Transitions of Care
National Transitions of Care Coalition (NTOCC) Definition of Care Transitions
"The movement of patients between health care locations, providers, or different levels of care within the same location as their conditions or care needs change"
Medication Reconciliation (APhA/ASHP Definition)
"the comprehensive evaluation of a patient's medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplication, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns" "this process should include a comparison of the existing and previous medication regimens and should occur at every transition of care in which new medications are ordered, existing orders are written or adjusted, or if the patient has added nonprescription medications to self-care"
Prevalence of Medication Errors During Care Transitions - Statistics
-1.5 million preventable ADEs occur annually = $3M in costs per year -20% of all hospital-related med errors and ADE's due to poor communication in transitions of care -67% patients have >= 1 discrepancy in med history on admission -54% of hospital med errors made by prescribers attributable to errors in ordering meds upon hospital admission -33% patients discharged from ICU >= 1 chronic medication omitted upon discharge -59% discrepancies could have resulted in patient harm if discrepancy continued after discharge
Highest Risk Populations for ADE
-older adults -poor health literacy -individuals at the end of life -children with special needs -patient on > 5 chronic meds -cognitive impairment -disabilities -low income or homeless -recent admissions to long-term care facilities
Joint Commission Hospital Readmissions Reduction Program (HRRP): Readmission Measure
1) Congestive Heart Failure 2) Acute Myocardial Infarction 3) Pneumonia 4) Chronic Obstructive Pulmonary Disease 5) Elective Total Hip and Knee Arthroplasty 6)Coronary Artery Bypass Graft
Care Transitions Pharmacy Services
1) Med Hx / Med Rec upon admission, transfer, discharge 2) Patient monitoring throughout stay (identify potential drug problems and evaluate therapy effectiveness) 3) Discharge Rx verification/generation/transmission 4) Provision in unique, patient-specific med list 5) Provision of med/disease state education throughout stay 6) Delivery of meds prior-to-discharge 7) Follow-up and referrals as appropriate
Care Transition Model Characteristics
1) Multidisciplinary communication, collaboration, and coordination 2) Clinician involvement and shared accountability 3) Comprehensive planning and risk assessment throughout hospital stay 4) Standardized transition plans 5) Standardized training 6) Timely follow-up, support and coordination after patient leaves care setting
Characteristics of Successful Care Transitions Programs
1) Multimodal 2) Multi-disciplinary 3) Begin before transition 4) Continue throughout transition 5) Long-term follow-up (CMM) 6) Early communication between providers 7) Include patients and caregivers
Readmission Risk Factors
1) Socioeconomic determinants 2) Medical (mental health or comorbidities) 3) Hospital (health system factors) 4) Illness severity 5) Prior utilization 6) Overall health and function 7) Sociodemographic determinants **These are some main risk factors, but no real science for who is at risk
Fraction of COMPLETION OF OUTPATIENT WORK-UPS recommended during inpatient stay
1/3
Percentage of DISCHARGE SUMMARIES available to PCPs during follow-up visits post-hospitalization
12-24%
Percentage of DIRECT COMMUNICATION between inpatient physicians and PCPs after discharge
3-20%
"Traditional" Transitional Care (compared to today's definition)
Transient care that dealt more with recovery after hospital discharge (transfer to SNF after hospitalization or recovery after surgery)
