Collaborative Transition Of Medication Care Part 2

Collaborative Medication Therapy
Management (MTM) Programs:
Polypharmacy
Transition of Care
MPRO, Quality Improvement Organization (QIO),
MHA Keystone Center
Care Transitions Statewide Summit
Vanita K. Pindolia, Pharm.D.
VP, HFHS/HAP Ambulatory Clinical Pharmacy Program_PCM
May 28, 2014
Outline
Background on Henry Ford Health System (HFHS) and
Health Alliance Plan (HAP)
Background on need for Medication Therapy
Management (MTM)
Define a MTM Program
Transition of Care MTM Program
– Patient identification through electronic queries
– Patient identification through healthcare provider referrals
Home Health Care
HAP Case Management
Inpatient staff
Henry Ford Health System
One of the Nation’s leading
comprehensive, integrated health
systems
Henry Ford Medical Group (HFMG)
 1200 physicians & researchers in 40
specialties - staff HFH and 27 HF
medical centers
Henry Ford Physician Group (HFPN)
 HFMG + 500 community physicians
4 Hospitals totaling > 2,000 total beds
Health Alliance Plan (HAP) is a
nonprofit managed care organization
- serves 660,000 members in 6
product lines; 2,000 employer groups
Community Care Services
– PCM - Ambulatory Clinical
Pharmacy Program
Ambulatory Clinical Pharmacy Programs
Optimize medication therapy with a cost-effective
model in the outpatient setting by engaging and
collaborating with patients, health care providers, and
other heath care stakeholders.
Henry Ford Health System
HAP
HFMG
HFPN
Community Care
Services
PCM - Ambulatory
Clinical Pharmacy
Programs
Henry
Ford
Health
System
Hospitals
Medication Use Impact on Quality of Life,
Health Care Cost and Readmissions
Relationship between number of medications consumed and
Adverse Drug Events (ADEs)1
– 4 or more medications carries a 38% risk of ADEs
– 7 or more medications carries a 82% risk of ADEs
The annual cost of ADEs occurring in the ambulatory setting
for Medicare senior enrollees is more than $2 billion.2
 Of the $2 billion, over 40% is attributed to preventable ADEs.2
Hospitalizations secondary to ADEs account for 2.4 to 6.7% of
all medical admissions for general public. The projected cost
to manage these admissions is $847 million.3-7
 Hospitalizations secondary to ADEs for seniors est. at 20 to 30%.6
1 Goldberg RM et al. Am J Emer Med 1996;14:447-50. 2 Philip Aspden et al. Editors. Preventing Medication Errors: Quality Chasm Series (2006). 3 Gallagher
P, et al. J Clin Pharm Therapeut 2007;32:113-21. 4 Pirmohamed M, et al. BMJ 2004;329:15-19. 5 Schneeweiss S et al. Eur J Clin Pharmacol 2002;58:285-91. 6
Grenouillet-Delacre M et al. Intensive Care Med 2007;33:2150-7. 7 Field TS, et al. Medical Care 2005;43(12):1171-6.
Medication Use Impact on Quality of Life,
Health Care Cost and Readmissions
Of the Medicare population who had been discharged from a
hospital, the following readmission rates were found: 1
– 19.6% for 30-day readmission rate
– 34% for 90-day readmission rate
– 56.1% for 1 year readmission rate
Cost for Medicare population being readmitted within 30 days
of discharge = $17.5 billion (2010)2
Of the patients discharged from a hospital to the home
setting, 19% experienced adverse events within first 2 weeks
of discharge.3
 66% of adverse events were drug-related ones (2/3 of ADEs
are preventable or ameliorable)
1. Jencks SF, et al. NEJM 2009;360:1418-28 2. http://www.kaiserhealthnews.org/Stories/2012/October/03/medicare-revises-hospitals-readmissionspenalties.aspx (accessed Oct ‘13) 3. Forster AJ et al. Ann Intern Med 2003;138:161-7.
What is a Medication Therapy
Management (MTM) Program?
HFHS/HAP MTM Program
GOAL
To ensure medication regimens provide optimal therapeutic outcomes
through integration of patient’s personal health care goals with evidencebased medicine in collaboration with the patient’s physicians.
METHOD
Clinical Pharmacist contacts the patient to:
– Educate patient on their current medication regimen
– Obtain the patient’s personal healthcare goals
– Identify barriers for receiving care
– Determine if any changes to the current medication plan are
necessary to meet both the patient’s goals and physician’s healthcare
goals
Clinical Pharmacist collaborates with the patient’s physician(s) to develop
and implement a new drug regimen
 eMR Access: Enter MTM note in eMR, Complete Med Rec in eMR
 Non-eMR: Fax MTM note to physician(s)’ offices
Amb Clin Pharmacist MTMP Case
75 year old male with a medical history for: Uncontrolled Diabetes, Dyslipidemia,
Chronic Kidney Disease Stage II, Hypertension
Medication Concerns: Patient had stopped taking many of his medications because
of a misunderstanding on his part. His clinical lab test results indicated that his
chronic diseases were NOT controlled.
Pharmacist Intervention (in collaboration with multiple community physicians):
1. Counseled the patient on purpose of medications, goals of therapy and
importance of taking his medications as prescribed.
2. Improved Dyslipidemia by changing 2 medications
3. Improved Chronic Kidney disease management by changing 2 medications
4. Improved Diabetes care by changing insulin dosing schedule
5. Re-engaged patient with his physicians
Outcomes Post-Medication Therapy Management Services:
Dyslipidemia Improved
LDL < 100 mg/dl, HDL > 45 mg/dl, Triglycerides normalized
Diabetes Improved
HbA1c < 7 gm/dl,
Chronic Kidney Disease Improved
Serum Creatinine staying level
Polypharmacy MTM Program:
Electronic Query Patient Identification Summary
From 2006 through 2013, over 7,000 patients have engaged
with a pharmacist for MTM
Avg of 3.5 drug interventions are recommended per patient
Highly positive patient survey results
For the 1,663 patients enrolled into our MTM Program in
2011 that completed the initial and follow-up MTM services:
 75% reached drug effectiveness and safety goals
 74% achieved desired drug adherence goals
 66% had lower prescription costs
MTM Program
Transition of Medication Care:
Inpatient
Point of Discharge
Outpatient
Transition of Medication Care MTM Program
GOAL: To reduce the number of hospital readmissions by identifying drugrelated concerns with the patient and collaborating with the patient’s physician
and other ambulatory team members to resolve them.
HFHS Partners for Intervention
– Henry Ford Physician Network (HFPN)
Collaborate with 1,200 staff and 500 community physicians
– Health Alliance Plan (HAP)
Collaborate with team members for referrals
– Ambulatory Clinical Pharmacy Programs (CCS-PCM)
Administer MTM Program
– Henry Ford Home Health Care
First Collaborative Transition of Medication Care Referral team
– System Hospitals
Collaboration with discharge teams for referrals
MTM: Transition of Medication Care
Electronic Query Patient Identification
Daily Electronic Files generated Post-Discharge
– Inclusion Criteria (all need to be met)
 ≥ 18 years of age
 Discharged from any of the System Hospitals to home setting
 Additional discharge from a hospital within past 6 months
 Patient on 8 or more medications at discharge
 Patient seen by a physician within past 12 months
 HFPN physician, any payor
 HAP member, any provider
– Exclusion Criteria
 Admissions related to cancer care, pregnancy/delivery, transplant,
drug addiction, suicide, schizophrenia, major depressive disorder
HFHS Hospitals – HFPN/HAP MTM
30-Day All Cause Readmission Rate
Eligible = 737
Eligible = 944
Eligible = 970
Eligible = 781
60% Enrolled
in MTM
58% with UDI
(507 UDIs)
48% Enrolled
in MTM
45% with UDI
(368 UDIs)
49% Enrolled
in MTM
45% with UDI
(443 UDIs)
48% Enrolled 52% Enrolled
in MTM
in MTM
42% with UDI 28% with UDI
(305 UDIs)
(*159 UDIs)
Eligible = *513
Eligible = *342
49% Enrolled
in MTM
35% with UDI
(*118 UDIs)
UDI = Urgent Drug Interventions
*Reasons for Decline in Volume of Eligible patients and Number of Urgent Drug Interventions:
1. In 2012, over a 6-month period, 5,059 patients were electronically identified for Intervention
2. In 2013, over a 6-month period, 4,134 patients were electronically identified for intervention (18.3% decline)
3. In November 2012 we implemented a strict patient eligibility limitation to HFPN and/or HAP patients.
HFHHC Referral to Ambulatory Clinical Pharmacists for MTM:
4Q2012 – 3Q2013
Total of 664 Patients Referred
 Avg Age: 73 years
 Avg # of Meds/Patient: 16
 329 (50%) Patients
referred for 30-day
Readmission
Avoidance
• 224 (68%) Engaged
with Pharmacist
HFHHC Referral to Ambulatory Clinical Pharmacists for MTM:
4Q2012 – 3Q2013
335 (50%) Patients referred for prevention of New Acute Episode
 234 (70%) Engaged with Pharmacist
30-Day Admission Rate
OASIS Question: Medication Knowledge Improvement
HHC-MTM Engaged: OASIS score difference calculated as
difference between baseline score prior to MTM and followup score within 60 days post MTM services
Brown RS, et al. Six Features Of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions Of High-Risk Patients. Health Affairs
31 (6); 2012: 1156–1166
MTM: Transition of Medication Care
Patient Satisfaction Survey Results
Electronic Query Identified Patients
(12% Survey Response Rate)
HHC Referred Patients
(30% Survey Response Rate)
Responses for Question: Pharmacist addressed drug-related concerns that I
wanted to discuss
71% - Agree
3% - Disagree
26% - N/A
83% - Agree
0% - Disagree
17% - N/A
Responses for Question: Pharmacist identified drug-related concerns that I was
previously unaware of
62% - Agree
4% - Disagree
34% - N/A
76% - Agree
0% - Disagree
24% - N/A
Responses for Question: Before Pharmacist called, I was unsure why or how to
take some of my drugs; now I know
54% - Agree
15% - Disagree
31% - N/A
76% - Agree
3% - Disagree
21% - N/A
Responses for Question: When necessary Pharmacist coordinated my drug needs
with my doctors and caregivers
57% - Agree
3% - Disagree
40% - N/A
70% - Agree
0% - Disagree
30% - N/A
Hosp Readmission Avoid MTM Intervention:
Lessons Learned
Need to move to a referral based process
 Improve Efficiency by increasing patient engagement with
Ambulatory Clinical Pharmacists through coordinated transition
of medication care process
 Over 20% Improvement in Engagement Rate with Referral
Process
 Improve Effectiveness by working on complex patients already
identified to have or potentially have medication concerns

Over 50% Increase # of UDIs Identified with Referral Process
 Improve Patient Satisfaction by working on patient identified
concerns and helping to coordinate their medication care
 >100% increase in survey response rate
 >10% increase in individual survey scores
 Potential translation to improvement in HCAHPS
MTM: Transition of Medication Care
Lessons Learned …
Evolution to Referral Process
Collaborative Transition of Medication Care Referrals
 4Q2012 implemented first MTM referral process with Henry Ford
Home Health Care (HFHHC)
 2013 implemented MTM referral process for HAP Case Managers
 2014 implementing MTM referral process for Inpatient Case Managers
• Discussions ongoing for Inpatient pharmacy referral process,
HFMG Outpatient Case Manager referral process
Cross referrals between HAP Case Management and
Pharmacy
 If patient meets criteria for programs, introduce the program for a soft
hand-off
 If patient is being actively managed by any of the HAP case
management programs, introduce ourselves as one of their team
members
MTM: Transition of Medication Care:
Lessons Learned
Educate other transition team members on ‘basic’ medication
management knowledge
GOAL: To facilitate independent resolution of non-complex medication
concerns by other ambulatory transition team members
 Drug/Disease In-services to HHC clinicians, HAP Case/Disease/
Transition Care clinicians
 Forward HAP Ambulatory Drug Formulary write-ups that pertain to
common ambulatory diseases
Identify Most Common Medication Concerns that Pharmacists
could Impact (development of MTM referral reasons):




Patient taking drugs ≥ 4 times a day
Medications required to be split/crushed
Patient non-adherent to drug regimen (excluding affordability)
Patient taking ≥ 20 drugs

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