lisa anne boothby, pharmd, bcps director of pharmacy, dukes memorial hospital
TRANSCRIPT
Future of Clinical Pharmacy Practice in Rural Health
Lisa Anne Boothby, PharmD, BCPSDirector of Pharmacy, Dukes Memorial Hospital
OBJECTIVES
Demonstrate the value of clinical pharmacy services to decrease 30-day readmission rates
Outline the pharmacist’s role in reducing medical waste
Detail ethical issues associated with drug shortage management
PHARMACEUTICAL CARE
Clinical pharmacy services Inpatient and outpatient settings Improve patient outcomes
PHARMACISTS AS PROVIDERS
Patient Accountability and Affordable Care Act Pharmacists are “other healthcare
providers” Social Security Act
Part B versus Part D Three MTM billing codes
Private insurance reimbursement followsSmock N. Affordable Care Act Regards Pharmacists as Health Care Providers, Not
Just Prescription Dispensers. Available at URL: http://www.pharmacytimes.com/publications/issue/2013/January2013/Affordable-Care-Act-Regards-Pharmacists-as-Health-Care-Providers-Not-Just-Prescription-Dispensers
WHERE IS THE REVENUE?
Capitated healthcare precede reimbursement May decrease need for pharmacy billing Share in savings once minimum
achieved Accountable care organizations
Not all hospitals have embraced Pilot programs
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
ACCOUNTABLE CARE ORGANIZATION
Providers accountable Achieving quality Reductions in rate of spending growth Physician led with many payer
arrangements National Committee for Quality
Assurance Established ACO criteria 7 categories with 4 levels
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
RURAL ACOs
To reach critical mass Incorporate multiple payers or multiple
hospitals Apply for a CMS wavier to include
Medicaid patients
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
MEDICAL HOME MODEL
Patient centered medical homes Led by physician Include pharmacist, nurse and other
health care practitioners Treat patient with chronic conditions
Prevent adverse events and optimize therapy
Team ensures all health care needs are met
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
PHARMACIST ROLE Medical Home Models
Improve medication management Preventing hospital
readmissions Decreases revenue in a traditional
hospital budgetary model
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
AMBULATORY CARE FOCUS
Keep patients healthy and out of the hospital
VA collaborative practice model Prescribing privileges More than 20 years of success Pharmacist credentialed providers
PHARMACY ROLE
Medication management Preventing disease Maintaining cardiovascular health Preventing end organ damage Medication compliance, adherence Therapeutic drug monitoring Supportive care
PHYSICIAN-PHARMACIST TEAM Study Design
1 month study at Mission Hospital 735 bed community teaching hospital Asheville, North Carolina
Pre-post design 2 weeks normal routine 2 weeks with clinical pharmacist
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
PHYSICIAN-PHARMACIST TEAM Pharmacist Role on Team
Drug information Discharge counseling Medication interventions Medication reconciliation Filling discharge prescriptions Submit discharge summaries
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
PHYSICIAN-PHARMACIST TEAM Measurements
15-day and 30-day readmission rates Number of ED visits Employee satisfaction surveys
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
PHYSICIAN-PHARMACIST TEAM
33% vs. 17% readmission within 30 days
11% vs. 2% readmission within 15 days
9% vs. 4% ED visits within 30 days
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
DISCHARGE PHARMACIST
Prospective cohort 729 patients over three months
Pharmacy medication reconciliation 30-day readmission rate Polypharmacy and readmission rate
Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy
2013;48(5):380-388.
READMISSION RATES
Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy
2013;48(5):380-388.
DISCHARGE PHARMACIST
Med reconciliation and counseling Decreased 30-day readmission rate 16.8% vs. 26%; p=0.006
Polypharmacy More than 5 scheduled medications Associated with increased readmission
rates
Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy
2013;48(5):380-388.
WELLTRANSITIONS
Walgreens program Reduces readmissions Pharmacists oversee medication
regimens Transitions of care
Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012.
http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions
WELLTRANSITIONS
Med review at admission and discharge Bedside medication delivery Counseling for patients and their
caregivers Regularly scheduled follow-up post
discharge 24-7 support for discharged patients Ensure follow up with physician Ensure appropriate self care Marian General and Lutheran HospitalWalgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November
20, 2012. http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions
MEDICATION RECONCILIATION Survey of Pharmacy Perceptions
11 pharmacists Vanderbilt University Brigham and Women’s Hospital
Medication reconciliation Time consuming Most important contribution Improving care transitions Correct the admission medication history
Haynes KT, Oberne A, Kripalani S. Pharmacists’ recommendations to improve care transitions. Ann Pharmacother 2012;46(9):1152-1159.
IMPLICATIONS
Translation to a rural critical access hospital
Minimal resources Decreased ED visits decreases
admissions Decreased revenue with traditional
models Next steps?
REDUCE READMISSION TOOLS
TARGETING TRANSITIONS Project BOOST: www.hospital-
medicine.org Project RED: www.projectred.org STAAR initiative: www.ihi.org/STAAR
Demonstration Pilot Critical Access Hospital
Medication reconciliation process Physician and nurse driven 2 to 3 errors per each
Follow-up by pharmacy Clarify and correct errors Time intensive
Increased safety risk Omissions Delays and duplications
Demonstration Pilot Critical Access Hospital
Develop criteria for consultation Greater than 10 scheduled
medications High-alert medications Anticoagulants Core-measure disease states
PHARMACEUTICAL WASTE STREAMS
INCOMPATIBLE
HAZARDOUS
WASTEAerosols• InhalersOxidizers• Silver
nitrateREGULAR TRASH
• Outside packaging• Empty items that once contained
medication• Shipping packaging• Recycle paper, glass, plastic
P-LISTED HAZARDOUS WASTE
• Coumadin plus wrapper
• Nicotine plus wrapper and peel
HAZARDOUS WASTE
• Insulin• Some
vitamins and minerals
• Phenylephrine
NON-HAZARDOUS RX WASTE
• Antibiotics• Lidocaine• Pitocin• Heparin
SHARPS • Needles and broken
ampoules• Empty syringes
SEWER• IV
dextrose• Potassium• Saline• Sodium• Calcium• lactated
ringers• magnesiu
m
CHEMO WASTE
Smith CA. Managing Pharmaceutical Waste. Journal of the Pharmaceutical Society of Wisconsin 2002;17-22.
INPATIENT MEDICAL WASTE Save money, prevent delays and
omissions Clinical pharmacists know formulary
medications Clinical pharmacists prevent non-formulary
and not-available medication orders at admission
Formulary management policies/procedures Therapeutic interchange programs Evaluate PAR levels for expired drugs
OUTPATIENT MEDICAL WASTE
Outpatient prescribing practices Polypharmacy Lack of follow-up
Mail order pharmacies automatic renewals Three month supplies Compliance Adherence Persistence
MEDICAL WASTE Ethics and the Environment
Controlled substance regulation Changes from DEA Expected in future
Vendors Stericycle, others … Environmentally conscious disposal
DRUG SHORTAGES Minimize Waste
Therapeutic interchange Drug classes Pharmacodynamics of medications
Superior therapeutic alternatives Evidence based medicine Avoid grey market distributers
GREY MARKET
Receive emails for information only Plan ahead Keep adequate inventory levels
Medications dispensed daily Accept small loss with expired
medications To stock adequate levels Prevent drug shortages from reaching
patient
DRUG SHORTAGES
Aminophylline Sincalade Nalbuphine Dextrose 25% and 50% syringes Furosemide IV Metoclopramide IV Fentanyl IV Potassium phosphate IV
PHARMACIST ROLE
Pharmacists vital part of the healthcare team
Pharmacotherapy experts Explain how medications work in the
body Suggest therapeutic alternatives Eliminate therapeutic duplications
PHARMACIST ROLE
Avoid polypharmacy Teach common side effects Action for severe side effects Ethical stewardship Medical and financial resources
RURAL HEALTH RESEARCH
Collaboration Rural health hospitals Payers
Obtain grant money Research New practice models Demonstrate added value