Adapting Practice to Keep Pace with Changes in Health Care. Change in Health Care. Professional Responsibilities?

Transcription

1 Accountable Care Innovations: Leading Medication Management Across the Continuum Adapting Practice to Keep Pace with Changes in Health Care Rick Couldry, M.S., FASHP University of Kansas Hospital Kansas City, Kansas Change in Health Care What will we do to manage changes in health care is not the question. The question is, How do we obtain the capacity to handle the pace of changes required to be successful? Professional Responsibilities? Task/process Outcomes Reactive cost management Proactive savings and revenue generation Adapting to change Anticipating change 117

2 Overview Present medication reconciliation project and outcomes metrics Discuss specialty pharmacy opportunities Provide leadership considerations throughout Medication Reconciliation (Med Rec) An operational process that reduces preventable adverse drug events that occur at transitional points of care due to discrepancies in the medication regimen Accomplished through support at admission, transfer, discharge Accurate documentation Clinical decision making Verification Communication to caregivers and patient Overview of Problem IOM Report: Preventing Medication Errors (2007) million preventable adverse drug events in U.S. Prescribing errors are a principal source of overall medication errors Incidence rates of 19 58% Estimated 46% of medication errors occur on admission or discharge when patient orders are placed study of Medicare claims data, Approximately 20% of hospitalized Medicare patients are readmitted within 30 days Cost: ~ $17 billion a year nationally 1 Committee on identifying and preventing medication errors; Lesar TS et al. JAMA. 1997; 277: Jancks SF et al. N Engl J Med. 2009; 360:

3 When leading change: Tell stories Facts are informative Emotions drive decision making Stories help people relate to facts and create an internal perspective on why the facts are important Why Med Rec? Patient Case May year-old man, multiple chronic conditions (ESRD, HTN, DM II, more) Inpatient RPh spoke to him about his home medications Wasn't sure what he took but said it was a pretty extensive list I put them all in a pill box to make sure I don't miss any and so that I take them all at the right times. Didn t know the names of the medications Why Med Rec? Patient Case May 2012 He suggested the RPh speak with his clinic as they have up-to-date list His medication list was faxed over, and the RPh made 19 changes to the patient s medical record 6 medications added that were missing 8 medications had the incorrect dose 5 medications were active that he was no longer taking 119

4 Why Med Rec? Patient Case May 2012 This patient's inpatient meds had been reordered directly from his original home medication list RPh updated the list and contacted the primary team Changes made before any adverse events occurred Patient had 6 prior encounters in inpatient admissions and 3 ED visits I am confident patients like this exist in my organization. a. True b. False Department of Pharmacy Focus How can our department contribute to world class care? How can we modify our current practice model and align our priorities with patient needs and organizational expectations? How can we hardwire this process for the frontline clinician? 120

5 Clinical Pharmacists Team Leader Pharmacist Ideas Patient Care Activity Percent Pharmacokinetic evaluation, monitoring, and dosing 94.3% Daily patient-specific medication profile review 92.5% Antimicrobial stewardship 90.6% Medication reconciliation on admission and during changes in level of care 86.8% Participation in patient care rounds 86.8% Policies/protocols expanding pharmacists scope of practice (renal dosing, IV to PO) 84.9% Patient education regarding high risk medication (warfarin, enoxaparin, insulin, etc.) 75.5% Anticoagulation management 77.4% Code team participation 77.4% Discharge education 71.7% Communication of medication therapy plans between transitions of care 67.9% Patient education regarding new medications 62.3% Documentation of patient care plans, activities, and related outcomes in the electronic 58.5% health record in an efficient manner which is integrated with documentation of other providers Ownership and accountability for medication related quality and pay for performance 56.6% metrics (Project Red/Discharge education, HCAHPS scores, VTE, SCIP, Medication Reconciliation) Communication of patient discharge information to the patient s pharmacy and physician 35.8% Post care phone calls and development of teaching tools (calendars) for patient education 30.2% Rapid response team participation 20.8% See enlargement p. 136 Pharmacist Expectations: 2012 Practice Model Changes Integration of transitions of care Admission history capture and reconciliation Transfer reconciliation from critical care to acute care and acute care to rehab Discharge process improvements focused on medication reconciliation and patient counseling Focus on pharmacist impact on directly reported quality outcomes 121

6 Pharmacy-facilitated Med Rec Patient safety Right thing to do for our patients Prevent medication errors across the continuum of care Performance on critical metrics Core measures HCAHPS Readmission rates Meaningful use HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems Pharmacy-facilitated Med Rec Alignment with organization s strategic goals Allows interdisciplinary peers (nursing, physicians) to focus on direct patient care activities Defined organizational owner of process Responsibilities better suited for pharmacists Improved communication with patient regarding medication use Improved throughput ED to admission time Background During a pilot on one unit - patient satisfaction 44 th percentile to 85 th and then 99 th! Avg # meds our patients are on at home = : PAT Clinic, TJC NPSG 2009: CVP, Med : BOOST, TJC NPSG 2005: ED Services (reassigned to PAT in 2009) AVG # discrepancies found by RPh doing med rec = : Huddles, core measure discharge support, Peds Frontline Leadership Project, quality rotation 122

7 Time Commitment Time (minutes) Admission Transfer Discharge Total Wilkinson ST et al. Hosp Pharm. 2011; 46: Time Commitment Time (minutes) Admission Transfer Discharge Total Wilkinson ST et al. Hosp Pharm. 2011; 46: Time Commitment: Discharge Mean Minutes Medication reconciliation Counseling Calendar / Contact Provider Updating Patient Questions Total discharge Education Admission History process Materials Discharge process steps Wilkinson ST et al. Hosp Pharm. 2011; 46:

8 Team Restructure Process Before New Resources Target RPh:Patient ratio 1:30 Use time data from pilots to justify 5.0 FTE pharmacist 3.0 FTE resident 4.0 FTE technician See enlargement p. 136 Role of Team Pharmacists Team Leader Oversees all patients Coordinates appropriate pharmacy services Rounds, huddles, transitions of care Reviews pharmacy tech and pharmacy resident work, if applicable Monitors off-service patients Organizes and leads precepting activities Lectures, topic discussions Role of Residents Primary pharmaceutical care provider for patients Initial medication history/reconciliation as needed Daily patient visits Daily medication review Pharmacokinetic monitoring Patient education on high-risk medications (anticoagulants, insulin, bronchodilators, antiplatelet agents +/- aspirin, digoxin, narcotics) Discharge counseling Documentation Pend discharge medication orders Co/primary preceptor and mentor to students Leads set number of topic discussions Write discharge medication summary note? 124

9 Role of Technicians Collect medication history for all patients (unless taken by student) Troubleshoot operation/distribution issues Create medication calendars? Role of Students Collect medication histories and reconcile patients Perform all duties of pharmacy resident under appropriate supervision Present patients to attending pharmacist or resident Admission Expectations Admission history capture and reconciliation Goal: Every inpatient admission, no exclusions Acute care: Completed within 24 hr of patient admission or prior to admission (e.g., PAT) Critical care: Completed prior to transfer to floor and/or home PAT = Pre-anesthesia testing clinic 125

10 Transfer Expectations Transfer reconciliation Focus areas Critical care (ICU) to acute care Acute care to rehab Labor and delivery to mother baby Transferring pharmacist will pend orders for admitting team and physician to evaluate Transfer: RPh Pending Orders Reconcile orders Pharmacist has ability to resume, discontinue, or modify active orders and PTA medications Pharmacist can add new orders, and previously entered signed and held orders can also be seen if they exist These are recommendations made to the providers with co-signature required Complements and facilitates physicians work Discharge Expectations Focus on pharmacist participation in the discharge process based on patient need determined by patient risk stratification Every discharge Pending completed prior to physician orders Support discharges as needed and requested by physicians 126

11 Discharge Process: Before Discharge Process: RPh Facilitated Discharge Expectations Pend medication orders for physician review Perform medication reconciliation to identify and resolve discrepancies Provide medication counseling, including written materials Identify potential adherence concerns documentation in care plan Participate in team huddles 127

12 Discharge Expectations High readmission risk Diagnosis: AMI, CHF, PN, core measure patients Age >65 yr or <18 yr >10 long term scheduled medications on discharge Receiving a medication requiring therapeutic monitoring (anticonvulsants, anticoagulants, immunosuppressant) Medium readmission risk Medication class Antibiotics Diuretics Angiotensin converting enzyme inhibitors Lipid lowering agents Low readmission risk Pend Orders Counsel Patient x x x x x x Provide Written Materials/Calendar Wilkinson ST et al. Hosp Pharm. 2011; 46: Chinthammit C et al. J Pharm Pract. 25: Which best describes effective communication for practice changes? a. Use of multiple communication media b. Direct engagement of all stakeholders prior to determination of practice change c. Repetition of the message including mention of how the change will affect me d. Multi-step plan incorporating all of the above Communication is key Change and uncertainty create fear and anxiety Effective communication creates confidence and clarity 128

13 Admission and Discharge Capture Rates Percentage of Pharmacy Admission History Completion and Pharmacist Supported Discharges (orders and education) October 2012 June 2013 See enlargement p. 137 HCAHPS: Medication Communication HCAHPS Medication Communication Performance (% always) October 2012 April 2013 Section average of 2 questions See enlargement p. 137 HCAHPS: Discharge HCAHPS Discharge Performance (% always) October 2012 May 2013 During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? See enlargement p

14 Meaningful Use: Transitions of Care Impact MU Compliance Element: The Eligible Hospital (EH) or Critical Access Hospital (CAH) performs medication reconciliation for more than 50% of transitions of care (TOC) in which the patient is admitted to the EH or CAH s inpatient or emergency department Date Range Number of Transitions of Care Where Medication Reconciliation Was Performed Number of Transitions of Care During the EHR Reporting Period Beginning October 1, 2012: pharmacy medication reconciliation is implemented Before October 1, 2012: 22% admit med histories were already being done by pharmacy Percentage 11/3/2011 1/31/ % 10/1/2012 1/3/ % Immunization Core Measure Compliance Organization immunization core measure compliance pre- and post- October 1, 2012 (TOC go-live date) See enlargement p. 138 Readmission Rates 30-day readmission rates for core measure patients from September 2012 (Baseline) April 2013 See enlargement p

15 What else do you have? Entrepreneurial Spirit Extend outside of your comfort zone Believe that you can Be bold and ask for help often Which best describes the importance of a pharmacy leader being able to adapt to and lead through change? a. Top priority critical to success b. Very important c. Somewhat important d. It depends e. Not so important 131

16 Rick s Knowledge of Specialty Pharmacy (self-rated) Industry leader 10 Highly informed 9 8 Enough to be dangerous 7 Can make useful 6 suggestions 5 Can participate in discussions 4 I use lingo 3 correctly 2 Isn t all pharmacy special? 1 Attended Conference on Specialty Pharmacy Huh? Specialty? 0 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Specialty Pharmaceuticals Growing opportunity U.S. spending on specialty medications will likely increase by 67% through 2015 Cancer care one third of market 69% of 182 drugs in late stages in pipeline 7 of 37 (19%) of drugs approved in % of prescriptions accessible Area market, Medicare any willing provider Expensive medications Express Scripts drug trend report. (accessed 2013 Oct 1). Specialty Pharmacy: Opportunities for Growth Express Scripts Drug Trend Report Higher drug spending for cancer, multiple sclerosis, and inflammatory conditions than any other class except diabetes by end of 2015 Spending for hepatitis C medications will likely quadruple over next 3 years Largest percentage in growth among classes Patients with hepatitis C receiving specialized care from specialty pharmacy were 60% more likely to achieve optimal adherence levels and have more concurrent therapy days Leading to overall medical savings Express Scripts drug trend report. (accessed 2013 Oct 1). 132

17 Specialty Market Dynamics Specialty Market in Drugs approved 16 year high! Consolidations Biosimilars on the horizon 45% 28% 17% Express Scripts/Medco #1 CVS/Caremark #2 Walgreens #3 Diplomat Specialty Pharmacy #4 2% 8% Total Other Specialty Market in 2013 Stable high growth market: twice the rate of the overall pharmaceutical market Health reform impacts Promising pipeline Oncology Medications Continue to Drive Growth of Industry One third of all specialty spending Largest number of products in the pipeline Data courtesy of Diplomat Specialty Pharmacy August. Our Situation ~45% of cancer market Major expansion in past 2 years How can we provide comprehensive, world-class care to our patients without including specialty cancer therapies? Case study: 75-year-old woman with cancer, PBM disallowed administration of Neulasta at our cancer center Long-term view of revenue impact of oral therapy Leaders ask for help Countless colleagues and people knowledgeable about the industry were contacted and helped Webinars, networking sessions, presentations, niche literature Forged a partnership with an industry leader 133

18 Vendor Partner Support Support Services in place since September, 2012 for Oncology Medications Drug Delivery University of Kansas Specialty Pharmacy Patient presents oncology Rx to treat cancer diagnosis/rx is e prescribed from U of K physician; pharmacist tells patient that it s a specialty drug and additional services are offered University of Kansas conducts PA coordination and communicates with physicians Rx information transmitted via nightly data feed University of Kansas ships medication to patient based on need by date Start Finish Diplomat Specialty Services Private-labeled as University of Kansas Specialty Pharmacy Diplomat Specialty Services enters info into enav, initiates benefits investigation, copay card enrollment, and PA coordination with U of K Diplomat Specialty Services contacts patient to assess condition, provides necessary training, gives initial offer to counsel on medication, and coordinates delivery date of medication. Diplomat Specialty Services proactively checks with patient to mitigate any adverse effects, helps with problems, and coordinates refills. See enlargement p. 139 Find Expertise in Partner Patient Retention Program Number of Patients New Patients Current Patients Specialty Pharmacy Results Go-live September 4, 2012 Results through June 2013 ~1700 new specialty prescriptions ~400 cancer patients ~$8,000,000 new revenue Providers perception: lifesavers Patient satisfaction very high 134

19 Specialty Pharmacy: Opportunities for Growth Clinical Area %Capture of Current Prescriptions GI/dermatology/rheumatology 4.9% Neurology/multiple sclerosis 0% Hepatitis B and C 5.5% Oncology 37.2% Endocrinology 1.5% HIV/ID/immune disorders 24.6% Transplant/nephrology 26.8% Total for all classes 22% Estimated >$120 million in revenue annually Conclusion Formulate practice changes that answer the So what? question really well Pharmacy practice has tremendous potential in quality and revenue leverage this value Become a leader who anticipates and thrives with change and your department will benefit Don t be afraid to win! Tell stories and set bold goals 135

20 Pharmacist Ideas Patient Care Activity Percent Pharmacokinetic evaluation, monitoring, and dosing 94.3% Daily patient-specific medication profile review 92.5% Antimicrobial stewardship 90.6% Medication reconciliation on admission and during changes in level of care 86.8% Participation in patient care rounds 86.8% Policies/protocols expanding pharmacists scope of practice (renal dosing, IV to PO) 84.9% Patient education regarding high risk medication (warfarin, enoxaparin, insulin, etc.) 75.5% Anticoagulation management 77.4% Code team participation 77.4% Discharge education 71.7% Communication of medication therapy plans between transitions of care 67.9% Patient education regarding new medications 62.3% Documentation of patient care plans, activities, and related outcomes in the electronic 58.5% health record in an efficient manner which is integrated with documentation of other providers Ownership and accountability for medication related quality and pay for performance 56.6% metrics (Project Red/Discharge education, HCAHPS scores, VTE, SCIP, Medication Reconciliation) Communication of patient discharge information to the patient s pharmacy and physician 35.8% Post care phone calls and development of teaching tools (calendars) for patient education 30.2% Rapid response team participation 20.8% Team Restructure Process Before New Resources Target RPh:Patient ratio 1:30 Use time data from pilots to justify 5.0 FTE pharmacist 3.0 FTE resident 4.0 FTE technician 136

21 Admission and Discharge Capture Rates Percentage of Pharmacy Admission History Completion and Pharmacist Supported Discharges (orders and education) October 2012 June 2013 HCAHPS: Medication Communication HCAHPS Medication Communication Performance (% always) October 2012 April 2013 Section average of 2 questions 137

22 HCAHPS: Discharge HCAHPS Discharge Performance (% always) October 2012 May 2013 During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Immunization Core Measure Compliance Organization immunization core measure compliance pre- and post- October 1, 2012 (TOC go-live date) 138

23 Readmission Rates 30-day readmission rates for core measure patients from September 2012 (Baseline) April 2013 Vendor Partner Support Support Services in place since September, 2012 for Oncology Medications Drug Delivery University of Kansas Specialty Pharmacy Patient presents oncology Rx to treat cancer diagnosis/rx is e prescribed from U of K physician; pharmacist tells patient that it s a specialty drug and additional services are offered University of Kansas conducts PA coordination and communicates with physicians Rx information transmitted via nightly data feed University of Kansas ships medication to patient based on need by date Start Finish Diplomat Specialty Services Private-labeled as University of Kansas Specialty Pharmacy Diplomat Specialty Services enters info into enav, initiates benefits investigation, copay card enrollment, and PA coordination with U of K Diplomat Specialty Services contacts patient to assess condition, provides necessary training, gives initial offer to counsel on medication, and coordinates delivery date of medication. Diplomat Specialty Services proactively checks with patient to mitigate any adverse effects, helps with problems, and coordinates refills. 139

24 18th Annual ASHP Conference for Leaders in Health-System Pharmacy SELECTED REFERENCES 1. Chinthammit C, Armstrong EP, Warholak TL. A cost-effectiveness evaluation of hospital discharge counseling by pharmacists. J Pharm Pract. 2012; 25: Committee on Identifying and Preventing Medication Errors; Aspden P, Wolcott JA, Bootman JL et al., eds. Preventing medication errors: quality chasm series. Washington, DC: National Academies Press; Express Scripts drug trend report. (accessed 2013 Oct 1). 4. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 360: Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997; 277: The Joint Commission. National patient safety goals. (accessed 2013 Oct 1). 7. Wilkinson ST, Pal A, Couldry RJ. Impacting readmission rates and patient satisfaction: results of a discharge pharmacist pilot program. Hosp Pharm. 2011; 46:

25 18th Annual ASHP Conference for Leaders in Health-System Pharmacy SELF ASSESSMENT QUESTIONS 1. Which of the following represents the primary reason that health system pharmacy leaders should implement practice changes that can improve the transition of care of patients discharged from the hospital? a. Brings national recognition to the pharmacy department. b. Provides additional source of revenue for the health system. c. Can potentially prevent costly readmissions and improve the health of patients outside of the hospital. d. Enables patients to obtain discharge medications and specialty drugs at reduced cost. 2. The pharmacy leadership team at XYZ Hospital is looking for opportunities to improve patient care and generate revenue for the institution. Which of the following would be the best approach for identifying potential practice changes that would also align with the organization s priorities of generating revenue but with little capital outlay? a. Identify options for modifying the current practice model even if the potential changes are not aligned with organizational expectations. b. Involve the staff in identifying options for modifying the current practice model and align the department s priorities with organizational expectations. c. Propose a wholesale change in the current practice model, including changes in the physical layout of the pharmacy. d. Avoid considering any ideas from previous proposals, even if they align the department s priorities and organizational expectations. 3. When a pharmacy leader is faced with challenging and changing circumstances, all of the following would be appropriate approaches for addressing those challenges EXCEPT a. Withdraw from professional contacts and work overtime to identify potential solutions. b. Connect with colleagues who may have faced similar challenges. c. Participate in relevant educational programs and networking sessions. d. Forge a partnership with an industry leader with expertise in the area. Answers 1. c 2. b 3. a 141