Purpose of the Call:
1.Provide background information about the PDiF initiative, outcomes and key lessons learned.
2.Identify how one organization addressed the obstacles patients face with respect to safe medication management after they are discharged from hospital.
3.Challenge all health care providers to incorporate discharge medication reconciliation into their assessment from the day of admission throughout the patients’ hospital stay.
4.Challenge pharmacists to expand their role in discharge medication reconciliation.
Watch the webinar: http://bit.ly/1ql1O2N
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Welcome also to our
francophone attendees
Bienvenue à nos participants
francophones
Hélène Riverin
Conseillère en sécurité et en amélioration
Safety Improvement Advisor
Bienvenue!
3. www.saferhealthcarenow.ca3
Objectives of today’s call
Colleen Cameron:
• Describe the PDiF initiative, its outcomes and
key lessons learned.
• A few practical “challenges” to consider.
Marg Colquhoun:
The MedRec Journey from 2005 and onwards.
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7. Making a PDiF-ference –
Results of the PDiF Quality
Improvement Initiative
Colleen Cameron, RPh, Pharm.D.
PDiF Coordinator, Grand River Hospital
ISMP Canada/Safer Healthcare Now!
April 8, 2014
8. Objectives
Describe the PDiF initiative, its outcomes and key
lessons learned.
A few practical “challenges” to consider.
15. Pharmacy Discharge Facilitator
Project
What is it?
Quality Improvement Initiative
Uniquely included 2 local CEOs in its
development
Possibly helped to keep the project’s profile and
momentum
January-September 2013
Facilitate medication discharge for high-risk
medicine patients with a goal of improving care
and outcomes
PDiF team = pharmacist + University of Waterloo
pharmacy co-op student
16. Pt Admitted
To Hospital
BPMH Completed / AMR
(Best Possible Medication
History/
Admission Med Red)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
Medication Care Map in Hospital
MD
Patient
Pharmacy
17. Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient Pharmacy
PDiF 1
On admission –
Identify
High-Risk
Patients
Components of PDiF
18. Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient Pharmacy
Components of PDiF
PDiF 2
During hospital
stay –
Modify
medications that
will be practical
and make sense
for discharge
19. Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient
Pharmacy
Components of PDiF PDiF 3
At time of
discharge –
1. Communicate
with involved
health care
providers about
medication
changes and
rationale for
those changes.
2. Talk to patient/
caregiver to
ensure they
understand
directions.
20. Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient Pharmacy
Components of PDiF
PDiF 4
Post-discharge -
Call patient 24-
72 hours post-
discharge to see
if they are able
to follow the
instructions we
gave them.
21. Outcomes
Qualitative
Patient / caregiver satisfaction
Primary Care Provider satisfaction
Community Pharmacist satisfaction
Hospitalist satisfaction
Quantitative
7, 30 and 90 day ER visits
7, 30 and 90 day readmissions
Conservable Bed Days…unexpected
22. Demographics
# of patients seen – 148 (+)
Average age – 74.2 years
7 patients died during index
hospital admission
0
5
10
15
20
25
30
35
40
45
50
20-40 41-60 61-80 81-96
Age Ranges
%
79%
23. Age
Range
% of
Patients
Heart
Failure
(# of pts)
Diabetes
(# of pts)
Warfarin
(# of pts)
20-40 3.4%
(N=5)
0 2 2
41-60 17.6%
(N=26)
5 16 9
61-80 35.1%
(N=52)
14 23 26
81-96 43.9%
(N=65)
20 22 39
Total 148 pts 26% 43% 51%
24. Qualitative Outcomes
Did we achieve Patient / Caregiver
satisfaction?
Did we achieve Primary Care Provider
satisfaction?
Did we achieve Community Pharmacist
satisfaction?
Did we achieve Hospitalist satisfaction?
25. Quantitative Outcomes (#, $)
ER/Readmission Rates
7, 30 and 90 day ER visits
7, 30 and 90 day hospital readmission rates
Data disclaimer
Historical =
All comers –
young
patients, DKA,
pneumonias,
acute
ingestions,
dialysis
PDiF patients
30. What do these numbers have the
statistical power to prove?
Anything? – probably not
Causality? – certainly not
Benchmarking? - maybe
Is that the only information that matters?
What if patients subsequently go elsewhere for care?
31. Quantitative Outcomes (#, $)
Hospital Readmissions and ED Visits
At first glance, our PDiF numbers look great…
32. Quantitative Outcomes (#, $)
Hospital Readmissions and ED Visits
At first glance, our PDiF numbers look great… BUT
34. Quantitative Outcomes (#, $)
Conservable Bed Days
Definition…relevance
Over 9 months, PDiF realized 8 weeks of
conservable bed days
Medications involved – Warfarin, Methadone
Unexpected, but fascinating
Consequently – have started targeting patients on
medications that are more likely to delay
discharge
Warfarin / NOACs
Insulin
35. Top 5 lessons learned…
1. Dare to look at your patients’ experience
post-discharge.
Are they seeing their family doctor post-
discharge?
Are they getting their prescriptions filled as
expected?
Are they going to other local hospitals for
subsequent visits?
Follow-up phone calls are quick, and incredibly
valuable!
36. Top 5 lessons learned…
2. Drugs delay discharge
Warfarin, LMWHs, insulins, methadone
We now assess 100% of patients on warfarin for
timely and safe discharge from Medicine
program
Assist with LMWH coordination post-discharge
Educate injection technique while in hospital
Phone call follow ups
Anticoagulation summary of INRs & warfarin doses,
Ensure patient has appt with PCP as well as plans to
go to lab
37. Top 5 lessons learned…
2 ½ . Where there is warfarin (or NOACs) there are
other medication misadventures looming
Warfarin and NOACs are predictors of other high-
risk medications (insulin, digoxin, spironolactone,
amiodarone etc)
Most computer systems can search for certain
medications.
This is the best place to start!
38. Top 5 lessons learned…
3. Use the hospital admission to optimize chronic
medications
Clinical inertia
Look for adherence issues!!!
ODB DPV has picked up on MANY misadventures
Incorporate practical medication discharge
assessment upstream
39. Top 5 lessons learned…
4. Medication knowledge transfer contributes to
efficient and safe patient care
GRH has an electronic discharge prescription
but….
PCPs and Community Pharmacists need
information about medications, including
rationale and plans of care.
What is your eHealth system?
Fusion software (transcription software)
Clinical Connect (LHIN EHR)
Medication-Focused Discharge Summaries
41. Medication-Focused Discharge
Summaries
Standardized document including
Date of Admission/Discharge
Adherence Issues Identified**
Drug Cost Issues Identified
Numerical List of medications
comment if same, increased, decreased or new
Medications discontinued or held
Additional information
Commentary including plan of care, monitoring plans,
concerns
My name and telephone extension
42. Top 5 lessons learned…
5. Discharge medication reconciliation is time
consuming!
Track outcomes/stories to strengthen your
argument for more funding
Go to your program director with proposal
Develop a business case?
Dr. Schnipper’s data
Be creative in staffing
Pharmacist : patient ratio
Pharmacy students
Pharmacy Technicians
Financially:
1 pharmacist ≈ 2 technicians ≈ 4 co-op students
43. Summary
Was the PDiF project successful? Did we improve outcomes?
Unequivocally
Are there simple strategies every hospital can implement to
help these patients?
Absolutely
Medication misadventures
We don’t even know the magnitude
of the problem yet
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Upcoming MedRec Webinars
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Thank you for attending
Join us on May 6, 2014 at 12 noon ET
for our next MedRec webinar
Safety, Sleuthing and Students: A Novel Collaborative
MedRec Event at the University of British Columbia
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Medication Safety Self-Assessment®
• Hospitals (acute care)(2006) – free for Ontario*
• Long-term care (2012) – free for Ontario*
• Complex Continuing Care and Rehabilitation
(2008) – free for Ontario*
• Community and Ambulatory Pharmacy (2007) –
free for Ontario*
• Operating Room Medication Safety Checklist
(2009) – free for Ontario*
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• HYDROmorphone Safety Self-Assessment (2014)
- $50
* Supported by the Ontario MOHLTC
For more information visit www.ismp-canada.org/MSSA or email mssa@ismp-canada.org