Hospital Readmissions: Case Study of a Bottom-up Network Research Initiative

1. Hospital Readmissions: Case Study of a Bottom-up Network Research Initiative David H. Kreling, R.Ph., Ph.D. Betty A. Chewning, Ph.D. Jia Pu, M.S. Korey A. Kennelty, Pharm.D., M.S., R.Ph. Sonderegger Research Center UW School of Pharmacy 2012 Wisconsin Health Improvement and Research Partnerships Forum 21 September 2012 Monona Terrace, Madison

2. Objective: Describe, as a case study, the process by which we have worked together with a pharmacist research network member on a project to develop tools and procedures to reduce the readmission rate for heart failure patients in his hospital. Describe challenges and problem solving: sample selection, data availability, and consent/human subject protection. Describe procedures and efforts to develop interventions for reducing readmissions and successes and failures of their efforts. Discuss issues related to exporting and expanding the project in other hospitals and communities.

3. Pharmacy Practice Enhancement and Action Research Link (PEARL Rx): A network of pharmacists who are potential partners for collaborative projects and research to enhance practice and expand pharmacist roles. Pharmacists in all settings invited - Community, Institutional, Benefits Managers. Located throughout the state - consistent with School’s experiential training hubs and clerkship locations. http://pharmacy.wisc.edu/pearlrx ** This network is supported by grant UL1TR000427from the Clinical & Translational Science Award (CTSA) program of the National Center for Research Resources National Institutes of Health.

4. Reimbursement for services Fall risk screenings Osteoporosis management Medication therapy management Blood pressure screenings Cholesterol screenings OTC product needs evaluation Medication reconciliation Patient-centered medical home Accountable Care Organizations ESL/ limited English proficiency Diabetes management Asthma management Pain management Preventive care screeners HIV/AIDS medication management Obesity education Medication compounding support Tobacco cessation Safe syringe disposal Patient medication use/ adherence Collaborative Practice Agreement Others: Interest Survey - August 2011 Check your areas of interest. Add others as appropriate

5. Project Genesis/Inception • Contacted by Network Member • Disease Management Pharmacist – A large hospital in southeast Wisconsin • Pharmacist responsible for identifying contributors (and solutions) to high rate of hospital readmissions for Heart Failure.a • Pharmacist had personal interest in moving pharmacists past order entry to patient care in the hospital and connecting to the outpatient arena (ACOs)b a (Hospital’s numbers were above norm - - potential financial implications vsv. CMS & Medicare payments) b(with previous connections on research and projects - smoking cessation project)

6. Project = Opportunity • One form of network/researcher collaboration • Example of a bottom-up, organic project stimulus • Develop and pilot tools, procedures, processes for potential future grant • Obtain pilot data to strengthen future grant prospects • Provide experiential base and understanding of how things can work • Build rapport, credibility with other network members ** This project is supported by UW- Madison School of Pharmacy Research Innovation Awards Program

7. Project Basics • Analyze subset of patient data collected by staff at time of hospitalization to describe key characteristics of the patient population relevant to adherence and rehospitalization. • Analysis to help identify at risk HF patients in terms of demographic, clinical, and capacity/adherence barrier variables. • Data sets: patient profiles, readmission worksheets, BOOST, and MAT.* • Goals: • Potentially establish a risk scoring tool to allow focus on patients who likely would/could be at risk for readmission • Intervene in critical areas that were likely to drive readmission, especially medication - related behaviors and factors. * BOOST - Better Outcomes for Older adults through Safe Transitions MAT - Medication Assessment and Teaching

8. ‘Navigating’ the Project IRB approvals - Hospital and UW levels Data acquisition: sources, formats, de-identifying, reliance on/default to paper systems & manual entry, logistics, resources for staff to generate data. Data: variable identification, interpretation

9. Where are we at now? Data entry Some thinking about tools, based on hunches and preliminary signals in data

10. Next Steps: Analysis and risk assessment/index Developing tools & evaluating their potential Engaging others (community pharmacies, visiting nurses, hospital outreach, etc.) “Exporting” success & tools - other network members, possibly with grant submission if opportunity.

11. Questions? Ideas? Suggestions?

12. BOOST • Better Outcomes for Older adults through Safe Transitions • 7 Ps- • Prior Hospitalization • Principal Diagnosis • Problem Medications • Polypharmacy • Psychological • Patient Suport • Poor Health Literacy MAT - Medication Assessment and Teaching medical literacy, compliance, barriers to use

15. Working with network member Develop tools? Analyze data? On site, off site work (here & there) We are participating in a study being done by the UW School of Pharmacy around heart failure and medications and readmissions. This study has been approved by both IRB’s and funding has been allocated for data pull and de-identification of patient data for up to $2800. I’d like to use our technician staff to do this. Since the funding for this comes from the study but we’re using our employees, I have some questions around the proper procedure for this.

16. Working with network member Navigating IRB(s) Getting/transferring data We are putting a lot of thought into both the risk index and also implications for interventions. input data from October '11 admissions and comparing these to October '11 readmissions, ie, putting data into the calculator and comparing scores.

17. Developing next steps “Exporting” success & tools Engaging others (community pharmacies, visiting nurses, hospital outreach, etc.

18. Introduction A survey of Pharmacy Practice Enhancement and Action Research Link (PEARL Rx) network members revealed that medication reconciliation was a popular topic of interest for potential research projects. This topic is of interest because it has implications across care settings (hospital and community) when patients transition from inpatient to outpatient care arenas. One hospital pharmacist in the network responsible for analyzing and improving his institution's rate of readmission for congestive heart failure patients reached out to us for input on developing strategies and tools to help predict (and thus potentially avert) patients who might be most at risk for readmission. Objective The objective of our presentation is to describe, as a case study, the process by which the pharmacist network member and researchers at the School of Pharmacy have worked together on a project to develop tools and procedures to reduce the readmission rate. In our presentation, we will describe challenges and problem solving that occurred in studying the problem of readmission such as sample selection, data availability, and consent/human subject protection. We also will describe procedures and efforts undertaken by the institution to develop interventions aimed at reducing readmissions and successes and failures of their efforts. Finally, we will discuss issues related to how the case study, tools developed, and lessons learned can inform our efforts to export and expand the project to help reduce the risks of readmissions in other hospitals and communities.

19. Where are we at now? What do we have to help others - “exportable” tools, etc.?