Transcript Presentation Title Line 1 Presentation Title Line 2

Preventing and Reducing
Adverse Drug Events in
Care Coordination Communities:
Cycle 1 Results
Anne Myrka, RPh, MAT
IPRO
July 30, 2015
Objectives
 Describe IPROs CMS 11th Scope of Work Priorities and Goals
 IPRO Drug Safety work overview
 Describe the Preventing and Reducing Adverse Drug Events
(PARADE) initiative: Objectives and Strategy
 Provide Cycle 1 (January – June) results
 Highlight facility specific interventions and experiences – guest
speakers
 Next Steps, Q & A
2
Thank You!!!
3
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
4
IPRO Drug Safety overview
 NYS Anticoagulation Coalition
 Appropriate DOAC use – included in utilization reports
 Effective EHR utilization – manuscript published
 Peri-procedural utilization of all anticoagulants – MAP
tool (app under development)
 Pain Management Task Force
 Reducing opioid-related adverse drug events (ADEs)
 Hypoglycemia agent Task Force
 Reducing hypoglycemia-related ADEs
5
What is IPRO’s PARADE Initiative?
6
PARADE Initiative – 2014 Pilot study and results
 Evidence-based system improvements were applied
to Anticoagulation Discharge Communication and
Med Rec on Admission according to site-specific
baseline 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%)
7
PARADE Initiative
 QIOs are directed by CMS in the 11th Statement of
Work (11SoW- 2015-2019) 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
8
PARADE Objectives and Strategy
9
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
10
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: measureable improvement in adherence to audit criteria
 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
11
PARADE Strategy
 Based on 6 month improvement cycles
 Cross setting work will be achieved within each care transition
coalition Medication Management Committee monthly meetings
 Eligible facilities: 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.
 Cycle 1 was January 6, 2015 – June 30, 2015
 All facilities focused on Medication Reconciliation and Anticoagulation
Discharge Communication
12
PARADE Strategy
 Cycle 2 is September 2015 – February 2016
 Continue to work on ADE hospital readmission measure,
high risk drug discharge communication and med rec
improvement processes (expanding to discharge)
 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
13
PARADE Process Measures: Audit Methods
14
PARADE Process Measures: Audit Methods
 Medication Reconciliation on Admission Audit
 Medication Discrepancy Tool
 Anticoagulation Discharge Communication Audit
 Anticoagulation Information Discovery Tool
15
Additional Ad Hoc Anticoagulation MeasureWarfarin 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/collaborativepartners/analytic-services
*TTR – Rosendaal’s method
16
Cycle 1 Results
17
Anticoagulation Discharge Communication
18
Medication Reconciliation
19
Outcomes: ADE Surveillance Process Hospitals
All patients possessing the following elements at time of hospital
discharge:
• ≥ 3 medications ordered in total, and;
• Anticoagulant
• Opioid
• Hypoglycemic
•How? EHR query
• Patient identifier - SSN and MRN
• Drugs - can be identified using drug name text string files provided by
IPRO
• Raw data files transferred to IPRO via secure data transfer protocol
•
Denominator
Raw
Numerator
All patients identified in Denominator with Emergency
Department Visit or Hospital Re-admission within 30 days
•How? IPRO analysis of Medicare Part A data
•
Final
Verified
Numerator
• Determination of presence of ADE by Root
Cause Analysis
• How? CDC abstraction tool verified for
anticoagulants, opioids, and hypoglycemic ADEs.
Preventable ADEs targeted for coalition-wide
evidence based intervention(s).
20
 Remeasure quarterly
after baseline is
completed
 Secure data transfer
protocol utilized
ADE Surveillance: Hospital Engagement
 Total hospitals engaged: 27
 Already sharing complete data: 6*
 Represents 22,380 unique Medicare Fee for Service Beneficiaries
discharged from participating hospitals on ≥ 1 high risk drug and
screened for ADEs
 Anticoagulant potential ADEs - 104
 Opioid potential ADEs - 55
 Hypoglycemic potential ADEs - 9
 Beginning test data query: 4*
 Agreed to share data: 17
Hospitals
currently participating in CT communities
21
PARADE Interventions
22
Medication Reconciliation Improvement Tools
23
Anticoagulation Improvement Tools
24
Facility Specific Interventions
25
HealthAlliance of the Hudson Valley,
Kingston, NY
 Medication Reconciliation Risk Reduction Strategies
Identified
 ASU staff were provided additional training on how to
enter home medications in the EMR to generate a
“clean” medication reconciliation. No free texting!
 Orthopedics -aggressive education with Medical Staff on
steps to complete medication reconciliation utilizing the
EMR. Informatics staff assisted MD with 1:1 concurrent
training
 Set up touch points with MD to address any concerns
identified with use of medication reconciliation process
 Sole use of the EMR for medication reconciliation. No
more paper!
26
HealthAlliance of the Hudson Valley,
Kingston, NY
 Medication Reconciliation Risk Reduction Strategies
Identified continued:
 The Emergency Department created dedicated resource
called “Clinical Data Specialist”
 This position is staffed with an a Pharmacy Tech or LPN.
They are required to enter into the hospital EMR all of
the “Home Medications” for all patients admitted.
 Two sources must be utilized to reconcile the list of
home medications




The patient’s list
Call pharmacy
Calling the patient’s MD
Reviewing the list from the ER EMR
27
HealthAlliance of the Hudson Valley,
Kingston, NY
 Medication Reconciliation Opportunities for
Improvement:
 CHF patient post discharge phone calls identified
need for clearer patient instructions on home
medication resumption or discontinuation. Not
always evident in the medical record.
 Pharmacy medical record application does not
allow pharmacist to view MD reason for
stopping/discontinuing medications.
28
HealthAlliance of the Hudson Valley,
Kingston, NY
 Blood Thinner Adverse Events – Risk Reduction
Strategies Identified:
 Orthopedics physicians managing post operative
course of blood thinner or conferring with patient’s
cardiologist.
 Orthopedics - plan to pilot a sequential
compression biomechanical device (SCBD)
replacing the use of utilizing blood thinner
medications
29
HealthAlliance of the Hudson Valley,
Kingston, NY
 Blood Thinner Adverse Events – Opportunities for
Improvement:
 Multiple places in EMR where information regarding
high risk blood thinner medication may be
documented.
 Auditing difficult due to inconsistent
documentation. Sub-group identified location of
possible documentation – evaluating possibility of
creating a blood thinner tab in EMR for centralized
documentation.
 Information needed for transition of care not
summarized.
30
HealthAlliance of the Hudson Valley,
Kingston, NY
 Medication Reconciliation – High Risk Medication –
Discharge Process Audit
 Audit 35 charts utilizing IPRO medication reconciliation
discharge tool to obtain baseline.
 Audits to be completed no later than July 31, 2015
 Charts to be audited by discharge location:
●
5 - SNF, Rehab, Acute Care
●
5 – ED
●
5 – Orthopedics
●
5 – General – Home
●
5 – Endo
●
5 – Hypoglycemic agents
●
5 – CHF
31
Albany Memorial Hospital, Albany, NY
 Anticoagulant-related high priority elements
highlighted for hospitalists in real time during
discharge summary dictation – facilitated by case
management at time of discharge
 Kaizen done regarding standardization of discharge
practices
● Patient teach back
● Identifying high risk patients
● ED med rec by pharmacist
● Contact PCP on admit
● Identify caregiver/family by day 2
● Rapid summaries for high risk drugs
32
Evergreen Commons, East Greenbush, NY
 Initiated the Blood Thinner Safety Plan
 Complete med list printed from Omniview indicating
drug, dosage and time of next dose due
 Most recent fall risk assessment faxed to community
PCP
 Resident PT/INR flow sheet faxed to community PCP
 Medication Reconciliation – home meds
 Developed a discharge check list
33
Home Healthcare
 Dominican Sisters Family Health Services
 Multiple PDSAs and PARADE huddles weekly
 Business Development Managers and Liaison Champions
 Standardized New Electronic Referral which includes mandatory
fields to capture Anticoagulant high priority elements




Collaboration with hospital readmission teams
Access to hospital electronic medical record attained
Nurse education
Cross-setting pilot of Blood Thinner Safety Plan - planning for next
cycle.
34
Home Healthcare
 VNA of the Hudson Valley
 Evidence Based Patient Education Protocols and
Materials – including BTSP, INR Worksheet, RN Pt.
Teaching Plan Checklist, Guidelines for Lovenox
Administration/Precautions; Patient self-test re: learning
achieved
 Guidelines for Home Health Intake Coordinators –
Baseline transfer information
 Anticoagulation information to be sent to PCP upon
discharge from homecare; Transfer summaries to reflect
status of anticoagulation therapy
 Nurse education
35
Home Healthcare
 VNS Westchester – Putnam Branch
 Implementing intake template revision to capture salient anticoagulation
information for use by Home Health Intake Coordinators and Liaisons
 Piloting Blood Thinner Safety Plan and Warfarin Dose and INR flow sheet
 Developing Discharge Summary Form for patients on AC therapy to be sent to
the PCP or other provider upon discharge from home care services: to include
diagnosis requiring need for AC therapy, flow sheet account of past INR
readings, corresponding AC medication changes, s/s bleeding, related teaching,
etc.
 Working with local hospital readmission task force for access to patient portal
and other options to obtain most current accurate discharge medication and
other pertinent data related to AC therapy: last 3 INR’s, reason for AC therapy,
identification of patients new to AC therapy, therapeutic level, etc.
 Working with Director of Pharmacy at local hospital for identification of patients
on AC therapy at risk for complications and in need of home care follow-up.
 Developing process for standardized, mandatory clinician education on the
assessment and pharmacology aspects of the anticoagulated patient.
36
Next Steps
 Webinar: PARADE Cycle 2 Launch
 Wednesday, September 9, 2015 2:00pm – 3:00pm
 This webinar will serve as an introduction to IPRO’s Preventing
and Reducing Adverse Drug Events (PARADE) initiative for new
communities and provide information for those communities
entering PARADE Cycle 2.
 Click or Copy and Paste this URL to your web browser:
https://qualitynet.webex.com
 Password: IPRO
 Dial in number is 866-209-5917. The access code is NO CODE
NEEDED.
37
Questions / Feedback
38
For more information
Anne Myrka
Pharmacist – Drug Safety
(518) 320-3591
[email protected]
Sara Butterfield
Senior Director – Care Coordination
(518) 320-3504
[email protected]
Darren Triller
Senior Director – Drug Safety
(518) 320-3525
[email protected]
IPRO Care Transitions Web Site:
http://qio.ipro.org/care-transitions/overview
IPRO CORPORATE HEADQUARTERS
IPRO Drug Safety Web Site:
http://qio.ipro.org/drug-safety/overview
1979 Marcus Avenue
Lake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, 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.3-15-25