Transcript Patient Safety & Clinical Pharmacy Services Collaborative

Patient Safety & Clinical Pharmacy Services
Collaborative
Rebecca Cheek
Director of Pharmacy
White House Clinics
606-287-7104
Questions to Run On
• How can you implement Clinical
Pharmacy Services at your site?
• Do you have a method in place to track
Adverse Drug Events (ADE’s) and
potential Adverse Drug Events (pADE’s)?
PSPC
 Similar to other HRSA sponsored
collaboratives
 All Teach, All Learn environment
 Starting 3rd year in October 2010
 White House Clinic has been involved
since the beginning-August 2008
Our Collaborative Team
Clinical Pharmacy Service Providers at the
Primary Health Care Home
Becky Cheek, PharmD
Pharmacy Director
Collaborative Lead
Sharon Davidson,
PharmD
Steven Wagers,
PharmD
Other Providers at the
Primary Health Care Home
Melissa Zook, M.D.
Family Physician
Medical Director
Sandra Dionisio, M.D.
Internist
PSPC Collaborative AIM
 To Save and Enhance thousands of lives each year
by:
– Achieving optimal health care outcomes and
– Eliminating Adverse Drug Events through
– Increased Clinical Pharmacy Services for the patients we
serve
 The Goal of Collaborative Services is to:
– Improve patient safety
– Improve patient health outcomes
– Integration of cost-effective clinical pharmacy services
Our PSPC Aim Statement
White House Clinics will
strive to provide clinical
pharmacy services to highrisk patients in an effort to
decrease adverse events
while encouraging those
patients to become active
partners in the
management of their
health condition.
What are Clinical Pharmacy Services?
 CPS are patient-centered services that promote
the appropriate selection and utilization of
medications through:
1. Medication access*
 340b formulary
 Recommending generic alternatives
 Patient Assistance Programs
2. Patient counseling *
 Rx pick-up (required by OBRA-90)
 Phone calls
3. Medication Therapy Management (MTM)*
 Poly-pharmacy management
 Recommendations given to patient or provider
 Changes to therapy after DUR/ADE
CPS Services cont.
4. Preventive Care Programs
 BMI or blood pressure
 Immunizations
 Drug Information Services to Patients
5. Drug Information Services to Patients*


Drug information leaflets
Disease state pamphlets
6. Medication Reconciliation Services

Having 1 accurate medication list
CPS services cont.
7. Provider Education*

Pharmacist provides evidence based drug information to
provider
8. Retrospective Drug Utilization Review*
 Review patients on certain meds or with certain disease
states to assess quality and safety
9. Disease State Management*
 Medications managed to obtain health outcomes and
improve safety
 Labs ordered and evaluated
CPS services cont
10. Prospective chart review and provider consultation*
 Review chart before visit and make recommendations to
provider team
*Clinical pharmacy services that we provide at WHC
Why Are We Doing This Work?
 Increase in multiple chronic conditions
 Institute of Medicine Report: ADEs are leading
cause of death and injury
 Every $ spent on a RX = a $ spent on an ADE
 Aging population/chronic disease – leading to
high prevalence of poly-pharmacy
 Lack of integration of clinical pharmacy services
 Alignment with HRSA Core Measures
Key Benefits
 It’s the Right Thing to Do for the Patients We Serve
– Safer
– Increased and Better Pharmacy Services
– Improved Health Outcomes
 Reduces/Manages Risk – and Risk is Increasing
 Builds on and Takes Prior Knowledge Base and Experience
to a New Level
 Takes HRSA Collaborative Experiences to the Next Power
Key Benefits
 Integrates Services to Maximize Community Health
 Reduces Inappropriate Use of Poly-pharmacy –
Better Medication Management
 Helps Create New Partnerships & Synergies Across
Provider Organizations
 Exposure to Cutting Edge People and Methods on
Quality Improvement, Leadership & Change
Management
 Opportunity to be a Part of a Major National
Movement in a Rewarding All Teach, All Learn
Environment
Examples of Disease States in
Collaborative
 Diabetes-HgA1C
 Hypertension-blood pressure
 Hyperlipidemia-LDL, triglycerides
 Asthma-peak flow, ACT test, controller
meds
 Anticoagulation-INR in range
 HIV
Teams
Patients with Health Status
"Under Control" vs. "Out of Control,"
Baseline
0
Out of Control
10
20
30
40
50
60
Number of Patients
70
80
90
100
Teams
Patients with Health Status
"Under Control" vs. "Out of Control"
through July 2010
0
Under Control
Out of Control
10
20
30
40
50
60
Number of Patients
70
80
90
100
National Health Status
Improvement Results for
First Ten Months of PSPC 2.0
49%
51%
Under Control
(999 patients)
Out of Control
(1026 patients)
PSPC Outcomes:
Improvements in Health Status
Average team improvement through July
2010
 49% improved from health status “out of
control” to “under control”
 Across a range of chronic diseases, using
standardized measures — such as A1C levels,
blood pressure, LDL, INR ranges, depression
scores, and viral load
What did we need to do for the
collaborative?
 We needed to choose a Population of
Focus (POF)
 We needed to track ADE’s and pADE’s to
improve safety
2% of Patients Can Benefit from CPS on
One of the ISMP High-Alert Medications
833,936 pat/year
16,284 pat/year
315 pat/yr
75
Total Patient Population
Total Population of Care
that could benefit
from CPS
Total Population of Focus
(Anticoagulant Treatment)
PSPC Population of Focus
20
White House Clinics Improvement
Story
 Population of Focus – Patients receiving
Coumadin® (Warfarin) therapy referred to
the Coumadin Clinic for anticoagulation
management
 Baseline data unavailable as no data
tracking methods in place
 After enrolling, developed plan to collect
data-manual, EMR template, EMR reports
Population of Focus
 Indications
•
•
•
•
•
CVA – 6%
Atrial Fibrillation – 61.4%
Mitral Valve Replacement – 10.8%
Deep Vein Thrombosis – 13.3%
Pulmonary Embolism –8.4%
 Patient Age





<50 = 11
50 – 65 = 24
65 – 74 = 22
75 – 84 = 20
85 – 94 = 3
 Setting
• Ambulatory – 75
• Home Health - 5
High Risk Qualities in POF Panel
•Medications per Patient – 7 to 8
•Providers per Patient – 3
•Largest Safety Issues – Bleeding, Thrombotic Event
•Largest Health Status Problems – Hypertension, Atrial
Fibrillation, Diabetes
Anticoagulation Management Data
 %INR values within range (goal 2.0-3.0)
– Usual medical care with physician: 29.6%
– Pharmacist-run Anticoagulation Clinic: 64%
Chiquette E, Amato MG, and Bussey HI. Comparison of an Anticoagulation Clinic with
Usual Medical Care. Arch Itern Med. 1998; 158:1641-1647.
White House Clinics
INR In Range >80%
100%
90%
Axis Title
80%
70%
60%
50%
40%
Series1, 70.80%
Improving Safety and Eliminating Adverse
Events
Tracking ADEs & pADE
 ADE – Adverse Drug Event
– Events that result in harm or injury to the patient due to
medication use
• Example – Bleeding as a result of Coumadin® (Warfarin)
administration
 pADE – Potential Adverse Drug Event
– Potential harm that was identified and avoided with appropriate
interventions before reaching the patient
• Example – Pharmacist catches an allergy to Penicillin and calls the
physician to change Amoxicillin to Azithromycin prior to
dispensing
• Example – A Pharmacist notices a duplication of drug therapy
(Lisinopril & Ramipril) and intervenes to have one of the
medications discontinued before the patient receives the medication
ADE’s & pADE’s
 No tracking prior to starting collaborative
 Through the collaborative many
organizations have observed a significant
amount of ADE’s and pADE’s due to a
lack in tracking data
 Clinical Pharmacy Services have allowed
these same organizations to see a decline in
them over time
How We Should Identify
ADEs/pADEs
Medication
Reconciliation
Nurse/CMA
Physician
ADE/pADE
Pharmacy
Patient
ER/Hospital
How Do We Plan On Collecting
Data on ADEs/pADEs
 Information concerning ADE’s and pADE’s will be
collected from all available venues
–
–
–
–
–
–
The Patient
The Pharmacy
Medication Reconciliation
Nurse/CMA
Physician
ER/Hospital Visit
 The data will be evaluated by the provider then
entered into an EMR note. This data is easily
extracted from EMR for reporting.
pADE’s and ADE’s for
White House Clinic POF
 pADE’s-low or high INR ranges, drug
interactions, interruptions in therapy
 ADE’s-bleeding, thrombosis
Example of pADE/ADE
 22 y.o female dx: hypercoagulable state,
s/p DVT/PE x5
Patient referred by primary care physician after INR had been followed by
cardiologist. She could no longer afford to have INR monitored at cardio office. INR
at initial visit =1.2. After CPS, we were able to bring her INR in range in a month.
She was also determine to conceive. We assisted her with a Patient Assistance
Program to get Lovenox and educated her on its use during pregnancy. We also
provided counseling and an option to receive Chantix to stop smoking. She has been
able to achieve appropriate anticoagulation levels and is now 3 months pregnant.
Hopefully, our service avoided potential adverse drug events and actual adverse drug
events for the patient and her unborn child.
White House Clinic pADEs/ADEs
Institute for Healthcare Improvement
Assessment Scale
The Assessment Scale is divided into the
following categories:
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


1.0 — Forming team
1.5 — Planning for the project has begun
2.0 — Activity, but no changes
2.5 — Changes tested, but no improvement
3.0 — Modest improvement
3.5 — Improvement
4.0 — Significant Improvement-White House Clinic
4.5 — Sustainable Improvement
5.0 — Outstanding sustainable results
IHI Assessment Scale
Team Self-Ratings
14
Number of Teams
12
10
8
6
4
2
0
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
IHI Assessment Scale Self-Ratings
5.0
PSPC 1 Awards
 Health Outcomes Management Award
– Successfully gathered data and reported it
 Life Saving Patient Safety Award
– Established systems to identify and prevent
ADE’s and have an example of a life
threatening ADE that was resolved
 PSPC Performance Award
– Showed overall excellence during the
collaborative
PSPC 2.0 Awards
 Health Outcomes Management Award
How did we do it?




Better, more focused education for patients
Closer patient follow-up
Better data tracking methods
Quality improvement efforts such as Byeth and CHADS2
scores
 Collaborative competition
 Communicated data to our providers
 Required continuing education in disease state
The Next Step…PSPC 3
 Spread of anticoagulation management to
other sites
 Asthma-working with pediatrician
 Diabetes-working with Physician Assistant
What do we need?
 Time
– Hard to balance with other duties of a
pharmacist
 Staff
– Hiring a new pharmacist
 Resources
– Pharmacy Expansion Grant, provider status for
billing services, other funding
 Support of our providers
Contact Information
 Rebecca Cheek, PharmD
[email protected]
 Office of Pharmacy Affairs
www.hrsa.gov/opa
 Healthcare Communities
www.healthcarecommunities.org