Objectives. Prevalence of Non-Adherence. Medications and Care Transitions. The Cost of Readmissions. The Pharmacist s Role in Improving Care 4/22/2015

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1 MEDS TO BEDS: DELIVERING REDUCED READMISSIONS, LOWER COSTS, AND IMPROVED QUALITY Laura S. Carr PharmD, Senior Attending Pharmacist, Transitional Care Massachusetts General Hospital Ed Cohen, PharmD, FAPhA Clinical Director, Health Outcomes Field Team Walgreens Objectives Describe medication-related gaps in care associated with hospital admissions and readmissions. Explain how pharmacist involvement during transitions of care benefits patients. Identify opportunities for health systems to positively impact readmission rates through partnerships with community or outpatient hospital pharmacies. The Cost of Readmissions 18% of all Medicare hospitalizations are 30- day re-hospitalizations Rate is > 20% for certain high risk populations 76% of Medicare re-hospitalizations were potentially preventable Costing $13 billion annually which may be unnecessary Findings led to changes in reimbursement and penalties for hospitals with high readmission rates Medications and Care Transitions Adverse events occur in nearly 20% of patients discharged from the hospital to home, 66% of these are drug-related 70% of the emergency hospitalizations among seniors were attributed to ADEs from high risk medications Patients with medication discrepancies at discharge had 30-day hospital readmission rate more than double that of patients without discrepancies Prevalence of Non-Adherence Up to 22% of adult patients do not fill their prescriptions after hospital discharge Up to 25% of prescriptions are not filled, when children are discharged from the hospital with a prescription Only 73% of post-ami patients filled discharge prescriptions within 7 days post discharge The Pharmacist s Role in Improving Care Pharmacist participation in care rounds decreases preventable Adverse Drug Events (ADEs) by 66% Medication review by a pharmacist at discharge reduces preventable ADEs in the 30 days post discharge period Counseling by a pharmacist reduces medication discrepancies and improves adherence at 2 weeks and 3 months post discharge 1

2 Massachusetts General Hospital (MGH) Hospital Services 1,000 Bed Hospital 3 rd oldest general hospital in the US, the largest in New England Teaching site for Harvard Medical School Approximately 50,000 discharges each year Average of 137 discharges a day MGH Outpatient Fills 600 prescriptions daily 7 days a week 9-5:30 M-F, reduced hours on weekends Care Transitions at MGH MGH s STAAR Findings Launched in 2009, the goal of the STate Action on Avoidable Rehospitalizations (STAAR) was to improve transitions in care and reduce hospital readmissions by building multidisciplinary teams to implement process improvements MGH Pharmacist Interventions for high risk patients at discharge: Medication Reconciliation Medication Review Medication Access Patient Counseling On average, patients going home at discharge 15 medications on their discharge care plan 6 changes to the pre-admission medication regimen 85% needed prescriptions to be filled 35% had medication related issues of clinical significance Pharmacist Pre-discharge interventions suggest a reduction in readmission rates 16% vs. 27% (p=0.55) Medication Related Issues Found Recommendations to Expand TOC Services Incomplete medication reconciliation Sub-optimal medication regimens Vague or conflicting discharge instructions Medication access issues Confusion or limited understanding of discharge medication plan Inpatient Pharmacists o Reconcile medications at admission and discharge o Proactively address problems o Facilitate communication with the care team o Optimize therapy Outpatient Pharmacists o Improve medication access for patients o Add convenience by filling prescriptions prior to discharge o Increase prescription volume and revenue Extenders o Deliver medications bedside o Assist pharmacists to streamline process o Improve patient satisfaction with care Hospital Leadership o Collaborate on quality improvement initiatives o Track the impact pharmacy has on quality measures o HCAHPS Scores o Readmission Rates o LOS 12 2

3 Goals of Meds to Beds Service Meds to Beds MGH s Bedside Delivery Service Improve patient care and prevent adverse drug events by optimizing medication regimens and resolving discrepancies Improve patient access to discharge prescriptions Improve the patient experience and satisfaction with care Increase discharge prescription capture and revenue to support resources for hospital-wide implementation MGH s Meds to Beds Service Meds to Beds Impact to Care Inpatient Pharmacist reviews and reconciles medications Patient is being discharged home with new prescriptions Inpatient Pharmacist counsels the patient at bedside Resolving Medication Reconciliation Discrepancies Optimizing Medication Regimens Changing dose or formulations, minimizing prescriptions Outpatient Pharmacist identifies access issues and fills prescriptions Extender delivers medications to the patient and collect co-pays Proactively Addressing Access Issues Prior authorizations and high cost meds Strengthening Patient Education and Understanding U500 i li I ill j t h t I h t h Other Early Findings ASHP/APHA Best Practices Patients are happy with the service Care Teams find the service very valuable Discharge prescription volume has increased Common Barriers Highlighted and Elements for Programs Success Reduced medication-related problems Lowered readmission rate Decreased average length of stay Increased patient satisfaction and HCAHPS scores Increased revenue through increased prescription capture 3

4 Walgreens services that help reduce costs, improve clinical outcomes and increase patient satisfaction Community Services Value Based Benefit Design Specialty Diabetes New to Therapy Interventions WellTransitions Health Systems Walgreens offers a broad range of services that are designed to address specific clinical and patient needs Specialized Pharmacies Innovative Patient Adherence Programs Healthcare Clinic Central Specialty Retail Infusion Services 20 Walgreens Healthcare Offering Well Experience: Transforming the Patient Experience Medication Management o MTM o Specialized Pharmacies o New to Therapy Interventions o Adherence Management o Specialty Quality Improvement o Gap Closure at Retail Pharmacies o Immunizations o Health Testing o Site of Service Optimization Care Coordination o MedGap Analysis o WellTransitions o Bedside Delivery o BDM o 340(b) Services Primary Care Extension o HealthCare Clinics o Infusion and Respiratory o Digital Health Programs o Patient Messaging o Patient Outreach Analytics/Reporting Patient Engagement Connectivity Bedside Delivery vs. Well Transitions WellTransitions Collaboration in Patient Care Bedside Delivery BSD Technician staffed* to coordinate prescription delivery Deliver Rx s to discharge patients who opt in and RPh to counsel 48 hour check-up call No Extra Fee to Hospital/Patient Focus: Increase HCAHPS Scores *BSD technician hours vary Well Transitions Review medication history upon admission Fill & align medications and perform medication reconciliation Bedside Delivery 48 hours RPh call - complete medication review 10 day RPh call* 25 day RPh call* Reimbursed by hospital/ patient (addition to rx s filled) Focus: Reduce Readmission Rates *RPh call from the call center 24 4

5 WellTransitions Strategic Vision Bridging the care gap with community integration Redefining role of the pharmacist Intervention based care model Collaboration efforts with interdisciplinary healthcare teams Increasing access and extending care through 8,000 community locations Enhanced Functions: Bridging the Gap Patient Population: Target high-risk, complex patients in conjunction with hospital or health system Focus on disease states most commonly associated with readmissions Clinical Collaboration: Conduct patient follow-up after discharge to ensure PCP visit, elevate medication adherence Key point of integration focused on the value of a patient s relationship with a community pharmacist Comprehensive Reporting and Performance Tracking: Analyze trends in avoidable readmissions, patient satisfaction and operational procedures Identify gaps in care, collaborate with hospital discharge team for process improvement WellTransitions Functional Strategic Benefits Hospital Focused Capabilities of WellTransitions Functions/Features Strategic Benefits Medication History Information is clearly presented and organized by newest date Timely return of information Provides both PBM and pharmacy fill data Reduces time spent validating patient medication history More complete than hospital EMR provides PBM data only Returns up to 70% of both national and local plan data Medication Delivery Convenient access to medications Offer of initial counsel prior to discharge Drives patient satisfaction Clinical Pharmacists Raises health awareness Promotes care plan as written Encourages medical home Risk Alerts Patient behavior can be influenced at time of risk Communication for collaborative care Outcomes Reporting Provides program results to reduce cost of care Effectively manage chronic patients and identify gaps in care 8,000 Points of Care Community based collaborative care Scalable solutions for most health systems WellTransitions Capabilities Proactive approach to patient care and complement to other intervention initiatives and activities Web based system utilizes data feed extraction from hospital ADT system to identify eligible patients upon admission Post discharge clinical calls are based on pharmacist review of discharge medication list with patient Matched with Hospital Objectives Reducing preventable readmissions Early assessment of high risk patients Support of physician based care plan Bedside delivery of medications Increase patient satisfaction/hcahps scores Follow-up calls reinforce patient self-care, Coordinate care with community providers including medication education and ensuring compliance with physician/specialists appointments Benefits Beyond Reduction in Readmissions Health System Expertise of pharmacists skilled in medication review and complex therapies Assists in providing medication history for validation by health system Improves health system discharge process Patient Ensures patient follow-up with proper medical providers Raises health awareness and optimizes community healthcare support system Decreases medication complications 29 WellTransitions Outcomes and Results 5

6 Walgreens WellTransitions Program for medication adherence has earned the exclusive endorsement of the American Hospital Association WellTransitions Retrospective Study Methods AHA Solutions, Inc. selected Walgreens WellTransitions program for: Leadership in assisting hospitals in reducing readmission rates Improving patients medication adherence post-discharge AHA Solutions awards the AHA endorsement to a product/service it believes best addresses a specific challenge for most member hospitals. Walgreens WellTransitions program for medication adherence has earned the exclusive endorsement of the American Hospital Association. The American Hospital Association Awards exclusive endorsement to Walgreens WellTransitions Program for medication adherence [press release]. Deerfield, IL: Walgreen Co.; September 16, Research examined 744 matched pairs of WellTransitions patients and non-patients in a retrospective case comparison study to evaluate the effectiveness of the program 12 month retrospective case comparison cohort study using propensity score matching Patients enrolled in this pharmacistled care transition program were matched with similar patients in terms of age, gender, disease state, illness severity, comorbidities, and other pertinent predictors of hospital readmission Primary outcome variable will be 30- day hospital readmission rates Covariate Characteristics Admitted from home CMS targeted condition (AMI, HF, PN) Discharged to home Minority Public Insurance Number of diagnosis Length of stay Age Unique medication count Presented at the American Pharmacists Association (APhA) Annual Meeting & Exposition, Orlando, FL, March 28-31, 2014 Research study conducted by Bobby Clark, PhD, MSPharm, MHA, MS, MA WellTransitions impact on readmissions Improve Patient Satisfaction WellTransitions patients were 46% less likely to be readmitted unexpectedly within 30 days of hospital discharge.* 1 Non-CMS targeted conditions: 26% less likely to be readmitted CMS targeted conditions: 55% less likely to be readmitted Age <65: 44% less likely to be readmitted Age 65: 48% less likely to be readmitted Impact of WellTransitions on risk of readmissions Total Non-CMS CMS Age <65 Age 65 patients targeted targeted conditions conditions WellTransitions patient sample group Relative risk Percent reduction in relative risk *Walgreens study conducted January 2013 through December 2013, with 744 matched pairs selected from four hospitals (744 WellTransitions patients and 744 non-welltransitions patients). 1. Clark B, Hou J, Cohen E, Kwasigroch D, Singer S. Reducing preventable hospital readmission through a pharmacist-led care transition intervention. Poster presented at: American Pharmacist Association (APhA) Annual Meeting; March 28-31, 2014; Orlando, FL. Relative risk % % % Relative risk = (risk of readmission in WellTransitions cohort)/(risk of readmission in usual care cohort) Reduction in risk = risk of readmission in usual care cohort relative risk Relative risk of 1.0 indicates there is no dif ference in risk between the two groups being compared % % 0.52 Walgreens worked with DeKalb Medical in Atlanta, Georgia to implement a medication adherence care transitions program in January 2011.* 1 Within 90 days, there was a 26 percent relative increase in the HCAHPS communication about medicines domain score 2 HCAHPS Score 65% 60% 55% 50% 45% Improves Patient Satisfaction 2 50% at 1 st percentile *This program was not the complete WellTransitions program but rather an early intervention collaboration between Walgreens and DeKalb Medical. 1. Duncan I, Healthcare Financial Management Association. DeKalb s comprehensive medication compliance approach cuts readmissions. Published February 28, Accessed November 18, Stemphiak M. Bedside delivery: an easier pill to swallow. Hosp Health Netw. 2012;86(8):16, % at 65 th percentile 0 days 90 days Time Period WellTransitions : Bridging the Gap, Coordinating Care In Summary Health System Walgreens Health Navigator Platform Community Health Providers Offered as part of patient care services If necessary, identifies and targets high risk patients Integrated into daily workflow Provides feedback and is an advocate of benefits Medication history provided at admission, medication review, alignment Ease of transition, follows patient in own environment, reviews medication instructions Documents any change in therapy, alerts health system and community provider to any issues Determines patient eligibility based on pre-select health criteria Collects and maintains data points (medical and pharmacy) Pushes tasks and communications based on role/responsibility and severity Integrates data points EMR, ADT, alerts Integrated into care continuum with two-way communications Educated on health status of patient Enhances patient/provider relationship with full view of medication history Pharmacist involvement during transitions benefits patients by closing many of the medication-related gaps in care. Opportunities exists for health systems to positively impact readmission rates through partnerships with either community or outpatient hospital pharmacies. 35 6

7 Thank You! References Any Questions? 1.Forster AJ, Murff HJ, Peterson JF et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3): Budnitz DS, Lovegrove MC, Shehab A et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N Engl J Med 2011; 365: Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165: Kripalani S, Price M, Vigil V, Epstein KR. Frequency and predictors of prescription-related issues after hospital discharge. J Hosp Med. 2008;3(1): Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282: Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166: Al-Rashed SA, Wright DJ, Roebuck N, Sunter W, Chrystyn H. The value of inpatient pharmaceutical counseling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002;54: \ 8. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165: AHRQ Patient Safety Network - Medication Reconciliation. Date Accessed: February 12, 2014,