PARADE: Preventing and Reducing Adverse Drug Events in Care Coordination Communities

Anne Myrka, RPh, MATIPROWebinarJanuary 6, 2015

Objectives

Introduce IPRO and the Centers for Medicare & Medicaid Quality Innovation Network/Quality Improvement Organization Program

Provide overview of CMS 11th Scope of Work Coordination of Care task

Describe the Preventing and Reducing Adverse Drug Events (PARADE) initiative

Describe PARADE Objectives and Strategy

Gain Cross-setting Community Commitment

Establish the PARADE Timeline

Next Steps, Q & A

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IPRO

The federally funded Medicare Quality Innovation Network – Quality Improvement Organization (QIN-QIO) for New York State.

Under contract with the Centers for Medicare & Medicaid Services (CMS).

Leading the Atlantic Quality Innovation Network (AQIN).

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Atlantic Quality Innovation Network (AQIN)

One of 14 QIN-QIOs across the country working to provide quality improvement learning opportunities, technical assistance and free resources in support of CMS healthcare quality goals.

Led by IPRO in New York State.

Partners include Delmarva Foundation in the District of Columbia and the Carolinas Center for Medical Excellence in South Carolina.

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QIN-QIO Program

Continued commitment to partnering with stakeholders on data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care and improve clinical quality.

Grounded in principles that align with the goals of the CMS Quality Strategy:

Eliminating disparities,

Strengthening infrastructure and data systems,

Enabling local innovation, and

Fostering learning collaboratives.

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QIN-QIO Program Goals and Initiatives (2014 – 2019)

Goal 1: Promote effective prevention and treatment of chronic disease by:

Partnering with physicians to provide more effective treatment to patients at risk for heart attack and stroke, especially those in underserved populations.

Supporting self-management education to patients with diabetes.

Helping physician practices use EHRs to full potential and provide patients with preventive services.

Goal 2: Make care safer and reduce harm caused in the delivery of care by:

Working with providers across the continuum of care of care to prevent HAI in hospitals and other settings.

Targeting prevention of HAC in nursing homes and facilitating collaboration, innovation and enhanced patient and family engagement.

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QIN-QIO Program Goals and Initiatives (cont’d)

Goal 3: Promote effective communication and coordination of care by:

Helping community stakeholders, providers, patients and families to collaborate for better coordination of care transitions, improved discharge communication, and better access to community services.

Sharing evidence-based approaches to reduce avoidable hospitals readmissions, especially in vulnerable populations.

Working with providers and stakeholders across settings to reduce potential adverse drug events and promoting medication management strategies.

Goal 4: Make care more affordable by:

Helping providers report on measures that assess clinical quality of care, care coordination, patient safety and patient and caregiver experience of care and helping providers improve care quality through effective use of healthcare IT.

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QIO-QINEssential Functions

1.Results-Oriented Quality Improvement Activities

2. Community Learning and Action Networks

3. Technical Assistance (i.e., Quality Improvement Experts)

4. Integrated Communications

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CMS 11th Scope of Work Task Priorities

Coordination of Care Task Goals

Promote Effective Communication and Coordination of Care

Reduce hospital readmission rates in the Medicare program by 20% by 2019 Reduce hospital admissions rates in the Medicare program by 20% by 2019

Increase community tenure, as evidenced by increased number of nights spent at home, for Medicare beneficiaries by 10% by 2019

Reduce the prevalence of adverse drug events (ADEs) that contribute to significant patient harm, emergency department visits, observation stays, hospital admissions or readmissions occurring as a result of the care transitions process

● Anticoagulants

● Hypoglycemic Agents

● Opioids

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What is IPRO’s PARADE Initiative?

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Reducing Adverse Drug Events: Federal Alignment of Resources

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Anticoagulants, Opioids,Hypoglycemics:

Communication failuresSuboptimal management systemsInadequate access to medication lists and lab results

PARADE Initiative – Pilot study and results

Based on an IPRO multi-facility rapid-cycle pre (February 2014) and post (July 2014) intervention quality improvement pilot study, “Medication Reconciliation and Anticoagulation Management Across Care Settings”

Four Care Transitions collaboratives comprised of hospitals, skilled nursing facilities (SNFs), home healthcare agencies

Evaluated the discharge communication of 17 evidence-based requisite anticoagulant-related information elements and 5 medication reconciliation processes across care settings 5 to 10 charts, retrospectively

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PARADE Initiative – Pilot study and results Evidence-based system improvements were applied

according to site-specific baseline results Results

Significant improvement in communication of requisite anticoagulation-related elements to subsequent provider upon transfer/discharge:

All facilities (16%, 95% CI 11.6%-20.3%)

Hospitals (8%, 95% CI 1.2%-15.2%)

SNFs (19%, 95% CI 12.7%- 25.8%)

Significant improvement in completion of medication reconciliation processes upon admission in SNFs (21.2%, 95% CI 9.6%- 31.9%)

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Medication Reconciliation Elements

Was an original home medications list collected on admission?

Did the list of original home medications collected at admission include the medication name, dose, route and frequency for each medication? (all elements for all drugs must be present for Yes)

Was the original home medication list reconciled with admission orders in less than 24 hours?

Did the reconciled medication list reside in a dedicated location in the medical record?

Was there is a 1:1 match for every medication on the home medication list to the admitting orders? (all elements for all drugs must match for Yes)

Requisite Anticoagulation Management Elements Communicated at

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Link to audit tool: http://qio.ipro.org/drug-safety/drug-safety-resources

PARADE Initiative

QIOs are directed by CMS in the 11th Statement of Work (11SoW) to:

Establish relationships and collaborations in the community to coordinate provider communication and medication management across care settings with a patient centered focus

Help providers utilize new or existing evidence-based tools and practices to improve the care of those prescribed high risk medications, specifically anticoagulants, diabetic agents and opioids

Use health information technology to screen for and prevent ADEs in Medicare beneficiaries

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PARADE Objectives and Strategy

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PARADE Objectives

To identify patients at risk of experiencing ADEs due to high risk medication use following hospital discharge

To identify hospital readmissions and emergency department visits associated with high risk drug exposure

To evaluate the post-discharge medication use system across care settings and identify opportunities for system improvements

To facilitate the implementation and serial evaluation of evidence-based intervention strategies

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PARADE Strategy Process measures – All facilities/healthcare providers

Small, low-impact audits of medication reconciliation processes and high risk drug discharge communication (5-10 charts, retrospective)

Serial evaluation to guide improvements

Goal: 100% adherence to audit criteria in 6 months

Interventions

Evidence based interventions according to site-specific results

Outcome measures – Hospitals only

Readmissions due to ADEs using data from electronic health record data (hospital) and claims data (IPRO)

Serial evaluation to identify improvements

Goal: Demonstrate measureable improvement over 5 year scope of work

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PARADE Strategy

Based on 6 month improvement cycles

Cross setting work will be achieved within each care transition coalition Medication Management Committee monthly meetings

Cycle 1 is January 6, 2015 – June 30, 2015 All facilities will focus on Medication Reconciliation and Anticoagulation

Discharge Communication

Educational webinars on management of hypoglycemics and opioids will be provided prior to the launch of Cycle 2 (which will expand to process improvements for hypoglycemics and opioids)

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PARADE Strategy Cycle 1 January 6, 2015 – June 30, 2015

All facilities (including those who participated in the pilot study) will complete and return a PARADE Request for Technical Assistance by January 16, 2015

Eligible facilities are hospitals, skilled nursing facilities (SNF), rehabilitation facilities, home healthcare services/agencies (HHA), residential facilities, adult homes, pharmacies (hospital, community, SNF vendors, etc.)

Participating individuals are administrators, physicians, nurses, pharmacists (including SNF consultant pharmacists), quality improvement professionals, discharge planners, HHA hospital liaisons, etc.

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PARADE Strategy

Cycle 2 is July 1, 2015 – December 31, 2015 Continue to work on ADE hospital readmission measure,

high risk drug discharge communication and med rec improvement processes

Expand to medication management of hypoglycemics, opioids, other (e.g. antibiotics)

IPRO is currently convening subject matter experts to provide guidance on best practices for management across care settings during transitions

Subsequent Cycle work will focus on continued evidence based improvements, sustainability and applicable cross-setting emerging measures

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PARADE Process Measures: Audit Methods

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Audit Methods – Medication Reconciliation

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Audit Methods – Medication Reconciliation

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Audit Methods – Anticoagulation Discharge Communication (AC-DC) Paper Tool

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Link to paper audit tool: http://qio.ipro.org/drug-safety/drug-safety-resources

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Additional Ad Hoc Anticoagulation Measure- Warfarin Time in Therapeutic Range

Designed for skilled nursing facilities, outpatient clinics and others that serve population over long term

For more information: http://qio.ipro.org/drug-safety/collaborative-partners/analytic-services

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*TTR – Rosendaal’s method

PARADE Interventions

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Interventions

Policy & Procedure improvements Educational programs Clinical tools & resources Monthly networking/collaboration through each

Coalitions’ Medication Management Committee meetings

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Medication Reconciliation Intervention Resources

http://www.hospitalmedicine.org/marquis/

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Medication Reconciliation Intervention Resources

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http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/index.html

Medication Reconciliation Improvement Tools

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Anticoagulation ManagementEvidence Based Resources

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The Anticoagulation Centers of Excellence: http://acforumexcellence.org/

http://qio.ipro.org/drug-safety/drug-safety-resources

Anticoagulation Improvement Tools

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PARADE Outcome Measure

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Outcomes: ADE Surveillance Process - Hospitals

Baseline measure completion date will be individualized per hospital

Remeasure quarterly after baseline is completed

Secure data transfer protocol utilized

Commitments, Timeline, and Due Dates

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IPRO’s strategy requires creation of a local ADE-specific collaborative comprised of at least one hospital and two or more downstream providers committed to sharing information and working across settings to successfully complete the work. Participants will:

Join your local cross-setting IPRO supported Community Care Transitions Coalition by signing on to its Coalition Charter

Establish an internal team to share project responsibility for your organization

Commit to collaborate with IPRO for duration of the project; agree to investigate adverse drug events and address performance outliers as part of the quality improvement plan

Commit to developing and implementing a sustainable quality improvement plan to address identified deficiencies

Implement and evaluate the impact of one or more intervention strategies

Attend and actively participate in the Medication Management Committee convened within your community’s Care Transition Coalition and attend IPRO coaching support calls as needed

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Organization/Provider Commitments

IPRO Commitments

Provide technical assistance to support serial data collection, analysis, and reporting

Perform analysis of prescription drug data at baseline and quarterly over each 6 month ADE improvement interval (hospitals)

Provide detailed reports characterizing at-risk population and suspected ADEs

Facilitate interpretation and root cause analysis to identify priorities for intervention

Lead the Medication Management Committee for the Community Coalition and facilitate communications between partner providers

Provide evidence-based clinical tools and educational resources for quality improvement interventions

Assist in determining effectiveness of interventions and support innovative strategies that sustain safety goals

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Commitments, Request for Technical Assistance and Completion Date

Due: January 16, 2015

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PARADE Cycle 1 Timeline and Due DatesDate/Time Topic/ActivityJanuary 6, 2015, 2-3pm PARADE Project Launch WebinarJanuary 16, 2015 Technical Assistance Request Due Date; AC-DC Excel tool will be

emailed to participating facilitiesJanuary 20, 2015, 2-3pm Webinar: PARADE Measures and Audit tool guidance and Q&A

January 22, 2015, 2-3pm Webinar: Reducing Hypoglycemic Events in the Elderly – Dr. Medha Munshi

January and monthly thereafter

Each Coalition has monthly Med Management Committee Meetings to advance work

February 6, 2015 Baseline audits due; IPRO analysis of baseline audit sent to facilities within 2 weeks

February and March Coalition Med Management Committee Meetings – interventions/prioritization

March 17, 2015, 2-3pm Coaching Call; teleconference only: 1-877-287-8135 *8949321*

March 30, 2015 Remeasure due; IPRO analysis of remeasure sent to facilities within 2 weeks

April Coalition Med Management Committee MeetingsMay 30, 2015 Remeasure due; IPRO analysis of remeasure sent to facilities

within 2 weeksJune Coalition Med Management Committee Meetings -

Review initial 6 month cycle outcomes; create plan for continuing improvements and sustainability; expand to hypoglycemic, opioids

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Summary & Next Steps PARADE Request for Technical Assistance Agreement due by January 16,

2015

SAVE the DATE - Webinar: January 20, 2015 2-3pm – audit tool guidance, Q&A

Audits:

Excel AC-DC audit tool (preferred) will be emailed to facilities after technical agreement is signed

Paper AC-DC audit tool can be utilized

Med rec audit – only paper tool is available

Fax completed paper audits by due dates to Anne at: 518-426-3418

Email completed Excel AC-DC tool by due dates to Anne at: anne.myrka@hcqis.org

Outcome ADE readmission baseline completion date will be individualized per hospital

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Collaborative Disclosures

Project is designed to encourage collaboration

Through that effort we will facilitate the sharing of facility names, team members and email addresses with all involved in project

We will not share your individual QI findings or QI data with any other organization without your consent

Please contact Anne by January 16, 2015 if you do NOT wish to have your contact information shared

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Questions / Feedback

For more informationAnne MyrkaPharmacist – Drug Safety(518) 320-3591Anne.Myrka@hcqis.org

IPRO CORPORATE HEADQUARTERS

1979 Marcus AvenueLake Success, NY 11042-1002

IPRO REGIONAL OFFICE

20 Corporate Woods BoulevardAlbany, NY 12211-2370

www.atlanticquality.org

This material was prepared by the Atlantic Quality Innovation Network/IPRO, the Medicare Quality Innovation Network Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-AQINNY-TskC.3-14-23

IPRO Care Transitions Web Site:http://qio.ipro.org/care-transitions/overview

IPRO Drug Safety Web Site:http://qio.ipro.org/drug-safety/overview

Sara ButterfieldSenior Director – Care Coordination(518) 320-3504Sara.Butterfield@hcqis.org

Darren TrillerSenior Director – Drug Safety(518) 320-3525Darren.Triller@hcqis.org