Expert: Optimizing Transitions of Care for Heart Failure Patients

In an interview with Pharmacy Times®, Eric Dueweke, MD, MBA, FACC, cardiologist and physician leader from UPMC, and Ashley Modany, PharmD, senior clinical pharmacy specialist from UPMC Health Plan, discussed improving transitions of care for heart failure patients through a collaborative approach between UPMC's cardiology team and UPMC Health Plan's pharmacy team. Dueweke and Modany shared that they utilize electronic medical records to help ensure seamless communication, medication reconciliation, and real-time updates to patient and member medication lists during the transition from inpatient to outpatient care. The team focuses on implementing standard therapies, evaluating medication regimens, and identifying opportunities for optimizing heart failure treatment through programs like medication optimization clinics and clinical outreach. Dueweke and Modany emphasized the goal to reduce readmission risks, improve medication adherence, and provide comprehensive, patient-centered care by leveraging analytics and bi-directional communication between health care providers.

Pharmacy Times: Could you describe the typical workflow or process for a patient with CHF transitioning from inpatient cardiology care within the health system to outpatient management under the health plan's pharmacy benefits? Specifically, how is medication reconciliation and continuity of care ensured during this transition?

Eric Dueweke, MD, MBA, FACC: One of the challenges we face in health care across the board is that that transition of care is often not well organized. Part of the intent of this effort was to bring a structure to the way that we handle the care for our patients with heart failure after their discharge from the hospital. That's one of the primary reasons that we stood up this process.

Ashley Modany, PharmD: Just to add to that, like Dueweke said, I think we're really trying to make the transitions of care process as seamless as possible. We're trying to touch as many patients as we can throughout this process. From a health plan standpoint, we actually use analytics to determine patients who are discharged from the hospital with a diagnosis of heart failure, who would most directly benefit from a telemedicine visit with a pharmacist to perform that transitions of care, medication reconciliation. From our standpoint, as the pharmacist at the health plan, when we outreach to these patients and talk to them about their medications, we're actually updating the medication list in real time. We do that directly within the electronic medical record based on our conversation with the patient, and then we add that to our note and route it directly to our heart and vascular institute providers. In doing so, when routing, we also route to our schedulers. We're not only communicating our recommendations to the provider, but we're also looping in the scheduler to ensure that that additional follow up with the provider themself is also scheduled.

Dueweke: Right now, at UPMC, we have multiple different electronic medical records, and most notably, the electronic medical record that's used inpatient is different than the one that's used outpatient. That does lead to some breaks in continuity, and much of the care and heart failure patients, as well as the use of wraparound services in heart failure really hinges on accurate medication lists. We saw this as mission critical to ensure continuity, starting with an accurate uniformly agreed upon medication regimen for the patient.

Pharmacy Times: What specific communication channels are utilized between the health system cardiology team and the health plan pharmacy team regarding CHF patient care? How frequently and in what format does this communication occur?

Dueweke: We utilize EPIC for all of our communication, and we're using provider messaging. I was on the team that helps stand up this initiative, but I'm also on the team taking care of patients on a daily basis and receiving these messages. I would say that the communications are excellent.

Modany: I think one nice thing too is that by utilizing the electronic medical record, we're not only routing our notes and communicating directly with the Heart and Vascular Institute provider, but it gives us the opportunity to look at the patient as a whole and also loop in their other providers who are also utilizing EPIC so we can route our notes to them as well and communicate those recommendations. The communication, I would say, is pretty bidirectional. That initial communication comes from us, but we also always encourage the providers to outreach back to us if they have any questions, or if they think that the patient would benefit from any additional pharmacist interaction, they can outreach trust for that as well.

Pharmacy Times: How are complex medication regimens, including those involving novel heart failure therapies (eg, ARNI, SGLT2i), managed and monitored collaboratively? What strategies are used to address potential drug interactions or adverse effects?

Dueweke: That's a great question. I would almost push back on the use of the word novel to say that these are very well-established therapies. We have good data showing that the use of a standard quadruple therapy drug cocktail has been associated with great outcomes in patients. With that lens I think that one of the biggest challenges that we face is ensuring that an old regimen has been appropriately discontinued, and the new regimen has been started. That has really been the key of reducing the likelihood of adverse pharmacologic events and just making sure that the patient knows these are the things that have stayed the same. These are the things that have changed, and these are the things that are new additions to your regimen.

Modany: Just to follow up on that too, I think ideally because we are so comfortable and confident in these therapies, we do try to implement them on the inpatient side. In terms of transitions, if they've been implemented already before discharge, we as the pharmacists, are kind of reinforcing that education on the purpose and the benefits. We're educating the patients about the side effects of the medications and just reinforcing it from that standpoint. But that being said, there also are a lot of times where the patient may not be appropriate for initiation of that medication before discharge. Whether that has to do with clinical status, hemodynamics, things like that. When we're performing that medication reconciliation after discharge, we're at least evaluating for opportunities for initiation, and even if it's not something that we can recommend right then and there, we're still including in our note. Just as kind of like an FYI, this is something to consider for future, once the patient's hemodynamically stable, or stable from a renal standpoint, or whatever that might be. Then we still include those additional monitoring things. If this is started, these are some other recommendations that we would have in regard to their other medications. Or these are some things to monitor for, this might be a potential interaction. Even if it's not something that we can do right in the moment, we're still always looking forward to that next visit and that next collaboration to see if there are opportunities there.

Pharmacy Times: What role does the health plan pharmacy team play in optimizing medication adherence for CHF patients? Are the specific programs or interventions implemented, and how are these coordinated with the cardiology team's efforts?

Dueweke: That's a really nice question because I see that some of this, just as Ashley mentioned, identifying the opportunity that maybe this is something that wasn't considered. But we have a lot of other resources, both at the health plan as well as the hospital level or the physician services level. For example, we make use of a medication optimization clinic. When further attention is necessary to ensure patients receive optimal heart failure therapy, we can suggest enrollment in that effort. We also are able to connect patients with other wraparound services, like a post discharge clinic in the heart failure team or remote patient monitoring or even cardiac rehabilitation, if appropriate.

Modany: From a health plan standpoint, in addition to these transitions of care collaboration program that we have, we also have a heart failure clinical outreach program. That program specifically identifies patients with heart failure medication related issues. We look at things like gaps in their guideline directed medical therapy, therapeutic duplications. We look for medication adherence issues, among other things. Then we use stratification criteria to determine which patients flagged within that program, and then we outreach when appropriate, to discuss things like medication adherence. If we identify an adherence issue, we will determine what barriers they're having to adherence. We would address those barriers, and then appropriately make any referrals like Dueweke said to any of those wraparound programs. Similar to the transitions of care program, we communicate all of this not only the Heart and Vascular Institute provider, but any other providers that it might be relevant to.

Pharmacy Times: How does the health plan pharmacy team contribute to the early identification and management of potential medication-related problems or readmission risks in CHF patients? What data or metrics are utilized for risk stratification?

Dueweke: I think that one of the biggest risks is not taking a critical look at the diuretic regimen that is being utilized. Many times, just an early point of contact is enough to know that the patient is moving in the wrong direction. If we haven't adequately addressed the patient's diuretic regimen. Most of our risks for adverse events is driven by, I'd say pharmacologic misadventure. The idea to put a critical eye on what the patient's understanding of their regimen and how to take it is, that probably one of the best ways to mitigate that risk.

Modany: I think fortunately, from a health plan standpoint, the majority of our clinical programs are developed internally. This really does allow us to customize our outreach based on our specific member population and specific issues that we're seeing within our heart failure population. Not only do we use that guideline directed clinical evidence to determine why we're outreaching to these patients or which medication related issues are being addressed. But we can also use clinical patient specific issues that we're seeing as well. We use all that data in conjunction to prioritize our outreach to members that we think would most benefit. We can incorporate things like recent acute care utilization to really target those members who we will most impact.