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Morgan Pendleton, PharmD, BCOPHematology/Oncology Clinical Pharmacist
Wake Forest Baptist Health
Administrative Update: How to Implement Discharge Pharmacy
Services (DPS)
Objectives
Evaluate the need for discharge pharmacy services
Discuss the role of the oncology pharmacist and technician in discharge pharmacy services
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Question
Does your hospital utilize discharge pharmacy services ?
A) Yes
B) No
C) For high risk patients only
Journal of Hospital Medicine. 2008;3(1):12-19
Background
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Question
A study in 2008 found that ____ percent of patients who reported medication issues after hospital discharge did not pick up their prescribed medications.
A) 5-10%
B) 15-20%
C) 50-60%
D) > 70%
Journal of Hospital Medicine. 2008;3(1):12-19
Background
2008 evaluation via patient survey
N = 31,199 patients
7.2% (2,253) reported prescription-related issues 48-72 hours post discharge
Journal of Hospital Medicine. 2008;3(1):12-19
Prescription-Related IssuePercentage of
Patients (n=2,253)n (%)
Not picking up prescribed discharge medications
1,797 (80)
Not knowing if prescriptions were picked up 55 (2)
Admitted not taking the medications 154 (7)
Not understanding how to take the medications
247 (11)
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Background
Poor medical adherence
Poor health outcomes
Increased healthcare costs
$100-300 billion dollars per year
Rates have not changed much in the last 3 decades (despite all initiatives)
20-50% of patients are non-adherent to medical therapy
American College of Preventive Medicine. 2011
Background
Pharmacy Quality Alliance (PQA)
Member-based organization (providers, payers, and pharmacy organizations)
Develop quality measures that pertain to effective use of medications
Primary medication non-adherence (PMN)
Patient is prescribed a medication but fails to obtain and take the medication
Includes “newly initiated” medications
Medications not prescribed within the previous 180 days
Network for Excellence in Health Innovation. 2014.
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Background
PMN rate based on patient not picking up a new prescription within 30 days of it being prescribed
List of chronic medications based on prior PQA metrics (based on Accountable Care Organization contracts)
PMN rates for treatment of chronic diseases ranges from 10-30%
Underestimation
Electronic prescribing has increased accuracy
Network for Excellence in Health Innovation. 2014.
Background
“Reducing PMN: Should Pharmacies Take the Lead?”
Access to data and providers
Knowledge to counsel and answer questions
Follow up by pharmacists in the outpatient setting has not been found to be effective
Time
Resources
Reimbursement
Network for Excellence in Health Innovation. 2014.
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Background
Initiate the process at discharge
Cost effective
Prior-authorizations or issues
Deliver medications so PMN rates decrease
Educate
Form relationships
Utilize face to face pharmacy or clinic encounters
Education, questions, refills, support, etc.
Network for Excellence in Health Innovation. 2014.
Question
Pharmacists are the appropriate team member to take the lead for discharge pharmacy and medication services based of their expertise, knowledge, and access to appropriate resources.
A) Yes
B) No
C) For high risk patients only
Journal of Hospital Medicine. 2008;3(1):12-19
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WFBH Experience
Wake Forest Baptist Medical Center
Academic medical center
Comprehensive Cancer Center
Brenner Children’s Hospital
Winston-Salem, NC
Nationally ranked by
U.S. News and World Report
17th in Cancer
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Nationally
50% of patients experience medication errors when transitioning from hospital to home
20% of Medicare patients are readmitted within
30 days
Wake Forest Baptist Health
25% baseline 30-day readmission rate (Heart Failure)
Pharmacotherapy. 2012
Background – Resident Project
Northwest Triad Care Transitions Consortium
Multi-hospital, multi-county partnership funded through Affordable Care Act with CMS oversight
Deploys Transitional Navigators
Engage hospital and community resources for targeted patients
Internal readmission teams created
Discharge Pharmacy Services (DPS)
Medical Center Solutions
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DPS program was developed and piloted to
augment 30-day readmission rate initiatives
and increase outpatient prescription capture
Phase 1:
Care Transitions Program Pilot (Heart Failure)
Phase 2:
Readmission Rate Pilot
(Hem/Onc)
Resident Research Project
Phase I: Care Transitions Program (Heart Failure)
Discharge medication reconciliation
Bedside delivery with education
Post-discharge home-based medication reconciliation with transitional navigator
Phase II: Readmission Rate Pilot (Hem/Onc)
Discharge medication reconciliation
Bedside delivery with education
Pharmacy ownership of the process
Pilot Study Requirements
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Transitional Navigator
• Enrolls patient
• Notifies outpatient pharmacist
Outpatient Technician
• Enters into outpatient system
• Notifies inpatient pharmacist
Inpatient Pharmacist
• Performs discharge medication reconciliation
• Notifies outpatient pharmacy
Outpatient Technician
• Fills prescription
• Delivers to bedside
Inpatient Pharmacist
• Provides discharge counseling
Transitional Navigator
• Performs in-home medication reconciliation
• Notifies inpatient pharmacist
Phase I: Basic Workflow Processes
Launched October
2012
Outpatient Technician• Enrolls patient• Enters into
outpatient system
• Notifies inpatient pharmacist
Inpatient Pharmacist• Performs
discharge medication reconciliation
• Notifies outpatient pharmacy when prescriptions are on the way
Outpatient Technician• Fills
prescriptions• Delivers to
bedside
Inpatient Pharmacist• Provides
discharge counseling
Phase II: Basic Workflow Processes
Launched December
2012
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Results
Program TotalPercentage of Readmissions
% (n)
Baseline - 25%
Phase I – Care Transitions (Heart Failure)
44 2.8% (1)
Phase II – Readmission Rates(Hem/Onc)
213 6.8% (14)
30-Day Readmission Rates
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Financial Return on Investment
Phase 1 Phase 2
Prescription and Patient Trend
0
20
40
60
80
100
120
140
160
180
200
Oct Nov Dec Jan Feb
Nu
mb
er
# ofScripts
# ofPatients
Phase 1 Phase 2
13
129
40
2215
63%
19%
11%7%
0
20
40
60
80
100
120
140
Enrolled Not Enrolled Pending Unknown
Nu
mb
er
of
Pa
tie
nts
Enrollment Status at DischargeN = 206 (12/1/12 – 2/28/13)
Enrollment: Phase II
42%
25%
17%
13%
4%0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Prefers usinganother pharmacy
SNF/Facility/Hospice Gets meds at VA Locked into anotherpharmacy due to
insurance
Involved inaffordability
assistance programReason for Not Enrolling
N = 40
Enrollment: Phase II
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Discharge Med Rec (Phase II)
House-wide baseline
Discharge medication reconciliation completed
in 40% of patients
Rolling 4-week average during Phase II of project
Discharge medication reconciliation completed
in 78% of patients
Pharmacy ownership of enrollment process is
key
Margin capture highly dependent on target
population
A major paradigm shift in pharmacy practice
Positive change for outpatient team
Lessons Learned
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House-wide roll out of DPS
Dedicated pharmacist for Care Transitions
patients
Model of Care Pilot Project
Future Steps
Structured discussions based on day of hospital stay
Day of admission
Insurance information
During Stay
Daily team huddles
Therapeutic recommendations
Prior-authorization and test prescriptions
Day Prior to discharge
Electronic prescribing and delivery of prescriptions
Day of Discharge
Counsel and answer questions
Model of Care (MOC) Pilot
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Impact of Residency Project and MOC Initiative
Daily huddles do not exist within the cancer center
Incorporated discussion into daily rounds
Running discharge list throughout the week
Social work as part of rounding team
Inpatient pharmacist in charge of the entire process
Dedicated DPS technician
Referral enrollment utilized if not captured by DPS technician
Contacts majority of admissions to evaluate desire for DPS services
DPS: As We Know it Today
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0
200
400
600
800
1000
1200
1400
Nu
mb
er
of
Pre
sc
rip
tio
ns
an
d P
ati
en
ts
Mar13 Apr13 May13 Jun13 Jul13 Aug13 Sep13 Oct13 Nov13 Dec13 Jan14 Feb14 Mar14 Apr14 May14 Jun14 Jul14 Aug14Prescriptions 202 298 358 322 215 185 216 260 168 258 413 609 1007 1000 1012 992 1119 1195Patients 53 78 111 92 58 54 78 73 70 96 145 176 310 332 269 319
Discharge Pharmacy Service (Cancer Center and Main Outpatient Pharmacy:New Prescriptions and Total Patients per Month
Pilot started
via resident project Dec
2012
Pilot started
via resident project Dec
2012
House-wide expansion via integration with MOC
initiative
House-wide expansion via integration with MOC
initiative
Change to “referral”
enrollment strategy
Change to “referral”
enrollment strategy
Creation of Transitions of
Care Technician role
Creation of Transitions of
Care Technician role
0
200
400
600
800
1000
1200
1400
1600Prescriptions
Patients
Average$/Patient
DPS Data: Cancer Center Pharmacy
2014 2015
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Average Day for DPS Technician
67
3329
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14 13 12 11 105 4 3 1
0
10
20
30
40
50
60
70
80
Times per Day for Each
Task
Role of Key Team Members in DPS
Success
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Technician Role
Enrollment (in person or via phone)
Test prescriptions
Relay information to pharmacist
Prior authorizations (PA) and enrollment in drug assistance programs
Deliver medications and receive payment (or set up payment plans as necessary)
Pharmacist Role
Enrollment and prior authorizations as necessary
Solicit test prescriptions
Make therapeutic recommendations based on availability of medications at discharge
Set up delivery of medications through specialty or mail order pharmacies
Mandatory discharge medication reconciliation
Prepare education document and counsel
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Social Work/Case Manager Role
Handle all prescription communication with the VA
Enrollment in medication assistance programs as necessary
Determine eligibility for charity care, crisis control ministry, cancer services, cancer patient support, and other resources
Patient Role
Maintain open communication about affordability
Provide appropriate tax or income information
Follow up with assistance programs or mail order pharmacies
Be accountable
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Workflow: is one way better than the other?
Cancer Center Pharmacy
Pharmacist or Technician enrolls in DPS
Pharmacist or Technician notifies the other team member via
pager/phone
Pharmacist and technician communicate via pager/phone
about test prescriptions
Pharmacist notifies technician via pager/phone that prescriptions
are on the way and to prepare for delivery
Main Outpatient Pharmacy
Pharmacist enrolls in DPS
Pharmacist notifies technician through EMR
Pharmacist and technician communicate via EMR about test
prescriptions
Pharmacist notifies technician via EMR that prescriptions are on the
way and to prepare for delivery
Summary
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Is it Worth the Time and Effort?
• Medications in hand at discharge• Education document with valuable information• Counseling with familiar face• Questions answered prior to getting home
Patient
• Know cost and availability prior to prescribing• Know patients have medications in hand• Can communicate with pharmacist about any issues and concerns
to focus on during education
Physician
• Integral part of patient’s transition of care• Use delivered prescriptions to assist in discharge education• Have pertinent information available (next dose, indication, etc)• Develop fundamental relationships with the patients and providers• Have resources to educate and develop plans for illiterate patients• Have translators available for those who don’t speak English
Pharmacist
Is it Worth the Time and Effort?
• Medications in hand at discharge• Education document with valuable information• Counseling with familiar face• Questions answered prior to getting home
Patient
• Know cost and availability prior to prescribing• Know patients have medications in hand• Can communicate with pharmacist about any issues and concerns
to focus on during education
Physician
• Integral part of patient’s transition of care• Use delivered prescriptions to assist in discharge education• Have information available via EMR and providers (next dose,
indication, etc)• Develop fundamental relationships with the patients and providers• Have resources to educate and develop plans for illiterate patients• Have translators available for those who don’t speak English
Pharmacist
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Morgan Pendleton, PharmD, BCOPHematology/Oncology Clinical Pharmacist
Wake Forest Baptist Health
Administrative Update: How to Implement Discharge Pharmacy
Services (DPS)
References American College of Preventive Medicine. “Medication Adherence – Improving Health
Outcomes.” 2011.
Hubbard T. “Ready for Pick Up: Reducing Primary Medication Non-Adherence. A New Prescription for Health Care Improvement.” The Network for Excellence in Health Innovation. 2014.
Hume A, Kirwin J, Bieber H, et al. “Improving care transitions: current practice and future opportunities for pharmacists.” Pharmacotherapy 2012;32(11);326-337
Kripalani S, Price M, Vigil V, Epstein K. “Frequency and Predictors of Prescription-Related Issues after Hospital Discharge.” Journal of Hospital Medicine. 2008;3(1):12-19
National Association of Chain Drug Stores. “Pharmacies: Improving Health, Reducing Costs.” July 2010.