Practice Spotlight Palomar Health Escondido, California North San Diego County www.palomarhealth.org Cedric Terrell, Pharm.D., MHA District Director, Pharmacy Services Diana Schultz, B.S.Pharm., MHSA Medication Safety Manager Jennifer Floyd, Pharm.D., BCPS Clinical Education Specialist IN YOUR VIEW, HOW WOULD YOU DEFINE THE IDEAL PHARMACY PRACTICE MODEL? Our ideal practice model centers on the patient and strives to utilize pharmacists and pharmacy technicians at the top of their professional license. It is a practice that upholds financial strength, customer service, quality, and workforce development and integrates pharmaceutical care across the healthcare continuum. We believe this ideal practice model will lead to the achievement of our vision: to optimize therapeutic outcomes by providing compassionate care through medication management, education, and collaboration with our patients and professional colleagues. HOW DO PHARMACISTS IN YOUR RE-DESIGNED PHARMACY PRACTICE MODEL PROVIDE CARE TO PATIENTS AND ENSURE SAFE AND EFFECTIVE MEDICATION THERAPY? Palomar Health (PPH) is the largest nonprofit public hospital district in California, serving more than 500,000 residents in Inland North San Diego County over an 850 square mile area. As a Level II Trauma center we service 2,200 square miles in the North County District. Palomar Health includes Palomar Medical Center (PMC), Palomar Health Downtown Campus (PHDC), Pomerado Hospital (POM), Villa Pomerado Skilled Nursing Facility, Palomar Behavioral Health Services, Palomar Acute Rehabilitative Services, Retail Health Clinics, Arch Health Partners (Physician Practice Group), and Palomar Home Health Care. American Society of Health-System Pharmacists 7272 Wisconsin Avenue, Bethesda, Maryland 20814 301-657-3000 1
Acute Care Services Previous staffing at all three of our facilities consisted of the traditional model, with central pharmacists responsible for distribution and unit pharmacists responsible for verification and clinical duties (pharmacokinetic, warfarin dosing, etc.) for their individual units. In order to expand clinical services and to provide further care to our patients we redesigned our model to include new verification shifts, in which the sole function is verification across the district. These were designed to be conducted in a quiet uninterrupted setting so those pharmacists are completely focused on each patient order. The new verification shifts decreased the turnaround time on medication dispensing and cut down the phone calls for our distribution pharmacists. Furthermore, these new shifts also allowed our unit pharmacists to focus on their clinical duties more efficiently and participate in interdisciplinary patient care rounds, medication reconciliation, discharge counseling, and precepting to our interns, clerkship students, and residents. Other pharmacy programs that are essential to safe and effective medication therapy are our antimicrobial stewardship, anticoagulation, and transitions of care programs. Transitions of Care (TOC) Program The district-wide staffing redesign not only improved our inpatient medication safety and efficacy but was also instrumental in expanding our transitions of care program (TOC). Our TOC program ensures accurate medication histories, provides consultative medication therapy management, comprehensive medication reconciliation at discharge, and direct patient education to support optimum therapeutic medication regimens, patient safety, a nd patient medication adherence. Our TOC program consists of two main programs: our Community-Based Care Transitions program and our Orthopedic Pharmacy Services program. Both are excellent examples of how we provide patient-centered pharmaceutical care that is integrated across the healthcare continuum and utilizes pharmacists and pharmacy technicians at the top of their professional licensure. For both programs, we have pharmacy technicians working as medication intake coordinators (MICs) who conduct patient interviews, document medication history in each patient medical record, and obtain home medication lists. For the orthopedic program, the MICs attend the preoperative joint replacement education class to obtain home medication lists from the patient and follow up with phone calls for any missing information. Pharmacists review all home medication lists at admission and reconcile any discrepancies. During the inpatient stay the pharmacists manage the patient s blood sugar through insulin protocols as well as provide renal dosing and other clinical pharmacy services. During the hospital stay the pharmacist begins discharge education for any new medications patients may continue at home, and at discharge the pharmacist reconciles home medications and provides the patient with a final list in a patient-friendly format. American Society of Health-System Pharmacists 7272 Wisconsin Avenue, Bethesda, Maryland 20814 301-657-3000 2
Ambulatory Care Pharmacist and technicians at Palomar Health are integrated in our patient care delivery model throughout the care continuum. Through collaborative agreements, our team provides ambulatory care based services in conjunction with our medical foundation, Arch Health Partners, a top-rated medical group formed by Palomar Health and Centre for Health Care. Through this collaboration, pharmacists are embedded in the team-based care model providing administrative, medication therapy management (anticoagulation therapy, hypertensive management, and annual wellness and prevention services ), and quality assurance services. Arch Health Partners is dedicated to improving the patient experience and providing comprehensive, high-quality medical care for residents in the North San Diego community. Our pharmacy team is proud to be an associate care provider with Arch Health Partners. WHAT SERVICES HAVE YOU DETERMINED TO BE ESSENTIAL TO SUPPORT YOUR PHARMACY PRACTICE MODEL? Having a strong operational service line is the foundation for a successful pharmacy practice model. Our innovative practice model is made possible through implementation of automation and technology and leverage of clinical decision support to ensure our technical and clinical staff may practice at the top of their licensure. Nurses, physicians, and ancillary clinical staff rely on us to get the right drug to the right place at the right time, and they view our clinical services as essential to safe patient care. An example of our integrated services can be seen in our Emergency Department, in which our pharmacists and pharmacy technicians have developed such a presence with the emergency/trauma center staff we routinely receive requests to consider expanding from the current 10-hour day to 18 hours per day, 7 days a week. The Emergency Department Service Model In our Emergency Department, pharmacists and pharmacy technicians work collaboratively with the team to optimize therapeutic outcomes for each patient. Pharmacists participate in trauma, stroke, and cardiac resuscitation codes. They assess antibiotic culture results and follow up with the physicians and patients at home if empiric treatment prescribed earlier was inappropriate. They review treatment protocols to ensure they are up to date with the most current evidence-based practice recommendations. They prospectively review all physician orders and intervene with dosing and therapy. MICs obtain home medication histories from the patient and verify the information with outside facilities, retail pharmacies, and patient family members. Analysis of their work shows that the MICs obtain both complete and accurate medication histories. Their work has also helped to prevent medication-related errors through identification of incorrect or incomplete medication or allergy information and by appropriate referral of complex patients to pharmacists or our diabetes clinical nurse specialists. American Society of Health-System Pharmacists 7272 Wisconsin Avenue, Bethesda, Maryland 20814 301-657-3000 3
WHAT TECHNOLOGIES HAVE YOU IMPLEMENTED WITHIN YOUR PRACTICE SITE TO FACILITATE YOUR PRACTICE MODEL? The medication use model at Palomar Health is considered state of the art. Automation and technology has been incorporated within each domain of the model, consisting of: Prescribe & Transcribe: CPOE and clinical decision support Procurement: electronic inventory management software with barcode technology Preparation: robotic IV admixture and automated storage with refrigeration Distribution: automated dispensing cabinets with barcode technology Administration: bedside barcode and wireless smart pump infusion technology Monitoring: clinical decision support based rules and electronic medication error reporting capabilities This technology helps our pharmacy services ensure appropriate oversight and management of medication therapy for patients and provision of quality pharmaceutical care to each customer. Through implementation of technology, we have been able to leverage our staff effectively and launch programs such as our Tech Check Tech program. The end result is effective use of our human resources in the most efficient manner possible. HOW WOULD YOU SHARE THE SUCCESSES OF YOUR PRACTICE MODEL WITH OTHER PHARMACY DIRECTORS AND ADMINISTRATORS? Our pharmacy leadership team works closely with our colleagues in San Diego County, sharing ideas, successes, and failures. This communication is often informal but can also be within a forum such as the San Diego Patient Safety Council (SDPSC). The SDPSC is a team of pharmacy leaders from the county that meet on a regular basis and have developed guidelines and toolkits for the safe use of patient-controlled analgesia, intensive care unit (ICU) sedation, and respiratory monitoring outside the ICU. Another example of our collaboration within the county is our Community-Based Care Transitions program. The San Diego Community-Based Care Transitions Program (SDCTP) is a collaboration of the County of San Diego, Aging & Independence Services (AIS), and 11 hospitals in the San Diego area. Through this consortium we share our best practices and outcomes of our TOC program with other members, both locally and nationally. SDCTP is one of the recipients of a 2014 Aging Achievement Award in the Care Transitions. In addition, we share our successes through professional association involvement, such as the American Society of Health-System Pharmacists (ASHP), American College of Clinical Pharmacy (ACCP), California Society of Health-System Pharmacy (CSHP), and others. Members of our pharmacy leadership team participate on various committees helping drive our professional practice model. Finally, our educational programs foster cross-pollination of expertise and services, whereby residents within the San Diego County enjoy flexibility of completing rotations at various sites with residency program preceptors of diverse backgrounds and experience. Our residency is part of the San Diego Pharmacy Residency Leaders group, in which American Society of Health-System Pharmacists 7272 Wisconsin Avenue, Bethesda, Maryland 20814 301-657-3000 4
all residency directors share and work collaboratively to improve their programs and conduct a teaching certificate. WHAT ARE SOME KEY CONSIDERATIONS TO GAIN EMPLOYEE ACCEPTANCE AND BUY-IN TO IMPLEMENT A NEW PRACTICE MODEL? We use the Strategy Implementation and Measurement under Pharmacy LEadership (SIMPLE) approach in implementing changes to our services and garnering employee engagement. Through this model we strategically align our pharmacy initiatives with our organizational initiatives and determine our mode of measurement and how we plan to monitor. Then we communicate to our employees how their performance with our initiatives contributes to the organizational initiatives. This transparent approach has been successful in garnishing support from our staff and collaborative partners within our organization. Communication is paramount to acceptance and buy-in for the new practice model. Palomar Health has several venues for communication among staff and between the staff and pharmacy leadership. An active Professional Practice Council, with a staff leader that sets the agenda and facilitates the meeting, is key to this communication. Managers also involve staff in our annual strategic retreat and have staff leaders in most patient care areas. Another method we use is incentivizing staff engagement in projects through our organization s Professional Enhancement Program, which has been instrumental in rewarding employees for their contribution to the organization. Careful planning of training, education, and credentialing is also very important in rolling out any new practice changes. Within our practice model, we have a professional dedicated to structuring the education for our professional pharmacy staff. The implementation of a Pharmacy Education Specialist role has been critical in helping with the training, education, and accountability of staff. HOW DID YOU GAIN SUPPORT OF HOSPITAL ADMINISTRATORS, PHYSICIANS, AND NURSING TO IMPLEMENT YOUR NEW PRACTICE MODEL? Our organization is structured similar to a matrix, in which various leaders carry responsibility throughout the health system and across various service lines. We are fortunate that our Pharmacy Services reports to a senior executive who understands the profession s importance within our organization. We are also fortunate that Pharmacy Services within the health system reports directly to the District Director of Pharmacy Services, facilitating cooperation and standardization throughout the health system. These fundamental differences have supported our efforts to increase patient safety and expand our pharmacy enterprise. Various executives within our organization have testified to the value of our services. We routinely involve administrators, physicians, and nursing in demonstration projects, when needed, and identify the core needs and gaps in services to fully implement programs. Additionally, we continually American Society of Health-System Pharmacists 7272 Wisconsin Avenue, Bethesda, Maryland 20814 301-657-3000 5
share our improvement metrics through a balance scorecard that rolls up to our Board of Directors. Finally, we openly advocate for and routinely assist other departments with their business plans. WHAT ARE SOME LESSONS LEARNED WHILE IMPLEMENTING YOUR PRACTICE MODEL THAT YOU WOULD LIKE TO SHARE WITH OTHER PHARMACISTS? Organizational engagement is paramount to strategic success. Our annual strategic retreat has helped refine our vision and develop our strategic goals. We have used the PPMI and the Pharmacy Forecast as tools to obtain baseline data. We used the data to complete a gap analysis and then brainstormed on viable solutions worth pursuing and prioritized deliverables. Our strategic retreats are multi-disciplinary in that we invite administrators, physicians, and key nurses to attend and help develop goals and form our plans to achieve them. American Society of Health-System Pharmacists 7272 Wisconsin Avenue, Bethesda, Maryland 20814 301-657-3000 6