Clinical Pearl Transitions of Care: A Primary Care Perspective

1. Clinical PearlTransitions of Care: A Primary Care Perspective Andrea Bishop, PharmD, BCACP, CDE Northwest Pharmacy Convention Coeur d’Alene, ID June 1, 2013

2. Background • National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH) • Hiring RN Specialists • Current state 4 RN Specialists • 2014 adding 10 RN Specialists • Key focus of RN Specialist: transitions of care

3. Pharmacy’s Role • Collaborate with RN Specialist • Avoid competing initiatives and rework • Work at the top of license • Creating algorithm for RN Specialist to identify patients for referral to pharmacist after discharge

4. Current Ideas Automatic Appointment Discuss with Pharmacist CHF or COPD exacerbation A1C > 9% ≥ 2 medication changes excluding short-term pain medications and antibiotics Smoking cessation New anticoagulation start RN Specialist determination of need CHF or COPD Diabetes measures not at goal Current anticoagulant therapy Adverse drug event Other

5. Current Ideas Automatic Appointment Discuss with Pharmacist CHF or COPD exacerbation A1C > 9% ≥ 2 medication changes excluding short-term pain medications and antibiotics Smoking cessation New anticoagulation start RN Specialist determination of need CHF or COPD Diabetes measures not at goal Current anticoagulant therapy Adverse drug event Other

6. Appointment In conjunction with PCP Independent of PCP Pros Patient-centered Facilitates immediate and direct communication One charge Cons Scheduling conflicts Appointment 20 min Pros Appointment 30-60 min Easily scheduled Phone/electronic communication Cons Two charges if pharmacist is face-to-face Asynchronous communication

7. Appointment In conjunction with PCP Independent of PCP Pros Patient-centered Facilitates immediate and direct communication One charge Cons Scheduling conflicts Appointment 20 min Pros Appointment 30-60 min Easily scheduled Phone/electronic communication Cons Two charges if pharmacist is face-to-face Asynchronous communication

8. Billing Standard Office Visit Transition of Care Codes Pharmacist unable to charge for phone/electronic communication Joint appointment results in one charge ($65-97) Independent appointments result in two charges (additional $50) One charge ($160-215) Pharmacist involvement can be face-to-face, phone or electronic Joint or independent appointments work Dependent on meeting criteria

9. Billing Standard Office Visit Transition of Care Codes Pharmacist unable to charge for phone/electronic communication Joint appointment results in one charge ($65-97) Independent appointments result in two charges (additional $50) One charge ($160-215) Pharmacist involvement can be face-to-face, phone or electronic Joint or independent appointments work Dependent on meeting criteria

10. Transition of Care Codes • Pharmacist Role • Communication with the patient or caregiver within two business days of discharge • Phone, electronic or face-to-face

11. Transition of Care Codes • Pharmacist Role • Communication with the patient or caregiver within two business days of discharge • Phone, electronic or face-to-face PCP Role • CPT Code 99495 • Involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge • CPT Code 99496 • Involves medical decision making of high complexity and a face-to-face visit within 7 days of discharge

12. What are some keys to success for this type of team based care and collaboration?

13. What other ideas do you have for the referral algorithm?

14. Current Ideas Automatic Appointment Discuss with Pharmacist CHF or COPD exacerbation A1C > 9% ≥ 2 medication changes excluding short-term pain medications and antibiotics Smoking cessation New anticoagulation start RN Specialist determination of need CHF or COPD Diabetes measures not at goal Current anticoagulant therapy Adverse drug event Other

15. Clinical PearlTransitions of Care: A Primary Care Perspective Andrea Bishop, PharmD, BCACP, CDE Northwest Pharmacy Convention Coeur d’Alene, ID June 1, 2013