Transitions of Care Samuel A. Allen, DO, FCCP Jacqueline Brewer, RN, BSN Jennifer Priziola, PharmD, BCPS

Disclosures Samuel A. Allen has no financial interest to disclose. Jacqueline Brewer has no financial interest to disclose. Jennifer Priziola has no financial interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the Pulmonary Hypertension Association. Neither PESG, nor PHA, nor any accrediting organization support or endorse any product or service mentioned in the is activity. PESG and PHA staff has no financial interest to disclose. Commercial Support was not received for this activity. 12/4/2018

Learning Objectives At the conclusion of this activity, the participant will be able to: Describe the role of the PH (Pulmonary Hypertension) physician and coordinator in facilitating care while in an extended care facility (ECF) Define the role of specialty pharmacy in facilitating proper administration of PH medications while in an ECF Summarize insurance issues with PH medications in an ECF Support patients to act as their own advocates while in an ECF

Transitions of Care “Transitions of care” refers to the movement of patients between health care practitioners, settings, and home as their condition and care needs change. For example a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally the patient might return home, where he receives care from a visiting nurse or support from a family member or friend. All patients are vulnerable at transitions of care; however, think about your PH patients and the opportunities for error at these transitions. The Joint Commission. Transitions in Care 2012.

Transitions of Care and PH Patients We all have worked diligently and established several hard stops and educational efforts to ensure patients are safe while in our hospitals; however, despite our best efforts, our hospitalized patients are still vulnerable to errors. What happens when patients transition from the security of the multidisciplinary hospital PH team and hospital technology to an ECF?

Errors Outside the Hospital 1 in 3 patients in skilled nursing facilities suffer a medication error, infection or some other type of harm related to their treatment 59% of errors and injuries are preventable More than half of those harmed are readmitted to the hospital 68% of long-term care patients receive ≥ 9 prescription medications 32% receive ≥ 20 prescription medications Medication errors occur most frequently during prescribing and administering actions The root cause of many of the errors is in the transition of care… www.propublica.org March 3, 2014. Patient Safety Solutions May 2007. www.amda.org April 2003.

Ineffective Care Transitions 80% of serious medical errors involve miscommunication during the hand-off between medical providers Communication breakdowns Expectations differ between senders and receivers of patients in transition Culture does not promote successful hand-off Inadequate amount of time provided for successful hand-off Lack of standardized procedures in conducting hand-off Incomplete or inaccurate medication reconciliation Why do errors occur? Problematic transitions occur from and to virtually every type of health care setting, but especially when patients leave the hospital The Joint Commission. Transitions in Care 2012.

Ineffective Care Transitions Patient education breakdowns Conflicting recommendations Confusing medication regimens Unclear instructions for follow-up Excluded from planning related to transition process Accountability breakdowns Not a single entity to take responsibility to assure that the patient’s health care is coordinated across various settings and among different providers The Joint Commission. Transitions in Care 2012.

Improving Transitions of Care Multidisciplinary team begins education and transition assessment at admission and continues through the hospital stay Clearly identifying accountable practitioner by name and with contact information at transition Engaging the patient and family Timely post-discharge follow-up Now that we have discussed breakdowns in transitions of care, I would like to discuss strategies that have been proven to improve this vulnerability in patient care The Joint Commission. Transitions in Care 2012.

Transitional Care Collaboration for the PH Patient Multidisciplinary PH Center Team Multidisciplinary Hospital Team Specialty Pharmacy Team Patient/Family/Support Team The PH patients are fortunate to have 2 teams that will guide them through their transitions of care. The following cases highlight the importance of this collaboration.

Inhaled Treprostinil Confusion: Case Presentation Patient on inhaled treprostinil admitted to ECF with 2 week supply of medication After 4 days the ECF RN calls office stating that they needed “more medication” PH Coordinator and Specialty Pharmacy team collaboratively evaluate the situation After investigation, 1 ampule was utilized for each treatment not each day Entire ampule was administered via mask over several minutes as a breathing treatment

PDE-5 Confusion Female patient admitted to ECF Patient called 5 days into her stay fearing that she was not receiving her sildenafil Further investigation showed sildenafil was stopped erroneously by physician believing these medications are only prescribed for males Male patient admitted to ECF Patient’s wife called fearing her husband was not receiving his tadalafil She confronted ECF staff who stated the medication had not been administered since admission Further investigation showed tadalafil was stopped erroneously by physician believing this medication was being used for the treatment of erectile dysfunction and therefore not necessary while in an ECF

Orenitram Confusion Patient has all 4 tablet strengths for titration Current dose in ECF only required 3 tablets Dose almost administered to patient included all 4 tablets Patient and wife identified the near dosing error Need to add additional details….this case highlights how an engaged patient and family are the best advocates for medication safety …refer back to Martha Kingman article where involving the patient is a strategy to decrease error

Role of PH Physician and Coordinator BEFORE PLACEMENT OCCURS: Open line of communication with hospital staff/discharge team Care management Educating hospital staff about complications with ECF placement Insurance coverage of medication Safety considerations Discussion with potential ECF staff before placement occurs Notify Specialty Pharmacy of potential placement Education of ECF staff regarding disease state and medications Involving specialty pharmacy in education of ECF If able, educate before transfer occurs rather than once patient has arrived AFTER PLACEMENT OCCURS: Follow up with ECF staff, patient, and caregiver throughout stay Follow up with Specialty Pharmacy Upon discharge, arrange for delivery of medication to patient home Open discussion with hospital staff earlier on in the hospitalization rather than at time of discharge Phone discussion with ECF staff about medications, safety considerations, etc

Insurance Considerations ˜MUST INITIATE DISCUSSION BEFORE PLACEMENT FOR BEST OUTCOME˜ Dependent upon patient coverage and length of stay Medicare/Commercial Possibility of medication shipments to patients home for a short period Purchasing from specialty pharmacy wholesale department ECF MUST be agreeable Discussion prior to admission Medicaid ECF must purchase wholesale from specialty pharmacy

Options Beyond ECF Inpatient rehabilitation Home Care Insurance qualification Training staff Disease state Specialty pharmacy involvement with education Use of Rapid Response Team RN’s Open line of communication with PH Team Home Care PT, OT, Respiratory Open line of communication with PH Center staff and specialty pharmacy

Empowering PH Patients Have the conversation early on “What if I am hospitalized or need rehab?” Encourage patients/caregivers to address concerns while discussing discharge Caregivers to visit potential ECF’s prior to placement Discuss concerns about medication/safety Ask questions Patient/caregivers notify specialty pharmacy of placement If something does not seem right with medication administration practices, say something Open line of communication with PH Center about care received in ECF Call PH staff with any concerns

What have you found to be effective in improving the transitions of care of your PH patients?

Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http://pha.cds.pesgce.com 12/4/2018