Pharmacy's Role in Improving
Patient Care - Moving from
Med WRECK to Med Rec
Bruce Thompson, RPh, M.S.
Hennepin County Medical Center
Learning
Objectives
At the conclusion of the program, the
participant will learn:
1. Identify steps to consider reducing patient
readmission from a pharmacy perspective
2. Understand the barriers with medication
discharge process
3. Adopt a process to develop new services
3
First Project
Medication
Error on Discharge.
Medication Not continued
Medication restarted that should not
Pilot
First 30 patients, only
8 % were Error Free
Pilot
Added Pharmacists to
review Discharge
Medication Orders
129 Patients average
over 6 months
Pilot
Step one,
Improvements in EPIC
Still 70% had
potential Errors
Pilot
Improved Process and
Pharmacists improved
Readmission Rate by
47% !
Pilot
Reduced from 10.2 %
to 5.4%
Now after 15 months
still below 6%.
Pilot
Added Pharmacists to
provide service for all
Patients in this
category.
Slowly Expanded to
other high risk areas
Next Phase
CCDS – Coordinated
Care Delivery System
Patient Stratification:
A blueprint for Reducing Readmissions
Stratification
Care System Initiative
Intervention
3 or more admits in
index year
Coordinated Care Center
Multidisciplinary team based care.
The ambulatory ICU
Healthcare Home “on steroids”
All other hospital
admits
Discharge Transition
Management
Time limited case management to assure
timely medical follow up and facilitate
connection with community based services.
All other patients
Disease Management
Improved
PCP engagement
ER Diversion
Registry management
Same day PCP access
Community visits
Community partners
Improve ER to clinic handoffs
Tier I Care
ZL 53 YO woman transfers to HCMC CCDS
Six chronic medical problems (includes DMII)
only four meds
Complex social issues (joblessness, social
isolation, home foreclosure with homelessness)
May 2010 Inpatient Psych admit with suicidality
Disrupted a multi-year primary care provider
relationship
Requesting primary care and mental health
follow-up
Meeting mental health needs a challenge
Tier II Care
JL 62 YO woman severe alcoholism
Heart and nerve toxicity, back pain
Independent but vulnerable
Admitted 6/17- 6/20 – Failure to thrive
Readmission 6/29-7/3 – Cognition assessed,
chemical dependency treatment refused
Successful Primary Care follow up 6 days after
discharge
Medication simplification, contact with home RN
Now lost to follow up
Tier III Care
JF 37 YO homeless man
Asthma, recent pulmonary embolism
Schizoaffective D/O – likely
Cocaine abuse – certain
Chronic abdominal pain from pancreatitis – possible
Nominally involved in chemical dependency
treatment
Spring 2010 – 6 admits with $225,000 in charges
JF-Changing the Care Paradigm
Admit ER
IP
Clinic
Visits Day Contact
System
Charges
(annual)
4/1 –
6/30
8
10
57
1
$225,000
($900,000)
7/1 –
1/15
1
4
11
35
$35,000
($65,000)
23
Percent of patients with over
10 active medications Tier I.
46
Percent in Tier II and Tier III
have over 10 medications.
Tier III care
Coordinated Care Center opened
mid-July
• 100/300 patients assigned
• Predominately from inpatient care
• Multi-disciplinary team:
MDs, NPs, Pharmacist, Social
Worker, Care Managers, chemical
dependency counselor and Mental
health member.
•
Tier III care
Intensive medical care and multidisciplinary care
• Low visit volume, high
contact/management model
• Expensive: 4-5 professional FTEs/150
patients
• Twice weekly care team meetings
•
Reduction in Readmissions
•
•
•
Readmission rate reduced by
30-50%
Total Hospitalizations reduced
by 43%.
ER Visits reduced by 37%
Pharmacy Role in Reducing
Readmissions
•Medication Reconciliation
•Both Admission and Discharge
•Right Medication
•Medication Therapy Management
•Visits within 5 days of discharge
•Routine appointments based on patients
•Automatic Refills
•Deliver to Clinics, Provider or MTM
Med Rec
•Proven
Success with a program
that documented a reduction in
readmissions by 47%.
• Value realized by Providers
MTM Services
•Proven Track
record with Clinics
•Visits increased in past 18 months.
•Increased Revenue.
•Improved Care
•Decrease total Health Care expenses
RX Delivery
•Adapt
process for CCDS Clinic
• Auto refill medications
•Deliver to clinics to avoid long
waits
•MTM Pharmacists improve
patient compliance.
Administrative
Approval
Pharmacy are integral to the
success of the program!
Additional Pilots
Projects
Similar results with
Psychiatry and
Medicine
Where do we go from
here?
• Get involved with Care
Redesign.
• Propose MTM services
• Evaluate Accuracy of Discharge
Medications.
• Need Community Pharmacies
to work with your health care
system.
Health-System Pharmacy and
Care Transitions
Moving from DRG/RVU to ACO
Craig Else, PharmD, MHA
Fairview Health System
Care Transition Models
 Eric
Coleman (www.caretransitions.org)
◦ Four Pillars
 Medication Self-Management
 Dynamic Patient-Centered Record
 Follow-up
 Red Flags
Care Transitions Models (cont’d)

Project RED (Re-Engineered Discharge)
◦ 8 similar points
◦ Louise videos
◦ https://www.bu.edu/fammed/projectred/index.h
tml
 BOOST (Better Outcomes for Older Adults through Safe Transitions)
◦ 9P Criteria (Problem Meds, Psych,
Polypharmacy, Diagnosis, Health Literacy,
Readmissions, Support, Palliative Care)
◦ http://www.hospitalmedicine.org
Care Transitions
Goals

Decreased Readmissions
Lower Total Cost of Care
 Increased Patient Satisfaction
 Increased Clinical Quality

Fairview’s Transition Projects
◦ carol.com/Fairview Ridges
◦ UMMC Pediatrics
◦ FPA/Ucare/Fairview Southdale
◦ MTM/CHF
◦ MTM/Eagan Clinic
Fairview Ridges
◦ Facilitated by carol.com
◦ CHF/COPD patients
◦ Pharmacy Discharge Reconciliation and
Education
◦ Home Care follow up
◦ MTM follow up
Discharge List Examples
EPIC
Advantages/Disadvantages
Want list to be clear, but complete
 Pictures can be problematic
 Add/Change/Discontinue section
 Times?
 Indication?
 MD?
 How does it handle Tapers or Insulin
Scales?

Pilot Learnings
Very few of FRH patients with CHF/COPD
were readmissions during pilot
 Around 50% weren’t associated with
Fairview Clinics
 The clinic care coordinator needs to control
the management of these patient
populations
 Communication with hand off information is
essential
 A minimum of 1 home care visit within 2448 hours post hospitalization is necessary to
ensure safe transition to home

FPA/UCare

Two primary interventions
◦ Pharmacy Discharge Reconciliation
◦ Follow up visit with Primary Care within five
days

Excellent outcomes demonstrated
◦ 30 day readmissions decreased by 42%
◦ Relatively low cost to administer
◦ Expanding to other facilities
UMMC Pediatrics
Intensive Discharge Reconciliation and
Education
 Post-discharge follow up calls
 75% capture rate for prescriptions

No readmission data demonstrated yet
 Excellent customer satisfaction

Which Patients?


Everyone?
High-risk Diagnoses (and high risk for
what…)?
◦ CHF/COPD
◦ Pneumonia
◦ AMI
High-Risk Medication Therapies or Regimens?
 Particular Payers?
 Risk Stratification?

Hotspotting
“The critical flaw in our health-care system…is that it was never
designed for the kind of patients who incur the highest costs.
Medicine’s primary mechanism of service is the doctor visit and
the E.R. visit. (Americans make more than a billion such visits
each year, according to the Centers for Disease Control.) For a
thirty-year-old with a fever, a twenty-minute visit to the doctor’s
office may be just the thing. For a pedestrian hit by a minivan,
there’s nowhere better than an emergency room.
But these institutions are vastly inadequate for people with
complex problems: the forty-year-old with drug and alcohol
addiction; the eighty-four-year-old with advanced Alzheimer’s
disease and a pneumonia; the sixty-year-old with heart failure,
obesity, gout, a bad memory for his eleven medications, and half a
dozen specialists recommending different tests and procedures.
It’s like arriving at a major construction project with nothing but
a screwdriver and a crane.”
New Yorker Article by Atul Gawande http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande
ETG/ERG Risk Scoring

Episode Treatment Groups
◦ Groups various encounters based on disease
“episodes”

Episode Risk Group
◦ Assigns a “risk score” to each episode based the
associated diagnosis

Average patient score is 1
◦ Higher scores are “sicker” patients, lower scores
are “healthier”

Scores are used to predict future healthcare
utilization
FRH Risk Score Audit
One fine June day
35
30
25
20
15
10
5
0
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W X
Y
Z AA BB CC DD EE
Readmission Risk vs. ERG Score
(n = 100 patients)
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
% NOT Readmitted within 90 days
% Readmitted within 90 days
Inpatient Hospitalization
TCU/SNF/Home Care/Home
Complex Medication
Regimen,
High DTP Risk
Complex Medication
Regimen,
High DTP Risk
Moderate DTP Risk or
Specific Drug Therapy
Problem
Moderate DTP Risk or
Specific Drug Therapy
Problem
Low DTP Risk
Low DTP Risk
Primary Care
Complex Medication
Regimen,
High DTP Risk
Moderate DTP Risk or
Specific Drug Therapy
Problem
Low DTP Risk
Questions?
bruce.thompson@hcmed.org