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7295 Week 12 Transitions of Care

Terms in this set (11)

Discuss the barriers associated with implementing transitions of care (TOC) services in the outpatient setting.
Primary barriers to TOC communications include:
- lack of electronic integration that does support HIE
- coordination between hospital and outpatient pharmacy
- lack of physician collaboration
- absence of compensation for services

Outpatient PharmD:
- inadequate time due to workload responsibilities and demands
- lack of interest and/or training of personnel
- ineffective methods in place to facilitate patient handoffs and HIE
- rapport with physicians to facilitate patient handoffs and HIE
- rapport with physicians to facilitate care coordination efforts
- consistency of service - especially when utilizing pharmacy students
- patient interest in the service
Describe opportunities for pharmacist involvement in outpatient TOC services.
- expand pharmacy services via extenders - measure impact of service
- revenue from services

Pharmacist-provided services include:
- medication therapy management
- post-discharge follow-up
- prescription services
Identify interventions to improve care coordination and patient outcomes in an outpatient setting.
- medication reconciliation
- patient education and counseling
- post discharge follow-up
- patient handoffs
Locate and discuss APhA resources to support TOC outpatient pharmacy services.
- ASHP-APhA Medication Management in Care Transitions Best Practices
- A Practical Guide for Pharmacists to Establish a TOC Program in an Outpatient Setting
- Transitions of Care Case Examples Resource
- Applying the Pharmacists' Patient Care Process to Care Transitions Services
- Transitions of Care Toolkit (RED, The Care Transitions, Coordination & Continuity Required)
Explain billing procedures for TOC outpatient pharmacy services.
- TCM is a billable under Medicare Part B by physicians and non-physician practitioners (NPP)
- Pharmacists may conduct non-face-to-face services under "general" supervision, while face-to-face visits must be conducted with direct supervision

TCM Service Components:
- Interactive contact within 48 hrs
- Non-face-to-face services (review D/C info, follow-up pending diagnostics, provide education, establish referrals and/or follow-ups, assess/support treatment adherence, assist in patient access to care and services)
- Moderate Complexity: face-to-face visit within 14 days
- High Complexity: face-to-face visit within 7 days
Define transitions of care.
- the movement of a patient from one health care provider or setting to another
How does transitioning care affect medication errors?
60% of all medication errors occur during transitions of care contributing to poor health outcomes and substantial economic burden.
What is the Hospital Readmission Reduction Program (HRRP)?
- created under Section 3025 of the Affordable Care Act as a pay-per-performance program that reduces payments to hospitals with excess readmissions
- under the HRRP, hospitals with excessive readmission rates will be penalized by payment reduction of all Medicare admissions- not just those that were readmitted
consequences of poor transitions of care
- ineffective/duplicative care
- medication errors and adverse events
- inadequate follow up
- increased hospital length of stay
- excessive ED visits and avoidable readmissions
- increased health care costs
- patient dissatisfaction
TOC service goals
- interdisciplinary approach to safety and efficiently transition patient through the healthcare system
- reduce medication errors and adverse events
- reduce excessive readmissions and emergency department visits
- improve patient satisfaction and quality of life
goal of the TOC Communication Template
- improve patient handoffs from hospital discharge to the community pharmacy setting
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