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Morgan Pendleton, PharmD, BCOPHematology/Oncology Clinical Pharmacist

Wake Forest Baptist Health

Administrative Update: How to Implement Discharge Pharmacy

Services (DPS)

Objectives

Evaluate the need for discharge pharmacy services

Discuss the role of the oncology pharmacist and technician in discharge pharmacy services

2

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

3

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%


Background

2008 evaluation via patient survey

N = 31,199 patients

7.2% (2,253) reported prescription-related issues 48-72 hours post discharge


Prescription-Related IssuePercentage of

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)

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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.

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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


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


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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.


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


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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

17th in Cancer

8

Nationally

50% of patients experience medication errors when transitioning from hospital to home

20% of Medicare patients are readmitted within

30 days


25% baseline 30-day readmission rate (Heart Failure)

Pharmacotherapy. 2012

Background – Resident Project

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)

Medical Center Solutions

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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)

Resident Research Project

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

Pilot Study Requirements

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Transitional Navigator

• Enrolls patient

• Notifies outpatient pharmacist

Outpatient Technician

• Enters into outpatient system

• Notifies inpatient pharmacist

Inpatient Pharmacist

• Performs discharge medication reconciliation

• Notifies outpatient pharmacy

Outpatient Technician

• Fills prescription

• Delivers to bedside

Inpatient Pharmacist

• Provides discharge counseling

Transitional Navigator

• Performs in-home medication reconciliation


Phase I: Basic Workflow Processes

Launched October

2012

Outpatient Technician• Enrolls patient• Enters into

outpatient system


Inpatient Pharmacist• Performs

discharge medication reconciliation

• Notifies outpatient pharmacy when prescriptions are on the way

Outpatient Technician• Fills

prescriptions• Delivers to

bedside

Inpatient Pharmacist• Provides

discharge counseling

Phase II: Basic Workflow Processes

Launched December

2012

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Results

Program TotalPercentage 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)

30-Day Readmission Rates

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Financial Return on Investment

Phase 1 Phase 2

Prescription and Patient Trend

0

20

40

60

80

100

120

140

160

180

200

Oct Nov Dec Jan Feb

Nu

mb

er

# ofScripts

# ofPatients

Phase 1 Phase 2

13

129

40

2215

63%

19%

11%7%

0

20

40

60

80

100

120

140

Enrolled Not Enrolled Pending Unknown

Nu

mb

er

of

Pa

tie

nts

Enrollment Status at DischargeN = 206 (12/1/12 – 2/28/13)

Enrollment: Phase II

42%

25%

17%

13%

4%0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Prefers usinganother pharmacy

SNF/Facility/Hospice Gets meds at VA Locked into anotherpharmacy due to

insurance

Involved inaffordability

assistance programReason for Not Enrolling

N = 40

Enrollment: Phase II

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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

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

Lessons Learned

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House-wide roll out of DPS

Dedicated pharmacist for Care Transitions

patients

Model of Care Pilot Project

Future Steps

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

Model of Care (MOC) Pilot

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Impact of Residency Project and MOC Initiative

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

DPS: As We Know it Today

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0

200

400

600

800

1000

1200

1400

Nu

mb

er

of

Pre

sc

rip

tio

ns

an

d P

ati

en

ts

Mar13 Apr13 May13 Jun13 Jul13 Aug13 Sep13 Oct13 Nov13 Dec13 Jan14 Feb14 Mar14 Apr14 May14 Jun14 Jul14 Aug14Prescriptions 202 298 358 322 215 185 216 260 168 258 413 609 1007 1000 1012 992 1119 1195Patients 53 78 111 92 58 54 78 73 70 96 145 176 310 332 269 319

Discharge Pharmacy Service (Cancer Center and Main Outpatient Pharmacy:New Prescriptions and Total Patients per Month

Pilot started

via resident project Dec

2012

Pilot started

via resident project Dec

2012

House-wide expansion via integration with MOC

initiative

House-wide expansion via integration with MOC

initiative

Change to “referral”

enrollment strategy

Change to “referral”

enrollment strategy

Creation of Transitions of

Care Technician role

Creation of Transitions of

Care Technician role

0

200

400

600

800

1000

1200

1400

1600Prescriptions

Patients

Average$/Patient

DPS Data: Cancer Center Pharmacy

2014 2015

18

Average Day for DPS Technician

67

3329

23

14 13 12 11 105 4 3 1

0

10

20

30

40

50

60

70

80

Times per Day for Each

Task

Role of Key Team Members in DPS

Success

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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

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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

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Workflow: is one way better than the other?

Cancer Center Pharmacy

Pharmacist or Technician enrolls in DPS

Pharmacist or Technician notifies the other team member via

pager/phone

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

Main Outpatient Pharmacy

Pharmacist enrolls in DPS

Pharmacist notifies technician through EMR

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

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Is it Worth the Time and Effort?

• Medications in hand at discharge• Education document with valuable information• Counseling with familiar face• Questions answered prior to getting home

Patient

• 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

Physician

• 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

Pharmacist

Is it Worth the Time and Effort?

• Medications in hand at discharge• Education document with valuable information• Counseling with familiar face• Questions answered prior to getting home

Patient

• 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

Physician

• 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

Pharmacist

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Morgan Pendleton, PharmD, BCOPHematology/Oncology Clinical Pharmacist


Administrative Update: How to Implement Discharge Pharmacy

Services (DPS)

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.

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