Exploring a Pharmacist s Role in a Super Utilizer Clinic

Transcription

1 Exploring a Pharmacist s Role in a Super Utilizer Clinic Natalia Tarasiuk, PharmD, BCACP ntarasiuk2@lghealth.org Pennsylvania Society of Health System Pharmacists Annual Assembly October 13, 2017

2 Objectives Discuss the nature of a super utilizer clinic Discover ways to involve pharmacists in a patient centered medical home caring for a vulnerable population Review the importance of a pharmacist on a multi-disciplinary team providing transition of care services

3 Super Utilizers Beneficiaries with complex, unaddressed health issues and a history of frequent encounters with health care providers A small section of the population that accounts for a large portion of emergency room visits and puts a heavy burden on hospital services and public health budgets Patients with complex health and social needs Healthcare Hot Spotters The Problem: Super-utilizers account for 3% of all hospital admissions, but 10% ($1.25 billion) in total hospital costs er-costs-and/article_844956f4-6e26-11e7-a06e-0fdc29b0702d.html Atul Gaw ande. The Hot Spotters -- Can w e low er medical costs by giving the neediest patients better care? The New Yorker. January 24, 2011

4 Care Connections A community care team providing an innovative, intensive, and temporary primary care medical home for high-risk patients. Mission: To transform the quality of care for patients with complex needs, by utilizing innovative delivery models and empowering each patient with sustainable skills and resources to self-manage care in his/her primary care setting. Engagement Advocacy Values Quality Care Sustainability Empowerment

5 The Care Connections Team Clinical Support Specialist (front staff), 3.2 FTE Patient Care Navigators, 3.0 FTE Physician, 2.1 FTE RN Case manager, 2.0 FTE Promotion Specialist, 1.0 FTE Program Supervisor, 1.0 FTE Program Manager, 1.0 FTE Advanced Practice Provider (NP), 2.0 FTE Social worker/ Behavioral Health, 1.0 FTE Chaplain, 1.0 FTE Additional Services: Population Health Fellow Geriatric Assessment Homeless Coalition Financial counseling Hershey Med Students NP students FP residents ACCT training Admin support Medical Legal Attorney, 0.8 FTE Clinical pharmacist, 0.5 FTE Clinical Psychologist, 0.1 FTE

6 The Care Connections Patient Complex Medical Issues/ 5+ Meds Utilization Psychosocial Barrier Care Connections Patient

7 Timeline and Success October 2010 FMEC Call to Action July 2011 First Care Navigator hired Pilot Kicks off Proof of Concept Patients Enrolled in the Program 42% ED Visits Spring 2011 Visit to Camden LG Foundation grant $75,000 August 2013 Care Connections is born 53% Hospital Visits

8 A Care Connections Patient 68 year old white male Past medical history: HFpEF, CKD stage III, atrial fibrillation, history of PE/DVT, CAD, DM2, HTN, HLD, hypothyroidism, developmental delay, history of CVA, GERD Hospitalizations mostly involving CHF exacerbations Lives in an apartment on his own but recently discharged from a skilled living facility Relies on his brother in law for medication management

9 Medication Sig Patient Adherence acetaminophen 650 MG CRtab Take 650 mg by mouth every 4 hours as needed for Pain. Patient has several bottles and a blister pack available as needed - does not use often amlodipine 5 MG tablet Take 1 tablet by mouth daily. Patient had two bottles with two different generic brands in them - pill box partially filled with this medication in the AM - appears to be taking apixaban 2.5 MG tablet Take 1 tablet by mouth 2 times daily. Present in blister pack bisacodyl 10 MG SUPP Insert 10 mg per rectum daily as needed. Not present; may not be taking Dextromethorphan-Guaifenesin Take by mouth every 4 hours as needed. Not present; may not be taking ergocalciferol (VITAMIN D) UNIT cap Take 50,000 Units by mouth every 30 days Takes on the 26th - missed last month's dose famotidine 20 MG tablet Take 20 mg by mouth daily. Taking once daily - potentially twice daily folic acid 1 MG tablet Take 1 mg by mouth daily. Taking once daily gabapentin 100 MG capsule Take 1 capsule by mouth 3 times daily. Has both 300 mg and 100 mg strength Glucagon, rdna1 MG KIT by Injection route. insulin glargine 100 UNIT/ML injector pen Inject 50 Units subcutaneously at bedtime. Taking 50 units once daily Insulin Lispro 100 UNIT/ML SOPN Inject 10 Units subcutaneously 2 times daily Taking 10 units with breakfast and lunch Other medications present in the home: Furosemide 40 mg once daily - not taking Quetiapine 25 mg once daily - taking Insulin Lispro 100 UNIT/ML SOPN Inject 8 Units subcutaneously daily (with dinner). Taking 8 units with dinner iron polysaccharides 150 MG CAPS Take 150 mg by mouth 2 times daily. Patient has multiple blister packs, bottles or niferex. Taking Hydralazine 10 mg once daily - 3 bottles -twice sporadically daily levothyroxine 100 MCG tablet Take taking 100 mcg by mouth every morning on empty Taking 30 minutes before meals - patient prefers this with all stomach, Rivaroxaban at least minutes mg once before daily food. taking his meds in a med box loratadine 10 MG capsule Take 10 mg by mouth daily. Not present; not taking Magnesium 200 MG TABS Take 200 mg by mouth 2 times daily. Has both 200 mg and 250 mg tablets present Does not keep this med in his med box metoprolol 25 MG 24 hrtab Take 1 tablet by mouth daily - Do not crush tablet -. Appears to have been taking 100 mg and 25 mg dose together omega-3 acid ethyl esters 1 GM capsule Take 1 g by mouth daily Takes in AM - multiple bottles polyethylene glycol PACK Take 17 g by mouth daily. Needs a refill potassium chloride SA 20 MEQ tablet Take 20 meq by mouth daily. Takes once daily pravastatin 80 MG tablet Take 80 mg by mouth at bedtime Several bottles with two different generic manufacturers present Sennosides 17.2 MG TABS Take 1 tablet by mouth daily. Takes two 8.6 mg tablets torsemide 20 MG tablet Take 2 tablets by mouth daily. One blister pack contained this dose. In addition, patient had 10 mg tablets present - may have been taking both

10 Home Visit Recommendations for Provider Medication Reconciliation Patient taking both apixaban and rivaroxaban - no overt bleeding, consider repeating Hgb Discarded rivaroxaban - consider apixaban 5 mg BID Patient taking up to metoprolol succinate 125 mg once daily - asymptomatic Removed 100 mg dose from home; monitor HR and BP Patient may be taking up to 50 mg torsemide daily (40 mg from blister pack + 10 mg filled in mediset) Repeat BMP and monitor fluid status; recent 2 lb weight loss Patient is taking hydralazine 10 mg once daily sporadically Removed from mediset - re-evaluate BP Patient taking quetiapine 25 mg once daily Unclear indication- documented potentially as cognitive impairment and dementia; added to med list as a historical med Patient may be taking gabapentin 100 mg TID + gabapentin 300 mg at random times Removed gabapentin 300 mg dose Consider twice daily dosing of gabapentin based on last checked renal function Patient currently has 100 mg capsules at home Patient may have been taking pravastatin 80 mg x2 daily Filled med box with once daily dosing Consider high intensity statin Patient not taking loratadine, robitussin dm, bisacodyl suppository Removed from med list

11 Pharmacist Role Comprehensive Medication Management Joint office visits with provider and team Anticoagulation Management Transition of Care medication review Home visits Chronic Disease State Collaborative Education and Management Pain Management and Addiction Medication Management Antimicrobial Stewardship Drug Information Resource Team Education Collaboration with specialty practices Medication adherence monitoring and assistance

12 Transitions of Care 67% of patients have unintended medication discrepancies upon hospitalization 11-59% of discrepancies may be clinically significant Best Possible Medication History Various levels of transitions: Home Hospital/Health Systems Facilities personal care homes, skilled nursing facilities Specialty Practices dialysis centers, transplant, cardiology practices

13 The Care Connections Transition Comprehensive Medication Management In office/home medication review Graduation summary Communication with primary care provider regarding medication related changes and adherence

14 Transitions of Care within Hospital Identification of patients in hospital/facility in daily clinical huddle Utilize electronic medical record for medication review at admission and discharge for patients at Lancaster General Health Patients at outside hospitals: clinical support staff communicate with hospitals to acquire medication lists, progress notes, discharge summaries Pharmacy note in medical record for every patient transitioning Medication reconciliation: Medications started, stopped, dosage modifications Recommendations for provider regarding medication management based on renal function, reason for admission, laboratory monitoring

15 Transitions with Facilities and Specialty Practice Sites Facilities Nurse case managers review facilities list once weekly Clinical support staff obtain documents Specialty Practice Sites Communication with nursing staff and patient care navigator

16 Summary and Future Directions Pharmacist is a valuable member of a super utilizer clinic Patients transitioning at various levels are vulnerable and involving a pharmacist in this process is critical There is an opportunity at Care Connections for more support rounding inpatient, more office time, and increased number of transition of care home visits