141st APHA Annual Meeting

In This section

275222
Community-based care transitions program: Pharmacist interventions (CCTP)

Tuesday, November 5, 2013

Stephanie Kleyman, PharmD. , Pharmacy Department, Penobscot Community Healthcare, Bangor, ME
Background: Congestive heart failure is the most common Medicare discharge diagnosis, and is more costly than any other diagnosis. In 2009, CMS added congestive heart failure readmission as a required and publicly reportable measure under the Reporting Hospital Quality Data for Annual Payment Update. In 2010 the Patient Protection and Affordable Care Act implemented penalties to hospitals whose readmissions were above federally set limits. This legislation is set to add COPD as another quality measure in 2014. COPD is the third leading cause of death within the US and accounts for over 600,000 hospitalizations annually. Often patients readmit due to non-adherence, or incorrect medication administration. While Care Management and Transitions programs exist within institutions reduce the risk of readmissions, it is the ambulatory care pharmacist's unique position that allows for expertise medication education and adherence counseling.

Purpose: To determine if pharmacist provided MTM and DSM to CHF and /or COPD patients with a recent hospitalization or emergency department visit due to exacerbation will reduce same-cause readmission at 7, 30, and 60 days. Secondary outcomes include identification of polypharmacy, medication discrepancies between institutions, and frequency of rehospitalization.

Methods: Pharmacists belonging to the patient centered medical home, Penobscot Community Healthcare in Bangor Maine, as part of the accountable care organization, review local in-hospital patient censuses. The pharmacist then identifies patients with either CHF and/or COPD exacerbation via shared health records between institutions. The pharmacist then conducts Medication Therapy Management (MTM) and Disease State Management (DSM) either in the primary care facility, or within the patient's home. Medication Therapy Management is in accordance with the certification: Delivering Medication Therapy Management in the Community, as sponsored by the American Pharmacist Association. Information among in-patient and out-patient health systems is shared via Maine's HealthInfoNet. Data is collected via retrospective chart review, and accessed via electronic health records (Centricity CPS 10 Client). Outcomes: Results are pending, as a stop-date for data collection is set at May 20th, 2012.

Learning Areas:
Administer health education strategies, interventions and programs
Conduct evaluation related to programs, research, and other areas of practice
Implementation of health education strategies, interventions and programs

Learning Objectives:
Demonstrate that in-facility or in-home pharmacist delivered Medication Therapy Management and Disease State Management to Congestive Heart Failure and /or Chronic Obstructive Pulmonary Disease patients with recent hospitalization or emergency department visits due to exacerbation will reduce same-cause readmission at 7, 30, and 60 days. Identify the following parameters for study eligible patients: Number of medications upon discharge; Number of prescription discrepancies between discharge list and primary care drug list; Number of medications changed while in the hospital; Number of days hospitalized; Admission diagnosis; Discharge diagnosis; Was this a readmission within 30 days?; Was this a readmission within 30 days for the same reason?; Is the patient on more than 5 medications: Recent hospitalization (last 30 days)?; and Was this an avoidable hospitalization or ED visit?

Keywords: Underserved Populations, Drug Use

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a doctorate of pharmacy in a post-grad residency program. I work with CHF and COPD patients in an ambulatory care setting. My research experience revolves around drug development with Covidien; electornic prescribing practices with the Ohio Pharmacist Association; and patient adherence/medication therapy management, with Kroger Pharmacies. I have also been a co-author on a grant aimed at funding pharmacist lead transitions of care.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.