Preventing Avoidable Readmissions
Together!
May 1, 2014
May 8, 2014
Rhonda Jones
Quality Director
East Georgia Regional Medical Center
The Self
The Us
The Now
State the case
30 Day Readmission Rate- Medicare Only
20.0%
120
18.0%
100
16.0%
14.0%
80
12.0%
10.0%
60
8.0%
40
6.0%
4.0%
20
2.0%
0.0%
0
2010
(Baseli
ne)
11Q1
11Q2
11Q3
11Q4
12Q1
12Q2
12Q3
12Q4
13Q1
13Q2
13Q3
# of Hosps
111
110
110
110
111
110
110
110
111
111
111
110
# Meeting HEN Target
18
26
30
26
22
33
33
34
36
36
42
44
# Meeting Nat'l Target
17
21
27
24
20
32
31
32
34
32
39
38
Readmission Rate
18.77%
18.5%
18.3%
18.5%
18.6%
18.2%
17.9%
17.6%
17.7%
17.4%
17.4%
17.3%
GA HEN Target
15.24%
15.24%
15.24%
15.24%
15.24%
15.24%
15.24%
15.24%
15.24%
15.24%
15.24%
15.24%
National Target
14.96%
14.96%
14.96%
14.96%
14.96%
14.96%
14.96%
14.96%
14.96%
14.96%
14.96%
14.96%
State the case
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•
•
•
Voice of the Patient
I didn’t hear the instructions accurately
Too much medical jargon
Why am I taking this medicine?
No one included me in the decision or plan – I
had no input
• They didn’t take into consideration my needs
(lifestyle or needs)
• No one talked to me about the alternative
options
• I heard what this drug can do to me
What is happening elsewhere?
Minnesota
• Words of wisdom from patients.* Help Us…
– Describe the intended medical use of each
medication
– Set realistic, patient-specific goals of
therapy
– Understand unique safety concerns specific
to my mix of conditions & medications
How Can Doctors Improve Adherence?
•
•
•
•
•
Respect
Communication
Education and Support
Personalize my Care
Coordinate my care
Nothing to me without me!
• Regroup
• Refocus
• Revitalize
Vision: Every Georgian will receive the
necessary tools and information that prepares and
supports them to participate in their health and
healthcare.
Mission: Improve the overall health outcomes of
the patient(s) we serve through a patient/family
centered, seamless, continuum of care addressing
care coordinating efforts and issues.
TOGETHER!!
 All partners – patients and families,
home health, palliative and hospice
care, AAA, CCTP, CMOs, physicians,
and other community partners strive for
seamless continuum of care
 Physician engagement
 Physician education
 Use of physician transition codes
 Share best practices on a transition
care plan in physicians’ newsletter
 Distribute letters to GA physicians
about reducing readmissions
 Create communication pathway
among physicians regarding timely
handover of patients
 Pilot – Care Coordination
 All nursing homes - use of INTERACT
 Conduct Environmental Scan
 All hospitals - use 12 key elements of
Project RED
 Education and partnership meetings
 Hold monthly Advisory Action calls
 Review data monthly
 Identify needed tools/resources
 Regional Partner Readmission
meetings
 Conduct monthly webinars for all
interested providers
 Provide med bags and PHRs
 Share “standard” transfer form/template
with providers statewide/Identify key
elements
 Revamp Toolkit
 Revitalize “Do Your PART” campaign
TOGETHER!!
MONTHLY INFORMATION AND BULLETIN BOARDS
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June: Everyone Takes Part in Patient Care, what’s your role?
July: Prepping for Patients
August: Medication Management
September: Patient Education
October: Health Literacy
November: Follow up care
December: Celebrate Your Success: highlight patients’ input
on their hospital experience
• Reducing Readmissions Affinity Group
11 a.m. – 11:30 a.m – 1st Wednesday of the month
June 4 (Report out from Regional Meetings)
July 2 (Tentative: Teach Back)
August 6 (Tentative: Follow up Phone Calls)
September – Regional Meeting
October 1 (Tentative: Pilot Results)
November 3 (Tentative: Celebrate Results/Next Steps)
• Toolkit
– www.GHA.org –
Quality & Health – Resources and Toolkits
• To order Personal Health Records and Medication Bags
– http://www.gmcf.org/alliantweb/Provider/Orders.aspx
Medication Management
• Bruce Trickel, CMPE Administrator Albany Internal
Medicine
• Pamela Tolliver Strategic Account Manager, Health
Systems, Walgreens
• Ed Cohen, Walgreens
• Kyle Lott, Pharm D Director of Pharmacy Services
Bacon County Hospital and Health System
• Thomas Wesley Wilkerson, PharmD, MS Pharmacy
Informatics Coordinator St. Francis Hospital, Inc.
Bruce Trickel, CMPE
Albany Internal Medicine
• Knowing your patient is in the hospital
• Communication between facility and provider
at time of discharge
• Discharge medication list forwarded to
provider
• Post discharge call from provider within 2
days, medication reconciliation
• Outpatient follow up visit, within 7 or 14 days
based on complexity
WellTransitions®
Bridge Gaps in Care and
Reduce Avoidable Hospital Readmissions
©2014 Walgreen Co. All rights reserved. Confidential and proprietary; should not be re-produced or re-distributed.
Walgreens WellTransitions®:
Bridge gaps in care
WellTransitions bridges gaps in
care by supporting patient
recovery through several
hospital-to-home transition steps
designed to:
• Reduce avoidable readmissions
• Increase patient satisfaction
• Lower overall care costs
Patient identified as eligible for the program
Offer outpatient medication at discharge
Counsel patients on medication
Clinical intervention outreach with
patients 48-72 hours post-discharge
Clinical intervention outreach
with patients 10 days post-discharge
Clinical intervention outreach
25 days post-discharge
Assess program effectiveness
with robust monthly outcomes reports
©2014 Walgreen Co. All rights reserved.
17
Walgreens WellTransitions® Program for medication
adherence has earned the exclusive endorsement of the
American Hospital Association
AHA Solutions, Inc. selected
Walgreens WellTransitions
program for:
• Leadership in assisting hospitals in
reducing readmission rates
• Improving patients’ medication
adherence
after discharge
AHA Solutions awards the AHA
endorsement to a product/service it
believes best addresses a specific
challenge for the most member
hospitals.
Walgreens WellTransitions Program
for medication adherence has earned
the exclusive endorsement of the American Hospital Association.
Reference: The American Hospital Association Awards exclusive endorsement to Walgreens WellTransitions® Program for medication adherence [press release].
Deerfield, IL: Walgreen Co.; September 16, 2013.
©2014 Walgreen Co. All rights reserved. Confidential and proprietary; should not be re-produced or re-distributed.
18
WellTransitions Early Model
Outcomes
WellTransitions –
Retrospective Study Methods
•
•
•
•
Research examined 744 matched pairs of
WellTransitions patients and non-patients in
a retrospective case comparison study to
evaluate the effectiveness of the program
Covariate Characteristics
Admitted from home
CMS targeted condition (AMI, HF, PN)
Discharged to home
12 month retrospective case comparison
cohort study using propensity score
matching
Patients enrolled in this pharmacist-led care
transition program were matched with
similar patients in terms of age, gender,
disease state, illness severity, comorbidities,
and other pertinent predictors of hospital
readmission
Minority
Public Insurance
Number of diagnosis
Length of stay
Age
Unique medication count
Primary outcome variable will be 30-day
hospital readmission rates
Presented at the American Pharmacists Association (APhA) Annual Meeting & Exposition, Orlando, FL, March 28-31, 2014
Research study conducted by Bobby Clark, PhD, MSPharm, MHA, MS, MA
WellTransitions – Retrospective Study Results
•
WellTransitions patients
• were 46% less likely to experience an unplanned readmission within 30 days than the
comparison cohort (RR; 0.54 (0.37 – 0.79))
• with non-CMS targeted conditions were 26% less likely to be readmitted (RR; 0.74 (0.46-1.17))
while those with CMS targeted conditions (AMI, HF and PN) were 55% less likely to be
readmitted (RR; 0.45 (0.22-0.95)) than the respective comparison cohort
• under age 65 were 44% less likely to be readmitted (RR; 0.56 (0.33 - 0.93)) while those age 65
or older were 48% less likely to be readmitted (RR; 0.52; 0.30 - 0.93)) than the respective
comparison cohort
Presented at the American Pharmacists Association (APhA) Annual Meeting & Exposition, Orlando, FL, March 28-31, 2014
Research study conducted by Bobby Clark, PhD, MSPharm, MHA, MS, MA
WellTransitions Impact on Readmissions:
June 2013 – January 2014
Results
15.1%
Eligible Not
Enrolled
Eligible
Engaged
6.9%
June'13-Jan'14
• WellTransitions patients who received at least
one telephone call had a 8.2% lower
readmission rate, relative to patients who were
eligible for but not enrolled in WellTransitions
‒ Absolute decrease in readmission rate: 10.6%
‒ Relative decrease in readmission rate: 54.3%
• Engaged:
‒ WellTransitions patients enrolled in the
program and completed at least one
clinical call intervention
• Eight hospitals represented in data results,
phased implementation
‒ Formal research study is planned to
systematically evaluate the program’s
effect on hospital readmissions rates
About DeKalb Medical
• Hospital system in Metro Atlanta Region – three campuses
‒ 407 beds, 22,000 discharges, 65,000 ED visits, 4.6 ALOS
‒ 100 bed, 5,800 discharges, 58,000 ED visits, 4.18 ALOS
‒ 40 bed LTACH
• Physician mix
• DPHO, mostly non-employed physicians
• Hospitalists – employed
• Major factors impacting hospital utilization trends
‒ Growing Uninsured populations
‒ Health Care Reform PPACA Impact
‒ Misalignment of financial incentives among healthcare
providers
‒ Fragmentation of health care delivery system
23
Methodology
• DeKalb Institutional Review Board (IRB):
‒ Expedited review
• Study Design
‒ Retrospective cohort
‒ Census of all discharges
• Control populations
‒ Historic data (a type of retrospective cohort study)
‒ Non-participating contemporaneous matches
a. North Decatur campus
b. Hillandale
• 30-day readmission calculation based on CMS SAS code, though
‒ Only 2-hospital system
‒ Not limited to Medicare population
• Multiple logistic regression, controlling for demographic and clinical variables
24
Key Findings & Study Limitations
• At both hospitals, readmission rates are trending higher
‒ Historic period (2010) versus current period (2011 – June
2012)
• Adjusting for gender, age, race, length of stay, month of
discharge, and CMS condition, all four control groups had
greater likelihood of readmission (adjusted OR = 1.6 – 2.1) as
compared to intervention cohort.
• Not adjusted for comorbid conditions
• Lack of data about readmissions to other area hospitals
• Selection bias likely
• Not all criteria in the CMS code could be applied
25
HCAHPS outcomes study:
DeKalb Medical Center results
Patient Perception of Care
(HCAHPS Scores) was a
significant driver of the
decision to implement bedside
delivery.
26% relative increase
in HCAHPS domain score
Dramatic improvement in HCAHPS “Communication
about medicines” domain scores1
63% at
65th
percentile
50%
at first
percentile
ACHIEVED IN THE FIRST 90 DAYS
From the first percentile to the 65th percentile.
Walgreens is now seen as another department within the hospital system—NOT a vendor.
1 Stemphiak
M., Bedside Delivery-an Easier Pill to Swallow. HHN (p2-3), August 2012
26
HCAHPS Outcomes Study:
DeKalb Medical Center Results
Feedback:
“Nursing staff love the constant interaction
(pharmacist/technician explaining the medications, involvement
in throughput huddles, discharge calls, etc).”
Walgreens is now seen as another department within the hospital system—NOT a vendor.
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Thank You!
Ed Cohen, Pharm.D., FAPhA
Senior Director –
Clinical Solutions
ed.cohen@walgreens.com
©2014 Walgreen Co. All rights reserved. Confidential and proprietary; should not be re-produced or re-distributed.
28
Medication Management:
A Rural Hospital Perspective
May 8, 2014
A. Bacon County Hospital and Health System
Medication Reconciliation Process
(FMEA – Failure Mode Effect Analysis)
2013
The negative screams.
While the positive only whispers.
B. Obtaining medication history and barriers
1. Bottles
a. Old bottles
b. Instructions have changed
c. Not current with refills
B. Obtaining medication history and barriers
2. List
a. Brought in by patient or family
- Is list up to date?
b. Generated by previous admission with Hospital Information System
- Up to date? User familiarity with system - not “confirming”
c. Physician Office
- Up to date? Accounts for specialties and OTC’s?
d. Pharmacy
- More than 1 pharmacy and OTC’s
3. Verbal History
a. Poor historians
b. What constitutes a medication?
C. Poly – Pharmacy
a. BCH averages 10 home medications per admission
b. Twin Oaks average prescriptions per month = 12
c. Ga Long Term Care Antipsychotic (20.9%) vs. Long Term Care (28.8%)
D. Poly –Physicians
a. Primary Care ≠ Attending ≠ On Call ≠ Mid – Levels
Who has ownership?
E. Hospital Information Systems – Meditech
a. Ambulatory drug file vs. formulary
b. Confirm home medications
c. Discharge paperwork > Retail pharmacy > Who resolves variances?
(example: hospital formulary substitutions)
d. New system that is in constant flux – Meaningful Use
e. Staff competency
F. How are we correcting Medication Reconciliation?
a. Frequent education
(nursing informatics classes, medication safety classes,
competency check offs)
b. Intensive pharmacy review – continuity with Nursing Home
c. Pharm D participation with all Care Teams (Acute Care and Long Term Care)
d. Appropriateness of use, indications, clinical care beyond dispensing
G. What’s Ahead
a. ePrescribing with Meditech (Dr. First)
b. Electronic histories (Dr. First)
c. Credentialing Pharmacist to control home medication ordering
New Measures
1. Pharmacist CPOE / Verification of Medication Orders within 24 hours
(patient safety)
2. E.D. Patient Transfer Communication
(care transitions)
H. Our Partners
a. GHA – Georgia State Office of Rural Health (SORH) project
b. CMS
c. The Joint Commission
d. Meditech
Questions
Kyle Lott, Pharm D
Director of Pharmacy Services
Bacon County Hospital and Health System
klott@bchsi.org
912-632-8961 ext. 1009
Medication Reconciliation –
A Patient Safety Initiative to Reduce Harm
St. Francis Hospital, Columbus, Georgia
Performance Improvement
Assessment and Planning
• The plan for this project was to reduce harm
by having safe and effective processes in place
to prevent adverse drug events through
Medication Reconciliation at transitions of
care.
• We utilized the principles of Crew Resource
Management (CRM) and the team approach to
performance improvement to assess clinical
impact on patient outcomes.
SFH Leadership Support to Reducing Harm
Proven strategies to reduce Medication Reconciliation errors
 Appoint Multi-disciplinary
Team to examine and redesign
the Medication Reconciliation
Process
 Assess and prioritize
improvement opportunities
 Develop an action plan of best
practice strategies to improve
transitions in care
 Use of information technology
to facilitate medication
reconciliation
Goals
Identify and implement innovative tools used to
improve the accuracy and complete collection and
reconciliation of patient’s medication information
Improve process used to document and handoff patient
medication information during transitions of care
Improve patient outcomes and reduce harm
Empower staff to “SPEAK UP” in the interest of
safety
Improve economic impact related to medication safety
A Burning Platform for Change
• Why do we need an accurate home medication list?
‒ Medication errors harm an estimated 1.5 million people in the U.S.
annually 1
‒ Medication errors cost the U.S. at least $3.5 billion in extra medical
cost 2
‒ Medication Reconciliation is a National Patient Safety Initiative.
More than 50% of admitted patients have at least one discrepancy
between medication history obtained by admitting clinicians and
actual pre-admission regimen 3
‒ 27%-59% of these have potential to harm
‒ Adverse Drug Events (ADE) are preventable complications that often
result in hospital readmissions. Improving Care Transitions and
reducing ADE’s is a core patient safety focus in Georgia 4
• Addressing accuracy in system = patient safety
Institute for Healthcare Improvement 1
The Joint Commission 2
Agency for Healthcare Research & Quality 3
Georgia Hospital Association (GHA) Partnership for Patients (PfP) 4
The Medication Reconciliation Challenge –
Whose Job is it?
• Many disciplines involved, with no one accountable.
• Divergent expectations about who is responsible for
reconciling medications and how it should be done
• Providers piece together medication history using
information from multiple, often imperfect, sources:
‒ Patient, caregiver, primary care physician, medical
specialists, outpatient medical records, hospital
discharge summaries, community pharmacies
Patient Intervention
• Project RED
– Medications at Transitions
and Clinical Handoffs
• Medication list accuracy
with RN & Clinical
Pharmacist, review list
with patient/family
– Teach Back
– Including patients and
families in the patient
safety plan
Discharge
Skilled Facility/
Inpatient
Unit
HH/Home
Cath
Lab/Endo/
PAT
Critical Care
Perioperative
Services
ER
The Bradley
Center
Quality Improvements and
Measurement of Progress
Patient
Intervention
“Your Personal
Medication History”
Form given to patient
to complete in the
Emergency
Department
Inpatient Interventions
Best Practices in Medication Reconciliation
• Involved all disciplines (physicians, nurses, pharmacists)
in building a robust medication reconciliation process and
defining ownership and responsibilities for each
component of the process assigned to the parties involved
‒ Nursing is responsible for building the home med list.
‒ Physicians shall conduct medication reconciliation.
‒ Pharmacist providing medication consults as needed.
• Defined Processes of Medication Reconciliation
‒ What to do and when to do it
‒ Who is accountable at each step
51
Inpatient Intervention
Medication Reconciliation Nurse Consults
• For patients on 15 or more meds
(Poly-pharmacy)
• when on multiple diabetic meds
• when on multiple anticoagulants
• for multiple unresolved
medication discrepancies
Information Technology Intervention
Primary Nurse uses Pharmacy Benefit Manager (PBM) Data Querying software to search outpatient prescription databases:
PBM Data – insurance claims data; eg. BCBS, United Healthcare, etc.
Rx Fill Data – voluntary submission of fill data by community pharmacies; eg. CVS
EMRs with PBM embedded – physician’s practices using PBM or eRx
Discrepancies Identified between Hospital Health Summary (HHS) and PBM
•
•
•
•
•
•
•
Example where 5 discrepancies were identified between HHS and PBM
HHS for Patient in the Emergency Room:
Aspirin 162mg PO QHS
Folic Acid 16mg PO QID
HCTZ 50mg PO Daily
Toprol XL (metoprolol succinate ER) 25mg PO QHS
Potassium 198mg PO QHS
Nursing Process
Horizon Health Summary
(HHS) Defined as “Source of
Truth” for Patient Medication
History. Nurse uses “ready for
Med Recon” button to send
message to physician that this is
their “Best Effort” to gather
patient’s medication history.
Physician Process
The Horizon Medication
Reconciliation system –
Displays message for the
physician to see required
medication reconciliation
actions needed.
Patient Process
Discharge instructions printed and
given to patient.
Nurse (Home med list) + Physician (Med Rec) = Best Practice (Safe Patients)
Information Technology Intervention
Staff Empowerment
• Ability to Communicate Concerns
‒ When it breaks down, submit a Concern Report
‒ Allows for anonymous submission since “Contact Name” is NOT
required
Community Intervention
“Know Your Medication”
booklets and cards given to patients to keep with them at all times
Education Interventions
• Implemented organization-wide
Mandatory Medication
Reconciliation Education classes
taught by pharmacists and nurses
• Conducted Research on
Medication Reconciliation process.
Analysis and Results
Performance Improvement Project Measurement
Congestive Heart Failure
Complete DC Instructions
100%
90%
80%
70%
60%
1Q12
2Q12
3Q12
4Q12
1Q13
2Q13
3Q13
4Q13
Results/Lessons Learned (Pearls):
Drivers of safety that produced positive results include:
• Living out core values of organization – safety, open
communication, compassion, creativity and ethical behavior
• Collaborating with all stakeholders (physician, nursing, patients,
information services and pharmacy)
• Engaging patients and family in the Patient Safety Plan - Your
Personal Medication History Forms, Medication Booklets and
Cards
• Empowering staff to “speak up” in the interest of safety for all Crew Resource Management Principles work!
• Advocating for accountability – educated on process ownership
• Implementing realistic work plans - Action plans, scheduled pilots
and audits to evaluate effectiveness of medication reconciliation
process.
Making A Difference in Reducing Harm!
Disclosures: The faculty/presenters and planners disclose no conflict of interest relative to this project
Regional Planning
Medication Management
• Discuss the Touch points
• Discuss community
‒ Strength
‒ Weakness
‒ Opportunities
‒ Barriers
• What Action(s) will you take by May 21, 2014
to improve medication management?
Regional Planning Medication Management
Questions to run on:
• How do we, as a community, help the patient
manage and understand their medications?
• What are we doing right?
• What are our opportunities?
• What role will my organization take in helping
the patient manage their medications?
Report Out