Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Morgan Pendleton, PharmD, BCOP Hematology/Oncology Clinical Pharmacist Wake Forest Baptist Health Objectives Evaluate the need for discharge pharmacy services Discuss the role of the oncology pharmacist and technician in discharge pharmacy services 1
Question Does your hospital utilize discharge pharmacy services? A) Yes B) No C) For high risk patients only Journal of Hospital Medicine. 2008;3(1):12-19 Background 2
Question A study in 2008 found that percent of patients who reported medication issues after hospital discharge did not pick up their prescribed medications. A) 5-10% B) 15-20% C) 50-60% D) > 70% Journal of Hospital Medicine. 2008;3(1):12-19 Background 2008 evaluation via patient survey N = 31,199 patients 7.2% (2,253) reported prescription-related issues 48-72 hours post discharge Percentage of Prescription-Related Issue Patients (n=2,253) n (%) Not picking up prescribed discharge medications 1,797 (80) Not knowing if prescriptions were picked up 55 (2) Admitted not taking the medications 154 (7) Not understanding how to take the medications 247 (11) Journal of Hospital Medicine. 2008;3(1):12-19 3
Background Poor medical adherence Poor health outcomes Increased healthcare costs $100-300 billion dollars per year Rates have not changed much in the last 3 decades (despite all initiatives) 20-50% of patients are non-adherent to medical therapy American College of Preventive Medicine. 2011 Background Pharmacy Quality Alliance (PQA) Member-based organization (providers, payers, and pharmacy organizations) Develop quality measures that pertain to effective use of medications Primary medication non-adherence (PMN) Patient is prescribed a medication but fails to obtain and take the medication Includes newly initiated medications Medications not prescribed within the previous 180 days Network for Excellence in Health Innovation. 2014. 4
Background PMN rate based on patient not picking up a new prescription within 30 days of it being prescribed List of chronic medications based on prior PQA metrics (based on Accountable Care Organization contracts) PMN rates for treatment of chronic diseases ranges from 10-30% Underestimation Electronic prescribing has increased accuracy Network for Excellence in Health Innovation. 2014. Background Reducing PMN: Should Pharmacies Take the Lead? Access to data and providers Knowledge to counsel and answer questions Follow up by pharmacists in the outpatient setting has not been found to be effective Time Resources Reimbursement Network for Excellence in Health Innovation. 2014. 5
Background Initiate the process at discharge Cost effective Prior-authorizations or issues Deliver medications so PMN rates decrease Educate Form relationships Utilize face to face pharmacy or clinic encounters Education, questions, refills, support, etc. Network for Excellence in Health Innovation. 2014. Question Pharmacists are the appropriate team member to take the lead for discharge pharmacy and medication services based of their expertise, knowledge, and access to appropriate resources. A) Yes B) No C) For high risk patients only Journal of Hospital Medicine. 2008;3(1):12-19 6
WFBH Experience Wake Forest Baptist Medical Center Academic medical center Comprehensive Cancer Center Brenner Children s Hospital Winston-Salem, NC Nationally ranked by U.S. News and World Report 17 th in Cancer 7
Background Resident Project Nationally 50% of patients experience medication errors when transitioning from hospital to home 20% of Medicare patients are readmitted within 30 days Wake Forest Baptist Health 25% baseline 30-day readmission rate (Heart Failure) Pharmacotherapy. 2012 Medical Center Solutions Northwest Triad Care Transitions Consortium Multi-hospital, multi-county partnership funded through Affordable Care Act with CMS oversight Deploys Transitional Navigators Engage hospital and community resources for targeted patients Internal readmission teams created Discharge Pharmacy Services (DPS) 8
Resident Research Project DPS program was developed and piloted to augment 30-day readmission rate initiatives and increase outpatient prescription capture Phase 1: Care Transitions Program Pilot (Heart Failure) Phase 2: Readmission Rate Pilot (Hem/Onc) Pilot Study Requirements Phase I: Care Transitions Program (Heart Failure) Discharge medication reconciliation Bedside delivery with education Post-discharge home-based medication reconciliation with transitional navigator Phase II: Readmission Rate Pilot (Hem/Onc) Discharge medication reconciliation Bedside delivery with education Pharmacy ownership of the process 9
Phase I: Basic Workflow Processes Launched October 2012 Transitional Navigator Enrolls patient Notifies outpatient pharmacist Outpatient Technician Enters into outpatient system Notifies inpatient pharmacist Outpatient Technician Inpatient Fills Pharmacist prescription Performs Delivers to discharge bedside medication reconciliation Notifies outpatient pharmacy Inpatient Pharmacist Provides discharge counseling Transitional Navigator Performs inhome medication reconciliation Notifies inpatient pharmacist Phase II: Basic Workflow Processes Inpatient Pharmacist Launched December 2012 Outpatient Technician Enrolls patient Enters into outpatient system Notifies inpatient pharmacist Inpatient Pharmacist Performs discharge medication reconciliation Notifies outpatient pharmacy when prescriptions are on the way Outpatient Technician Fills prescriptions Delivers to bedside Provides discharge counseling 10
Results 30-Day Readmission Rates Program Total Percentage of Readmissions % (n) Baseline - 25% Phase I Care Transitions (Heart Failure) 44 2.8% (1) Phase II Readmission Rates (Hem/Onc) 213 6.8% (14) 11
Financial Return on Investment Phase 1 Phase 2 Prescription and Patient Trend 200 180 160 140 Number 120 100 80 60 # of Scripts # of Patients 40 20 0 Oct Nov Dec Jan Feb Phase 1 Phase 2 12
Enrollment: Phase II 140 120 63% 129 Number of Patients 100 80 60 40 20 0 19% 40 11% 22 Enrolled Not Enrolled Pending Unknown Enrollment Status at Discharge N = 206 (12/1/12 2/28/13) 7% 15 Enrollment: Phase II 45% 40% 42% 35% 30% 25% 20% 25% 15% 10% 17% 13% 5% 0% Prefers using SNF/Facility/Hospice Gets meds at VA Locked into another another pharmacy pharmacy due to insurance Reason for Not Enrolling N = 40 4% Involved in affordability assistance program 13
Discharge Med Rec (Phase II) House-wide baseline Discharge medication reconciliation completed in 40% of patients Rolling 4-week average during Phase II of project Discharge medication reconciliation completed in 78% of patients Lessons Learned Pharmacy ownership of enrollment process is key Margin capture highly dependent on target population A major paradigm shift in pharmacy practice Positive change for outpatient team 14
Future Steps House-wide roll out of DPS Dedicated pharmacist for Care Transitions patients Model of Care Pilot Project Model of Care (MOC) Pilot Structured discussions based on day of hospital stay Day of admission Insurance information During Stay Daily team huddles Therapeutic recommendations Prior-authorization and test prescriptions Day Prior to discharge Electronic prescribing and delivery of prescriptions Day of Discharge Counsel and answer questions 15
Impact of Residency Project and MOC Initiative DPS: As We Know it Today Daily huddles do not exist within the cancer center Incorporated discussion into daily rounds Running discharge list throughout the week Social work as part of rounding team Inpatient pharmacist in charge of the entire process Dedicated DPS technician Referral enrollment utilized if not captured by DPS technician Contacts majority of admissions to evaluate desire for DPS services 16
Number of Prescriptions and Patients 1400 1200 1000 800 600 400 200 Discharge Pharmacy Service (Cancer Center and Main Outpatient Pharmacy: New Prescriptions and Total Patients per Month 0 Mar13 Apr13 May13 Jun13 Jul13 Aug13Sep13 Oct13 Nov13Dec13 Jan14 Feb14 Mar14 Apr14 May14 Jun14 Jul14 Aug14 Prescriptions 202 298 358 322 215 185 216 260 168 258 413 609 1007 1000 1012 992 1119 1195 Patients 53 78 111 92 58 54 78 73 70 96 145 176 310 332 269 319 Pilot started via resident project Dec 2012 House-wide expansion via integration with MOC initiative Change to referral enrollment strategy Creation of Transitions of Care Technician role 1600 1400 1200 1000 800 600 400 200 0 DPS Data: Cancer Center Pharmacy Prescriptions Patients Average $/Patient 2014 2015 17
Average Day for DPS Technician 80 70 67 Times per Day for Each Task 60 50 40 30 20 33 29 23 14 13 12 11 10 10 5 4 3 1 0 Role of Key Team Members in DPS Success 18
Technician Role Enrollment (in person or via phone) Test prescriptions Relay information to pharmacist Prior authorizations (PA) and enrollment in drug assistance programs Deliver medications and receive payment (or set up payment plans as necessary) Pharmacist Role Enrollment and prior authorizations as necessary Solicit test prescriptions Make therapeutic recommendations based on availability of medications at discharge Set up delivery of medications through specialty or mail order pharmacies Mandatory discharge medication reconciliation Prepare education document and counsel 19
Social Work/Case Manager Role Handle all prescription communication with the VA Enrollment in medication assistance programs as necessary Determine eligibility for charity care, crisis control ministry, cancer services, cancer patient support, and other resources Patient Role Maintain open communication about affordability Provide appropriate tax or income information Follow up with assistance programs or mail order pharmacies Be accountable 20
Workflow: is one way better than the other? Cancer Center Pharmacy Main Outpatient Pharmacy Pharmacist or Technician enrolls in DPS Pharmacist enrolls in DPS Pharmacist or Technician notifies the other team member via pager/phone Pharmacist notifies technician through EMR Pharmacist and technician communicate via pager/phone about test prescriptions Pharmacist notifies technician via pager/phone that prescriptions are on the way and to prepare for delivery Pharmacist and technician communicate via EMR about test prescriptions Pharmacist notifies technician via EMR that prescriptions are on the way and to prepare for delivery Summary 21
Is it Worth the Time and Effort? Patient Medications in hand at discharge Education document with valuable information Counseling with familiar face Questions answered prior to getting home Physician Know cost and availability prior to prescribing Know patients have medications in hand Can communicate with pharmacist about any issues and concerns to focus on during education Pharmacist Integral part of patient s transition of care Use delivered prescriptions to assist in discharge education Have pertinent information available (next dose, indication, etc) Develop fundamental relationships with the patients and providers Have resources to educate and develop plans for illiterate patients Have translators available for those who don t speak English Is it Worth the Time and Effort? Patient Medications in hand at discharge Education document with valuable information Counseling with familiar face Questions answered prior to getting home Physician Know cost and availability prior to prescribing Know patients have medications in hand Can communicate with pharmacist about any issues and concerns to focus on during education Pharmacist Integral part of patient s transition of care Use delivered prescriptions to assist in discharge education Have information available via EMR and providers (next dose, indication, etc) Develop fundamental relationships with the patients and providers Have resources to educate and develop plans for illiterate patients Have translators available for those who don t speak English 22
Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Morgan Pendleton, PharmD, BCOP Hematology/Oncology Clinical Pharmacist Wake Forest Baptist Health References American College of Preventive Medicine. Medication Adherence Improving Health Outcomes. 2011. Hubbard T. Ready for Pick Up: Reducing Primary Medication Non-Adherence. A New Prescription for Health Care Improvement. The Network for Excellence in Health Innovation. 2014. Hume A, Kirwin J, Bieber H, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy 2012;32(11);326-337 Kripalani S, Price M, Vigil V, Epstein K. Frequency and Predictors of Prescription- Related Issues after Hospital Discharge. Journal of Hospital Medicine. 2008;3(1):12-19 National Association of Chain Drug Stores. Pharmacies: Improving Health, Reducing Costs. July 2010. 23