Linda Brocato, RPh Pharmacy Manager Westerly Hospital Mark Rogers, PharmD, CDOE

1. Linda Brocato, RPh Pharmacy Manager Westerly Hospital Mark Rogers, PharmD, CDOE Clinical Pharmacy Supervisor Westerly Hospital Kevin Emond, PharmD Candidate ‘16 University of Saint Joseph School of Pharmacy “A Patient Safety and Improved Outcomes Initiative” Trials and Tribulations of the Med History Verification Program at Westerly HospitalNPSG 03.06.01

2. Objectives • Pharmacist Objectives • Examine the relationship between accurate medication reconciliation and positive patient outcomes • Identify the impact of pharmacy driven home medication verification • Explain the connection between medication reconciliation and cost avoidance savings

3. Objectives • Technician Objectives • Describe the impact that pharmacy technicians have on home medication verification • Understand the importance of medication reconciliation during transitions of care

4. Background • Over 110 million ED visits annually in the United States • Approx. 45 visits per 100 persons • Research shows increasing trends in the usage of Emergency Departments as sources of Primary Care • BOTTOM LINE: • Larger patient volumes and transitions of care may lead to increases in adverse reactions, poor patient outcomes, and increased cost of interventions Nana B, Lee-Such S, Allen G. Initiation of an emergency department pharmacy program during economically challenging times. Am J Health-Sys Pharm. 2012;69:1682-86.

5. Background • Westerly Hospital strives to achieve positive health outcomes and meet or exceed standards set by regulatory institutions • Joint Commission - NPSG compliance 03.06.01 • Centers of Medicare and Medicaid Services • Affordable Care Act • Home Medication Verification (HMV) program

6. Medication Reconciliation • Studies have shown that Med Rec (MR) decreases rates of adverse drug events as well as increases positive patient outcomes • Nana et al. demonstrates the benefits of proper MR by highlighting associated positive outcomes • Reduced rates of adverse effects • Timely provision of medications • Increased adherence to evidence-based guidelines • Increased use of cost-effective drug therapies Nana B, Lee-Such S, Allen G. Initiation of an emergency department pharmacy program during economically challenging times. Am J Health-Sys Pharm. 2012;69:1682-86.

7. Medication Reconciliation • Nana et al. also strongly advocates for pharmacy driven MR, stating, “It is a critical component of an accurate patient evaluation during any admission” • 90.2% of admission medication reconciliations performed by pharmacists were accurate, compared with only 66.7% accuracy of those performed by nurses Nana B, Lee-Such S, Allen G. Initiation of an emergency department pharmacy program during economically challenging times. Am J Health-Sys Pharm. 2012;69:1682-86.

8. Medication Reconciliation • Nursing • Lack of expertise and time to devote to comprehensive HMV • Physicians • Inefficient use of resources • Contributed to patient admission delays • CPOE challenges • Pharmacists • Burdened with clean-up after orders written • Delayed patient medication delivery

9. History of MR at Westerly Hospital • Initiation of Pilot Program (1/7/13 - 2/14/13) • Objective: Collect data in order to demonstrate the significance of accurate Home Medication Verifications (HMV) • 19 day trial: 140 completed HMV • 7.37 average HMV per day (7:00 am to 3:30 pm)

10. Westerly Pilot Program • Staffing Structure • 6th-Year APPE Pharmacy Interns • Utilized on day shifts Monday-Friday • Senior interns fully capable of completing HMV tasks • Replaced nurses, physicians • Pharmacists are the drug experts • Realignment of disciplines to capitalize on key strengths

11. Westerly Pilot Program • Pros • Results illustrated a growing need for increased pharmacy involvement during patient admissions • Identified need for standardized HMV forms and procedures • Cons • High staff turnover and retraining of interns • Shift coverage challenges (nights, weekends/holidays) • Narrowed APPE experience (lack of time for students to participate in other experiential objectives) • Efficiency lag with new student trainees

12. Pilot Program By The NumbersCompleted Medication Reconciliations in the Emergency Department Red: January 2013, Blue: February 2013; 19 total days, Daily average: 7.37 Med Recs

13. Pilot Program Results • Illustrated the significant need for a better program with more reliable/efficient staffing coverage • Highlighted the importance of pharmacy led HMV • Error rate 54% with nurse-driven HMV • Paid student support approved for weekday evening shifts and weekends/holidays • Two per diem students hired in April, 2013

14. Per Diem Student HMV Program • April 2013 – October 2014 • Initially two 6th-Year Interns hired for HMV position • 2nd shift coverage during weekdays • Start time varied based on APPE rotation schedule • Single-shift coverage on weekends (12 – 8:30 pm) • Provided excellent service and enforced the value of pharmacy-driven HMV • Setbacks • Staffing holes due to lack of trained pharmacy staff to cover all shifts • PD Student positions were not officially legitimized into department staffing model

15. Per Diem Student HMV Program • Ongoing “improvements” • May 2014, received FTE Committee approval to hire an additional 6-10 PD students to cover all shifts • Transitioned to four 8-hour weekend shift positions (days and evenings on Saturday and Sunday) • Continuous coverage on weekdays and during times without APPE students on weekdays • Unforeseencomplications • Difficultto coordinate schedules

16. Transition Plan From PD to FT Staff • Started in October 2014 • Goal was to transition away from intern positions on weekdays • FT staff needed to sustain and legitimize the program • Program could not continue to operate on students alone • Insufficient resources for pharmacist staff • Oversight of HMV was lacking, leading to a false sense of safety by providers • Pharmacist resources needed in the ED to address complex clinical questions • Initial FTE Requests denied

17. Per Diem Student HMV Program: The Dark Days • The Perfect Storm: November 2014 • Scheduling nightmare • APPE student breaks • Midyear • Holidays • Student vacations • Final/Core exams • Job offers/Commitments • Medical Leave (broken knee) • FTE Committee request process revamped and not available to WH management! • Pharmacy could not staff committed HMV shifts • Program shut down for over 1 month…all hell broke loose! • Nursing grossly unprepared for completing HMV

18. The Battle For Legitimacy • Current Hospital Environment • WH just emerged from receivership with limited resources/staffing/building investment • L+M had labor strike causing massive financial loss • Consultants hired with objective to cut costs • L+M did not have a HMV program

19. Business Plan Proposal • Proposed plan for FTE Committee approval • 2 FTE Pharmacy Technicians (7 am – 11:30 pm coverage) • 1 FTE RPh position (8 am – 4:30 pm) • 0.8 FTE weekend coverage with paid student interns • Bets anyone??? • Data collection was key to justifying need • Cost Avoidance calculations

20. Business Plan Proposal • Data collection was key to justifying the program • Cost Avoidance calculations • Categorized interventions per month: Meds added/removed, free text conversions • Time spent per patient • Adverse Drug Reactions prevented • Allergy/Immunization updates • Verification sources • Outcomes compared to published literature articles • Cost avoidance from HMV interventions achieved staggering results

21. HMV Associated Cost Avoidance *Total calculated cost avoidance from Dec 2013 through October 2014 - $1,663,470

22. Business Plan Proposal • Support and momentum grew • Hospitalists and President of Medical Staff lobbied for approval of positions through written statements describing importance of Pharmacy HMV • Plan proposed again to FTE Committee • This time we had letters of support from providers • Final approval granted in February, 2015

23. Current HMV Positions • HMV Pharmacy Technicians • 2 full time positions, Weekdays hired 2/2015 • 7:00 am to 3:30 pm • 3:00 pm to 11:30 pm • Weekend and Holiday coverage with PD positions • Technicians and Paid Interns (two shifts/day) • HMV Pharmacist • Full time position • Weekdays • 8:00 am to 4:30 pm • Off shift supervision provided by Staff Pharmacist

24. HMV By The Numbers • 2013: Blue, Pilot Program • 2014: Red, Hired Per Diem Interns • 2015: Green, Full time Positions Approved (2/2015)

25. HMV Documentation • HMV Activity Form • Worksheet for technicians/students collecting HMV data • Dr. First Report • Used to verify retail pharmacy dispensing history obtained via data feeds from community pharmacies and PBMs • Patient-Provided Lists, SNF MARs • SBAR Communication Form

27. Home Medication Verification SBAR Communication Form • Objective is to communicate discrepancies identified during HMV to Med Rec providers • Examples: • Patient reports taking Lisinopril ½ tab daily; CVS verifies Rx directions state 1 tablet daily • Patient prescribed three HIV meds, but patient states that they haven’t taken meds in 3 months

28. Home Medication Verification SBAR Communication Form • Sections include SBAR problem communication and a field for provider response • All supporting documentation attached to SBAR form and retained as part of the permanent medical record • Completed by Pharmacy (nursing completes on 3rd shift)

29. Employee Satisfaction • Nursing • “[Home Med Verification] by Pharmacy is the best thing that has happened to nursing in a long time” • Physicians • “…with pharmacy students the process of Med Rec instantly improved and greatly advanced the quality and safety of care for patients...” • Pharmacy Technicians • Provides direct patient care connection • Professional development, confidence, respect • Pharmacists • Expands the scope of influence and respect of the profession to be part of “the solution” • Allows the pharmacist to go beyond the bench and provide direct patient care

30. Future HMV Program Opportunities • Implementation of pharmacy Pre-Op patient HMV review • Chief of Emergency Medicine requested that the Pharmacy Tech/Pharmacist be relocated to the central nursing station in the ED • Discharge counseling • Program expansion to L+M main campus

31. Thank you! • Questions? • Contact info for Mark and Linda • mrogers@westerlyhospital.org • lbrocato@westerlyhospital.org