Improving Healthcare Quality and Safety While Reducing Costs Through Clinical Pharmacy Service Integration

Steven W. Chen PharmD, FASHP, FCSHP, FNAP

Associate Professor and Chair

Titus Family Department of Clinical Pharmacy and Pharmacoeconomics and Policy

William A. Heeres and Josephine A. Heeres Endowed Chair in Community Pharmacy

Co-Chair Emeritus, HRSA Patient Safety & Clinical Pharmacy Services Collaborative

Michael Hochman, MD, MPH

Director

Gehr Family Center for Implementation Science

Keck School of Medicine of USC

Agenda

• Comprehensive Medication Management at AltaMed Health Services

• The “Business Case” for Comprehensive Medication Management

• The Gehr Family Center for Implementation Science

Medication Safety Problems in U.S.

• 1.5 million people are injured each year due to medications

• ~25% of ambulatory patients experience adverse drug events

• 90% of chronic diseases require medications as first-line therapy

• “…for every dollar spent on ambulatory medications, another dollar is spent to treat new health problems caused by the medication.”

Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System, Washington, DC: National Academy Press; 2000.

$12 Million USC / AltaMed CMMI Project: Specific Aims

UNIVERSITY OF SOUTHERN CALIFORNIA

National Conference on Best Practices and Collaborations to Improve Medication Safety and

Healthcare Quality

Feb 20-21, 2014

Resident and technician training

for expansion

Web-based pharmacist training and credentialing

OUTCOME MEASURES Healthcare Quality Safety Total Cost / ROI Patient & provider

satisfaction Patient access

Telehealth clinical pharmacy 10 teams

Pharmacist + Resident + Clinical Pharmacy Technician

USC Patient Targeting and Management Strategy

Clinical Pharmacy

Comprehensive

Medication

Management

Clinical pharmacy

tech “check-ins”

every 2 months

Yes

Unstable

No

Treatment Goal

Reached?

High cost patients

Frequent and recent

acute care utilizers

48 EHR-embedded triggers

to detect high risk patients

MD referrals

Outcome: Recruit high risk patients

• Enrolled 6,000 patients since Oct 2012

• Predominantly Hispanic, non-elderly women

• 3/4ths have hypertension, 36% uncontrolled

• 2/3rds have diabetes, 60% uncontrolled

• High rates of hospitalizations

Outcome: Improvement in Clinical Markers

125

130

135

140

145

150

155

Baseline 3 Months MostRecent

Systolic Blood Pressure

72

74

76

78

80

82

84

86

88

Baseline 3 Months MostRecent

Diastolic Blood Pressure

* Among those with uncontrolled hypertension at baseline

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Less than 7 7 to 8 8 to 9 9 to 10 Greater than 10

A1C Levels

Baseline 6 months Most Recent

Outcome: Improvement in Clinical Markers

Outcome: Hospitalizations are declining

Control Group Selection

Propensity scoring to match CPS enrollees (treatments) to similar patients

receiving care at non-treatment clinics (controls) in three steps:

• Wave 1 treatment patients

• PACE treatment patients from Wave 2

• Non-PACE treatment patients from Wave 2

Covariates used to model the propensity score:

• Demographics

• Health status

• Utilization

• Other

Clinical results

HbA1C average change in 6 months, uncontrolled at baseline

BP % under control in 6 months, uncontrolled at baseline

-11%

-9.3%

Utilization results (Probit Analysis)

Readmissons per year per patient (6 month panel)

Readmissions per year per patient primarily attributed to

medications (6 month panel)

-16%

-33%

Summary of Difference-in-Differences Results

(Treatment – Control)

http://www.careinnovations.org/uploads/USC.C

EPC.pharm_webinar_FinalV.pdf

Untreated (Cohort) vs. Treated Patients,

USC CMMI Program

Mortality rates

- 25.7%

absolute

difference

0.01

0.009

0.008

0.007

0.006

0.005

0.004

0.003

0.002

0.001

0 1 2 3 6 9 12

Months after enrollment

Untreated Treated

Preliminary analysis, data on file

USC Schaeffer Center for Health Policy & Economics

Medication-Related Problems Identified Through

CMMI Clinical Pharmacy Program 67,169 problems among 5,775 patients (Avg 11.6 per patient)

9,222, 14%

22,229, 33%

13,352, 20%

14,059, 21%

8,267, 12% Medication

Nonadherence

Safety Issues

Appropriateness /

Effectiveness

Misc

Insufficient Patient

Self-Management

http://www.careinnovations.org/uploads/USC.CEPC.pharm_webinar_FinalV.pdf, Updated July 2016

Top Actions Taken by Pharmacists to Resolve Medication-Related Problems (excluding education)

2,665

3,847

4,230

5,554

14,981

Substitute Medication

Discontinue Medication

Order test

Add Medication

Change Dose or Drug Interval

Physician Satisfaction

Average score = 9.6

Average score = 9.7

Patient Satisfaction

Patient Engagement / Retention Keys

Engagement Retention

Make room for walk-ins / “warm hand-offs”

PCP endorsement to targeted / enrolled patients

Match team member language skills

Clinical pharmacy technicians

Align appointments

Engage family and caregivers

Consider selective home visits

Extended hours / weekend clinics

Transportation support if possible

Flyers explaining program benefits in lay terms

Consider peer-led group appointments

Continuity of pharmacist / tech provider

USC Pharmacy Program Recognitions

Clinical Pharmacy Impact

1. Innovation Challenge Finalist in the Let’s Get Healthy California Goal Area of “Lowering the Cost of

Care”! - January 26, 2016, Innovation Conference, Sacramento

2. Los Angeles Times article: http://www.latimes.com/local/great-reads/la-me-c1-pharmacists-clinics-

20150406-story.html

3. Selected for inclusion in the AHRQ Health Care Innovations

Exchange: https://innovations.ahrq.gov/profiles/pharmacy-teams-use-telepharmacy-provide-

medication-management-risk-patients-safety-net

4. Recognized as Exemplar Innovator, UCSF Center for Excellence in Primary Care and Center for

Care Innovations: https://innovations.ahrq.gov/profiles/pharmacy-teams-use-telepharmacy-provide-

medication-management-risk-patients-safety-net

5. Interviewed for article in California Healthcare Foundation’s Center for Health

Reporting: “Prescription for Success: Caring”- http://www.losangelesregister.com/articles/metcalfe-

597822-chen-eat.html

6. Cover story for Pharmacy Today: “Chen, colleagues provide MTM in L.A.’s most vulnerable

neighborhoods, (http://www.pharmacist.com/node/49949)relate

7. Pharmacy Times article: “Effectiveness of Clinical Pharmacy Services to be Tested”,

(http://www.pharmacytimes.com/news/Effectiveness-of-Clinical-Pharmacy-Services-to-Be-Tested)

8. Semi-Finalist, Harvard Business School / Harvard Medical School Health Acceleration Challenge -

https://openforum.hbs.org/challenge/hbs-hms-health-acceleration-challenge/refinement/good-

medicine-medication-therapy-management-and-saving-the-health-care-system-millions

9. Pinnacle Award, American Pharmacists Association: https://pharmacyschool.usc.edu/steven-chen-

receives-2013-pinnacle-award-in-washington-dc/

10. Innovator Award, Health Resources and Services Administration (HRSA) Patient Safety and Clinical

Pharmacy Services Collaborative (PSPC)

Agenda

• Comprehensive Medication Management at AltaMed Health Services

• The “Business Case” for Comprehensive Medication Management

• The Gehr Family Center for Implementation Science

WHY DO THIS?

Clinical Pharmacy

WHY DO THIS?

Clinical Pharmacy

WHY DO THIS?

• Doctors don’t like to follow protocols …

• Pharmacists manage drug therapy better

through collaborative practice agreements!

Clinical Pharmacy

OVERCOMING ANXIETY

• Can pharmacists do this?

• Will they communicate?

• Why did I go to medical school?

Clinical Pharmacy

IMPACT

• Staff Satisfaction

• Patient Satisfaction

• Quality Goals

• Reduction in ER and Hospital Utilization

• Unexpected benefits:

- patient assistance programs

- help with medication errors

- staff education

Clinical Pharmacy

MAJOR CHALLENGE

Clinical Pharmacy

BUSINESS CASE

• Does clinic pharmacy save money?

• Is clinical pharmacy a high-value service?

• If yes, how do we pay for it?

Clinical Pharmacy

OPTIONS

• Billing policy changes

• Pay for performance

• Health Home Demonstration

• More risk-bearing, capitated payment

arrangements

Clinical Pharmacy

Our Team

28

David Goldstein, MD Michael Hochman, MD, MPH Rachel Lim

Welmoed van Deen, MD, PhD Faculty

Rusha Modi, MD Faculty

• Collaborate and partner with local health systems

• Help implement best practices

• Develop sustainable innovations

• Advance knowledge in care delivery

Mission

29

• The “Triple Aim”

• Quality/Experience

• Population Health

• Efficiency

• Co-development with health systems

• Sustainable

• Scientifically important data

• Engages University and local communities

• Trainees can participate

Principles

30

Projects in Development

31

• Getting hospitalized patients out of bed

• Evaluating “Whole Person Care” waiver

• Medication assisted therapy for high utilizers

• Preventing readmissions from primary care perspective

• Scaling Comprehensive Medication Management

Gehr Innovation Awards

32