PARADE: Audit Tool and Intervention Guidance

1. PARADE: Audit Tool and Intervention Guidance Anne Myrka IPRO January 20, 2015 2-3pm

2. Collaborative Disclosures • Project is designed to encourage collaboration • Through that effort we will facilitate the sharing of facility names, team members and email addresses with all involved in project • We will not share your individual QI findings or QI data with any other organization without your consent • Please contact Anne if you do NOT wish to have your contact information shared

3. Objectives • Reiterate project focus, objectives and strategy • Provide support identifying team members • Identify target patient population • Provide audit tool and intervention guidance • Open Q&A

4. Brief Recap • Complete PARADE Request for Technical Assistance if not already done and forward to Anne (anne.myrka@hcqis.org or fax: 518-426-3418) • January 6th Webinar, Request for Technical Assistance and recording is found at: http://qio.ipro.org/care-transitions/healthcare- professionals/past-events

5. Cycle 1 • Med Related Patient Safety Goals: • Improve care coordination: • Cross setting communication • Improve care management: • Quality improvement • Reduce readmissions caused by ADEs Cycle 2

6. Goal of Medication Reconciliation and High Risk Drug Safety Process Decrease medication errors and patient harm by: • Obtaining, verifying, and documenting patient’s current prescription and over-the-counter medications; including vitamins, supplements, eye drops, creams, ointments, and herbals • Comparing patient’s pre-admission/home medication list to ordered medicines and treatment plans to identify unintended discrepancies • Discussing unintended discrepancies (e.g., those not explained by the patient’s clinical condition or formulary status) with the physician for resolution • Providing and communicating an updated medication list to patients and to the next provider of service at discharge •  Identifying patients on high risk drugs, and; •  Integrating evidence based ADE prevention processes for identified patients across care settings Adapted from The Joint Commission National Patient Safety Goal 03.06.01  Steps 5 & 6 are unique to IPRO’s process

7. PARADE Strategy Based on 6 month improvement cycles Cross setting work will be achieved within each care transition coalition Medication Management Committee monthly meetings Cycle 1 is January 6, 2015 – June 30, 2015 • All facilities will focus on Medication Reconciliation and Anticoagulation Discharge Communication • Educational webinars on management of hypoglycemics and opioids will be provided prior to the launch of Cycle 2 (which will expand to process improvements for hypoglycemics and opioids)

8. PARADE Strategy Cycle 1 January 6, 2015 – June 30, 2015 • All facilities (including those who participated in the pilot study) will complete and return a PARADE Request for Technical Assistance by January 16, 2015 • Eligible facilities are hospitals, skilled nursing facilities (SNF), rehabilitation facilities, home healthcare services/agencies (HHA), residential facilities, adult homes, primary care providers, pharmacies (hospital, community, SNF vendors, etc.) • Participating individuals are administrators, physicians, nurses, pharmacists (including SNF consultant pharmacists), quality improvement professionals, discharge planners, HHA hospital liaisons, etc.

9. PARADE Strategy Cycle 2 is July 1, 2015 – December 31, 2015 • Continue to work on ADE hospital readmission measure, high risk drug discharge communication and med rec improvement processes • Expand to medication management of hypoglycemics, opioids, other (e.g. antibiotics) • IPRO is currently convening subject matter experts to provide guidance on best practices for management across care settings during transitions Subsequent Cycle work will focus on continued evidence based improvements, sustainability and applicable cross-setting emerging measures

10. Who should sign Request for Technical Assistance?Who should be on the team?

11. Request for Technical Assistance The “Primary and Secondary Contacts” should be employees in your facility who can: • Ensure that the work will be done • People who are materially invested in wanting to do the work and achieve improved outcomes • Remove barriers to improvement The Primary and Secondary Contacts will receive PARADE emails and notices for webinars, meetings, etc. The “Organizational Representative Signature” can be anyone in the facility who can ensure ongoing commitment of resources (usually leadership)

12. Identifying Team Members Within Your Facility Team Leader – someone who can build consensus and knows who, how and when to ask for resources Administrative leader – to remove barriers, assign resources Clinical Champion(s) – physicians, pharmacists, nurses with expertise/knowledge regarding anticoagulation, med rec, high risk drugs, care transitions, the discharge process, etc. Direct patient care/front line staff – those who know current workflow and who can envision how to improve Pharmacists – can include pharmacy administration, consultant pharmacists, dispensing pharmacists, pharmacy techs Quality Improvement staff (is often a team leader) Information technology staff

13. Identifying Target Patient Population

14. Identify Target Patient Population Retrospective Audits: Patients discharged on an anticoagulant within the last 30-60 days Hospitals: • VTE/Stroke Core Measures • Pharmacy reports to identify patients on anticoagulants Skilled Nursing Facility • MDS 3.0, Section N, NO400 Medications Received • Intake referral information/PRI • Pharmacy reports to identify patients on anticoagulants

15. Identify Target Patient Population Home Health • OASIS C responses to M2000, M2004, M2010, M2015 • Intake referral information Transition Coach Services • Use MDT data and CTM-3 to target interventions

16. Identify Target Patient Population Common Diagnoses/Conditions associated with anticoagulation use: • Treatment and Prevention of blood clots (VTE) • Atrial fibrillation/flutter • Orthopedics • Stroke https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2 FPage%2FQnetTier4&cid=1228773564870 (see appendix A for a complete list of ICD-9 codes)

17. Measures and Tools

18. Process Measure: Medication Reconciliation Audits

19. Elements of an Improved Med Rec Process • Process design - should center on the concept of a single list to document patient’s current medications (“one source of truth”) • Defining roles and responsibilities for medication reconciliation - determine which discipline(s) should be involved in each step of your medication reconciliation process, including their respective roles and responsibilities • Integrating medication reconciliation into your existing workflow - prompts to complete required steps for medication reconciliation are essential

20. “One Source of Truth” • Single list documents home medications • Standardized across the facility • Maintained in a consistent location in the medical record • All providers are empowered to update the list as new and more accurate information is available • Used at admission, transfer, and discharge for medication reconciliation

21. Page 46 of the MATCH toolkit

22. Types of Unintended Medication Discrepancies • Omission: Patient reports taking a medication before hospitalization. It was not ordered on admission or it was not listed on the patient’s discharge instructions. No clinical explanation supports omission. • Commission: Medication is ordered at admission that the patient did not take before hospitalization. Medication is listed on the patients discharge instructions but it was not ordered during the hospital stay and the patient did not take before hospitalization. No clinical explanation supports commission. • Different dose, route or frequency of medication than the patient reports taking before hospitalization. Different dose, route or frequency of medication listed on the patients discharge instructions than what was ordered during the hospital stay or that the patient reports taking before hospitalization. No clinical explanation supports difference. • Duplication and/or different medication ordered. Medication in the same therapeutic class is ordered on admission or is listed on the patents' discharge instructions and differs from, or duplicates, what the patient reports . No clinical explanation or formulary substitution supports difference.

23. Process Audits of Internal Facility Procedures The Medication Reconciliation Audit Tool – Evaluates: Collection and accuracy of the home medication list Accuracy and timeliness of the medication reconciliation of the home list to the admission orders Documentation of rationale for intended medication discrepancies Incidence of unintended medication discrepancies You will audit 5-10 medical records of patients discharged from your facility on any anticoagulant who have been re-hospitalized within the past 30 days (if there are no re-hospitalizations within 30 days, try 45 days or 60 days, if needed) Choosing records of patients discharged on anticoagulants is to assist with identification and subsequent root cause analysis of anticoagulant medication discrepancies

25. Process Measure: Anticoagulation Discharge Communication Audits

26. Baseline Process Audits of Internal Facility Procedures The Anticoagulation Discharge Communication Audit Tool Evaluates: Your facilities internal discharge communication practices for patients who are discharged on an anticoagulant Using the same 5-10 records that were used for the Med Rec tool, audit medical records of patients discharged from your facility on any anticoagulant within the past 30 days (can extend to 45 days or 60 days, if needed)

27. Audit Methods: • Anticoagulation Discharge Communication (AC-DC) Audit Tool • Excel version • Preferred method of data collection • Calculates performance statistics automatically and includes performance dashboard • Color coded performance: • Green = >90% of completed fields as "yes“ • Yellow = 60-90% “yes” • Red = <60% “yes” • Demonstration video

28. Audit Methods – Anticoagulation Discharge Communication (AC-DC) Paper Tool

30. Additional Ad Hoc Anticoagulation Baseline Measure Designed for skilled nursing facilities, outpatient clinics and others that serve population over long term IPRO study done in 12 SNFs showed aggregate TTR of 45.5%. Quality goal is 70%. For more information: http://qio.ipro.org/drug-safety/collaborative-partners/analytic-services

31. Outcome Measure

32. Outcome Measure: Hospital Re-admissions due to High Risk Drug ADEs IPRO will work with each hospital individually to obtain baseline.

33. Outcome Measure: Hospital Re-admissions due to High Risk Drug ADEs IPRO will contact key hospital leads in next few weeks regarding ADE data retrieval and transfer procedures Hospitals should identify an IT lead to participate in discussions with IPRO for the electronic data retrieval process IPRO will schedule subsequent meetings

34. Intervention Resources

35. Medication Reconciliation Intervention Resources http://www.hospitalmedicine.org/marquis/

36. Medication Reconciliation Improvement Tools

37. Anticoagulation Management Interventions Anticoagulation Management Interventions: AHRQ educational DVD and partner teaching booklet • http://www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/index.html IPRO’s Management of Anticoagulation in the Peri-Procedural Period http://qio.ipro.org/drug-safety/drug-safety-resources Identification of and referral to Anticoagulation Clinics that may exist in your community Anticoagulation Centers of Excellence

38. Goals for Cycle 1 January – June 2015 Medication Reconciliation • All facilities will have processes (including policy and procedure) in place for successful admission medication reconciliation by the end of Cycle 1 Anticoagulation Discharge Communication • All facilities will communicate greater than 90% of the requisite anticoagulation management elements to the subsequent provider upon transfer or discharge by the end of Cycle 1

39. PARADE Cycle 1 Timeline and Due Dates

40. Summary & Next Steps Baseline Med Rec and ACDC process audits to be completed by Feb. 6, 2015 Email or fax or completed audits to Anne at: anne.myrka@hcqis.org or fax: 518-426-3418 Outcome baseline completion date will be individualized per hospital Coaching Teleconference Call March 17th, 3-4pm – agenda forthcoming Anne can provide individualized support to all facilities and will be contacting the team leads to schedule support calls and/or facility visits to assist with baseline audits

41. Discussion & Questions

42. Sara Butterfield Senior Director – Care Coordination (518) 320-3504 Sara.Butterfield@hcqis.org For more information Darren Triller Senior Director – Drug Safety (518) 320-3525 Darren.Triller@hcqis.org IPRO Care Transitions Web Site: http://qio.ipro.org/care-transitions/overview IPRO Drug Safety Web Site: http://qio.ipro.org/drug-safety/overview Anne Myrka Pharmacist – Drug Safety (518) 320-3591 Anne.Myrka@hcqis.org IPRO CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.atlanticquality.org This material was prepared by the Atlantic Quality Innovation Network/IPRO, the Medicare Quality Innovation Network Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-AQIN-NY-TskC.3-15-04