Lisa Anne Boothby, PharmD, BCPS Director of Pharmacy, Dukes Memorial Hospital

   Demonstrate the value of clinical pharmacy services to decrease 30-day readmission rates Outline the pharmacist’s role in reducing medical waste Detail ethical issues associated with drug shortage management

   Clinical pharmacy services Inpatient and outpatient settings Improve patient outcomes

 Patient Accountability and Affordable Care Act   Pharmacists are “other healthcare providers” Social Security Act  Part B versus Part D   Three MTM billing codes Private insurance reimbursement follows

Smock N. Affordable Care Act Regards Pharmacists as Health Care Providers, Not Just Prescription Dispensers. Available at URL:

http://www.pharmacytimes.com/publications/issue/2013/January2013/Affordable-Care-Act Regards-Pharmacists-as-Health-Care-Providers-Not-Just-Prescription-Dispensers

 Capitated healthcare precede reimbursement  May decrease need for pharmacy billing   Share in savings once minimum achieved Accountable care organizations  Not all hospitals have embraced  Pilot programs

Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

 Providers accountable  Achieving quality   Reductions in rate of spending growth  Physician led with many payer arrangements National Committee for Quality Assurance  Established ACO criteria  7 categories with 4 levels

Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

To reach critical mass  Incorporate multiple payers or multiple hospitals  Apply for a CMS wavier to include Medicaid patients

Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

 Patient centered medical homes  Led by physician   Include pharmacist, nurse and other health care practitioners Treat patient with chronic conditions  Prevent adverse events and optimize therapy  Team ensures all health care needs are met

Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

   Improve medication management Preventing hospital readmissions Decreases revenue in a traditional hospital budgetary model

Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

     Keep patients healthy and out of the hospital VA collaborative practice model Prescribing privileges More than 20 years of success Pharmacist credentialed providers

       Medication management Preventing disease Maintaining cardiovascular health Preventing end organ damage Medication compliance, adherence Therapeutic drug monitoring Supportive care

 1 month study at Mission Hospital  735 bed community teaching hospital   Asheville, North Carolina Pre-post design  2 weeks normal routine  2 weeks with clinical pharmacist

Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

      Drug information Discharge counseling Medication interventions Medication reconciliation Filling discharge prescriptions Submit discharge summaries

Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

   15-day and 30-day readmission rates Number of ED visits Employee satisfaction surveys

Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

   33% vs. 17% readmission within 30 days 11% vs. 2% readmission within 15 days 9% vs. 4% ED visits within 30 days

Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

  Prospective cohort  729 patients over three months Pharmacy medication reconciliation  30-day readmission rate  Polypharmacy and readmission rate

Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

 Med reconciliation and counseling  Decreased 30-day readmission rate   16.8% vs. 26%; p=0.006

Polypharmacy  More than 5 scheduled medications  Associated with increased readmission rates

Pal A. , Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

    Walgreens program Reduces readmissions Pharmacists oversee medication regimens Transitions of care

Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012. http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions

        Med review at admission and discharge Bedside medication delivery Counseling for patients and their caregivers Regularly scheduled follow-up post discharge 24-7 support for discharged patients Ensure follow up with physician Ensure appropriate self care Marian General and Lutheran Hospital

Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012. http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions

 11 pharmacists  Vanderbilt University   Brigham and Women’s Hospital Medication reconciliation  Time consuming  Most important contribution  Improving care transitions  Correct the admission medication history

Haynes KT, Oberne A, Kripalani S. Pharmacists’ recommendations to improve care transitions. Ann Pharmacother 2012;46(9):1152-1159.

     Translation to a rural critical access hospital Minimal resources Decreased ED visits decreases admissions Decreased revenue with traditional models Next steps?

TARGETING TRANSITIONS  Project BOOST: www.hospital-medicine.org

  Project RED: www.projectred.org

STAAR initiative: www.ihi.org/STAAR

   Medication reconciliation process  Physician and nurse driven  2 to 3 errors per each Follow-up by pharmacy  Clarify and correct errors  Time intensive Increased safety risk  Omissions  Delays and duplications

     Develop criteria for consultation Greater than 10 scheduled medications High-alert medications Anticoagulants Core-measure disease states

• • • • • • • • • • •

SEWER

IV dextrose Potassium Saline Sodium Calcium lactated ringers magnesium • • • •

NON HAZARDOUS RX WASTE

Antibiotics Lidocaine Pitocin Heparin • • •

HAZARDOUS WASTE

Insulin Some vitamins and minerals Phenylephrine • •

P-LISTED HAZARDOUS WASTE

Coumadin plus wrapper Nicotine plus wrapper and peel •

INCOMPATIBLE HAZARDOUS WASTE

Aerosols • Inhalers Oxidizers Silver nitrate

CHEMO WASTE REGULAR TRASH

Outside packaging Empty items that once contained medication Shipping packaging Recycle paper, glass, plastic • •

SHARPS

Needles and broken ampoules Empty syringes

Smith CA. Managing Pharmaceutical Waste. Journal of the Pharmaceutical Society of Wisconsin 2002;17-22.

 Save money, prevent delays and omissions  Clinical pharmacists know formulary medications   Clinical pharmacists prevent non-formulary and not-available medication orders at admission Formulary management policies/procedures  Therapeutic interchange programs  Evaluate PAR levels for expired drugs

 Outpatient prescribing practices  Polypharmacy   Lack of follow-up Mail order pharmacies automatic renewals  Three month supplies  Compliance  Adherence  Persistence

 Controlled substance regulation  Changes from DEA   Expected in future Vendors  Stericycle, others …  Environmentally conscious disposal

 Therapeutic interchange  Drug classes   Pharmacodynamics of medications Superior therapeutic alternatives  Evidence based medicine  Avoid grey market distributers

 Receive emails for information only  Plan ahead   Keep adequate inventory levels Medications dispensed daily  Accept small loss with expired medications  To stock adequate levels  Prevent drug shortages from reaching patient

        Aminophylline Sincalade Nalbuphine Dextrose 25% and 50% syringes Furosemide IV Metoclopramide IV Fentanyl IV Potassium phosphate IV

     Pharmacists vital part of the healthcare team Pharmacotherapy experts Explain how medications work in the body Suggest therapeutic alternatives Eliminate therapeutic duplications

     Avoid polypharmacy Teach common side effects Action for severe side effects Ethical stewardship Medical and financial resources

 PHARMACY COST CENTER

 Collaboration  Rural health hospitals   Payers Obtain grant money  Research  New practice models  Demonstrate added value

Lisa Anne Boothby, PharmD, BCPS Director of Pharmacy, Dukes Memorial Hospital