Mental Health Clinical Pharmacy
Services and Pilot at
Regions Hospital
Craig Harvey, Director of Pharmaceutical Services
Meg Moen, Clinical Pharmacy Resident
Dan Rehrauer, MTM, HealthPartners
Regions Hospital, Saint Paul, MN
February 19, 2014
Objectives
• Regions and current Pharmacy operations
• Pilot design and initial objectives
• Preliminary results
• What we learned along the way
• MTM Services
• Future
*This was a quality assurance project and any results obtained are not intended for
generalized application/knowledge
• 460 Bed hospital
Regions Hospital
• Level 1 Trauma Center
• 79,000 ED visits in 2012.
• Disproportionate Share
Hospital (DSH) – 340B
• 100 Mental Health
Inpatient beds
• 24 x 7 Pharmacy
• Discharge Pharmacy with
bedside delivery
• New 2012, 100 private
inpatient rooms
Regions Mental
Health
• Provide acute mental health
services for inpatients
• Care delivered by team of
psychiatrists, nurses,
occupational therapists,
pharmacists, and medicine
physicians
Inpatient facility, Saint Paul, MN
• Crisis staff for emergency
evaluations in Emergency
Center
• Outpatient services offered at
a variety of HealthPartners
clinic locations
RARE
• How can Pharmacy help to improve patient care
AND reduce readmissions?
Current Model - IP
• Clinical Pharmacist (DCP) spends 5 hours daily to
consult and review of 100 MH patient profiles.
• The mental health department has the highest patient to
pharmacist ratio of any clinical pharmacist position
• DCP works remotely - little to no direct interaction
between pharmacist and patient, provider, or nurse.
• DCP is not involved in the discharge process.
• Patients not routinely referred for MTM at discharge
Current Model - OP
• 82% of MH discharge Rx’s filled at Regions,
delivered to patient’s nurse prior to discharge.
• Regions is 340B – lowest drug cost available.
• Pharmacy bills insurance if available. Bills patient
co-pay or retail price after patient leaves the hospital.
• If “too early”, “not covered”, “PA” or need to
expedite - 30 days supply billed to nursing unit.
Pre-pilot data
• Progress notes average 0.97 per patient case
• Average number of medications per inpatient: 17.5
• Average number of doses per inpatient: 73 doses per
patient per stay
• Average cost of medications billed to MH floor at
discharge: $5,000 - $7,000 monthly
Nursing
The Players
Clinical
Pharmacy
Admin
Collaborative, team-oriented
initiative necessary to make
quality patient impact
MTM
Clinic
Patient
Medicine
Discharge
Pharmacy
Psychiatry
Social
Work
Pilot Objectives
November 11th – December 13th 2013
• Identify potential impact of full-time clinical
pharmacist services – measure interventions, costsavings and satisfaction with services provided.
• Identify areas for patient care improvement.
• Determine justification of a dedicated mental health
pharmacist resource.
Expanded Clinical
Pharmacist Role
Continued adherence to current
role expectations with additional
duties.
•
Increased direct interactions with
MD and nursing with
recommendations
•
Profile review to reduce
polypharmacy
•
Increase pharmacist involvement
in discharge medication
reconciliation.
•
Place MTM referrals for high-risk
patients
•
Track interventions
•
Reduce monthly cost of
medications billed to MH units.
•
Participate in team rounding
•
Improved med patient safety
Clinical
Pharmacy
Over the course of 24 days:
• 360 interventions
Nursing
Interventions
Medicine
• 92.8% of recommendations
accepted by psychiatrist
*Preliminary data from clinical
Psychiatry
surveillance software system – no
eMAR results yet
Most common interventions:
Clinical
Pharmacy
Nursing
Interventions
•
Discontinue inappropriate therapy (72)
•
Change in Drug Formulation
Recommendation (46)
•
Medication reconciliation upon
discharge (39)
•
Alternative therapy recommendation
(18)
•
Antibiotic therapy recommended (16)
Medicine
Greatest cost savings:
Psychiatry
•
Antibiotic therapy recommendation
•
Discontinue inappropriate therapy
•
Alternative therapy recommendation
Key Interventions
Pilot Savings
Clinical
Pharmacy
Over the course of 24 days:
• Pilot savings: $99,301
Nursing
Pilot Savings
• Potential annual savings:
$1.5 million
Medicine
Psychiatry
*Preliminary data from clinical
surveillance software system – no
eMAR results yet
Clinical
Pharmacy
• Some patients have their home
medications stored in pharmacy
upon admit
• Discharge medications sent up
WITH home meds
Nursing
Discharge
Medications
Discharge
Pharmacy
• Pharmacist reconciled patients
home meds with discharge meds
and identified:
• Duplicates
• New medications
• Discontinued medications
• Opportunity:
Psychiatry
• Pharmacist review meds
personally with patient
• Reduce med costs (patient and
institution)
• Intuitively this may improve
compliance
Clinical
Pharmacy
MTM
Clinic
MTM
Referrals
Patient
Social
Work
• HealthPartners Clinics
offer unique opportunity
for MTM coordination of
care
• Most pilot interventions
occurred on floors where
patients were working
towards discharge
• Established process for
DCP to easily place an
MTM order
• This was a challenge
Clinical
Pharmacy
MTM
Clinic
MTM
Referrals
• Current order instructs
patient to contact
appointment line
• Patients may not call to
make an appointment
• Many patients may not
keep their appointment
• Opportunities identified:
Patient
Social
Work
• Can we enable social work
to make MTM appointment
prior to discharge
• Can we establish outpatient
MTM services at Regions
Hospital to increase
convenience to our patients
Medication Therapy Management
(MTM)
Why do we want to promote this service?
• An outpatient service that optimizes pharmacotherapeutic
outcomes for individual patients.
• Are the medications indicated, effective, safe and convenient
• When offered by a pharmacist the service has been shown to
improve clinical outcomes and reduce adverse drug effects from
medications for chronic conditions.
• Dramatic increase in psychotropic medications and complexity
of medication regimens makes MTM essential
• Pre and post discharge education, medications
reconcilliation/education and transition managers have been
demonstrated to reduce risk of readmission by up to 37%
Who would benefit
• People on multiple medications (>4)
• Patients who see multiple prescribers
• Patients who mention concerns with costs of their
medications
• Patients who are confused about their medications
• Patient that aren’t taking their medications the way they
are supposed to (non-adherence)
• Everybody!
Nursing
Perceptions
Post-pilot survey distributed to
mental health professionals to
gauge perceptions of pharmacist
services
Clinical
Pharmacy
Admin
MTM
Clinic
Patient
Medicine
Discharge
Pharmacy
Psychiatry
Social
Work
Perceptions
Perceptions
Perceptions
Perceptions
Impact opportunities
(What we learned)
• Discharge medication process
• MTM and transitions of care
• Interprofessional relationships
• Cost savings
• Other areas:
• Are patients getting re-admitted due to
cost/administration of long-acting injectables?
Future Model – IP
• Hiring 1 FTE BCPP (Board Certified Psychiatric
Pharmacist) 2nd quarter 2014. Focus at start
•
•
•
•
Admission Med List – accurate and complete
Formulary Management – clinical and cost effective
Education – staff and patient focused with indications for Rx
Discharge Med Rec – insurance, formulary.
• Patient home meds – reconcile with discharge orders
• Use where appropriate – patient safety, cost savings for all
• All MH patients leave with 30 days supply of meds to
improve med compliance, reduce readmissions.
Future Model – IP continued
• Refer high risk patients to MTM post-discharge
• ED Clinical Pharmacist partners with MH
pharmacist
• Measure Results of Pharmacist Interventions –
• Cost Savings, formulary compliance, polypharmacy
reduction
• Outcomes – LOS, reduced readmissions
• Patient AND staff satisfaction
• Reduced patient days
How can Pharmacy help to reduce Mental
Health Readmissions at Regions?
•
Medication Optimization
•
•
Medication Reconciliation
•
•
•
Recommending patients for MTM with scheduled appointment
Accurate discharge med list on patient discharge summary (AVS)
Access to medication
•
•
•
“Why” this med is important – “indication” on bottle,
MTM where needed – reinforces, educates after discharge
Transitions of Care
•
•
•
Accurate, verified medication list upon admission
Discharge to home with current meds only
Patient Education
•
•
•
Medical and psychiatric
Meds in hand when discharged
Trouble shoot compliance issues - affordable, reminders
Evaluate if strategy works? Measure results.
Thank You
Questions?