Optimizing Clinical Quality Performance with Pharmacist ...

Optimizing Clinical Quality Performance with Pharmacist-Driven Programs

Presented By:Lee Klevens, Pharm.D. – [email protected] Ho, Pharm.D. – [email protected] Chuong, Pharm.D. – [email protected] Kim, Pharm.D. – [email protected] County Regional Medical Center (RCRMC)January 18, 2011

Pharmacy Patient Safety Projects 2010Project Description Start Date Progress

Boxed warning medications: ACEi/ARB

• Daily monitoring for boxed warning (contraindicated in pregnancy)

• Warning in Pharmacy Information System

• Warning on Medication Administration Record

• Warning in Pyxis when retrieving medication

Started in 2009 • 0% pregnant patients on ACEi/ARB

Methotrexate Monitoring

• Daily monitoring to ensure compliance according to regulations, medication management standards

• Patient education, follow-up, monitoring

Started in 2010 • 100% compliance with no ADR/ADE

Anticoagulation Management

• Daily monitoring for appropriate management per protocol

• Patient education, follow-up, documentation for compliance

Started in 2009 • 85% monitored by pharmacist in inpatient, no recurrent DVT/PE 30 days post-discharge

• Therapeutic INR10 to 15% higher than national average (outpatient)

Antibiotic Stewardship

• Daily monitoring for appropriate dosing, indications, cultures ordered

• Reducing unnecessary use of antibiotics

Started in 2010 • Monitoring for improvement

Boxed warning mediations: NSAIDs

• Daily monitoring for boxed warning


Started in 2009 • 100% patient monitored

Pharmacy Patient Safety Projects 2010

Project Description Start Date Progress Boxed warning medications: ESAs (Epogen, Aranesp)

• Daily monitoring for boxed warning


Started in 2009 • Compliance improved from 90% to 100%

High-risk medications: QT Prolongation Medications

• Daily monitoring for risks • Patient education, follow-up,

monitoring

Started in 2009 • 100% patient monitored

Boxed warning medication: Fentanyl transdermal patch

• Daily monitoring for opiate tolerance


Started in 2009 • 60% to above 80% compliance

• All incomplete documentations are corrected

Therapeutic drug monitoring

• Daily monitoring for appropriate therapeutic drug levels


Started in 2009 • More than 80% patient’s drug levels are therapeutics within 72 hours

Non-formulary medications

• Ensure criteria of use are met • Ensure compliance, provide

education, appropriate documentation

Started in 2010 • 100% are monitored

Pharmacy Patient Safety Projects 2010Project Description Start Date Progress

DVT/VTE/PE Prophylaxis

• Daily screening, monitoring to ensure that all qualified patients are on appropriate prophylaxis therapy

• Reduce re-admission within 30 days post-discharge

Started in 2010 • 100% patients on appropriate prophylaxis within 24 hours of adminission

Unit-based pharmacists

• Medication reconciliation • Medication management • Patient education, monitoring,

follow-up

Started in late 2010

• Currently 70% medications are reconciled within 24 hours, including patient counseling, education, documentation

Pharmacist-driven vaccinations

• Screening, vaccination, documentation

• Improving core measures (influenza, pneumococcal)

• Tdap vaccination to comply with OSHA for employees

• Tdap vaccination for outpatient “household contacts” via ORRA grant

• Vaccination and medication management program outreach for pediatrics


• 100% core-measure patients vaccinated with influenza, pneumococcal

PCA monitoring

• Daily monitoring and correction to ensure compliance (medication management standards)


• Monitoring for improvement

Infusion monitoring

• Daily monitoring and correction to ensure compliance (medication management standards)



Pharmacy Patient Safety Projects 2010

Project Description Start Date Progress Selective Disease-state management (HF, Glycemic Control, Stroke, Sepsis, Adherence program, Discharge Counseling)

• To improve patient outcome (core measures)

• To decrease re-admission rate, patient quality of life (QoL)

• To educate patients and family about medication management related to disease-state

Some started in 2010, some will start in 2011

• HF: 98-100% compliance, re-admission rate from around 14% to less than 10%

Nutritional • Daily pharmacist oversight and facilitation of appropriate medical nutrition therapy/electrolytes


Pyxis Parx • System upgrade to reduce medication error through bar-coding



Pharmacist-driven MM of Hep C

• Medication management • ADR monitoring


P = Problem (In terms of Patient Care Diagnosis)I = Intervention (Include: short term goals, education)

P = Plan (Evaluation of interventions, response to treatment, change in patient status, chronological

documentation of patient’s clinical course) Date/Time Discipline

Pharmacist Home Medication Reconciliation - reviewed by pharmacist Discussed with: Patient Family Other _______________________________

Source of patient’s medication history: : Patient Family Other_____________

Allergies: Ht/ Wt: Pregnancy/Lactation Status: Home Medications Continued on Admission: Home Medications Not Continued on Admission: New Medications: IVF: Prn Fever/HA Prn N/V: Prn Sleep: Prn Pain: Current medications were reviewed for appropriate criteria of use and dosage. Communicated with Monitored patient’s response to new medication(s):

No adverse reaction reported Adverse reaction reported with_________________

Provided education on new medications(s) to patient/family with expected effects, significant adverse drug reactions, and potential drug interactions. Pharmacological VTE prophylaxis received on day or day after admission. All questions/concerns regarding medications were addressed to patient/family Pharmacist will monitor medications use. Tran Phan, Pharm.D Ext: 66636 DISCIPLINE LEGEND: MD/DO Physician RT Respiratory Therapy R.D. Registered DieticianRN Nursing PT Physical Therapy S.W. Social ServiceRPH Pharmacist OT Occupational Therapy SP Speech Pathology

Riverside County Regional Medical Center

INTERDISCIPLINARY PATIENT PROGRESS NOTES P.I.P. Charting

#104 Rev. 10/03

ADDRESSOGRAPH

Medication Reconciliation Form

Objectives of Presentation

Describe pharmacist-driven programs that utilize patient safety initiativesDescribe tools used by pharmacists to increase quality outcomes, reduce medication errors, enhance adherence, promote continuity of care, increase cost savings Describe the financial impact that the various pharmacist-driven programs may have on a large county-wide organization

Background

Riverside County7,200 square miles shares borders with Orange, San Bernardino, San Diego, and Imperial counties extends from within 14 miles of the Pacific Ocean all the way to Arizonatopographically, mostly desert

http://www.rctlma.org/rcd/default.aspx

Background – Riverside County

Historical Populations

Census Year

Population

1900 17,8971910 34,6961920 50,2971930 81,0241940 105,5241950 170,0461960 306,1911970 459,0741980 663,1661990 1,170,4132000 1,545,3872008 2,100,516

http://factfinder.census.gov/home/saff/main.html?_lang=en

Racial Demographics 2006-2008 Census

Race Percent

White 74.3%

Black/African American 12.3%

American Indian/Alaska Native 0.8%

Asian 4.4%

Native Hawaiian/Other Pacific Islander 0.1%

Some Other Race 5.8%

Two or More Races 2.2%

Hispanic/Latino (of any race) 15.1%

36% ↑

Background - RCRMC

Institution > 100 years, new location since March 1998 –Moreno ValleyLevel II adult & pediatric trauma center439 beds – 362 at RCRMC and 77 at separate psychiatric facility12 operating roomsIntensive care units (adult, pediatric, neonatal)24 hour physician staffingImmediate OR accessAdjacent helipad

Complete radiology services (MRI, CT)Occupational and physical therapy servicesComplete laboratory servicesComplete pulmonary services (Hyperbaric oxygen treatments)Complete diagnostic services (EEG, ECG, ECHO)Full pediatric servicesEmergency room and Level II trauma centerPharmacy with Clinical Pharmacists on site

http://rcrmc.org/home/

System Change

Transactional ChangeIndividual tasks, skills, abilities

Transformational ChangeAltered paradigmShift in valuesReform in beliefs

Cost Control is Cost Control is TransactionalTransactional

Quality Improvement is Quality Improvement is TransformationalTransformational

““Transformed means that when Transformed means that when times are tough, we invest more times are tough, we invest more in qualityin quality””

Charles Buck – retired GE executive

Inpatient

Outpatient

Admission Pharmacists

Unit Based Pharmacists

Core Measures Pharmacists

Discharge PharmacistsOutpatient Pharmacists

Telephonic Disease

Management Pharmacists

Ambulatory Care Pharmacists

KineticsPharmacists

Specialty Service Pharmacists

ED Pharmacists

Community / School Based Clinic Pharmacists

Mail Order Pharmacists

ID Pharmacists

Managed CarePharmacists

Medication Safety Pharmacists

ITPharmacists

Goals of Pharmacist-Driven Programs

Increase quality outcomes Reduce medication errorsEnhance adherencePromote continuity of careImproving financial impact

Increase Quality Outcomes

Pharmacist Driven Core Measures: PNA, stroke, HF, immunization, SCIP, VTE

Ensure compliance with core-measures and quality patient careCoordinate Multi-disciplinary approachImprove outcomes by: providing evidence-based care, increasing patient’s understanding of disease state/medications, continuity of carePI: Readmission rate, Compliance rate

Antimicrobial StewardshipDe-escalation/Targeted therapyEnsure judicious use of ABX

Anticoagulation Programs: inpatient & outpatientAmbulatory care programsTelephonic Disease state program

Create continuum of careEnsure medication compliance/follow-up for safe & efficacious use of meds

The future…Sepsis ProgramGlycemic Control


Pharmacist-Driven Sepsis Program

Pharmacists will respond with rapid response teamsAssess patients hospital-wide to meet criteria for sepsis criteriaEligible patients will be activated into the 24-hour sepsis bundle and followed by the clinical pharmacistThe clinical pharmacist will ensure that the 24-hour sepsis bundle are being followed


Glycemic Control BackgroundIncrease Quality Outcomes

Glycemic Control Proposal

Improved documentation of a diagnosis of diabetes, when a patient is on anti-diabetic medicationsA1C readings for all patients with diabetes within 48 hours of admissionChart review/ward review for other high risk areas, e.g. Med/Surg, Post-partum, pre-op/post-opImplementation of a multidisciplinary care team, including pharmacists to follow and manage identified patients


Example: Heart Failure Program

HF Admission

HF Inpatient

HF DischargeHF ‐Telephonic Disease State Management

HF Ambulatory

Clinic

Discharge –Non‐HF Admits

Physician Referrals


Reduction in Readmission Rates

24.0%

15.3% 15.3% 17.6% 17.2% 14.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Prior to HF Program

May 2010 Jun 2010 July 2010 Aug 2010 Sept 2010


P = Problem (In terms of Patient Care Diagnosis) I = Intervention (Include: short term goals, education)



Pharmacy HF Initial Progress Note EF: _______%

PMH:

If patient is diagnosed with HF or admitted for HF exacerbation or has a history of HF w/ ↓ LVEF (<40%), recommend patient be discharged with the following:

ACEI/ARB Current Dose

Benazepril (Lotensin)

Losartan (Cozaar)

Beta-Blocker

Carvedilol (Coreg)

Metoprolol XL (Toprol XL)

Only sustained release form of metoprolol has been proven to reduce mortality. Please consider changing metoprolol (Lopressor) to metoprolol XL (Toprol XL)

NOTE: If patient cannot be discharged with these medications please document the reason (ie. contraindication, allergy, bradycardia)

Patient Consultation:

Discussed low-salt diet, fluid restriction, healthy life-style, activity level, smoking cessation, avoidance of EtOH & illicit drugs, daily weight monitoring.

Educated patient on s/sx of worsening HF and what to do if symptoms worsen.

HF verbal and written education given to patient addressing 1. Activity level, 2. Diet 3. Follow-up monitoring 4. Weight monitoring, 5. What to do if symptoms worsen

Educated patient on HF medications, proper use, expected effects, significant ADRs, and potential drug interactions

Spanish translation provided if Spanish-speaking

Intervention:

Recommend considering alternate agent for NSAID __________. NSAID can cause sodium retention and peripheral vasoconstriction and can attenuate the efficacy and enhance the toxicity of diuretics and ACE inhibitors.

Recommend considering alternate agent for antiarrhythmic agent __________. Antiarrhtymic agent can exert important cardiodepressant and proarrhythmic effects. Only amiodarone and dofetilide have been shown not to adversely affect survival.

Recommend considering alternate agent for Calcium Channel Blocker __________. Calcium channel blockers can lead to worsening HF and have been associated with an increased risk of cardiovascular events. Only the vasoselective ones have been shown not to adversely affect survival.

Other recommendation:

Please feel free to contact with any questions.

Pharmacist: PharmD. Ext 30222 - pager 344-5646


NTERDISCIPLINARY PATIENT PROGRESS NOTES 04

Rev. 5/10

ADDRESSOGRAPH

HF Initial HF Initial Progress Progress NotesNotes





Pharmacy Pharmacy Discharge Progress Note: Discharge Medication Reconciliation/Consultation

ACUTE MYOCARDIAL INFARCTION

Patient is being discharged with the following: If not, reason stated:

Aspirin Beta-Blocker

ACEI or ARB for LVSD Statin

HEART FAILURE EF: % Patient is being discharged with the following: If not, reason stated:

ACEI/ARB Beta-Blocker

HF written and verbal education provided to patient addressing the following: 1. Activity level, 2. Diet, 3. Discharge medications, 4. Follow-up appointment, 5. Daily weight monitoring, 6. What to do if symptoms worsen

STROKE

Patient is being discharged with the following: If not, reason stated

Antithrombotic therapy Statin

Anticoagulation therapy for Afib/flutter N/A

Stroke verbal and written education given to patient addressing: 1. Activation of emergency medical system 2. Follow-up after discharge 3. Discharge Medications 4. Risk factors for stroke 5. Warning signs and symptoms of stroke

Assessed for Rehabilitation ALL PATIENTS

Patient has received Pneumococcal and Influenza vaccination (Oct-Mar) prior or during hospital stay If not, reason stated:

Smoking cessation advice/Counseling

Discharge medication reconciliation performed by pharmacist. Educated patient on medications, changes in medication regimen and proper use, expected effects, significant ADRs, and potential drug interactions. Patient was given a written list of complete discharge medications.

Educated patient to STOP following medications:

Spanish translation provided if Spanish-speaking.

Follow-up Appointments: Per discharge summary

Pharm.D Ext DISCIPLINE LEGEND: MD/DO Physician RT Respiratory Therapy R.D. Registered DieticianRN Nursing PT Physical Therapy S.W. Social Service RPH Pharmacist OT Occupational Therapy SP Speech Pathology



#104 Rev. 05/10

ADDRESSOGRAPH

Pharmacist Discharge Medication Reconciliation/Consultation


IV infusion ProgramPCA monitoringUnit-based pharmacist: daily review of medication profiles, med reconciliation on admission and dischargeBlack box warningsHigh risk medicationsNon-Formulary processPeer Review

Reduce Medication Errors

Rm Name IV/Med

CkTime

DateOrdered

Rate/FreqOrdered

Rate On MAR

RateOnPump

Med GivenOn Time

Discrepancy/Note

IV Infusion Pump Monitoring Record





Pharmacist Medication management performed by Pharmacist

Review transfer medication reconciliation

Reviewed physician orders and patient’s medication profile

Reviewed medications for appropriate criteria of use and dosage

Reviewed current / new medication(s) with patient regarding expected

effects, significant ADRs, potential drug interactions

Checked medication administration record

Monitored patient’s response to new medication(s):

Adverse reaction reported with_________________

No adverse reaction reported

All questions, concerns regarding medications were addressed to patient.

DISCIPLINE LEGEND: MD/DO Physician RT Respiratory Therapy R.D. Registered DieticianRN Nursing PT Physical Therapy S.W. Social Service RPH Pharmacist OT Occupational Therapy SP Speech Pathology



#104 Rev. 10/03

ADDRESSOGRAPH


Medication Management Progress Note

Example 1: APAP MonitoringMedication

Safety Goal Numerator /Denominator 2009 2010

APAP totalAbove

4grams/day0%

# pt getting more than 4 g a day per MAR review/# patients on APAP

Qtr 1 Qtr 2 Qtr 3 Qtr 4 2009 Qtr 1 Qtr 2 Qtr 3 Qtr 4 2010

Rate 10% 13% 9% 11% 1% 3% 2%

Numerator 27 62 32 121 2 6 4

Denominator 282 481 375 1138 279 233 170

Daily Acetaminophen Usage Less Than 4 g/Day

0%

10%

20%

Qtr 1 '09

Qtr 2 '09

Qtr 3 '09

Qtr 4 '09

Qtr 1 '10

Qtr 2 '10

Qtr 3 '10

Qtr 4 '10


Example 2: Erythropoetin Monitoring

GoalNumerator /Denominator 2009 2010

Erythropetinonly

in patients WithHgb<12

100%

# patients with Hgb less than 12/# patients on EPO Qtr1 Qtr2 Qtr3 Qtr4 Year

2009 Qtr1 Qtr2 Qtr3 Qtr4Year2010

Rate (%) 93 94 94 95 94 94 96 100

Numerator (N)117 08 111 119 137 83

Denominator (D)124 115 117 127 143 83

EPO Only Dispensed to Patients with Hgb less than 12

60%

70%

80%

90%

100%

Qtr 1 '09

Qtr 2 '09

Qtr 3 '09

Qtr 4 '09

Qtr 1 '10

Qtr 2 '10

Qtr 3 '10

Qtr 4 '10


WHO – Statistics50% of patients take medications incorrectlyOveruse, underuse or misuse of medicines harms people and wastes resources > 50% of all countries do not implement basic policies to promote rational use of medicines

World Health Organization: www.who.int/mediacentre

Enhance Adherence

United States:The direct & indirect costs ~ $100 billion/yearUnfilled prescriptions ~140 million prescriptions/year ≈ $2.8 billion125,000 deaths annually are attributed to nonadherenceUp to 11% of hospital admissions and 40% of nursing home admissions are due to lack of adherence with medication therapy

American Pharmacists Association: www.pharmacist.com

Enhance Adherence

Provider-related BarriersLack of counseling

Financial BarriersInability to pay for medications

Patient-related BarriersLack of transportationDisease-related: memory loss, cognitive impairmentLack of understanding (language, regimen)

American Pharmacists Association: www.pharmacist.com

Enhance Adherence

Admission

Hospital StayDischarge

Medication Reconciliation

•Home Medication Reconciliation

•Review Meds for dosing, appropriateness, ADR

•Patient Education

•Confirm coverage upon discharge

Enhance Adherence

Patient Assistance Program (PAP)PAP Coordinator within Dept. of PharmacyFree or discounted medications from Pharmacompanies

Low-income, uninsured or under-insuredWhy use PAP?

PAP medications supplement and expand formularyEases workflow in the Dispensary

Relief of financial burden on MISPCalifornia clinics were less likely to use PAP than other states in 2003*

*Duke KS et al. Patient-assistance programs: assessment of and use by safety-net clinics. AJHP. 2005;62:726-731.

Enhance Adherence

Mail Order Services90-days supplyWaived co-pays10-days compliance callsDiabetic supplies for indigent patients

Enhance Adherence

Generalized Plan for Clinical Pharmacy DSM Call Center

New Rx for Atypical Antipsychotics* – list from

FSI

CHF patients d/c from RCRMC – list from CHF

pharmacists

Pilot Disease/Medications

CHF Antipsychotics

Pilot Population of Focus - PoF

Telephone Scripts

Technician/OAs/students - TBD

Pharmacists/Interns - TBD

Roles and Responsibilities

Technician/OAs/Students • Confirm patient picked up

medications upon discharge • Assist patient in filling/refilling

RX, refer to mail order • Confirm patient’s current

medication regimen – call pharmacies, check med rec/charts, etc.

• Interview patients and collect information** for pharmacist’s review

• Refer to pharmacist for questions/concerns

Pharmacist/Interns • Answer questions/concerns from

referred patients • Educate patient on medications as

needed, importance of compliance/adherence, diet, physical exercise, etc.

• Review information gathered by tech/OA for appropriateness of drug therapies***

• Set up clinic appt for follow-up as necessary

• Set up lab appt prior to follow-up as necessary

• Prescriptive authority for 1x refill until clinic appt if necessary?

• Document review/consultation/recommendation as progress note in charts****

Enhance Adherence

Inpatient

Outpatient

Admission Pharmacists

Unit Based Pharmacists

Core Measures Pharmacists

Discharge PharmacistsOutpatient Pharmacists

Telephonic Disease

Management Pharmacists

Ambulatory Care Pharmacists

KineticsPharmacists

Specialty Service Pharmacists

ED Pharmacists

Community / School Based Clinic Pharmacists

Mail Order Pharmacists

ID Pharmacists

Managed CarePharmacists

Medication Safety Pharmacists

ITPharmacists

Improving Financial Impact

Perez et al. Economic Evaluation of Pharmacy Services 2001-2005, ACCP


$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

$900,000

$1,000,000

Jul 09 Aug 09 Sept 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sept 10 Oct 10 Nov 10

Pharmacist-Run Indigent Managed Care Program


$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

$900,000

$1,000,000

Jul 09 Aug 09 Sept 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sept 10 Oct 10 Nov 10

~ $450,000 / month

= ~$5.4 M / year

Gross Savings

Pharmacist-Run Indigent Managed Care Program


Patient Assistance Program

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000

Sept 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 July 10 Aug 10 Sept 10 Oct 10

$170,000 / month= $2 million / year


8 readmissions prevented per month

8 x $15,293* = $122,344 / month

= $1.46M / year

* Cost based on article by Peacock ,2003

24.0%

15.3% 15.3% 17.6% 17.2% 14.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Prior to HF Program

May 2010 Jun 2010 July 2010 Aug 2010 Sept 2010

Readmission Rate Reduction


Sepsis Program - Projection

Preliminary Data*Average Severe Sepsis Mortality: 37.51%Sepsis-Related Costs (2008 – 2010): $159,004,530.80Average Length of Stay (LOS): 23.25 days

Goal: 10 % Reduction in BenchmarksProjected Reduction in Mortality: 3.75%Projected Annual Savings: $5,300,151.03Projected Reduction in LOS: 2.325 days

*Based on ICD9 Codes


Glycemic Control - Projections

Reduce hyper/hypoglycemic events.Reduce LOS due to poor glycemic control.Reduce ER visits and readmission.

Estimated $3 - 5 million / year saved.


CE Questions1. Name 3 pharmacist-driven programs at RCRMC that have played a role in patient

safety initiatives:A. Medication Safety, Unit-Based, Core MeasuresB. Admissions, Discharge, Ambulatory CareC. Mail Order, Ambulatory Care, Telephonic Disease State ManagementD. A, B and C

2. Which tool is used by pharmacists to increase medication safety, improve patient safety, and improve Core Measure data?

A. Giving patients free lunchB. Compliance callsC. Patient consultation upon admission and dischargeD. Both B and C

3. What kind of financial impact may pharmacist-driven programs have on a large hospital organization?

A. Minimal from any pharmacist-driven programB. The sepsis program shows a projected decrease in the length of stay in the hospitalC. The CHF program have shown an increase in readmission rateD. Both A and C

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