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Fresh Tactics: Utilizing Pharmacy to control costs, improve quality, and decrease readmissions

Fresh Tactics: Utilizing Pharmacy to control costs, improve quality, and decrease readmissions. Joseph Dula, Pharm.D ., BCPS Regional Director of Clinical Services Pharmacy Systems, Inc. Objectives. At the completion of this program, the participant will be able to:

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Fresh Tactics: Utilizing Pharmacy to control costs, improve quality, and decrease readmissions

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  1. Fresh Tactics: Utilizing Pharmacy to control costs, improve quality, and decrease readmissions Joseph Dula, Pharm.D., BCPS Regional Director of Clinical Services Pharmacy Systems, Inc.

  2. Objectives At the completion of this program, the participant will be able to: • Communicate the value and impact of pharmacist involvement on cost of treatment and patient safety. • Describe the need for pharmacist involvement in the medication reconciliation process and the resulting improvement in patient safety and satisfaction. • Explain the role of the pharmacist in promoting medication adherence, and the potential impact on patient survey (HCAHPS) scores and readmission rates.

  3. The average Medicare patient with multiple chronic illness: • Receives care from 13 physicians • Fills 50 prescriptions annually • Accounts for 76% of admits • Is 100x more likely to have a preventable hospitalization • The Patient Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Patient-Centered Primary Care Collaborative. http://www.pcpcc.net

  4. Importance of Adherence Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43:521-530. Ho PM, Magid DJ, Shetterly SM, et al. Medication non-adherence is associated with a broad range of adverse outcomes in patients with coronary artery disease. Am Heart J. 2008;155(4):772–779. Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication non-adherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166(17):1836–1841

  5. Consequences of Non-adherence • A study of diabetes patients revealed: • More than 20% of studied patients non-adherent • ↑ all-cause mortality (4% vs. 5.9%) • ↑ all-cause hospitalization (19.2% vs. 23.2%) • ↑ LDL levels (85.5 vs. 98.2) • ↑ hA1C (7.7 vs. 8.1) • → Blood pressure (131.4/74.2 vs. 132.1/75.8) Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication non-adherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166(17):1836–1841

  6. Medication Adherence Benefits • A 25% increase in medication adherent days was positively correlated with improvement in clinical condition • The magnitude in decrease in hospitalization and mortality was more than could be explained by adherence • Interviewing suggests medication adherence is correlated with indirect self-care behaviors Coronary Drug Research Project Research Group. Influence of adherence to treatment and response of cholesterol on mortality in the Coronary Drug Project Group. N Engl J Med. 1980;303:1038-1041.

  7. Peripheral Benefits of Adherence • Increasing medication adherence indirectly increases other behaviors which may further reduce hospitalization • Acceptance of lifestyle modification recommendations • Conversely, medication non-adherence is correlated with a decrease in indirect measures • Decreased cognition, depression, missed appts • Associated with poor outcomes and increased cost World Health Organization. Adherence to long-term therapies: evidence for action. 2003. http://www.who.int/chronic_conditions/en/adherence_report.pdf. Accessed 10/10/11

  8. Active Learning – Question #1 Which of the following is associated with medication non-adherence? • Increased hospitalization • Increased adverse drug reactions • Increased morbidity & mortality • All of the above

  9. Adherence Barriers • Social and economic factors • Health care team/system poorly equipped with strategies to increase adherence • Disease characteristics • Complex therapies • Patient-related factors • Adverse effects World Health Organization. Adherence to long-term therapies: evidence for action. 2003. http://www.who.int/chronic_conditions/en/adherence_report.pdf. Accessed 10/10/11

  10. Role of the Pharmacist • Pharmacists are uniquely qualified to respond to the barriers of non-adherence • Trained in adherence strategies • Aware of disease related conditions which may be a barrier to adherence • May suggest consolidation of therapies upon reconciliation • Conversation with patient to assess readiness Weinberger M, Murray MD, Marrero DG, Brewer N, Lykens M, Harris LE, et al. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA. 2002;288:1594-602.

  11. The Pharmacist’s Role in Adherence Weinberger M, Murray MD, Marrero DG, Brewer N, Lykens M, Harris LE, et al. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA. 2002;288:1594-602. Hope C, Overhage JM, Seger A, Teal E, Mills V, Fiskio J, et al. A tiered approach is more cost effective than traditional pharmacist-based review for classifying computer-detected signals as adverse drug events. J Biomed Inform. 2003;36:92-8.

  12. Initiation of Therapy • Initiation is often where non-adherence starts • Misunderstanding of side effects or benefits • Cost (prescriptions never filled) • Additional medication burden • Pharmacists during discharge counseling are able to warn of transient initial side effects • Leading cause of spontaneous discontinuation Wang PS, Gilman SE, Guardino M, Christiana JM, Morselli PL, Mickelson K, et al. Initiation of and adherence to treatment for mental disorders: examination of patient advocate group members in 11 countries. Med Care 2000;38:926–36.

  13. Pill Burden and Adherence • Decreasing the amount of pills may or may not increase adherence • Symptomatic patients perceive higher risk of non-adherence than asymptomatic patients • Decreasing dose frequency is most positively correlated with adherence • Pharmacists may be able to suggest a medication on discharge which better “fits” a patient’s lifestyle and expectations World Health Organization. Adherence to long-term therapies: evidence for action. 2003. http://www.who.int/chronic_conditions/en/adherence_report.pdf. Accessed 10/10/11

  14. Gattis WA, Hasselblad V, Whellan DJ, O’Connor CM. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) Study. Arch Intern Med. 1999;159:1939-45. Tsuyuki RT, Olson KL, Dubyk AM, Schindel TJ, Johnson JA. Effect of community pharmacist intervention on cholesterol levels in patients at high risk of cardiovascular events: the Second Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP-plus). Am J Med. 2004;116:130-3. Bouvy ML, Heerdink ER, Urquhart J, Grobbee DE, Hoes AW, Leufkens HG, et al. Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study. J Card Fail. 2003;9:404-11. Goodyer LI, Miskelly F, Milligan P. Does encouraging good compliance improve patients’ clinical condition in heart failure? Br J ClinPract. 1995;49: 173-6.

  15. Techniques to Consider • Solicit Complete Medication History • Prescription medications • Over-the-counter (OTC) drugs • Vitamins • Complete dosing information for each drug • Name of the medication • Strength • Formulations (e.g., XR, CD) • Herbals • Nutraceuticals/Health supplements • Respiratory therapy-related (inhalers) • Route of administration • Frequency • Last dose taken

  16. Techniques to Consider • Medication History Prompts • Use both open-ended questions and close-ended questions • If patient is unable to participate, other sources may be used • Don’t forget about compliance • Good Medication History • Identifies patient’s needs • Explores the patient’s perspective of illness and its treatment (needs and concerns) • Assess medication management ability

  17. Impact of Readmissions

  18. Impact of Readmissions • Readmission is a re-hospitalization in a 30-day period with a diagnosis related to the original reason for admission • Readmissions accounted for $17.4 billion in Medicare spending in 2004 • 1 in 5 Medicare hospitalizations are readmitted or have an adverse event in 30 days • 66% are preventable drug events

  19. Causes of Readmissions • http://www.ihi.org/offerings/Initiatives/STAAR/Documents/STAAR%20Diagnostic%20Tool.pdf

  20. Active Learning – Question #2 Which of the following is NOT considered a “patient-related failure” leading to readmission, as reported by the Institute for Healthcare Improvement? • Failure to recognize worsening clinical status • Multiple drugs exceeding the patient’s ability to manage • Non-adherence to self-care • Inadequate or illegible discharge instructions

  21. Increasing in Difficulty… The CEO’s Guide for Value-Based Purchasing. Ohio Hospital Association Webinar August 2012.

  22. …and Financial Impact • All measures mentioned are familiar, the spotlight is now on compliance • All data is visible to the general public • Application of financial incentive to performance • Result is increased awareness to administration =

  23. Clinical Process of Care Measures

  24. The Impact of a Pharmacist

  25. Success Stories • Pharmacists targeting HCAHPS • Prior to implementation, Hospital scored below state and national averages • Hospital is now above both averages and top decile for Central Ohio hospitals

  26. Success Stories Truman Medical Centers

  27. Success Stories

  28. Measuring Outcomes Clinical Changes in disease management such as labs, physical assessment, and disease progression. Humanistic Patient symptoms, quality of life, and satisfaction such as activities of daily living, adherence, and exercise. Economic Reduced medication use, ER or hospitalizations avoided, and productivity measures (missed/unproductive days)

  29. Affecting Care Transitions: Inpatient Program

  30. Hospital Demographics • Berger Health System – Circleville, Ohio • Average monthly discharges = 230 patients • 2011 recipient of OHA Hospital Safety Award • 2012 Joint Commission Top Performer on Key Quality Measures • The Berger Way • Attitude of Excellence • Commitment to Compassionate Care • Spirit of Pride and Teamwork

  31. Pharmacy Operating Statistics • Berger Health System Pharmacy Department • Average doses dispensed per month = 31,000 • Documenting >1,000 clinical interventions monthly • Hours of Operation • 0700 to 2100 (M-F) and 0700 to 1630 (Sa, Su, Hol) • Hospital commitment to progressive services and investment in technology and automation

  32. A Commitment to Quality New Clinical Support A clinical support pharmacist (CSP) position is added to the staffing model to deliver improved quality of care and ensure appropriate medication therapy. Focus on Discharges The personnel commitment to the clinical program is enhanced and the CSP is charged with participating in the improvement of the patient counseling and discharge process. Partnership in Community Berger Health System signs agreements with local community pharmacies to foster continuity of care between the inpatient and outpatient pharmacies.

  33. harmacists P A ffecting C are T ransitions

  34. Implementing PACT Model

  35. Tools to Assist Implementation

  36. Discharge order entered Pharmacist accesses EMR Pharmacist reconciles discrepancies Pharmacist speaks with patient Encounter documented

  37. PACT Model: Efficiency Since implementation in July 2011, pharmacists documented 1,400+ patient counseling sessions.

  38. Medication Reconciliation Figure 1: Medication-Related Interventions (n=479) Documented by Clinical Support Pharmacist over a nineteen (19) month period [July 2011 through January 2013]

  39. Medication Reconciliation • Pharmacist participation improved safety overall • Identified and documented 479 med related problems • Adverse Drug Event frequently identified (19%) • Discharge composite (47%) • Incorrect drug on discharge papers • Incorrect sig/strength on discharge papers • Drug Omission on discharge papers • Adding the pharmacist as the final check improved the final medication discharge list

  40. Active Learning – Question #3 True or False – Discharge issues (incorrect drug, incorrect dose, drug omitted) are potential areas of intervention that can be corrected by pharmacist review. • True • False

  41. Financial Correlation to Interventions • Pharmacist participation improved safety overall • Assigned “value” in literature is very broad • Can illustrate workload or time (vs. doses dispensed) • AHRQ MATCH value of $4,800 per preventable ADE • Identification of ADEs alone = $280,280 in first 8 months • Important to note as cost avoidance

  42. Tracking Readmissions The retrospective chart review to establish a control group (patients in this time period that were not counseled) is ongoing and will be made available when complete.

  43. Achievement by Comparison All diagnosis State Average provided by Ohio Hospital Association from The Commonwealth Fund State Scorecard, 2009. DRG based State averages obtained from Community-Based Care Transitions Project on August 8, 2012. Accessible at https://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/CCTP_FourthQuartileHospsbyState.pdf Hospital and National averages (CMS patients, any hospital) obtained from Hospital Compare website, Accessed September 19, 2012.

  44. Patient Satisfaction • Added questions to internal phone follow-up process • Did a pharmacist/nurse review med list with you prior to discharge? • If yes, how was the information helpful to you? • Use of MR # to correlate with consultation • “helped her understand exactly what to take especially with the new prescriptions” • “helpful because of all of the changes” • “review of medications provided overall picture” • “information at discharge can be overwhelming”

  45. Selecting Patients for Referral • Currently referring patients to both pharmacies • Driven by patient preference at this time • Patients with select disease states targeted for purposes of the pilot / “ramp up”

  46. Affecting Care Transitions: Referral to Outpatient

  47. PACT Model: MTM Collaboration • Transitions of Care Emphasis in Community • SchieberFamily Pharmacy & Circleville Apothecary • Community pharmacists to conduct MTM session with targeted patients • Process discharged prescriptions through 340b program • Access information from inpatient charting system to help guide evaluation and counseling

  48. Access to Inpatient Chart Record • Worked with Compliance Office and outpatient pharmacists required to sign an EMR acceptable use policy (in addition to business associate agreement) • Hospital IT Department provided individual login information and instructions for access • Community pharmacist has visibility to specific patient record through the provider portal

  49. 2013 Program Goals

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