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FHS Discharge - FINAL

A review of methods pharmacists can impact Transitions of Care, and a review of discharge programs.

Dan Tran

on 17 April 2014

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Transcript of FHS Discharge - FINAL

Systemic Approaches
Franciscan Health Systems
safe landing
Involvement of patients empowered them to help reduce errors
what parts of this can a pharmacist help with?
EMR not designed to move information between sites; patient records are inaccessible to referring and consulting clinicians.
discharge home is just part of the puzzle
Southern California Kaiser
patient factors > systemic issues
Can patient non-adherence be a system failure?
Pilot studies to form a contract with patients post-discharge
Patients take contract to heart
Can we just target the 20%?
Interns, residents, nurses, case managers, etc.
Correctly identified: 32% readmission rate.
No group was significantly better than chance!
Problem Meds? Insulin, Coumadin, Digoxin, ASA/Plavix
Polypharmacy? >5 Meds
21% reduction in readmissions
Increased Patient Satisfaction Scores
National Program: 4000 sites, 31 states
Endorsed by Society of Hospital Medicine
Formalized training and CE "implementation guide"
Communication between sites and pooling of data
"team based" interdisciplinary comprehensive, research based approach
National Program
Funded by AHRQ Gov't Agency
30% reduction in readmissions
Cost savings of $412/pt
Formalized training and CE "implementation guide"
Communication between sites and pooling of data
"team based" interdisciplinary comprehensive, research based approach
RN: Discharge Advocate
- Educate/prepare throughout hospitalization
- 1.5 hours total (average)

Pharmacist Follow-up Call
30 minutes

After Hospital Care Plan (AHCP)
-Meds, pending tests, follow-up appointments
lack of large-scale data, but shown to decrease readmissions

Benefits seen for 5 months
Stimulate "skill transfer"
4 Pillars aka "conceptual domains"
4 week program
target patients with complex care needs
76 year old F
Community Acquired Pneumonia (CAP)
Transitions of Care: Discharge Process
A Pharmacy-focused Review
Dan Tran, PharmD Candidate 2014
A portion of this material has been adapted, with permission, from "Transitioning Care from the Inpatient to Outpatient Setting" by Michael D. Gibbons, MD
So, what's causing re-admits?
Why the focus on re-admits
and transition of care?


"What does this have to do
with me?"
Are pharmacists in a strong position to affect these measures? YES!
Reconciled med list... transition record...
follow-up phone calls... integrating the patient..
By the end of this presentation, you should be able to:
Describe how pharmacists can impact rates of re-admissions in the hospital.
Identify three systemic approaches that have been implemented across the nation for discharge.
- Recognize key aspects of each approach that may
be applicable to practice at Franciscan Health Systems
Methods of Improvement
Safe Landing
(adopted by one hospital)
Quality/Usability of Discharge Information
Patient Education
Prevention of Hospital Readmission
How can pharmacists at FHS integrate into
the delivery of these services?
How does Franciscan tackle:
Safe Landing, Quality of Discharge Information,
Patient Education, and Discharge Follow-up?
Can we identify the 20% ?
How can we change the "system" ?
Who do we target?
DM2 (oral meds @ home) , CAD with CABG 4 years ago, CKD, COPD with 2 PPD tobacco use (2L of home oxygen)

Meds: Insulin sliding scale, ASA, metoprolol, lisinopril, advair, albuterol, rocephin, azithromycin

Allergy: Levaquin
Presentation: dyspnea, O2 86% on home oxygen, cough/sputum, Temp 102 F, somnelent, ill-appearing

Course: Admission to PCU, given antibiotics, nebulizer medications. Transferred to general floor evening of day 2.

Improving... more alert, afebrile.
Hospital Course
Day 3 : "I'm going home this morning!"
Home care , PT, MDs and RN follow-up, discharge paperwork, verbal communication, communication with PCP, knowledge regarding ADL, who to call, care setup...etc etc etc...
Safe Landing
Medication Assistance
Cornerstone Club Diabetes Assistance
Discharge Accountability: Empowering Patients
Patient Education
Early Discharge Planning
Follow-up: Phone Interview
Care Coordination Program
For high risk patients: MI, DM, CHF
Immediate RN follow-up HOME VISIT, and minimum of 4 follow-up PHONE interviews
Go over discharge instructions, teaching/education, problem solving
EPIC-Generated Discharge
Medications (Start, Stop, Continue)
Instructions after discharge
Patient Info on Dx
Summary of Hospital
Medication Chart
Key Items:
St. Anthony & FHS Clinic Follow-up

1. Allaudeen, Nazima, et al. "Inability of providers to predict unplanned readmissions." Journal of general internal medicine 26.7 (2011): 771-776.
2. Forster, Alan J., et al. "The incidence and severity of adverse events affecting patients after discharge from the hospital." Annals of internal medicine 138.3 (2003): 161-167.
3. Forster, Alan J., et al. "Adverse events among medical patients after discharge from hospital." Canadian Medical Association Journal 170.3 (2004): 345-349.
4. Improving Provider Communication and Patient Transitions: Hospital-Based Best Practices. Clinical Advisory Board, The Advisory Board Company. Physician Executive Council.
5. Project BOOST - Society of Hospital Medicine. www.hospitalmedicine.org/boost/. Accessed August 18, 2013.
6. Project Red: Revolutionizing Education. www.projectred.org. Accessed August 18, 2013.
7. The Care Transitions Program - Program Overview. www.caretransitions.org/transitions_coach.asp. Accessed August 18, 2013.
8. "Transitions of Care: Hospital Syndrome". Powerpoint Presentation, Michael B Gibbons, MD.
Remember our CAP Patient?
After discharge, she was re-admitted 6 days later for exacerbation of COPD symptoms (dypsnea, hypercapnia, hypoxemia).
In what ways could pharmacist intervention have prevented this re-admission?

- Safe Landing
- Patient Education / Empowerment
- Discharge follow-up
- Communication with PCP
- Others?
- Discontinued home antibiotics because she "felt better"
Food for Thought
Full transcript