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CTCS Interactive Case Studies
Certified Transitions of Care Specialist (CTCS)
The Scenario: Reconciling Complex Polypharmacy
A 78-year-old male is being discharged after a 5-day stay for a heart failure exacerbation. As the CTCS, your role is to perform medication reconciliation by comparing the hospital discharge list to the pre-admission list to identify and resolve discrepancies, ensuring a safe transition home.
Medication Lists
Pre-Admission Home Med List
| Medication |
|---|
| Lisinopril 20mg daily |
| Metoprolol succinate 50mg daily |
| Atorvastatin 40mg daily |
| Apixaban 5mg twice daily |
Hospital Discharge Med List
| Medication |
|---|
| Lisinopril 20mg daily |
| Metoprolol tartrate 25mg twice daily |
| Furosemide 40mg daily |
| Atorvastatin 40mg daily |
| Pantoprazole 40mg daily |
Your Task
Task 1: Identify two major discrepancies (one omission, one change) between the pre-admission and discharge lists.
Answer:
1. Omission: The patient's home medication, apixaban, is completely missing from the discharge list. 2. Change: The patient's long-acting, once-daily metoprolol succinate was switched to short-acting, twice-daily metoprolol tartrate.
Task 2: What is the most critical and potentially life-threatening discrepancy, and what is its potential consequence?
Answer:
The most critical discrepancy is the omission of apixaban. The potential consequence is a thromboembolic event, such as a stroke, due to his untreated atrial fibrillation (the likely indication for apixaban).
Task 3: The discharge list includes a new prescription for pantoprazole, likely for in-hospital stress ulcer prophylaxis. Is this medication necessary at discharge?
Answer:
No, it is likely not necessary. Stress ulcer prophylaxis is an intervention for critically ill inpatients. There is typically no indication to continue it upon discharge. Continuing it unnecessarily contributes to polypharmacy and should be a target for deprescribing.
Task 4: What is your final, reconciled medication plan recommendation to the discharging physician?
Answer:
- Restart Anticoagulant: "The patient's home apixaban for A-fib was omitted. To prevent a stroke, recommend we add Apixaban 5mg BID back to his regimen."
- Clarify Beta-Blocker: "He was switched from metoprolol succinate to tartrate. To simplify the regimen to once-daily dosing and improve adherence, recommend switching back to his home dose of Metoprolol Succinate 50mg daily."
- Deprescribe PPI: "The pantoprazole for stress ulcer prophylaxis is no longer indicated. Recommend discontinuing the pantoprazole at discharge."
- Confirm Final List: "The final proposed list is: Lisinopril 20mg, Metoprolol Succinate 50mg, Atorvastatin 40mg, Apixaban 5mg BID, and Furosemide 40mg daily."
The Scenario: Complex Discharge Counseling for a Low-Literacy Patient
An 80-year-old male is being discharged after a hospitalization for a deep vein thrombosis (DVT). He is being started on a new, high-risk medication, warfarin. The patient has low health literacy and lives alone. As the CTCS, you are responsible for providing discharge counseling that he can understand and act upon to prevent a serious bleeding event or recurrent clot.
Patient Data & Discharge Orders
Patient Profile
- Age: 80 years old
- Diagnosis: Acute DVT
- Social: Lives alone, low health literacy.
Discharge Plan
- Medication: Warfarin 5mg daily.
- Monitoring: Must follow up for an INR check at the anticoagulation clinic in 3 days.
- Diet: "Maintain consistent Vitamin K intake."
Your Task
Task 1: What is the primary goal of discharge counseling in transitions of care?
Answer:
The primary goal is to empower the patient and/or their caregiver with the essential knowledge and skills needed to manage their medications safely and effectively at home. This is done to prevent adverse drug events, reduce the risk of hospital readmission, and ensure a smooth transition to the next level of care.
Task 2: The instruction "Maintain consistent Vitamin K intake" is not patient-friendly. How would you explain this concept using plain language?
Answer:
"This new blood thinner, warfarin, works by blocking Vitamin K in your body. Vitamin K is found in leafy green vegetables like spinach and kale. You do not need to stop eating these healthy foods. The most important thing is to be consistent. Try to eat about the same amount of green vegetables each week. A big salad every day is fine, and no salad at all is fine. The problem is having a big salad one day and then none for two weeks, as that will make your blood thinner level go up and down."
Task 3: What is the "teach-back" method, and how would you use it to confirm the patient understands his follow-up plan?
Answer:
The teach-back method is a health literacy tool where you ask the patient to explain the instructions back in their own words. To confirm understanding of the follow-up plan, you would ask: "Just to make sure I did a good job explaining everything, can you tell me what you need to do in three days?" A correct response would be: "I need to go to the anticoagulation clinic to get my blood checked."
Task 4: What is the single most important action you will take to ensure the patient makes it to his critical 3-day follow-up appointment?
Answer:
The single most important action is to proactively schedule the follow-up appointment for him before he leaves the hospital. You would call the anticoagulation clinic, schedule the appointment, write down the date, time, and location on his discharge paperwork, and verbally confirm it with him. For an elderly patient with low health literacy who lives alone, simply telling him "follow up in 3 days" has a high risk of failure.
The Scenario: Coordinating Care with an Outpatient Pharmacy
A 70-year-old female is being discharged after a complicated hospital stay. Her medication list is long, and several high-cost medications were changed. The patient expresses concern about how she will get and afford all her new prescriptions. As the CTCS, you must coordinate with her outpatient community pharmacy to ensure a seamless and affordable medication access plan.
Discharge Plan & Patient Concerns
Key Discharge Medications
- New Start: Apixaban 5mg BID
- New Start: Sacubitril/Valsartan 24/26mg BID
- Dose Change: Furosemide increased to 80mg BID
- Continue: Atorvastatin, Metoprolol, Spironolactone
Patient Concerns & Pharmacy Info
- "I don't know if my insurance will cover these new heart pills. They sound expensive."
- "I'm worried about getting all these prescriptions mixed up."
- Outpatient Pharmacy: "Main Street Pharmacy" (a local independent).
Your Task
Task 1: What is the primary purpose of communicating the reconciled discharge list to the outpatient pharmacy?
Answer:
The purpose is to provide the outpatient pharmacy with a single source of truth for the patient's new, correct medication regimen. This allows them to update the patient's profile, discontinue any old prescriptions that are no longer active, and correctly fill the new prescriptions without confusion or delay. It prevents the patient from accidentally getting refills of discontinued medications.
Task 2: What potential access barrier is associated with the new apixaban and sacubitril/valsartan prescriptions?
Answer:
The primary barrier is cost and insurance coverage. Both apixaban and sacubitril/valsartan are high-cost, branded medications that frequently require prior authorization from insurance plans. Without a PA, the claims will be rejected, and the patient will be unable to afford the medications.
Task 3: To address the access barrier, what action should you take before the patient is discharged?
Answer:
You should proactively initiate the prior authorization process for both apixaban and sacubitril/valsartan while the patient is still in the hospital. By gathering the necessary clinical documentation from the inpatient record and submitting the PAs before discharge, you can often get them approved so the medications are ready for the patient to pick up without delay upon returning home.
Task 4: How would you coordinate with Main Street Pharmacy to address the patient's concern about getting her prescriptions mixed up?
Answer:
You would call the pharmacist at Main Street Pharmacy and recommend they enroll the patient in their medication synchronization program and dispense her medications in a multi-dose compliance package (e.g., a blister pack or pouch packaging). This would consolidate all her medications to a single monthly pickup date and pre-sort them into clearly labeled packets for each time of day, significantly reducing the risk of confusion and improving adherence.
