Event ID: 2859347Event Started: 2/10/2016 12:58:48 PM ET

Good afternoon everyone. Welcome to the Quality Innovation Network Learning and Action Network event. Today we will present Patients as Partners: How to Discuss Medications, increase HCAHPS scores, and reduce ADEs. I am the clinical pharmacy specialist subject matter expert for atom Alliance. 

Here's a look at the agenda today. We will begin with a few opening remarks and housekeeping items, then we'll have a polling question for you, followed by a presentation from our two guest speakers. There will be time for Q&A after each speaker. We will then finish up with another question and some closing remarks. 

As you may know, atom Alliance is a five year, five state initiative to ignite powerful and sustainable change in healthcare quality. We welcome participants from Alabama, Indiana, Kentucky, Mississippi, and Tennessee. Atom Alliance is made up of three nonprofit healthcare consulting companies. Qsource in Indiana, Kentucky, and Tennessee, IQH in Mississippi, and AQAF in Alabama. 

There are three objectives for the session today. The first is to identify how Ask 3/Teach 3 is used by frontline staff to engage patients in understanding their medications. The second is to identify how engaging patients in these types of medication discussions can help improve HCAHPS scores, and finally, we will describe two techniques for educating patients about medications and how those techniques can reduce ADEs.

We want to thank you for taking the time to join us today. We certainly appreciate all you do to improve health care quality and achieve better outcomes in health and healthcare at lower cost for the patients and the communities that we serve. Before we begin, I want to run through a few housekeeping items. First, we will have the phone lines on mute. We will not be opening up the phone lines during today's webinar; however, we have a chat feature. Depending on how the window is set up, a chat box is either located on the right or the top of your screen. Several of us from atom Alliance will be monitoring the chat feature as we move through the presentation today. If you have a question or a comment, you can post it to us in chat and we will respond to you either in chat or on the call. To enable full-screen, you can click the two diagonal arrows just above the PowerPoint presentation. To disable full-screen mode or to access the chat function, scroll up to the top of your screen to access the menu of items. Our presenters may be asking you to use the chat feature at different times during today's webinar. If you would like your questions, comments or participation answers to be private, you can choose my name Amanda Ryan, or the

chat monitors Kristin Celesnik or Cindy Todd instead of all participants. During today's presentations you may be asked to participate in some polling questions. When you do answer a question, please be sure to hit the submit button so it can be sure to capture the answer. This call is being recorded and will be posted on the atom Alliance website as soon as it is available. 

A few things to think about during the call - we ask that you please be attentive and open-minded to new ideas and ways of applying the concepts that we talk about. We ask also for you to be patient with us especially if we happen to experience any unexpected technical difficulties. Finally we ask that you consider to be actionable. Think about the opportunities for action within your organization as we go through the presentation today. 

Before we introduce our speakers, we have a question that we would like you to answer. 

We are curious about what state you are from. If you would click the circle next to your state name and if you're not from one of the atom Alliance states, choose other and type in your state. We would like to take a look to see where everybody is from today. You have 20 seconds to finish.  

I will start to introduce our first speaker to you while the questions and responses come up then we can go through the answers as soon as they have appeared. It is my pleasure to introduce today to you Mr. Greg Horvath. He is an RN, BA, MBA and has been employed at the Cleveland Clinic for the past 16 years as a telemetry step down, ICU, and critical care transport nurse manager. And in his current role as a patient experience manager, and the office of patient experience, he brings 38 years of nursing and hospital management experience both as a bedside clinician and as a nurse manager director spanning four different hospitals. In his current role he is tasked with acting as a subject matter specialist for HCAHPS surveys, especially miscommunications, responsiveness, medication education, and quiet at night. He has assisted in the assessment of both individual units and hospital readiness in understanding and implementing the HCAHPS survey. We'll take a second and have a look and see where everybody is from. 

It looks like we have a pretty good mix. We have some representation from all of our atom Alliance states so we want to say thank you for joining us and welcome. 

I will pass the ball over to Greg. Thank you for joining us today. 

Thank you it's my pleasure to be here. I want to thank Amanda and the atom Alliance for asking me to get this opportunity get in front of what I'm sure is a combination of

frontline staff, managers, and directors. Everybody has a vested interest in this and while the topic for the discussion today is about medications and education as it regards the patients, I also will diverge a little bit during this process because an important part that we found with this along the way is simplifying what we think is just one more duty they are asking us to do. Too often when the frontline staff looks at this and we bring them a new idea and new concepts it’s just one more thing to have to try to fit into my day and I will address that. 

Initially what we always do as we do these different programs is we keep in focus what is the best thing for the patient and going forward if all of you keep that in mind, if everybody is focused on that one point - what is the best thing to do for the patient - you will not be too far off the mark in what you need to do. They deserve to know what medications have been prescribed for the period. They also need to know why they are taking them to make them more compliant and we found over time that if patients understand fully why they are taking the medication they are much more apt to comply with taking that medication and taking it the way they're supposed to. 

The other key issue and one that I know CMS is interested in, is the fact that the patient understands the side effects of medications that they are taking. This shows up in the HCAHPS questions and this is probably one of biggest sticking points we have. If you have not ventured into this process, one of the push backs we got from the physician staff was their hesitance to tell patients what side effects of particular medications are because of the fear if we tell what they are they will come up with them. What we found is that not necessarily true at all. In fact, one of the benefits to letting them know what some side effects are plays heavily into another factor that CMS and we are very interested in and that is reducing readmission rates. That the patient will go home and know what to expect from their medication and what possible side effects might be coming along with and which of those might be serious (Definitely call us, definitely come back to an emergency department) and those that are more of an annoyance that will subside or you may have to put up with while you are taking the medication. They will do you no harm and they're not going to be a concern in the long-term. So it has helped with readmission rates and patient understanding of not going back to the emergency department for something that was expected. 

What we ask from our patients is we do ask for patient participation. We want them to help us know what they need and one of the things I like to tell our staff and all of us try to impress upon our staff is we get so caught up on a daily basis in doing our jobs and doing the technical skills and performing, we often forget about two big emotions that patients come to the hospital with and that is fear and anxiety. I think if you can think back in your own past the last time you were fearful or anxious about something and it could have been a hospitalization, how much learning really gets done for you

at that point in time. Are you really listening to somebody who's trying to teach you? If we do not do our best to reduce that anxiety level and the biggest factor to reducing that is communication, if patients do not know what to expect and when to expect it and we are not in front of them on a regular basis, our chances of them learning and retaining the information we give them is probably slim and none and slim probably left town. Those are the kinds of things that we have to pay attention to and remember day in and day out when we're in front of the patients - to be attentive to those emotions that they come with. We asked the patients to do what I just showed you - to tell us if we're not communicating and ask us what the medications name is and ask us with the medication why am I taking it will this help me? And what can I expect as far as side effects with this, what do I need to watch out for? 

When it comes to the caregiver, we ask our caregivers to name the medication for the patient and clearly. Use not only the generic name but also the brand name because people understand brand-name sometimes better than generic. They need to understand both of those, the purpose of the medication, clearly, why am I taking this? What is the benefit? 

And the side effects - and use the word side effects. It is part of what they are going to see on the survey and the patient is making the connection that you had the conversation and feel free to use the term side effects so they understand that specifically. It helps with the education process. 

Prescribers role, besides delaying their fears for patients who may falsely come up with some side effects because we tell them what they are, we also asked them to be the lead in educating the patients. When we go in to sit and talk to the patients - and we sit and advocate sitting highly - one of our key initiatives, the prescriber and the physician, the advanced nurse, that have prescriptive authority, need to sit down and explain the very same three items. What is this medication that you’re giving me? What is it being used for and why am I prescribing it to you at this point in time, why is it the best thing for you? The Lexicomp patient handout is a particular brand-name that we have in our hospital formula system. It's available on our hospital intranet within the hospital for us to print out and give to the patients for information. 

An example is here. This is not a great quality slide in terms of those of you that cannot read fine print. If you pay attention to some of the bigger headings, these are the key things that we want patients to come away with. If you notice we have the medication pronunciation - helps them remember if they know how to pronounce it and the brand names of the medication, and because we get a lot of outside the country take patients in particular and a lot of patients within US go to Canada to buy the medications online, we also give the Canadian equivalent name so they understand what that is. We talk about key warnings, and what should I look for while I'm taking

this medication, when is it not safe to take the medication, so we talk about certain circumstances. Case in point - if you did start to see bleeding like if you get a nosebleed, you are able to stop the medication at this point and call the doctor, so you're making sure you're not running into a more critical situation down the line. And what is the drug used for is key. This is a one page handout that just has a small snapshot. This is a one-page front and back that we use with the patients in order to do the education. The process that we do is we give people in the front line 1 thing to do. The list grows and they just keep thinking this is more and more burden on the little time that I have as it is with my patients. If you think about it in the other context that this actually falls into many other things that we already should be doing, as I described, the better we do rounding. The clinic is all of our regional hospitals so as a part of purpose rounding, we encourage our staff to use the opportunity when you're going in with the patient because a lot of the nurses say “my patient is not that sick”, or “they do not need something every hour”. Perfect time to print out the Lexicomp report sheet, go in, take a seat, sit at the bedside, and get the connection that you need. And go over the medication either one they are already taking or new medications. Listen - we need to sometimes close our lips and open our ears a little bit better. This is about the patient at this point in time - it's not about us. Explain about the medication and please do not use medical jargon. It flows out of us easily the longer you've been in the business the easier it flows, but abbreviations and our jargon makes no sense in helping patients. Make sure you concentrate on this - it is difficult. Put in simple terms and it has been out there that we need to be talking at about a 6 th grade level on average, just to give a point of reference. And repeat. So what we do is we ask them (nurse) to go in and sit down and explain to the patient, “I will go over your medication and tell you what the name is, how to take it and any side effects and I will leave the paperwork with you and when I come back I will ask you to explain to me those three items of information.” 

The other piece of this process is we found over time it doesn't just apply to medication. It also applies to anything that we sent patients home and expect them to perform -a task or technique that we need them to do and this can be self injection of medications, wound and dressing care, ostomy care, catheter care - they are all key things that we send patients home and expect them to do. We can use this method to pull up three key items that we want them to make sure they are paying attention to and I'm sure you're sitting out there thinking there are probably another 4-5 out there we could add to the list also. It reaches out to more than just the medication. When you start using these kind of techniques, it helps you in a lot of other ways. 

The last thing I will show you is what I put together to help your managers and your front-line staff - your managers as you go through with your staff to explain some of these things we want them to do. It's easier if you can bundle concepts and make them

understand we don't go in and out of the room to do each of these. When you go in to do your morning bedside shift report, it's all part of your rounding. When you go in to do your purposeful hourly rounding and the four piece as you've heard about, it's time to do the medication administration discussions for the patients. You can bundle a lot of these concepts in the same five minutes that you spent with the patient and make it that much more effective and less burden on you and for the front-line staff it saves you time. 

Those are some of the key pieces and parts. We try to keep everything that we do as simple as possible. Knowing how complicated our days are with the front-line staff, with that I will see if there were any questions or anything I can answer at this point in time. 

Thank you. We have a question about the patient instruction sheet. Is that format something developed by the Cleveland Clinic, your vendor, maybe and tweaked by the clinic, or something that is standard within your EHR? 

This came as part of the Lexicomp system which is a system that our pharmacy folks for the formulary decided on many years ago. We previously had a different formulary system so these are systems that are out there, Lexicomp being one of those This was developed by Lexicomp company who put the process program together for the formulary. This is the one our pharmacy uses so it is embedded in the package that we have with them. 

Any other questions? 

This is Amanda - I did not see anything else but I was curious Greg, about the timing of the Ask 3/Teach 3. Do you tend to start this at the beginning of the hospitalization and carry all the way through the patient stay and have you tried this at all in any outpatient settings? 

Yes on the first question. We start as soon as the patient is admitted - the opportunity about repeating, you cannot really go over this too many times with the patient to really get them comfortable with the medications. You know once they've been on it for a while, things change as we know, suggestions and recommendations. Yes, we recommend early and often. So we get started on that certainly at the beginning of the introduction of any new medications You want to start as quickly as possible to make sure the patient’s educated right along the way. It falls into that repetition scenario, the more they hear about it the more they read about it and they understand it the better chance to have at retaining it when they go home and being compliant, so early and often. 

The last question was again? 

Have you tried any Ask 3/Teach 3 in outpatient settings? 

Yes, the ED is a little bit of different circumstance, on the outpatient side, physician office type visit. ED for obvious reason gets a little sometimes short on time and moving things through (that we don't advocate) and we do especially when there's any patient’s home medications, but it has lent itself as well in the emergency department setting as it does in the physician practice. 

Thank you for that. Kristen and Cindy, anything else? 

I did not. 

If anybody thinks of another question for Greg as we move along feel free to send it to us in the chat box. We will be happy to address it. 

I want to thank Greg for sharing with us. And would you mind passing the ball over to Jessica please? 

It is my pleasure to introduce to you Jessika Chinn Pharm.D. she is the clinical pharmacy manager at the Owensboro Health Outpatient Pharmacy in Owensboro Kentucky. She earned her Doctor of Pharmacy degree from the University of Kentucky and has nearly 17 years of experience as a pharmacist in both community and health system settings. 

She is a past president of the Kentucky Pharmacist Association and was named 2009 presenter of the year for the University of Kentucky College of pharmacy. Thank you for being with us also today Jessika. 

Thank you Amanda and I appreciate the opportunity that atom Alliance has afforded us today. Thank you participants for joining us and I want to thank Greg because the work of the Cleveland Clinic and what you do is exciting and it pushes the rest of us to strive for better care. 

We lovingly call it OHRx, that's what you'll see on the slide, but we are transitional care pharmacy - probably the best way to describe us. We opened in April 2014, we’re located within the medical office building of the Owensboro Health Regional Hospital that is located in Owensboro, Kentucky. We currently staff five clinical pharmacists and five technicians. We are an open door pharmacy, we provide pharmacy services to everyone including our employees. 

Owensboro Health has a mantra that we want to reach every patient every time. And we do know our patients are the most important members of our team. In addition to the typical pharmacy services, we initiated several clinical pharmacy services for our patients that were transitioned from hospital to home. The goal is to improve the patient experience, to standardize our process and to reduce readmissions. 

Readmissions obviously is important to anyone in the healthcare arena today, specifically 30 day readmissions are an area that present us with savings as well as a place to improve care coordination. In 2011, there were 3.3 million US hospital readmissions in adults and that is a staggering number resulting in $41.3 billion in hospital cost. 

There was a study done in 2014 that says one in six Medicare patients are readmitted within 30 days of discharge. Obviously this is an area we have to target. 

We want to look at why the readmissions occur. And as you can see, no follow-up care, patient doesn't understand the discharge instructions, problems with medications, no follow-up appointments in a timely manner on the discharge needs, and poor communication, especially with a primary provider. 

We can look at the top CMS 30 day readmissions to see who we need to target and really specific targets for pharmacy start to stand out with CHF and COPD. The role of the pharmacist has been demonstrated to reduce readmissions in many different studies and pharmacists provide comprehensive medication reviews, patient and caregiver education, medication therapy management (MTM). Sometimes people don’t understand why that it is different from patient counseling, I thought they were supposed to tell me about my medication every time I came here. Pharmacists should provide information and we strive to do that, but that's focusing on a specific medication for that specific patient at that time. MTM is a more comprehensive, global look at the patient as a whole and what disease states they have and what herbs they are taking, what other influences such as exercise and diet can have on the medication, so it's much more in-depth. We also provide medication counseling before and after discharge and reconcile this medication. So what do we do at Owensboro health? 

These are some of the services that we started that have shown success. We will look at discharge huddles and discharge medication reconciliation in a little more detail. We provide concierge pharmacy services. We bring the medication right to the bedside for patients that are being discharged and want to get the medicine before they go home. It prevents another stop. When you’ve been in the hospital and you're ready to go home, you want to go home. You don't want to have to make another trip to the

pharmacy down the road, so we deliver those to the bedside. We provide discharge counseling for the patients as well. 

We staff technicians down in the emergency department and we started that in January of last year. The inpatient side of the hospital pharmacy does a great job of obtaining the prior medication list. So pharmacists interview patients and try to find out what is the most accurate picture of how a patient is managing the medication.

So they only take it once a day, he wants to know at Owensboro health what are they taking. We don't want to make decisions on his medications based on what the patient should be doing - we want to know what they are doing so we make the best intervention. We found in the emergency department the numbers were not as high as we wanted and we realized pharmacy technicians would be the perfect augmentation to the process. We have a residency trained specialized pharmacist in emergency medicine, but her efforts were targeted at antimicrobial stewardship, and so we put the technicians down in emergency department and they have done an excellent job of helping to obtain the medication histories and it works because retail pharmacy technicians do this sort of thing all day long. They been an integral part and the numbers in January 2015 were around 10% success and after the first 30 days we were at 88%. 

We also received counseling referrals for the prescription assistance program in Daviess County that is the access project. We realize patients that maybe need prescription assistance get the medicines through similar programs but nobody is talking to them about the medications because they're getting it straight from the manufacturer so we take the counseling referrals from the health department to take care of the patients and answer questions. 

We are also integrating with our accountable care organization and we have lots of efforts underway to coordinate the efforts with what they are doing to improve patient care on the outpatient side as well as the inpatient side. 

Discharge huddles. This was a pilot in July 2014 is when we started. We started on the pulmonary medical unit and these are pharmacist led interdisciplinary rounds. We round on patients who are going home either today or tomorrow, and it is a team of pharmacist, nursing, dietary, discharge planning and pastoral care people. We try to target specific questions about what the patient needs. What we have found were patients were going home and maybe the social worker working got them a wheelchair but when they got home there was no ramp to their house. We had a specific instance where a patient reported to us that she broke her hip and she used her wheelchair in the house but there was no ramp for her so she didn’t ever use it when she went out, she just used it in the house. She actually fell on the way to her car. So

we have been able to target things like that. When the different disciplines are looking at the patient as a whole and discussing it with the patient, the patient being the most important part of the team, we found many opportunities for intervention. We found some patients have been sent home with a nebulizer medication, but they do not have a nebulizer at home and so we have been able to prevent some of these adverse events from occurring through these rounds. We saw that sometimes we were missing patients because they would be discharged after hours or on the weekends and we do the rounds Monday through Friday. So we started rounding on day three patients when we are able so for the patient who has been in the hospital for three full days, we will come and round on the patient as well. 

We've had a lot of success and we'll talk about that more, but the goal is to spread to six units in fiscal year 2016. 

We also have the discharge medication reconciliation service. That was a fiscal year 15 success and the goal was to reach 50% of the target population with pharmacist providing discharge medication reconciliation. We want to target the hospital patients because we felt this was a vulnerable population. Either these patients don't have a primary care provider or they are going to have the transition from a hospital inpatient provider to their primary care on the outside and we felt like those were gaps that make these patients more vulnerable. The goal for the end of the year was 50% but at December we had 83% success and we maintained it above 90% success in January through April. We work to incorporate the discharge medication reconciliation as well with our discharge huddles so we target the hospital patients but we also provide the services when we do the discharge huddles for patients that have needs for the next patients as well. 

We see decreased adverse events with this process. We have a very successful inpatient pharmacy model that reconciles the prior to admission medication list so you might think why do you need a discharge medication reconciliation if you are doing a good job on the front end? 

In actual application, the impact has been significant and even though we're doing a good job on the front end there are still opportunities for us to catch problems on the back end. 

Anytime you implement new services there are challenges. Staffing and resources is important. You cannot provide services if you do not have the hands and feet to carry it out. Documentation - how will you document, where will you document and what is the important piece that needs to be documented and documentation of course is important for being able to see the successes, to be able to carry out a service that you're providing to other units, as well as for reimbursement. 

One of the biggest challenges we have is acceptance among the different disciplines, especially the nursing staff. At first they did not see the value but as they came to see the successes with the patients and how excited they were, especially with the discharge rounds, then the nurses have bought in and they actually will ask for us to round on certain patients. They will say, Mr. Smith down in room 302, he is not really qualified for the rounds today but he has some issues and I think we should go round, so we'll go round on the patient even if they are not on the list for the day. 

Consistency is important and as I said we’re spreading the discharge huddle to six units this year. We want to make sure that what we did on one unit transfers to another easily so we want to make that process very standardized. You have to be sure of the competency of the staff. The timing of the services is important. We found the issues particularly with discharge huddles. We were doing them in the afternoon and at that point a lot of times we had staff that had not had lunch, they were busy and behind and so we had some nurses say they were hungry and angry by the time the rounds came so we moved those to a different time of day and the success really skyrocketed. 

Being efficient is difficult. We believe wholeheartedly the patient has to be involved in their care and it's an important thing but sometimes involving a patient makes things take longer and so it's important that the team understands that maybe spending more time down in Mr. Smith's room is important for him and it might help prevent him from being readmitted but it is going to help them have a better experience and be more engaged in the health so he can be more successful in managing his health. 

And reimbursement is a challenge. We continue to work on this. So we looked at the challenges. Now let's look at a little bit of our success. 

We started our pilot on the pulmonary unit in July 2014 with the discharge huddle. We were going along and trying to overcome the challenges and tweaking the project as I said before moving the timing of the rounds to see if we could be more successful. In December, we're starting to get frustrated because it seems like we were not getting the buy-in from the other disciplines, and the timing was off. We moved the time on January 1 and that is when we started to see huge successes. I got a call in January from our director patient experience - she was raving about our success and at that point I'd only been with Owensboro health for about one year. 

As a retail pharmacist, I worked in the community pharmacy for most of my career. She (director, patient experience) was talking about HCAHPS scores and I did not understand what HCAHPS scores were, but she was telling me my score was great. I went to my boss and I said, we have moved those HCAHPS scores 30 points. She said

I don't think you understand HCAHPS scores, there is no way you moved them 30 points. We'll talk about that in more detail, there is no way you moved them 30 points. With the question for communication about medications, the hospital was working on the project for the last couple of years and they had only been able to move the communication about medications two or three points, even with the concerted effort. We moved it 30 points. As you can see in November the HCAHPS score rank was 61 and by January we were at 94% so we had that huge jump and my boss was ecstatic and shocked at the same time. We haven't determined statistical significance for the numbers as it is on one unit. We are in the process of a research project to evaluate the success of the program, looking at readmissions as well as patient satisfaction. You can see a trend for both the right and the top score, when you look at the top box score. If you look at the top box score, if you break it down if you were to survey 10 patients and five of them said they do the best job every time, they do a perfect job every time, your top box percent would be roughly 50% if five of those patients answered that way out of 10. 

In November we were at 65% on the pulmonary unit, and by January we were at 74%, so a positive trend. 

We want to see what happened hospital-wide and was there any influence and we have improved statistical significance yet but we are in that study. 

Looking at the rate for Owensboro Health Regional Hospital as a whole for 2015, it was the first full year that we had discharge huddles and in January we were at 56% and in December we close to 66% so positive results. 

We had spread to other units in August 2015. The success goal for fiscal year 16 was to spread to six total units. We started in August 2015 on the oncology unit so we were not there long, but from August until December we've gone from a rank of the 1st percentile to the fifth. Nobody wants to be right there but we are trending upward even in the small time. 

Looking at the top box score, for the oncology unit from August until December we see about a 10% increase in the HCAHPS score, so we definitely have seen the benefits of these rounds and the biggest compliment to our services for patients just cannot believe that so many people are there to help with their care. The first thing we say when we go into a patient room, we get their permission, and we bring a pretty good entourage in - a pharmacist, students, nurses, dietitians, chaplains, social workers, a pretty good entourage, over and over patients say, all of you are here for me? When we introduce the service, I want patients to understand you don't always see anybody besides your nurse or your doctor but there is a whole host of Allied services behind the scenes helping to take care of patients. 

We’re now on five units and in March will spread to neurology and that will meet the success shared goal for the year. 

Some of the adverse events that we have avoided, through the services, discharge huddles and the meds to bed pharmacy service, we reconcile the medications we have seen patients who were sent home on antibiotic that their lab showed they were resistant to, so we could get that switched to an appropriate antibiotic. We're seeing duplicate therapies, and usually that happens when you have two or more providers caring for the same patient. We had one specific example of patient on Plavix. The second doctor came in and said I need to switch this patient to (??). He started the patient and the primary physician who started the Plavix did not know and did not stop it so the patient on home on two antiplatelet drugs. We have seen dosage and frequency errors, probably most common with insulin patients who are on insulin but we see dosage and frequency errors on the discharge medication reconciliation and we could take care of those before the patient gets home. 

We see lots of drug to drug interactions and we tackle those before the patient leaves so we do prevent harm. We had one patient on a g tube and at discharge the pharmacist noted the patient had been prescribed a capsule that cannot be given via the G-tube and then after she looked at the patient in more depth, there were several medications that cannot be crushed or given through the tube, so we had two successes in preventing some adverse drug events. 

We cannot stop there, we want to expand in any way we can to help the patients and we’re in the final stages of putting together an anticoagulation clinic for the ACO. They came to us and said, we would like you to manage anticoagulation for the patients in the outpatient setting. We have the collaborative care agreement being reviewed by the physicians. We want to expand the MTM services and we want to look at adherence monitoring and synchronizing of medication. We want to see where we can make interventions to help patients adhere to the medicines. There's a study or an article in Pharmacy Today that says according to the National Council on Patient Information, poor adherence equals increase of $2000 per person per year, so not only are patients getting sicker because they are not taking the medications correctly, it is costing a lot of money. 

We had a lot of success. It's been great to work with our patients and I cannot say enough for involving your patients and letting them be the key person on the healthcare team. Any questions?

Thank you Jessica. We have a few questions. Regarding your challenges, and overcoming the challenge of staffing and resources, how did you overcome that and were you able to add any staff or resources based on the results of your pilot work? 

I came into Owensboro Health and was just excited because they gave me a strong support staff. There were myself and two other pharmacists and one part-time pharmacist when we opened in April 2014. We're now at five full-time pharmacists so definitely one of the solid benefits of the services they are just asking for more. We started with the research huddles and couldn't start medication reconciliation because there were not physically enough bodies to do it and so they increased my staff. We’re looking at the anticoagulation clinic with the ACO and the first thing that was said was “you do not have the staff to do this, so if we want to do this we have to expand the staff.” With the discharge huddles, there are five of us and we’re on six units and that's logistically not possible. We have someone who has to stock the pharmacy, go to the discharge huddles, we cannot be in all the huddles. It was because often the nursing units have the discharge huddles at the same time. So we have worked with our inpatient pharmacy as well and they are providing discharge huddles services as well. So what we do is we go in and start a unit and outpatient pharmacist takes care of that. Once an active unit is up and going we pass it off to the inpatient pharmacy team and they takeover and we go start another one. Once we're live on all units, I anticipate the outpatient pharmacy will continue to take care of at least two or three units for discharge huddles. 

I want to squeeze in a couple more questions real quickly. Can you review what time of day you do the discharge huddles? 

On the pulmonary medical unit we started at 1:30 in the afternoon and it was not a good time and we moved it to 10:00 in the morning and it blossomed from there and the nurses went from resenting having to do this to chasing us down the hall and saying wait, I want you to go see Mr. Smith. What worked on pulmonary did not necessarily work on oncology so what worked on those do not work on all units. They are different times and we try to make it optimum for each unit. So what we do is we bring in the team, we bring in someone from each discipline, we bring in the nurse managers where we are live. We brought in this manager for the pulmonary unit, then we bring in if we're going to start on oncology we brought in the nurse manager and we would sit down and talk about the logistics, or the things that need to be done differently on this unit than the other unit, what time is really optimum or whatever time works best for them. It has to be targeted to the unit and we keep growing and at each meeting it is rewarding to have the team sit down and talk and we do that a couple of months if we start on a unit, which we’re starting on neuro in March. We already in January had our first talk with the manager and getting it so it is optimum for each unit, there is some difference among the units. 

Thank you. We're out of time for questions. I'll turn it back over to Amanda. 

Thank you Kristin and thank you also to Jessica. We have one last polling question. 

We would like to know what the top barriers you face in educating your patients about the medications in your facility. Emily, can you pull that up for us? 

You will see a list of different barriers that you may be facing and let us know what you are thinking and as you are doing that, there was one last question. Jessika do you use the pharmacy appointed based model and do you find synchronizing medications will decrease ADEs and improve endurance? 

I'm not familiar with the pharmacy -- I'm not sure could you repeat the question? 

The pharmacy appointment-based model? I think that's typically when you synchronize a patient's medications and they will come in on a specific date of the month to pick up the medications and get education. 

We do not have a specific program like that but we work with patients to try to synchronize the medications. That is also something we would do when we provide medication therapy management to the patient. I definitely think synchronization helps with adherence. It is frustrating for people to come back to have to keep coming back to the pharmacy and they will not do it. I think it drops 40% after the first refill the patients will not even come back and get the refill. 

Make it as easy as possible. 

Okay. I've seen similar numbers to that as well. Thank you. The polling question looks like the top barrier to educating patients is insufficient time and staffing. So I think Greg addressed some of those points a little bit but certainly if you would like more information on how to make something like this work with time and staffing that's what we're here for - to supply assistance to you among many other things so reach out to us if you're finding that's an issue and we can try to help you. 

To wrap up quickly, to respect your time we want to extend a heartfelt thank you to the speakers and to all of the participants for joining us today. As I mentioned, the atom Alliance staff is here to help you so feel free to contact us anytime you have a question about you have heard, of if you need any technical assistance with your quality improvement initiatives. We want to make sure everyone is aware we are actively recruiting all provider types to work with us on improving medication safety and reducing adverse drug events. 

We hope the speakers today have inspired you to try something new to educate patients about the medications, and improve safety along with your HCAHPS scores and also if you're not in a hospital setting, keep in mind the information shared by the speakers today could be adapted to other care settings like long-term care so contact us at any time to partner with us in this work and we are happy to help you. 

We ask you would please take a few moments to complete the post-event survey that will appear as you exit the webinar. Your feedback is valuable, it will help us shape the future of virtual learning and action events. Reminder this call is being recorded and will be posted on the atom Alliance website as soon as it is available. 

Thank you for joining us today and have a great afternoon.