The answer is: One Bite at a TimeThe question… How do we eat this PSPC elephant

ACHS Presentation on Patient Safety Pharmacy Collaborative (PSPC)Dallas 2010

Ammonoosuc Community Health Services, Inc (ACHS) Federally Qualified Health Center (FQHC)

Jennifer Jewell, CMA, CPhT, Certified Medical Assistant / Pharmacy TechnicianLisa Mackenzie, Patient Navigator

Linda Noyes, RN, Electronic Health Record ManagerEdward D Shanshala II, MSHSA, MSEd, Chief Executive Officer

Charles J. Wolcott, MD, Medical Director

Littleton Regional Hospital (LRH)Critical Access Hospital (CAH)

Karl Herzig, R.Ph Director of Pharmacy

ACHS - A Brief History• 1975 Incorporated as a 501-c-3 non-profit with one visionary leader, one staff person,

$12,000 and a dream.• 1994 sought and received designation as a Federally Qualified Health Center• 1996 implemented Electronic Health Record (EHR)• 1998 initiated work with Health Resource Service Administration (HRSA) Chronic Disease

Collaborative beginning with Depression, Diabetes, Asthma, Coronary Artery Disease, Patient Safety Clinical Pharmacy

• 2005 performed Patient Centered Reengineering• 2008 recognized by HRSA & National Institute of Health (NIH) as 1 of 26 other FQHCs as “High

Performers” for Chronic Disease Collaborative Outcomes• 2008 Accepted into New Hampshire Citizens Health Initiative Multi-Stakeholder Patient

Centered Medical Home Pilot Project• 2008 Recognized by National Committee on Quality Assurance (NCQA) as a Level 3 (highest)

Patient Centered Medical Home• 2009 accepted into HRSA PSPC2 Collaborative• 2010 Accepted into the New Hampshire Citizens Health Initiative Accountable Care

Organization in collaboration with Littleton Regional and Cottage Hospitals and the North Country Home Health and Hospice

• 2010 Received an American Recovery and Reinvestment Act Facilities Improvement Program Grants to increase access to care including an in-house pharmacy.

Importance of PSPC The big picture is about saving lives• 32% of US adults do not fill a prescription they considered unnecessary.• For patients with chronic disease

– 25% report that their medications may be making them ill– 20% do not take their medications because of side effects– 10% take medications despite serious side effects and do not tell their medical

provider– 30% have not had their medications formally reviewed in last 2 years

• Use of prescription drugs has increased by 80% in last decade• Average of 6+ medications / month for patients over age 65• Adverse Drug Events average

– 5% for patients with up to 5 medications– 10% for patients with 6 to 10 medications– 30% for patients with 11 – 15 medications

• It has been estimate 140,000 deaths / year associated with adverse drug events

• For every $1.00 spent on medication $1.30 spent on adverse event

Perfect Day Why 99.9% Just Won’t Do

“Lets get real here. Is it truly necessary to go for ‘zero defects? Why isn’t 99.9% defect-free good enough?”

Those are the questions often posed to quality consultant Jeff Dewar, of Red Bluff, California-based QFI International, when he argues for the elimination of defects altogether. To make his point, Dewar has come up with some examples of what life would look like if things were done right 99.9% f the time. We would have to accept :– 1 hour of unsafe drinking water per month– 2 unsafe plane landings per day at O’Hare International Airport in Chicago– 16,000 pieces of mail lost by the U.S. Postal Service per hour– 20,000 incorrect drug prescriptions per year– 500 incorrect surgical operations each week– 50 newborn babies dropped at birth by doctors every day– 22,000 checks deducted from the wrong bank account each hour– 32,000 missed heart beats per person per year

Suddenly, the quest for zero defects makes a lot of sense…”– Excerpt from In. Magazine

Defining Population of Focus • Dallas 09 – leveraged

technology to refine Population of Focus (POF) from – N = 431– N = 62

• PDSA – 01 cycle time <20 minutes.

• Keep it small and manageable.

• Leadership is a behavior not a position on an org. chart!

Initiate 1st PDSAUse Blackberry

to contact EHR Manager

POF Diabetics w/ >12 Rx

N = 62

POF N = 431 patients w/ >10 Rx

Leaned POF too largeNeed to refine

Receive new POF report

on Blackberry

Population of Focus Details(Diabetics with 12 + prescription medications)

• 32 (51%) went to the Emergency Department (ED) at least once in the past year.

• 16(26%) were hospitalized at least once this past year.

• 22(35%) have a HbA1C over 8.0 (17 over 9.0)• 27(43%) have depression• 15(24%) have Congestive Heart Failure (CHF)• 24(39%) have Coronary Artery Disease (CAD)

Short term goals for POF(Eating the Elephant; one bite at a time)

• Clean up the abbreviations• Add a diagnosis to each medication• Print out a medication letter EACH visit• (Think about adopting these as habits over

time for all our patients).

Long Term Goals(Take another bite or two…)

• Decrease hospitalizations• Decrease Emergency Department visits• Decrease average HbA1C• Improve depression• Develop full time Pharmacy services• Include pharmacist at all transitions of care• Avoid adverse drug reactions• Identify potential adverse drug reactions• Decrease the number of drugs if at all possible

Choosing the Population Of Focus• ACHS working on Diabetes

since 2000 as POF in HRSA Disease Collaborative.

• Patient’s defined as high risk - polypharmacy with Diabetes as a subpopulation of existing collaborative

• Further defined polypharmacy as 12+ prescription medications12 or less

13 to 1617 to 20

21 or more

Post

Pre

0%

82%

11%

6%

33%

43%

15%

9%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pre Collaborative / 12 Months Post Collaborative Prevalence of Poly Pharmacy for Diabetic Population of Focus

Pre N Value = 62Post N Value = 54

Post Pre

Data Collection/Reporting• How the team used the reporting template for the Population of Focus

and the methods used for data collection & reporting.• **Gold Star for our IT Team - highly defined monthly reports• **Shared Drive so all members of PSPC Team can help collect/report • Screen shot of reporting Data Template

Challenges• Scheduling challenges in collaborating with

Critical Access Hospital Pharmacist.• Meetings scheduled Weekly - attendance

fluctuated although work continued.• We worked faster than we could document

PDSA; we need a narrator.

Successes• Developed Electronic Health Record (EHR) Drug Utilization Review

Template• Redesigned Medication Letter • Removed abbreviations from Patient Medication Letter• Added diagnosis associated with each medication on Patient Medication

Letter • Decreased Prevalence of Poly Pharmacy• Increased distribution of patient medication letter• Decreased use of abbreviations on patient medication letter• Increased use of diagnoses associated with medication on patient

medication letter• Decreased Emergency Department Utilization• Decreased Hospitalization Utilization• Created Provider Custom Medication List in Electronic Health Record• Affiliate Pharmacist Drug Utilization Review for 50% POF in collaboration

with Littleton Regional Hospital Pharmacist

EHR Drug Utilization Template

EHR Drug Utilization Template

Individualizing POF for SuccessThe Providers and Support Staff

• Organization buy-in • Charles Wolcott MD, Medical Director provided education to

the following audiences. – Senior Leadership– Board Members– Care Model Team– Medical Providers

Medical Provider Education

• Clearly write out instructions!– Have the medication instructions readable. Often

multiple caregivers are involved (such as family, friends, hired aides, HHA, PT, OT) or patient may have memory lapses, etc.

• Use NO abbreviations– “for control of AF for RVR”– “1 HHN tx as needed”– 29/62 (47%) of med lists had abbreviations

Medical Provider Education (continued)

• Link diagnosis with each drug– Lovosa 1 gram daily for ?– Fortimet 1000mg daily for ?– Lisinopril 10mg daily for ? DM or BP or CHF?– (This could even help a provider who is seeing the

patient for the first time and who might not be familiar with every drug.)

Medical Provider Education (continued)

• Print out a medication letter EACH visit– 9 of 62 had had a medication letter printed in the

past year.– I would like to see us all get into the habit of

printing a medication letter for every patient at every visit if they have 5 or more prescriptions. It is just one extra click…..

Printing Medication List from EHR

Individualizing POF for Success The patient

Pre Collaboration Medication Letter

Post Collaboration Medication Letter

12 or less13 to 16

17 to 2021 or more

Post

Pre

0%

82%

11%

6%

33%

43%

15%

9%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pre Collaborative / 12 Months Post Collaborative Prevalence of Poly Pharmacy for Diabetic Population of Focus

Pre N Value = 62Post N Value = 54

Post Pre

15%

85%

98%

2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre Post

Percent Patients Receiving Medication Letter

Received Medication Letter Did Not Receive Medication Letter

74%

26%

95%

5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre Post

Medications with or without Abreviations on Patient Medication List

Without Abreviation With Abreviation

88%

12%

9%

91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre Post

Medication List Where Medication includes or does not include Diagnosis with each Medication

Diagnosis not included Diagnosis includes diagnosis

Pre

Post

Emergency Department Visits per POF Patient,

1.34

Hospitalizations per POF Patient, 0.40

Emergency Department Visits per POF Patient,

0.91

Hospitalizations per POF Patient, 0.31

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Vis

its

or

Ad

mis

sio

ns

per

Po

pu

lati

on

of

Fo

cus

Pat

ien

t

Non Trauma Related Emergency Department Visits (32% improvement) and Hospitalizations (22% improvement)

Emergency Department Visits per POF Patient Hospitalizations per POF Patient

ACHS PSPC-3; Solution After Next• 2011

– Hire Pharmacist and integrate into care delivery team with medical and behavioral health care providers

– Open In-House Pharmacy at ACHS – Littleton Care Delivery Site– Continue PDSA to include and not be limited to

• Enhanced identification of Adverse and Potential Adverse Drug Events– Spread Lesson Learned to Accountable Care Organization (ACO) Pilot

Program• 2012

– Tele-Pharmacy to other four ACHS Care Delivery Sites• For delivery of medications• For delivery of medication therapy management interventions

– Collaboration with County Corrections