Project #40: Collaborative Transition of Medication Care for Patients with Heart Failure

Project #40: Collaborative Transition of Medication Care for Patients with Heart Failure

Description

According to the Centers for Medicare and Medicaid Services (CMS), one in four to five patients will experience a re-admission within 30 days of hospital discharge. Consequently, CMS has developed the hospital readmissions reduction program, a Medicare value-based program, that reduces payments to hospitals with excessive readmissions. This payment reduction can be up to 3% (that is, a payment adjustment factor of 0.97), calculated over a 3-year rolling period. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program. Patients with congestive heart failure (CHF) are at increased risk for readmissions, thus timely medication review and education is critical during care transitions from a hospital to home setting. The partnership between the Community Care Service (CCS) pharmacy teams, the Henry Ford Health System Hospitals Discharge Pharmacy team and the clinic based Ambulatory Clinical Pharmacy Medication Therapy Management (MTM) team allows for pharmacy-based hand offs to optimize medication therapy during transitions of care. The Ambulatory Clinical MTM team has collaborated with the CCS Home Health Care (HHC) team for nearly 9 years to provide pharmacy consultations for patient’s post-discharge as well as those identified has having medication related concerns by their HHC provider. This collaboration has resulted yearly reduction in readmission rates for those patients who engaged in MTM services. The MTM pharmacy team has an established relationship with HHC providers to assist with in-home medication needs post discharge for patients with HHC services. Moreover, since the Ambulatory MTM pharmacists work within HFMG clinics throughout the system, they have close working relationships with the Primary Care Providers and Ambulatory Case Managers who care for these HHC patients. The overall aim of this initiative was to reduce 30-day readmissions for CHF patients discharged from Henry Ford West Bloomfield Hospital (HF WBF) (initiated November 2019) and Henry Ford Wyandotte Hospital (HFWyan) (initiated August 2020) to their home setting. Specifically, the CCS Hospital Discharge Pharmacy team identified patients with a working diagnosis of CHF during their inpatient admission at HF WBF or HF Wyan, and as time for discharge approached, the CCS discharge pharmacists confirmed discharge medications were affordable and covered by the patient’s insurance, notified the hospital physician/nursing team of any medication issues, delivered discharge medications to the bedside, provided medication education as well as assessed patient understanding of diet and lifestyle modification/ answered questions and, introduced the MTM team to the patient to foster seamless transition of medication care in the home setting. For patients who agreed to speak with an MTM pharmacist, the CCS discharge pharmacy team then placed an MTM referral in EPIC and highlighted any identified medication related needs/concerns that should be addressed upon discharge. The MTM pharmacist’s virtual outreach occurred 48 to 72 hours post discharge and included the following clinical interventions: 1. Medication reconciliation in EPIC to ensure post-discharge drug changes were updated, 2. Patient and/or caregiver medication education including how to best schedule and administer medications, 3. Assessment and resolution of any medication related issues and identification of needed blood work due to medication additions, 4. Drug therapy modifications to address patient needs/ resolve unveiled post-discharges issues, and 5. Reiteration of the importance of attending post-discharge doctors’ appointments. If barriers to appointments, transportation or other follow up care was needed, the pharmacist sent a referral in EPIC to the RN Case Manager (if HFMG patient) or the HHC provider (if patient has this service). Finally, the MTM pharmacist created a Clinical Pharmacy Consult for the next care provider to review. In summary, the goal was to locate patients with working diagnosis of CHF while in the hospital to ensure they have medications and were educated on CHF at discharge, then improve engagement of patients post discharge utilizing virtual outreaches to improve understanding of CHF, optimize drug therapy and educate on the importance of follow up to reduce 30- day readmissions.

Publication Date

3-16-2021

Project #40: Collaborative Transition of Medication Care for Patients with Heart Failure

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