Pharmacy Practice Innovations:
Best Practices in Care Transitions
Michelle Cudnik, PharmD
John Moorman, PharmD, BCPS
June 27th, 2013
Michelle Cudnik, PharmD
Clinical Ambulatory Care Lead
Pharmacist, Summa Health System
Associate Professor of Pharmacy
Practice, NEOMED
Local Ohioans Uninsured
The percentage of persons aged 18 to 64 without
health insurance
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
© 2012
What is the highest percentage of
admission rates seen in the country
that are due to 30-day readmissions?
1.
2.
3.
4.
15%
17%
19%
21%
Hospital Readmissions
Medicare 30 day readmissions as a percentage of
admissions in 2009
Source: “Improving Care Transitions,” Health Affairs, September 13, 2012, Available at http://www.healthaffairs.org/healthpolicybriefs/
© 2012
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 illness
Institute 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 disease
The 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
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.
www.cms.gov for meaningful use
www.innovation.cms.gov for accountable care organizations
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
System
Multiple care
Settings/Pharmacy
Sub-specialist
clinicians
and services
EHR
Health
Information
Exchange
Mid
level provider
NP/PharmD
Office
Administrator
, Greeter
Care
coordinator
RN/LPN/M
A
Care
Plan
Patient
Centered
Home
Roles
Patient
Portal
Family
member,
caregiver
PCP
Patient
Office
Patient and family
System
Multiple care
Settings/Pharmacy
Sub-specialist
clinicians
and services
EHR
Health
Information
Exchange
Office
Administrator
, Greeter
Care
coordinator
RN/LPN/M
A
Identifies,
follows high risk
patients
• Assembles PreVisit results
• Follows up on
care plan
Patient
Centered
Home
Roles
•
Mid
level
provider
NP/PharmD
Patient
Portal
Family
member,
caregiver
PCP
Patient
Office
Patient and family
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 PatientCentered 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 highestrisk patients
• Reimbursement for Transitions of Care
visits
John Moorman, PharmD, BCPS
Pharmacotherapy 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
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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
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•
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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
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•
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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?