Future of Clinical Pharmacy Practice in Rural Health

1. Lisa Anne Boothby, PharmD, BCPS Director of Pharmacy, Dukes Memorial Hospital Future of Clinical Pharmacy Practice in Rural Health

2. OBJECTIVES • Demonstrate the value of clinical pharmacy services to decrease 30-day readmission rates • Outline the pharmacist’s role in reducing medical waste • Detail ethical issues associated with drug shortage management

3. PHARMACEUTICAL CARE • Clinical pharmacy services • Inpatient and outpatient settings • Improve patient outcomes

4. PHARMACISTS AS PROVIDERS • Patient Accountability and Affordable Care Act • Pharmacists are “other healthcare providers” • Social Security Act • Part B versus Part D • Three MTM billing codes • Private insurance reimbursement follows Smock N. Affordable Care Act Regards Pharmacists as Health Care Providers, Not Just Prescription Dispensers. Available at URL: http://www.pharmacytimes.com/publications/issue/2013/January2013/Affordable-Care-Act-Regards-Pharmacists-as-Health-Care-Providers-Not-Just-Prescription-Dispensers

5. WHERE IS THE REVENUE? • Capitated healthcare precede reimbursement • May decrease need for pharmacy billing • Share in savings once minimum achieved • Accountable care organizations • Not all hospitals have embraced • Pilot programs Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

6. ACCOUNTABLE CARE ORGANIZATION • Providersaccountable • Achieving quality • Reductions in rate of spending growth • Physician led with many payer arrangements • National Committee for Quality Assurance • Established ACO criteria • 7 categories with 4 levels Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

7. RURAL ACOs To reach critical mass • Incorporate multiple payers or multiple hospitals • Apply for a CMS wavier to include Medicaid patients Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

8. MEDICAL HOME MODEL • Patient centered medical homes • Led by physician • Include pharmacist, nurse and other health care practitioners • Treat patient with chronic conditions • Prevent adverse events and optimize therapy • Team ensures all health care needs are met Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

9. PHARMACIST ROLE Medical Home Models • Improve medication management • Preventing hospital readmissions • Decreases revenue in a traditional hospital budgetary model Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

10. AMBULATORY CARE FOCUS • Keep patients healthy and out of the hospital • VA collaborative practice model • Prescribing privileges • More than 20 years of success • Pharmacist credentialed providers

11. PHARMACY ROLE • Medication management • Preventing disease • Maintaining cardiovascular health • Preventing end organ damage • Medication compliance, adherence • Therapeutic drug monitoring • Supportive care

12. CLINICAL RESEARCH

13. PHYSICIAN-PHARMACIST TEAM Study Design • 1 month study at Mission Hospital • 735 bed community teaching hospital • Asheville, North Carolina • Pre-post design • 2 weeks normal routine • 2 weeks with clinical pharmacist Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

14. PHYSICIAN-PHARMACIST TEAM Pharmacist Role on Team • Drug information • Discharge counseling • Medication interventions • Medication reconciliation • Filling discharge prescriptions • Submit discharge summaries Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

15. PHYSICIAN-PHARMACIST TEAM Measurements • 15-day and 30-day readmission rates • Number of ED visits • Employee satisfaction surveys Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

16. PHYSICIAN-PHARMACIST TEAM • 33% vs. 17% readmission within 30 days • 11% vs. 2% readmission within 15 days • 9% vs. 4% ED visits within 30 days Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

17. DISCHARGE PHARMACIST • Prospective cohort • 729 patients over three months • Pharmacy medication reconciliation • 30-day readmission rate • Polypharmacy and readmission rate Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

18. READMISSION RATES Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

19. DISCHARGE PHARMACIST • Med reconciliation and counseling • Decreased 30-day readmission rate • 16.8% vs. 26%; p=0.006 • Polypharmacy • More than 5 scheduled medications • Associated with increased readmission rates Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

20. TRANSITIONS OF CARE

21. WELLTRANSITIONS • Walgreens program • Reduces readmissions • Pharmacists oversee medication regimens • Transitions of care Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012. http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions

22. WELLTRANSITIONS • Med review at admission and discharge • Bedside medication delivery • Counseling for patients and their caregivers • Regularly scheduled follow-up post discharge • 24-7 support for discharged patients • Ensure follow up with physician • Ensure appropriate self care • Marian General and Lutheran Hospital Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012. http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions

23. MEDICATION RECONCILIATION Survey of Pharmacy Perceptions • 11 pharmacists • Vanderbilt University • Brigham and Women’s Hospital • Medication reconciliation • Time consuming • Most important contribution • Improving care transitions • Correct the admission medication history Haynes KT, Oberne A, Kripalani S. Pharmacists’ recommendations to improve care transitions. Ann Pharmacother 2012;46(9):1152-1159.

24. IMPLICATIONS • Translation to a rural critical access hospital • Minimal resources • Decreased ED visits decreases admissions • Decreased revenue with traditional models • Next steps?

25. REDUCE READMISSION TOOLS TARGETING TRANSITIONS • Project BOOST: www.hospital-medicine.org • Project RED: www.projectred.org • STAAR initiative: www.ihi.org/STAAR

26. Demonstration Pilot Critical Access Hospital • Medication reconciliation process • Physician and nurse driven • 2 to 3 errors per each • Follow-up by pharmacy • Clarify and correct errors • Time intensive • Increased safety risk • Omissions • Delays and duplications

27. Demonstration Pilot Critical Access Hospital • Develop criteria for consultation • Greater than 10 scheduled medications • High-alert medications • Anticoagulants • Core-measure disease states

28. MEDICAL WASTE REDUCTION

29. PHARMACEUTICAL WASTE STREAMS • INCOMPATIBLE HAZARDOUS • WASTE • Aerosols • Inhalers • Oxidizers • Silver nitrate • SEWER • IV dextrose • Potassium • Saline • Sodium • Calcium • lactated ringers • magnesium • P-LISTED HAZARDOUS WASTE • Coumadin plus wrapper • Nicotine plus wrapper and peel • NON-HAZARDOUS RX WASTE • Antibiotics • Lidocaine • Pitocin • Heparin • HAZARDOUS WASTE • Insulin • Some vitamins and minerals • Phenylephrine CHEMO WASTE • REGULAR TRASH • Outside packaging • Empty items that once contained medication • Shipping packaging • Recycle paper, glass, plastic • SHARPS • Needles and broken ampoules • Empty syringes Smith CA. Managing Pharmaceutical Waste. Journal of the Pharmaceutical Society of Wisconsin 2002;17-22.

30. INPATIENT MEDICAL WASTE • Save money, prevent delays and omissions • Clinical pharmacists know formulary medications • Clinical pharmacists prevent non-formulary and not-available medication orders at admission • Formulary management policies/procedures • Therapeutic interchange programs • Evaluate PAR levels for expired drugs

31. OUTPATIENT MEDICAL WASTE • Outpatient prescribing practices • Polypharmacy • Lack of follow-up • Mail order pharmacies automatic renewals • Three month supplies • Compliance • Adherence • Persistence

32. MEDICAL WASTE Ethics and the Environment • Controlled substance regulation • Changes from DEA • Expected in future • Vendors • Stericycle, others … • Environmentally conscious disposal

33. DRUG SHORTAGES

34. DRUG SHORTAGES Minimize Waste • Therapeutic interchange • Drug classes • Pharmacodynamics of medications • Superior therapeutic alternatives • Evidence based medicine • Avoid grey market distributers

35. GREY MARKET • Receive emails for information only • Plan ahead • Keep adequate inventory levels • Medications dispensed daily • Accept small loss with expired medications • To stock adequate levels • Prevent drug shortages from reaching patient

36. DRUG SHORTAGES • Aminophylline • Sincalade • Nalbuphine • Dextrose 25% and 50% syringes • Furosemide IV • Metoclopramide IV • Fentanyl IV • Potassium phosphate IV

37. DRUG SHORTAGE RESOURCES

38. FDA REGULATION

39. PHARMACIST ROLE • Pharmacists vital part of the healthcare team • Pharmacotherapy experts • Explain how medications work in the body • Suggest therapeutic alternatives • Eliminate therapeutic duplications

40. PHARMACIST ROLE • Avoid polypharmacy • Teach common side effects • Action for severe side effects • Ethical stewardship • Medical and financial resources

41. PARADIGM SHIFT • PHARMACY COST CENTER

42. RURAL HEALTH RESEARCH • Collaboration • Rural health hospitals • Payers • Obtain grant money • Research • New practice models • Demonstrate added value

43. Lisa Anne Boothby, PharmD, BCPS Director of Pharmacy, Dukes Memorial Hospital Future of Clinical Pharmacy Practice in Rural Health