Future of Clinical Pharmacy Practice in Rural Health

Lisa Anne Boothby, PharmD, BCPSDirector of Pharmacy, Dukes Memorial Hospital

OBJECTIVES

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

PHARMACEUTICAL CARE

Clinical pharmacy services Inpatient and outpatient settings Improve patient outcomes

PHARMACISTS AS PROVIDERS

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 followsSmock 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

WHERE IS THE REVENUE?

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.

ACCOUNTABLE CARE ORGANIZATION

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.

RURAL ACOs

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.

MEDICAL HOME MODEL

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.

PHARMACIST ROLE Medical Home Models

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.

AMBULATORY CARE FOCUS

Keep patients healthy and out of the hospital

VA collaborative practice model Prescribing privileges More than 20 years of success Pharmacist credentialed providers

PHARMACY ROLE

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

CLINICAL RESEARCH

PHYSICIAN-PHARMACIST TEAM Study Design

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

PHYSICIAN-PHARMACIST TEAM Pharmacist Role on Team

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

PHYSICIAN-PHARMACIST TEAM Measurements

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

PHYSICIAN-PHARMACIST TEAM

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

DISCHARGE PHARMACIST

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.

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.

DISCHARGE PHARMACIST

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.

TRANSITIONS OF CARE

WELLTRANSITIONS

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

WELLTRANSITIONS

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 HospitalWalgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November

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

MEDICATION RECONCILIATION Survey of Pharmacy Perceptions

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.

IMPLICATIONS

Translation to a rural critical access hospital

Minimal resources Decreased ED visits decreases

admissions Decreased revenue with traditional

models Next steps?

REDUCE READMISSION TOOLS

TARGETING TRANSITIONS Project BOOST: www.hospital-

medicine.org Project RED: www.projectred.org STAAR initiative: www.ihi.org/STAAR

Demonstration Pilot Critical Access Hospital

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

Demonstration Pilot Critical Access Hospital

Develop criteria for consultation Greater than 10 scheduled

medications High-alert medications Anticoagulants Core-measure disease states

MEDICAL WASTE REDUCTION

PHARMACEUTICAL WASTE STREAMS

INCOMPATIBLE

HAZARDOUS

WASTEAerosols• InhalersOxidizers• Silver

nitrateREGULAR TRASH

• Outside packaging• Empty items that once contained

medication• Shipping packaging• Recycle paper, glass, plastic

P-LISTED HAZARDOUS WASTE

• Coumadin plus wrapper

• Nicotine plus wrapper and peel

HAZARDOUS WASTE

• Insulin• Some

vitamins and minerals

• Phenylephrine

NON-HAZARDOUS RX WASTE

• Antibiotics• Lidocaine• Pitocin• Heparin

SHARPS • Needles and broken

ampoules• Empty syringes

SEWER• IV

dextrose• Potassium• Saline• Sodium• Calcium• lactated

ringers• magnesiu

m

CHEMO WASTE

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

INPATIENT MEDICAL WASTE 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 MEDICAL WASTE

Outpatient prescribing practices Polypharmacy Lack of follow-up

Mail order pharmacies automatic renewals Three month supplies Compliance Adherence Persistence

MEDICAL WASTE Ethics and the Environment

Controlled substance regulation Changes from DEA Expected in future

Vendors Stericycle, others … Environmentally conscious disposal

DRUG SHORTAGES

DRUG SHORTAGES Minimize Waste

Therapeutic interchange Drug classes Pharmacodynamics of medications

Superior therapeutic alternatives Evidence based medicine Avoid grey market distributers

GREY MARKET

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

DRUG SHORTAGES

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

DRUG SHORTAGE RESOURCES

FDA REGULATION

PHARMACIST ROLE

Pharmacists vital part of the healthcare team

Pharmacotherapy experts Explain how medications work in the

body Suggest therapeutic alternatives Eliminate therapeutic duplications

PHARMACIST ROLE

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

PARADIGM SHIFT

PHARMACY COST CENTER

RURAL HEALTH RESEARCH

Collaboration Rural health hospitals Payers

Obtain grant money Research New practice models Demonstrate added value

Future of Clinical Pharmacy Practice in Rural Health

Lisa Anne Boothby, PharmD, BCPSDirector of Pharmacy, Dukes Memorial Hospital