Mental Health Clinical Pharmacy Services and Pilot at

Regions Hospital

Craig Harvey, Director of Pharmaceutical ServicesMeg Moen, Clinical Pharmacy Resident

Dan Rehrauer, MTM, HealthPartners

Regions Hospital, Saint Paul, MNFebruary 19, 2014

Objectives

• Regions and current Pharmacy operations

• Pilot design and initial objectives

• Preliminary results

• What we learned along the way

• MTM Services

• Future

*This was a quality assurance project and any results obtained are not intended for generalized application/knowledge

Regions Hospital

• 460 Bed hospital

• Level 1 Trauma Center

• 79,000 ED visits in 2012.

• Disproportionate Share Hospital (DSH) – 340B

• 100 Mental Health Inpatient beds

• 24 x 7 Pharmacy

• Discharge Pharmacy with bedside delivery

Regions Mental Health

• New 2012, 100 private inpatient rooms

• Provide acute mental health services for inpatients

• Care delivered by team of psychiatrists, nurses, occupational therapists, pharmacists, and medicine physicians

• Crisis staff for emergency evaluations in Emergency Center

• Outpatient services offered at a variety of HealthPartners clinic locations

Inpatient facility, Saint Paul, MN

RARE

• How can Pharmacy help to improve patient care AND reduce readmissions?

Current Model - IP

• Clinical Pharmacist (DCP) spends 5 hours daily to consult and review of 100 MH patient profiles.

• The mental health department has the highest patient to pharmacist ratio of any clinical pharmacist position

• DCP works remotely - little to no direct interaction between pharmacist and patient, provider, or nurse.

• DCP is not involved in the discharge process.

• Patients not routinely referred for MTM at discharge

Current Model - OP

• 82% of MH discharge Rx’s filled at Regions, delivered to patient’s nurse prior to discharge.

• Regions is 340B – lowest drug cost available.

• Pharmacy bills insurance if available. Bills patient co-pay or retail price after patient leaves the hospital.

• If “too early”, “not covered”, “PA” or need to expedite - 30 days supply billed to nursing unit.

Pre-pilot data

• Progress notes average 0.97 per patient case

• Average number of medications per inpatient: 17.5

• Average number of doses per inpatient: 73 doses per patient per stay

• Average cost of medications billed to MH floor at discharge: $5,000 - $7,000 monthly

The PlayersCollaborative, team-oriented initiative necessary to make quality patient impact

Pilot ObjectivesNovember 11th – December 13th

2013

• Identify potential impact of full-time clinical pharmacist services – measure interventions, cost-savings and satisfaction with services provided.

• Identify areas for patient care improvement.

• Determine justification of a dedicated mental health pharmacist resource.

Expanded Clinical Pharmacist Role

• Increased direct interactions with MD and nursing with recommendations

• Profile review to reduce polypharmacy

• Increase pharmacist involvement in discharge medication reconciliation.

• Place MTM referrals for high-risk patients

• Track interventions

• Reduce monthly cost of medications billed to MH units.

• Participate in team rounding

• Improved med patient safety

Continued adherence to current role expectations with additional duties.

Interventions

Over the course of 24 days:

•360 interventions

•92.8% of recommendations accepted by psychiatrist

*Preliminary data from clinical surveillance software system – no eMAR results yet

Interventions

Most common interventions:

•Discontinue inappropriate therapy (72)

•Change in Drug Formulation Recommendation (46)

•Medication reconciliation upon discharge (39)

•Alternative therapy recommendation (18)

•Antibiotic therapy recommended (16)

Greatest cost savings:

•Antibiotic therapy recommendation

•Discontinue inappropriate therapy

•Alternative therapy recommendation

Key Interventions

Pilot Savings

Pilot Savings

Over the course of 24 days:

•Pilot savings: $99,301

•Potential annual savings: $1.5 million

*Preliminary data from clinical surveillance software system – no eMAR results yet

Discharge Medications

• Some patients have their home medications stored in pharmacy upon admit

• Discharge medications sent up WITH home meds

• Pharmacist reconciled patients home meds with discharge meds and identified:• Duplicates• New medications• Discontinued medications

• Opportunity: • Pharmacist review meds

personally with patient• Reduce med costs (patient

and institution)• Intuitively this may improve

compliance

MTM Referrals

• HealthPartners Clinics offer unique opportunity for MTM coordination of care

• Most pilot interventions occurred on floors where patients were working towards discharge

• Established process for DCP to easily place an MTM order• This was a challenge

MTM Referrals

• Current order instructs patient to contact appointment line• Patients may not call to

make an appointment• Many patients may not

keep their appointment

• Opportunities identified: • Can we enable social

work to make MTM appointment prior to discharge

• Can we establish outpatient MTM services at Regions Hospital to increase convenience to our patients

Medication Therapy Management (MTM)

Why do we want to promote this service?

•An outpatient service that optimizes pharmacotherapeutic outcomes for individual patients.• Are the medications indicated, effective, safe and

convenient• When offered by a pharmacist the service has been

shown to improve clinical outcomes and reduce adverse drug effects from medications for chronic conditions.

•Dramatic increase in psychotropic medications and complexity of medication regimens makes MTM essential

•Pre and post discharge education, medications reconcilliation/education and transition managers have been demonstrated to reduce risk of readmission by up to 37%

Who would benefit

• People on multiple medications (>4)

• Patients who see multiple prescribers

• Patients who mention concerns with costs of their medications

• Patients who are confused about their medications

• Patient that aren’t taking their medications the way they are supposed to (non-adherence)

• Everybody!

PerceptionsPost-pilot survey distributed to mental health professionals to gauge perceptions of pharmacist services

Perceptions

Perceptions

Perceptions

Perceptions

Impact opportunities(What we learned)

• Discharge medication process

• MTM and transitions of care

• Interprofessional relationships

• Cost savings

• Other areas:• Are patients getting re-admitted due to

cost/administration of long-acting injectables?

Future Model – IP

• Hiring 1 FTE BCPP (Board Certified Psychiatric Pharmacist) 2nd quarter 2014. Focus at start• Admission Med List – accurate and complete• Formulary Management – clinical and cost effective• Education – staff and patient focused with indications for

Rx• Discharge Med Rec – insurance, formulary.

• Patient home meds – reconcile with discharge orders• Use where appropriate – patient safety, cost savings for

all

• All MH patients leave with 30 days supply of meds to improve med compliance, reduce readmissions.

Future Model – IP continued

• Refer high risk patients to MTM post-discharge

• ED Clinical Pharmacist partners with MH pharmacist

• Measure Results of Pharmacist Interventions –• Cost Savings, formulary compliance,

polypharmacy reduction• Outcomes – LOS, reduced readmissions• Patient AND staff satisfaction• Reduced patient days

How can Pharmacy help to reduce Mental Health Readmissions at

Regions?• Medication Optimization

• Medical and psychiatric

• Medication Reconciliation• Accurate, verified medication list upon admission• Discharge to home with current meds only

• Patient Education• “Why” this med is important – “indication” on bottle,• MTM where needed – reinforces, educates after discharge

• Transitions of Care• Recommending patients for MTM with scheduled appointment• Accurate discharge med list on patient discharge summary (AVS)

• Access to medication • Meds in hand when discharged• Trouble shoot compliance issues - affordable, reminders

• Evaluate if strategy works? Measure results.

Thank You

Questions?