Multidisciplinary team puts the ‘home’ in hospital-to-home

Abstract

Kim Thrasher, PharmD, BCPS, CPP, recently received a call from a care manager at Community Care of the Lower Cape Fear (CCLCF) about a medically fragile 2-year-old patient. The child had had numerous hospitalizations and was on multiple chronic medications. Most recently, the child had been discharged from the hospital after being on a ventilator and receiving narcotics for several weeks. She was discharged with a 36-hour supply of compounded methadone solution to combat withdrawal symptoms. Kim Thrasher, PharmD, BCPS, CPP, recently received a call from a care manager at Community Care of the Lower Cape Fear (CCLCF) about a medically fragile 2-year-old patient. The child had had numerous hospitalizations and was on multiple chronic medications. Most recently, the child had been discharged from the hospital after being on a ventilator and receiving narcotics for several weeks. She was discharged with a 36-hour supply of compounded methadone solution to combat withdrawal symptoms. Coordinated careDuring a follow-up appointment with her pediatrician and the care manager, the girl’s mother reported that her daughter was irritable and couldn’t sleep; she was worried her daughter was experiencing a withdrawal. After an assessment, the pediatrician agreed that the child was in withdrawal. The care manager contacted Thrasher, who assisted the provider with appropriate dosing and a reasonable taper for the child. “Because the patient was a young child, it was methadone, and it had to be compounded, acquiring it that day would be a challenge, [and] access was limited to a few local pharmacies,” said Thrasher. Working with the pediatrician, the care manager, a hospital pharmacist, and a community pharmacist, Thrasher helped the mother obtain the methadone that day. “The care manager messaged us the next day to say the mom was relieved and the child had slept through the night [for] the first time since being discharged from the hospital,” said Thrasher.Caring for the sickest patientsThrasher is one of four clinical pharmacists at CCLCF who carry out the comprehensive medication reviews for extremely complex patients. She also provides direct patient care during a small portion of her workweek. With a special emphasis on care transitions, Thrasher, her pharmacist colleagues, and a team of other health care providers coordinate care for the most vulnerable patients in their region.CCLCF is 1 of 14 regional networks of Community Care of North Carolina (CCNC). The physician-led, community-based organization contracts with the state to manage 80% of its Medicaid population. The Lower Cape Fear network serves six southeastern counties. Bladen and Columbus counties are two of North Carolina’s most impoverished, ranking 96th and 100th, respectively, in the state’s county health rankings. “These are two of the sickest counties in North Carolina. They’re very rural and the citizens tend to be very chronically ill,” Thrasher said.Since 2009, CCLCF’s interventions have helped reduce monthly spending per patient by 9%, emergency department use and hospital admissions by 12% each, and potentially preventable hospital readmissions by 2.4% for Carolina Access Medicaid Patients.“The home visit is so instrumental in helping uncover medication list discrepancies.”CCLCF deploys care managers to the hospital bedsides of Medicaid, NC Health Choice, and select Medicare, Blue Cross Blue Shield, and other privately insured enrollees who are at high risk of hospital readmissions. The nursing and social work care managers collaborate with patients to ensure they understand their care plans. Within 3 days of discharge, care managers follow up with their patients at home.HIGHLIGHTS■North Carolina leads the country in containing Medicaid spending growth at 3.5% per year.■Community Care of North Carolina’s programs helped North Carolina avoid $1 billion in Medicaid costs from 2007 to 2010.Complete careHome visits provide a more complete picture of the medications that patients take. Care managers can often identify many more medications than they would if patients were asked to bring a brown bag of all their medications to a clinic appointment. Patients are often confused after hospitalization as to whether they should continue prior medications and add those prescribed at discharge, or replace prior medications with discharge instructions.Working closely with the transitional care managers, Thrasher identifies discrepancies between the admission and discharge medication lists, the pharmacy fill history, and the patient interview during the home visit.“At CCLCF, Dr. Thrasher is a vital part of the care team,” said Henry Hawthorne, MD, Associate Medical Director and Pediatric Consultant at CCLCF. “Serious medication discrepancies are common for our high-risk patients after hospital discharge. Through her work on our team, we can summarize identified issues for the primary care physician and help resolve any discrepancies. This team-based approach is the cornerstone of CCLCF.”A common challenge to medication reconciliation and optimum hospital-to-home transitions is lack of complete information. Patients fill prescriptions from a number of prescribers at a number of pharmacies. Community pharmacists may have partial lists of patients’ medications, while physicians across various specialties have additional pieces of that puzzle. The hospital could have still other information. Some of the information overlaps; some does not.In addition to the wealth of information the home visit provides, CCLCF pharmacists have access to patients’ prescription fill history, prescription claim history, and—most of the time—discharge instructions through CCNC’s Informatics Center and PHARMACeHOME. “We are looking at a multitude of factors, including duplications, interactions, and, perhaps more importantly, gaps in drug therapy,” said Thrasher. “Our goal is to optimize medication therapy and keep patients with chronic disease states healthier and out of the emergency department or hospital.”As CCNC helps shrink the pool of patients with the highest risk of readmissions, the organization continues to seek out and use new strategies to further help patients that remain among the sickest. New software for pharmacists estimates a patient’s risk of hospital readmission based on their medications.“This program provides an in-depth view of patients with medication-related problems who are potentially at risk of hospitalization,” said Thrasher. “This risk stratification helps direct our interventions.”Community/clinical partnershipsCCNC information technology helps illuminate patients’ medication needs, and teamwork helps meet those needs. When pharmacists at CCLCF face a barrier to getting the right medications to their patients after discharge, relationships with community partners, providers, pharmacists, and clinical teammates can help overcome those challenges.CCLCF’s network includes more than 500 providers of primary or obstetric care at 165 practices and three federally qualified health centers. The organization’s staff includes, among others, nurse and social work care managers, pharmacists, a psychiatrist, an obstetrician/gynecologist, a dietitian, diabetes educators, a pediatric team, and a patient outreach team. The organization maintains relationships with various community resources that help address socioeconomic barriers to care, such as lack of food, transportation, or inability to make a copayment.Physicians in the network rely on the expertise of Thrasher and her pharmacist colleagues. “Dr. Thrasher detects medication-related issues that [other] providers may not be aware of, while educating our patients on their medications and conditions,” said Robert Rich, MD, Medical Director at CCLCF and a physician at Bladen Medical Associates.View Large Image Figure ViewerDownload (PPT)Thrasher works especially closely with the transitional care managers. “Jean” was recently hospitalized with a fractured ankle. She had suffered a fall from a syncope episode. Within 72 hours of her hospital discharge, Jean’s CCLCF care manager paid her a visit at home. As a routine part of the visit, the care manager took an inventory of Jean’s medicine cabinet. The medication list was later reviewed by Thrasher, who noticed a product called ZXT Gold, a nutritional supplement marketed for weight loss. Government health agencies had previously warned that supplements like these contained the potentially harmful undeclared pharmaceuticals—sibutramine and phenolphthalein. Thrasher suspected that this product had contributed to Jean’s syncope. “The home visit is so instrumental in helping uncover medication list discrepancies like these,” said Thrasher.Top: (L-R) CCLCF clinical pharmacists Trish Scarlett-Rafferty, PharmD, BSNSP; Megan Rose, PharmD, Director of Pharmacy Services; and Thrasher use Community Care of North Carolina data to assess patient risk of hospitalization.Show full captionLeft: Hawthorne and Thrasher meet regularly to discuss patient care plans.View Large Image Figure ViewerDownload (PPT)Direct patient relationshipsThrasher has provided direct patient care, what she describes as “real-time comprehensive medication reviews,” at two rural practices in CCLCF’s network. There she met patients who first approached her with skepticism, but later came to count on her care. “They love their primary care provider, so at first, they seemed to be thinking, ‘Who’s this other person, and why is she asking me questions?’” Thrasher recalled. “But later they would come in and ask if they could speak to the pharmacist.”In her direct patient encounters, Thrasher has helped patients and their physicians untangle the most complicated of medication lists. “There was a patient [who] went into the hospital with 18 chronic medications and came home with 18 medications, but the majority of them were different from the ones prior to admission,” said Thrasher. “The patient’s family was grateful when the primary care physician and I reconciled the list to clarify her medication plan.”Unseen opportunitiesWith 25 years of experience behind her, Thrasher’s 2 years at CCLCF have shown her things she’d rarely seen in her previous pharmacy practice. For 15 years, CCNC has trailblazed ways to care for patients in a realm that is now gaining momentum in the health care system: the transition between hospital and home. In the process, CCNC programs helped save the state $1 billion in avoided costs from 2007 to 2010. CCNC’s strategies help North Carolina lead the country in containing Medicaid spending growth at 3.5% per year.“Working with this group of health care professionals,” Thrasher said, “I go home every day feeling that I’ve made a positive impact, whether large or small, for patients at a time when they are most vulnerable.” Coordinated careDuring a follow-up appointment with her pediatrician and the care manager, the girl’s mother reported that her daughter was irritable and couldn’t sleep; she was worried her daughter was experiencing a withdrawal. After an assessment, the pediatrician agreed that the child was in withdrawal. The care manager contacted Thrasher, who assisted the provider with appropriate dosing and a reasonable taper for the child. “Because the patient was a young child, it was methadone, and it had to be compounded, acquiring it that day would be a challenge, [and] access was limited to a few local pharmacies,” said Thrasher. Working with the pediatrician, the care manager, a hospital pharmacist, and a community pharmacist, Thrasher helped the mother obtain the methadone that day. “The care manager messaged us the next day to say the mom was relieved and the child had slept through the night [for] the first time since being discharged from the hospital,” said Thrasher. During a follow-up appointment with her pediatrician and the care manager, the girl’s mother reported that her daughter was irritable and couldn’t sleep; she was worried her daughter was experiencing a withdrawal. After an assessment, the pediatrician agreed that the child was in withdrawal. The care manager contacted Thrasher, who assisted the provider with appropriate dosing and a reasonable taper for the child. “Because the patient was a young child, it was methadone, and it had to be compounded, acquiring it that day would be a challenge, [and] access was limited to a few local pharmacies,” said Thrasher. Working with the pediatrician, the care manager, a hospital pharmacist, and a community pharmacist, Thrasher helped the mother obtain the methadone that day. “The care manager messaged us the next day to say the mom was relieved and the child had slept through the night [for] the first time since being discharged from the hospital,” said Thrasher. Caring for the sickest patientsThrasher is one of four clinical pharmacists at CCLCF who carry out the comprehensive medication reviews for extremely complex patients. She also provides direct patient care during a small portion of her workweek. With a special emphasis on care transitions, Thrasher, her pharmacist colleagues, and a team of other health care providers coordinate care for the most vulnerable patients in their region.CCLCF is 1 of 14 regional networks of Community Care of North Carolina (CCNC). The physician-led, community-based organization contracts with the state to manage 80% of its Medicaid population. The Lower Cape Fear network serves six southeastern counties. Bladen and Columbus counties are two of North Carolina’s most impoverished, ranking 96th and 100th, respectively, in the state’s county health rankings. “These are two of the sickest counties in North Carolina. They’re very rural and the citizens tend to be very chronically ill,” Thrasher said.Since 2009, CCLCF’s interventions have helped reduce monthly spending per patient by 9%, emergency department use and hospital admissions by 12% each, and potentially preventable hospital readmissions by 2.4% for Carolina Access Medicaid Patients.“The home visit is so instrumental in helping uncover medication list discrepancies.”CCLCF deploys care managers to the hospital bedsides of Medicaid, NC Health Choice, and select Medicare, Blue Cross Blue Shield, and other privately insured enrollees who are at high risk of hospital readmissions. The nursing and social work care managers collaborate with patients to ensure they understand their care plans. Within 3 days of discharge, care managers follow up with their patients at home.HIGHLIGHTS■North Carolina leads the country in containing Medicaid spending growth at 3.5% per year.■Community Care of North Carolina’s programs helped North Carolina avoid $1 billion in Medicaid costs from 2007 to 2010. Thrasher is one of four clinical pharmacists at CCLCF who carry out the comprehensive medication reviews for extremely complex patients. She also provides direct patient care during a small portion of her workweek. With a special emphasis on care transitions, Thrasher, her pharmacist colleagues, and a team of other health care providers coordinate care for the most vulnerable patients in their region. CCLCF is 1 of 14 regional networks of Community Care of North Carolina (CCNC). The physician-led, community-based organization contracts with the state to manage 80% of its Medicaid population. The Lower Cape Fear network serves six southeastern counties. Bladen and Columbus counties are two of North Carolina’s most impoverished, ranking 96th and 100th, respectively, in the state’s county health rankings. “These are two of the sickest counties in North Carolina. They’re very rural and the citizens tend to be very chronically ill,” Thrasher said. Since 2009, CCLCF’s interventions have helped reduce monthly spending per patient by 9%, emergency department use and hospital admissions by 12% each, and potentially preventable hospital readmissions by 2.4% for Carolina Access Medicaid Patients. “The home visit is so instrumental in helping uncover medication list discrepancies.” CCLCF deploys care managers to the hospital bedsides of Medicaid, NC Health Choice, and select Medicare, Blue Cross Blue Shield, and other privately insured enrollees who are at high risk of hospital readmissions. The nursing and social work care managers collaborate with patients to ensure they understand their care plans. Within 3 days of discharge, care managers follow up with their patients at home. HIGHLIGHTS■North Carolina leads the country in containing Medicaid spending growth at 3.5% per year.■Community Care of North Carolina’s programs helped North Carolina avoid $1 billion in Medicaid costs from 2007 to 2010. ■North Carolina leads the country in containing Medicaid spending growth at 3.5% per year.■Community Care of North Carolina’s programs helped North Carolina avoid $1 billion in Medicaid costs from 2007 to 2010. ■North Carolina leads the country in containing Medicaid spending growth at 3.5% per year.■Community Care of North Carolina’s programs helped North Carolina avoid $1 billion in Medicaid costs from 2007 to 2010. Complete careHome visits provide a more complete picture of the medications that patients take. Care managers can often identify many more medications than they would if patients were asked to bring a brown bag of all their medications to a clinic appointment. Patients are often confused after hospitalization as to whether they should continue prior medications and add those prescribed at discharge, or replace prior medications with discharge instructions.Working closely with the transitional care managers, Thrasher identifies discrepancies between the admission and discharge medication lists, the pharmacy fill history, and the patient interview during the home visit.“At CCLCF, Dr. Thrasher is a vital part of the care team,” said Henry Hawthorne, MD, Associate Medical Director and Pediatric Consultant at CCLCF. “Serious medication discrepancies are common for our high-risk patients after hospital discharge. Through her work on our team, we can summarize identified issues for the primary care physician and help resolve any discrepancies. This team-based approach is the cornerstone of CCLCF.”A common challenge to medication reconciliation and optimum hospital-to-home transitions is lack of complete information. Patients fill prescriptions from a number of prescribers at a number of pharmacies. Community pharmacists may have partial lists of patients’ medications, while physicians across various specialties have additional pieces of that puzzle. The hospital could have still other information. Some of the information overlaps; some does not.In addition to the wealth of information the home visit provides, CCLCF pharmacists have access to patients’ prescription fill history, prescription claim history, and—most of the time—discharge instructions through CCNC’s Informatics Center and PHARMACeHOME. “We are looking at a multitude of factors, including duplications, interactions, and, perhaps more importantly, gaps in drug therapy,” said Thrasher. “Our goal is to optimize medication therapy and keep patients with chronic disease states healthier and out of the emergency department or hospital.”As CCNC helps shrink the pool of patients with the highest risk of readmissions, the organization continues to seek out and use new strategies to further help patients that remain among the sickest. New software for pharmacists estimates a patient’s risk of hospital readmission based on their medications.“This program provides an in-depth view of patients with medication-related problems who are potentially at risk of hospitalization,” said Thrasher. “This risk stratification helps direct our interventions.” Home visits provide a more complete picture of the medications that patients take. Care managers can often identify many more medications than they would if patients were asked to bring a brown bag of all their medications to a clinic appointment. Patients are often confused after hospitalization as to whether they should continue prior medications and add those prescribed at discharge, or replace prior medications with discharge instructions. Working closely with the transitional care managers, Thrasher identifies discrepancies between the admission and discharge medication lists, the pharmacy fill history, and the patient interview during the home visit. “At CCLCF, Dr. Thrasher is a vital part of the care team,” said Henry Hawthorne, MD, Associate Medical Director and Pediatric Consultant at CCLCF. “Serious medication discrepancies are common for our high-risk patients after hospital discharge. Through her work on our team, we can summarize identified issues for the primary care physician and help resolve any discrepancies. This team-based approach is the cornerstone of CCLCF.” A common challenge to medication reconciliation and optimum hospital-to-home transitions is lack of complete information. Patients fill prescriptions from a number of prescribers at a number of pharmacies. Community pharmacists may have partial lists of patients’ medications, while physicians across various specialties have additional pieces of that puzzle. The hospital could have still other information. Some of the information overlaps; some does not. In addition to the wealth of information the home visit provides, CCLCF pharmacists have access to patients’ prescription fill history, prescription claim history, and—most of the time—discharge instructions through CCNC’s Informatics Center and PHARMACeHOME. “We are looking at a multitude of factors, including duplications, interactions, and, perhaps more importantly, gaps in drug therapy,” said Thrasher. “Our goal is to optimize medication therapy and keep patients with chronic disease states healthier and out of the emergency department or hospital.” As CCNC helps shrink the pool of patients with the highest risk of readmissions, the organization continues to seek out and use new strategies to further help patients that remain among the sickest. New software for pharmacists estimates a patient’s risk of hospital readmission based on their medications. “This program provides an in-depth view of patients with medication-related problems who are potentially at risk of hospitalization,” said Thrasher. “This risk stratification helps direct our interventions.” Community/clinical partnershipsCCNC information technology helps illuminate patients’ medication needs, and teamwork helps meet those needs. When pharmacists at CCLCF face a barrier to getting the right medications to their patients after discharge, relationships with community partners, providers, pharmacists, and clinical teammates can help overcome those challenges.CCLCF’s network includes more than 500 providers of primary or obstetric care at 165 practices and three federally qualified health centers. The organization’s staff includes, among others, nurse and social work care managers, pharmacists, a psychiatrist, an obstetrician/gynecologist, a dietitian, diabetes educators, a pediatric team, and a patient outreach team. The organization maintains relationships with various community resources that help address socioeconomic barriers to care, such as lack of food, transportation, or inability to make a copayment.Physicians in the network rely on the expertise of Thrasher and her pharmacist colleagues. “Dr. Thrasher detects medication-related issues that [other] providers may not be aware of, while educating our patients on their medications and conditions,” said Robert Rich, MD, Medical Director at CCLCF and a physician at Bladen Medical Associates.Thrasher works especially closely with the transitional care managers. “Jean” was recently hospitalized with a fractured ankle. She had suffered a fall from a syncope episode. Within 72 hours of her hospital discharge, Jean’s CCLCF care manager paid her a visit at home. As a routine part of the visit, the care manager took an inventory of Jean’s medicine cabinet. The medication list was later reviewed by Thrasher, who noticed a product called ZXT Gold, a nutritional supplement marketed for weight loss. Government health agencies had previously warned that supplements like these contained the potentially harmful undeclared pharmaceuticals—sibutramine and phenolphthalein. Thrasher suspected that this product had contributed to Jean’s syncope. “The home visit is so instrumental in helping uncover medication list discrepancies like these,” said Thrasher.Top: (L-R) CCLCF clinical pharmacists Trish Scarlett-Rafferty, PharmD, BSNSP; Megan Rose, PharmD, Director of Pharmacy Services; and Thrasher use Community Care of North Carolina data to assess patient risk of hospitalization.Show full captionLeft: Hawthorne and Thrasher meet regularly to discuss patient care plans.View Large Image Figure ViewerDownload (PPT) CCNC information technology helps illuminate patients’ medication needs, and teamwork helps meet those needs. When pharmacists at CCLCF face a barrier to getting the right medications to their patients after discharge, relationships with community partners, providers, pharmacists, and clinical teammates can help overcome those challenges. CCLCF’s network includes more than 500 providers of primary or obstetric care at 165 practices and three federally qualified health centers. The organization’s staff includes, among others, nurse and social work care managers, pharmacists, a psychiatrist, an obstetrician/gynecologist, a dietitian, diabetes educators, a pediatric team, and a patient outreach team. The organization maintains relationships with various community resources that help address socioeconomic barriers to care, such as lack of food, transportation, or inability to make a copayment. Physicians in the network rely on the expertise of Thrasher and her pharmacist colleagues. “Dr. Thrasher detects medication-related issues that [other] providers may not be aware of, while educating our patients on their medications and conditions,” said Robert Rich, MD, Medical Director at CCLCF and a physician at Bladen Medical Associates. Thrasher works especially closely with the transitional care managers. “Jean” was recently hospitalized with a fractured ankle. She had suffered a fall from a syncope episode. Within 72 hours of her hospital discharge, Jean’s CCLCF care manager paid her a visit at home. As a routine part of the visit, the care manager took an inventory of Jean’s medicine cabinet. The medication list was later reviewed by Thrasher, who noticed a product called ZXT Gold, a nutritional supplement marketed for weight loss. Government health agencies had previously warned that supplements like these contained the potentially harmful undeclared pharmaceuticals—sibutramine and phenolphthalein. Thrasher suspected that this product had contributed to Jean’s syncope. “The home visit is so instrumental in helping uncover medication list discrepancies like these,” said Thrasher. Left: Hawthorne and Thrasher meet regularly to discuss patient care plans. Direct patient relationshipsThrasher has provided direct patient care, what she describes as “real-time comprehensive medication reviews,” at two rural practices in CCLCF’s network. There she met patients who first approached her with skepticism, but later came to count on her care. “They love their primary care provider, so at first, they seemed to be thinking, ‘Who’s this other person, and why is she asking me questions?’” Thrasher recalled. “But later they would come in and ask if they could speak to the pharmacist.”In her direct patient encounters, Thrasher has helped patients and their physicians untangle the most complicated of medication lists. “There was a patient [who] went into the hospital with 18 chronic medications and came home with 18 medications, but the majority of them were different from the ones prior to admission,” said Thrasher. “The patient’s family was grateful when the primary care physician and I reconciled the list to clarify her medication plan.” Thrasher has provided direct patient care, what she describes as “real-time comprehensive medication reviews,” at two rural practices in CCLCF’s network. There she met patients who first approached her with skepticism, but later came to count on her care. “They love their primary care provider, so at first, they seemed to be thinking, ‘Who’s this other person, and why is she asking me questions?’” Thrasher recalled. “But later they would come in and ask if they could speak to the pharmacist.” In her direct patient encounters, Thrasher has helped patients and their physicians untangle the most complicated of medication lists. “There was a patient [who] went into the hospital with 18 chronic medications and came home with 18 medications, but the majority of them were different from the ones prior to admission,” said Thrasher. “The patient’s family was grateful when the primary care physician and I reconciled the list to clarify her medication plan.” Unseen opportunitiesWith 25 years of experience behind her, Thrasher’s 2 years at CCLCF have shown her things she’d rarely seen in her previous pharmacy practice. For 15 years, CCNC has trailblazed ways to care for patients in a realm that is now gaining momentum in the health care system: the transition between hospital and home. In the process, CCNC programs helped save the state $1 billion in avoided costs from 2007 to 2010. CCNC’s strategies help North Carolina lead the country in containing Medicaid spending growth at 3.5% per year.“Working with this group of health care professionals,” Thrasher said, “I go home every day feeling that I’ve made a positive impact, whether large or small, for patients at a time when they are most vulnerable.” With 25 years of experience behind her, Thrasher’s 2 years at CCLCF have shown her things she’d rarely seen in her previous pharmacy practice. For 15 years, CCNC has trailblazed ways to care for patients in a realm that is now gaining momentum in the health care system: the transition between hospital and home. In the process, CCNC programs helped save the state $1 billion in avoided costs from 2007 to 2010. CCNC’s strategies help North Carolina lead the country in containing Medicaid spending growth at 3.5% per year. “Working with this group of health care professionals,” Thrasher said, “I go home every day feeling that I’ve made a positive impact, whether large or small, for patients at a time when they are most vulnerable.”