Today s Presenters: Amanda Schroepfer, PharmD, BCACP

Transcription

1 Optimizing Medications to Support Patients Through Care Transitions Amanda Schroepfer, PharmD, BCACP Goodrich Pharmacy Calloway Van Epern, PharmD Froedtert Hospital June 22, 2016 Today s Presenters: Amanda Schroepfer, PharmD, BCACP Medication Therapy Management and Clinical Staff Pharmacist for Goodrich Pharmacy Graduated from Creighton University in 2010 with her doctorate of pharmacy Completed a residency with Goodrich Pharmacy the following year Currently provides MTM services in Health Partners clinics located in Elk River, Andover and Anoka and staffs the Goodrich Pharmacy in Anoka Resident site director for Goodrich Pharmacy Helps precept and coordinate learning experience for student pharmacists at Goodrich Pharmacy Volunteers as a preceptor at the Phillips Neighborhood Clinic. 2 1

2 Today s Presenters: Calloway VanEpern, PharmD Ambulatory clinical staff pharmacist at Froedtert Hospital in Milwaukee, WI Graduated from the University of St. Thomas (St. Paul, MN) with a bachelor s of science in biology in 2009 & from the University of Minnesota with a doctorate of pharmacy in 2013 Completed a PGY1 Community Pharmacy Residency from Froedtert Hospital in 2014 and a PGY2 Ambulatory Pharmacy Residency the following year from Froedtert Hospital Provides clinical pharmacy services in a variety of clinics at Froedtert Hospital, primarily in the Hospital Discharge Care Program, as well as in the Sickle Cell Clinic and the Metabolic Clinic. 3 Improving continuity of care through the healthcare continuum: from hospital discharge to prescription refills Amanda Schroepfer, PharmD, BCACP Goodrich Pharmacy 2

3 Learning Objectives Identify the role pharmacy may play as part of the health care team in helping manage medications during transitions of care. Describe strategies used to initiate and sustain cross-institutional collaboration Identify challenges and steps taken to overcome these challenges that may be faced during transitions of care collaborations Comprehensive Medication Management/Medication Therapy Management (MTM) Assessment Identification of Medication-Related Problems Care Plan Follow-Up Patient-Centered Primary Care Collaborative. Integrating Comprehensive Medication Management to Optimize Patient Outcomes: Resource Guide. Second Edition. June

4 Goodrich Pharmacy Independently owned community pharmacy practice in the northern metro suburbs Collaborative relationships with local clinics and providers began in the 1980 s and pharmacist-provided MTM began in the 1990 s Patients are seen for MTM services in the community pharmacy and Riverway clinic by pharmacists, the pharmacy resident and student pharmacists. Background 30% of patients have at least one medication discrepancy upon discharge from a hospital. 1 in 10 patients discharged home from the hospital experience an avoidable medication-related adverse event within three weeks of discharge. 19.6% of Medicare patients are readmitted within 30 days accounting for 15 billion dollars of Medicare spending National transitions of care coalition. Issue brief: Improving transitions of care. September

5 Objective Create a sustainable, pharmacist coordinated, patient centered practice model involving inpatient pharmacist collaboration with ambulatory care pharmacists in the clinic and community pharmacy setting. Goals Reduce medication-related adverse events Prevent hospital re-admissions Improve continuity of interprofessional communication and health care delivery Family Nurse Patient centered care as the future of healthcare Physician Pharmacist Health Coach Biggest obstacle to globalization of patient centered care: NP/PA Institutional isolation 5

6 Evolution of Our Healthcare Model The The Healthcare Northwest Continuum Alliance Model Model The Classic Model Methods setting a foundation for collaboration Transition care service plan presented to Riverway and Mercy stakeholders Goodrich pharmacists propose transition care services to Mercy pharmacists IRB exemption determination submitted to both Allina and Health Partners 6

7 Methods setting a foundation for collaboration Developed Process for communicating patient referrals between Mercy, Riverway, and Goodrich Clinic MTM schedule created at Riverway for Mercy referral patients Pharmacist-based transitions of care service go-live! Methods Patient Selection Criteria for MTM referral (any of the following): > 2 > 3 ADE Inpatient hospitalizations within 30 days New medications at discharge from an inpatient unit Hospital admission was due to an adverse drug event 7

8 Methods Institutional Communication Mercy hospital pharmacist adds MTM referral note to EMR of patients who meet referral criteria Riverway nurses receive list of mutual patients, recently discharged from Mercy Hospital, and screen their chart for referral note* Nurse contacts patient to set up an MTM appointment with Goodrich pharmacist *Riverway nurse have access to Mercy EMR through the Northwest Metro Alliance Methods Post-Discharge MTM Initial patient visit: Review all medications Chronic disease state management Follow-up visits: Scheduled as needed Further chronic disease state management 8

9 Methods Outcome Measures Readmission within 30 days Number of medication discrepancies at hospital admission Number of medication discrepancies post-discharge Number of drug therapy problems identified Number of pharmacy visits required for optimal care Results Preliminary 3/3/16 4/1/16 54 Riverway Clinic patients seen at Mercy Hospital 22% of patients seen were hospitalized 33% of hospitalized patients met referral criteria 42 Seen in ED, but not admitted 2 Patients Pending Scheduling 54 Patients Screened 4 Referred for MTM 12 Patients Admitted 1 Seen by MTM pharmacist 8 Inclusion criteria not met 1 Declined MTM 9

10 Challenges Encountered Mercy Hospital Legal clearance to share patient information with Goodrich MTM pharmacists Riverway Clinic Stakeholder buy-in Exam room space Education of clinic staff Goodrich Pharmacy Pharmacists are not part of Northwest Metro Alliance Patient confusion with appointment location Conclusion Electronic health care records can facilitate interdisciplinary patient care at the hospital, clinic, and pharmacy level The main barrier to this is approval of communication regarding patients between institutions to coordinate care This project shows that such care coordination can occur even between unaffiliated facilities, especially when pharmacist are utilized to coordinate and deliver care 10

11 Future initiatives Implement pre-discharge medication reconciliation and counseling by pharmacists at Mercy Hospital, with incorporated MTM referral process Expand program to include other clinics and long-term care facilities Incorporate other health care professions into the model References 1. Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, Kennedy AK, LaPointe NM, Burkhardt CD, Schilli K, Seaton T, Trujillo J, Wiggins B. Improving care transitions: current practice and future opportunities for pharmacists. American College of Clinical Pharmacy. Pharmacotherapy Nov;32(11):e Lalonde L, Lampron AM, Vanier MC, Levasseur P, Khaddag R, Chaar N. Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings. Am J Health Syst Pharm Aug 1;65(15): Karapinar-Çarkıt F, van Breukelen BR, Borgsteede SD, Janssen MJ, Egberts AC, van den Bemt PM. Completeness of patient records in community pharmacies post-discharge after in-patient medication reconciliation: a before-after study. Int J Clin Pharm Aug;36(4): Kirkham, H., Clark, B., Paynter, J., Lewis, G., & Duncan, I. (2014). The effect of a collaborative pharmacist-hospital care transition program on the likelihood of 30-day readmission. American Journal of Health-system Pharmacy AJHP., 71(9), Chisholm-Burns, M., Kim Lee, J., Spivey, C., Slack, M., Herrier, R., Hall-Lipsy, E.,Wunz, T. (2010). US pharmacists' effect as team members on patient care: Systematic review and meta-analyses. Medical Care, 48(10), Hawes EM, Maxwell WD, White SF, Mangun J, Lin FC. Impact of an outpatient pharmacist intervention on medication discrepancies and health care resource utilization in posthospitalization care transitions. J Prim Care Community Health Jan 1;5(1):

12 TRANSITIONS OF CARE AT FROEDTERT HOSPITAL Calloway Van Epern, PharmD. Ambulatory Clinical Pharmacist June 22, 2016 Objectives Review current practice at Froedtert Hospital as it relates to transitions of care Describe current efforts to expand transitions of care services: Explain the development process of new transitions of care clinic Recognizing need for team based care for this population 12

13 Froedtert Hospital Licensed Beds 655 Beds Staffed Beds 516 Beds FY15 Admissions 27,176 Emergency Visits 67,089 Continuum of Care Inpatient PCMH Community 13

14 Inpatient Pharmacy Services Admission During Admission Discharge Collect medication history Compare medication history to inpatient orders Completed by provider (H&P) and by pharmacist Medication changes New medications Medications discontinued Dose adjustments Review inpatient stay (progress notes) Compare prior to admission medications to inpatient medications to discharge orders Completed by provider and final review by pharmacist Inpatient ToC Pharmacy Services Admission medication history and reconciliation Participate in daily care coordination rounds Purpose of CCRs is to proactively plan for discharges and transfers, increase collaboration between disciplines, increase communication with the patient/family Discharge reconciliation Discharge medication education Discharge prescription facilitation to onsite pharmacies Discharge technicians Bedside delivery 14

15 Continuum of Care Sargeant Pilot Inpatient PCMH Community Sargeant Pilot: Transitions of Care Collaborative in the Patient Centered Medical Home Purpose: To determine if intensive management within the medical home can effectively reduce readmissions and control costs in a high risk population PCMH team members Primary care provider Advanced practice nurse practitioner Discharge advocate nurse coordinator Social worker Home care nurse Pharmacist 15

16 Sargeant Pilot Timeframe: 4 months Part time presence of pharmacist N = 22 patients Patient Encounters: 108 Pharmacist involved primarily in initial visit Sargeant Pilot Outcomes Average 2 drug related problems per patient encounter Average of 3 medication discrepancies per patient Readmission rate reduced from 35% to 12% Cost reduced by 44% 16

17 Sargeant Pilot Conclusions Early identification Initial intervention in hospital Early involvement with home care home visit within 24 hours Explicit handoff to clinic care provider (care plan) Early visits with the care provider & pharmacist Frequent visits provider tailored to the patient's needs Rapid access to specially services as needed Personal communication amongst home care, care coordinator and provider via regular huddles Developing rapport between home care & clinical provider, and ability to receive orders in real time ONGOING TRANSITIONS OF CARE EFFORTS Hospital Discharge Care Program (HDCP): centralized transitions of care clinic for high risk patents 17

18 Hospital Discharge Care Program (HDCP) Collaboration program between Froedtert & The Medical College of Wisconsin and Horizon Home Helps patients at very high risk for readmission to the hospital Provides care after discharge from the hospital for ~30 days until stable enough to resume usual care with your primary care provider Alternative to primary care provider resuming care for the patient Additional services & support Primary objective: Reduce readmission rates Virtual visits New Transitions of Care Cycle Medical Home HDCP Hospital 18

19 Inpatient case managers Initially identify candidates for HDCP and initiates enrollment process Contributes to discharge care plan Medical Director Assists in shaping discharge care plan Huddles with team daily Home Care RN Comes to patient s home within 24 hours of discharge & on regular interval Reviews medications in patient s home Available after hours and weekends HDCP Team Members RN Care Coordinator Involved in enrolling patient Facilitates each virtual visit Facilitates communication between visits Advanced Practice Provider Provides care to patients in the program Communicates with PCP s and other members of the care team Pharmacist Provides comprehensive medication management» Assess each med: indication, safety, efficacy, convenience» Provides med education MA/scheduler Tracks information/data Assists care coordinator Identifying High Risk Patients for HDCP 19

20 Identifying High Risk Patients for HDCP HARRD Correlation with Readmissions Readmission HAARD score No Yes TOTAL 0 n % n % n % n % n % n % Total n %

21 Enrolling a patient in HDCP Early during admission: Case manager identifies potential candidate & consults HDCP HDCP reaches out to patient s PCP for permission to enroll and to get recommendations for patient s care HDCP care coordinator meets with inpatient to explain program First HDCP appointment is scheduled before discharge Developing discharge care coordination plan Hospital Discharge Care Program Care Coordination Plan Example Background: This patient has been recently discharged from the hospital and is part of the Hospital Discharge Care Program (HDCP) designed to assist in the transition of patients at very high risk for readmission. The goal is to keep patients out of the Emergency Department and the hospital. General: This patient is being followed by Horizon Home Health. Please see the Care team list for the Horizon nurse name and contact number. This patient has been instructed that with any changes in their condition their first call should be to the HHH RN. The RN will triage the patient. If the patient arrives in the ED with a non-life threatening condition, contact Horizon Home care prior to making a disposition decision. Horizon Home Care: Clinical: Brief Overview: Hospitalized 4/10 for shortness of breath and chest pain. In mild CHF with acute on chronic renal failure, worsening anemia and hyponatremia Priorities: 1. CHF - Bumex initiated. Monitoring weight 2. Kidney function - Monitoring creatinine 3. Hyponatremia - secondary to CHF. Monitoring sodium 4. Chronic GI bleed for which she is on octreotide 5. Anxiety and chronic pain - modifying current regimen Barriers: Underlying psychological issues. Hesitant to follow through and take some meds. Preferences: Has mechanical mitral valve. Has elected to remain off anticoagulation because of GI bleed 21

22 HDCP Appointments Post-Discharge Day 1 post-discharge: The Horizon Home Care nurse will come to home for first intake visit Within 3-4 days of discharge: First virtual visit with Horizon Home Care nurse and HDCP team ~Weekly: At least one virtual visit a week with HDCP team Urgent visits in clinic available: anticipate ~10% of visits After 4-6 weeks: HDCP will transition care back to PCP Process Mapping 22

23 Typical Virtual Visit Workflow Types of HDCP Encounters Home health RN intake visit New patient visit (virtual) Pharmacist and APP APP only visit (virtual) Pharmacist only visit (virtual) APP & Pharmacist visit (virtual) Urgent Visit In clinic APP Handoffs (back to PCP) 23

24 Clinical Measures HDCP Outcomes Measured Readmission/ED return rate Patient satisfaction Medication discrepancies Achieving individual patient and clinical goals Process Measures Identified patients Enrolled patients Visits by discipline/type Show rate Internal vs. External PCP vs. No PCP at admission Length of enrollment Assessment of virtual technology On time starts Reimbursement Challenges Transitional Care Management codes (99495 & 99496) not being used initially Supported by cost savings Readmission rate reduction 24

25 Steps in Development Optimize & share risk stratification tool for inpatient identification Hospital Admit Readmission Risk Discriminator (HARRD) tool New EMR build Goals, barriers, preferences Mix of virtual + in person visits Communication program with internal & external stakeholders Test technology via patient simulation Develop specific workflows*** Stakeholder buy-in Challenges Encountered Enrolling patients: new step for case managers Inpatient pharmacist communication Communicating and getting approval from PCP s Teamwork: Who owns what tasks? Labs: The results, where did they go? Stat labs Weekend lab challenges Weekends How do we enroll patients in HDCP during the weekend? 25

26 Summary Data needed to support ToC efforts Team-based care necessary to treat high risk patients Frequent & efficient communication and follow-up Continuous process improvement: PDCA Questions? Amanda Schoepfer, PharmD, BCACP Calloway Van Epern, PharmD. MetaStar represents Wisconsin in Lake Superior Quality Innovation Network

27 This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C