharmacist  2-3 nurses  2 nursing assistants  1 unit secretary  Pharmacy residents  Students

Assessment A centralized interdisciplinary transitional care program has been shown to decrease 30-day all cause readmission rates by how many percent? A. 35% B. 50% C. 80% D. 90% 4

Background  In 2013, pneumonia was associated with 127,601 readmissions and $1.8 billion in additional costs  Centers for Medicare and Medicaid Services (CMS) enacted the Readmission Reduction Program  Medicare Payment Advisory Commission: > 75% of hospital readmissions are associated with preventable causes 5 1.Agency for Healthcare Research and Quality. All Patient Readmissions within 30 Days National Statistics, Centers for Medicare and Medicaid Services. Readmissions Reduction Program August. 3.Medicare Payment Advisory Commission (MEDPAC). Payment policy for readmissions. In: Report to the Congress: promoting greater efficiency in Medicare. Washington, DC; p

Literature Review  Pharmacists involved in discharge process and a follow- up phone call  Higher patient satisfaction  14% reduction in 30-day readmission rates  Included subset of patients diagnosed with pneumonia  No studies to date have evaluated the effect of a transitional care program in patients diagnosed with community-acquired pneumonia 6 Dudas V, et al. Am J Med. 2001;111:26S-30S.

Study Objective  Determine the impact of a transitional care program on 30-day readmission rates in patients diagnosed with CAP 7

Methods 8 Study Design Retrospective chart review Location JSUMC Time Period November 1, 2014 to April 30, 2015 Data collected up to 30 days after discharge IRB Status Approval granted by Meridian Health IRB

Inclusion and Exclusion Criteria InclusionExclusion  Age ≥ 18 years of age  Diagnosed with CAP  Treated with ≥ 1 antibiotic  Received an order for “High risk for readmission send patient to the Care Transition Center on Discharge”  Discharged from a patient care unit or the CTC  Death in the hospital  Transfer to another hospital  History of cystic fibrosis  Diagnosed with hospital- acquired pneumonia or ventilator-associated pneumonia 9

Statistical Methods 10 Significance Level Used: α = 0.05 SAS software Version 9.3 of the SAS System for Windows (SAS Institute Inc. [2011], Cary NC, USA.) CategoricalContinuous Chi-Square Test  Gender  Antibiotic route Fisher's Exact Test  Insurance type  Comorbidities  Treatment regimens  Discharge services  Readmission(s) Wilcoxon Rank Sum Test  Age  Hospital length of stay  CrCl  Antibiotic duration  Time to readmission

Patient Sample 11 CTC n = Included 54 Total charts reviewed 3 Excluded Healthcare- associated pneumonia n=1 Aspiration pneumonia n=2 Patient care units n = 30

Baseline Characteristics 12 Population Characteristics CTC n= 21 Patient Care Units n = 30 Mean Age (years) 69.7 ± ± 18.3 Mean Length of Stay (days) 5.9 ± ± 3.3 Gender Female15 (71.4%)18 (60.0%) Male6 (28.6%)12 (40.0%) Insurance Type CMS16 (76.2%)25 (83.3%) Commercial3 (14.3%)2 (6.7%) Both2 (9.5%)2 (6.7%) Uninsured0 (0.0)1 (3.3%) Comorbidities* Asthma2 (9.5%)1 (3.3%) Bronchitis0 (0.0%)1 (3.3%) COPD6 (28.6%)7 (23.3%) Heart Failure2 (9.5%)5 (16.7%) Lung Cancer1 (4.8%)1 (3.3%) Recurrent Pneumonia 3 (14.3%)4 (13.3%) Other 1 (4.8%)2 (6.7%) None10 (47.6%)5 (50.0%) * Note: Some patients have more than one condition CTC n= 21 Patient Care Units n = 30 P-value Mean Age (years)69.7 ± ± Gender Female15 (71.4%)18 (60.0%) 0.4 Male6 (28.6%)12 (40.0%) Patient Origin Home 15 (71.4%)22 (73.3%) 0.88 Nursing home/rehab6 (28.6%)8 (26.7%) Mean CrCl89.6 ± ±

Baseline Characteristics: Insurance Type 13 CTC Patient Care Units

Patient Characteristics: Comorbidities 14 Population Characteristics CTC n= 21 Patient Care Units n = 30 Mean Age (years)69.7 ± ± 18.3 Mean Length of Stay (days)5.9 ± ± 3.3 Gender Female15 (71.4%)18 (60.0%) Male6 (28.6%)12 (40.0%) Insurance Type CMS16 (76.2%)25 (83.3%) Commercial3 (14.3%)2 (6.7%) Both2 (9.5%)2 (6.7%) Uninsured0 (0.0)1 (3.3%) Comorbidities* Asthma2 (9.5%)1 (3.3%) Bronchitis0 (0.0%)1 (3.3%) COPD6 (28.6%)7 (23.3%) Heart Failure2 (9.5%)5 (16.7%) Lung Cancer1 (4.8%)1 (3.3%) Recurrent Pneumonia3 (14.3%)4 (13.3%) Other 1 (4.8%)2 (6.7%) None10 (47.6%)5 (50.0%) * Note: Some patients have more than one condition Comorbidities* CTC n= 21 Patient Care Units n = 30 P-value Asthma2 (9.5%)1 (3.3%) 0.9 Bronchitis0 (0.0%)1 (3.3%) COPD6 (28.6%)7 (23.3%) Heart Failure2 (9.5%)5 (16.7%) Lung Cancer1 (4.8%)1 (3.3%) Recurrent Pneumonia3 (14.3%)4 (13.3%) Other1 (4.8%)2 (6.7%) None10 (47.6%)12 (40.0%) * Note: Some patients had more than one condition

Services Provided at Discharge  Prescription services (p < 0.001)  Follow-up appointments (p = 0.05) 15 CTCPatient Care Units Exclusion Criteria = Ineligible for servicesN= 21N= 30 Facility Transfer/ Left AMA6 (28.6%)16 (53.3%) No prescriptions for pneumonia medications2 (13.3%)0 Prescription Services for Eligible Patientsn= 13n = 14 Filled at Hospital Ambulatory Pharmacy5 (38.5%)0 Called to Pharmacy by physician5 (38.5%)0 Faxed to Pharmacy3 (23.1%)0 No Action Taken2 (15.4%)14 (100%) Note: 2 CTC Patients had more than one service provided Follow-Up Appt(s) Scheduled for Eligible Patients n = 15 n = 14 Yes8 (53.3%)2 (14.3%) No7 (46.7%)12 (85.7%)

CTC Service Measures 16 CTC Measurements n= 21 Educated by a Pharmacist17 (80.9%) Interventions by a Pharmacist11 (52.4%) Post-Discharge Telephone Calls for Eligible Patients Contacted on both calls12 (80%)* Contacted on one call2 (13.3%)* Unreachable1 (6.67%)* Not eligible6/21 (28.6%) * Percentage excludes patients transferred to an outside facility

Readmission Rates 17 P-value ED visit0.1 Inpatient hospitalization 0.4  Mean time to readmission longer with CTC discharge (24 days vs. 9.7 days, p = 0.5)

Discussion  Prescription services may facilitate medication adherence  11/13 eligible patients in CTC vs. 0 patients in standard discharge  Scheduled follow-up appointments may aid in overall continuum of care  8/15 eligible patients in CTC vs. 2/14 patients in standard discharge  Interventions by a pharmacist in CTC :  Missing prescriptions  Incorrect doses  Switching to a cost-effective medication 18

Discussion  Approximately 80% of Medicare/Medicaid patients  30- day readmission rate for pneumonia  Clinically significant reduction in 30-day all-cause (CTC group):  Hospital readmission by 80% (1 vs. 5)  Post-discharge ED visit by 86% (1 vs.7)  Time to hospital readmission longer in CTC group Health Indicators Warehouse. Hospital 30-day Readmission for Pneumonia.

Limitations Small sample size Readmission consideration only within 5 Meridian Health hospitals Lack of documentation from patient care units 20

Conclusion  Centralized interdisciplinary transitional care program has a clinically significant impact on 30-day all-cause hospital readmission rates  May reduce hospital reimbursement penalties from CMS 21  Institutional changes:  Increase high risk discharge orders  Standardize follow-up appointments  Larger, prospective studies are warranted:  Other high risk disease states  Patient satisfaction  Readmission at any institution Image from:

Assessment A centralized interdisciplinary transitional care program has been shown to decrease 30-day all cause readmission rates by how many percent? A. 35% B. 50% C. 80% D. 90% 22

Acknowledgements  Danielle M. Candelario, Pharm.D., BCPS 1  Saira B. Chaudhry, Pharm.D. MPH 1,2  Michelle L. Kohute, Pharm.D. 1  Frances Mclaughlin, BSN, RN 1  Patricia J. Kooker, M.S. 1  Joyce Henn, MSN, RN, NE-BC 1 1. Jersey Shore University Medical Center 2. Ernest Mario School of Pharmacy, Rutgers, The State University of NJ 23

Community-Acquired Pneumonia and the Effect of a Transitional Care Program on 30-Day Readmission Rates Questions, Sarah H. Lee