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

2. 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

3. 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

4. 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.

5. 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?

6. 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…
March 3, 2014.
Patient Safety Solutions May 2007.
April 2003.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

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