Transcript Ammonoosuc Community Health Services Patient Safety Presentation

The answer is: One Bite at a Time
The 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 Technician
Lisa Mackenzie, Patient Navigator
Linda Noyes, RN, Electronic Health Record Manager
Edward 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
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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 :
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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…”
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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!
POF N = 431
patients w/ >10 Rx
Leaned POF too large
Need to refine
POF
Diabetics w/ >12 Rx
N = 62
Initiate 1st PDSA
Use Blackberry
to contact
EHR Manager
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)
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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…)
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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
Pre Collaborative / 12 Months Post Collaborative
Prevalence of Poly Pharmacy for Diabetic Population of Focus
Pre N Value = 62
Post N Value = 54
90%
82%
80%
70%
60%
50%
43%
40%
33%
30%
20%
0%
10%
11%
15%
6%
9%
0%
12 or less
Post
13 to 16
17 to 20
21 or more
Post
Pre
Pre
• 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 medications
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 Success
The Providers and Support Staff
• Organization buy-in
• Charles Wolcott MD, Medical Director provided education to
the following audiences.
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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
Pre Collaborative / 12 Months Post Collaborative
Prevalence of Poly Pharmacy for Diabetic Population of Focus
Pre N Value = 62
Post N Value = 54
90%
82%
80%
70%
60%
50%
43%
40%
33%
30%
20%
0%
10%
11%
15%
6%
9%
0%
12 or less
Post
13 to 16
17 to 20
21 or more
Post
Pre
Pre
Percent Patients Receiving Medication Letter
2%
100%
90%
80%
70%
85%
60%
98%
50%
40%
30%
20%
15%
10%
0%
Pre
Post
Received Medication Letter
Did Not Receive Medication Letter
Medications with or without Abreviations on Patient Medication List
5%
100%
26%
90%
80%
70%
60%
95%
50%
74%
40%
30%
20%
10%
0%
Pre
Without Abreviation
Post
With Abreviation
Medication List
Where Medication includes or does not include Diagnosis with each Medication
12%
100%
90%
80%
70%
91%
60%
88%
50%
40%
30%
20%
9%
10%
0%
Pre
Post
Diagnosis not included
Diagnosis includes diagnosis
Non Trauma Related Emergency Department Visits (32% improvement)
and Hospitalizations (22% improvement)
Visits or Admissions per Population of Focus Patient
1.40
1.20
Emergency Department Visits per
POF Patient,
1.34
1.00
Emergency Department Visits per
POF Patient,
0.91
0.80
0.60
0.40
Hospitalizations per POF Patient,
0.40
0.20
Hospitalizations per POF Patient,
0.31
0.00
Pre
Post
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