Presentation Objectives PPMI in a Community Teaching Targeting VBP and ACO metrics Pharmacist Objective: List ACO metrics that pharmacists can share accountability to achieve targets Technician Objective: Describe how technicians can assist in identifying high risk patients Fairview Overview Part of the Cleveland Health System Teaching 458-beds Level II Trauma Center Volume Admissions: 25,100 Emergency Dept.Visits: 83,000 Oncology Treatment Visits: 10,000 Financial Fairview - Pharmacy Pharmacists resources: 27 FTEs All inclusive Truven 25 th percentile as a department Pharmacy locations Central 24 hours ICU Satellite Oncology Satellite Operations model Carousels Carefusion Pyxis dynamic PPMI Inpatient Ambulatory PPMI a Journey Journey stated in earnest in 2012 Beyond specialty service Alignment vs. Interest Mandatory in-services VBP Targeted PPMI Plan PPMI Engagement vs. Satisfaction Patient based vs. Therapy based Accountabilities for metrics Team based vs. Individual based A story to tell Resources Residency Inpatient - Target Metric driven Med/ Surg ED Pharmacy Service Ambulatory - Growth Center for Family Medicine 1
Inpatient PPMI Journey Pharmacist recruitment HCAHPs Medication Communication domain. 1/12: HCAHPs focus New Challenges with pharmacists accepting model and results Drug vs. Rounds Shared Governance Alignment required Pharmacists select metrics ASHP PPMI and literature reviewed 7/13: Discharge focus Metrics Layered Learner model use of students and residents High Risk versus all comers Alignment with CNO and CMO Service at : Admission, Daily, Discharge, Follow-up 12/14: High Risk Patient Focus - Metric: Readmission Alignment with Healthcare Reform Fiscal Year Affordable Care Act Mandated Programs VBP Program* Readmission Reduction Program* Acquired Conditions Program* Overall, Potential Reduction Risk by Fiscal Year 2015 1.50% 3.00% 1.00% 5.50% 2016 1.75% 3.00% 1.00% 5.75% 2017 2.00% 3.00% 1.00% 6.00% *Potential Reduction in Payment by Fiscal Year FY 2015 Value-Based Purchasing Domain Weighting FY 2015 7/2012 VBP - HCAHPs Focus Automation Bar-code verification Efficiency, 20% al Processes of Care, 20% Outcomes, 30% Patient Experience, 30% Residency Initiation Stroke Service Metric HCAHPs: Medication Communication > 90 th percentile Study: New meds vs. Rounds focus Story to tell HCAHPs fatigue Engagement hit 7/12: PPMI Metric Impact 7/13: PPMI Shared Governance Pharmacy Retreat PPMI Pharmacists embraced Shared Governance Shared Governance Must be aligned with hospital goals Must be supported by the literature Consensus Metrics Discharge capture rate HCAHPs (Med, Discharge, TOC) 30-day All-cause Readmissions Bedside Delivery Referral Rate Layered Learner Model Students handle consults Resident Project: ED Technician and then pharmacist 2
Literature to support Discharge focus Pharmacy Practice Model Literature Search Outcomes Practice Readmission Medication HCAHPS Other Rates Errors Fairview 3 - Admission medication reconciliation - - (Cleveland, OH) - Target: Orthopedic patients - Discharge medication reconciliation - Comprehensive and patient-focused REACH Program education and counseling Einstein Healthcare - Resolving medication access issues Network 4 - - - 72 hour post discharge follow up phone (Philadelphia, PA) call by a pharmacist - Primary Target: Patients on telemetry; patients with HF, AMI, HTN - Medication reconciliation at admission, any transition of care, and discharge Froedtert Health System 4 - Counseling, education, and bedside - delivery service (Milwaukee, WI) - Follow up phone call by a pharmacist for high-risk patients - Multidisciplinary rounds - High-risk medication education - Discharge medication reconciliation Johns Hopkins Medicine 4-72 hour post discharge phone call follow Length of - up stay (Baltimore, MD) - Face-to-face pharmacist follow up as necessary - Target: High-risk patients Discharge Focus Successes Bedside Delivery Referral Rate Met Goal Engagement Scores Exceeded hospital targets Challenges HCAHPs domain score goals Goal Not Met CNO concern how pharmacists value on the floors without impact on Medication Communication Readmission impact: Goal Not Met Shared Governance assessment All comers service vs. High Risk 12/14: PPMI High Risk Shared Governance overhaul HCAHPs: Medication Communication Nursing Pilot No available tool Designed (EPIC) manual scoring system - technicians to score all 144 patients daily (60 minutes) HCAHPs: Medication Communication facilitate and reiterate nursing s role Alignment: Readmission rate High Risk Group Service: Continuum of care PPMI High Risk Continuous Progress Moved from manual scoring to a standard scoring system in EPIC CCHS will be adopting a standard scoring system Individual pharmacists daily report card Process to remove patients from program Calculated readmission rate for this high risk group: 19.4% (versus 12.5% for all comers) Students: Patient greeters Bedside delivery Early results: 11% for High Risk Group Future Inpatient PPMI initiatives Layered Learner Model Medication reconciliation in ED - % of admits Orthopedic Bundling Medication Histories Readmission successes Pharmacist support Story to tell Billing for inpatient MTM Peer Review Credentialing and Privileging 3
Ambulatory PPMI Journey Collaborative Care Agreement established. Resident Project: Effect of Integrated Pharmacy Services on an Outpatient Family Health Center. 2012: Residents Evaluated percent of recommendations accepted and perception of service Resident Project: Impact of pharmacist participation in a new outpatient transition-of-care shared discharge visit program on 30-day readmission rates. 2013: Residents Charged TOC CPT codes and evaluated 30-day readmission Resident Project: Impact of Pharmacist Management of Dyslipidemia in Patients with Type 2 Diabetes Mellitus Evaluate number of type 2 diabetes mellitus patients with appropriate statin therapy after pharmacist management of dyslipidemia according to the 2013 ACC/AHA Cholesterol Treatment Guidelines 2014: Residents Ambulatory Care Pharmacy Specialist Justified to start service 7/13/2015 Justification based on: Service: Improvement in ACO metrics 2015: Ambulatory Pharmacy al Revenue: Disease State Management, Transition of care Discharge Program, Outcomes MTM Post-acute Visit and Specialist Student education Quality Performance Benchmarks for Accountable Care Organizations 33 quality measures for 2014 quality reporting year. ACOs are required to report quality data used to calculate and assess their quality performance Measures span four quality domains Patient/Caregiver Experience Care Coordination/Patient Safety Preventive Health At-Risk Populations ACOs required to submit for 3-year period as performance benchmarks are phased-in Am Care Pharmacists impact on ACO measures Targets mentioned in our Justification Transition of Care Program: ACO #8 Risk Standardized, All Condition Readmission. Pharmacists Disease Management s: ACO Metric CFM Medicine Institute National Benchmark 23 DM: LDL < 100mg/dl 39.47% 53.27% 56% 29 IVD: LDL < 100 mg/dl 36.1% 51.2% - 32 CAD: LDL < 100 ml/dl 52.25% 71.06% 89.9% 24 DM: BP < 140/90 mm Hg 76.51% 71.07% 69% 28 HTN: BP < 140/90 71.46% 70.50% 67% 22 DM: HbA1c < 8% 63.44% 66.92% 80% 27 DM: HbA1c > 9% 23.24% 22.67% 21% Am Care Disease Management Assumptions: Total of 5 half days per week Visits per half clinic day: 1 new patients (60 minutes) 6 follow-up patients (30 minutes) For ½ day clinic/day = 6 visits For 5 days/week = 6 visits x 5 = 30 visits/week For 48 weeks per year = 1440 visits/year max Assuming approximately 10% no-show for visits = 1300 visits Numbers are supported by our Residents experience and outcomes in clinic Am Care Transition of Care Program Am Care Transition of Care Program Assumptions: 5 eligible candidates per week Visit length 60 minutes x 5 visits per week For 48 weeks per year=240 visits per year Payer-mix Number of visits Billing Method Reimbursement Sub-total Medicare (60%)* 144 99495 (99496) $109.55 $15,775 Other (40%)* 96 99214 107.29 $10,299 Total $26,074 *Based on pilot program study results (9 of 15 patients were Medicare) 4
Future Ambulatory Care PPMI Initiatives PGY-2 Ambulatory Care Interface with other hospital clinics to reduce readmission rates: CHF/Coumadin Our PPMI Journey Affect the Metics Tell a story Continuous Quality Improvement Patient Recruitment Our Goal: To Enhance Patient Care Through the Unique Skills of the Pharmacist Healthcare is a Team Sport References Questions Stuckey NT. Determining a method of pharmacist-patient interaction to improve HCAHPS scores. ASHP 2013 Summer Meeting & Exhibition; 2013 June; Minneapolis, MN. The consensus of the Pharmacy Practice Model Summit. Am J Health Syst Pharm. 2011;68(12) Gibson S, Zebrowski J, Stuckey NT. Pharmacist-led medication reconciliation in orthopedic surgery patients: Effect on HCAHPS scores (Poster). ASHP 2013 Midyear al Meeting; 2013 December; Orlando, FL. Cassano A. Best Practices from the ASHP-APhA MedicationManagement in Care Transitions Initiative. American Pharmacist Association. February 27, 2013. Available at http://media.pharmacist.com/practice/ashp_apha_medicationmanagementincaretransitionsbestpract icesreport2_2013.pdf. Accessed June 4, 2013 He J. Implementation and assessment of pharmacist intervention during discharge medication reconciliation (POSTER). ASHP Midyear al Meeting; 2013 December; Orlando, FL. Mathis AS, Ghin HL. Impact of decentralized pharmacy practice model on quality reporting metrics: patient satisfaction (POSTER). ASHP Midyear al Meeting; 2013 December; Orlando, FL. Prusi R, Baltz-ward B, Vetter E, Phatak A, Postelnick M. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and post-discharge callbacks (POSTER). ASHP Midyear al Meeting; 2013 December; Orlando, FL. Lee AJ, Boro MS, Knapp KK et al. al and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health Syst Pharm. 2002;59:2070 7. Agency for Healthcare Research and Quality. US Department of Health and Human Services. {updated 2012; cited 2013}. Available from: http://psnet.ahrq.gov/primer.aspx?primerid=23. Lada P, Delgado G. Documentation of pharmacists interventions in an emergency department and associated cost avoidance. AJHSP. 2007;64:63 8. 5