Medical Delivery Network

Karine Azizian, PharmD Director, Pharmacy Services

Rachel Mashburn, PharmD Pharmacy Program Coordinator

PATH TO EXCELLENCE THROUGH TEAM CARE AND ENHANCING THE ROLE OF THE PHARMACIST

Cedars-­‐Sinai  Health  System  

Cedars-­‐Sinai  Medical  Center   Medical  Delivery  Network   Educa<on  and  Research  

Cedars-­‐Sinai  Medical  Group  

Cedars-­‐Sinai  Health  Associates  

Inpa<ent  Specialty  Prac<ces  

California  Heart  Center  

Tower  Hematology  Oncology  Medical  

Group  

Physician  Billing  Services  (PBS)  

Cedars-­‐Sinai  

Medical  Network  Services  (MNS)  

The Cedars-Sinai Medical Group (CSMG) is a multi-specialty group of physicians serving the community at eight sites throughout Los Angeles. The approximately 130 physicians have formed a company dedicated to serving a wide range of medical needs for all patients.

The Cedars-Sinai Health Associates (CSHA) is a network of individual physicians with independent offices throughout Los Angeles. These physicians have come together to form an independent physician association (IPA) to serve the community’s managed care medical needs.

Inpatient Specialty Practices (ISP) is a medical group comprised of Hospitalists who provide inpatient services to our patients at Cedars-Sinai Medical Center.

California Heart Center consists of cardiologists that specialize in pre and post transplant services that deliver comprehensive, individualized care; offering the latest in diagnostic testing and access to the newest research advances.

Tower Hematology Oncology Medical Group (THOMG)  consists of ten physicians specializing in high quality and comprehensive hematological and oncological cancer care including conventional, innovative and investigational modalities.  THOMG has an excellent reputation in the community for their cancer care and ongoing leadership in clinical trials.

Medical  Provider  

Network  for  Workers’  

Compensa<on  

Clinical  Integration  

Los  Angeles  Cardiology  Associates  

Los Angeles Cardiology Associates (LACA) consists of 10 physicians who specialize in all of the major disciplines of cardiology including electrophysiology, interventional cardiology and noninvasive cardiology. Their primary offices are located in Downtown Los Angeles with outreach throughout Los Angeles and San Bernardino Counties.

Cedars-Sinai Medical Group

§ 130 multi-specialty physician group located in Beverly Hills, CA — 35 Internal Medicine physicians

§ Pharmacist involvement since 1995 — 11 Clinical Pharmacist FTEs — 7 Pharmacy Support Specialists (pharmacy

technicians) to support the Refill Center and medication purchasing and distribution

Discussion Points for Today

§ Clinical pharmacist services provided for Cedars-Sinai Care Foundation

§ Goals of the Patient-Centered Medical Home project at CSMG

§ Care Management strategies to reduce pharmacy-related total cost of care

Clinical Pharmacist Credentials

§ Doctor of Pharmacy Degree (PharmD) § California Registered Pharmacist license § Completed Residency Training § DEA Certificate § NPI

Other certificates: § Certified Asthma Educator (AE-C) § Certificate in Travel Health (Certified by International

Society of Travel Medicine) § Certified Diabetes Educator (CDE) § Basic Life Support Certificate

Pharmacists in a Medical Group

ü Developed drug therapy management (DTM) protocols according to nationally accepted guidelines

ü Established Collaborative Practice Agreements with physicians ü Physicians place a patient specific order when referring for DTM

Pharmacist Interventions under Protocol: §  Educate patients regarding disease, medications and treatment goals. Provide

patient education/ self management materials/kits, Rx compliance boxes, etc.

§  Initiate, substitute, titrate and/or DC medications under protocols §  Ensure immunization series completion and timeliness §  Identify significant ADR’s; drug interactions; drug/vaccine duplications; CI’s; and/

or allergies §  Order and monitor labs §  Panel management role: proactively reaching out to patients on P4P lists in a

systematic approach to improve DM and cholesterol

Evolution of Pharmacist Services at CSMG

Anticoagulation Asthma

Hyperlipidemia Hypertension Polypharmacy

Chronic Hepatitis C Smoking

Cessation Travel

Medicine

Diabetes Injection Center Pyxis

Refill Center

Patient Centered Medical Home –

Pharmacist Decentralized

Transitions of Care

Heart Failure DOT

Post Discharge

Clinic

1995 2002 2009 2010 2012 2011 2013

Anticoagulation Program January – March 2013

1: “INR goal” is defined as no less than 0.2 below the lower limit and no greater than 0.5 above the upper limit of the PCP-designated INR target range 2: INR results obtained within 30 days of Anticoagulation Clinic enrollment (n=304) are not included

0%

20%

40%

60%

80%

INR Within Goal INR Below Goal

INR Above Goal

77%

17% 6%

ANTICOAGULATION CONTROL: ATTAINMENT OF INR GOAL1

(n=1,438 INR RESULTS2)

•  Coumadin (warfarin) initiation and titration under protocol •  LMWH initiation and patient self injection technique education/training •  Bridging with LMWH when indicated •  POCT (Coaguchek XS) •  Monthly “no show” report for patients lost to follow up

Chronic Hepatitis C

§ Educate patients with chronic Hepatitis C on their disease and treatment regimens

§  Initiate and monitor chronic Hepatitis C drug therapy § Manage and treat adverse events from therapy § Order appropriate labs throughout the course of

treatment

Chronic Hepatitis C Ø  194 patients referred since 2003

Ø 58 patients: declined treatment; were referred to clinical trails; or had acute Hepatitis C

Ø  136 patients treated/treatment ongoing*

Ø  106 patients completed treatment and follow up (2003-2010)

Ø  68 patients (64%) had SVR ( “cured”)

0%

20%

40%

60%

80% 55% 64%

SVR

Total SVR 2003-2010 National vs. CSMG Hepatitis C Clinic

National CSMG Hep C Program

0

50

100

150

200

2003 2004 2005 2006 2007 2008 2009 2010 2011 Total

194

136

Number of Patients 2003-2011

Patients Seen Patients Treated

Smoking Cessation

•  One on one consultation to provide individualized smoking cessation plan •  Strategies for behavior modification and how to control cravings/withdrawal symptoms •  Prescription for medications or nicotine replacement therapy when appropriate •  Carbon monoxide level monitored at each visit

Travel Consultation and Immunization Program Jan 2011 – June 2013

BayGam 1% Flu

4% Hep A 29%

Hep B 6%

Japanese Encephalitis

3% Meningococal

3% MMR 0%

Polio 7%

Rabies 0%

Td/Tdap 7%

Yellow Fever 11%

Typhoid 29%

Vaccine Use 2013

0

20

40

60

80

100

120

140

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Travel Clinic Enrollment (Number of new patients seen per month)

2011 TRV

2012 TRV

2013 TRV

•  Education and recommendations for disease prevention •  Personalized Travel Health Booklet •  Appropriate immunization administered per CDC and WHO recommendations •  Prescriptions provided as needed

Heart Failure Program

§ Initiated pilot November 2012 § Interdisciplinary team:

— 2 Cardiologists — 1 Pharmacist- part time — 2 Nursing staff

§ Program Goals — Decrease CHF hospital admissions and 30 day

readmissions — Decrease total cost of care — Improve quality of care

Heart Failure Program

§ Management —  Patient education and care coordination —  Medication optimization —  Medication adherence and safety monitoring —  Medication reconciliation —  BNP guided diuresis, IV diuretics —  Bed-side ultrasound —  Cardiovascular co-morbidity management —  Nutrition consultation —  Nurse practitioner house call and home health —  Supportive care and advanced directive

PRIOR%TOTAL% POST%TOTAL%PRE/POST% 74%% 26%%

n% 114% 41%

74%%

26%%

0%%10%%20%%30%%40%%50%%60%%70%%80%%

Distribu(on+of+Admissions+

Overall % of Hospital Admission for Patients Pre and Post Enrollment in the Heart Failure Program

n=138 patients

12#Mth#Prior#

11#Mth#Prior#

10#Mth#Prior#

9#Mth#Prior#

8#Mth#Prior#

7#Mth#Prior#

6#Mth#Prior#

5#Mth#Prior#

4#Mth#Prior#

3#Mth#Prior#

2#Mth#Prior#

1#Mth#Prior#

1#Mth#Post#

2#Mth#Post#

3#Mth#Post#

4#Mth#Post#

5#Mth#Post#

6#Mth#Post#

7#Mth#Post#

8#Mth#Post#

9#Mth#Post#

10#Mth#Post#

11#Mth#Post#

12#Mth#Post#

Non6readmit# 17# 4# 4# 4# 4# 4# 3# 10# 2# 5# 17# 24# 6# 3# 1# 7# 4# 1# 2# 1# 1# 3# 0# 10#

Readmits# 3# 0# 0# 0# 0# 0# 1# 0# 1# 2# 4# 5# 0# 0# 1# 1# 0# 0# 0# 0# 0# 0# 0# 0#

SUM# 20# 4# 4# 4# 4# 4# 4# 10# 3# 7# 21# 29# 6# 3# 2# 8# 4# 1# 2# 1# 1# 3# 0# 10#

0#5#10#15#20#25#30#35#

Axis%Title%

Distribu.on%of%Admissions/Readmissions%by%Month%

12 month pre- and post-enrollment admissions and readmissions for Heart Failure Patients

*Known deceased patients have been removed from both pre and post counts

16 readmissions pre-enrollment vs. 2 post-enrollment in Heart Failure Program

Heart Failure Program- Next Steps

§ March 1st Rollout —  Open to other cardiologists in group and IPA —  Assign Cardiology Pharmacist Full time —  Add additional members to the team:

§  Dietician §  Case Manger §  LVN coordinator

—  Develop Heart Failure Registry —  Develop clinical research program

Injection Center

Goals of the Injection Center: § Quality

Ø Appropriateness of the drug, dose, frequency, dosage form, route of administration, and duration Ø Check for drug-drug interactions and duplications Ø Review side effects prior to administration Ø Order appropriate labs prior to administration

§ Patient Safety and education § Proper coding and documentation

§ Decrease wasted/expired medications

Injection Center

Directly Observed Therapy (DOT) Program §  Implemented Protocol June 2012 § Overseen by Pharmacist Services § Physician refers patient to Injection Center for Directly

Observed Therapy of INH + RPT regimen § Patient seen weekly for 12 weeks and directly observed taking

medication regimen —  Educate patient and monitor for possible ADRs of treatment and/or

disease

Secrets to our Success!

§ Great team! —  Physicians and pharmacists work well together

§ Achieve High Patient and Provider satisfaction scores —  Scores consistently >90% for program and individual pharmacists

§ Very Accessible —  Frequent patient follow-up via telephone or office visits

§ Good panel managers —  Several reports assure patients are not lost to follow up

§ Return patient to PCP/specialist management when patient goals are attained

Patient Centered Medical Home

§ Refill Center § Medical Home Overview § Clinical Pharmacist in PCMH

Refill Center §  Pharmacists authorize continuation of medications for chronic

diseases under protocol —  22 refill authorization protocols and 4 conversion protocols

§  Quality —  Assure patients are seen by their PCP annually —  Chronic medication lab monitoring, i.e. annual BMP for patients on

ACE-Inhibitors —  Identify patients with above goal LDL and HgA1Cs. —  Collaborate with physicians to have their patients’ reach LDL and

HgA1C goals

§  Resource Utilization —  Therapeutic Conversions

§  Statins §  ARBs §  Intranasal Steroids §  Proton Pump Inhibitors

§  Prior Authorizations

Refill Center - continued

Year Total Submitted Approved Denied Changed to formulary

alternative Denied and changed to formulary alternative

2013 381 315 (83%) 18 (4%) 19 (5%) 29 (8%)

Prior Authorizations for Protocol Medications

Conversions (Jan-Dec 2013) - Statins, ARBs, Nasal Steroids & PPIs

Refill Period Total # of Rx’s Protocol Rx’s Non-Protocol Rx’s

Jan – Dec 2013 86,467 54,911(64%) 31,556 (36%)

Volume of Prescriptions Processed

Statins ARBs Nasal Steroids PPIs

Converted 9 (16%) 25 (64%) 24 (45%) 31 (46%)

Not Converted 48 (84%) 14 (36%) 29 (55%) 36 (54%)

Total 57 39 53 67

Reasons for Not Converting: -Cost is not an issue -Hx of intolerance to generic alternative -Lipids/BP/GERD not controlled -Unable to reach patient -Want to speak to my doctor -No dose equivalent

Generic Drug Utilization Rates Pre Refill

Center Post Refill

Center

2010 Q3 2013 Q1

Statins 67.9% 92.2%

ARBs 31.3% 68.2%

Nasal Steroids 57.4% 85.3%

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Overarching Project Goals: PATIENT CENTERED MEDICAL HOME

Maintain/improve  quality  while  improving  clinical  

efficiency  and  lowering  the  cost  of  care  

Coordinate  and  standardize  transi<ons  of  care  

Reduce  the  PCP  burden     Improve  popula<on  health  management  

IN  ORDER  TO:    -­‐  Reduce  30-­‐day  readmission  rate  -­‐  Reduce  admissions/1000  -­‐  Reduce  ED  visits/1000  -­‐  Increase  pa<ent  access  

Ensuring:

ü  Maximum PCP and care team efficiency and adoption

ü  Scalability

ü  Minimum physician disruption

The Most

Fragile

Chronic Disease

Management

Routine Medical Care

Wellness Promotion & Preventive Services

Chart Prep, Huddles Intake Refill Center Check-out w/AVS Panel Management MyCSLink Patient Portal

Pharmacist Health Coach Panel Management Medication reconciliation MyCSLink Patient Portal

“Hot Spotter” Program - Ambulatory Case Manager - Post discharge house calls - Medication reconciliation - SNF coverage -  Advance Care Planning -  Biometric monitoring

Clinical Pharmacist in PCMH

§  Starting in 2011, one clinical pharmacist to 6-7 physicians §  Pharmacist located in or near physicians office §  Huddle with Care Team weekly §  Services provided:

—  Drug Therapy Management Programs §  Diabetes, Hypertension, Dyslipidemia, Asthma, Smoking Cessation, Polypharmacy

—  Paired visits with physicians or independent consultations —  Medication reconciliation —  Post discharge medication reconciliation —  Panel management using various registries and reports —  Drug information to physicians and staff —  Collaborates with NP that does patient home visits —  P4P Quality Measures (LDL, BP, DM, Persistent Medications)

P4P Quality Measures Diabetes CSMG 2012 Rate MY 2012 75th Percentile A1C Screening 95.3% 92.2% A1C <8 70.6% 65.8% A1C <7 58.8% 45.1% LDL Screening 90.6% 89.0% LDL <100 64.4% 54.6% Nephropathy Screening 93.8% 91.3% BP Control 79.6% 69.6%

Cholesterol Mgmt for CVD

CSMG 2012 Rate MY 2012 75th Percentile

LDL Screening 95.6% 95.2% LDL <100 77.9% 75.3%

Miscellaneous CSMG 2012 Rate MY 2012 75th Percentile Persistent Medications 93.7% 86.5%

Medication Reconciliation Programs §  Transition of Care Program

—  ISP physicians and in-patient pharmacists identify “high risk” patients during admission. PTA and admission meds are reconciled by an in-patient pharmacist. Pt is referred to a CSMCF out-patient pharmacist for post-discharge med review and reconciliation.

§ CSMC Daily Discharge List

—  Medical Home clinical pharmacists receive the daily CSMC patient discharge list. Clinical pharmacist will provide medication review and reconciliation within 3 days of discharge.

§  Polypharmacy Program

—  Any patient referred by their physician to be seen by a clinical pharmacist for medication review and reconciliation.

*Prior to admission

Pilot starting February 2014

Total Cost of Care Pharmacy Tactics

Pharmacy Tactics

Specialty Medications

Generics DAW Report Sample Use

Policy

Target Medications

Oncology Initiatives

Aligning Processes and Initiatives with TCC Goals

32

MD Workflow Use of Samples

Dispense as written Pay Plan Alignment

Medical Home Dashboards

Pt level interventions

Medication level interventions

HIV, $2,061,702.07

ENDO, $701,602.15

RA, $678,446.61

IM, $585,523.45

PSYCH/, $476,935.11

NEURO, $280,325.50

MS, $271,828.75

Specialty Medication Expenditures Medventive Jan-June 2013

Other Specialties

Expenses

ONC 260173.82

PULM 220503.11

NEURO/ 121198.36

TX 120538.23

ID 85286.4

GAUCHER

81648

PAIN 67089.9

GI 65308.28

Opportunities to Improve Performance-Generics P4P Goals

—  Generic prescribing rates for: Antidepressants, Antihyperlipidemics, Anti-ulcer agents, Cardiac (hypertension and cardiovascular), Nasal Steroids, Diabetes, Anxiety/sedation (sleep aids), anti-migraine and Overall Generic Drug Rate for all prescriptions

—  Rates determined from health plan pharmacy data Current Practice

—  Dispense as Written Utilization —  Sampling permitted in specialty practices —  Patient Expectations

Recommendations §  Implement Sampling Policy across all practices limiting use to best practices

with P&T Committee approval §  Implement Best Practice Alert (BPA) to discourage Dispense as Written

(DAW) prescribing §  MD and PharmD patient education re: generics as part of patient visits

—  Develop patient-centered brochure

34

Opportunities to Improve Performance Current Practice §  MD and patient specific data at drug level based on HMO patients’-report cards

previously and currently provided to Pods and MDs —  Reports consist of lists of patients to convert by MD

§  Drugs targeted for reduction integrated into Refill Center —  50% conversion rate due to patient demand

Recommendations §  Establish alignment of goals for TCC Pharmacy and Physician Performance

—  Specialty medications- Note: RA guidelines in progress §  Identify champions for each specialty §  Develop and implement guidelines and utilization system

—  Concurrent RX and MD review for use outside of guidelines

—  Target medications §  Order questions in CS-Link-pending Jan 2014 P&T approval

—  Medical home §  MA support to flag patient on target drugs §  Pharmacist best practice checklist: reduce overuse; target drugs; med rec, etc

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Thank you!