“Can I get a Med Rec?”
And then what?
Patient Care Doesn’t End at Discharge
Heath Denmark, PA-SII
South University c/o 2013
May 10, 2012
Alper E, O’Malley TA, Greenwald J. Hospital Discharge. UpToDate.com. Dec 19, 2011
Time for Discharge
 Discharge planning is a mandatory complex
process that seeks to determine the appropriate
level of services required by the patient and then
match the patient to an appropriate site of care.
 This process ideally begins at the start of the
hospitalization
Discharge Process Elements
 Discharge planning
 Medication reconciliation
 Discharge summary
 Patient instructions
 Discharge checklist
Post-Discharge Site of Care
 When it has been determined that a patient is
medically ready for discharge, the health care
team must determine the most appropriate
setting for ongoing care.
 Need to consider:
 Medical
 Functional
 Social
Home?
 Must consider these factors first:
 Patient cognitive status
 Patient activity level and functional status
 The nature of the patient's current home and
suitability for the patient's conditions (eg, presence
of stairways, cleanliness)
 Availability of family or companion support
 Ability to obtain medications and services
 Availability of transportation from hospital to home
and for follow-up visits
 Availability of services in the community to assist the
patient with ongoing care
Medication Reconciliation
 Accurate list of home meds
 Needs to be updated
 Accurate list of medications being taken at time of
discharge
 Indications for each medication changes or
initiation of new meds
 In Sweden, patients 80 years or older who were
randomly assigned to receive a medication
reconciliation intervention by unit-based
pharmacists had 16 percent fewer visits to the
hospital and 47 percent fewer emergency
department visits than controls. Medication-related
readmissions were reduced by 80 percent.
Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce
morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med 2009;
169:894
Unresolved Issues with
Med Recs
 Who should perform medication reconciliation (eg, nurse,
pharmacist, physician)?
 How can resources (personnel, systems) be most effectively
allocated to perform medication reconciliation, and
reimbursement attached to safety-oriented, time-consuming
tasks such as medication reconciliation?
 How should one determine the "gold standard" list of
medications for individual patients, to use as the basis for
reconciliation?
 How can aftercare providers reliably be informed of
medication changes in a timely and accurate fashion?
 How can patients and family/caregivers be engaged in
understanding the importance of medication reconciliation?
Important Elements of
Discharge Summary
 The outcome of the hospitalization
 The disposition of the patient
 Provisions for follow-up care including
appointments, statements of how care needs will
be met, and plans for additional services (eg,
hospice, home health assistance, skilled nursing)
Patient Instructions
 One model for patient materials, developed by
the National Patient Safety Foundation, is called
Ask Me 3.
1.
What is my main problem?
2.
What do I need to do?
3.
Why is it important for me to do this?
 Discharge instructions, both written and verbal,
should be reviewed with the patient/family
caregivers with an emphasis on assessing and
ensuring comprehension.
Discharge Checklist
Factors Contributing to
Rehospitalization
 Many rehospitalizations are unavoidable
 Progression of disease process
 Separate problem unrelated to initial admission
 Patient not following through with initial discharge
plan
 However, many are also preventable
 Systemic review of 34 studies found that the median
proportion of readmissions deemed avoidable was
27% but what was deemed “preventable” was
varied between the studies.
van Walraven C, Bennett C, Jennings A, et al. Proportion of hospital readmissions deemed
avoidable: a systematic review. CMAJ 2011; 183:E391.
Modifiable Factors of
Rehospitalization
 Several factors that increase the likelihood of
rehospitalization may be modifiable
 Premature discharge or inadequate post-discharge
support
 Insufficient follow-up
 Therapeutic errors
 Adverse drug events and other medication related
issues
 Failed handoffs
 Complications following procedures
 Nosocomial infections, pressure ulcers, and patient
falls.
Therapeutic Error
 Medication error occurs in approximately 20% of
patients post-discharge
 Examples of these types of errors include:
 Patients sent home without prescriptions for
necessary medications
 Patients receiving duplicate prescriptions for
medications they have at home labeled with
different name (eg, generic and proprietary names)
 Inadequate monitoring and follow-up for drug side
effects
Failed Handoffs
 Poor information transfer from hospital-based
providers to primary care providers occurs
commonly
 Tests that are pending at discharge often fail to be
communicated to providers responsible for their
follow-up
Failed Handoff cont.
 In one study, 41 percent of discharged patients
had a test pending at discharge. Almost one in
ten patients potentially required an intervention,
but almost two-thirds of responsible aftercare
providers were unaware that a test was
outstanding.
Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return
after hospital discharge. Ann Intern Med 2005; 143:121
 A meta-analysis revealed that only 12 to 34
percent of discharge summaries had reached
aftercare providers by the time of the first post
hospitalization appointment
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer
between hospital-based and primary care physicians: implications for patient safety and continuity
of care. JAMA 2007; 297:831.
Absent or Delayed
Follow Up
 Most studies affirm that patients who are
scheduled or seen for post hospital follow-up are
less likely to be readmitted
High Risk Patients
 Screening for increased risk may help healthcare
providers and organizations target resources to
patients most likely to be rehospitalized.
Clinical factors to consider
for risk assessment
 Use of high risk medication
 antibiotics, glucocorticoids, anticoagulants,
narcotics, antiepileptic medications, antipsychotics,
antidepressants, and hypoglycemic agents
 Polypharmacy (five or more medications)
 Specific clinical conditions
 eg, advanced COPD, diabetes, heart failure, stroke,
cancer, weight loss, and depression
Demographic factors to
consider for risk assessment
 Prior hospitalization, typically including
unplanned hospitalizations within the last 6 to 12
months
 Black race
 Low health literacy
 Reduced social network
 i.e. Living alone with little or no contacts
Post Discharge Interventions
 Follow-up
 Phone call
 Communication with ambulatory provider
 Home visits
Phone Call
 Calls have been moderately effective at
reducing emergency department visits and
improving follow-up with providers, but
demonstrated a trend towards reduced hospital
readmissions in only one study
Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients
after hospitalization. Am J Med 2001; 111:26S.
Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital
discharge to enhance patient care: a randomized controlled study. J Gen Intern Med 2008; 23:1228
Home Visits
 One trial illustrated that a single home visit by a
nurse and pharmacist to patients discharged
with a diagnosis of heart failure, with a goal of
optimizing medication management, showed a
trend towards almost a 50 percent reduced risk
of unplanned readmission
Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with
congestive heart failure discharged from acute hospital care. Arch Intern Med 1998; 158:1067.
Telemonitoring
 Using an integrated telephonic stethoscope in
conjunction with follow-up nursing calls in
patients with heart failure reduced emergency
department visits in one small study, and
demonstrated a trend toward reduced
readmissions and overall costs.
 blood pressure
 heart rate
 weight
 Oxygen saturation
Multidisciplinary Team Effort
 A nurse discharge advocate to assist with discharge
planning and preparation
 A clinical pharmacist to call the patient 2-4 days
following hospital discharge, to review the
medication list, address any medication questions
or concerns, reinforce the plan, and assess for
adverse effects related to medications
 Follow-up appointments scheduled at times
convenient to the patient
 Medication reconciliation
 A low literacy discharge instruction booklet for
patients, also provided to the primary care clinician
H2H
 A new quality improvement initiative by the
American College of Cardiology (ACC) and the
Institute for Healthcare Improvement (IHI) called
Hospital to Home (H2H) was developed to help in
this endeavor. The program was designed to
improve patient outcomes and decrease
readmission rates for cardiovascular patients,
specifically heart failure (HF) and acute
myocardial infarction (AMI) patients. The goal of
the H2H initiative is to decrease HF and AMI
readmission rates by 20% by the year 2012
Summary
 Several systems initiatives have shown promise in
minimizing rehospitalizations. These interventions
include improved collaboration between the
care team, patient, and aftercare provider prior
to discharge; medication reconciliation;
enhanced patient education and
empowerment; home visits or telephone calls by
clinical providers; remote monitoring; and early
post-discharge follow up. Patient instructions
should take into account the patient's cognitive
status, health literacy, and other barriers to selfcare. Multiple concurrent interventions may be
more effective than single components.