Practice Transformation Research Informing the Future Delivery of Healthcare: Insights from IHARP

Transcription

1 Practice Transformation Research Informing the Future Delivery of Healthcare: Insights from IHARP William T. Lee, BSPharm, MPA, FASCP Pharmacy System Director, Carilion Medical Center Gary R. Matzke, BS Pharm, PharmD, FCP, FCCP Professor VCU School of Pharmacy Medical College of Wisconsin School of Pharmacy Symposium: Emerging Pharmacy Practice Models in Healthcare Delivery June 24, 2016

2 OBJECTIVES Describe the clinical processes that comprise the IHARP care delivery model. State the key lessons learned during the implementation of the IHARP care delivery model. Characterize how the clinical care and health utilization outcome evaluation metrics were impacted by the IHARP program. Describe the IHARP program s influence on the cost of health care services delivery. Assess the relative contribution of improvements in clinical outcomes, patient and provider satisfaction and economic measures on the sustainability of clinical pharmacy services.

3 CMMI Medication Management (MM) Health Care Innovation Awardees University of Southern California (USC) University of Pennsylvania s HeartStrong program (HeartStrong) Pharmacy Society of Wisconsin (PSW) University of Tennessee s SafeMed program (SafeMed) University of Hawaii at Hilo s Pharm2Pharm program (Pharm2Pharm) and Carilion New River Valley Medical Center in partnership with Virginia Commonwealth University s Improving Health for At-risk Rural Patients (IHARP)

4 Status of MM Innovation Projects Quantitative analysis for three of the six programs: IHARP, USC, and Pharm2Pharm was conducted by an external consultant group. They did not conduct a quantitative analysis for the HeartStrong or SafeMed programs, because they did not have sufficient participant-level program data to conduct an analysis. Additionally, due to clarity concerns regarding PSW s targeting criteria a quantitative analysis of PSW was not conducted.

5 PROJECT GOALS Create a sustainable patient centered continuity of care health care delivery model within a rural health system comprised of multiple hospitals, primary care practices, and community pharmacies; Achieve better patient health outcomes Smarter spending by optimizing medication-related health outcomes Implement and evaluate a new model of pharmacist workforce development; and Evaluate the clinical, humanistic and economic outcomes associated with this new health care delivery model

6 PROJECT DESIGN -- Key Elements Inclusion criteria 18 years of age at enrollment Primary use of English for oral and written communication 2 chronic diseases (one condition must be one of the following: asthma, CHF, DM, COPD, HTN, hyperlipidemia, depression) 4 chronic prescription medications Have a telephone line available Exclusion criteria Terminal condition with life expectancy 6 months

7 HOSPITAL PHARMACIST ROLE Review the algorithmic generated list of eligible patients Enroll eligible patients Identify medication-related problems (MRPs) with which the patient is entering the hospital Provide input into medication care plan Monitor clinical course of patient throughout hospital stay Communicate medication changes and known MRPs with Primary Care Pharmacist

8 THE PCCP INTERVENTION Patients have scheduled visits with their primary care pharmacist First appointment usually within 2 weeks of enrollment. Each pharmacist staffs up to 4 clinics Collaborate with physicians to enhance patient outcomes through: innovative individual and group educational sessions medication adherence counseling comprehensive medication management Follow standard care practices for making recommendations CDSM protocols were designed based on national consensus guidelines Utilization of a programmatic approach to initiate and monitor the recommended care for each patient

9 OUTCOME EVALUATIONS Clinical, economic, and humanistic outcomes have been evaluated quarterly since January 2013 Disease specific clinical outcomes were assessed longitudinally -- from baseline to last visit Patient satisfaction and physician, nursing staff, and pharmacist perceptions of IHARP were evaluated routinely The economic analysis assessed the impact of this intervention on healthcare costs: Estimation of cost avoidance by primary care pharmacists Comparison of health care services utilization in the 6,9, and 12 months prior to and during their 6,9, and 12 months of participation. Assess the actual care costs of the retrospectively identified control group with those who participated for at least 6,9, and 12 months

10 Humanistic Outcomes Measure Baseline Humanistic outcomes Physician and Staff Satisfaction X X X X survey Patient satisfaction X X X X Mailed Survey Pharmacist and Provider X X Interviews Experience

11 Care Model Documentation: Customization of Electronic Medical Records

12 Documentation Tool Selection Captures required data Interoperability with EMR Communication features Customization potential Reporting Security Sustainability

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14 Medication Related Problem Documentation Unnecessary Drug Therapy Problem Type Examples Needs Additional Drug Therapy No valid indication Therapeutic duplication Nondrug therapy needed Initiation of drug therapy required Additional drug required for additive effects Intervention Examples Add drug Change drug to another Rx Discontinue drug Increase dose Decrease dose Education - Prescription Med

15 PATIENT ENROLLMENT Number Enrolled Enrollment Total: 2,678 Primary Care Enrolled Hospital Enrolled 0

16 DEMOGRAPHICS Mean (SD) Frequency (%) Age (5.29) 535 (19.99%) (5.55) 1452 (54.24%) (2.88) 494 (18.45%) > (2.51) 138 (5.16%) Gender Female 1538 (57.45%) Male 1139 (42.55%) Race White 2349 (87.75%) Black 303 (11.32%) Hispanic 8 (0.30%) Number of chronic conditions 3.23 (1.36)

17 Chronic Conditions at time of Enrollment Disease State (N=18427) n (%) Hypertension Hyperlipidemia Diabetes Anxiety COPD Thyroid Chronic kidney disease Gout Chronic heart failure

18 Medication Related Problems MRP Type n Total 18,428 Medication Reconciliation 7,138 Noncompliance 5,424 Needs Additional Drug Therapy 1,519 Dose Too Low 1,051 Unnecessary Drug Therapy 983 Dose Too High 586 Adverse Drug Reaction 901 Ineffective Drug 450 Other 374

19 What did the details reveal? Medication Reconciliation (n = 7138, 38.74% MRP) Dose Dosage form Unnecessary drug therapy Incorrect instructions Omission Duplication Noncompliance (n = 5424, 29.44% MRP) Too expensive Did not understand instructions Prefers not to take the medication Refill overdue Forgets to take the medication Cannot swallow or self-administer correctly Not able to pick up medication

20 Pharmacist Interventions Interventions (n = 19,677) (n) (%) Discontinue Drug Add Drug Increase Dose Change Drug to Another Rx Education Adherence Decrease Dose Education Prescribed Med Cost Switch Refill Drug Initiation of Monitoring

21 Verification of CMM Process Outcomes

22 Verification of CMM Process Outcomes

23 CLINICAL OUTCOMES

24 Clinical Measures Month Data Source Medication-related problems Baseline Number and type of MRPs identified and X X X X X resolved Epic Clinical outcomes Change in A1C from baseline to follow-up; proportion at goal A1C X X X X X Epic Change in systolic and diastolic blood pressure from baseline to follow-up; proportion at goal systolic and diastolic blood pressure X X X X X Epic Change in LDL, HDL, triglycerides, total cholesterol from baseline to follow-up; proportion at goal for cholesterol measures X X X X X Epic Number of asthma/copd ED/hospital visits Epic, Medicare and

25 Not All Desired Data may be Available FEV1 Measure Ejection Fraction Disease Asthma, COPD Heart Failure Data not reliably recorded in a reportable field or systematically collected Alternative measures for Asthma, COPD, and CHF are utilization of ED and inpatient services

26 Outcomes in Poorly Controlled Diabetic Patients Primary Clinical Outcome Measures A1c SBP DBP > 60 LDL Last Visit Baseline

27 Outcomes in Poorly Controlled Non-Diabetic Patients Primary Clinical Outcome Measures SBP <60 SBP > 60 DBP < 60 DBP > 60 LDL Last Visit Baseline

28 PATIENT AND PROVIDER SATISFACTION

29 PATIENT SATISFACTION

30 Patient Comments I was sad I hadn't known of this sooner, but ecstatic that I do now. She helped me save substantially on expenses. She also explained the importance of taking meds as directed e.g. twice a day means exactly that, not combining both doses into one. Obviously my experience with IHARP has been great! This is a great program. It has helped me a lot to understand my medications. It is great to know what I am taking and what it is for. Everyone needs to be in this program and it would be great for the older people (that's me). It is really great the pharmacist calls to make sure I am doing O.K.

31 Provider and Clinic staff Satisfaction Data

32 Physician Comments This is hands down the most helpful program that has ever been offered in our primary care clinic. It has been enormously useful to me as a provider--- it saves tremendous time and the pharmacists are a great resource for medication related questions. It has likewise been tremendously helpful to patients-- it has improved their understanding of their medications and disease process, has saved them money and has likely improved outcomes and decreased risk by ensuring compliance with prescribed therapies. The best thing since sliced bread, in my humble opinion.

33 ESTIMATED COST AVOIDANCE, AND HEALTH CARE SERVICES UTILIZATION

34 Estimated Cost Avoidance associated with resolution of Medication Related Problems Avoidance Value n Total Reduced drug product costs $ $ 102,496 Additional physician visit $ $ 151,114 Additional prescription order $ $ 744,462 Emergency room visit $ 1, $ 215,130 Hospital admission $ 28, $ 2,204,526 Project Total $3,417,728

35 HEALTH CARE SERVICES UTILIZATION Carilion Clinic utilization data: The number of hospitalizations declined from 1277 during the year to 974 in the year while in the program. ED visits declined from 2301 to Medicare data: The influence of the IHARP care delivery model on the utilization of ED visits and hospital admissions for those enrolled for 6, 9, and 12 months revealed reductions in utilization for both measures:

36 SUSTAINABILITY PLANNING Generate Revenue Reduced Costs Enhance Quality

37 LESSONS LEARNED Data collection and archiving were challenging but essential Continual monitoring of data (CQI) allowed for adjustment of procedures to facilitate achievement of desired outcomes Access to EMR data greatly facilitates continuity of care The role for a pharmacist on a primary care team is not apparent to everyone Building relationships with staff is as important as building relationships with patients Adherence is sometimes all about money Role for pharmacy technician?

38 Institutional Implications Transitions of Care model-- implications for pharmacy staffing patterns Collaboration with community pharmacies and Carilion owned retail pharmacies a challenge Medication reconciliation process system wide and pharmacy coordinated Increased MAP needs recognized- required changes in staffing and communication

39 Institutional Implications IHARP Analysis of institutional data provides a basis for sound ROI for expansion Changing Role of Inpatient Pharmacist. Preadmission understanding, post-discharge continuity Impact -- Patient Satisfaction / patient Engagement initiatives Contribution to improvements in HCAHPS and CG-HCAHPS implications for sustainability

40 Professional Implications Medicare Provider status is this the holy grail Refine training and curriculum of pharmacists (initial training and updating skills) New expanded roles for technicians New practice paradigm shift - continuum of care Standardization of clinical pharmacy care Telepharmacy and template for standard of care

41 Conclusions The addition of comprehensive medication and disease state management into team based PCMH is scalable and can be delivered to high risk patients PCMH staff, physicians, and pharmacists have a high degree of satisfaction with the skills pharmacists bring to a patient care team Early data strongly suggest that there is a positive return on investment associated with the IHARP care model

42 IHARP PROJECT TEAM Leadership William Lee, DPh, MPA, FASCP Michael J. Czar, RPh, PhD Anthony R. Stavola, MD Gary R. Matzke, PharmD FCP, FCCP Leticia R. Moczygemba, PharmD, PhD Carilion Partners Michael Jeremiah, MD Charles Tarasidis, PharmD Chad Alvarez, PharmD Clinical Pharmacists Karen J. Williams, PharmD, BCPS Heidi D. Wengerd, PharmD Kelley D. Mills, PharmD Courtney P. Dickerson, PharmD Tanvi Patil, PharmD Nikisa Blevins, PharmD Ann Lucktong, PharmD Randi Carpenter, PharmD IHARP Staff Kristy Crigger Christine Riddell Andrea Pierce, PharmD Della Varghese Bhavini Kaneria, MS Samantha Marks, PharmD

43 DISCUSSION PHARMACY