Care Transitions

Pro Pharma Talks

Topic: Care Transitions

What are care transitions?

-Acute to home or chronic care/step down

-Example: Hospital to home

Concern

-Don’t want patient to return to the hospital within 30 days for same problem

- Medicare refusal to pay for certain conditions to promote prevention

Issues

-Understand discharge orders

-Comply with discharge orders

-Drug coordination from pre-hospital, to in hospital, or post-hospital regimen

-Labs and services to follow up

Examples

-Pneumonia & Serious infections – injectable to oral antibiotic, antibiotics compliance, monitor for symptoms (temperature, swelling, pain, GI symptoms, dizzy/confused, etc.)

-Heart Failure – monitor weight everyday, comply with medicines

-COPD/Emphysema – arrange for O2, use FiO2 to expand vital capacity, correct use of inhalers

-Asthma – correct use of inhalers

-Heart Attack – BP, lipid, ACEI regimen of medications – promote compliance

-DVT – transition from injectable-to-oral anticoagulants – promote compliance, alert notification if bleed

-Pain management – CDC recommendations

Support

-Nurse case managers

-Pharmacists

-Home – rest, anabolic diet, hydration

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