Rita Shane, Pharm.D., FASHP, FCSHP Chief Pharmacy Officer Cedars-Sinai Medical Center Asst. Dean, Clinical Pharmacy, UCSF School of Pharmacy

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1 Rita Shane, Pharm.D., FASHP, FCSHP Chief Pharmacy Officer Cedars-Sinai Medical Center Asst. Dean, Clinical Pharmacy, UCSF School of Pharmacy

2 Describe the transformation of health-systems in response to changes in the healthcare landscape Cite recent evidence supporting advanced roles for pharmacists and technicians Describe the pharmacist s role in ensuring safe transitions of care Identify essential aspects of managing complex, chronic diseases

3 Traditional Acute Care Focus Episode-based Medical care Treatment of acute conditions Admissions Medication orders Outpatient revenue Oral medications mainstay for chronic diseases Health and Wellness Focus Patient-centered care Team-based care Preventing readmissions Transitions of care Patient s medication list Outpatient costs Biologics infusions, injections and therapeutic advances for chronic diseases

4 Principles Supporting Dynamic Clinical Care Teams- American College of Physicians Position Statement, Sept 2013 Shift from clinicians practicing independently to groups of MDs, RNs, PAs, clinical pharmacists, social workers and other clinicians to better meet patient needs Nimble, adaptable partnerships to encourage teamwork, collaboration and smooth transitions of responsibility Matching pt with team member(s) most qualified to deliver care Collaborative team models needed to address MD shortages. Doherty RB, Crowley RA. Ann Intern Med 2013; 159

5 Team-Based Care Initiatives Transitions of Care Programs to reduce readmissions BOOST (better outcomes for older adults through transitions of care) focusing on the elderly Project RED (re-engineering discharge) Medical Homes: integrating pharmacists into teams Why Pharmacists Belong in the Medical Home, 2010 Health Affairs Iowa Family Medicine: Significant improvement in BP control Asheville Project: Significant improvement in HA1c and BP control and reduced costs 1. m&contentid= Smith MA, Bates DW, Bodenheimer T, et al. Health Affairs. 2010; 29(5):

6 Center for Medicare and Medicaid Services (CMS) expansion of the definition of medical staff to include pharmacists along with other health professionals, 2012 Pharmacists with advanced clinical knowledge collaborating with physicians, nurses and other members of the team improve medication outcomes, Regina Benjamin, U.S. Surgeon General 2011 report to the U.S. Surgeon General: U.S. Pharmacists Effect as Team Members on Patient Care National efforts to achieve provider status; recently granted in California accessed 7/28/13. accessed 9/8/13.

7 Smith M, Bates DW, et al. Health Affairs. 2013; 32(11):

8 Medications are cornerstone for chronic disease mgmt MDs don t have time to take a complete medication history MDs spend an average of 49 seconds discussing a new prescription during an office visit Poor communication at care transitions contributed to 50% of all hospital-related medication errors and 20% of adverse drug events Smith M, Bates DW, et al. Health Affairs. 2013; 32(11):

9 Up to 67% of patients admitted to the hospital have unintended medication discrepancies Review of 12 studies demonstrated that 45% of patients had at least 1 clinically significant discrepancy Nearly 23% of pts discharged have an adverse event of which 72% are medication-related 51% of pts had at least 1 clinically important medication error during the first 30 days post-discharge; approx 13% resulted in ED visit or readmission Clinicians rely on the information and prescribe medications that are listed even though the information may be inaccurate Kwan, JL; Lo, L. Medication Reconciliation During Transitions of Care as a Patient Safety Strategy. Ann Intern Med. 2013;158:

10 Errors introduced in any of these settings can become hardwired into the pt record MD Office/ Outpatient Settings Certified medical assistants Physicians Community pharmacies Patients ED/Hospital Nurses Physicians Pharmacists Pharmacy technicians Pharmacy residents, students Home/Skilled Nursing Facility Nurses

11 Ensuring Safe Medication Transitions

12 Medications Prior to Admit Medication List AND New Orders Drug Indication Dose Route Frequency Dosage form Duration Patient Characteristics Age (pediatrics/ geriatrics) Gender Height/Weight Allergies Kidney/Liver Function Current labs Previous admissions Current Medication List Drug-drug interactions Drug-disease interactions Drug-food interactions Duplicate therapy Contraindications Medications needed but not prescribed Monitoring requirements Special Considerations High risk patients or therapies such as: Chemotherapy Pediatrics ICU Blood thinners Antibiotics

13 Novant Health's Safe Med Program Post-discharge follow up of high risk pts by pharmacists including medication reconciliation, education and f/u with MDs 30-day readmission rate from 13.1 to 6%; 60-day rate from 7.7 to 2.7 % Hennepin County Medical Center Program for Patients Discharged to Skilled Nursing Homes Team approach to medication reconciliation and medication therapy management visits by pharmacists for high risk pts 50% in readmission rate from 10.2% to 5.4%; results sustained over 4 years No medication errors compared to 1 error in 70% of pts at baselines accessed 12/15/13 accessed 12/1/13.

14 ED PTA Medication Reconciliation Inpatient PTA Medication Reconciliation Skilled Nursing Facilities PTA medication reconciliation for highrisk populations Congestive Heart Failure Ensuring Accurate Medication Handoffs Continuum of care Hospitalist Program PTA: Prior to Admission

15 Objective: Evaluation of Medication List, Adherence, and Literacy Identify High-Risk Patients Validate Medication List Assess Adherence and Literacy Educate Patient Notify MD of Drug-Related Problems and Recommendations Post- Discharge Follow-Up within 72 Hr -Med Rec -Adherence & Literacy Reinforcement -Education Additional Calls up to 30 Days Based on Risk Assessment

16 Adherence 1. Do you ever forget to take your medicine? 2. Are you careless at times about taking your medicine? 3. When you feel better do you sometimes stop taking your medicine? 4. Sometimes if you feel worse when you take the medicine, do you stop taking it? Literacy 1. Name of medicine? 2. Indication of medicine? 3. Strength of medicine? 4. Frequency/directions of medicine? Cutler, DM; Everett, W. Thinking Outside the Pillbox Medication Adherence as a Priority for Health Care Reform. N Engl J Med 2010; 362:

17 Pts with low adherence and literacy who received postdischarge follow up had a 14% readmission rate compared to 42% who did not receive follow up 2013 Enhanced Care Program for skilled nursing facility (SNF) patients 25% 30-day readmission Post-discharge medication reconciliation completed for 620 pts 455 serious/significant drug-related problems identified in 39% of patients

18 Reason for Admission 90 y/o F w/ Afib and CHF. 89 y/o F w/ Type 2 DM and DVT. 79 y/o M w/ ESRD w/ S. aureus bacteremia. Drug-Related Problems Identified Post- Discharge and Pharmacist Intervention Issue discovered: Pt discharged on supratherapeutic home warfarin dose. Intervention: Recommended inpt dose and checking INR ASAP. Issue discovered: Pt discharged on Xareltro BID but was receiving daily at SNF. Erroneous Amaryl and Lantus continued. Intervention: Recommended to change Xareltro to BID w/ meals, and after 3 wks, 20mg PO daily. D/c Amaryl and Lantus. Issue discovered: No order was given to dialysis center for vancomycin. Intervention: Ensured vancomycin administration occurred. 18 Adverse Outcome Prevented Avoided increased risk of bleeding d/t 3-fold dosing error. Avoided morbidity and possible mortality due to hypoglycemia and progression of DVT to potential PE. Avoided progression of bacteremia.

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20 High cost chronic disease Targeted cellular therapies add costs and require special knowledge and skills Oral chemotherapy agents are transforming cancer care and require close follow up to manage side effects, ensure adherence and prevent drug interactions Lack of health literacy is a major challenge for cancer patients

21 Oncology pharmacy specialists participate in teambased care Episode payment being piloted Health-systems are acquiring oncology practices in response to reduced chemotherapy margins and to advance integration of care Oncology medical home models of care Pain management, palliative care and end of life management are patient care and economic priorities

22 Used to treat complex, chronic diseases such as multiple sclerosis, cancer, Crohn s disease, rheumatoid arthritis and orphan diseases Expensive: $20,000 to >$200,000/yr Generally injectable medications which need to be infused but can also include oral medications Represent 1/3 of national total drug costs $75.8 billion in 2010 >20% growth/year 1. Owens GM. New FDA approvals for 2013: a 15 year high. American Health and Drug Benefits.2013; 6(3): White Paper. Excelera Specialty Pharmacy Network ExceleraRX, LL 3. percent-of-all-drug-costs-by html. 22

23 907 drugs in biotech pipeline Anticipate that by 2017 will account for 50% of a health plan s pharmaceutical expenses Represents 1-5% of population Patients generally have other chronic conditions Require ongoing monitoring and patient follow up to ensure adherence and prevent adverse events

24 Multiple medications with risk for adverse events Multiple pharmacies and locations to obtain/administer medications Patient medication literacy, adherence and financial burden Essential patient care components: Complete and accurate medication lists Comprehensive patient and medication evaluation Determining optimal location for medication administration Patient education, ongoing follow-up and coordination of medications

25 Medication Ordered Order for toclizumab for rheumatoid arthritis at 12.7 mg/kg; however dose should have been 8mg/kg Order for nataluzimab; medical record review revealed previous anaphylactic (life threatening allergy) reaction Order for infliximab in patient with order for a herpes zoster (live shingles) vaccine Order for infliximab with potential tuberculosis based on PPD results Outcome Avoided Continuation of dose at 60% above manufacturer s maximum dose recommendations; risk of severe, life-threatening infections Potentially life-threatening allergic reaction Potential development of active shingle infection Potential exacerbation of infection and employee exposure

26 Pharmacist across all settings should ensure the accuracy of the medication list Pharmacists across the continuum of care should be actively engaged in ensuring handoffs occur especially for high risk patients The pharmacist should be the member of the team who is responsible for ensuring medication literacy and adherence

27 Pharmacists should be the provider responsible for ensuring the safety and effectiveness of the patient s pharmacotherapy plan Evaluation and simplification of chronic medication regimens should be a priority focus area At a minimum, all patients should have an annual review of their medication lists by a pharmacist

28 Practicing at the top of our license* Being Bold Pushing Traditional Boundaries Recognition as an essential team member Patient demand for pharmacistdirected medication management *ASHP Pharmacy Practice Model Summit