Transitions in Care Models: Case Studies in Pharmacy Practice. A conversation with Michelle Thoma, PharmD and Desi Kotis, PharmD

Transcription

1 Biography: Transitions in Care Models: Case Studies in Pharmacy Practice A conversation with Michelle Thoma, PharmD and Desi Kotis, PharmD Michelle Thoma, RPh, PharmD is Pharmacy Manager, Ambulatory and Transitional Patient Care Services, Compliance and Quality Improvement Officer at the University of Wisconsin Hospital and Clinics, and Clinical Instructor with the UW School of Pharmacy. She is responsible for managing patient care pharmacy services throughout ambulatory care, including primary care and specialty clinic sites and infusion center services, as well as serving as the administrative pharmacy director over the transplant and neurosciences service line. Michelle coordinates department and organization wide regulatory compliance and quality improvement initiatives. Michelle is an active member of the Pharmacy Society of Wisconsin, American Society of Health-System Pharmacists, the Wisconsin Department of Health Services Mental Health Drug Advisory Board and the University Health System Consortium's Pharmacy Performance Improvement & Compliance Committee. Desi Kotis, PharmD, is the Director of Pharmacy at Northwestern Memorial Hospital in Chicago. She is responsible for clinical leadership development, teaching post-graduate pharmacy students in administration advanced clerkship with a clinical focus on Prentice women s hospital and gynecologic oncology patients and training new clinical pharmacists and pharmacy technicians. Desi assisted in integrating CPOE, automated MAR, BCMA for the pharmacy department with a primary responsibility for the integration of the automated dispensing machines in the critical care, medicine, oncology, and the medical/surgical units. She serves as Co-head of implementation of the HIV ambulatory care clinic, ICU, transplant, and medicine pharmacists. Introduction: Transitions of care refers to a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. Care transition models involving pharmacists are emerging, but have not yet been well-defined. This program presented 2 examples of successful pharmacist-led care transition models. USMP/MG1/ b 1 12/13

2 Questions and answers with Michelle Thoma and Desi Kotis: Question: How do your organizations use pharmacy students as pharmacist extenders within your transition in care model? Desi Kotis: At Northwestern we train about 250 pharmacy students per year, from schools of pharmacy in Illinois, Indiana, Nebraska, and Iowa. We use the students similar to medical students in the medical model. The students hit the ground running with medication histories and medication reconciliation. The pharmacist on the service is really the attending pharmacist, and residents on the service are like house staff, medical residents. So, the second-year resident, the specialty resident, is over the PGY1 resident, for example. We use pharmacy students in this process. We did not add any staff, we rearranged what staff did. But having students, and having them consistently on these services, is key to a successful program. Michelle Thoma: We do very similar things at the University of Wisconsin. We have our students involved in a lot of the different programs that you heard about today, right from the very beginning when they're doing rotations with us. So, it is not only limited to our fourth-year students, but the students that are coming to us in their second and third year for their IPPE rotations are involved as well. We try to involve them very early on. Question: Does your hospital have an outpatient pharmacy? How do you obtain patient permission to fill their prescriptions at your pharmacy versus their regular pharmacy? Michelle Thoma: Yes, we do. When the discharge specialist meets with the patient, they ask if they are interested in filling their prescriptions with us in the outpatient pharmacy and using the bedside delivery service. We call this the "Discharge Express" program, and we actually enroll patients in the Discharge Express program. Patients sign up for this during the admission process. Within our electronic medical record, we are able to identify the patient's preferred pharmacies. If a patient is, for example, out of the Dane County area, where Madison is located, or they use a pharmacy in Illinois, we tend to try not to enroll patients in our Discharge Express program. We want to make sure that if they're going to be taking chronic medications, they're enrolled in their own pharmacy at home for those medications. We try to be selective in the patients that we enroll. Desi Kotis: We do not have a retail pharmacy. We have a Walgreens pharmacy in our hospital building. If patients choose to get their prescriptions filled at the Walgreens pharmacy, the Walgreens pharmacy technician will deliver to the unit. The Walgreens pharmacist and pharmacy technicians do not currently educate the patients on their medication, so we still use our pharmacists and our pharmacy students for that. Question: What advice do you have for more resource-challenged hospitals for reorganizing staff responsibilities to implement a transition in care model? Desi Kotis: I think first is to restructure and repurpose what your pharmacists do and how they do things. Again, we did not get additional resources. Yes, the students do help quite a bit. But looking at the pharmacist's role, establishing yourself as a pharmacist on a team, decentralizing the interdisciplinary rounds on these units are critical. Then, look at what is necessary from a medication perspective, look at some of the tools available nationally. USMP/MG1/ b 2 12/13

3 We don't need to reinvent the wheel. Boost Red, many of the care transition tools are robust and very user-friendly. So, I would look at wha t some of these national programs have accomplished. Tap into your other groups. We have had a community hospital about 30 miles away from downtown Chicago, Northwestern Lake Forest Hospital, for about 2 years. And we are now decentralizing pharmacists and getting ready to implement this program there, in a 100-bed acute care and 100-bed extended-care facility. You can do it with a small group of resources. Sometimes it's easier to do this with a smaller group. But, it's really about establishing yourself on the team, and then repurposing and reorganizing to achieve the goals and tasks day to day. Question: Other than 30-day readmission rate, what outcome measures do your organizations use to measure success of your transition in care model? Michelle Thoma: At Wisconsin, we are using not only patient satisfaction, but physician and other discipline satisfaction as well. Much of what is going to be driving reimbursement in the future are things like satisfaction scores and quality of outcomes, not just readmissions. We wanted to include that in our model. Desi Kotis: We are looking at employee engagement within not just the pharmacy department, but other employees and how well they're engaged. And if you're a pharmacist and you're practicing at the top of your license, you're usually very satisfied in your work. In addition to patient satisfaction, some of the HCAP scores in which we showed some results are key. Also, documenting avoidable adverse drug events is huge. Since 2008, we have documentation of preventing about 90 events a month. That's 3 adverse events that may have caused harm or death a day. That is another thing that is very valuable for our Chief Medical Officer, our Pharmacy and Therapeutics committee, the nurses in our organization, and the Board of Directors to see. Adverse events was a key metric that the Board of Directors was interested in. Question: What are your criteria for pharmacists ordering lab tests related to medication adherence monitoring? Michelle Thoma: We have a protocol at Wisconsin that allows the pharmacists to order labs under certain conditions. And one of those conditions is the patient has to be eligible for a primary care pharmacist referral. The primary care pharmacist referral includes things like patients being on 4 or more chronic medications, having certain diagnoses codes, and acknowledgment from the primary care physician that we are allowed to participate in the care of the patient. We have a list of 6 or 7 different things that actually allow the pharmacist to say, "Yes, this patient is enrolled in our program." Once we've verified that they meet the criteria for enrolling in the program, we have a laboratory protocol which we can implement. The laboratory protocol has lists of the defined lab tests and situations in which pharmacists can order each one of those tests. For example, if a patient's creatinine has changed by more than 10% from the time of admission to the time of discharge, then we are allowed to order a creatinine level. Question: How long are you following patients for readmission? Desi Kotis: For this study, we looked at 30 days. I know that North Carolina has published quite a bit recently and they are going out to the 120-day range and looking at medical home models. I think that's really where our future will be. USMP/MG1/ b 3 12/13

4 Question: How do you ensure that you have enough staff to consistently provide this transition in care service, especially when the model includes students and/or residents? Desi Kotis: We really incorporated our PGY1 residents, and to some extent our PGY2 specialty residents, and had pharmacists taking accountability for patient outcomes and working in this process. So, if a resident was an attending pharmacist on their Medicine 2 rotation, that would free up a pharmacist to take a smaller patient load. When we started, our pharmacist to patient ratio was 1 pharmacist to 60 to 85 patients. Come September, we'll be 1 pharmacist to 30 patients by incorporating the residents, not adding more staff. We're just repurposing what the staff do and what the students do as extenders. Michelle Thoma: We have the same approach at Wisconsin. You do need to take a look at the activities that all the folks in your department are focused on during the day. Are they valueadded activities, or could you shift some activities that really don t need pharmacist oversight to, say, pharmacy technicians or pharmacy students so you can free up that pharmacist to do more things? We've actually tried to take this philosophy whenever we're starting a new program. We really want to say, "Is everybody practicing at the top of their game? And if not, do we still need those activities? Can they be eliminated? If they can't be eliminated, could we hire someone to do those activities that may not be as costly of a resource to the organization?". Question: What is the greatest challenge that your institution has faced related to your transition in care model? Desi Kotis: I think the hardest challenge is sustainability. We started this a little over a year ago, and now we're expanding this to all of our medicine, hematology, oncology patients. Actually, we received an ASHP Foundation grant with respect to PPMI. We're using pharmacy students as technicians to work on the callback portion. And we're calling at 48 hours, 1 week, 2 weeks, et cetera out to 30 days. Sustainability in anything you do and keeping all the trains running on time I think is the biggest challenge. Michelle Thoma: The other thing is spread strategy. I am still struggling with reaching all of the patients that really need to have this intervention, especially with the primary care pharmacists project. While we're recognizing the value of the role of that pharmacist, and would really like that pharmacist to be able to touch more patients, we're close to 400 patients on census. With 500,000 clinic visits every year we could be doing so much more, such as with patients that are not post-discharge to prevent that first admission from occurring. It's a value-added service that clinicians are starting to recognize, and they'd like to see more of it. Defining that spread strategy going forward is going to be one of my major challenges. Question: How do you assess and document competency of individuals (students, technicians, and pharmacists) participating in your transition in care service? Michelle Thoma: We have a competency that we've developed for both our technicians and our students. It's administered to the students and technicians with pharmacist oversight. Then the students and technicians have to do 3 medication histories before we allow them to do them on their own, and they have to pass that competency under the pharmacist's supervision. It's a pretty robust training program. It takes at least 8 hours for them to complete both. There is a lecture and then the observations that they have to perform. We administer a post-test as well. For technicians that are allowed to do medication histories, we do a reassessment of their competency on an annual basis. They have to have a second, third, fourth observation with the pharmacist as long as they continue to be in the program. USMP/MG1/ b 4 12/13

5 Desi Kotis: Our competency program is fairly new, and very similar but not as well-developed. The only technicians we use at this time are pharmacy students, since it is a new program. We use the Boost tools as well for our pharmacists. Each pharmacy group has clinical pharmacist leaders that do the evaluation with the pharmacist. For the students, we do something very similar to what Wisconsin does. I think the key for sustainability is having that competency at various points, such as year 1, year 2, year 3. Question: Please comment on the role of your prior authorization specialist. How is that individual brought into the process? Michelle Thoma: The pharmacist can consult the prior authorization coordinator if they have a concern about a medication that may have an issue with reimbursement post-discharge. We have a couple of different prior authorization coordinators. One really focuses on oral medications. The discharge medication prior authorization coordinators help run test claims so we know if the medications are actually going to be covered prior to discharge. If they are not covered, they help enroll the patient in patient assistance programs. We also have prior authorization coordinators that focus on infusions and specialty medications. It takes a lot more clinical expertise to know whether or not these medications are going to be covered postdischarge, so we actually employ 2 LPNs to help us do the prior authorizations for specialty drugs and infusions. Question: Within your transition in care model, how do you coordinate with other pharmacists, such as in community, long term care, or home care pharmacies? Desi Kotis: The process is very informal. Home care is a little bit more developed. Having a Walgreens pharmacy in our building says a lot about where we're going as a profession with community pharmacies. Mostly, it's just the coordination of care. If patients decide that they don't want to stop somewhere else before they go home and they are a Walgreens pharmacy customer, they want to pick up their prescriptions from Walgreens pharmacy. When we look at the PPMI, and we look at the future of our profession, it is that accountability for patient outcome by the community pharmacist, and their role in reinforcing education. We do a lot of work with long-term care facilities and skilled nursing homes when our patients go there. We work with those teams in transition, we do a lot of communication there. Where we're going to have to focus going forward with our profession is with the community pharmacists. One of the things that we're working on, and our biggest challenge with our pilot last year, is being able to get patients in to see a primary care physician. We have a huge group of patients who receive free care. Northwestern is not usually thought of as a free care hospital but I think we're third in Illinois. We had quite a few patients who either had no insurance or were waiting for their Medicaid benefits who were not able to get into a couple of our outreach clinics within that one-week timeframe. So, we created a post-discharge follow-up clinic for those patients. Our pharmacy department is in the beginning stages of collaboration with some safety net hospitals. We could provide services with these other pharmacists in the community for things like heart failure, diabetes, and hypertension, extend their staff, talk about students and residents, and work on mentoring for our future. Michelle Thoma: We do not have any formal program in place. One of the most exciting groups that I've been asked to be a part of over the last couple of months is a community transitions program. Various providers throughout the state from skilled nursing homes, other hospitals, community pharmacy, and representatives from our state society have been invited to USMP/MG1/ b 5 12/13

6 participate in this committee. One of the things the group is charged with is how we communicate care plans. Not just medication, but how do we make sure that the care plan includes the information that the outside providers are going to need to properly care for the patient? How do we get that information to them consistently? It's definitely something that we're going to be tackling in a more formalized way going forward, but for right now, it's not as robust of a program as it could be. It's definitely an opportunity for us. Question: How would you recommend that organizations with limited resources decide which patients to prioritize for a transition in care program? Desi Kotis: First we looked at what we were documenting for preventable adverse events. We saw our high-risk patients were inpatient HIV patients, anyone with a solid organ (heart or lung) transplant, anyone on antiepileptic medications, and anyone on anticoagulation. We started there. I would look to see where the pharmacist's interventions are in your organization? Where are the high-risk patients with prevented medication misadventures? Michelle Thoma: We did something very similar. We considered where we would be subsidized through Medicare for decreasing readmissions, but we really didn't have a good picture. There were other disease states or drugs that were potentially contributing to our readmission rates. So, we worked with our data analyst to look at readmissions and identify trends within our patient population that made them more at risk than, say, a typical heart failure patient. We confirmed some of the things that we already knew, but we also had some additional patient populations that we wanted to target based on that analysis. Antiepileptic meds turned out to be a risk factor for readmission, which most folks were not considering prior to that. Doing that analysis of what really puts your patients at risk for readmission and then targeting your interventions at that patient population. Question: How do you report or present the financial impact or cost-avoidance of your transition in care service? Desi Kotis: It is linked to our pharmacist-documented clinical decision support. We use that to report interventions and soft dollars. Everybody's C-suite is a little bit different, our C-suite doesn't look at soft dollars. We need to show how having pharmacists decentralized, having pharmacy students do patient callbacks, affects our drug spend. On the inpatient side, we have calculated that for every dollar we spend on a pharmacist, we save about five and a half dollars on drug costs. You have to individualize to your C-suite. The metrics that are publicly reported, like the core measures and patient satisfaction, is also important. We've looked at some of our high-cost DRGs. Stem cell transplant, for example, is a very high cost per drug on the inpatient side, about 11% of our inpatient drug budget and only about 0.6% of our admissions. Look at those DRGs, quality outcomes, mortality indexes, readmission rates, length of stay, and the outcomes of the patient. If it's very expensive and you have good outcomes, you could be the most expensive in the country as long as your outcomes are good. If your outcomes are terrible and you're expensive, then you need to question some of your practices and drill those down to the clinicians. Michelle Thoma: I've definitely found that our C-suite has become more receptive to soft dollars, cost avoidance, and cost savings. When I prepare my reports for programs like the primary care pharmacists, I try to align what I'm reporting with our strategic goals for the hospital. I'm looking at not only cost, but patient satisfaction, quality of outcomes, safety. I do try to tie some dollars to it. For example, we know medication reconciliation leads to avoidable USMP/MG1/ b 6 12/13

7 events. We can look at events that have been associated with medication reconciliation at our institution and know the cost of those events. If I potentially avoid 5% of those events over the course of a year, I can usually demonstrate what a potential return on investment would be using pharmacists and their activities. Now our C-suite and other organizations are starting to look more big picture and not tying pharmacy so much to revenue. They are looking to some of those other areas where pharmacists could potentially make a larger impact to the organization. Question: Please comment on staff motivation. How do you motivate pharmacists to change their practice when implementing a new program such as this? Desi Kotis: I think it was easy. Change is good, but none of us really love change. It does start from leadership, walking the walk, talking the talk, and getting excited about it and telling the story. I thought it was very easy because our pharmacists wanted to practice at the top of their game. They are very well-trained. When we restructured a few years ago, we looked at various levels. We have a one-tier system at Northwestern, where everybody is a clinical pharmacist. But if you're at a level 1, 2, or 3, you have different responsibilities. A level 1 pharmacist is in the satellites. They work mostly off-shifts like the night shift, or they work mostly in a satellite or central pharmacy. The majority of our people are level 2s, and they spend at least 50% of their time decentralized in the interdisciplinary setting. Some needed more competency and training, others really ran with it. When you have a lot of students and residents around, their excitement is contagious. There are some that need more challenge and work, and that's why we added level 3 pharmacists, clinical leaders to work with our formal leadership. They're more informal leaders to kind of help get the job done. A really good point is not micromanaging, and empowering. One example we saw was with heart failure. The pharmacist really got involved in all the disease state education. We do group classes for our patients here before they leave the organization, empowering them to open up communication lines with the other disciplines, and making sure patients had, for example, scales at home to weigh themselves. Michelle Thoma: We probably have a very similar approach. I've been very lucky that most folks involved in these programs have been involved from the ground up. When we were making changes to how we were going to do competency training for our technicians, we had one of our senior pharmacists involved from the very beginning. Having them engaged in the process of design and development of programs is very helpful. I always try to get a couple of naysayers on those program design teams as well. Having folks who tend to be a little bit more resistant to change on those development teams usually helps to provide some insight of where you may run into some problems in the future. Having them involved from the ground up is really important. Baxter and Pharmacy Advisor are trademarks of Baxter International Inc. USMP/MG1/ b 7 12/13