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Transitions of Care: The Financial Burden and Impact on Delivery of Care

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Title: Transitions of Care: The Financial Burden and Impact on Delivery of Care


1
Transitions of Care The Financial Burden and
Impact on Delivery of Care
Why are we involved?
  • www.ntocc.org

2
Current State of Healthcare
  • Care is complex
  • Care is uncoordinated
  • Information is often not available to those who
    need it when they need it
  • As a result patients often do not get care they
    need or do get care they dont need

IOM, Crossing the Quality Chasm
3
What is Transition of Care
  • The movement of patients from one health care
    practitioner or setting to another as their
    condition and care needs change
  • Occurs at multiple levels
  • Within Settings
  • Primary care ? Specialty care
  • ICU ? Ward
  • Between Settings
  • Hospital ? Sub-acute facility
  • Ambulatory clinic ? Senior center
  • Hospital ? Home
  • Across health states
  • Curative care ? Palliative care/Hospice
  • Personal residence ? Assisted living

(c) Eric A. Coleman, MD, MPH
4
What is Transitional Care?
  • A set of actions designed to ensure the
    coordination and continuity of health care as
    patients transfer between different locations or
    different levels of care within the same location
  • Based on a comprehensive care plan and
    availability of well-trained practitioners that
    have current information about the patient's
    goals, preferences, and clinical status.
  • Includes
  • Logistical arrangements
  • Education of the patient and family
  • Coordination among the health professionals
    involved in the transition

Coleman EA, Boult C. J Am Geriatr Soc
200351556-7.
5
Ineffective Transitions Lead to Poor Outcomes
  • Wrong treatment
  • Delay in diagnosis
  • Severe adverse events
  • Patient complaints
  • Increased healthcare costs
  • Increased length of stay

Australian Council for Safety and Quality in
Health Care. Clinical hand-over and Patient
Safety literature Review Report. March 2005.
Available www.safetyandquality.org/internet/safety
/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0
081CD95/File/clinhovrlitrev.pdf
6
Transition Issues Dramatically Impact Patient Care
  • OUTPATIENT
  • Home
  • PCP
  • Specialty
  • Pharmacy
  • Case Mgr.
  • Care Giver

Patient
ER
ICU
In-Patient
SNF
ALF
Patient
7
Transition Issues Dramatically Impact Patient Care
  • OUTPATIENT
  • Home
  • PCP
  • Specialty
  • Pharmacy
  • Case Mgr.
  • Care Giver

Patient
ER
ICU
In-Patient
SNF
ALF
Patient
8
Barriers to Improving Transitions of Care
  • We Need To Understand Them First!

9
Barriers to Care Coordination
  • System level barriers
  • Practitioner level barriers
  • Patient level barriers

(c) Eric A. Coleman, MD, MPH
10
System Level Barriers
(c) Eric A. Coleman, MD, MPH
11
Practitioner Level Barriers
  • Practitioners often have not practiced in
    settings where they transfer patients
  • Sending practitioners may not communicate
    critical information to receiving practitioners
  • Practitioners may not know the patient and his or
    her preferences for care
  • Practitioners have no accountability

(c) Eric A. Coleman, MD, MPH
12
Patient Level Barriers
  • Patients assume that someone is in charge of
    coordinating care
  • Patients (and caregivers) are often the only
    common thread weaving between care sites
  • Yet they navigate the system with few tools or
    training to manage in this role

(c) Eric A. Coleman, MD, MPH
13
Problems that Illustrate Inadequacies of Care
Transitions
  • Medication errors
  • Increased health care utilization
  • Inefficient/duplicative care
  • Inadequate patient/caregiver preparation
  • Inadequate follow-up care
  • Dissatisfaction
  • Litigation/Bad publicity

(c) Eric A. Coleman, MD, MPH
14
The Facts
15
Hospital Admission
  • On hospital admission, more than 50 of patients
    have at least one medication discrepancy
  • Approximately 40 of those have potential to
    cause harm

Discrepancy defined as error between admission
medication orders and patient interview of
medication history.
Cornish PL et al. Arch Intern Med 2005165424-9.
16
Hospital Discharge
  • On discharge from the hospital, 30 of patients
    have at least one medication discrepancy with
    the potential to cause possible or probable harm

Most common discrepancy is omission of pre-admit
medication.
Kwan Y et al. Arch Intern Med 20071671034-40.
17
AHRQ Hospital Survey on Patient Safety Culture
2007 Report
18
Hospital to Home
  • 40 of patients experienced at least 1 medical
    error
  • Those with a work-up error were 6 times more
    likely to be rehospitalized within 3 months

Work-up error occurred if an outpatient test or
procedure suggested or scheduled by the inpatient
provider was not adequately followed up by the
outpatient provider (e.g., colonoscopy for
positive fecal occult blood test scheduled at
discharge but not documented in outpatient chart).
Moore C et al. J Gen Intern Med 200318646-51.
19
Hospital to PCP transfer
  • Meta-analysis
  • Direct communication between hospital physicians
    and primary care physicians occurred infrequently
  • Discharge summary
  • Availability at first postdischarge visit low
    (12-34)
  • Remained poor at 4 weeks (51-77)
  • Affected quality of care in 25 of follow-up
    visits
  • Often lacked important information (e.g., lab
    results, discharge medications, treatment,
    follow-up plan)

Kripalani S, et al. JAMA 2007297831-41.
20
Completing Recommended Outpatient Workups
Total No. () Completed Completed
Workup Type Total No. () Yes No
Diagnostic procedure 115 (47.9) 50.4 49.6
Subspecialty referral 85 (35.4) 72.6 27.4
Laboratory test 40 (16.7) 85.0 15.0
Total 240 (100) 64.1 35.9
Workup Type is the outpatient workup recommended
upon discharge from the hospital. Completed
indicates whether the recommended workup was done
within 6 months after discharge. 240 workups
recommended in 191 discharges.
Moore C et al. Arch Intern Med 2007.
21
Hospital to Nursing Home
  • Transfers and Adverse Events
  • Adverse drug events (ADEs) attributable to
    medication changes occurred in 20 of
    bi-directional transfers
  • 50 of ADEs were caused by discontinuation of
    medications during hospital stay

Boockvar K et al. Arch Intern Med 2004164545-50.
22
Independent Risk Factors for Having a Preventable
ADE
Risk Factor Risk Factor Odds Ratio 95 CI
Male Male 0.55 0.30 - 0.99
No. regularly scheduled meds No. regularly scheduled meds No. regularly scheduled meds
0-4 5-6 7-8 gt9 1.0 1.7 3.2 2.9 1.0 1.7 3.2 2.9 Referent 0.83 - 3.5 1.4 - 6.9 1.3 - 6.8
New resident 2.9 2.9 1.5 -5.7
within 60 days of admission
Field TS, Gurwitz JH et al. Arch Intern Med
20011611629-34.
23
Adverse Events in Nursing Home Residents
Transferred to the Hospital
  • 122 nursing home to hospital transfers
  • 98 returned to the nursing home
  • In 86 of transfers, at least one medication
    order was altered (mean 1.4)
  • 65 - discontinued
  • 19 - dose changes
  • 10 - substitutions
  • 20 of changes resulted in an adverse event

Boockvar KS, Fishman E, Kyriacou CK et al. Arch
Intern Med 2004164545-50.
24
OIG Report June 07
  • Consecutive Medicare stays involving inpatient
    and skilled nursing facilities
  • Key findings
  • 35 of consecutive stays were associated with
    quality-of-care problems and/or fragmentation of
    services
  • 11 of individual stays within consecutive stay
    sequences involved problems with quality-of-care,
    admission, treatments or discharges

DHHS OIG, June 2007 OEI-07-05-00340
25
Cost of Morbidity Due to Medication Errors
  • Estimates
  • Hospital care 3.5 billion (2006 dollars) (Bates
    et al., 1997)
  • Outpatient Medicare 887 million (2000 dollars)
    (Field et al., 2005)
  • Many major costs are excluded, for example
  • Failure to receive drugs that should have been
    prescribed
  • Patient non-compliance with prescribed drug
    regimens
  • Lost earnings and inability to perform household
    tasks
  • Errors that do not result in harm, but create
    extra work

26
Costs of Adverse Drug Events
  • Bates et al, 1997
  • Additional length of stay associated with ADE
    2.2 days
  • Increased cost associated with ADE 3244
  • For preventable ADEs, increased length of stay
    4.6 days increased cost 5857
  • Classen et al, 1997
  • 91, 574 admissions over 4 years (1990-1993) in
    LDS hospital (tertiary care facility)
  • 2227 patients developed an ADE
  • ADEs complicated 2.43 of 100 admissions
  • Excess cost associated with ADE was 2013

27
Data on Safety and Quality
  • 44,000-98,000 deaths/year in hospitals as a
    result of adverse drug events
  • Over 1,000,000 injuries
  • Enormous practice variation
  • Estimated 450 billion unnecessary spending
  • Slow translation of research to practice
  • One estimate 17 years

IOM, Crossing the Quality Chasm
28
Medication Errors Involving Reconciliation Failure
September 2004 July 2005 MEDMARX Data (N2022) September 2004 July 2005 MEDMARX Data (N2022) September 2004 July 2005 MEDMARX Data (N2022) September 2004 July 2005 MEDMARX Data (N2022)
Site of Error Site of Error Site of Error
Admission Transition Discharge
Total 23 67 12
Source U.S. Pharmacopeia Patient Safety
CAPSLinkTM 2005.
29
Medication Error Type by Transition Category
Transition Category Transition Category Transition Category
Error Type Admission Transition Discharge
Improper Dose/Quantity 55 73 62
Prescribing Error 49 36 27
Omission Error 35 36 76
Source U.S. Pharmacopeia Patient Safety
CAPSLinkTM 2005.
30
Case Examples of Medication Errors on Admission
  • Patients home medication recorded as Coreg 25
    mg twice daily on admission
  • Patient actually taking 6.25 mg twice daily at
    home
  • Patient received 4 doses of excessive strength
    and developed leg edema
  • Error was not discovered until after leg
    ultrasound test to rule out DVT
  • Nursing home patient receiving propranolol 20
    mg/5mL twice daily
  • Admitting orders written as propranolol 20 mg/mL
    give 5 mL (which equates to 100 mg) twice daily
  • Patient received 5 doses of 100 mg strength
    before error was discovered

Source U.S. Pharmacopeia Patient Safety
CAPSLinkTM 2005.
31
Case Examples of Medication Errors on
Transition/Transfer
  • Patient with prior history of several arterial
    stent replacements
  • Receiving aspirin, enoxaparin, clopidogrel
  • Meds placed on hold prior to surgery for removal
    of toe Physician did not reordered after surgery
  • 2 of patients coronary arteries with stents
    became 100 occluded patient expired
  • Patient transferred from ICU to step-down unit
  • Prior to transfer, patient received morning doses
    of scheduled meds
  • Administration of same meds repeated upon arrival
    to new unit due to unclear documentation and
    communication

Source U.S. Pharmacopeia Patient Safety
CAPSLinkTM 2005.
32
National Efforts
33
The Joint Commission National Patient Safety Goals
  • Goal 8 Accurately and completely reconcile
    medications across the continuum of care
  • 8A There is a process for comparing the
    patient/residents current medications with those
    ordered for the patient/resident while under the
    care of the organization
  • 8B A complete list of the residents medications
    is communicated to the next provider of service
    when a resident is referred or transferred to
    another setting, service, practitioner or level
    of care within or outside the organization. The
    complete list of medications is also provided to
    the patient/resident on discharge from the
    facility

The Joint Commission National Patient Safety
Goals. Available at htt//www.jointcommission.org/
PatientSafety/NationalPatientSafetyGoals/07_ltc_np
sgs.htm
34
One Patient, Many PlacesManaging Health Care
Transitions

A Report from the HMO Care Management Workgroup
Supported by the Robert Wood Johnson Foundation
35
AGS Position Statement
  • Position 1
  • Clinical professionals must prepare patients and
    their caregivers to receive care in the next
    setting and actively involve them in decisions
    related to the formulation and execution of the
    transitional care plan

Coleman EA, Boult C. J Am Geriatr Soc
200351556-7.
36
AGS Position Statement
  • Position 2
  • Bidirectional communication between clinical
    professionals is essential to ensuring high
    quality transition care
  • Position 3
  • Develop policies that promote high quality
    transitional care

Coleman EA, Boult C. J Am Geriatr Soc
200351556-7.
37
AGS Position Statement
  • Position 4
  • Education in transitional care should be provided
    to all health professionals involved in the
    transfer of patients across settings
  • Position 5
  • Research should be conducted to improve the
    process of transitional care

Coleman EA, Boult C. J Am Geriatr Soc
200351556-7.
38
What Can We Do
39
The Care Transitions Intervention
  • Does encouraging older patients and their
    caregivers to assert a more active role in their
    care transition reduce rates of
    rehospitalization?

Coleman EA et al. Arch Intern Med 2006
40
Utilization Outcomes
Group Group Group Group Adj. p-value Adj. p-value OR (95 CI)
Variable Intervention (n379) Intervention (n379) Control (n371) Control (n371) Adj. p-value Adj. p-value OR (95 CI)
Rehospitalization Rehospitalization Rehospitalization Rehospitalization Rehospitalization Rehospitalization Rehospitalization Rehospitalization
Within 30 d 8.3 11.9 11.9 .048 .048 0.59 (0.35-1.00) 0.59 (0.35-1.00)
Within 90 d 16.7 22.5 22.5 .04 .04 0.64 (0.42-0.99) 0.64 (0.42-0.99)
Rehospitalization for same dx as index hospitalization Rehospitalization for same dx as index hospitalization Rehospitalization for same dx as index hospitalization Rehospitalization for same dx as index hospitalization Rehospitalization for same dx as index hospitalization Rehospitalization for same dx as index hospitalization Rehospitalization for same dx as index hospitalization Rehospitalization for same dx as index hospitalization
Within 30 d 2.8 4.6 4.6 .18 .18 0.56 (0.24-1.31) 0.56 (0.24-1.31)
Within 90 d 5.3 9.8 9.8 .04 .04 0.40 (0.26-0.96) 0.40 (0.26-0.96)
Within 180 d 8.6 13.9 13.9 .046 .046 0.55 (0.30-0.99) 0.55 (0.30-0.99)
Adjusted for age, sex, education, race,
self-reported health status, chronic disease
score, prior hospitalization and ED utilization
and discharge diagnosis
Coleman EA et al. Arch Intern Med 2006
41
Follow-up of Hospitalized Elders with Heart
Failure
  • An advanced practice nurse home follow-up program
    reduced 1 year hospitalization rates by over 60
    with a mean cost savings of 4,845 per patient

Naylor MD et al. J Am Geriatr Soc 200452675-84.
42
Role of Pharmacist Counseling in Preventing ADEs
After Hospitalization
  • Does pharmacist counseling before discharge
    reduce the rate of preventable ADEs?
  • Randomized controlled trial of pharmacist
    intervention (n92) vs usual care (n84)
  • Intervention on day of discharge
  • Medication reconciliation
  • Screening for nonadherence, previous drug-related
    problems, lack of drug efficacy, and side effects
  • Review of indications, directions for use, and
    potential side effects with patient

Schnipper JL et al. Arch Intern Med
2006166565-71.
43
Study Outcomes Pharmacist Intervention vs Usual
Care
Outcome Pharmacist Intervention (n92) Pharmacist Intervention (n92) Pharmacist Intervention (n92) Usual Care (n84) P Value
Adverse drug events, No. () Adverse drug events, No. () Adverse drug events, No. () Adverse drug events, No. () Adverse drug events, No. () Adverse drug events, No. ()
All All 14/79 (18) 12/73 (16) 12/73 (16) gt.99
Preventable Preventable 1/79 (1) 8/73 (11) 8/73 (11) .01
Health Care Utilization, No. () Health Care Utilization, No. () Health Care Utilization, No. () Health Care Utilization, No. () Health Care Utilization, No. () Health Care Utilization, No. ()
ED visit or readmission ED visit or readmission 28/92 (30) 25/84 (30) 25/84 (30) gt.99
Medication-related Medication-related 4/92 (4) 8/84 (8) 8/84 (8) .36
Preventable medication-related Preventable medication-related 1/92 (1) 7/84 (8) 7/84 (8) .03
Outcome 30 days postdischarge
Schnipper JL et al. Arch Intern Med
2006166565-71.
44
Readmission Rates with Comprehensive Discharge
Planning Postdischarge Support
Strategy Intervention Events/ Total Control Events/ Total RR (95 CI)
Single home visit 95/233 129/243 0.76 (0.63-0.93)
Clinic follow-up /- phone 151/370 161/395 0.64 (0.32-1.28)
Home visit /- phone 168/437 262/533 0.79 (0.69-0.91)
Extended home care 132/438 152/421 0.82 (0.68-1.00)
Total 555/1590 741/1714 0.75 (0.64-0.88)

Relative Risk

0.5
2
1.0
Intervention
Control
Phillips CO et al. JAMA 20042911358-67.
45
Transitions of CareA National Crisis
  • Why are we involved?

46
Sanofi aventis Chairman
Sanofi-aventis is supporting the National
Transitions of Care Coalition (NTOCC) and its
multidisciplinary team of health care leaders to
address complex issues like health literacy,
patient safety and non-adherence. At
sanofi-aventis, patients are at the center of all
we do. Our mission is to fight for patients
health and well being - because health matters.
If we fail to help patients understand why they
need to take medications, or how to take them, it
can lead to non-adherence. Non-adherence can
lead to increased emergency room visits,
admittance or re-admittance to hospitals, longer
hospital stays, higher health care costs and even
life-threatening situations. We believe the work
of this Coalition will play a vital role for
health care professionals, patients, caregivers,
and payers.
Tim Rothwell, Chairman, sanofi-aventis U.S.
47
  • The Case Management Society of America will
  • positively impact and improve patient well being
    and patient health care outcomes
  • We envision case managers as pioneers of health
    care change nursing case managers, disease
    managers, health care coaches, social workers,
    pharmacists, physicians and others who are key
    initiators of and participants in the health care
    team as patient care managers.

48
The Statistics are Staggering
  • Non-adherence statistics
  • 45 of hospital NRxes or Rx changes are never
    documented in out-patient medical records1
  • 12 of NRxes are never filled2
  • 29 dont complete LOT2
  • 22 take lt than prescribed2
  • Average hospital LOS due to medication
    non-compliance is 4.2 days2

Medication Reconciliation across care settings
is a Joint Commission National Patient Safety Goal
Closing gaps across the continuum
Mobilize sanofi-aventis resources to optimize
appropriate medication use across all channels
Convene experts and apply evidence based clinical
practice guidelines
National Quality Forum (NQF) endorsed 3-Item
Care Coordination Measures to expand voluntary
hospital consensus standards in care
transitions4,5
Despite wide distribution, evidence based
clinical practice guidelines have not changed
physician behaviors3
COALITION LAUNCH October 18, 2006 - National
Transitions of Care Coalition
Chicago Collaboration with CMSA to lead
multidisciplinary coalition of experts Employers
JCAHO - NQF SHM ACHE ASHP ASCP ASA
AGS - IHI NASW - URAC

49
2008 Advisory Task Force
  • These groups represent over 200,000 health care
    professionals, 11,000 employers and 30,000,000
    consumers throughout the United States.

49
50
  • Working to Address the Issues?

51
Draft NTOCC Tools
52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
Raise NTOCC Awareness
  • Information and tools available by stakeholder

56
The NTOCC Tools Make it Possibleto Address the
Transition Issues
  • OUTPATIENT
  • Home
  • PCP
  • Specialty
  • Pharmacy
  • Case Mgr.
  • Care Giver

ER
ICU
In-Patient
Patient
SNF
ALF
57
Working Groups
Education Awareness
Policy Advocacy
Tools Resources
NTOCC
Metrics Outcomes
58
We Can Will Make A Difference!
59
Case Studies for Discussion
60
Case 1
  • During a patients monthly follow-up appointment
    with the cardiologist, he informed the doctor
    that he was having trouble with one of his
    medications. The doctor asked which one. The
    patient said The patch, the nurse told me to put
    on a new one every day and now Im running out of
    places to put it! The physician had him undress
    and discovered that the man had over a two dozen
    patches on his body.

61
Case 2
  • An older man with atrial fibrillation who takes
    warfarin for stroke prophylaxis was hospitalized
    for pneumonia. His dose of warfarin was adjusted
    during the hospital stay and was not reduced to
    his usual dose prior to discharge. The new dose
    turned out to be double his usual dose and within
    two days he was rehospitalized with
    uncontrollable bleeding.
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