Pharmacy Practice Innovations:

Best Practices in Care Transitions

Michelle Cudnik, PharmD

John Moorman, PharmD, BCPS

June 27th, 2013

Michelle Cudnik, PharmDClinical Ambulatory Care Lead

Pharmacist, Summa Health System

Associate Professor of Pharmacy Practice, NEOMED

Local Ohioans Uninsured

© 2012

Source: Powel, C “Health care issue stirs emotion because it is so personal”, Akron Beacon Journal, 7 October 2012, Available at http://www.ohio.com/news/local/health-care-issue-stirs-emotion-because-it-is-so-personal-1.340025

The percentage of persons aged 18 to 64 without health insurance

What is the highest percentage of admission rates seen in the country

that are due to 30-day readmissions?

1. 15%

2. 17%

3. 19%

4. 21%

Hospital Readmissions

© 2012

Source: “Improving Care Transitions,” Health Affairs, September 13, 2012, Available at http://www.healthaffairs.org/healthpolicybriefs/

Medicare 30 day readmissions as a percentage of admissions in 2009

Why a new model?

• Institute of Medicine Report 2001, “Crossing the Quality Chasm”– Less than 50% of patients with major chronic

illness receive accepted treatments– Less than 50% have satisfactory disease control– Focus on episodic and not continuous care– Little attention given to the patient’s knowledge,

skills, behavior in managing their own illnessInstitute of Medicine. Crossing the Quality Chasm: A New Health System

for the 21st Century. Washington DC. National Academy Press; 2001

A tested Model: PCMH• Patient-centered (using patient goals)• Physician-guided (EBM, directs the team)• Cost-efficient• Reimbursable (sustainable)• Longitudinal, (goals persist through many

contacts over time)• A continuous healing relationship (not just

services)• Care provided in a variety of settings-Transitions are Key!• “Medical Home” refers to primary responsibility to assemble and interpret

data and assist patient with self care of diseaseThe Advanced Medical Home. American College of Physicians Policy Monograph, 2006

•

National and Regional Relevance

• Model is centerpiece of Affordable Care Act, 2009

• Meaningful Use (15 required core objectives; 5 menu objectives)

• Accountable Care Organization: (89 nationally under Center for Medicare and Medicaid services)

• NCQA (National Committee for Quality Assurance) Patient Centered Medical Home certification

www.cms.gov for meaningful use

www.innovation.cms.gov for accountable care organizations

They all require:

•A new practice focus on quality outcomes.

•Exchange level data systems to track and report outcomes.

•Care delivery systems require team-based care to achieve outcomes.

They all require:

•A new practice focus on quality outcomes.

•Exchange level data systems to track and report outcomes.

•Care delivery systems require team-based care to achieve outcomes.

2011 Patient-Centered Medical Home Standards

• Enhance Access and Continuity• Identify and Manage Patient Populations• Plan and Manage Care• Provide Self-care and Community Support• Track and Coordinate Care• Measure and Improve Performance

National Committee for Quality Assurance 2011

Familymember,caregiver

Familymember,caregiver

PCPPCP

Midlevel providerNP/PharmD

Midlevel providerNP/PharmD

Care coordinatorRN/LPN/

MA

Care coordinatorRN/LPN/

MA

OfficeAdministrator

, Greeter

OfficeAdministrator

, Greeter

PatientPatient

HealthInformationExchange

Sub-specialistclinicians

and services

Multiple care Settings/Pharmacy

System

Office

Patient and family

EHR

PatientPortal

Patient Centered

HomeRoles

CarePlan

CarePlan

• Identifies, follows high risk patients

•Assembles Pre-Visit results

•Follows up on care plan

• Identifies, follows high risk patients

•Assembles Pre-Visit results

•Follows up on care plan

Familymember,caregiver

Familymember,caregiver

PCPPCP

Midlevel

providerNP/PharmD

Midlevel

providerNP/PharmD

Care coordinatorRN/LPN/

MA

Care coordinatorRN/LPN/

MA

OfficeAdministrator

, Greeter

OfficeAdministrator

, Greeter

PatientPatient

HealthInformationExchange

Sub-specialistclinicians and services

Multiple care Settings/Pharmacy

System

OfficePatient and family

EHR

PatientPortal

Patient Centered

HomeRoles

Summa Health System• 8 hospitals and centers representing over

2,000 inpatient beds• Summit County’s largest employer with over

10,000 employees• 1,200 credentialed physicians and 280

resident physicians• One of top 3 largest integrated healthcare

delivery systems in Ohio • Health Plan (SummaCare)• Affiliated with NEOMED University

Summa Health System Payer Mix

• Commercial/Managed Care: 30%• Self-Pay: 7% (27% in Internal Medicine Center)

• Medicaid: 15%

• Medicare: 47%

My Practice • Akron City Hospital- Internal Medicine Clinic

• Shared Faculty with

NEOMED

• 12,000 patients

(mostly indigent)

• Certified Patient-

Centered Medical

Home

A Day in the Life…

• Collaborative Practice Agreement

• Daily Huddles- identify high-risk patients

• Diabetic Planned visits 3 days per week

• Hypertension Clinic visits 1 day per week

• Medication Therapy Management visits each day

A Day in the Life…

• Key member of the Patient-centered medical home!

• Plan and manage care, coordinate follow-up visits, interface with community pharmacies and focus on continuity of care.

• Facility fee billing

Successes

• Continued improvement in clinical outcome measurements in our diabetic patients

• Improved education to medication residents, faculty and staff in the Internal medicine center

• Comprehensive medication reconciliation completed at all visits

Barriers

• Initial delay in collaborative practice agreement

• Knowledge by healthcare providers of what a pharmacist can offer to patients

• Financial reimbursement for services

Next Steps

• Pilot study of a pharmacist in various primary care clinics within our healthcare system- different days of week (Resources by ACO?)

• Focus on transitions of care for highest-risk patients

• Reimbursement for Transitions of Care visits

John Moorman, PharmD, BCPSPharmacotherapy Specialist,

Endocrinology, Akron General Medical Center

Assistant Professor of Pharmacy Practice, NEOMED

“The scenario in which a patient moves from one care setting to

another”

Cost of poor care transition

34,500 patients discharged and readmitted on the same day in 1996-1997

Cost = $226 million

J. Gibbs Brown, personal communication, February 11, 2000

Cost of poor care transition

20% of Medicare hospitalizations followed by readmission within 30 days in 2003-2004

~50% had no physician visit before readmission

N Engl J Med 2009;360:1418-28

Cost of poor care transition

19% of Medicare discharges followed by adverse event within 30 days

66% were drug-related

Ann Intern Med 2003;138:161-7

Cost of poor care transition

Potential for cost savings by preventing unplanned readmissions

$17.4 billion

N Engl J Med 2009;360:1418-28

Cost of poor care transition

A decrease in diabetes medication adherence results in a 58% increase in

hospitalizations

…and an 81% increase in all-cause mortality

Arch Intern Med 2006;166:1836-41

National Transitions of Care Coalition (NTOCC)

• Implementation and evaluation outline

• Multiple resources developed:– TOC checklist– Interventions for low health literacy– Standardized forms– Metrics for tracking outcomes

General recommendations

• Improve communication

• Implement electronic medical records

• Establish points of accountability

• Increase use of case management

• Expand role of pharmacist in TOC

• Implement payment systems

• Develop performance measures

When implementing a new TOC service, when should one decide which

metrics to track?

1. Once management has been approached

2. Once personnel have been hired

3. Once a gap in care has been identified

4. Once a service has been implemented

Akron General Medical Center• 511 adult-bed

teaching hospital– Affiliated with

Northeast Ohio Medical University

• Significant proportion of admissions for underserved patients

Personal experiences with TOC

A day in the life…

• Inpatient diabetes management team– Endocrinologist– Pharmacist– Diabetes educators (RN, CDE)– Dieticians

• Outpatient transitional care clinic– “Bridge” clinic– Private endocrinology practice

Interventions

• Inpatient education

• Medication reconciliation

• Involve social work/care management

• Plan development– Medication regimen– Goals of therapy– Follow-up

Follow-up structure

• Follow-up plan established– Discharge location– Need for transitional care visit?

• “Bridge” clinic appointments set as inpatient– Not intended as chronic management– Communicated to primary care physician

“Bridge” clinic

• Review of discharge medication list

• Goals of therapy reviewed

• Education/Literature provided

• Medication therapy performed if needed– Collaborative practice agreement

• Follow-up plan established

• All information sent to primary care

Successes

• Initially, patients instructed to call for appointment– Scheduling while inpatient improved show rate

• As “Bridge” appointments increased, readmission rates decreased– Significantly lower than general readmission rate

• Increased consultations by hospitalist groups/attending physicians

Barriers

• Private practice vs. health system– Inability to bill for services– Use of EMR limited

• Limited to patients seen on inpatient service– Collaborative practice agreement– Concern over number of consults per physician

• Length of stay

Next steps• Diabetes Needs Assessment

– Diabetic patients admitted to hospital prompts immediate referral

– Triage based on need for education/management• Increase exposure to at-risk population

• Intention to begin education on day 1– Potential for decreased length of stay

• Avoids “last-hour” consultations

– Identify barriers earlier in hospital stay

Conclusions

• Established role for pharmacists in TOC– Diabetes vs. other disease states– Role needs to be expanded

• Multiple interventions shown to be beneficial– Discharge counseling/med rec.

• Implementing programs may be challenging– Requires focused approach with proper personnel– Know metrics before implementing

Conclusions

• These are just 2 models that focus on pharmacists involvement in transitions of care/continuity of care

• These models can be adapted to other settings to provide innovative pharmacy services!

Thank you for your attention!

Questions?