Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists

Transcription

1 Pharmacy Leadership Forum Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists Presented as a Sunday Symposium at the 47 th ASHP Midyear Clinical Meeting and Exhibition Sunday, December 2, 2012 Las Vegas, Nevada Planned and conducted by ASHP Advantage and the Center for Health-System Pharmacy Leadership. Supported by an educational grant from Baxter Healthcare Corporation

2 Please be advised that this activity is being audio and/or video recorded for archival purposes and, in some cases, for repurposing of the content for enduring materials. 2

3 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists A G E N D A 2:00 p.m. 2:15 p.m. Welcome and Introductions James G. Stevenson, Pharm.D., FASHP 2:15 p.m. 2:50 p.m. The ABCs of Accountable Care Organizations James G. Stevenson, Pharm.D., FASHP 2:50 p.m. 3:20 p.m. Value-based Purchasing Program: An Overview Darin L. Smith, Pharm.D., BCPS, FASHP 3:20 p.m. 3:40 p.m. Refreshment Break 3:40 p.m. 4:10 p.m. Clinical Quality Measures and Meaningful Use of EHRs: Are You Ready for Stage 2? Shelly Spiro, B.S.Pharm., FASCP 4:10 p.m. 4:40 p.m. The Pharmacist s Role in the New Health Care Model: New Opportunities and Challenges Kathleen S. Pawlicki, M.S., B.S.Pharm., FASHP 4:40 p.m. 5:00 p.m. Faculty Discussion and Audience Questions All Faculty F A C U L T Y James G. Stevenson, Pharm.D., FASHP, Activity Chair Chief Pharmacy Officer University of Michigan Health System Professor and Associate Dean for Clinical Sciences University of Michigan College of Pharmacy Ann Arbor, Michigan Darin L. Smith, Pharm.D., BCPS, FASHP Director Pharmacy Services and Performance Improvement Norman Regional Health System Norman, Oklahoma Shelly Spiro, B.S.Pharm., FASCP Executive Director Pharmacy e-hit Collaborative Alexandria, Virginia Kathleen S. Pawlicki, M.S., B.S.Pharm., FASHP Administrative Director of Professional Services and Director of Pharmaceutical Services William Beaumont Hospital Royal Oak, Michigan 3

4 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists D I S C L O S U R E S T A T E M E N T In accordance with the Accreditation Council for Continuing Medical Education s Standards for Commercial Support and the Accreditation Council for Pharmacy Education s Guidelines for Standards for Commercial Support, ASHP Advantage requires that all individuals involved in the development of activity content disclose their relevant financial relationships. A person has a relevant financial relationship if the individual or his or her spouse/partner has a financial relationship (e.g., employee, consultant, research grant recipient, speakers bureau, or stockholder) in any amount occurring in the last 12 months with a commercial interest whose products or services may be discussed in the educational activity content over which the individual has control. The existence of these relationships is provided for the information of participants and should not be assumed to have an adverse impact on presentations. All faculty and planners for ASHP Advantage education activities are qualified and selected by ASHP Advantage and required to disclose any relevant financial relationships with commercial interests. ASHP Advantage identifies and resolves conflicts of interest prior to an individual s participation in development of content for an educational activity. The faculty and planners report the following relationships: James G. Stevenson, Pharm.D., FASHP Dr. Stevenson declares that he has no relationships pertinent to this activity. Darin L. Smith, Pharm.D., BCPS, FASHP Dr. Smith declares that he has no relationships pertinent to this activity. Shelly Spiro, B.S.Pharm., FASCP Ms. Spiro declares that she has no relationships pertinent to this activity. Kathleen S. Pawlicki, M.S., B.S.Pharm., FASHP Ms. Pawlicki declares that she has no relationships pertinent to this activity. Erika L. Thomas, M.B.A., B.S.Pharm. Ms. Thomas declares that she has no relationships pertinent to this activity. ASHP staff has no relevant financial relationships to disclose. 4

5 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists A C T I V I T Y O V E R V I E W Health care in the United States is in transition as technologies and treatments continue to emerge and the population continues to age. The active engagement of all health care practitioners will be required to embrace quality improvement and change management strategies to ensure that patients receive care that is effective and safe. Requirements of the Affordable Care Act are also driving change and accountability in all areas of the health care system. The accountable care organization (ACO) model is impacting medication management across the health system, and pharmacists can significantly impact medication-use management in this evolving health care model. Additionally, hospitals will be rewarded for high-level performance and penalized for poor performance on quality measures, patient perceptions, readmissions, mortality, and safety measures as they relate to Medicare beneficiaries through value-based purchasing. The goal of the Centers for Medicare & Medicaid Services (CMS) meaningful use incentive program is to promote the spread of electronic health records (EHR) to improve health care in the United States. Eligible providers and hospitals are allowed to earn incentive payments by meeting specific criteria. Important changes in health care policy and technologies impact medication management and the pharmacist s role in patient care. This educational activity will explain how current practices will be impacted and changes that will be required as these additional roles and opportunities evolve. A C T I V I T Y O B J E C T I V E S After attending this application-based educational activity, participants should be able to Explain the fundamental principles behind the concept of ACOs. Predict potential opportunities for pharmacists to actively participate in ACOs. Explain the mechanisms by which performance will be measured under the CMS hospital value-based purchasing program. Define the role of clinical quality measures under the CMS EHR meaningful use incentive program. Describe possible roles for pharmacy in the new health care model. 5

6 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists C O N T I N U I N G E D U C A T I O N A C C R E D I T A T I O N The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity provides 3 hours (0.3 CEUs) of continuing pharmacy education credit (ACPE activity # L04-P). Attendees must complete a Continuing Pharmacy Education Request online and may immediately print their official statements of continuing pharmacy education credit at the ASHP CE Center at following the activity. Complete instructions for receiving your statement of continuing pharmacy education online are on the next page. Be sure to record the session code beginning with A announced during the activity. Available soon at A Web-based version of this educational activity will be available at on March 1, Tell you pharmacy colleagues who were unable to attend the Midyear about this outstanding on-demand educational activity! (Please note that individuals who claim CPE credit for the live symposium are ineligible to claim credit for the web-based activity.) 6

7 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists P R O C E S S I N G C P E O N L I N E The ASHP CE Center allows participants to obtain statements of continuing pharmacy education (CPE) conveniently and immediately using any computer with an internet connection. To obtain CPE statements for ASHP Advantage activities, please visit 1. Log in to the ASHP CE Center using your address and password. If you have not logged in to the ASHP CE Center and are not a member of ASHP, you will need to set up an account by clicking on Become a user and follow the instructions. 2. Once logged in to the site, click on Process Meeting CE. 3. If you are a registered attendee at the ASHP Midyear Clinical Meeting, click on the start button to the right of ASHP Midyear Clinical Meeting If you are not registered to attend the ASHP Midyear Clinical Meeting, click on the start link to the right of the activity title. If this activity title does not appear in your meeting list, enter the 5-digit activity code in the box above the list and click submit. The activity code is noted below. Click submit when prompted and then click on the start link to the right of the activity title. Do not click on remove" next to an activity title unless you did not attend that activity. 4. Click on the click here link to view sessions associated with the day of the activity. 5. Enter the session code announced during the activity (e.g., A12XXX and note that the letter is case sensitive) and select the number of hours equal to your participation in the activity. 6. Click submit to receive the attestation page. 7. Confirm your participation and click submit. 8. Complete the evaluation and click the finish button. You will then be able to view and print your transcript. Date of Activity Activity Code Session Code (announced during the live activity) CPE credit hours December 2, A12 3 NEED HELP? Contact ASHP Advantage at support@ashpadvantage.com. 7

8 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists 8

9 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists James G. Stevenson, Pharm.D., FASHP Activity Chair Chief Pharmacy Officer University of Michigan Health System Professor and Associate Dean for Clinical Sciences University of Michigan College of Pharmacy Ann Arbor, Michigan James G. Stevenson, Pharm.D., FASHP, is Chief Pharmacy Officer at the University of Michigan Health System, as well as Professor and Associate Dean for the Department of Clinical Sciences at the University of Michigan College of Pharmacy. Dr. Stevenson received his Bachelor of Science and Doctor of Pharmacy degrees from Wayne State University in Detroit, Michigan. He then joined the faculty at the West Virginia University School of Pharmacy in Morgantown. Dr. Stevenson s previous appointments include Assistant Director for Clinical Services, and subsequently Associate Director for Patient Care, Education and Research Services in the Department of Pharmaceutical Services at West Virginia University Hospitals, before being appointed Director of Pharmaceutical Services. He has also served as Director of Pharmacy Services at Detroit Receiving Hospital and University Health Center, Director of the Graduate Program in Health Systems Pharmacy Management in the Wayne State University College of Pharmacy, and Executive Director of Pharmacy Services for the Detroit Medical Center. He is a Fellow of the American Society of Health-System Pharmacists (ASHP) and has been recognized as Pharmacist of the Year by both the Michigan Society of Health- System Pharmacists and the Michigan Pharmacists Association. He has also been honored with the Distinguished Alumnus Award by the Wayne State University College of Pharmacy and the Joseph Oddis Leadership Award by the Michigan Society of Health-System Pharmacists. He recently completed a term of service on the ASHP Board of Directors and received the John W. Webb Lecture Award in In 2012, Dr. Stevenson was appointed to the Michigan Board of Pharmacy. 9

10 Pharmacy Leadership Forum Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists Planned and conducted by ASHP Advantage and the Center for Health-System Pharmacy Leadership. Supported by an educational grant from Baxter Healthcare Corporation. Pharmacy Leadership Forum Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists The ABCs of Accountable Care Organizations James G. Stevenson, Pharm.D., FASHP, Chair Chief Pharmacy Officer University of Michigan Health System Professor and Associate Dean for Clinical Sciences University of Michigan College of Pharmacy Ann Arbor, Michigan Why Accountable Care Organizations (ACO)? Desire to integrate hospital and physician care Better align incentives around quality and costs, with an opportunity to share in savings Promote evidence-based and patientcentered care with improved coordination 10

11 Accountable Care Organizations Networks of physicians and other providers that work together to improve the quality and costs of health care services for a defined population Need for new system that creates incentives for providers to work together to bend the cost curve and improve quality Goal Improve care for individuals Improve health of the population Reduce growth in health care expenditures ACOs were compared to the elusive unicorn: everyone seemed to know what it looks like, but no one had actually seen one. Jenny Gold, Kaiser Staff Writer ACO Patient Centered Medical Home (Primary Care) Specialty Areas Inpatient Care and Transitions of Care Challenge to take principles from PCMH and extend to specialty care/areas; integrate with inpatient care and transitions 11

12 ACO Goals Avoid unnecessary duplication of services and medical errors Link provider reimbursements to quality metrics and reduction in the total cost of care for the assigned population When an ACO succeeds in saving health care dollars, it shares in the savings it achieved for the program Shared Savings Program Providers agree to be accountable for quality and cost of care of at least 5000 beneficiaries ACO is allowed to share in the savings it achieves if it meets specified quality measures and cost controls targets Demonstration projects have shown that with integrated approaches and coordination, significant reductions in cost of care can be realized Basic Features Enrollment of patients may be formal or through attribution to ACO that provides the preponderance of care Performance measurement including data on utilization, costs, and quality measures Costs in the ACO population are compared to other non-aco populations and savings or costs may be shared with the ACO (risk) 12

13 Key Strategies Considered by ACOs Treat patients in best location Utilize practice guidelines Utilize the expertise of team-based care Avoid unnecessary admissions Enhance data integration between providers/hospitals in all sites of care Focus on chronic care of populations Focus on preventative care, screenings, and wellness Refer internally Improve transitions of care Audience Response Which one of the following is a goal of ACOs? a. Better care for populations. b. Focus on inpatient care. c. Increase hospital admissions and revenue. d. Provide care for groups > 10,000 patients. Organization Core Principles for ACOs Strong base of primary care collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients Payments linked to quality improvements that also reduce overall costs Reliable and progressively more sophisticated performance measurement, to support improvement and provide confidence that savings are achieved through improvements in care 13

14 Organization Core Principles By placing some of the financial responsibility on the provider, ACOs hope to limit unnecessary expenditures while continuing to provide patients with the freedom to select their medical services By increasing care coordination, ACOs can help reduce unnecessary medical care and improve health outcomes, leading to a decrease in utilization of acute care services Organization Payment Models One-sided risk ACO share any savings without any financial risk through a defined time period Two-sided risk ACOs share in the savings and losses for a defined time period Importance of Medications At least 2/3 of physician visits result in prescription medication Chronic diseases managed primarily by drug therapy Medicare beneficiaries have high utilization of medications and multiple chronic conditions Suboptimal use of medications can lead to excess costs in care, hospital admissions, ED visits 14

15 Key Medication-Related Measures in CMS* Demonstration Project (Pioneer) Risk standardized, all condition readmissions Medication reconciliation after discharge from inpatient facility Currently defined as being overseen by a physician or a clinical pharmacist Influenza immunization Pneumococcal vaccination Tobacco use and tobacco cessation intervention *CMS Centers for Medicare & Medicaid Services Key Medication-Related Measures in CMS Demonstration Project (Pioneer) Diabetes hemoglobin A1c <8 LDL <100 BP < 140/90 Aspirin use poor control hemoglobin A1c >9 Controlling high blood pressure Ischemic vascular disease LDL <100 Aspirin use Heart failure Beta-blocker therapy for left ventricular systolic dysfunction Coronary artery disease Drug therapy for lowering LDL ACE inhibitor or ARB for CAD and diabetes and/or LVSD Audience Response To what degree is your pharmacy currently engaged in initiatives to improve the measures in the Pioneer ACO? a. Not at all. b. To a small degree. c. To a moderate degree. d. We are currently engaged in improving all of these through the pharmacy. 15

16 The Role of Pharmacists in ACOs Key role in assuring optimal outcomes related to medications through: Ensuring appropriate medication use Reducing adverse drug events Improving transitions of care Preventing hospital readmissions More optimal management of chronic conditions Preparation for Pharmacist Integration Developed a systematic and standardized pharmacy practice model to provide comprehensive patient care Established collaborative practice agreements with physicians Obtained special clinical privileges endorsed by credentialing committee Developed new billing structure and process for service reimbursement Pharmacist Practice Model Embedded pharmacists in primary care clinics Patient recruitment Physician referral Site-specific disease registries Targeted interventions without referral Collaborative practice agreements with delegated prescriptive authority Diabetes, hypertension, hyperlipidemia Scheduled patient visits/consults Clinic visits (30 minutes) Phone consults (15 30 minutes) 16

17 Therapeutic Interventions by Pharmacists Year 3: 2,674 interventions increased dose added medication decreased dose deleted medication optimized regimen Example of Impact on Clinical Measures Diabetes Management by pharmacists Results during Year 1 (ramp up) Patients with baseline A1c > 7% (n=270) had a mean decrease of 0.8% (95% CI 0.6 to 1.0, p<0.001) Patients with baseline A1c > 9% (n=118) had a mean decrease in A1c of 1.4% (95% CI 1.1 to 1.8, p<0.001) Focus on High Risk Patients Average Number of Admissions <$10,000 (n=1210) $10-50,000 (n=197) $>50,000 (n=40) Annual Health Care Cost 17

18 11 Large Number of Medications in High Cost Patient Population Average number of medications $20,000-50,000 (n=147) $50,000-80,000 (n=76) $80, ,000 (n=55) $110, ,000 (n=34) Annual Health Care Cost Opportunity/Call to Action Pharmacists should be actively engaged within their health-system s ACO initiatives Pharmacists should be an integral part of providing team-based care Selection of most appropriate regimen Modifying regimens as needed to achieve goals Patient education/patient empowerment Enhancing medication adherence Targeted interventions for high risk populations Opportunity/Call to Action Identify opportunities for starting new services or expanding existing programs Chronic disease management Polypharmacy Adherence Transitions of care Educational needs of patients Medication access issues Case management of high risk populations 18

19 ACO Summary Accountable for quality, cost and overall care for patients Payment reform that promotes value Shared savings program that rewards providers with incentive payments for improving quality of care and reducing cost Performance measurement that allows organizations to be accountable for quality and cost for a defined population Delivery system changes that promote integrated, organized processes of care must embrace a teambased approach Significant opportunities for pharmacists 19

20 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists 20

21 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists Darin Smith, Pharm.D., BCPS, FASHP Director Pharmacy Services and Performance Improvement Norman Regional Health System Norman, Oklahoma Darin Smith, Pharm.D., BCPS, FASHP, is Director of Pharmacy Services and Performance Improvement for Norman Regional Health System in Norman, Oklahoma. He is responsible for oversight of pharmacy services as well as leading performance improvement initiatives for Norman Regional Hospital, Norman Regional Healthplex, and Moore Medical Center. Dr. Smith received his Bachelor of Pharmacy and Doctor of Pharmacy degrees from the University of Oklahoma College of Pharmacy (OUCOP). He completed a specialty residency in pharmacokinetics at OUCOP and is board-certified in pharmacotherapy. Dr. Smith was recognized as a Fellow of the American Society of Health-System Pharmacists (ASHP) in March Dr. Smith is active with the Oklahoma Society of Health-System Pharmacists (OSHP), serving as president in , and state delegate to the ASHP House of Delegates for multiple terms. He was awarded the Oklahoma Health-System Pharmacist of the Year in 2001 and the Quality Professional Award by the Oklahoma Hospital Association in 2004 for his accomplishments and contributions in the area of quality improvement. Dr. Smith currently serves as Vice Chair for the Board of Directors of the Oklahoma Foundation for Medical Quality (Oklahoma s QIO) and chairs the Oklahoma Hospital Association Council on Quality and Patient Safety. He also serves on the Joint Commission s Hospital Advisory Council. 21

22 Pharmacy Leadership Forum Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists Value-based Purchasing Program: An Overview Darin L. Smith, Pharm.D., BCPS, FASHP Director Pharmacy Services and Performance Improvement Norman Regional Health System Norman, Oklahoma Value-Based Purchasing The Patient Protection and Affordable Care Act (H.R. 3590) Established Value-Based Purchasing Hospital Performance Score Reimbursement dollars withheld then awarded based on positive performance Percentage of Medicare reimbursement at risk 22

23 Value-Based Purchasing FFY 2013 Proposed Rules Published in Federal Register Jan 13, 2011 Vol. 76, No. 9, 42 CFR Parts 422 and 480 Comments were due no later than 5 pm, March 8 th, 2011 Applies to payments for discharges occurring on or after Oct 1 st, We are here Medicare FFY = October 1 st through September 30 th Baseline period: July 1 st, 2009 March 31 st, 2010 Measurement period: July 1 st, 2011 March 31 st, 2012 Incentive payments funded for FFY 2013 through a reduction in FFY 2013 base operating DRG payments for each discharge of 1% Proposed Rules Federal Register 23

24 Rules and Regulation Federal Register Rules and Regulation Federal Register 24

25 The overarching goal of these initiatives is to transform Medicare from a passive payer of claims to an active purchaser of quality healthcare for its beneficiaries. This new program will necessarily be a fluid model, subject to change as knowledge, measures and tools evolve. Measures or measurement domains need not be given equal weight, but over time, scoring methodologies should be more weighted towards outcome, patient experience and functional status measures. Across all programs, CMS seeks to move as quickly as possible to the use of primarily outcome and patient experience measures. 25

26 HR 3590 The Patient Protection and Affordable Care Value-Based Purchasing (VBP) 30-day Mortality: AMI,HF,PNE FFY2014 Medicare spending per beneficiary AMI, PNE, HF SCIP/HOP Efficiency Measures (Section 3001) At Risk: FFY2014 Core Measures (Section 3001) CLABSI SSI Healthcare-Associated Infections (HAI) (Section 3001) At Risk: 1% FFY2013, 1.25% FFY2014, 1.5% FFY2015, 1.75% FFY2016, 2% FFY2017 and beyond Medicare Reimbursement Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Section 3001) Winners/Losers Budget Neutral CAUTI, Vascular Catheter Associated Infections, Poor Glycemic Control Hospital Acquired Conditions (HAC) (Section 3008) AHRQ Patient Safety Indicators At Risk: 1% reduction beginning FFY2015 Foreign Object Postop, Air Embolism, Blood Incompatibility, Pressure Ulcer, Falls/Trauma Losers Only - $1.4 billion cut/10 yrs nationwide At Risk: 1% reduction in FFY2013, may increase to 3 to 5% Readmission Rates (Section 3025) COPD, CABG, PTCA, etc. Losers Only - $10 billion cut/10 yrs nationwide AMI, PNE, HF HR 3590 The Patient Protection and Affordable Care Value-Based Purchasing (VBP) 30-day Mortality: AMI,HF,PNE FFY2014 Medicare spending per beneficiary AMI, PNE, HF SCIP/HOP Efficiency Measures (Section 3001) At Risk: FFY2014 Core Measures (Section 3001) CLABSI SSI Healthcare-Associated Infections (HAI) (Section 3001) At Risk: 1% FFY2013, 1.25% FFY2014, 1.5% FFY2015, 1.75% FFY2016, 2% FFY2017 and beyond Medicare Reimbursement Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Section 3001) Winners/Losers Budget Neutral CAUTI, Vascular Catheter Associated Infections, Poor Glycemic Control Hospital Acquired Conditions (HAC) (Section 3008) AHRQ Patient Safety Indicators At Risk: 1% reduction beginning FFY2015 Foreign Object Postop, Air Embolism, Blood Incompatibility, Pressure Ulcer, Falls/Trauma Losers Only - $1.4 billion cut/10 yrs nationwide At Risk: 1% reduction in FFY2013, may increase to 3 to 5% Readmission Rates (Section 3025) COPD, CABG, PTCA, etc. Losers Only - $10 billion cut/10 yrs nationwide AMI, PNE, HF 26

27 VBP FFY We are here VBP Patient Experience VBP FFY 2013 HCAHPS 30% Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication about Medications Cleanliness and Quietness Discharge Information Overall Rating of Hospital VBP FFY 2014 HCAHPS 30% Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication about Medications Cleanliness and Quietness Discharge Information Overall Rating of Hospital VBP FFY 2015 HCAHPS 30% Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication about Medications Cleanliness and Quietness Discharge Information Overall Rating of Hospital We are here 27

28 VBP Process of Care Measures FFY 2013 FFY 2014 FFY % 45% 20% AMI-7A Fibrinolytic received within 30 min of arrival X X X AMI-8A PCI received within 90 min of arrival X X X HF-1 Discharge instructions X X Retired PN-3b Blood culture before 1 st antibiotic X X X PN-6 Initial antibiotic selection X X X SCIP-1 Antibiotic within 1 hour before incision (2 hours if Vancomycin/Quinolone) X X X SCIP-2 Appropriate prophylactic antibiotic selection X X X SCIP-3 Prophylactic antibiotic discontinued within 24 hours X X X SCIP-4 Controlled 6 AM post-op glucose cardiac surgery X X X SCIP-9 Post-op urinary catheter removal on day 1 or 2 New X SCIP VTE-1 VTE prophylaxis ordered X X Retired SCIP VTE-2 VTE prophylaxis received within 24 hours prior to or after surgery X X X SCIP Card-2 Pre-admission/peri-operative beta-blocker X X X Achievement Points Applies to Process of Care and HCAHPS* Scoring Points awarded based on individual hospital performance compared to all hospitals (achievement) (threshold) 50 th percentile of all hospitals (benchmark) mean of the top decile (~95 th %ile) Scoring 10 points (hospital rate at or above benchmark) 1 to 9 points (hospital rate equal to or greater than the achievement threshold and less than the benchmark) 0 points (hospital rate below achievement threshold) HCAHPS - Hospital Consumer Assessment of Healthcare Providers and System 28

29 Improvement Points Applies to Process of Care and HCAHPS Scoring Points awarded by comparing hospital s current performance rate to baseline period (self comparison) Scoring: 9 points (hospital rate at or above benchmark) 0 to 9 points (hospital rate between the baseline rate and the benchmark) 0 points (hospital rate at or below baseline rate) Consistency Points Applies to HCAHPS Scoring Only Purpose: to reward hospitals that have scores above the national 50 th percentile for all 8 HCAHPS dimensions Scoring (possible 20 points): 20 points (hospital rate 50th %ile for all 8 HCAHPS dimensions) 0-20 points (lowest dimension is compared to the range between the national 0 percentile (floor) and the 50 th percentile (threshold) and awarded points proportionately 29

30 Norman Regional Health System Payment Summary FFY 2013 Norman Regional Health System Payment Summary FFY 2013 Top Decile 50 th %ile 30

31 Norman Regional Health System Payment Summary FFY 2013 Top Decile 50 th %ile Norman Regional Health System Payment Summary FFY 2013 NRHS at Risk ~$500,000 (1%) x = Return of $476,794 Estimated Loss = $23,206 31

32 VBP Outcomes (Mortality) VBP FFY % MORTALITY 30 Day Mortality Acute Myocardial Infarction 30 Day Mortality Heart Failure 30 Day Mortality Pneumonia VBP FFY % MORTALITY 30 Day Mortality Acute Myocardial Infarction 30 Day Mortality Heart Failure 30 Day Mortality Pneumonia COMPLICATIONS/PATIENT SAFETY AHRQ Patient Safety Indicator Composite CLABSI Central Line-Associated Blood Stream Infection VBP Efficiency VBP FFY % Medicare Spending Per Beneficiary (MSBP) 32

33 VBP Efficiency VBP Baseline vs Performance We are here FFY2013 (Oct 2012-Sep 2013) Baseline Performance Period Core Measures/SCIP Jul 1, 2009-Mar 31, 2010 Jul 1, 2011-Mar 31, 2012 HCAHPS Jul 1, 2009-Mar 31, 2010 Jul 1, 2011-Mar 31, 2012 FFY2014 (Oct 2013-Sep 2014) Baseline Performance Period Core Measures/SCIP Apr 1, 2010-Dec 31, 2010 Apr 1, 2012-Dec 31, 2012 HCAHPS Apr 1, 2010-Dec 31, 2010 Apr 1, 2012-Dec 31, 2012 Outcomes (Mortality) Jul 1, 2009-Jun 30, 2010 Jul 1, 2011-Jun 30, 2012 FFY2015 (Oct 2014-Sep 2015) Baseline Performance Period Core Measures/SCIP Jan 1, 2011-Dec 31, 2011 Jan 1, 2013-Dec 31, 2013 HCAHPS Jan 1, 2011-Dec 31, 2011 Jan 1, 2013-Dec 31, 2013 Outcomes Mortality Oct 1, 2010-Jun 30, 2011 Oct 1, 2012-Jun 30, 2013 PSI Composite Oct 15, 2010-Jun30, 2011 Oct 15, 2012-Jun 30, 2013 CLABSI Jan 1, 2011-Dec 31, 2011 Feb 1, 2013-Dec 31, 2013 Efficiency May 1, 2011-Dec 31, 2011 May, Dec 31,

34 HR 3590 The Patient Protection and Affordable Care Value-Based Purchasing (VBP) 30-day Mortality: AMI,HF,PNE FFY2014 Medicare spending per beneficiary AMI, PNE, HF SCIP/HOP Efficiency Measures (Section 3001) At Risk: FFY2014 Core Measures (Section 3001) CLABSI SSI Healthcare-Associated Infections (HAI) (Section 3001) At Risk: 1% FFY2013, 1.25% FFY2014, 1.5% FFY2015, 1.75% FFY2016, 2% FFY2017 and beyond Medicare Reimbursement Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Section 3001) Winners/Losers Budget Neutral CAUTI, Vascular Catheter Associated Infections, Poor Glycemic Control Hospital Acquired Conditions (HAC) (Section 3008) AHRQ Patient Safety Indicators At Risk: 1% reduction beginning FFY2015 Foreign Object Postop, Air Embolism, Blood Incompatibility, Pressure Ulcer, Falls/Trauma Losers Only - $1.4 billion cut/10 yrs nationwide At Risk: 1% reduction in FFY2013, may increase to 3 to 5% Readmission Rates (Section 3025) COPD, CABG, PTCA, etc. Losers Only - $10 billion cut/10 yrs nationwide AMI, PNE, HF VBP Hospital-Acquired Conditions Condition Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcers Stages III & IV Falls and Trauma Vascular Catheter-Associated Infection Catheter-Associated UTI Manifestations of Poor Glycemic Control 34

35 VBP Hospital-Acquired Conditions NRHS at Risk ~$500,000 (1%) x? = Return of $? HR 3590 The Patient Protection and Affordable Care Value-Based Purchasing (VBP) 30-day Mortality: AMI,HF,PNE FFY2014 Medicare spending per beneficiary AMI, PNE, HF SCIP/HOP Efficiency Measures (Section 3001) At Risk: FFY2014 Core Measures (Section 3001) CLABSI SSI Healthcare-Associated Infections (HAI) (Section 3001) At Risk: 1% FFY2013, 1.25% FFY2014, 1.5% FFY2015, 1.75% FFY2016, 2% FFY2017 and beyond Medicare Reimbursement Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Section 3001) Winners/Losers Budget Neutral CAUTI, Vascular Catheter Associated Infections, Poor Glycemic Control Hospital Acquired Conditions (HAC) (Section 3008) AHRQ Patient Safety Indicators At Risk: 1% reduction beginning FFY2015 Foreign Object Postop, Air Embolism, Blood Incompatibility, Pressure Ulcer, Falls/Trauma Losers Only - $1.4 billion cut/10 yrs nationwide At Risk: 1% reduction in FFY2013, may increase to 3 to 5% Readmission Rates (Section 3025) COPD, CABG, PTCA, etc. Losers Only - $10 billion cut/10 yrs nationwide AMI, PNE, HF 35

36 Readmissions Readmissions (30 Day All Cause) FFY 2013, FFY 2014 Acute Myocardial Infarction (AMI) Pneumonia (PNE) Heart Failure (HF) Readmissions (30 Day All Cause) FFY 2015 Chronic Obstructive Pulmonary Disease (COPD) Coronary Artery Bypass Graft (CABG) Percutaneous Transluminal Coronary Angioplasty (PTCA) Other Vascular Conditions Readmissions 36

37 Readmissions VBP Medicare Dollars at Risk FFY 11 FFY 12 FFY 13 FFY 14 FFY 15 FFY 16 FFY 17 VBP 1% VBP 1.25% VBP 1.5% VBP 1.75% VBP 2% 2%? Readmissions 1% Readmissions 2% Readmissions 3% Readmissions 3% Readmissions 3% 3%? HAC 1% HAC 1% HAC 1% 1%? 2% Total 3.25% Total 5.5% Total 5.75% Total 6% Total 6%? Medicare Federal Fiscal Year (FFY) = Oct 1 st Sep 30 th (ie. FFY 13 = Oct 1 st, 2012 Sep 30 th, 2013) 37

38 38

39 39

40 40

41 Remember Data must be publicly reported for 1 year on to be eligible for VBP inclusion Opportunities for the Pharmacist Process of Care/HCAHPS Medication Related Process of Care Measures Readmissions and 30-Day Mortality Impact of evidence-based medication use (AMI, HF, PNE) Hospital Acquired Conditions Falls and Trauma (inappropriate medication use) Manifestations of Poor Glycemic Control (hyperglycemia management) CAUTI, CLABSI (antimicrobial stewardship) Future measures proposed for potential VBP inclusion Immunization (Pneumococcal and Influenza) Healthcare Provider (HCP) Influenza Immunization Rates Venous Thromboembolism (VTE) Measures (medication use) Stroke Measures (STK) (medication use) Clostridium difficile rates (antimicrobial stewardship) Medication Related HCAHPS Measures FFY2013 (11 of 12) (2 of 8)* FFY 2014 (11 of 13) (2 of 8)* FFY 2015 (9 of 11) (2 of 8)* *Pain Management, Communication about Medications 41

42 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists 42

43 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists Shelly Spiro, B.S.Pharm., FASCP Executive Director Pharmacy e-hit Collaborative Alexandria, Virginia Shelly Spiro, B.S.Pharm., FASCP, is Executive Director of the Pharmacy e-health Information Technology Collaborative (e-hit Collaborative). The e-hit Collaborative is an organization of major national pharmacy associations and associate members focused on assuring the meaningful use of standardized electronic health records that support safe, efficient, and effective medication use and continuity of care. An additional goal of the e-hit Collaborative is to assure that pharmacists are part of the health care team providing quality patient-care services that are integrated into the national health information technology (HIT) interoperability framework. Ms. Spiro received her Bachelor of Pharmacy degree from the University of Illinois at Chicago. Ms. Spiro is active in national pharmacy associations and standards development organizations including the National Council for Prescription Drug Programs, Health Level Seven International, and The Accredited Standards Committee X12. She is a past president and fellow of the American Society of Consultant Pharmacists. 43

44 Pharmacy Leadership Forum Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists Clinical Quality Measures and Meaningful Use of EHRs: Are You Ready for Stage 2? Shelly Spiro, B.S.Pharm., FASCP Executive Director Pharmacy e-hit Collaborative Alexandria, Virginia Background Reporting of clinical quality measures (CQMs) will change for all providers beginning 2014 Eligible Professionals (EPs) Eligible Hospitals (EHs) Critical Access Hospitals (CAHs) CQMs are now incorporated into the definition of a meaningful user rather than part of Core Set Measures 16 CQMs required for EH/CAH 9 Measures for EP Source: 2014 Clinical Quality Measures. Guidance/Legislation/EHRIncentivePrograms/2014_ClinicalQualityMeasures.html (2012 October 29). Download Useful Tools and Educate Yourself Publicly Available Tools hosted by the Advisory Board Company Meaningful Use The Whiteboard Story Quick Guide Comparison Stage 1 to Stage 2 Objectives and Measures Bookmark versions of the Final Rules advisory.com 44

45 Meaningful Use the Whiteboard Story Stage 1 Stage 2 Certification Standards A Red band on a cell = change from the proposed rule Data Elements Legend Zoom to 100% and Scroll Around to See the Text Objectives, Numerators, Denominators, Thresholds, Exclusions, and more Meaningful Use Pocket Guide 45

46 Pocket Guide Source: Pocket Quick Guide Comparison Stage 1 to Stage 2 Meaningful Use Final Rule Objectives and Measures. (2012 October 29). EH View Download - Transmit 46

47 Audience Response Reporting of clinical quality measures (CQMs) will change for all providers beginning: a b c d Audience Response For reporting on Clinical Quality Measures (CQMs): a. EPs, EHs, and CAHs all report on the same number of CQMs. b. EPs and EHs report on 16 CQMs and CAHs report on 9 CQMs. c. EPs report on16 CQMs and EHs/CAHs report on 9 CQMs. d. EPs report on 9 CQMs and EHs/CAHs report on 16 CQMs. Eligible Professionals (EP), Eligible Hospitals (EHs),Critical Access Hospitals (CAHs), Clinical Quality Measures (CQMs) CQMs Relate to Certified EHR CQMs eliminated from the core objective EPs and EHs are still required to report CQMs to CMS or the States To demonstrate MU of certified EHR technology EHs and CAHs must report on 16 of the 29 CQMs EHs and CAHs must select CQMs from at least 3 of the 6 key healthcare quality domains 47

48 National Quality Strategy (NQS) Domains Patient and Family Engagement Patient Safety Care Coordination Population and Public Health Effective Use of Healthcare Resources Clinical Process/Effectiveness USHIK United States Health Information Knowledgebase (USHIK) USHIK website provides Publicly accessible registry and repository Human-readable and some computable formats for viewing, downloading, and comparing electronic CQM versions and their value sets AHRQ USHIK is a metadata registry of healthcare-related standards Data elements, and metadata funded and directed by AHRQ, in partnership with the Centers for Medicare and Medicaid Services (CMS) and the Veterans Administration Agency for Healthcare Research and Quality 2014 Meaningful Use Clinical Quality Measures Posted to United States Health Information Knowledgebase (USHIK). (2012 November 1). AHRQ - USHIK Agency for Healthcare Research and Quality 2014 Meaningful Use Clinical Quality Measures Posted to United States Health Information Knowledgebase (USHIK). (2012 November 1). 48

49 MU Measures and Meta Data Agency for Healthcare Research and Quality 2014 Meaningful Use Clinical Quality Measures Posted to United States Health Information Knowledgebase (USHIK). (2012 November 1). AHRQ MU CQMs Agency for Healthcare Research and Quality 2014 Meaningful Use Clinical Quality Measures Posted to United States Health Information Knowledgebase (USHIK). (2012 November 1). Audience Response Eligible Hospitals (EHs)and Critical Access Hospitals (CAHs) will submit: a. 9 Clinical Quality Measures (CQMs) from at least 3 of the National Quality Strategy (NQS) domains out of a potential 64 CQMs across 6 domains. b. 9 CQMs from at least 3 of the NQS domains out of a potential 29 CQMs across 6 domains. c. 16 CQMs from at least 3 of the NQS domains out of a potential 64 CQMs across 6 domains. d. 16 CQMs from at least 3 of the NQS domains out of a potential 29 CQMs across 6 domains. 49

50 Pharmacists Focus Care transitions including MR Active reconciled medication list Bi-directional exchange Patient Engagement Electronic access to patients medical record Blue Button project MU Stages 2 & 3 Comments Pharmacy e-hit Collaborative Comments Collaborative Measure Comments for Pharmacists using Pharmacist EHR (Dec 2010) Medication Reconciliation (MR) Improving Care Transitions: Optimizing Medication Reconciliation: March oclibrary/policy/patien tsafety/optimizing- Med- Reconciliation.aspx 50

51 Foundational Concepts Through MR Improve care transitions Reduce the impact of medication-related problem Pharmacist play an important role in all practice settings Continuity of Care Document (CCD) Exchange of clinical data between EHRs Development of metadata standards for structured documents Clinical Document Architecture, Release Two (CDA R2) Standard developed by Health Level Seven (HL7) Provides wide coverage across metadata elements A single standard would make implementation easier Contain narrative text Use of Normalized Terminologies Consolidated CDA Release 2 Some contain structured data elements or clinical statements Some are coded using standard vocabularies (e.g. Systematized Nomenclature of Medicine--Clinical Terms, SNOMED CT) Extensible Markup Language (XML) structured documents Discharge Summary, Patient Care Summary, Imaging Report, Admission & Physical, Pathology Report, Medication Action Plan (MAP) 51

52 HL7-NCPDP Joint Project Electronic Documentation Medication Action Plan (MAP) Active reconciled medication list Indications for each medications Recommended instructions Use RxNorm*, SNOMED CT**, and LOINC *** *RxNorm- normalized names for clinical drugs; **SNOMED clinical terms, ***LOINC - universal code system for laboratory and clinical observations Structured Standard Terminology In September 2012, 274 MTM specific SNOMED CT definitions approved for nationwide use by National Library of Medicine (NLM) Collaborative volunteer PSTAC work group working on reference guide for med management documentation and exchange of the SNOMED CT clinical concepts The reference guide categories the codes by encounters, interventions and outcomes To educate pharmacists and PMS vendors on incorporating the MTM SNOMED CT codes into their systems 52

53 PSTAC WG Next Steps Work on IG for Professional Care Plan, Quality and Value Assessment, and Care Transitions More SNOMED CT codes CPT Codes for Pharmacists Standardized terminology Process of Care Structure Documents Pharmacy Care Transitions Document Quality & Value Assessment Pharmacy Care Note With Reconciled Medication List Medication Action Plan Pharmacy e-health Information Technology Collaborative The Roadmap for Pharmacy Health Information Technology Integration in U.S. Health Care 53

54 Website ( Pharmacists Contribute to MU 54

55 EH View Download - Transmit Required data elements to be available for EH View, Download, and Transmit Patient name Admit and discharge date and location Reason for hospitalization Care team including the attending of record as well as other providers of care Procedures performed during admission Current and past problem list Current medication list and medication history Current medication allergy list and medication allergy history Vital signs at discharge Laboratory test results (available at time of discharge) Summary of care record for transitions of care or referrals to another provider 2012 THE ADVISORY BOARD COMPANY ADVISORY.COM Care plan field(s), including goals, and instructions Discharge instructions for patient Demographics maintained by hospital (sex, race, ethnicity, date of birth, preferred language) Smoking status Note: Discharge summary NOT included. 55

56 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists 56

57 Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists Kathleen S. Pawlicki, M.S., B.S.Pharm., FASHP Administrative Director of Professional Services and Director of Pharmaceutical Services William Beaumont Hospital Royal Oak, Michigan Kathleen S. Pawlicki, M.S., B.S.Pharm., FASHP, is Administrative Director of Professional Services and Director of Pharmaceutical Services at William Beaumont Hospital in Royal Oak, Michigan. Over the past 20 years, she has held several administrative roles at small, medium, and large hospitals. Ms. Pawlicki is also a clinical instructor for the College of Pharmacy at the University of Michigan and an Adjunct Assistant Professor for the College of Pharmacy and Allied Health Professions at Wayne State University. Ms. Pawlicki received her Bachelor of Pharmacy degree from Ferris State University in Big Rapids, Michigan, and her Master of Science degree in pharmacy from Wayne State University in Detroit, Michigan. She also completed an ASHP-accredited residency in hospital pharmacy. Ms. Pawlicki was recognized as a Fellow of the American Society of Health-System Pharmacists (ASHP) in In September, Ms. Pawlicki was elected to the ASHP Board of Directors. Her term will begin in June She has served in various capacities in regional and state healthsystem pharmacy associations, including president of both the Southeast Michigan Society of Health-System Pharmacists and the Michigan Society of Health-System Pharmacists (MSHP). For over seven years, Ms. Pawlicki has served as delegate to the ASHP House of Delegates for the State of Michigan. In 2004, she received the MSHP Pharmacist of the Year Award. Ms. Pawlicki is an active member of ASHP and served on the ASHP Council for Administrative Affairs and as Director-at-Large and Chair of the Executive Committee of the ASHP Section of Pharmacy Practice Mangers. 57

58 Pharmacy Leadership Forum Pharmacy and the New Health Care Model: Roles and Responsibilities for Pharmacists The Pharmacist s Role in the New Health Care Model: New Opportunities and Challenges Kathleen S. Pawlicki, M.S., B.S.Pharm., FASHP Administrative Director of Professional Services and Director of Pharmaceutical Services William Beaumont Hospital Royal Oak, Michigan Opportunities Quality Measures & Financial Impact Accountable Care Organization (ACO) shared savings when ACO meets specified quality measures and cost controls targets Value-based Purchasing (VBP) Medicare will be an active purchaser of quality (Core Measures) Electronic Health Records (EHR) and Meaningful Use reporting of clinical quality measures Opportunities Acute Care Reduced readmissions Core Measures Patient satisfaction (medication education) Ambulatory Care Chronic conditions Medication adherence Transitions of Care Medication histories Appropriate discharge prescribing 58

59 Challenges 2010 PPMI* Results 147 beliefs, assumptions, and recommendations focused on: Imperatives Optimal pharmacy practice models Technology/technicians Successful implementation Includes barriers to meeting the practice model imitative PPMI -The Pharmacy Practice Model Initiative Challenges PPMI Results: Top Barriers Pharmacists commitment: Resistance to change from current pharmacy staff is a barrier to optimal pharmacy practice models Consensus vote: 100% Challenges PPMI Results: Top Barriers Institutional Culture Insufficient recognition by health care executives, medical staff, nursing staff, & others outside the pharmacy profession of the value of pharmacists provision of drug-therapy management services is a barrier to optimal pharmacy practice models. Consensus vote: 100% 59

60 Challenges PPMI Results: Top Barriers Legal & regulatory environment State laws that limit pharmacists scopes of practice are barriers to optimal pharmacy practice models - Consensus vote: 100% Opportunities versus Challenges Opportunities ACO, VBP, Clinical Quality Measures External forces, not in our control Challenges Pharmacists, Culture, Regulatory Internal forces, within our control We are our own worst enemy The Biggest Opportunity and Challenge Creating Change Pharmacists Institutional Culture 60

61 Start with yourself..... Creating Change Are you ready for the challenge, do you believe in the opportunities and possibilities? Are you a great leader? Are you an effective leader? Creating Change Are you a great leader? Great leaders are those who see themselves as having a responsibility, not those who view themselves as having a job - Jim Collins Creating Change Are you an effective leader? Ineffective Leaders No, because. Effective Leaders Yes, if. 61