This is the final day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding shovel ready interventions and provide a research-based comparison of each intervention discussed this week in a handy chart for you to use.

For another look at how Hope Street Group looks to improve the quality and cost of transitions between acute and other types of care, click here: http://www.hopestreetgroup.org/docs/DOC-2479 .

Shovel Ready Interventions

Three packaged interventions stood out as well evidenced partial solutions that can reduce medication errors during transition of care from the hospital to nursing home or long-term care during the literature review.

MATCH- Medication Reconciliation Tool Kit

     Using an AHRQ grant, Northwestern Memorial Hospital created a medication reconciliation toolkit that can be used within either a paper-based or electronic medical system (Northwest Memorial Hospital, 2011). The researchers use a multidisciplinary team based approach to address the entire process as seen in Table 2.

(Northwest Memorial Hospital, 2011)

This is a tool that is feasible and appropriate to be used in conjunction with a larger strategy to reduce medication errors when a patient is going from a hospital to a nursing home.

Nursing Home Survey Kit (Agency for Healthcare Research  and Quality, 2011)

     AHRQ sponsored the development of the Nursing Home Survey on Patient Safety Culture. The Tool Kit contains the survey form, survey items and dimensions, user’s guide and feedback report template. An interesting complement to the survey is the comparative database that is a central repository for survey data from nursing homes that have administered the instrument. Preliminary data from 2008 is available from 40 nursing homes and with over 3,500 respondents.

     This kit is included because 1) it is an easy way to contribute to the science of patient safety (creating benchmark data) and 2) the participants can use this to trigger organizational learning and change.

TeamSTEPPS (Agency for Healthcare Research and Quality)

     TeamSTEPPS is a three-phased, process based, teamwork system designed for health care professionals aimed at creating and sustaining a culture of safety in order to drive quality and safety. While not specifically hospital based, it appears to be focused on large systems as a target for implementation. The Department of Defense and AHRQ partnered for the creation and national implementation of TeamSTEPPS. This is another evidenced based intervention for building teamwork and increasing the culture of safety in an organization.

Summary

The many factors that lead to medication errors during transition between a hospital and nursing home or long-term care are not easily addressed. Effective interventions are needed at an individual, team and organizational level at within both points of the continuum but also when interfacing with each other.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Agency for Healthcare Research and Quality. (n.d.). TeamSTEPPS:National Implementation. Retrieved 2011 10-August from Agency for Healthcare Research and Quality: http://teamstepps.ahrq.gov/abouot-2cl_3.htm

Northwest Memorial Hospital. (2011). MATCH Medicatin Reconciliation Toolkit. Retrieved 2011 14-March from Northwest Memorial Hospital: http://www.nmh.org/nm/making+the++case

This is the second day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding checklists and Computer Order Entry that will illuminate their “true” impact in reducing medication errors. For another look at how Hope Street Group conceives to Improve the quality and cost of transitions between acute and other types of care, click here: http://www.hopestreetgroup.org/docs/DOC-2479

Checklists

A check list is an “algorithmic listing of actions to be performed in a given clinical setting” with the goal of ensuring steps of a given task are not forgotten(Agency for Healthcare Research and Quality). Checklists are a favored intervention in patient safety since the majority of errors in health care are due to “slips” or failures due to distractions, fatigue or lack of attention (Agency for Healthcare Research and Quality). The use of checklists has the potential to convey and delineate the critical thinking, collaboration and goal setting needed for a successful transition to the next environment (Halasyamani, et al., 2006). The Society of Hospital Medicine leveraged this potential by creating a basic but comprehensive checklist of the processes and elements considered necessary for optimal patient handoff at hospital discharge(Halasyamani, et al., 2006). One of the most important aspects identified by the Society is the need to treat discharges as important and time intensive as admissions, since in essence, a discharge from on place is an “admission” to another.

In theory, checklists should be easy to reproduce and bring to scale as a valid intervention. However, the literature suggests that checklists may not be successful where the “gold standard” safety practices have yet to be determined, when the preparatory work of creating a safety culture has not taken place and when relevant co-interventions are not used (Agency for Healthcare Research and Quality). Further, checklists are not proven to impact errors that primarily involve attentional behavior or adaptive situations(Agency for Healthcare Research and Quality). Checklists need to be created and implemented with an understanding of local needs, organizational buy-in and evidence for targeted problem in order to lower barriers for use (Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009). For example, checklists do not perform well when used to track baggage for airlines(Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009). Bosk et al, state that this is a reasonable comparison to patient transitions since they both require: a high degree of coordination (often done poorly), ability to deal with schedule changes, time-pressured decision making and heterogeneous populations(Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009). According to these authors, this is what has led the U.S. Veterans Affairs to classify checklists as weak interventions based on the low probability that they will reduce risks(Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009).

Computerized Order Entry and Clinical Decision Support Systems

Computerized Provider Order Entry (CPOE) generally refers to a system in which clinicians directly enter medication orders into a computer system (Agency for Healthcare Research and Quality). It has been reported that 90% of inpatient medication errors occurred at either the ordering or transcribing stage (Bates, et al., 1995). These systems are more common in the inpatient setting than in the outpatient setting (Agency for Healthcare Research and Quality). Often, CPOE is paired with clinical decision support systems (CDSS), which can help prevent errors of commission and omission(Agency for Healthcare Research and Quality).

There are drawbacks to CPOE despite the fact that it directly addresses issues such as handwriting; drug interactions; similar drug names; system communication and adverse drug event reporting.(Agency for Healthcare Research and Quality). In fact, CDSS may be the key intervention in reducing errors in conjunction with CPOE since it has been reported that together (CPOE and CDSS), they reduced serious medication errors by 81% (National Priorities Partnership, 2010). However, the immediate implications of these findings are unclear. Although nursing homes are leading the way in terms of electronic medical record use (43%) it is unclear what percentage of those use CPOE (Leading Age, 2008). Additionally, the Agency for Healthcare Research and Quality (AHRQ) reports that only 17% of U.S. hospitals have implemented a CPOE system in 2009(Agency for Healthcare Research and Quality). AHRQ also indicates that problems with CPOE include cost, time, onsite customization, resistance and interoperability. CPOE and CDSS appear to not be able to make a large impact based on the low and inconsistent penetration of these technologies.

I know there are dedicated supporters of each intervention. Let us hear what you have to say! Log in and share below.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Agency for Healthcare Research and Quality. (n.d.). PSNET, Patient Safety Primer, Checklists. Retrieved 2011 10-August from Agency for Healthcare Research and Quality: http://www.psnet.ahrq.gov/primer.aspx?[rimerID=14

Agency for Healthcare Research and Quality. (n.d.). PSNet, Patient Stafety Primer, Computerized Order Entry. Retrieved 2011 10-August from Agency for Healthcare Research and Quality: http://www.psnet.ahrq.gov/primer.aspx?primerID=6

Bosk, C., Dixon-Woods, M., Goeschel, C., & Pronovost, P. (2009). Reality Check for Checklists. The Lancet , 374 (9688), 444-445.

Halasyamani, L., Kripalani, S., Coleman, E., Schnipper, J., vanWalraven, C., Nagamine, J., et al. (2006). Transition of Care for Hospitalized Elderly Patients: Development of a Discharge Checklist for Hospitalists. Journal fo Hospital Medicine , 1 (6), 354-360.

Leading Age. (2008  7-November). Press Release: Research Shows Nursing Homes Lead the Way in Electronic Health Record Use. Retrieved 2011 10-August from Leading Age: http://www.leadingage.org/Article.aspx?id=952

National Priorities Partnership. (2011 10 August). National Qulaity Forurm, Overuse. Retrieved 2011 10-August from National Quality Forum: http://www.qualityforum.org/Topics/Overuse.aspx

Walmart changed the pharmaceutical retail industry forever by creating the $4 Prescription Program. In one fell swoop, a gargantuan company disrupted part of the health care ecosystem. Today it looks like they are taking a new angle on how to manage in store health clinics. In the past, Walmart utilized a separate company that ran health clinics within the store but these closed in 2008 after about 3 years in operation. By partnering with St. Dominic in Mississippi, Walmart has made a deliberate choice to support local health care professionals ability to provide care to their community.

This type of movement directly ties with Hope Street Group’s belief that using new places to deliver primary care can achieve greater capacity at lower cost.

You can read more about this here: Walmart to open clinics in stores , The Clinic at Walmart and Recommendation 3: Use new people, places, and tools to achieve greater capacity at lower cost.

We can all agree that we have reached a point where the status quo in prevention is not enough.  Obesity continues to negatively impact adults’ lives and the lives of future generations.  Heart disease continues to affect thousands of Americans and is the leading cause of death for men and women.  Disparities in health outcomes by class and race persist, despite advances in technology and even improved access.  Whatever we have been doing is simply not enough.  Now is the time for truly innovative thinking in prevention.

Despite looming shortages, the United States is fortunate to have an expansive network of physicians, nurses, and other practitioners.  Unfortunately, health does not happen in hour-long office visits, let alone in 15-minute office visits.  Health happens at home.  It happens on the job, in schools, on the playground, and in our neighborhoods.  We cannot expect primary care to have an improved impact if we do not improve our efforts.  The Patient Protection and Affordable Care Act is a great start, but providing better health care coverage, albeit important, is only a minute piece of the complex puzzle we know as “health.”  Individual health is shaped and impacted by a wide variety of factors, including many that we think of as outside the realm of typical primary health care practice.  Racism, discrimination, housing quality, neighborhood safety, income, transportation, education and the availability of fresh food – just to name a few – all play a role in our health.  These social and economic factors are collectively known as the social determinants of health and impact all people.  Disparities arise because some people have more and better resources for coping with the factors that have a negative influence, while others have very few or no resources.  (To learn more about the social determinants of health, please visit the links provided below.) 

Work has already begun to address many of these factors from both policy and grassroots perspectives.  Organizations such as PolicyLink and Prevention Institute have been highly active in getting some of these issues on local, state, and federal policy agendas.  The First Lady’s Let’s Move! initiative is a great example of a large-scale, comprehensive effort to bring awareness to the factors that contribute to obesity in children.  Let’s Move! not only encourages healthy eating and physical activity, but seeks to improve access to healthy food and empower parents and caregivers to make good nutrition choices for their children.  The Let’s Move! website reports that since the initiative launched in February 2010, more physicians and pediatricians have conducted Body Mass Index screenings.    Those results are interesting in their own right, but it begs the question what else can primary care providers do to help their patients live the healthiest lives possible.

Some might argue that everyone has a unique role to play in this fight for better health outcomes, that primary care providers do not have control over these external forces, and that it is not right to expect them to engage in something they didn’t sign up for.  I agree that it is not reasonable to expect primary care to be able to change the situations their patients encounter outside of the care settign, but I do believe that health care providers have a duty to do as much as possible in the best interest of their patients.  Health Leads (formerly Project HEALTH) is an organization that has successfully implemented an innovative model for increasing primary care’s role in addressing the challenges many people face on their journey to health and wellbeing.  In the Health Leads model, volunteers fill “prescriptions” that care providers write for resources such as food, housing, job training, and fuel assistance.  Patients are connected with resources in their communities to help them protect and improve the health of themselves and their families.  Health Leads and many others are working towards a world where disease is not just managed but prevented and where well-being is promoted.

Primary care, with its connection to communities and to individuals, is in prime position to take on an expanded role in the fight for health and we must continue to ask ourselves tough questions. What is primary care’s evolving role in creating and implementing sustainable solutions that help all people achieve and maintain optimal health? How can we better help patients navigate the terrain encountered outside of clinic and office visits?  What does disease prevention mean in a social and economic context?  I don’t have all of the answers as to how this can happen or what exactly should be done, but I know that it can and that it should.   

Resources

WHO: Commission on Social Determinants of Health

http://www.who.int/social_determinants/thecommission/en/

Unnatural Causes

http://www.unnaturalcauses.org/

CDC: Health Disparities and Inequalities Report, 2011

http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

Marmot Review: Fair Society, Healthy Lives

http://www.marmotreview.org/

RWJF: A New Way to talk about The Social Determinants of Health

http://www.rwjf.org/vulnerablepopulations/product.jsp?id=66428&cid=xtw_rwjf

PolicyLink

http://www.policylink.org/site/c.lkIXLbMNJrE/b.5136633/k.F267/PolicyLink_Center_for_Health_and_Place.htm

Prevention Institute

http://www.preventioninstitute.org/about-us.html

Health Leads

http://www.healthleadsusa.org/

Determinants of health: the role of the general practitioner?

http://www.primary-care.ch/pdf_d/2009/2009-15/2009-15-249.PDF

Nova Scotia Premier Darrell Dexter has announced in a speech earlier this month plans for a $16-million collaborative primary care clinic in Queens County. The overarching goal is to bring Better Care Sooner to Nova Scotia residents by reshaping how emergency care is delivered.

The collaborative care clinic will have space for five  family  physicians, a nurse practitioner, family practice nurses and  other  health professionals.The new plans also call for an upgraded 22-bed  inpatient unit.

Additionally the Better Care Sooner is poised to:

-improve access to primary care, especially in smaller communities.

-make emergency care more patient-centered and streamlined.

-provide care that is better tailored to those whose needs are more complex (i.e. seniors).

-increase public awareness of 911 and the healthlink nurse line 811.

-make changes to the way health care is funded (reward better, patient-centered care).

The government states that roughly 84 percent of ER visits at the hospital would be better addressed by primary care.

Dexter says the province is committing $2.5 million to the project while the Region of Queens Municipality has committed $1 million.

About $11 million comes from the Queens Foundation and private donors, and another $1.5 million still needs to be raised.

Check out the whole story at http://www.canadaviews.ca/2010/12/23/improvements-will-ease-er-overcrowding-access-to-care/

As Hope Street Group builds momentum on “Policy 2.0: Using Open Innovation to Reinvent Primary Care” we knew we could not miss out on the launch of the new issue of Health Affairs entitled “Reinventing Primary Care”.  Not only does the title mirror the focus of our open collaboration, the new issue also proved to contain a wealth of scholarly discussion and practical policy prescriptions for the future of primary care.

Kathleen Sebelius (Health and Human Services Secretary) kicked off the launch with a keynote address setting out the Administration’s funding provisions impacting on primary care, both through the Recovery Act and the Patient Protection and Affordable Care Act.  She also acknowledged the tremendous challenges ahead in implementing the legislation, including the many places where it says, “The Secretary shall…”

The launch provided an overview of new models of primary care delivery, focusing in particular on patient centered medical homes and retail clinics.  It also highlighted the importance of interprofessional teams in primary care, looking at the way teams work (or don’t work) in primary care settings, and the roles of nurse practitioners, physician assistants and pharmacists in primary care practice teams.  The event concluded with a series of practice profiles, covering: Greenhouse Internists, the Group Health Cooperative, QuadMed, the implementation of electronic referrals to specialists, and the role of Medical Assistants in chronic disease management.

I attended the event with Monique Nadeau (Executive Director, Hope Street Group) and was impressed by the quality and breadth of the information covered and the interesting dialogue that occurred between panel members and the audience.  I would be interested in the reactions of anyone else who attended or who has had an opportunity to look at the new Health Affairs issue.