Lisa Anne Boothby, PharmD, BCPS
Director of Pharmacy, Dukes Memorial Hospital
Demonstrate the value of clinical pharmacy services
to decrease 30-day readmission rates
 Outline the pharmacist’s role in reducing medical
waste
 Detail ethical issues associated with drug shortage
management
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Clinical pharmacy services
Inpatient and outpatient settings
Improve patient outcomes
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Patient Accountability and Affordable Care
Act
 Pharmacists are “other healthcare providers”
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Social Security Act
 Part B versus Part D
 Three MTM billing codes
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Private insurance reimbursement follows
Smock N. Affordable Care Act Regards Pharmacists as Health Care Providers, Not Just Prescription Dispensers.
Available at URL: http://www.pharmacytimes.com/publications/issue/2013/January2013/Affordable-Care-ActRegards-Pharmacists-as-Health-Care-Providers-Not-Just-Prescription-Dispensers
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Capitated healthcare precede reimbursement
 May decrease need for pharmacy billing
 Share in savings once minimum achieved
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Accountable care organizations
 Not all hospitals have embraced
 Pilot programs
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
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Providers accountable
 Achieving quality
 Reductions in rate of spending growth
 Physician led with many payer arrangements
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National Committee for Quality Assurance
 Established ACO criteria
 7 categories with 4 levels
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
To reach critical mass
 Incorporate multiple payers or multiple hospitals
 Apply for a CMS wavier to include Medicaid
patients
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
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Patient centered medical homes
 Led by physician
 Include pharmacist, nurse and other health care
practitioners
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Treat patient with chronic conditions
 Prevent adverse events and optimize therapy
 Team ensures all health care needs are met
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
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Improve medication management
Preventing hospital readmissions
Decreases revenue in a traditional hospital
budgetary model
Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.
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Keep patients healthy and out of the hospital
VA collaborative practice model
Prescribing privileges
More than 20 years of success
Pharmacist credentialed providers
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Medication management
Preventing disease
Maintaining cardiovascular health
Preventing end organ damage
Medication compliance, adherence
Therapeutic drug monitoring
Supportive care
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1 month study at Mission Hospital
 735 bed community teaching hospital
 Asheville, North Carolina
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Pre-post design
 2 weeks normal routine
 2 weeks with clinical pharmacist
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at
http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
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Drug information
Discharge counseling
Medication interventions
Medication reconciliation
Filling discharge prescriptions
Submit discharge summaries
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at
http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
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15-day and 30-day readmission rates
Number of ED visits
Employee satisfaction surveys
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at
http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
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33% vs. 17% readmission within 30 days
11% vs. 2% readmission within 15 days
9% vs. 4% ED visits within 30 days
Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at
http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care
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Prospective cohort
 729 patients over three months
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Pharmacy medication reconciliation
 30-day readmission rate
 Polypharmacy and readmission rate
Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day
readmissions? Hospital Pharmacy 2013;48(5):380-388.
Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day
readmissions? Hospital Pharmacy 2013;48(5):380-388.
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Med reconciliation and counseling
 Decreased 30-day readmission rate
 16.8% vs. 26%; p=0.006
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Polypharmacy
 More than 5 scheduled medications
 Associated with increased readmission rates
Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day
readmissions? Hospital Pharmacy 2013;48(5):380-388.
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Walgreens program
Reduces readmissions
Pharmacists oversee medication regimens
Transitions of care
Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012.
http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions
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Med review at admission and discharge
Bedside medication delivery
Counseling for patients and their caregivers
Regularly scheduled follow-up post discharge
24-7 support for discharged patients
Ensure follow up with physician
Ensure appropriate self care
Marian General and Lutheran Hospital
Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012.
http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions
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11 pharmacists
 Vanderbilt University
 Brigham and Women’s Hospital
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Medication reconciliation
 Time consuming
 Most important contribution
 Improving care transitions
 Correct the admission medication history
Haynes KT, Oberne A, Kripalani S. Pharmacists’ recommendations to improve care transitions.
Ann Pharmacother 2012;46(9):1152-1159.
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Translation to a rural critical access hospital
Minimal resources
Decreased ED visits decreases admissions
Decreased revenue with traditional models
Next steps?
TARGETING TRANSITIONS
 Project BOOST: www.hospital-medicine.org
 Project RED: www.projectred.org
 STAAR initiative: www.ihi.org/STAAR
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Medication reconciliation process
 Physician and nurse driven
 2 to 3 errors per each
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Follow-up by pharmacy
 Clarify and correct errors
 Time intensive
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Increased safety risk
 Omissions
 Delays and duplications
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Develop criteria for consultation
Greater than 10 scheduled medications
High-alert medications
Anticoagulants
Core-measure disease states
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SEWER
IV dextrose
Potassium
Saline
Sodium
Calcium
lactated
ringers
magnesium
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REGULAR TRASH
Outside packaging
Empty items that once contained medication
Shipping packaging
Recycle paper, glass, plastic
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NONHAZARDOUS
RX WASTE
Antibiotics
Lidocaine
Pitocin
Heparin
HAZARDOUS
WASTE
• Insulin
• Some vitamins
and minerals
• Phenylephrine
P-LISTED
HAZARDOUS
WASTE
• Coumadin
plus
wrapper
• Nicotine
plus
wrapper
and peel
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INCOMPATIBLE
HAZARDOUS
WASTE
Aerosols
• Inhalers
Oxidizers
• Silver nitrate
CHEMO
WASTE
SHARPS
Needles and broken ampoules
Empty syringes
Smith CA. Managing Pharmaceutical Waste. Journal of the Pharmaceutical Society of Wisconsin 2002;17-22.
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Save money, prevent delays and omissions
 Clinical pharmacists know formulary medications
 Clinical pharmacists prevent non-formulary and
not-available medication orders at admission
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Formulary management policies/procedures
 Therapeutic interchange programs
 Evaluate PAR levels for expired drugs
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Outpatient prescribing practices
 Polypharmacy
 Lack of follow-up
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Mail order pharmacies automatic renewals
 Three month supplies
 Compliance
 Adherence
 Persistence
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Controlled substance regulation
 Changes from DEA
 Expected in future
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Vendors
 Stericycle, others …
 Environmentally conscious disposal
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Therapeutic interchange
 Drug classes
 Pharmacodynamics of medications
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Superior therapeutic alternatives
 Evidence based medicine
 Avoid grey market distributers
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Receive emails for information only
 Plan ahead
 Keep adequate inventory levels
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Medications dispensed daily
 Accept small loss with expired medications
 To stock adequate levels
 Prevent drug shortages from reaching patient
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Aminophylline
Sincalade
Nalbuphine
Dextrose 25% and 50% syringes
Furosemide IV
Metoclopramide IV
Fentanyl IV
Potassium phosphate IV
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Pharmacists vital part of the healthcare team
Pharmacotherapy experts
Explain how medications work in the body
Suggest therapeutic alternatives
Eliminate therapeutic duplications
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Avoid polypharmacy
Teach common side effects
Action for severe side effects
Ethical stewardship
Medical and financial resources
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PHARMACY COST
CENTER
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Collaboration
 Rural health hospitals
 Payers
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Obtain grant money
 Research
 New practice models
 Demonstrate added value
Lisa Anne Boothby, PharmD, BCPS
Director of Pharmacy, Dukes Memorial Hospital