fshp 54 th annual meeting – august 7-9, 2020 disclosure · 2020. 8. 3. · – a vested interest...

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FSHP 54th Annual Meeting – August 7-9, 2020

Ambulatory Care Track: Transitions of Care –Discharging Patients with Chronic Disease StatesTim L’Hommedieu, PharmD, MS, Director of Pharmacy Services Lauren Verbosky, PharmD, MS, Ambulatory Pharmacy Manager BayCare Health System

Disclosure


• We do not have (nor does any immediate family member have):– a vested interest in or affiliation with any corporate organization

offering financial support or grant monies for this continuing education activity

– any affiliation with an organization whose philosophy could potentially bias my presentation

Objectives


• Discuss the impact of readmissions on hospital quality and financials

• Explore opportunities for pharmacy to impact readmissions through transitions of care services

• Review method for scaling a Pharmacy Transitions of Care Program

• Discuss success and challenges of a formal Pharmacy Transitions of Care (PTOC) Program

Transition of care of unplanned hospital readmissions were preventable

of post discharge adverse events are medication related

of all medication errors occur during times of care transition

76%

72%

Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003; 52(4): 556-557.Improving Care Transitions: Optimizing Medication , March 2012, APhA/ASHP.

60%


Medication Impact on hospital readmissions

• On discharge from the hospital, 30% of patients have at least 1 medication discrepancy.

• 1 in 5 U.S. patients discharged to their home from the hospital experienced an adverse event within three weeks of discharge.

• 60% were medication related and could have been avoided.

• 17.6% of Medicare enrollees were readmitted within 30 days at a cost of $15 billion

Harris, G, “Report Finds a Heavy Toll from Medication Errors,” New York Times, 21 July 2006 .Kwan, Y, Fernandes, OA, , JJ et al., “Pharmacist medication assessments in a surgical preadmission clinic,” Arch Intern Med, 2007;167:1034-40.Forester, AJ, Murff, HJ, Peterson, JF, et al., “The incidence and severity of adverse events affecting patients after discharge from the hospital,” Annals of Internal Medicine, 2003:138(3):161-7.Jencks, Stephen F, Williams, Mark V, Coleman, Eric A, “Rehospitilizations among Patients in the Medicare Fee for Service Program,” New England Journal of Medicine, 2 Apr 2009;360:1418-1428.Medicare Payment Advisory Commission, “Report to Congress: Promoting Greater Efficiency in Medicare,” June 2007, Chapter 5


Hospital Readmission Reduction Program (HRRP)


• Established by Section 3025 of the 2010 Affordable Care Act• Reduce payments to IPPS hospitals for excess readmissions• Includes six condition/procedure-specific measures

• Acute Myocardial Infarction

• Chronic Obstructive Pulmonary Disease (COPD)

• Heart Failure (HF)

• Pneumonia

• Coronary Artery Bypass Graft (CABG) Surgery

• Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)

• Unplanned readmission within 30 days of index to same or another hospital for any reason

https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/Readmissions‐Reduction‐Program

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Hospital Readmission Reduction Program (HRRP)


All subsection (d) hospitals are subject to HRRP. Exempted hospitals include:

• Critical Access

• Rehab hospitals and units

• Long‐term care hospitals

• Children’s hospitals

• Prospective Payment System (PPS)‐exempt cancer hospitals

• Veterans Affairs hospitals (VA)

• Short‐term acute care hospitals in US territories

• Religious non‐medical health care institutions


HRRP Payment


• CMS categorizes five peer groups based on volume of dual-eligible Medicare and full-benefit Medicaid,

• FY20 stays between July 1, 2015 and June 30, 2018.

• CMS calculates a median Excess readmission ratio (ERR) for each measure and each peer group.

• The payment reduction amount increases with each ERR above the peer group median ERR, until it reaches 3%, the maximum payment reduction.


HRRP Payment


• Predicted 30-day readmission• # of readmissions anticipated in hospital given case mix and hospital’s quality

of care

• Expected 30-day readmission• # of readmissions expected if the same patients with same characteristics were

treated at an “average” hospital, given “average” quality of care

• Excess Readmission Ratio (ERR): Predicted/Expected

• Publicly available on https://www.medicare.gov/hospitalcompare/readmission‐reduction‐program.html


Hospital Compare Website


https://www.medicare.gov/hospitalcompare/readmission‐reduction‐program.html

HRRP Payment


• CMS calculates payment adjustment factor (PAF) based on ERRs• 0.97 is the PAF minimum for FY 2020

• CMS applies the PAF to all Medicare FFS base operating DRG payments regardless of condition between Oct 1, 2019 – Sept 30, 2020.

• https://www.medicare.gov/hospitalcompare/readmission-reduction-program.html


Hospital readmissions

Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), 2010‐2016 Nationwide Readmissions Database (NRD)


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BayCare Health System

3

WellnessCenters

8

Walk‐In Care

Stations Inside Publix

Stores

139

Physician Practice Locations

15

UrgentCare

13

Diagnostic/Imaging Centers

4

Ambulatory Surgery Centers

Community‐Based Care

1

Free‐Standing

ER

15

Acute Care

Hospitals

2

Behavioral Health

Hospitals

2

Inpatient Acute Care Rehab

Locations

Acute Care

SkilledNursing Facilities

HomeCareOffices

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OutpatientRehabFacilities

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PostAcute Care


PTOC Pilot Phase I in 2015


• Two pharmacists began pilot in 2015 onsite at a large hospital• Began remotely covering a small hospital 4 months later

• Target Population• Patients discharged to home, assisted living, home health, high risk meds,

poly-pharmacy

• Clinical service• TOC Pharmacist contacts patient 0-7 days post discharge

PTOC Pilot Phase I Results


PTOC Phase II in 2016


• Hired 4 new pharmacists (total of 6 FTE)

• Target Population• Medicare patients discharged to home, assisted living, home health• Core measure disease states: AMI, CHF, COPD, STK, THA/TKA, PN

• Provided same clinical service in Phase 1 (post-discharge phone calls)

PTOC Phase II Results


PTOC Phase III in 2017


• Hired 4 new pharmacists (total of 10 FTE)

• Target Population• Medicare patients discharged to home, assisted living, home health• Core measure disease states: AMI, CHF, COPD, STK, THA/TKA, PN

• Provided same clinical service in Phase 1/2 (post-discharge phone calls)

• Initiated discharge medication reconciliation pilot• TOC pharmacist plans med rec prospectively prior to discharge• Physician reviews planned med rec, accept or change as appropriate

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PTOC Phase III Results

• Patient Specific FINs are matched to validate impact Pharmacy Service• Utilize Observed vs Expected Readmission Rates to account for acuity of patients• Data is statistically significant, demonstrated with P value <0.05 (Chi Square Fisher’s Exact Test)

2017 Readmission KPI – No Pharmacy Service2017 Readmission KPI –Pharmacy Service

Readmission Rate 7.63% O/E Ratio=0.69

Readmission Rate 15.45% O/E Ratio=1.09


Discharge Med List Audit


PTOC Expansion in 2018


• Request to scale and expand Pharmacy TOC Program• 13 additional full-time pharmacists • Offer discharge med rec service in addition to telephonic service• Target all traditional Medicare patients

PTOC Expansion Overview


• Location

• Pharmacist schedule

• Goals

• Services

• Documentation

• Implementation

PTOC Expansion: LocationFSHP 54th Annual Meeting – August 7-9, 2020

• TOC pharmacists need to be onsite• Training• Precepting • Education/presentations• At-elbow support• Building relationships • Presence at readmission/key initiative meetings

• Inpatient rounds• Physician advisors • “First Focus” safety meetings• Interdisciplinary readmission meetings • Pathway development meetings

Transitions of Care Pharmacist Location=

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PTOC Expansion: Pharmacist Schedule


Consists of residency‐trained, board‐certified clinical pharmacists

Monday‐Friday during normal business hours

PTO coverage is handled by the respective region

PTOC Expansion: Vision


Determine goals and track outcomes/metrics

• Unite the team

• Define success

• Monitor progress

• Provide feedback and benchmarking

• Readily available to share with key stakeholders

Program goals

• Improve patient safety

• Improve medication reconciliation process for medical staff

• Reduce 30‐day readmissions

PTOC Expansion: Service FSHP 54th Annual Meeting – August 7-9, 2020

Medicare Beneficiaries > 65 years old (excluding hospice)

Pre-discharge: Pharmacists review Medicare patients daily for discharge

readiness

Prospective: Pharmacist plans d/c med rec

Physician signs d/c med rec prior to patient leaving

Retrospective: Pharmacist reviews d/c med rec after provider has signed and calls provider as needed for changes and recommendations

Post-discharge: Only patients discharged home or to assisted living

facility

0-7 days post-discharge follow-up call: Targeted med review, clinical assessment, med counseling, etc.

21-day post-discharge follow-up call: Based on clinical discretion-coordinate

patient needs, health assessment, counseling

PTOC Expansion: Clinical Documentation


• Documentation in Cerner Electronic Medical Record • HealtheCare Platform

• Notes are visible to inpatient and outpatient providers

• Post-Acute Programs and Services• Enterprise Care Coordination Office• BayCare HomeCare• Telemonitoring Program

Post-Acute programs document under same folder and encounter

PTOC Implementation Overview

Focus on team members

Create educational material

Spread the word

Collaborate with inpatient pharmacists

Provide at-elbow support

Track and report outcomes

Continue to socialize the program


PTOC Implementation: Focus on Team Members


• Multiple training sessions, PowerPoints, job aids

Train existing TOC pharmacists

• Site-level

Orientation for 13 new TOC pharmacists

• Standardized new hire training material • Standard Operating Procedure • Monthly department meetings • Increased methods of communication

• Monthly site meetings, quarterly in-person retreats, Skype, and Microsoft Teams• Developed committees

Standardization across the team

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PTOC Implementation: Educational Materials


• Create educational material on PTOC service across the health system• Standard presentation for meetings • Materials

• TOC program contact sheet • Program flyers• Hospital-specific flyers • Job aids

• Providers

• Nursing

• Hospital pharmacy

• Intranet website page

PTOC Implementation: Spread the Word

• Road Tour• System-level

• P&T subcommittees • Regional physician meetings • Department meetings

• CASAs

• Nursing informatics

• Care coordination (case management)

• Telehealth

• HomeCare

• Enterprise Care Coordination Office

• Site-level• Leadership meetings• Department meetings

• Physician groups

• Care coordination (case management)

• HomeCare

• Inpatient pharmacy

• Face-to-face whenever possible


PTOC Implementation: Collaboration

• Collaborate with clinical pharmacists at each hospital• Acute care clinical pharmacists and TOC pharmacists both attend rounds

• Acute care pharmacists are responsible for medication use process, order verification, clinical consults, and codes

• TOC pharmacists are responsible for planning the DCMR and optimizing the plan of care for the post-acute care setting

• Contact the inpatient pharmacist with interventions during inpatient stay• Duplicate therapy, missing meds, and therapy optimization

• Contact the provider with interventions based on personal clinical judgement


Example of home meds not continued for inpatient stay


Review med rec

and sign

FSHP 54th Annual Meeting – August 7-9, 2020 FSHP 54th Annual Meeting – August 7-9, 2020

Discharge Medication Reconciliation

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PTOC Implementation: SupportFSHP 54th Annual Meeting – August 7-9, 2020

• Provide “at-elbow” support • Leverage screen sharing • Collaborate with IT pharmacy coordinator• Differentiate between PTOC program issue and Cerner limitation

Pharmacist Discharge Med Rec Interventions Accepted by Physicians Across BayCare


Sept 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Overall

# of Recs Made 36,524 53,588 51,051 49,876 50,828 47,992 289,859

# of Recs Accepted 35,648 52,835 49,364 48,801 49,764 46,567 282,979

Total Acceptance Rate 98% 99% 97% 98% 98% 97% 98%

PTOC Implementation: OutcomesFSHP 54th Annual Meeting – August 7-9, 2020

• Track and report outcomes• Each pharmacist is responsible for maintaining their own tracking sheet• Data committee aggregates the individual spreadsheets into one spreadsheet

for analyses every month• Hospital data is used to calculate our outcomes

PTOC Program Data


• Service Capture Rate• Goal > 90%

Capture Rate: 2019

Group Core Measure dx Medicare ≥ 65 yo All dx Medicare ≥ 65 yo

# Eligible for services* 8,146 34,747

# Receiving at least 1 service 7,516 31,767

% Pt receiving services 92.3% 91.4%

* Services include DCMR and/or post-acute telephonic follow-up

PTOC Program Data


• 30-day all cause readmission rate• O/E < 1 indicates better than expected

30-day All Cause Readmissions: 2019

Group Core Measure dx Medicare ≥ 65 yo

Core Measure dx Medicare ≥ 65 yo

All dx Medicare ≥ 65 yo

Services Received* 1 or more Both Both

Observed/Expected Readmissions (O/E) 0.97 0.8 0.83

* Services include DCMR and/or post-acute telephonic follow-up

PTOC Program Data


• Outcomes are shared at monthly team meetings

• Final data is delayed 2-3 months due to scrubbing

• Utilize soft data pulls for more timely feedback • Available about 6 weeks after month end

• For example, August data is available mid-October

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PTOC Program Data


• Data is used for internal benchmarking and workload distribution

PTOC Implementation: Socialize


• Continue to socialize the program • Presented our impact on readmission rates and physician acceptance rates at

the same hospital meetings• Opportunities to obtain feedback

• MAR note format, specific drugs/recommendations, co-pay assistance links

• Workflow with other post-acute care programs

• Continue to educate providers

Successes


• Won the ASHP Best Practice Award in 2017

• Selected as the Quality of BayCare’s Quality Sharing Day 2019

• Featured in the BayCare Community Report 2019

• Accepted in AJHP in 2019

• Won the FSHP Best Practice Award in 2020

Challenges


• Coordinate with BayCare post-acute programs on which days to call patients

Patient call-fatigue/engagement

• Track and report physician acceptance rate of pharmacist recommendations• Tailor recommendations and MAR note format to physician preferences• Partner with physician advisors and leaders

Physician buy-in

• Maintain separate excel spreadsheet to manage daily workload and track outcomes

EMR functionality

New Challenge: COVID-19


• TOC pharmacists began working from home to ensure safety

• Returned onsite 50%/WFH 50% with at least 1 person onsite • Resolved capacity issues in order to maintain social distancing and to be

consistent across the team

• Maintained business as usual • Achieved capture rate goals

• Additional benefits • Team member satisfaction• Patient satisfaction


Ambulatory Care Track: Transitions of Care –Discharging Patients with Chronic Disease StatesTim L’Hommedieu, PharmD, MS, Director of Pharmacy Services [email protected] Verbosky, PharmD, MS, Ambulatory Pharmacy Manager [email protected] Health System

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fshp 54 th annual meeting – august 7-9, 2020 disclosure · 2020. 8. 3. · – a vested interest...

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