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Orchestrating Transitions of Care

by Mark F. Perry, MD

Medical Director, BlueCross BlueShield of Western New York

October 24, 2019

To: All Providers

Well-orchestrated transitions from one health care setting to another can literally save lives.

Transitioning patients from hospital stays to home or another facility usually involves multiple handoffs. As a practicing physician and former medical group leader, I’ve witnessed a variety of workflows that ensure a smooth and accurate exchange of information between providers.

Much has been written about how best to do this, but it’s worth summarizing a few points:

Assign medication reconciliation to an expert. The treating provider at the time of transition should be accountable for the reconciliation. Pharmacists are best able to prevent medical discrepancies, and therefore avoid adverse drug events (ADEs). A pharmacist or pharmacy tech is best suited for this responsibility in the hospital setting, and some research has shown that this can increase accuracy. In most PCP offices, RNs and physicians are most qualified.

Get a list of medications prior to a visit or procedure, then verify for accuracy. Ask patients or caregivers to bring or take photos of every pill bottle and its label – medicine, herbal remedies and supplements included. Or do this over the phone while they are still at home, and ask about adherence. Ask them to verify accuracy of the list when they arrive.

Put processes in place to ensure timely transfer of essential information to the next care setting. Make sure relevant clinical stakeholders are identified, and receipt of any electronic information transfer is confirmed. Beyond medications, information about diagnoses, comorbidities, lab tests, and cognitive or functional impairments should be communicated.

Use patient portals to engage patients in medication reconciliation post-discharge. One study sent a secure email message to patients asking them to confirm their discharge medication list within 72 hours of discharge. The study found 108 medication discrepancies in the 51 medication lists that were returned. There may be other ways to leverage information technology, but making use of your existing patient portal could immediately improve results.  

Pay attention to social determinants of health. What are the patient’s self-management abilities and what is the extent of their support system? Do they have transportation challenges and housing and food stability? BlueCross BlueShield has case and disease managers who can assist with these and other issues. Providers can engage our case and disease managers by calling 1-877-878-8785, option 2.

In closing, when medication reconciliation is done after a hospital (Inpatient or Observation) stay, you can make sure this is reflected in claims data by billing CPT II code 1111F. We reimburse for this code, and it helps us confirm that this important quality process was performed for your patient.

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