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Download Successful Discharge - Society of Hospital Medicine
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Medication Non-Adherence: The Hidden Epidemic Managing Medication Adherence & A Safe Hospital Discharge Incidence of Medication Noncompliance 50% of the 1.8 billion prescription medications dispensed annually in the United States are not taken correctly by patients Adherence to Long-Term Therapies: Evidence for Action. WHO 2003 Smith DL - Med Interface 1993; 74-84 U.S. Patients Do Not Take Medications as Prescribed -12% -12% -29% 100% 88% 76%* 47%* Rx prescribed Rx filled Rx taken Rx continued * 22% of U.S. patients take less of the medication than is prescribed American Heart Association: Statistics you need to know. http://216.185.102.50/CAP/pro/prof_statistics2.html. Accessed July 27, 2002. Impact of Medication Adherence on Hospitalization Risk 60 50 40 30 20 10 0 1-19* 2039* 4059* 6079* 80100 Medication Possession Ratio Diabetes Hypertension *P<0.05 when compared to the 80-100% group Sokol etal. Med Care 2005;43: 521-530 Hypercholesterolemia Healthcare Cost Impact of Medication Adherence on AllCause Healthcare Costs 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Diabetes 1-19* 20-39* Hypertension 40-59* 60-79+ 80-100 Hypercholesterolemia *P<0.05 when compared to the 80-100% group + P<0.05 when compared to the 80-100% group in Diabetes and Hypercholesterolemia Patients Sokol etal. Med Care 2005;43: 521-530 Potential Barriers to Improving Adherence Poor attitude Denial Memory deficits Fear or Language Literacy Cultural beliefs Alternative health beliefs Poor support Pride Vermiere E, et al. J Clin Pharm Ther. 2001;26:331-342. embarrassment Side effects Religious beliefs Unable to “see” results of drug therapy Lack of choices Cost What is CMAG? Developed from concepts presented by the World Health Organization (WHO) Case Management Adherence Guidelines or CMAG provides an interaction and management algorithm to assess and improve the patient's knowledge and his/her motivation to take medications as they are prescribed. The guidelines provide great flexibility in that individual patient needs can be taken into account. WHO White Paper on Adherence The World Health Organization has made a strong case that medication adherence is based on three pillars: patient information, motivation, and behavioral skill requirements. Adherence to Long-Term Therapies: Evidence for Action. WHO 2003 CMAG Algorithm Case Management Adherence Guidelines. Copyright© 2004. CMSA CMAG Assessment Tools Tools to assess patient knowledge Health Literacy – RealmR Medication Knowledge Survey Modified Morisky Scale Health Literacy Health literacy is defined as the ability to read, understand, and act on health information. Poor health literacy results in medication errors, impaired ability to remember and follow treatment recommendations, and reduced ability to navigate within the healthcare system. The Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), a brief eight-item screening test Bass Pf, Wilson JF, Griffith, CH. J Gen Intern Med.2003;18:1036-1038. Medication Knowledge Survey Assesses knowledge of various medications to be taken, their dosing schedule, benefits and storage Useful as part of the knowledge assessment for CMAG to determine if the patient is in the high or low knowledge domain CMAG Assessment Tools Tools to assess patient motivation Readiness Ruler Duke-UNC Functional Social Support Questionnaire Readiness Ruler Assess willingness to change behavior Zimmerman GL, Olsen CG, Bosworth MF. Am Fam Physician.2000:61;1409-1416 Social Support Family or social support is a significant predictor of adherence to long-term medical therapy Duke-UNC Functional Social Support Questionnaire Eight-item, self-administered, multidimensional instrument Broadhead WE, et al. Med Care.1989:27;221-223. Modified Morisky Scale Patients on existing therapy Morisky 4 item validated adherence predictor scale Two new items to recognize patient understanding of medication benefits as well as refill behavior Allows patients to be categorized as either High or Low on Knowledge and Motivation domains Morisky DE, Green LW, Levine DM. Med Care. 1986;24:67-74. New to CMAG Revision Recognize unique needs of those working with inpatients Hospital Discharge The Hospitalized Patient Acknowledges patients higher level of acuity Case managers may only be involved with a small percent of inpatients Case managers & Nurses have a decreased period of time to interact and plan interventions with patients Successful Discharge Collaboration with other healthcare providers both within and outside the inpatient setting is extremely important to ensure a Successful Discharge Steps to Ensure a Successful Discharge Educate the patient and ensure patient understanding on their diabetes disease process and factors that can influence their condition Ensure the patient has the resources to manage their diabetes after discharge from the hospital Make certain that the discharge will be “safe” for the individual patient Ensure that the patient understands the plan for transition of care into the post discharge setting Make certain that the patient has access to the follow up care and therapy Information for Patients to Ensure a Successful Discharge Patients that are educated regarding their diabetes and treatments are more likely to remain adherent to treatment recommendations Many patients discharged from the hospital will leave on new medications or different routes of administration Information for Patients to Ensure a Successful Discharge Medications that are newly started during hospitalization need to be reconciled with other medications Patients need to know how to monitor their diabetes and treatment in an outpatient setting. Questions Addressed With Patients Prior To Discharge What is wrong with me and what will this condition mean to my long-term health? What do I need to do when I get home to treat my condition? Who should I contact if I have questions regarding my treatment after I am discharged? What are things that I need to watch for to know if my condition is getting worse and what should I do if these occur? How will I pay for my outpatient medical supplies or services? Why discharge counseling and adherence messaging are important for the hospital? Maintain Accreditation JCAHO, NCQA, CMS Successfully compete with other hospitals in the community Patient satisfaction Publicly available quality rankings Financial Prevent readmissions Promote timely patient discharges Competitive Advantage for Hospital Discharge Planning Hospitals seek to be viewed as providing an outstanding level of care Hospitals work to maintain a high level of patient satisfaction Discharge counseling is one of the last points of contact with the patient Patients and payers can now easily compare quality indicators on hospitals in their community www.hospitalcompare.hhs.gov www.jcaho.org/quality+check/home.htm Current State of Hospital Discharge Counseling and Adherence Messaging Studies of patients recently discharged from the hospital have found that: < 50% of patients could state their diagnosis < 50% of patients could list all their medications < 25% of patients could state common side effects and what to expect from their medications, Patients taking three or more medications were more likely to have problems with medication knowledge King, 1998; Makaryus, 2005 Key Elements of Successful Discharge Planning Recruit a champion Build a multidisciplinary hospital team Review baseline data Develop protocols and order sets that include appropriate evidence-based therapies Conduct hospital staff conferences to introduce process and gain buy in Continue data analysis and report results back to hospital staff on a regular basis Evaluate data and look for opportunities for improvement Create an adherence program AHA, Get with the Guidelines Coordination of Care and Transition of Care Outside the Hospital Transition of Care to the Outpatient Setting Involve family and caregivers in patient education Ensure that patient has a plan for outpatient follow up Facilitate referral for outpatient services and healthcare providers Assist patients with resolving issues relating to the cost of outpatient services and treatments Evaluate Adherence Intention prior to discharge using CMAG tools
