CTCS Certification Review

Certified Transitions of Care Specialist (CTCS) Review

A Review Guide for the Certified Transitions of Care Specialist (CTCS) Exam

Block 1: Foundations of Transitions of Care

A-C

  • ACO: Accountable Care Organization.
  • ADL: Activities of Daily Living.
  • ADR: Adverse Drug Reaction.
  • ADE: Adverse Drug Event.
  • BPMH: Best Possible Medication History.
  • CCM: Chronic Care Management.
  • CHW: Community Health Worker.
  • CMR: Comprehensive Medication Review.
  • CMS: Centers for Medicare & Medicaid Services.
  • CPOE: Computerized Provider Order Entry.

D-H

  • DME: Durable Medical Equipment.
  • DOAC: Direct Oral Anticoagulant.
  • EHR: Electronic Health Record.
  • EMR: Electronic Medical Record.
  • eMAR: electronic Medication Administration Record.
  • HAC: Hospital-Acquired Condition.
  • HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems.
  • HHA: Home Health Agency.
  • HIE: Health Information Exchange.
  • HIPAA: Health Insurance Portability and Accountability Act.

I-P

  • IADL: Instrumental Activities of Daily Living.
  • ICD-10: International Classification of Diseases, 10th Revision.
  • IDN: Integrated Delivery Network.
  • LACE: Length of stay, Acuity of admission, Comorbidities, Emergency department visits.
  • LTCF: Long-Term Care Facility.
  • Med Rec: Medication Reconciliation.
  • MTM: Medication Therapy Management.
  • NPSG: National Patient Safety Goals (TJC).
  • PCP: Primary Care Provider.
  • PCMH: Patient-Centered Medical Home.

P-S

  • PHI: Protected Health Information.
  • PML: Patient Medication List.
  • POA: Power of Attorney.
  • QALY: Quality-Adjusted Life Year.
  • QI: Quality Improvement.
  • RCA: Root Cause Analysis.
  • SDOH: Social Determinants of Health.
  • SNF: Skilled Nursing Facility.
  • SOAP: Subjective, Objective, Assessment, Plan.
  • STAAR: STate Action on Avoidable Rehospitalizations.

T-Z

  • TCM: Transitional Care Management.
  • TJC: The Joint Commission.
  • TMR: Targeted Medication Review.
  • ToC: Transitions of Care.
  • UTI: Urinary Tract Infection.
  • VBC: Value-Based Contracting.
  • VBP: Value-Based Purchasing.
  • WARS: Warfarin-Aspirin Risk Score.
  • PIM: Potentially Inappropriate Medication.
  • PACE: Programs of All-Inclusive Care for the Elderly.

Defining Transitions of Care

  • ToC refers to the movement of patients between healthcare practitioners, settings, and levels of care as their condition and care needs change.
  • Examples include a transition from a hospital to home, or from a primary care provider to a specialist.
  • These transitions are vulnerable points in the healthcare system.
  • Poorly managed transitions can lead to adverse events, hospital readmissions, and increased costs.
  • The goal of a ToC program is to ensure the coordination and continuity of healthcare.
  • A CTCS is an expert in managing these complex transitions.

The Problem of Poor Transitions

  • Poor transitions are a major cause of preventable harm and waste in the healthcare system.
  • Breakdowns in communication between providers are a primary cause.
  • Medication errors are the most common adverse event following a hospital discharge.
  • Patients and families are often confused about the discharge plan and their medications.
  • This can lead to high rates of preventable hospital readmissions.
  • Nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge.
  • Many of these readmissions are related to medication problems.

The Role of the Pharmacist in ToC

  • Pharmacists are uniquely qualified to lead medication-focused ToC services.
  • They are experts in medication reconciliation, patient counseling, and care coordination.
  • Pharmacist-led ToC services have been shown to significantly reduce medication errors and hospital readmissions.
  • The CTCS is a specialist who designs, implements, and manages these services.
  • They work as a key member of the interdisciplinary care team.

Key Components of a ToC Program

  • A comprehensive ToC program includes interventions at multiple points in the process.
  • Pre-Discharge: Medication reconciliation, patient education, and scheduling follow-up appointments.
  • At Discharge: Providing a clear discharge summary and medication list to the patient and the next provider.
  • Post-Discharge: A follow-up phone call or home visit to reinforce education and identify any problems.
  • Coordination with the patient's primary care provider and community pharmacy is essential.
  • A CTCS must be an expert in all of these components.

The Business Case for ToC

  • ToC programs are not just a quality improvement initiative; they also have a strong business case.
  • CMS and other payers penalize hospitals with high rates of preventable readmissions through programs like the Hospital Readmissions Reduction Program (HRRP).
  • There are also new billing codes, such as for Transitional Care Management (TCM), that provide reimbursement for ToC services.
  • In value-based care models like ACOs, reducing readmissions is a key strategy for success.
  • A CTCS must be able to articulate this value proposition to hospital leadership.

Block 2: The ToC Process & Key Interventions

Definition and Purpose

  • Medication reconciliation ("Med Rec") is the process of creating the most accurate list possible of all medications a patient is taking.
  • This list is then compared against the physician's admission, transfer, and/or discharge orders.
  • The goal is to identify and resolve any discrepancies.
  • It is a critical patient safety process designed to prevent medication errors at points of transition in care.
  • The Joint Commission has a National Patient Safety Goal dedicated to this process.
  • It is the single most important intervention in a ToC program.

The Best Possible Medication History (BPMH)

  • The foundation of any good Med Rec is a high-quality BPMH.
  • This is much more than just asking the patient what they take.
  • It is a systematic process of interviewing the patient and reviewing at least one other source of information.
  • Other sources include the patient's pharmacy records, their pill bottles, and their medical records from other providers.
  • This multi-source approach is needed to create a truly accurate list.
  • Pharmacy technicians are often specially trained to take a BPMH.

The Reconciliation Process

  • Once the BPMH is created, it is compared to the new orders written by the provider.
  • This comparison, or reconciliation, is done by a clinician (often a pharmacist).
  • The goal is to identify any discrepancies.
  • Unintentional Discrepancies: Errors, such as an omitted home medication or an incorrect dose. These must be corrected.
  • Intentional Discrepancies: A deliberate change made by the provider (e.g., stopping a blood pressure med because the patient is hypotensive). These should be documented.

Key Transition Points for Med Rec

  • Med Rec must be performed at every transition in care.
  • Admission: To ensure that necessary home medications are continued in the hospital.
  • Intra-Hospital Transfer: When a patient moves from one level of care to another (e.g., ICU to floor).
  • Discharge: To provide the patient with a clear and accurate list of their medications to take at home.
  • A failure at any of these points can lead to a serious medication error.

The Pharmacist's Role as a Leader

  • Pharmacists are the medication experts and are the ideal leaders for the Med Rec process.
  • A CTCS is responsible for designing a robust, hospital-wide Med Rec process.
  • This includes developing policies and procedures.
  • It also involves training other healthcare professionals (pharmacists, technicians, nurses) on how to perform their role in the process.
  • The CTCS is also responsible for auditing the quality of the Med Rec process and driving continuous improvement.

The Importance of Discharge Counseling

  • The hospital discharge is a high-risk time for patients.
  • They are often still recovering from their illness and are faced with a complex set of new instructions.
  • Effective patient education is a critical intervention to ensure a safe transition.
  • The goal is to empower the patient and their family to be able to safely manage their care at home.
  • A CTCS ensures that this education is provided in a systematic and patient-centered way.

The "Teach-Back" Method

  • The teach-back method is an evidence-based technique for ensuring that a patient understands their health information.
  • Instead of asking "Do you have any questions?", the provider asks the patient to explain in their own words what they need to know or do.
  • For example, "We've gone over a lot of information about this new blood thinner. To make sure I was clear, can you tell me in your own words how you are going to take it?"
  • This is a test of how well the provider explained the information, not a test of the patient.
  • A CTCS must be an expert at using the teach-back method.

The Patient Medication List (PML)

  • At discharge, every patient should be provided with a clear, concise, and easy-to-understand list of all their medications.
  • This PML should be reconciled with the patient's pre-admission medications.
  • It should clearly state which medications to stop, which to start, and which have had a change in dose.
  • The list should use plain language and avoid confusing jargon.
  • The CTCS is responsible for designing a patient-friendly PML format.

Health Literacy and Numeracy

  • Patient education must be tailored to the individual's level of health literacy and numeracy.
  • Health literacy is the ability to understand and use health information.
  • Numeracy is the ability to understand and use numbers, which is critical for understanding medication doses.
  • A universal precautions approach should be used, assuming that all patients may have difficulty understanding.
  • The CTCS must ensure that all patient education materials are written in plain language.

Engaging Family and Caregivers

  • Family members and caregivers are a critical part of the care team, especially for older adults or those with cognitive impairment.
  • They should be included in the discharge education whenever possible, with the patient's permission.
  • They are a key partner in helping the patient to manage their medications at home.
  • The CTCS ensures that the discharge plan is effectively communicated to these key partners.

The Importance of Post-Discharge Contact

  • Research has shown that a follow-up contact with a patient within the first few days after discharge is a highly effective intervention.
  • It provides an opportunity to reinforce discharge education.
  • It allows the clinician to identify and resolve any new problems before they lead to an ER visit or readmission.
  • This contact is a core component of all major ToC models.
  • This can be done via a phone call or a home visit.

The Post-Discharge Phone Call

  • A structured follow-up phone call, often performed by a pharmacist or nurse, is a common and effective strategy.
  • The call should be made within 2-3 days of discharge.
  • The caller performs a "virtual pill count," reviewing each medication with the patient.
  • They can identify any new side effects or barriers to access.
  • They can also confirm that the patient has made an appointment for their follow-up visit with their PCP.
  • A CTCS is often responsible for designing the script and workflow for these calls.

Home Visits

  • For very high-risk patients, a home visit from a pharmacist, nurse, or community health worker can be even more effective.
  • The home visit allows for a direct assessment of the patient's environment.
  • The clinician can perform a pill box fill and remove any old, discontinued medications from the home.
  • This is a resource-intensive intervention that should be targeted to the highest-risk patients.
  • A CTCS uses risk stratification models to identify these patients.

Transitional Care Management (TCM) Codes

  • TCM is a set of billing codes that can be used by physicians and other providers to get reimbursed for ToC services.
  • The service requires a follow-up contact within 2 business days and a face-to-face visit within 7 or 14 days of discharge.
  • It also includes medication reconciliation and other non-face-to-face services.
  • While the pharmacist cannot bill for these codes directly, they can work as part of the team that provides the service under the supervision of the billing provider.
  • A CTCS should be an expert on the requirements of the TCM codes.

Closing the Loop with the PCP

  • A key goal of the post-discharge follow-up is to ensure a safe handoff to the patient's primary care provider.
  • The results of the post-discharge call or visit must be communicated to the PCP.
  • This "closes the loop" and ensures that the PCP has all the information they need to resume management of the patient's care.
  • A CTCS is responsible for designing the workflow to ensure this communication happens reliably.

Block 3: Care Settings & Coordination

The Importance of Team Communication

  • Breakdowns in communication between healthcare professionals are a leading cause of medical errors.
  • This is especially true during transitions of care.
  • A successful ToC program is built on a foundation of effective and reliable interdisciplinary communication.
  • A CTCS must be an expert communicator and a facilitator of communication between others.

Standardized Communication Tools (SBAR)

  • Using a standardized format for communication can improve its clarity and effectiveness.
  • SBAR is a widely used tool for this.
  • Situation: A concise statement of the problem.
  • Background: Brief, relevant information related to the situation.
  • Assessment: What you think is going on.
  • Recommendation: What you think should be done.
  • A CTCS can use SBAR to structure their communications with physicians and other providers.

Warm Handoffs

  • A "warm handoff" is a transfer of care that is done in person or over the phone, with a real-time conversation between the sending and receiving providers.
  • This is much more effective than a "cold handoff," which relies only on the written record.
  • It allows for clarification and questions.
  • While not always feasible, a warm handoff should be used for the most complex and high-risk patients.
  • A CTCS can facilitate these warm handoffs between the hospital team and the PCP.

The Role of the EHR

  • The EHR is the primary tool for written communication.
  • However, it can also be a source of information overload.
  • A key challenge is ensuring that the important information from the hospital stay is easily accessible to the outpatient provider.
  • A well-designed discharge summary is essential.
  • A CTCS often works with the informatics team to optimize the design of the discharge summary and other communication tools in the EHR.

Health Information Exchanges (HIEs)

  • An HIE is a system that allows for the electronic sharing of patient information between different healthcare organizations that have different EHR systems.
  • HIEs are a key piece of infrastructure for improving communication during transitions of care.
  • They can allow a PCP to see the records from a patient's recent hospitalization, even if it was at a different health system.
  • A CTCS should be an advocate for their organization's participation in the regional HIE.

Hospital to Home

  • This is the most common transition.
  • The key challenge is ensuring the patient and family can manage the complex discharge plan on their own.
  • This requires excellent patient education and a robust post-discharge follow-up process.
  • A CTCS is an expert in managing this high-volume transition.

Hospital to Skilled Nursing Facility (SNF)

  • Patients who are not yet ready to go home but no longer need acute hospital care are often transferred to a SNF for rehabilitation.
  • This is a very high-risk transition, as these patients are often frail and on many medications.
  • A warm handoff between the hospital team and the SNF team is essential.
  • Medication reconciliation is critical at both the time of transfer to the SNF and the time of discharge from the SNF.
  • A CTCS is often a key liaison with the hospital's preferred SNF partners.

Hospital to Home with Home Health Services

  • Some patients are discharged home with services from a Home Health Agency (HHA).
  • This can include skilled nursing, physical therapy, and home health aides.
  • The HHA nurse can be a key partner in medication management for the first few weeks after discharge.
  • A CTCS must ensure that the HHA has a clear and accurate medication list.
  • They are a key member of the post-discharge care team.

Long-Term Care Facilities (LTCFs)

  • Transitions between the hospital and a long-term care facility (nursing home) are also very high-risk.
  • These residents are often very frail and have significant cognitive impairment.
  • The medication regimens are often very complex.
  • The pharmacist plays a key role in the monthly drug regimen review for all LTCF residents.
  • A CTCS with expertise in geriatrics is a valuable resource for managing these transitions.

The Role of the Community Pharmacist

  • The patient's community pharmacist is a critical but often overlooked member of the ToC team.
  • They are the ones who will see the patient after discharge.
  • It is essential that the community pharmacy receives an accurate medication list.
  • A key role for the CTCS is to build partnerships with the high-volume community pharmacies in their area.
  • This collaboration is key to closing the loop and ensuring a safe transition.

The Need for Risk Stratification

  • It is not feasible to provide the most intensive ToC interventions (like a home visit) to every single patient.
  • Therefore, it is essential to have a system to identify the patients who are at the highest risk for readmission.
  • This process is called risk stratification.
  • It allows an organization to target its resources to the patients who will benefit the most.
  • A CTCS must be an expert in the use of risk stratification tools.

Common Risk Factors for Readmission

  • There are many well-established risk factors for hospital readmission.
  • Clinical Factors: Specific diagnoses (e.g., heart failure, COPD), number of comorbidities, and prior hospitalizations.
  • Medication-Related Factors: Polypharmacy (e.g., >5 medications), use of high-risk medications, and a recent change in regimen.
  • Social Factors: Low health literacy, lack of social support, and financial insecurity.
  • A good risk stratification model will include all of these factors.

The LACE Index

  • The LACE index is a simple, validated tool for predicting the risk of 30-day readmission.
  • It is an acronym for the four variables it includes:
  • Length of stay.
  • Acuity of the admission (emergent or elective).
  • Comorbidities (using the Charlson Comorbidity Index).
  • Emergency department visits in the last 6 months.
  • Each variable is assigned a point value, and the total score corresponds to a specific risk of readmission.
  • Many hospitals have built this tool into their EHR.

Other Risk Assessment Tools

  • There are many other risk prediction models available.
  • The "8 P's" model is another conceptual framework that includes factors like Psychological state and Principal Diagnosis.
  • Many hospitals have developed their own, more complex predictive models using machine learning.
  • These models can analyze hundreds of variables from the EHR to generate a real-time risk score.
  • A CTCS must be familiar with the specific risk stratification tool used by their organization.

Using the Risk Score to Target Interventions

  • The output of the risk stratification model is a risk score for each patient.
  • The ToC team then uses this score to tailor the intensity of the intervention.
  • Low-Risk Patients: May receive standard discharge education.
  • Moderate-Risk Patients: May receive a post-discharge phone call.
  • High-Risk Patients: May receive a pharmacist-led, in-person consultation before discharge and a home visit after discharge.
  • This data-driven approach ensures that resources are allocated efficiently and effectively.

Block 4: Quality Metrics & Payment Models

The Importance of Measurement

  • To improve transitions of care, we must be able to measure their quality.
  • Quality metrics are standardized, evidence-based measures of healthcare processes and outcomes.
  • They are used for public reporting, pay-for-performance, and internal quality improvement.
  • A CTCS must be an expert on the key quality metrics related to ToC.

Hospital Readmission Rates

  • The 30-day hospital readmission rate is the most well-known ToC outcome measure.
  • It is the percentage of patients who are readmitted to any acute care hospital within 30 days of being discharged.
  • CMS publicly reports the risk-adjusted readmission rates for all hospitals.
  • Hospitals with excess readmissions are subject to financial penalties under the Hospital Readmissions Reduction Program (HRRP).
  • Reducing preventable readmissions is the primary goal of most ToC programs.

Medication Reconciliation Post-Discharge (MRP)

  • This is a HEDIS process measure used by health plans.
  • It measures the percentage of members who had a medication reconciliation conducted within 30 days of being discharged from a hospital.
  • This is a key measure of the quality of a transitional care process.
  • A CTCS is responsible for designing a workflow that ensures this measure is met.
  • This requires close collaboration between the hospital and the outpatient providers.

HCAHPS Survey

  • The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized survey of patients' perspectives on their hospital care.
  • It includes several questions that are directly related to transitions of care.
  • These include questions about communication about medications and the clarity of discharge information.
  • The results of this survey are publicly reported and are a component of the hospital's value-based purchasing score.
  • A high-quality ToC program can have a direct, positive impact on these HCAHPS scores.

Measuring the Impact of a ToC Program

  • A CTCS is responsible for measuring the impact of their own program.
  • This involves tracking a dashboard of key process and outcome measures.
  • Process Measures: e.g., number of high-risk patients who received a pharmacist consultation.
  • Outcome Measures: e.g., the 30-day readmission rate for the patients who received the intervention compared to a control group.
  • This data is essential for demonstrating the value of the ToC program and for driving continuous quality improvement.

The Shift from Volume to Value

  • The U.S. healthcare system is in the midst of a major shift from a fee-for-service (volume-based) payment system to a value-based system.
  • Value-based payment models reward providers for the quality and efficiency of the care they provide, not just the quantity.
  • Transitions of care is a key focus area in all value-based care models.
  • This is because well-managed transitions are a key strategy for improving quality and reducing costs.

Hospital Readmissions Reduction Program (HRRP)

  • The HRRP is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions.
  • It is a "penalty-only" program.
  • CMS calculates a risk-adjusted expected readmission rate for each hospital.
  • If the hospital's actual readmission rate is higher than its expected rate, it receives a payment penalty.
  • This program has created a strong financial incentive for hospitals to invest in ToC programs.

Bundled Payments

  • A bundled payment is a single, pre-determined payment for all the services related to a specific episode of care (e.g., a knee replacement).
  • The bundle includes the hospital stay and all post-acute care for a period of time (e.g., 90 days).
  • This gives the hospital a strong incentive to coordinate care across the entire episode to prevent costly complications and readmissions.
  • Effective transitions of care are essential for success under a bundled payment model.

Accountable Care Organizations (ACOs)

  • An ACO is a group of providers who are held accountable for the total cost and quality of care for a defined population of patients.
  • If the ACO can provide high-quality care and reduce the total cost of care below a benchmark, they can share in the savings with the payer.
  • Reducing preventable hospitalizations and readmissions is a primary strategy for ACOs to generate savings.
  • This makes transitions of care a core competency for any successful ACO.
  • A CTCS is a key leader in an ACO's population health strategy.

Transitional Care Management (TCM) Services

  • As discussed, TCM codes provide a direct fee-for-service payment for ToC services.
  • This allows outpatient providers to be paid for the non-face-to-face work involved in coordinating care after a hospital discharge.
  • This helps to create a business case for building the necessary infrastructure in the outpatient setting.
  • A CTCS works to build a seamless process between the inpatient and outpatient teams to ensure that all the requirements for billing the TCM codes are met.

Block 5: Care Settings & Coordination

The Importance of Team Communication

  • Breakdowns in communication between healthcare professionals are a leading cause of medical errors.
  • This is especially true during transitions of care.
  • A successful ToC program is built on a foundation of effective and reliable interdisciplinary communication.
  • A CTCS must be an expert communicator and a facilitator of communication between others.

Standardized Communication Tools (SBAR)

  • Using a standardized format for communication can improve its clarity and effectiveness.
  • SBAR is a widely used tool for this.
  • Situation: A concise statement of the problem.
  • Background: Brief, relevant information related to the situation.
  • Assessment: What you think is going on.
  • Recommendation: What you think should be done.
  • A CTCS can use SBAR to structure their communications with physicians and other providers.

Warm Handoffs

  • A "warm handoff" is a transfer of care that is done in person or over the phone, with a real-time conversation between the sending and receiving providers.
  • This is much more effective than a "cold handoff," which relies only on the written record.
  • It allows for clarification and questions.
  • While not always feasible, a warm handoff should be used for the most complex and high-risk patients.
  • A CTCS can facilitate these warm handoffs between the hospital team and the PCP.

The Role of the EHR

  • The EHR is the primary tool for written communication.
  • However, it can also be a source of information overload.
  • A key challenge is ensuring that the important information from the hospital stay is easily accessible to the outpatient provider.
  • A well-designed discharge summary is essential.
  • A CTCS often works with the informatics team to optimize the design of the discharge summary and other communication tools in the EHR.

Health Information Exchanges (HIEs)

  • An HIE is a system that allows for the electronic sharing of patient information between different healthcare organizations that have different EHR systems.
  • HIEs are a key piece of infrastructure for improving communication during transitions of care.
  • They can allow a PCP to see the records from a patient's recent hospitalization, even if it was at a different health system.
  • A CTCS should be an advocate for their organization's participation in the regional HIE.

Hospital to Home

  • This is the most common transition.
  • The key challenge is ensuring the patient and family can manage the complex discharge plan on their own.
  • This requires excellent patient education and a robust post-discharge follow-up process.
  • A CTCS is an expert in managing this high-volume transition.

Hospital to Skilled Nursing Facility (SNF)

  • Patients who are not yet ready to go home but no longer need acute hospital care are often transferred to a SNF for rehabilitation.
  • This is a very high-risk transition, as these patients are often frail and on many medications.
  • A warm handoff between the hospital team and the SNF team is essential.
  • Medication reconciliation is critical at both the time of transfer to the SNF and the time of discharge from the SNF.
  • A CTCS is often a key liaison with the hospital's preferred SNF partners.

Hospital to Home with Home Health Services

  • Some patients are discharged home with services from a Home Health Agency (HHA).
  • This can include skilled nursing, physical therapy, and home health aides.
  • The HHA nurse can be a key partner in medication management for the first few weeks after discharge.
  • A CTCS must ensure that the HHA has a clear and accurate medication list.
  • They are a key member of the post-discharge care team.

Long-Term Care Facilities (LTCFs)

  • Transitions between the hospital and a long-term care facility (nursing home) are also very high-risk.
  • These residents are often very frail and have significant cognitive impairment.
  • The medication regimens are often very complex.
  • The pharmacist plays a key role in the monthly drug regimen review for all LTCF residents.
  • A CTCS with expertise in geriatrics is a valuable resource for managing these transitions.

The Role of the Community Pharmacist

  • The patient's community pharmacist is a critical but often overlooked member of the ToC team.
  • They are the ones who will see the patient after discharge.
  • It is essential that the community pharmacy receives an accurate medication list.
  • A key role for the CTCS is to build partnerships with the high-volume community pharmacies in their area.
  • This collaboration is key to closing the loop and ensuring a safe transition.

The Need for Risk Stratification

  • It is not feasible to provide the most intensive ToC interventions (like a home visit) to every single patient.
  • Therefore, it is essential to have a system to identify the patients who are at the highest risk for readmission.
  • This process is called risk stratification.
  • It allows an organization to target its resources to the patients who will benefit the most.
  • A CTCS must be an expert in the use of risk stratification tools.

Common Risk Factors for Readmission

  • There are many well-established risk factors for hospital readmission.
  • Clinical Factors: Specific diagnoses (e.g., heart failure, COPD), number of comorbidities, and prior hospitalizations.
  • Medication-Related Factors: Polypharmacy (e.g., >5 medications), use of high-risk medications, and a recent change in regimen.
  • Social Factors: Low health literacy, lack of social support, and financial insecurity.
  • A good risk stratification model will include all of these factors.

The LACE Index

  • The LACE index is a simple, validated tool for predicting the risk of 30-day readmission.
  • It is an acronym for the four variables it includes:
  • Length of stay.
  • Acuity of the admission (emergent or elective).
  • Comorbidities (using the Charlson Comorbidity Index).
  • Emergency department visits in the last 6 months.
  • Each variable is assigned a point value, and the total score corresponds to a specific risk of readmission.
  • Many hospitals have built this tool into their EHR.

Other Risk Assessment Tools

  • There are many other risk prediction models available.
  • The "8 P's" model is another conceptual framework that includes factors like Psychological state and Principal Diagnosis.
  • Many hospitals have developed their own, more complex predictive models using machine learning.
  • These models can analyze hundreds of variables from the EHR to generate a real-time risk score.
  • A CTCS must be familiar with the specific risk stratification tool used by their organization.

Using the Risk Score to Target Interventions

  • The output of the risk stratification model is a risk score for each patient.
  • The ToC team then uses this score to tailor the intensity of the intervention.
  • Low-Risk Patients: May receive standard discharge education.
  • Moderate-Risk Patients: May receive a post-discharge phone call.
  • High-Risk Patients: May receive a pharmacist-led, in-person consultation before discharge and a home visit after discharge.
  • This data-driven approach ensures that resources are allocated efficiently and effectively.

The Community Pharmacist as a ToC Partner

  • The patient's community pharmacist is a critical but often underutilized member of the ToC team.
  • They are the healthcare professional who will see the patient most frequently after discharge.
  • They are in a key position to reinforce discharge counseling and to identify post-discharge problems.
  • A successful ToC program must have a strategy for engaging community pharmacists.

Closing the Communication Loop

  • A key barrier is the lack of communication between the hospital and the community pharmacy.
  • The community pharmacist often does not receive the patient's discharge medication list.
  • This can lead to confusion and errors when the patient tries to fill their new prescriptions.
  • A key role for the CTCS is to design a reliable workflow for transmitting the discharge medication list to the patient's chosen pharmacy.

"Meds-to-Beds" Programs

  • A "Meds-to-Beds" program is an innovative model that brings the community pharmacy to the patient.
  • The hospital's outpatient pharmacy or a partner community pharmacy fills the patient's discharge prescriptions and delivers them to the bedside before the patient leaves.
  • This ensures the patient goes home with their medications in hand and has a chance to be counseled.
  • It is a highly effective strategy for improving adherence and reducing readmissions.
  • A CTCS is often the leader who implements these programs.

Building Partnerships

  • A CTCS should work to build formal partnerships with the key community pharmacies in their area.
  • This can involve creating a preferred pharmacy network.
  • It can also involve regular meetings to share data and best practices.
  • This collaborative approach is much more effective than working in silos.

Leveraging Community Pharmacy Services

  • Community pharmacists offer a range of services that can support a safe transition.
  • This includes medication synchronization, adherence packaging (blister packs), and MTM.
  • The CTCS should be aware of which local pharmacies offer these advanced services.
  • They can then refer high-risk patients to these pharmacies at the time of discharge.

The EHR as a ToC Tool

  • The EHR is the central hub for all ToC activities.
  • It is used to perform medication reconciliation.
  • It is used to generate the discharge summary and patient medication list.
  • It can be used to send electronic referrals to the PCP and home health agency.
  • A CTCS must be an expert user of their institution's EHR.
  • They work with the informatics team to optimize the EHR to support a safe and efficient ToC process.

Health Information Exchanges (HIEs)

  • An HIE is a secure network for sharing patient information between different EHR systems.
  • HIEs are a critical piece of infrastructure for care coordination.
  • They can allow a hospital to see a patient's medication history from their outpatient pharmacy.
  • They can also allow a PCP to see the discharge summary from a recent hospitalization at a different health system.
  • A CTCS should be an advocate for and a power user of their regional HIE.

Telehealth and Remote Monitoring

  • Telehealth can be a powerful tool for post-discharge follow-up.
  • A video visit with a pharmacist can be used to conduct a "virtual" medication reconciliation and counseling session.
  • Remote monitoring devices (e.g., for blood pressure or glucose) can transmit data directly to the care team.
  • This allows for proactive management of any post-discharge issues.
  • A CTCS should be familiar with these emerging technologies.

Patient Portals

  • Most EHRs now have a patient portal.
  • The portal allows patients to securely access their own medical information, including their medication list and lab results.
  • It can also be used for secure messaging with the care team.
  • The portal can be a key tool for engaging patients in their own care during a transition.
  • A CTCS can use the portal to send educational materials and follow-up messages to the patient.

Predictive Analytics

  • As discussed, predictive analytics can be used to risk-stratify patients.
  • Machine learning models can analyze hundreds of variables in the EHR in real-time to generate a highly accurate readmission risk score.
  • This allows for the dynamic targeting of ToC interventions.
  • A CTCS is a key end-user of these advanced analytical tools.
  • They use the output of the model to prioritize their daily work.

Block 6: Quality Metrics & Payment Models

The Importance of Measurement

  • To improve transitions of care, we must be able to measure their quality.
  • Quality metrics are standardized, evidence-based measures of healthcare processes and outcomes.
  • They are used for public reporting, pay-for-performance, and internal quality improvement.
  • A CTCS must be an expert on the key quality metrics related to ToC.

Hospital Readmission Rates

  • The 30-day hospital readmission rate is the most well-known ToC outcome measure.
  • It is the percentage of patients who are readmitted to any acute care hospital within 30 days of being discharged.
  • CMS publicly reports the risk-adjusted readmission rates for all hospitals.
  • Hospitals with excess readmissions are subject to financial penalties under the Hospital Readmissions Reduction Program (HRRP).
  • Reducing preventable readmissions is the primary goal of most ToC programs.

Medication Reconciliation Post-Discharge (MRP)

  • This is a HEDIS process measure used by health plans.
  • It measures the percentage of members who had a medication reconciliation conducted within 30 days of being discharged from a hospital.
  • This is a key measure of the quality of a transitional care process.
  • A CTCS is responsible for designing a workflow that ensures this measure is met.
  • This requires close collaboration between the hospital and the outpatient providers.

HCAHPS Survey

  • The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized survey of patients' perspectives on their hospital care.
  • It includes several questions that are directly related to transitions of care.
  • These include questions about communication about medications and the clarity of discharge information.
  • The results of this survey are publicly reported and are a component of the hospital's value-based purchasing score.
  • A high-quality ToC program can have a direct, positive impact on these HCAHPS scores.

Measuring the Impact of a ToC Program

  • A CTCS is responsible for measuring the impact of their own program.
  • This involves tracking a dashboard of key process and outcome measures.
  • Process Measures: e.g., number of high-risk patients who received a pharmacist consultation.
  • Outcome Measures: e.g., the 30-day readmission rate for the patients who received the intervention compared to a control group.
  • This data is essential for demonstrating the value of the ToC program and for driving continuous quality improvement.

The Shift from Volume to Value

  • The U.S. healthcare system is in the midst of a major shift from a fee-for-service (volume-based) payment system to a value-based system.
  • Value-based payment models reward providers for the quality and efficiency of the care they provide, not just the quantity.
  • Transitions of care is a key focus area in all value-based care models.
  • This is because well-managed transitions are a key strategy for improving quality and reducing costs.

Hospital Readmissions Reduction Program (HRRP)

  • The HRRP is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions.
  • It is a "penalty-only" program.
  • CMS calculates a risk-adjusted expected readmission rate for each hospital.
  • If the hospital's actual readmission rate is higher than its expected rate, it receives a payment penalty.
  • This program has created a strong financial incentive for hospitals to invest in ToC programs.

Bundled Payments

  • A bundled payment is a single, pre-determined payment for all the services related to a specific episode of care (e.g., a knee replacement).
  • The bundle includes the hospital stay and all post-acute care for a period of time (e.g., 90 days).
  • This gives the hospital a strong incentive to coordinate care across the entire episode to prevent costly complications and readmissions.
  • Effective transitions of care are essential for success under a bundled payment model.

Accountable Care Organizations (ACOs)

  • An ACO is a group of providers who are held accountable for the total cost and quality of care for a defined population of patients.
  • If the ACO can provide high-quality care and reduce the total cost of care below a benchmark, they can share in the savings with the payer.
  • Reducing preventable hospitalizations and readmissions is a primary strategy for ACOs to generate savings.
  • This makes transitions of care a core competency for any successful ACO.
  • A CTCS is a key leader in an ACO's population health strategy.

Transitional Care Management (TCM) Services

  • As discussed, TCM codes provide a direct fee-for-service payment for ToC services.
  • This allows outpatient providers to be paid for the non-face-to-face work involved in coordinating care after a hospital discharge.
  • This helps to create a business case for building the necessary infrastructure in the outpatient setting.
  • A CTCS works to build a seamless process between the inpatient and outpatient teams to ensure that all the requirements for billing the TCM codes are met.

Purpose of TCM Codes

  • TCM codes (99495 and 99496) were created by Medicare to reimburse providers for the work involved in managing a patient's transition from the hospital to the community.
  • They provide a fee-for-service payment for what was previously uncompensated care coordination.
  • The goal is to provide a financial incentive for providers to invest in robust ToC services.
  • A CTCS must be an expert on the detailed requirements for billing these codes.

Key Components of the Service

  • To bill for TCM, three components must be completed within a 30-day period.
  • 1. Initial Contact: An interactive contact (phone, email, or face-to-face) must be made with the patient within 2 business days of discharge.
  • 2. Non-Face-to-Face Services: This includes medication reconciliation and other care coordination activities.
  • 3. Face-to-Face Visit: The patient must have a face-to-face visit with the billing provider within a specific timeframe.

The Two TCM Codes (99495 and 99496)

  • The choice of code depends on the complexity of the medical decision making and the timing of the face-to-face visit.
  • CPT 99495: For moderate complexity. Requires a face-to-face visit within 14 calendar days of discharge.
  • CPT 99496: For high complexity. Requires a face-to-face visit within 7 calendar days of discharge.
  • The reimbursement is higher for the 99496 code.

The Role of "Clinical Staff"

  • The TCM codes allow for many of the services to be provided by "clinical staff" under the general supervision of the billing provider (e.g., a physician).
  • Pharmacists are explicitly included in the definition of clinical staff.
  • This means that a pharmacist (like a CTCS) can be the person who performs the initial phone call and the medication reconciliation.
  • This is a key mechanism that allows pharmacists to be an integral part of a billable TCM service.

Operationalizing a TCM Service

  • A successful TCM program requires a very tight and reliable workflow.
  • A system is needed to identify all eligible discharges in real-time.
  • A process must be in place to ensure the 2-day phone call and the 7- or 14-day visit are completed and documented.
  • The CTCS is often the person responsible for designing and managing this complex, time-sensitive workflow.
  • It requires close collaboration between the hospital, the outpatient clinic, and the billing department.

The Need for a Business Case

  • A ToC program requires a significant investment in staff resources.
  • To get approval and funding from hospital leadership, a formal business case must be presented.
  • The business case must clearly articulate the problem (e.g., high readmission rates) and the proposed solution.
  • Most importantly, it must include a detailed financial analysis.
  • The CTCS is the leader who develops and presents this business case.

Identifying Costs

  • The first part of the financial analysis is to identify all the costs of the proposed program.
  • The main cost is the salary and benefits of the new staff (e.g., pharmacists and technicians).
  • There may also be costs for new technology, such as a patient tracking database.
  • These costs should be projected over a multi-year period.

Identifying Financial Benefits (ROI)

  • The other side of the analysis is to quantify the financial benefits, or the Return on Investment (ROI).
  • The biggest financial benefit is the avoidance of readmission penalties from CMS.
  • The business case should project the number of readmissions that the program will prevent.
  • The cost of a readmission is then used to calculate the total cost avoidance.
  • Other financial benefits can include new revenue from billing TCM codes.

Calculating ROI

  • The ROI is calculated by comparing the financial benefits to the costs.
  • The Net Benefit = (Total Financial Benefits) - (Total Program Costs).
  • The ROI = (Net Benefit / Total Program Costs) x 100%.
  • A positive ROI means the program is expected to save more money than it costs.
  • This is a powerful argument for getting the program approved.
  • The CTCS must be skilled at performing this analysis.

Measuring and Reporting Performance

  • Once the program is implemented, the CTCS is responsible for tracking its performance against the business case projections.
  • This involves tracking the number of readmissions prevented and the actual ROI.
  • This data must be reported back to leadership on a regular basis.
  • This demonstrates the value of the program and provides accountability.
  • It is also used to identify opportunities to improve the program's effectiveness.

Geriatric Patients

  • Older adults are the primary focus of most ToC programs.
  • They are at the highest risk for readmission due to factors like polypharmacy, multimorbidity, and cognitive impairment.
  • A CTCS must be an expert in geriatric pharmacotherapy.
  • This includes knowledge of the AGS Beers Criteria for PIMs.
  • The ToC interventions for this population must be tailored to their specific needs, such as including a caregiver in the education.

Pediatric Patients

  • Transitions of care for children also present unique challenges.
  • The family and caregivers are the central partners in care.
  • Medication dosing is almost always weight-based and requires careful calculation.
  • Many medications require special formulations, like oral liquids, that must be prepared by the pharmacy.
  • Communication must be tailored to the developmental level of the child and the health literacy of the parents.

Patients with Behavioral Health Conditions

  • Patients with mental illness or substance use disorders are at a very high risk for poor transitions.
  • They often have complex medication regimens and significant social challenges.
  • A warm handoff to the outpatient behavioral health provider is essential.
  • Ensuring access to medications, especially for substance use disorder (e.g., buprenorphine), is a critical part of the discharge plan.
  • The CTCS must be skilled at providing non-judgmental, trauma-informed care to this population.

Patients with Low Health Literacy

  • As discussed, low health literacy is a major barrier to a safe transition.
  • A CTCS must use a universal precautions approach and tailor all communication to be as clear and simple as possible.
  • This includes using plain language, avoiding jargon, and using the teach-back method.
  • Patient education materials should be written at a 5th-grade reading level and use lots of pictures.

Patients with Social and Economic Barriers

  • Social determinants of health, such as poverty, housing instability, and food insecurity, are major risk factors for readmission.
  • A key part of the ToC process is to screen for these social needs.
  • The CTCS must be knowledgeable about the community resources available to help patients with these needs.
  • They work closely with the social work and case management teams to provide referrals.
  • Addressing these upstream factors is essential for a truly successful transition.

Block 7: Program Management & Quality Improvement

Needs Assessment and Gaining Buy-In

  • The first step is to conduct a needs assessment to demonstrate the problem of poor transitions at your institution.
  • This involves analyzing your hospital's readmission rates and identifying the key drivers.
  • The data from this assessment is used to gain buy-in from key stakeholders, including hospital leadership, physicians, and nurses.
  • The CTCS must be able to make a compelling case for why a ToC program is needed.

Building the Interdisciplinary Team

  • A ToC program is a team sport.
  • A multidisciplinary steering committee should be formed to oversee the program.
  • This committee should include representatives from pharmacy, medicine, nursing, case management, and social work.
  • The CTCS is a key leader on this team.
  • This collaborative approach is essential for success.

Defining the Scope and Target Population

  • The program must have a clearly defined scope.
  • What are the specific interventions that will be provided?
  • Who is the target population?
  • It is often best to start with a pilot program focused on a single, high-risk patient population (e.g., patients with heart failure).
  • The program can then be expanded over time.
  • The CTCS uses risk stratification tools to define this target population.

Developing Policies and Procedures

  • A formal set of policies and procedures is needed to standardize the work of the ToC program.
  • This includes policies for medication reconciliation, patient education, and post-discharge follow-up.
  • These policies ensure that every patient receives the same high standard of care.
  • The CTCS is the primary author of these policies.

Measuring and Reporting Outcomes

  • The program must have a plan for measuring and reporting its outcomes from the very beginning.
  • This includes tracking both process measures (e.g., number of patients served) and outcome measures (e.g., 30-day readmission rate).
  • This data is used to demonstrate the value of the program to leadership.
  • It is also used for continuous quality improvement.
  • The CTCS is responsible for this ongoing program evaluation.

Defining Staff Roles

  • A successful ToC program utilizes a team of professionals working at the top of their license.
  • Pharmacists (CTCS): Lead the program, perform the final medication reconciliation, provide complex patient counseling, and manage the highest-risk patients.
  • Pharmacy Technicians: Can be specially trained to take the Best Possible Medication History (BPMH).
  • Nurses: Often provide discharge education and make post-discharge phone calls.
  • Social Workers/Case Managers: Address the social determinants of health.

Pharmacist Staffing Models

  • There are different models for staffing the pharmacist role.
  • Dedicated ToC Pharmacist: A pharmacist whose sole job is to provide ToC services. This allows for deep expertise but can be costly.
  • Decentralized Clinical Pharmacist: The unit-based clinical pharmacists are responsible for providing ToC services for the patients on their unit.
  • Hybrid Model: A combination of the two.
  • The CTCS must be able to analyze the pros and cons of these different models.

The Role of the Pharmacy Technician

  • Using trained pharmacy technicians to take the BPMH is a key strategy for an efficient program.
  • This allows the pharmacist to focus their time on the more complex clinical tasks of reconciliation and counseling.
  • This requires a significant investment in technician training and competency assessment.
  • The CTCS is responsible for developing this advanced role for technicians.

Training and Competency Assessment

  • All staff involved in the ToC program must receive specific training.
  • This includes training on the medication reconciliation process, the use of the teach-back method, and the specific documentation requirements.
  • Competency must be assessed and documented for all staff.
  • This can involve direct observation and case reviews.
  • Ongoing education is needed to keep the team up-to-date on best practices.
  • The CTCS is responsible for this entire training and competency program.

Productivity and Workload

  • The manager of a ToC program must be able to measure the productivity of their team.
  • This includes tracking metrics like the number of medication histories completed per day.
  • This data is used to justify staffing levels and to ensure that the workload is distributed equitably.
  • The CTCS must be able to balance the need for high productivity with the need for high-quality, thorough work.

Mapping the Current State

  • The first step in improving a process is to understand the current state.
  • This involves creating a detailed process map or flowchart of the existing ToC workflow.
  • This exercise often reveals redundancies, bottlenecks, and unnecessary steps.
  • The CTCS should lead a multidisciplinary team in this mapping exercise.

Designing the Future State

  • Once the current state is understood, the team can design the ideal "future state" workflow.
  • This involves applying the principles of quality improvement (like Lean) to eliminate waste and streamline the process.
  • The goal is to design a workflow that is safe, efficient, reliable, and patient-centered.
  • The CTCS is the primary architect of this future state.

Integrating with the EHR

  • The workflow must be seamlessly integrated into the EHR.
  • This can include creating specific order sets for the ToC service.
  • It can also involve building standardized templates for documentation.
  • The goal is to make it as easy as possible for clinicians to follow the standard process.
  • A close partnership with the informatics team is essential.

Standard Work

  • Standard work is a core Lean principle.
  • It is the practice of developing and implementing the one best way to perform a task.
  • In ToC, this would involve creating standard work for taking a medication history, performing discharge counseling, or making a post-discharge phone call.
  • This reduces variation and ensures that all patients receive the same high standard of care.
  • The CTCS is responsible for developing and training staff on this standard work.

Continuous Improvement

  • Workflow design is not a one-time event.
  • The CTCS must foster a culture of continuous improvement.
  • This involves regularly reviewing performance data and seeking feedback from the frontline staff.
  • The PDSA cycle is used to test small changes to the workflow.
  • The goal is to be constantly refining and improving the process.

The LACE Index

  • A simple, validated tool for predicting the risk of 30-day readmission.
  • It scores patients based on Length of stay, Acuity of admission, Comorbidities, and Emergency department visits in the last 6 months.
  • It is a key tool for risk stratification to target ToC interventions.

The HOSPITAL Score

  • Another validated readmission risk prediction tool.
  • It uses seven variables that are readily available in the EHR at the time of discharge.
  • These include Hemoglobin, Oncology admission, Sodium level, Procedure during admission, Index admission Type (emergent), number of Admissions in the last year, and Length of stay.
  • Like LACE, it is used to identify high-risk patients.

Medication Adherence Rating Scales

  • Tools used to assess a patient's self-reported medication adherence.
  • The Morisky Medication Adherence Scale (MMAS-8) is a widely used, validated 8-item questionnaire.
  • These scales can be used to identify patients who may need more intensive adherence support after discharge.

Health Literacy Assessment Tools

  • Tools used to assess an individual's health literacy.
  • REALM (Rapid Estimate of Adult Literacy in Medicine): A word recognition test.
  • Newest Vital Sign: A quick test that uses a nutrition label to assess both literacy and numeracy.
  • These tools can help the CTCS to tailor their patient education to the appropriate level.

Care Transitions Measure (CTM-3)

  • A 3-item patient-reported survey that measures the quality of a patient's transition from the hospital.
  • It asks the patient to rate their understanding of their medications, their management plan, and their preferences.
  • The results can be used as a quality metric to evaluate the performance of a ToC program from the patient's perspective.

Readmission Rate

  • The primary outcome measure for most ToC programs. It is the percentage of discharged patients who are readmitted to the hospital within a specific timeframe, typically 30 days.

\( \text{Readmission Rate} = \frac{\text{Number of Readmissions}}{\text{Number of Discharges}} \times 100\% \)

Return on Investment (ROI)

  • A key financial calculation used to build the business case for a ToC program. It compares the financial savings from the program (e.g., from avoided readmission penalties) to the cost of the program.

\( \text{ROI} = \frac{\text{Financial Benefit} - \text{Program Cost}}{\text{Program Cost}} \times 100\% \)

Proportion of Days Covered (PDC)

  • A measure of medication adherence calculated from pharmacy claims data. It is often used as a key outcome measure to evaluate the effectiveness of a post-discharge adherence intervention.

\( \text{PDC} = \frac{\text{Number of Days Covered by a Drug}}{\text{Number of Days in Measurement Period}} \times 100\% \)

Number Needed to Treat (NNT)

  • An epidemiological measure used to evaluate the effectiveness of an intervention. It represents the number of patients who need to receive the intervention (e.g., a ToC service) to prevent one additional bad outcome (e.g., one readmission).

\( \text{NNT} = \frac{1}{\text{Absolute Risk Reduction (ARR)}} \)

Creatinine Clearance (CrCl) - Cockcroft-Gault

  • A fundamental clinical calculation. In ToC, it is essential for reconciling medication regimens and ensuring that the doses of renally-cleared drugs are appropriate for the patient's current kidney function, which may have changed during their hospital stay.

\( \text{CrCl (mL/min)} = \frac{(140 - \text{Age}) \times \text{Weight (kg)}}{72 \times \text{Serum Cr (mg/dL)}} \times (0.85 \text{ if female}) \)

Block 8: Advanced Topics & Final Review

HIPAA and Patient Privacy

  • A ToC specialist handles a large amount of Protected Health Information (PHI).
  • They must be an expert on all aspects of the HIPAA Privacy and Security Rules.
  • Sharing information between different healthcare entities (e.g., hospital to home health) must be done in a secure and compliant manner.
  • This requires having Business Associate Agreements (BAAs) in place with all partners.
  • Patient consent is also a key consideration.

Collaborative Practice Agreements (CPAs)

  • To practice at the top of their license, a CTCS often works under a CPA.
  • This legal agreement with a provider allows the pharmacist to perform certain patient care functions, such as adjusting medication doses.
  • The specific scope of a CPA is determined by state law.
  • A CTCS must be an expert on the CPA laws and regulations in their state.

Liability and Risk Management

  • Providing direct patient care in ToC carries a professional liability risk.
  • Thorough documentation of all assessments and interventions is the best protection against liability.
  • The use of standardized workflows and protocols also helps to mitigate risk.
  • Professional liability insurance should be reviewed to ensure it covers these types of advanced practice activities.

Ethical Principles

  • The CTCS must be guided by the core ethical principles of healthcare.
  • Beneficence: Acting in the best interest of the patient.
  • Non-maleficence: Doing no harm.
  • Autonomy: Respecting the patient's right to make their own decisions.
  • Justice: Ensuring that care is provided in a fair and equitable manner.
  • These principles guide the difficult decisions that can arise in complex patient cases.

Health Equity

  • There is an ethical imperative to ensure that ToC services are provided in an equitable manner.
  • Patients with social and economic barriers are often at the highest risk for poor transitions.
  • The ToC program must be designed to proactively identify and address the needs of these vulnerable populations.
  • This is a key part of the "justice" principle.
  • A CTCS is an advocate for health equity.

The Role of Policy in ToC

  • Public policy has a major impact on transitions of care.
  • Payment policies from CMS, like the HRRP, have been the primary driver of the growth of ToC programs.
  • State-level policies on the pharmacist's scope of practice can either enable or hinder pharmacist-led ToC services.
  • A CTCS should be knowledgeable about these key policies.

The Hospital Readmissions Reduction Program (HRRP)

  • As discussed, this CMS policy penalizes hospitals for excess readmissions.
  • A CTCS must be an expert on the details of this program.
  • This includes knowing which clinical conditions are included in the program.
  • It also involves understanding the complex risk-adjustment methodology that CMS uses to calculate the penalties.

Value-Based Purchasing (VBP)

  • The Hospital VBP program is another CMS initiative that rewards hospitals for the quality of care they provide.
  • A portion of a hospital's payment is tied to its performance on a set of quality measures.
  • Several of these measures, such as the HCAHPS patient experience survey, are directly impacted by the quality of the transition of care.
  • A CTCS helps their hospital to succeed in this value-based payment environment.

State Scope of Practice Laws

  • The ability of a pharmacist to lead ToC services is highly dependent on their state's pharmacy practice act.
  • Key issues include the laws governing collaborative practice agreements, provider status, and the ability of technicians to take medication histories.
  • A CTCS should be an active advocate for policies that modernize the practice act and allow pharmacists to practice at the top of their license.

Advocacy

  • A CTCS has a professional responsibility to be an advocate for their patients and their profession.
  • This involves working through professional organizations like ASHP and APhA to advocate for policies that support pharmacist-led ToC services.
  • It also involves educating local policymakers about the value of these services.
  • This advocacy is essential for creating a sustainable future for the profession.

Anticoagulants

  • Anticoagulants are a major source of medication errors and adverse events during transitions of care.
  • A key challenge is the transition from IV anticoagulants in the hospital to oral agents at discharge.
  • Clear communication and patient education about the specific dosing regimen is essential.
  • For warfarin, ensuring that a plan is in place for follow-up INR monitoring is critical.
  • For DOACs, ensuring the dose is appropriate for the patient's renal function is key.
  • A CTCS must be an expert in managing these high-risk medications.

Insulin and Other Antidiabetics

  • Diabetes medications are another high-risk class.
  • A patient's insulin needs can change dramatically during a hospitalization.
  • A common error is to continue the inpatient insulin dose at discharge, which can lead to severe hypoglycemia.
  • A thorough medication reconciliation and clear discharge instructions are essential.
  • Patient education on the signs and symptoms of hypoglycemia is a critical counseling point.

Opioids

  • The transition from the hospital can be a high-risk time for patients on opioids.
  • A clear tapering plan is needed for patients who were started on opioids for acute pain.
  • For patients on chronic opioid therapy, it is essential to reconcile the inpatient regimen with their outpatient regimen.
  • All patients discharged on an opioid should also be co-prescribed naloxone.
  • Counseling on safe storage and disposal is also a key part of the discharge plan.

Cardiovascular Medications

  • Heart failure and myocardial infarction are two of the most common reasons for hospitalization.
  • There are several classes of evidence-based, guideline-directed medications that these patients should be on at discharge.
  • A key role for the CTCS is to ensure that all patients are on the appropriate medications at the appropriate doses.
  • This is a major opportunity to close gaps in care.

Polypharmacy in Geriatrics

  • As discussed, older adults are at the highest risk for medication-related problems.
  • The hospital admission is a key opportunity to perform a deprescribing review.
  • The CTCS is an expert in identifying and stopping potentially inappropriate medications (PIMs).
  • This can simplify the medication regimen and reduce the risk of adverse events after discharge.
  • This is a key part of a comprehensive geriatric ToC service.

The Evidence Base for ToC

  • There is a large and growing body of evidence demonstrating the effectiveness of pharmacist-led ToC services.
  • Multiple systematic reviews and meta-analyses have shown that these services reduce readmission rates and improve other outcomes.
  • A CTCS must be familiar with this key literature.
  • This evidence is the foundation for building a business case for a new ToC service.

The Role of Research

  • While much is known, there are still many unanswered questions in ToC.
  • A key area of research is to determine which specific components of a ToC intervention are most effective.
  • Another is to determine the optimal way to target interventions to the highest-risk patients.
  • A CTCS practicing in an academic medical center may be involved in conducting this type of health services research.

The Future of Technology

  • Technology will continue to transform the practice of ToC.
  • Artificial intelligence and machine learning will lead to more accurate readmission risk prediction models.
  • Telehealth and remote monitoring will allow for more proactive post-discharge management.
  • Improved interoperability between EHR systems will make communication more seamless.
  • A forward-looking CTCS must stay on top of these technological trends.

Integration with Population Health

  • Transitions of care is a key component of the broader field of population health management.
  • The skills of a CTCS are highly valuable in any value-based care organization, such as an ACO.
  • The future will likely see a greater integration of hospital-based ToC programs with the ambulatory care management teams of these larger organizations.
  • This will allow for a more seamless continuum of care.

The Evolving Role of the CTCS

  • The role of the ToC specialist will continue to evolve.
  • There will be a greater focus on addressing the social determinants of health.
  • There will be an increased use of data and analytics to drive the work.
  • The CTCS will be a key leader in designing and managing these more sophisticated, data-driven, and holistic models of care.
  • This certification represents a commitment to being at the forefront of this exciting and impactful field.

Communication is Everything

  • The root cause of most transitional care errors is a breakdown in communication.
  • A successful CTCS is a master communicator.
  • They are the central hub of communication, connecting the hospital team, the outpatient team, the community pharmacy, and the patient and family.
  • This requires a commitment to clear, timely, and collaborative communication.

Medication Reconciliation is the Core Intervention

  • Medication reconciliation is the single most important and effective intervention for improving safety during transitions.
  • A high-quality, multi-source medication history is the non-negotiable foundation of the entire process.
  • A CTCS must be an expert and a champion for a robust medication reconciliation process at all points of transition.

Patient and Family Engagement is Key

  • The patient and their family are the most important members of the care team.
  • A successful transition depends on their ability to understand and manage the care plan at home.
  • This requires a commitment to patient-centered education, using tools like the teach-back method.
  • It also requires understanding the patient's goals and preferences through shared decision-making.
  • A CTCS empowers patients to be active partners in their own care.

A Team-Based Approach is Essential

  • Transitions of care is a team sport.
  • No single profession can do it alone.
  • Success requires a high degree of collaboration between pharmacists, physicians, nurses, case managers, and social workers.
  • It also requires building strong partnerships with the providers in the next setting of care.
  • A CTCS is a skilled team player and relationship-builder.

Data Drives Improvement

  • A high-performing ToC program is a data-driven one.
  • Data is used to identify high-risk patients, to measure the quality of care, and to evaluate the impact of the program.
  • A CTCS must be comfortable with data and analytics.
  • They use this data not just to report on their performance, but to drive a continuous cycle of quality improvement.
  • This commitment to measurement and improvement is the hallmark of a true specialist.
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