“successful medication management through transitions of care”
TRANSCRIPT
1
“Successful Medication
Management Through
Transitions of Care”
Presenters:
Rosa Lee, Pharm.D.
Transitional Care Clinical Pharmacist,
Kaiser Permanente
&
Bonnie Levin, Pharm.D., MBA
Corporate AVP Pharmacy Services,
MedStar Health
This material was prepared by the Atlantic Quality Innovation Network (AQIN), the Medicare Quality Innovation Network-Quality Improvement
Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid
Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.
11SOW-AQINDC-TskC.3-15-16
Kaiser Permanente: Transitional Care Clinical Pharmacy
Rosa J. Lee, Pharm. D. Transitional Care Clinical Pharmacist Holy Cross Hospital
Disclosure
We have no actual or potential conflicts of interest in relation to this program.
3 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Objectives
Discuss why the Transitional Care Clinical Pharmacy (TCCP) team was started
Analyze the approach to initiating a transitional care program
Present the current practice and challenges of medication reconciliation by TCCP team
4 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
KAISER PERMANENTE
5 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
What is Kaiser Permanente and how is it different?
Mission
– Kaiser Permanente exists to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve.
6 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Health Plan Hospital System
Medical Group
Kaiser Permanente Regions
Northern California
Southern California
Hawaii
Northwest
Colorado
Georgia
Mid-Atlantic States
7 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Kaiser Permanente in the hospitals
Internists to Hospitalists
Kaiser community hospitals
– California, Hawaii, Oregon
Contracted Core Hospitals
– Mid-Atlantic Region
8 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Holy Cross Hospital
Suburban Hospital
Greater Baltimore Medical Center
St. Agnes Hospital
Medstar Washington Hospital Center
Virginia Hospital Center
Stafford Hospital
Reston Hospital
Kaiser Permanente in the hospitals
Core hospitals: Kaiser employees collaboratively caring for Kaiser patients on a multidisciplinary team using Kaiser’s integrated computer system
Physicians
Case Managers
Clinical Pharmacists
9 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
TRANSITIONAL CARE CLINICAL PHARMACY:
10 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Why We Started this Program
Expedite discharge (original reason)
Streamline therapy
Low molecular weight heparin to warfarin transition
IV to PO conversions.
Home IV therapy
Steps Taken To Start Program
Physician acceptance
– Why this service is critical for patient care.
– How this service will help the physician.
– How this service will streamline or coordinate patient care.
Nursing/Case Manager acceptance
– Needed to coordinate with both hospital and Kaisers nursing
– Coordinate how we will work with them to facilitate discharge.
Steps Taken To Start Program
Inpatient Pharmacy Acceptance and Delineation of Roles
– Who is responsible for patient education
– Who is responsible for order input at the facility
Contract Negotiation with Hospital Administration
– Negotiate per diem rates
– Access to hospital computer systems
– Kaiser computers on site to provide prompt and focused care
– Office space
– Name badges, parking
– Establishment of a “Kaiser floor”
TCCP’s Current Practice
Conduct medication reconciliation on LACE patients within 3 days of discharge
– Resolve issues or discrepancies
KP Pharmacy Initiatives
HEDIS measures
Bridge the gap between hospital discharge to home and
decrease 30-day readmission rates.
14 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
15 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
LACE
The higher the LACE score, the higher risk the patient is for readmission and/or death.
– L - Length of stay
Added at the end of the hospitalization
– A - Acuity of admission
Scheduled versus unscheduled admission
– C – Co-morbidities
Points are given if a patient has certain disease states which are prone towards readmission
– E - Emergency room visits within the past 6 months
Does not include ER visits prior to current hospitalization or repatriation
16 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
LACE Scoring Tool
NCQA HEDIS measures
National Committee for Quality Assurance (NCQA)
– Private, not-for-profit organization working to improve the quality of health care
Healthcare Effectiveness Data and Information Set (HEDIS)
– Tool used by NCQA to measure performance
– Sets standards that allows for comparisons of health plans
Pharmacotherapy Management of COPD Exacerbation
Persistence of Beta-Blocker Treatment after a Heart Attack
Osteoporosis Management in Women Who Had a Fracture
Anti-depressant Medication Management
17 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Post-Discharge Medication Reconciliation Call
Transitional Care Clinical Pharmacists are located at Kaiser Permanente business offices
Contact patients with a LACE score of > 6 within 2 business days from hospital discharge
Conduct medication reconciliation comparing discharge medication list to home medication list
Suggest recommendations to physician
If needed, follow-up with patient on physicians’ response
18 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
19 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Advantages
Post-Discharge Medical Reconciliation Call
Potentially reach more patients
Patients has bottles right in front of them
Quieter working environment
Flexible schedule
20 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Challenges
Post-Discharge Medical Reconciliation Call
Patients cannot always be reached
Physicians may not respond in a timely manner
Takes longer to resolve issues
Playing “catch-up”
Limited remote access to hospital systems
Limited communication with case managers
Hospital Pre-discharge Medication Reconciliation
On-site at hospitals
Conduct medication reconciliation pre-discharge
Suggest recommendations to physician
HEDIS measures
– Post-MI Beta Blocker
– COPD
– Others
21 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
22 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Goals
Hospital Pre-discharge Medication Reconciliation
PREVENTION MODE
Resolve issues with hospitalist and/or patients on-site before discharge
Build professional relationships with physicians and other healthcare providers
Get involved with HEDIS measures
Hospital Pre-discharge Medication Reconciliation
Challenges
Gaining trust of physicians
Turf wars with other disciplines such as hospital pharmacy
Communication within and outside the team
Access to workspace and computers
Reaching patient before discharge
Actions Taken
Establish rapport with hospitalists
Work collaboratively instead of competitively
Provide updates, obtain business cell phone
Find desk space, obtain work laptop
Review potential discharges early
23 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
24 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Goals
Skilled Nursing Facility Medication Reconciliation
Resolve issues with rounding SNF and/or patients on-site
Conduct medication reconciliation
Act as a clinical resource for healthcare professionals
Help prevent readmissions into SNF
Outcomes
Impact of TCCP’s comprehensive medication review in reducing readmission rates for LACE patients (score > 6) going from hospital to home
Impact of TCCP’s pilot program: hospital to SNF
Impact of WHC and Children’s Hospital’s bedside delivery program
25 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Absolute Reduction Relative Reduction
LACE > 10 3-14% 15-43%
LACE 6-9 3-11% 20-50%
Future Goals
Progress pre-discharge medication reconciliation at WHC and VHC
Initiate SNF involvement
– Phase 1: medication reconciliation pre-discharge for patients going to SNF
– Phase 2: medication reconciliation post-discharge for patients going home from SNF
Expand bedside delivery program
– Established at Children’s Hospital and WHC
26 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. September 3, 2015
Bonnie Levin, PharmD, MBA
Corporate AVP, Pharmacy Services
MedStar Health
Successful Medication Management
through Transitions of Care
the DC Capitol Care Coordination/Medication Safety-ADE Prevention Coalition May 19, 2015
Objectives
Describe two programs that can improve medication management across transitions of care
Identify three pharmacy interventions that enhance patient engagement
Define resource requirements for transitions of care programs
28
Transitions of Care at MedStar
• Active Readmission Steering Committee for system x 4 years; each hospital has working groups
• Interdisciplinary, includes: – Case Management
– Physicians
– Finance/rates and reimbursement
– Quality/safety
• Defined initiatives and metrics
Sites of care
Inpatient transitions
ED/pre-op med hx
Adm med rec
Inpatient med mgt
Discharge med rec
Discharge RX
Pharmacy activities
Home med histories
Medication reconciliation
Risk assessment
Medication optimization
Discharge counseling/education
Bedside discharge Rx delivery
REMIND Study - Medication Pill Box
Post-discharge follow-up calls
Home Med Histories
ASHP Connect survey 01-15*: "Which of the following staff members is/are PRIMARILY responsible for obtaining the best possible medication history and medication list?
• 117 responses: – ED Triage Nurse 6%
– ED MD or LIP 2%
– ED Bedside Nurse 7%
– ED Pharmacist 12%
– ED Pharmacy Tech 25%
– Pharmacy Student 0%
– Floor nurse 12%
– It's a Team Effort 33%
*ASHP Connect Listserve (subscription required) http://connect.ashp.org/communities/alldiscussions/message/?MID=37463
Home Med Histories at MedStar
• Technicians collect home med histories in ED
– 2 sites; 2nd shift, 1-2 FTEs per site
– Access external Rx databases
– Contact PCPs, community pharmacies, nursing homes, etc.
• Entered into EMR
• One site interviewed 37% of admitted patients
• Metrics: hospitalist to review histories collected.
Operational Issues
• Needs ED champion
• Standardized training and competencies
• Recruitment: ideal candidate has retail pharmacy experience:
– Customer service
– Familiarity with multiple dosage forms
• Access to EMR, external data bases
• Pharmacist support for complex cases
• Cost effective model as compared to RN or pharmacist
Inpatient interventions
• Med reconciliation
• Risk assessment – various scales
• Moderate risk patients*:
– Significant reduction in readmissions
– Average 4 interventions per patient
*Consult Pharm 2013; 28: 775 – 85
Pharmacy Activities
0
500
1000
1500
2000
2500
Inpt interventions per month at 7 hospitals
Preparation for Discharge
• Lifestyle Modification
• Referral for other Providers (Social Work, Physical Therapy, Dietician, Palliative Care)
• Discharge Medication Reconciliation: – Rx on PBM formulary
– Patient can afford co-pay
– $4 Rx plans
• Discharge Medication Counseling – high-risk, problem-prone medications (indications, side
effects, and address barriers to post-discharge adherence)
Operational Issues
• Resource intensive:
– Unit-based pharmacists – 1 FTE/15-30 beds
– IT support
• EMR access, tablets, iPADs
• Decision support
• Interdisciplinary rounds
• Varying governance models
– Automatic vs. consult dosing changes,
monitoring
Bedside Rx Delivery
• “Meds to Beds”
Program live at seven MedStar hospitals
The Challenge
Program planning
• Leadership support:
– Communications from VPMA, CNO, Case Managers, to gain support
• Recruitment – at least 1 FTE per 150-200 bed site
• Develop metrics and monitoring program
• Ongoing promotion- Public Affairs
• Word of mouth
• Concierge program
– Associate delivery as well as patients
Operational Issues
• Need insurance card scanned/available
• Rx must be written at least 2 hours before discharge
• Discharge during business hours
• Patient assessed for ability to pay co-pay, if not need Case Management evaluation and voucher issued
• Patient must approve use of in-house pharmacy (“choice”)
• eRx vs. hard copy
Post-discharge activities
• Post-discharge calls or visits – transitions to:
– transitions to Rehab/TCU
– warfarin clinic
– CHF clinic
– Joint Ex discharge follow-up calls)
• REMIND Study – electronic pillbox project
Next Steps
• Implement med history techs at other sites
• Improve metrics, data collection, analytics
and reporting
• Expand bedside delivery programs, couple
with expanded discharge education
• Explore adherence tools: – Phone/text reminders
– “Bingo cards”
– Electronic pillboxes (beyond trial)
Thank you!