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INTRODUCTION

Transitions of care (TOC) is a term that refers to movement of patients among health care practitioners, settings, and home as their condition and care needs change.¹ Because of our health care system’s infrastructure, patients often encounter fragmented care when moving between health care settings.¹ Poor TOC create considerable cost in the United States. About 18% of Medicare hospital admissions result in readmissions within 30 days of discharge, accounting for $15 billion in spending.² Of that amount, the Medicare Payment Advisory Commission found that Medicare spends about $12 billion on potentially preventable readmissions.² Safely transitioning patients from hospital to home is a complex process that requires successfully completing a number of tasks, from coordinating care with outside physicians to educating patients.³ To improve overall quality of care, the federal government instituted the Patient Protection and Affordable Care Act of 2010 (ACA). It imposes financial penalties on hospitals with excessively high readmission rates for Medicare patients. Since the enactment of the ACA, many TOC models have emerged to reduce readmissions (see Table 1).

The Joint Commission (TJC) has outlined methods to optimize patients’ transition between health care settings.¹ Root causes for ineffective TOC include the following:

• Communication breakdown: Information often remains at the site of care in silos and exchange of information is limited. The Center for Transforming Health Care’s Handoff Communication Project highlights several risk factors that promote this breakdown in communication⁴:
• Culture does not promote successful handoff (e.g., lack of teamwork and respect).
• Expectations between the communication initiator (sender) and receiver differ.
• The sender uses ineffective communication methods (e.g., verbal, recorded, bedside, written) and provides inaccurate or incomplete information, which may include medication lists, concerns/issues, and contact information. This contributes to duplicate prescriptions and increases risk for drug-drug interactions.
• The team does not synchronize timing of physical transfer of the patient and the handoff.
• The team lacks standardized procedures describing successful handoff.
• Lack of accountability and care coordination: Each provider may treat only a single aspect of a patient’s care without regard to other providers’ treatment.² Providers may focus on acute needs as opposed to holistic and patient-centered needs. Poorly coordinated care between multiple providers may result in patient confusion, over-treatment, duplicate services, higher spending, and lower quality care.²

Patient education breakdown: Patients and caregivers may be excluded from planning related to the transition process.¹ They may receive conflicting recommendations, unclear medication regimens, and confusing instructions about follow-up care, which can lead to poor medication adherence.

FOUNDATIONS TO ENSURE SAFE TRANSITIONS OF CARE

Whether TOC interventions are provided within the hospital or ambulatory clinic, or are outsourced to nearby pharmacies, TOC efforts are everywhere. Hospitals that do not implement a service will have a hard time competing in the new value-based environment. TJC recommends that all institutions establish 7 foundations to ensure safe transitions between health care settings⁵:

• Medication management
• Transitional planning
• Early identification of patients/clients at risk
• Patient and family action/engagement
• Leadership support
• Multidisciplinary collaboration
• Transfer of information

Medication Management

TJC has established medication reconciliation as a national patient safety goal (NPSG). Medication-related issues such as cost barriers, poor understanding of how to take medications correctly, and serious adverse drug events (ADEs) resulting from lack of medication reconciliation can contribute to hospital readmissions. In September 2018, California Senate Bill 1254 (SB 1254) was enacted; it requires pharmacists, intern pharmacists, and pharmacy technicians with proper training to obtain an accurate medication profile for each high-risk patient admitted to the hospital.⁶ TJC does not specify who “owns” medication reconciliation, but this patient safety bill recognizes pharmacy as the profession responsible for this function.

The Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) was a multisite mentored quality improvement (QI) study that assessed the effects of medication reconciliation and QI interventions on unintentional medication discrepancies with potential for patient harm.⁷ It details the most important components of a medication reconciliation program in the MARQUIS Implementation Guide.⁸ This manual is a valuable resource that compiles best practices for medications to be prescribed, recorded, and reconciled accurately at care transitions. The manual and its accompanying online resources provide enough detail for sites to adapt these concepts to their environments, recognizing that each site will have different strengths and weaknesses.⁸

The MARQUIS tools offer videos, pocket guides, and tools on how to obtain a best possible medication history (BPMH) to ensure providers make informed decisions with accurate medication lists. More comprehensive than a routine primary medication history, a BPMH involves 2 steps: obtaining a thorough history of all prescribed and nonprescribed medications using a structured patient interview and verifying this information with a second source. A complete medication entry should include the medication’s name, formulation, dosage, route, and frequency. A medication list (if available) may supplement patient or caregiver interviews. However, medication lists are highly likely to be inaccurate depending on when they were updated.

The interview should be conducted by asking open-ended questions, and clinicians should avoid reading the list to the patient. If the patient is taking medications as needed, clinicians should ask how many times a week that medication is used and for what symptoms. They should also ask about recent changes to medications; over-the-counter products including herbs and supplements, samples; and other commonly forgotten medications such as inhalers, nebulizers, and creams. If the patient is a reliable historian, it may be unnecessary to gather additional data. However, if the patient is a poor historian (i.e., is unsure about medication names, doses, and indications or cannot provide medication information from memory), clinicians will need secondary sources.

Secondary verification sources include calling the patient’s pharmacy for a fill history, obtaining information from family members, and using original bottles or pill identifier tools if the patients brings medications in an unlabeled pill box. The medication reconciliation process is dynamic, and the patient’s medication list should be updated as new information becomes available. Once the medication list is as complete as possible, given the information available at the time of gathering, clinicians need to reconcile it by comparing it with current inpatient orders and addressing discrepancies. They must assess the last dose taken, especially for medications with narrow therapeutic indexes, or if missing information is potentially dangerous or creates high risk of over-treatment or under-treatment (e.g., warfarin, insulin, immunosuppressive therapy). If any information is missing, clinicians may need to investigate further.

A new requirement in the national patient safety goals (NPSG) for medication reconciliation addresses the patient’s role in medication safety and requires organizations to inform the patient about the importance of maintaining updated medication information.⁹ Examples include giving the patient a medication list that clearly outlines when medications are discontinued, doses are changed, or new medications are added. Although SB 1254 requires only that medication histories are gathered at the time of admission, the revisions of the NPSG suggest the importance of medication reconciliation at the time of discharge to allow for more effective communication of the medication plan with the next provider of care.

Transitional Planning, Early Identification, and Action/Engagement

Discharge risk assessment should begin within 24–48 hours of admission and continue throughout the hospital stay. Risk factors for readmission include older age, lack of caregiver support, and psychosocial matters such as mental health issues.⁵ Clinicians should also assess barriers such as access to medications, transportation, financial shortcomings (e.g., lack of insurance or underinsured status), and caregiver availability. These need to be addressed before discharge.

To promote patient involvement in the discharge plan, Centers for Medicare & Medicaid Services (CMS) developed a discharge planning checklist for patients and their caregivers preparing to leave a hospital, nursing home, or other care setting.¹⁰ The checklist outlines action items to prompt patients/caregivers to ask questions regarding health status, recovery plan, medication, and follow-up care.

In September 2019, CMS released the final ruling on discharge planning requirements for hospitalsand home health agencies. The overall message is to empower patients to be active participants in their care.¹¹ The proposal is designed to achieve this by focusing on the seamless exchange of patient information between health care settings so patients and families can make informed decisions while addressing their goals of care and treatment preferences. This allows for more flexibility for providers to engage with patients to create a more personalized, meaningful plan to reduce their chance of rehospitalization.

Leadership Support

As tempting as it is to start a service within a single area of the hospital (i.e., pharmacy department), it is unlikely to become a hospital-wide program without administrator buy-in. To provide sustainable TOC interventions that are likely to improve care and patient satisfaction, the health-system’s top administrators (i.e., senior executives or “C-suite”) must invest in the program. Each available TOC or Med Rec toolkit—including Project RED, BOOST, and MARQUIS—mentions significant administrator buy-in as a key component to a successful program.^8,12,13 The primary literature has shown the value of administrator buy-in with the subsequent development of a clear leadership structure in TOC interventions.¹⁴ Because this first step is often beyond the care provider’s control, it is seen as the most difficult aspect to achieve when creating a new TOC program.

There are many ways to justify implementing a TOC service within a health system. The first and most obvious is that TOC services should significantly improve patient care by decreasing the number of medication discrepancies that reach the patient. Beyond improving patient care, administrators specifically seek revenue-generating or potential cost-saving interventions that justify any new program’s cost. Fortunately, the amount of literature concerning TOC has increased appreciably in the last 10 years, providing ample avenues to take when presenting a proposal to corporate leaders.

Reducing ADEs

One of the more straightforward approaches to determining the value of medication reconciliations and TOC programs is to determine the average cost of an ADE, and estimate the total cost of ADEs based on bed capacity and the ratio of average discrepancies per patient. This represents potential cost savings and money available for staffing if administration believes that TOC will prevent ADEs.

UC Davis Medical Center (UCDMC) conducted a pilot study, Reduce Medication Errors by Doing Early Medication Reconciliation in the Emergency Department (ED) from January 6 to January 23, 2014.¹⁵ The study evaluated the number of discrepancies found in patients who received medication reconciliation early in the ED (treatment group) and compared them with patients who received medication reconciliation after admission into a hospital unit (control group). More patients in the control group (n = 173) received medication reconciliation than those in the treatment group (n = 134), but more discrepancies were discovered in the treatment group. The treatment group averaged 2.91 discrepancies per mediation reconciliation versus 1.59 in the control group (Table 2).

In both groups, 97% of the discrepancies were unintentional, with the majority being medication omissions. An expert panel of 2 physicians and 1 pharmacist reviewed these discrepancies to rank their level of severity. They found that most discrepancies were of low severity but a few discrepancies could have potentially caused injury or even death. The investigators concluded that if admission orders are based on the prior to admission (PTA) medication list, errors are likely to occur during the patient’s hospitalization, emphasizing the importance of completing medication reconciliation at all transition points. The earlier this process is completed, the sooner discrepancies can be identified and addressed to prevent potential ADEs to the patient. The estimated cost per ADE in hospitalized patients can be as high as $4,800.¹⁶ The National Quality Forum estimated that annual losses of more than $21 billion are attributable to preventable medication errors.¹⁷ Studies like these portray the stark reality of a problem that was largely overlooked in previous decades.

Return on Investment

Calculating return on investment (ROI) for a proposed TOC service can help hospital leadership make more informed decisions when prioritizing resources for quality improvement initiatives.¹⁸ The Agency for Healthcare Research and Quality (AHRQ) outlines step-by-step instructions on how to calculate an ROI. The ROI can be used as a planning tool to project revenue and operating costs and to adjust the intervention to better optimize both quality and financial performance. It can also evaluate the value of the service and guide future improvement actions. The MARQUIS manual provides specific examples of ROI calculations that estimate the potential annual net savings based on the number of ADEs avoided.⁸ Factors involved in this calculation include the number of discrepancies per patient multiplied by the percentage of patients with discrepancies that would result in an ADE and cost of an average ADE. An ROI is calculated as the ratio of these financial estimates:

ROI = Net financial returns from improvement actions/
Financial investment in improvement actions

When and ROI ratio is 1 or greater, the returns generated by improvement actions exceed the costs for development and implementation.¹⁸ For example, and ROI of 1.5 indicates that for every $1 you invest in the program, $1.50 will be gained for the hospital. Thus, a positive ROI can justify the service and further increase leadership support.

Reducing 30-Day Readmissions

In addition to the more straightforward ROI approach, the Hospital Readmissions Reduction Program (HRRP) began on October 1, 2012.¹⁹ This CMS program uses a complicated process to determine financial penalties for hospitals based on excessive readmissions for certain disease states. The penalties have increased each year, and CMS plans to add disease states as they move toward value-based care.

Administrators are aware of the HRRP and are actively looking for ways to keep patients from being readmitted. One article described 4 interventions, each implemented by different hospitals, that could avoid $1 million in losses annually at each hospital.²⁰ Interventions included medication reconciliation, patient education, bedside delivery, and development of clinics for high-risk patients. Because of the potential for acute financial loss, a proposal showing a TOC program’s potential to avoid penalties has more funding potential now than ever before.

Accountable Care Organizations, Value-Based Purchasing, and Patient Satisfaction

CMS estimates that the total amount of Medicare reimbursements available to value-based purchasing (VBP) programs in fiscal year 2019 was approximately $1.9 billion.²¹ Even without the HRRP penalties, hospital administrators are looking for ways to improve patient care and improve the bottom line. They must prepare for a future in which funding models are based not only on best practices, but also on improved outcomes and stellar patient experiences.

When CMS funded its first accountable care organization (ACO) Shared Savings demonstration project,²² it provided participating hospitals the opportunity to share in joint savings with Medicare by providing safe, effective, and fiscally efficient care. In addition, many hospitals have improved patient satisfaction scores by implementing TOC programs. Patient satisfaction is directly linked to reimbursement through VBP.²³ VBP shifts the focus of billing from the care process to care outcomes and includes a patient satisfaction element. With the 3 new Care Transitions Hospital Consumer Assessment of Health Care Providers Score (HCAHPS) questions,²⁴ 1 of which directly relates to medication understanding at discharge, organizations have an incentive to implement TOC programs and include a pharmacy component.

Payment Models

In addition to the money being saved by keeping patients out of the hospital and/or improving outcomes, health systems can consider increasing revenue by billing. For example, if a system has a PCMH system or an attachment to ambulatory care clinics in place, they can provide transitional care management (TCM) services²⁵ and bill certain current procedural terminology (CPT) codes that reimburse at higher rates per visit than do standard evaluation and management (E/M) codes. Various health care professionals such as physicians, nurse practitioners, and physician assistants may furnish TCM services. Organizations must meet specific components to bill for this type of visit:

• The 30-day TCM period begins on the patient’s inpatient discharge date and continues for the next 29 days.
• These CPT codes apply only to patients with moderate- or high-complexity needs upon discharge; each patient must be contacted within 2 days of discharge to qualify.
• Patients must have a face-to-face visit within 7 days (high-complexity patients) or 14 days (moderate-complexity patients) to bill the 99496 and 99495 CPT codes, respectively. Using eligible telehealth services can substitute for an in-person encounter.

TCM services can still be reported if the patient is readmitted in the 30-day period as long as no other provider bills the service for the first discharge. Only one individual may report TCM services once per patient within 30 days of discharge. Therefore, health systems will need to determine which provider will use the CPT code and who will use standard E/M codes.

Although pharmacists cannot bill these visits independently, they are able to see patients in tandem with physicians. It is possible for pharmacists in the PCMH setting to see patients under these codes, provided that they work in concert with a physician in their practice area. Additionally, pharmacists can see patients for comprehensive medication management (CMM) services and bill using medication therapy management (MTM) codes. These codes can be difficult to set up, but some pharmacists have billed using these codes for their more complex and/or older patients.²⁶

Multidisciplinary Collaboration and Transfer of Information

TJC reports that the need for collaboration is TOC’s greatest challenge. The National Transitions of Care Coalition (NTOCC) addresses this concern by providing a publicly available compendium of online resources for patients, providers, payers, and policymakers who are interested in TOC and its challenges.²⁷ The NTOCC Advisors Council has created 4 work groups to address key areas including education and awareness, tools and resources, performance measures, and policy and advocacy. In addition, NTOCC has a taskforce dedicated to Health Information Technology Innovations that address gaps in TOC issues such as transfer of information between settings.

The Joint Commission Center for Transforming Healthcare has also continued efforts to improve the health information exchange by creating a Handoff Communications Targeted Solutions Tool. This tool is a model for launching handoff communications performance improvement projects within health care organizations.

A total of 53 CMS-funded quality improvement organizations (QIOs) are taking progressive steps to provide a robust set of resources that can be shared among community coalitions consisting of hospitals, nursing homes, patient advocacy organizations, and other stakeholders. Each QIO works to reduce avoidable readmissions by improving processes relating to issues such as medication management, postdischarge follow-up, and care plans for patients who move across health care settings.²⁸

Health Services Advisory Group (HSAG) is multistate QIO tasked by CMS to assist communities, hospitals, and postacute providers with improving the quality of care for Medicare beneficiaries who transition among care settings. HSAG is currently in the preliminary planning phase, recruiting stakeholders to form a Greater Sacramento Collaborative in California. The collaborative is multidisciplinary and customized by its members based on root cause analyses identified using Lean methodology (an approach used to accelerate the velocity and reduce the cost of any process) and brainstorming sessions. Their work continues to evolve with the aim of reducing hospital readmissions and identifying solutions to transfer information efficiently between various settings in their region.

INPATIENT AND OUTPATIENT TRANSITIONS OF CARE

UCDMC has taken advantage of an automated patient outreach technology by partnering with Cipher Health’s postdischarge call program.²⁹ Customized call scripts were developed by multidisciplinary providers involved in the handoff between inpatient and outpatient settings including triage nurses, nurse case managers, and pharmacists. At the time of hospital discharge, the patient is informed that they will receive a telephone call within 48 hours of discharge as an opportunity to address any potential issues that arise after discharge. UCDMC’s call script includes pointed medication-related questions to ensure that the patient has been able to get their medications and ask if they have questions about taking any of the agents. Issues are triaged to dedicated nursing staff and can be escalated to the inpatient transitions of care pharmacy service for further assistance.

In addition to inpatient hospital-to-home TOC practices, a number of outpatient interventions can be implemented to improve a health system’s TOC. If a hospital is associated with its own hospital-based clinics and/or medical practices, then it can place pharmacists and other specialized personnel (such as behavioral health experts, social workers, and health education specialists) in clinics to develop a patient-centered medical home (PCMH). One of UCDMC’s TOC interventions was the development of a PCMH model that included a pharmacist. This model allowed TOC pharmacists in the hospital to hand off patients to a primary care team. The outpatient PCMH pharmacist would then follow up on medication issues that were unresolved during hospitalization. Examples include Medicare Part D plan restrictions, copayment assistance, and patient assistance programs (PAPs).

For Medicare Part D coverage problems, PCMH pharmacists worked with patients during open enrollment face-to-face in a clinic setting or by telephone to help them choose plans that would cover their medications. Choosing a Medicare Part D plan and applying for low-income subsidies for extra financial help requires the use of an online plan finder, which non-tech-savvy patients can find difficult to navigate. Patients eligible for copayment assistance programs and PAPs benefited from enrollment; pharmacists helped patients receive long-term medications without interruption if cost was a major barrier. Enrolling in Medicare Part D or PAPs takes time and requires direct patient involvement, which can be difficult during a hectic discharge. The use of pharmacy technicians and/or other pharmacist extenders can create further efficiencies during TOCs.

Even when patients receive accurate medication lists thorough discharge education, they remember only 40% to 80% of medical information given to them.³⁰ This can lead to patient medication administration errors and readmissions. PCMH pharmacists provide additional and repeated education to patients to promote a deeper understanding of their medications and how to take them. They use motivational interviewing (MI) strategies to help patients reach their health goals. MI involves listening to patients describe their desired objectives and applying techniques to show them how taking better care of themselves will achieve these goals. Examples of health goals include increasing exercise and mobility. A provider could use this goal to manage patients’ uncontrolled diabetes better by educating them about the risks of developing peripheral neuropathy, which can result in limb removal. Other examples include the following:

• Promoting medication adherence to prevent hospitalization
• Changing the timing of medications to help target symptoms
• Empowering patients to be in better control of their role in medication management

The PCMH concept is not new. In fact, most customer service models in the business world provide services that revolve around the person receiving the service. Use of this concept in health care has shifted the way that medicine is practiced and significantly improved patient care. The Patient Centered Primary Care Collaborative (PCPCC) has based its entire TOC service around ensuring a smooth transition back to the community setting, thus preventing many readmissions.³¹

COMMUNITY-BASED TRANSITIONS OF CARE

TOC also occurs in community pharmacy settings. Pharmacists in these settings have restructured their usual product-focused operations to include methods to improve patient medication adherence, provide MTM services, and offer bedside delivery to nearby hospitals that may lack internal pharmacies.

One example is the WellTransitions program initiated by Walgreens in 2012.³² Poor medication adherence rates are highly correlated with early readmissions. Walgreen’s pharmacists and pharmacy technicians obtain access to the patient’s hospital medication list. They provide MTM services and deliver the patient’s discharge medications to the bedside before discharge.³³ Currently, the WellTransitions program provides bedside delivery services to more than 100 hospitals. In some cases, Walgreens pharmacists telephone patients to check for problems that may arise during the critical 30-day postdischarge window. These services have shown some initial improvement in patient satisfaction rates and are an option for hospitals that lack internal pharmacy support.

Other community pharmacies have joined the effort. Kroger began TOC services in Cincinnati, OH, to decrease readmissions for high-risk patients.^34,35 Sen et al. found that a collaboration between Mercy Hospital and SunRay community pharmacy that included bedside delivery, 72-hour postdischarge telephone calls, and CMM, which includes medication reconciliation and medication action plans decreased readmission rates at their hospital.³⁶ Some hospitals have begun to support integration of social services into the health care team to improve readmissions. New York City Health and Hospitals Corporation invested in transitional housing for their highest risk patients. It reports dramatic improvements in readmission rates, emergency department visits, and overall cost.³⁷

SKILLED-NURSING FACILITIES

In 2006, nearly 1 in 4 Medicare beneficiaries discharged from the hospital to skilled-nursing facilities (SNFs) were readmitted within 30 days at a cost of $4.3 billion.³⁸ Congress passed the Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT Act) that establishes a quality reporting program for SNFs. Failure to comply with data submission requirements will result in reduced payment penalties beginning fiscal year 2018.³⁹

Lapses in communication among facility staff along with documentation and transcription errors have led to poor coordination of care. Information on discharge summaries differs from that on transfer/referral forms in more than 50% of long-term care admissions, and 70% of all admission records contain at least 1 medication discrepancy. Up to 60% of these errors have been serious, life-threatening, or fatal. Errors involved in transitions from hospitals to long-term care (LTC) facilities may be more likely to cause harm to patients; they often involve high-alert medications including warfarin, insulin, opioids, and cardiovascular medications. ISMP recognizes that pharmacists can help identify omitted medications, nonindicated medications, and dosing errors. Pharmacists can reconcile medications and note discrepancies, provide reasons for changes to medications, and verify the accuracy of discharge summaries.⁴⁰

One hospital launched a quality-improvement project that focused on developing a standardized discharge order reconciliation process that included a clinical pharmacist. After the hospital-wide implementation of the new workflow, the readmission rate for SNF patients decreased from 9.5% to 6.7%.⁴¹

Another group randomly reviewed electronic medical records and paper chart medication reconciliation lists across 3 transitions of care: hospital admission to discharge (time 1), hospital discharge to SNF (time 2), and SNF admission to discharge home or LTC (time 3).⁴² A principal investigator and a pharmacist identified and categorized medication discrepancies in 132 TOC involving 1,696 medications. Discrepancies were defined as any documented but unexplained change in the patient’s medication lists between sites. Unintentional discrepancies were defined as any omission, duplication, or failure to change back to the original regimen when indicated. More than 300 discrepancies were identified at each transition point, and 86% of patients had at least 1 unintentional discrepancy in their records. On average each patient had 8.1, 7.2, and 7.6 discrepancies at times 1, 2, and 3, respectively. This study demonstrated the widespread prevalence of medication discrepancies in these settings, emphasizing the role for pharmacists to protect patients from medication-related harm during vulnerable transitions.

Furthermore, pharmacists can play an integral role in hands-on medication management during postdischarge home visits. One study evaluated the value of health information technologies by managing medication regimens using an electronic personal health records (ePHR) coupled with a pharmacist visit to recently discharged patients' homes.⁴³ Usual care consisted of medication reconciliation at discharge provided by hospital clinicians, but no subsequent home visits from pharmacists. Pharmacists were more likely to detect medication-related problems among patients who agreed to use the ePHR than in patients who declined the ePHR. Though this study’s sample size was too small to conclude a statistically significant impact, the results suggest that pharmacist home visits following a hospitalization can help identify medication-related problems. The ePHR can enhance the pharmacist’s assessment and allow patients to share their medical information readily with other health care providers.

CONCLUSION

TOC is a complex and time-consuming endeavor, but it is worthy of implementing at each and every health care setting to improve patient outcomes. While implementation may take time, energy, and effort, the investment will pay dividends as our health care marketplace changes from fee-for-service to an outcomes-based model, and pharmacists and pharmacy technicians are proving to be integral in achieving these goals.

GLOSSARY OF TERMS ACO — accountable care organization ADE — adverse drug event AHRQ — Agency for Healthcare Research and Quality BPMH — Best Possible Medication History CMM — comprehensive medication management CMS — Centers for Medicare & Medicaid Services CPT – Current Procedural Terminology E/M – evaluation and management ePHR — electronic personal health records HCAHPS — Hospital Consumer Assessment of Health Care Providers Score HRRP — Hospital Readmissions Reduction Program LTC — long-term care MARQUIS – Multi-Center Medication Reconciliation Quality Improvement Study MTM — medication therapy management NPSG — National Patient Safety Goal PCPCC —Patient Centered Primary Care Collaborative PPACA — Patient Protection and Affordable Care Act PTA — prior to admission QI — quality improvement ROI — return on investment SNF — skilled-nursing facility TCM — transitional care management TJC — The Joint Commission TOC — transitions of care UCDMC — UC Davis Medical Center VBP — value-based purchasing

REFERENCES

1. The Joint Commission. Hot Topics in Health Care. Transitions of Care: The need for a more effective approach to continuing patient care. June 27, 2012. http://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf. Accessed July 15, 2019.
2. Medicare Payment Advisory Commission, Report to the Congress: Reforming the Delivery System, Washington, D.C.: MedPAC; June 2008. https://www2.lawrence.edu/fast/finklerm/Miller%20Medpac%20report%202008.pdf. Accessed September 2, 2019.
3. Horwitz LI, Moriarty JP, Chen C, et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013;173(18):1715–1722.
4. The Joint Commission Center for Transforming Health care. Improving Transitions of Care: Handoff Communications. https://www.centerfortransforminghealthcare.org/-/media/cth/documents/improvement-topics/handoff_comm_storyboard.pdf Accessed August 29, 2019.
5. The Joint Commission. Hot Topics in Health Care, Issue 2. Transitions of Care: The need for collaboration across entire care continuum. February 19, 2013. http://www.jointcommission.org/assets/1/6/TOC_Hot_Topics.pdf. Accessed July 15, 2019.
6. California Legislative Information. SB-1254 Chapter 697. Hospital pharmacies: medication profiles or lists for high-risk patients. September 2018. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1254. Accessed July 15, 2019.
7. Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ Qual Saf. 2018;27(12):954-964.
8. MARQUIS Implementation Manual. http://tools.hospitalmedicine.org/resource_rooms/imp_guides/MARQUIS/Marquis_Manual2011.pdf. Accessed September 2, 2019.
9. The Joint Commission. National Patient Safety Goals Effective January 2019. January 2019. https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf. Accessed July 15, 2019.
10. Centers for Medicare and Medicaid Services. Your Discharge Planning Checklist. Revised June 2015. https://www.medicare.gov/pubs/pdf/11376-discharge-planning-checklist.pdf. Accessed July 15, 2019.
11. Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies, and Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care. September 30, 2019. https://federalregister.gov/d/2019-20732. Accessed November 27, 2019.
12. Society of Hospital Medicine. Project Better Outcomes by Optimizing Safe Transitions (BOOST) Implementation Toolkit. http://www.hret-hiin.org/resources/display/project-boost-implementation-toolkit. Accessed July 15, 2019.
13. Boston University School of Medicine. Project Re-Engineered Discharge (RED). http://www.bu.edu/fammed/projectred/index.html. Accessed July 15, 2019.
14. Byrnes J, Fifer J. Recommendations for responding to changes in reimbursement policy. Front Health Serv Manage. 2010;27:3-11.
15. ACCP Global Conference Poster Abstracts. Quach JA, Burton J, Hua S, et al. Reduce medication errors by doing early medication reconciliation in the emergency department. Pharmacotherapy. 2015; e197. https://accpjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/phar.1659. Accessed September 2, 2019.
16. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277(4):307-311.
17. National Quality Forum. https://www.qualityforum.org/Home.aspx. Accessed July 15, 2019.
18. Return on Investment Estimation. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf. Accessed September 2, 2019.
19. Centers for Medicare and Medicaid Services. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed July 15, 2019.
20. Thompson CA. Pharmacy departments innovate to reduce readmissions penalty. Am J Health-Syst Pharm. 2013;70:296, 298.
21. Centers for Medicare and Medicaid Services. CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2019. https://www.cms.gov/newsroom/fact-sheets/cms-hospital-value-based-purchasing-program-results-fiscal-year-2019. Accessed May 12, 2019.
22. Shared Savings Program. Centers for Medicare and Medicaid Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram. Accessed July 15, 2019.
23. Value-Based Purchasing Payment Adjustments. Medicare/Hospital Compare. https://www.medicare.gov/HospitalCompare/Data/payment-adjustments.html. Accessed July 15, 2019.
24. Center for Medicare and Medicaid Services. HCAHPS Executive Insights Spring 2015. http://www.hcahpsonline.org/executive_insight/. Accessed July 15, 2019.
25. Center for Medicare and Medicaid Services. Transitional Care Management Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Accessed September 2, 2019.
26. Vecchione A. MTM services effective, but where’s the payment? Pharm Pract News. 2008 (May 14).
27. National Transitions of Care Coalition website. http://www.ntocc.org/. Accessed July 15, 2019.
28. The Joint Commission. Hot Topics in Health Care, Issue 2. Transitions of Care: The need for collaboration across entire care continuum. February 19, 2013. http://www.jointcommission.org/assets/1/6/TOC_Hot_Topics.pdf. Accessed July 15, 2019.
29. CipherHealth Post Discharge Follow Up. https://cipherhealth.com/post-discharge-follow-up/. Accessed July 15, 2019.
30. Kessels RP. Patient’s memory for medical information. J R Soc Med. 2003;96(5):219-222.
31. Patient-Centered Primary Care Collaborative (PCPCC). 2012 The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes Resource Guide. https://www.pcpcc.org/guide/patient-health-through-medication-management. Accessed July 15, 2019.
32. Walgreens. WellTransitions. Community Partnerships to Reduce Readmissions, Lower Costs, and Improve Quality. https://atlanticquality.org/download/well_trans_4-23-15.pdf. Accessed July 15, 2019.
33. Hubbard, T, McNeill N. The Network for Excellence in Health Innovation (NEHI).Improving Medication Adherence and Reducing Readmissions. October 2012. http://www.nacds.org/pdfs/pr/2012/nehi-readmissions.pdf. Accessed July 15, 2019.
34. Freund JE, Martin BA, Kieser MA, et al. Transitions in care: medication reconciliation in the community pharmacy setting after discharge. Innov Pharm. 2013;4:Article 117.
35. University of Cincinnati Health News. Pharmacy study expects to lower hospital readmissions. https://www.uspharmacist.com/article/pharmacy-study-hopes-to-reduce-hospital-readmissions. Accessed July 15, 2019.
36. Sen S, Bowen JF, Ganetsky VS, et al. Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings. Pharm Pract. 2014;12(2):439-447.
37. Evans M. Residential therapy—hospitals take on finding housing for the homeless patients, hoping to reduce readmissions, lower costs. Mod Healthc. 2012;42(39):6-7.
38. Mor V, Intrator O, Feng Z, Gabrowski DC. The revolving door of rehospitalization from skilled nursing facilities. Health Aff. 2010; 29:57-64.
39. Centers for Medicare and Medicaid Services. Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/SNF-Quality-Reporting.html. Accessed July 15, 2019.
40. Institute for Safe Medication Practices. From the Hospital to Long-Term Care: Protecting Vulnerable Patients During Handoff. http://ismp.org/newsletters/acutecare/showarticle.aspx?id=54. Accessed July 15, 2019.
41. Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70:815-820.
42. Sinavi LD, Beizer J, Akerman J, et al. Medication reconciliation in continuum of care transitions: a moving target. J Am Med Dir Assoc. 2013;14(9):668-672.
43. Kogut SJ, Goldstein E, Charbonneau C, et al. Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study. Drug Healthc Patient Saf. 2014;6:1-6.
44. Coleman EA, Perry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1882-1888.
45. Institute for Healthcare Improvement. State Action on Avoidable Rehospitalizations (STAAR). http://www.ihi.org/Engage/Initiatives/Completed/STAAR/Pages/default.aspx. Accessed July 15, 2019.
46. Ouslander, J, Perloe M, Givens J, et al. Reducing potentially avoidable hospitalizations of nursing home residents: results of a pilot quality improvement project (INTERACT). J Am Med Dir Assoc. 2009;15(3):162-170.

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