PARADE: Preventing and Reducing
Adverse Drug Events in Care
Coordination Communities
Anne Myrka, RPh, MAT
IPRO
Webinar
January 6, 2015
Objectives
 Introduce IPRO and the Centers for Medicare & Medicaid Quality
Innovation Network/Quality Improvement Organization Program
 Provide overview of CMS 11th Scope of Work Coordination of
Care task
 Describe the Preventing and Reducing Adverse Drug Events
(PARADE) initiative




Describe PARADE Objectives and Strategy
Gain Cross-setting Community Commitment
Establish the PARADE Timeline
Next Steps, Q & A
2
IPRO
 The federally funded Medicare Quality Innovation Network –
Quality Improvement Organization (QIN-QIO) for New York
State.
 Under contract with the Centers for Medicare & Medicaid
Services (CMS).
 Leading the Atlantic Quality Innovation Network (AQIN).
3
Atlantic Quality Innovation Network (AQIN)
 One of 14 QIN-QIOs across the country working to provide
quality improvement learning opportunities, technical
assistance and free resources in support of CMS healthcare
quality goals.
 Led by IPRO in New York State.
 Partners include Delmarva Foundation in the District of
Columbia and the Carolinas Center for Medical Excellence in
South Carolina.
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QIN-QIO Program
 Continued commitment to partnering with stakeholders on datadriven initiatives that increase patient safety, make communities
healthier, better coordinate post-hospital care and improve
clinical quality.
 Grounded in principles that align with the goals of the CMS
Quality Strategy:
 Eliminating disparities,
 Strengthening infrastructure and data systems,
 Enabling local innovation, and
 Fostering learning collaboratives.
5
QIN-QIO Program Goals and Initiatives
(2014 – 2019)
 Goal 1: Promote effective prevention and treatment of chronic disease by:
 Partnering with physicians to provide more effective treatment to patients at risk for heart
attack and stroke, especially those in underserved populations.
 Supporting self-management education to patients with diabetes.
 Helping physician practices use EHRs to full potential and provide patients with preventive
services.
 Goal 2: Make care safer and reduce harm caused in the delivery of care by:
 Working with providers across the continuum of care of care to prevent HAI in hospitals
and other settings.
 Targeting prevention of HAC in nursing homes and facilitating collaboration, innovation
and enhanced patient and family engagement.
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QIN-QIO Program Goals and Initiatives (cont’d)
 Goal 3: Promote effective communication and coordination of care by:
 Helping community stakeholders, providers, patients and families to collaborate for better
coordination of care transitions, improved discharge communication, and better access to
community services.
 Sharing evidence-based approaches to reduce avoidable hospitals readmissions,
especially in vulnerable populations.
 Working with providers and stakeholders across settings to reduce potential adverse drug
events and promoting medication management strategies.
 Goal 4: Make care more affordable by:
 Helping providers report on measures that assess clinical quality of care, care
coordination, patient safety and patient and caregiver experience of care and helping
providers improve care quality through effective use of healthcare IT.
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CMS 11th Scope of Work Task Priorities
A
Excellence in Operations
Better Health
QIO-QIN
Essential Functions
B
1. Results-Oriented
Quality Improvement
Activities
Better Care
C
2. Community Learning
and Action Networks
3. Technical Assistance
(i.e., Quality
Improvement Experts)
4. Integrated
Communications
•B1. Improving cardiac health & reducing cardiac disparities
•B2. Reducing disparities in diabetes care
•B3. Coordinating care through Immunization Information Systems
•B4. Coordinating prevention through Health Information
Technology
D
E
•C1. Reducing care-associated infections
•C2. Reducing care-acquired conditions
• C3. Coordinating care to reduce readmits & adverse
drug events
Lower Costs
•D1. Quality Improvement through Physician Value Modifier
•D2. Local QIO Projects
Technical Assistance
•BFCC-QIO, et al – Quality Improvement Initiatives
•Value-Based Purchasing
Coordination of Care Task Goals
Promote Effective Communication and Coordination of Care
 Reduce hospital readmission rates in the Medicare program by 20% by 2019
 Reduce hospital admissions rates in the Medicare program by 20% by 2019
 Increase community tenure, as evidenced by increased number of nights spent
at home, for Medicare beneficiaries by 10% by 2019
 Reduce the prevalence of adverse drug events (ADEs) that contribute to
significant patient harm, emergency department visits, observation stays,
hospital admissions or readmissions occurring as a result of the care
transitions process
●
Anticoagulants
●
Hypoglycemic Agents
●
Opioids
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What is IPRO’s PARADE Initiative?
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Reducing Adverse Drug Events:
Federal Alignment of Resources
Anticoagulants, Opioids,
Hypoglycemics:
 Communication failures
 Suboptimal management
systems
 Inadequate access to
medication lists and lab
results
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PARADE Initiative – Pilot study and results
 Based on an IPRO multi-facility rapid-cycle pre
(February 2014) and post (July 2014) intervention quality
improvement pilot study, “Medication Reconciliation
and Anticoagulation Management Across Care Settings”
 Four Care Transitions collaboratives comprised of
hospitals, skilled nursing facilities (SNFs), home
healthcare agencies
 Evaluated the discharge communication of 17 evidencebased requisite anticoagulant-related information
elements and 5 medication reconciliation processes
across care settings  5 to 10 charts, retrospectively
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PARADE Initiative – Pilot study and results
 Evidence-based system improvements were applied
according to site-specific baseline results
 Results
 Significant improvement in communication of requisite
anticoagulation-related elements to subsequent
provider upon transfer/discharge:
 All facilities (16%, 95% CI 11.6%-20.3%)
 Hospitals (8%, 95% CI 1.2%-15.2%)
 SNFs (19%, 95% CI 12.7%- 25.8%)
 Significant improvement in completion of medication
reconciliation processes upon admission
in SNFs (21.2%, 95% CI 9.6%- 31.9%)
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Medication Reconciliation Elements
Was an original home medications list collected on admission?
Did the list of original home medications collected at admission
include the medication name, dose, route and frequency for
each medication? (all elements for all drugs must be present
for Yes)
Was the original home medication list reconciled with
admission orders in less than 24 hours?
Did the reconciled medication list reside in a dedicated
location in the medical record?
Was there is a 1:1 match for every medication on the home
medication list to the admitting orders? (all elements for all
drugs must match for Yes)
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Requisite Anticoagulation Management Elements Communicated at
Transfer/Discharge to Subsequent Provider
Was the primary indication for use of the anticoagulant clearly documented?
Was an assessment of fall risk clearly documented?
Anticoagulation Management Elements Communicated at
Did documentation indicate whether Requisite
the patient
was new to anticoagulation therapy or a previous user?
If new, was start date of anticoagulation therapy provided?
Did documentation indicate whether treatment is intended to be acute (short term) or chronic (long term)?
If acute (short term) was total duration of therapy provided? (was there a stop/end date?)
Date, time, and strength of last dose given documented? (all must be present for Yes)
Date, time, and strength of next dose due provided? (all must be present for Yes)
If on Coumadin (warfarin), was the target INR or INR range documented?
If on Coumadin (warfarin), were the last 2 INR lab results provided (with dates and results)?
If on Coumadin (warfarin), was the date provided for when the next INR was due?
Was the most recent serum creatinine or creatinine clearance evaluation provided (with date and results)?
Was the patient provided with educational material?
Was an assessment of patient/caregiver understanding of the education documented?
Was documentation of patient/caregiver education and understanding communicated to the next provider?
Was contact information provided for the anticoagulation management prescriber/physician?
Was patient referred to an anticoagulation management service? (e.g. Coumadin/warfarin clinic)
Link to audit tool: http://qio.ipro.org/drug-safety/drug-safety-resources
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PARADE Initiative
 QIOs are directed by CMS in the 11th Statement of
Work (11SoW) to:
 Establish relationships and collaborations in the
community to coordinate provider communication and
medication management across care settings with a
patient centered focus
 Help providers utilize new or existing evidence-based
tools and practices to improve the care of those
prescribed high risk medications, specifically
anticoagulants, diabetic agents and opioids
 Use health information technology to screen for and
prevent ADEs in Medicare beneficiaries
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PARADE Objectives and Strategy
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PARADE Objectives
 To identify patients at risk of experiencing ADEs due
to high risk medication use following hospital
discharge
 To identify hospital readmissions and emergency
department visits associated with high risk drug
exposure
 To evaluate the post-discharge medication use
system across care settings and identify
opportunities for system improvements
 To facilitate the implementation and serial evaluation
of evidence-based intervention strategies
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PARADE Strategy
 Process measures – All facilities/healthcare providers
 Small, low-impact audits of medication reconciliation processes and
high risk drug discharge communication (5-10 charts, retrospective)
 Serial evaluation to guide improvements
 Goal: 100% adherence to audit criteria in 6 months
 Interventions
 Evidence based interventions according to site-specific results
 Outcome measures – Hospitals only
 Readmissions due to ADEs using data from electronic health record
data (hospital) and claims data (IPRO)
 Serial evaluation to identify improvements
 Goal: Demonstrate measureable improvement over 5 year scope of
work
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PARADE Strategy
 Based on 6 month improvement cycles
 Cross setting work will be achieved within each care transition
coalition Medication Management Committee monthly meetings
 Cycle 1 is January 6, 2015 – June 30, 2015
 All facilities will focus on Medication Reconciliation and Anticoagulation
Discharge Communication
 Educational webinars on management of hypoglycemics and opioids will
be provided prior to the launch of Cycle 2 (which will expand to process
improvements for hypoglycemics and opioids)
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PARADE Strategy
 Cycle 1 January 6, 2015 – June 30, 2015
 All facilities (including those who participated in the
pilot study) will complete and return a PARADE Request
for Technical Assistance by January 16, 2015
 Eligible facilities are hospitals, skilled nursing facilities
(SNF), rehabilitation facilities, home healthcare
services/agencies (HHA), residential facilities, adult
homes, pharmacies (hospital, community, SNF vendors,
etc.)
 Participating individuals are administrators, physicians,
nurses, pharmacists (including SNF consultant
pharmacists), quality improvement professionals,
discharge planners, HHA hospital liaisons, etc.
21
PARADE Strategy
 Cycle 2 is July 1, 2015 – December 31, 2015
 Continue to work on ADE hospital readmission
measure, high risk drug discharge communication and
med rec improvement processes
 Expand to medication management of hypoglycemics,
opioids, other (e.g. antibiotics)
 IPRO is currently convening subject matter experts to
provide guidance on best practices for management across
care settings during transitions
 Subsequent Cycle work will focus on continued
evidence based improvements, sustainability and
applicable cross-setting emerging measures
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PARADE Process Measures: Audit Methods
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Audit Methods – Medication Reconciliation
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Audit Methods – Medication Reconciliation
25
Audit Methods:
Anticoagulation Discharge
Communication (AC-DC)
Audit Tool
Excel version

Preferred method of data
collection

Calculates performance
statistics automatically and
includes performance
dashboard

Color coded performance:
 Green = >90% of
completed fields as
"yes“
= 60-90% “yes”
 Red = <60% “yes”
26
Audit Methods – Anticoagulation Discharge
Communication (AC-DC) Paper Tool
Link to paper audit tool: http://qio.ipro.org/drug-safety/drug-safety-resources
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28
Additional Ad Hoc Anticoagulation MeasureWarfarin Time in Therapeutic Range
 Designed for skilled nursing facilities, outpatient clinics and
others that serve population over long term
 For more information: http://qio.ipro.org/drug-safety/collaborativepartners/analytic-services
*TTR – Rosendaal’s method
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PARADE Interventions
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Interventions
 Policy & Procedure improvements
 Educational programs
 Clinical tools & resources
 Monthly networking/collaboration through each
Coalitions’ Medication Management Committee
meetings
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Medication Reconciliation
Intervention Resources
http://www.hospitalmedicine.org/marquis/
32
Medication Reconciliation
Intervention Resources
http://www.ahrq.gov/professionals/quality-patientsafety/patient-safety-resources/resources/match/index.html
33
Medication Reconciliation Improvement Tools
34
Anticoagulation Management
Evidence Based Resources
The Anticoagulation Centers of Excellence:
http://acforumexcellence.org/
35
http://qio.ipro.org/drug-safety/drug-safety-resources
Anticoagulation Improvement Tools
37
PARADE Outcome Measure
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Outcomes: ADE Surveillance Process Hospitals
All patients possessing the following elements at time of hospital
discharge:
• ≥ 3 medications ordered in total, and;
• Anticoagulant
• Opioid
• Hypoglycemic
•How? EHR query
• Patient identifier - SSN and MRN
• Drugs - can be identified using drug name text string files provided by
IPRO
• Raw data files transferred to IPRO via secure data transfer protocol
•
Denominator
Raw
Numerator
All patients identified in Denominator with Emergency
Department Visit or Hospital Re-admission within 30 days
•How? IPRO analysis of Medicare Part A data
•
Final
Verified
Numerator
• Determination of presence of ADE by Root
Cause Analysis
• How? CDC abstraction tool verified for
anticoagulants, opioids, and hypoglycemic ADEs.
Preventable ADEs targeted for coalition-wide
evidence based intervention(s).
39
 Baseline measure
completion date will
be individualized per
hospital
 Remeasure quarterly
after baseline is
completed
 Secure data transfer
protocol utilized
Commitments, Timeline, and Due Dates
40
Organization/Provider Commitments
 IPRO’s strategy requires creation of a local ADE-specific collaborative
comprised of at least one hospital and two or more downstream providers
committed to sharing information and working across settings to
successfully complete the work. Participants will:

Join your local cross-setting IPRO supported Community Care Transitions Coalition
by signing on to its Coalition Charter

Establish an internal team to share project responsibility for your organization

Commit to collaborate with IPRO for duration of the project; agree to investigate
adverse drug events and address performance outliers as part of the quality
improvement plan

Commit to developing and implementing a sustainable quality improvement plan to
address identified deficiencies

Implement and evaluate the impact of one or more intervention strategies

Attend and actively participate in the Medication Management Committee convened
within your community’s Care Transition Coalition and attend IPRO coaching
support calls as needed
41
IPRO Commitments
 Provide technical assistance to support serial data collection, analysis,
and reporting
 Perform analysis of prescription drug data at baseline and quarterly
over each 6 month ADE improvement interval (hospitals)
 Provide detailed reports characterizing at-risk population and
suspected ADEs
 Facilitate interpretation and root cause analysis to identify priorities for
intervention
 Lead the Medication Management Committee for the Community
Coalition and facilitate communications between partner providers
 Provide evidence-based clinical tools and educational resources for
quality improvement interventions
 Assist in determining effectiveness of interventions and support
innovative strategies that sustain safety goals
42
Commitments, Request for Technical
Assistance and Completion Date
Due: January 16, 2015
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PARADE Cycle 1 Timeline and Due Dates
Date/Time
January 6, 2015, 2-3pm
January 16, 2015
January 20, 2015, 2-3pm
January 22, 2015, 2-3pm
January and monthly
thereafter
February 6, 2015
February and March
March 17, 2015, 2-3pm
March 30, 2015
April
May 30, 2015
June
Topic/Activity
PARADE Project Launch Webinar
Technical Assistance Request Due Date; AC-DC Excel tool
will be emailed to participating facilities
Webinar: PARADE Measures and Audit tool guidance and
Q&A
Webinar: Reducing Hypoglycemic Events in the Elderly – Dr.
Medha Munshi
Each Coalition has monthly Med Management Committee
Meetings to advance work
Baseline audits due; IPRO analysis of baseline audit sent to
facilities within 2 weeks
Coalition Med Management Committee Meetings –
interventions/prioritization
Coaching Call; teleconference only: 1-877-287-8135
*8949321*
Remeasure due; IPRO analysis of remeasure sent to
facilities within 2 weeks
Coalition Med Management Committee Meetings
Remeasure due; IPRO analysis of remeasure sent to
facilities within 2 weeks
Coalition Med Management Committee Meetings Review initial 6 month cycle outcomes; create plan for
continuing improvements and sustainability; expand to
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hypoglycemic, opioids
45
Summary & Next Steps
 PARADE Request for Technical Assistance Agreement due by January 16,
2015
 SAVE the DATE - Webinar: January 20, 2015 2-3pm – audit tool guidance,
Q&A
 Audits:
 Excel AC-DC audit tool (preferred) will be emailed to facilities after
technical agreement is signed
 Paper AC-DC audit tool can be utilized
 Med rec audit – only paper tool is available
 Fax completed paper audits by due dates to Anne at: 518-426-3418
 Email completed Excel AC-DC tool by due dates to Anne at:
anne.myrka@hcqis.org
 Outcome ADE readmission baseline completion date will be individualized
per hospital
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Collaborative Disclosures
 Project is designed to encourage collaboration
 Through that effort we will facilitate the sharing of facility
names, team members and email addresses with all
involved in project
 We will not share your individual QI findings or QI data
with any other organization without your consent
 Please contact Anne by January 16, 2015 if you do NOT
wish to have your contact information shared
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Questions / Feedback
48
For more information
Anne Myrka
Pharmacist – Drug Safety
(518) 320-3591
Anne.Myrka@hcqis.org
Sara Butterfield
Senior Director – Care Coordination
(518) 320-3504
Sara.Butterfield@hcqis.org
Darren Triller
Senior Director – Drug Safety
(518) 320-3525
Darren.Triller@hcqis.org
IPRO Care Transitions Web Site:
http://qio.ipro.org/care-transitions/overview
IPRO CORPORATE HEADQUARTERS
IPRO Drug Safety Web Site:
http://qio.ipro.org/drug-safety/overview
1979 Marcus Avenue
Lake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, NY 12211-2370
www.atlanticquality.org
This material was prepared by the Atlantic Quality Innovation Network/IPRO, the Medicare Quality Innovation Network Quality Improvement Organization
for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-AQINNY-TskC.3-14-23