ASHP InterSections ASHP InterSections

February 13, 2019

A3 Collaborative Elevates Diabetes Care in Rural Appalachia

Amy Westmoreland, Pharm.D., BCGP, counsels a patient about her medications.

Amy Westmoreland, Pharm.D., BCGP, Pharmacy Manager and Clinical Pharmacist at Carilion Giles Community Hospital, has a frontline view of the challenges of diabetes management. For years she wondered if there was a way for her and the other pharmacists at the hospital to provide services to patients beyond filling lifesaving prescriptions. Many of the patients admitted to the 25-bed facility in rural Appalachia were there due to lack of adherence to a diabetes medication regimen.

“Many of my patients didn’t understand all of the complexities involved in taking care of their diabetes, and that could spell disaster once they were discharged from the hospital,” explained Dr. Westmoreland. She noticed that some patients weren’t entirely sure how to monitor their blood sugar, and others had only a vague idea of what they should and should not eat. Many were resistant to any sort of dietary education, or those interventions proved to be ineffective.

A3 Collaborative
About a year ago, Dr. Westmoreland heard about a unique program known as the A3 Collaborative. The collaborative is made up of three organizations – ASHP, Apexus, and AIMM (Alliance for Integrated Medication Management). Its purpose is to help healthcare providers and organizations step in to and succeed in the new era of value-based payment models. The A3 Collaborative provides funding to hospitals that would like to bolster the role pharmacists play in value-based patient care.

Dr. Westmoreland (right), collaborates with case manager Jody Janney, R.N., medical social worker Drema Gautier, Mariana Gomez De La Espriella, M.D., and hospitalist Stephanie Boggs, Pharm.D.

Through Dr. Westmoreland’s efforts, Carilion became a member of the A3 Collaborative and was the recipient of 12 months of guidance and leadership from ASHP, Apexus, and AIMM. The comprehensive medication management program she and her colleagues created with help from the collaborative is simple, but it’s already delivering significant results. Carilion’s new value-based patient care model allows diabetes patients more access to their pharmacist in the days, weeks, and months after discharge.

“Our patients are really happy that they have someone they can turn to, someone they can call and help them understand their illness better,” said Dr. Westmoreland. There have been times when she met patients who were on 30 different medications and they needed someone who could help them understand their diabetes management plan.

Postdischarge Counseling
Dr. Westmoreland and her colleagues started the program in July 2018, and they are currently following 22 patients after discharge. Before the patient is discharged, Dr. Westmoreland and her colleagues meet with the patient. They review their medication list and determine what information and help they may need after they’re discharged from the hospital and moved to ambulatory care.

Before discharge from the hospital, the attending pharmacist will ask the patient if they’d like a follow up phone call from a pharmacist to answer any lingering questions. The pharmacist also provides their information and phone number so the patient can contact them during business hours.

If a patient opts into the medication management program, then the pharmacist coach will call to follow up at 10 days, 20 days, a month, and two months after discharge. After that, calls are made once a month. During each call, a pharmacist ask a specific list of questions:

  • Are you able to afford your medication?
  • Are you taking your meds as prescribed?
  • How often do you check your blood sugar?
  • What is the range of your blood sugar ratings? Are you keeping a log?
  • Are you having any side effects such as low blood sugar occurrences?

Although the program is still relatively new, Dr. Westmoreland and her colleagues have already identified a number of medication-related problems such as duplication errors. They found, for example, that one patient was unnecessarily taking two different forms of thyroid replacement therapy. She’s observed other concerning trends as well: Many patients don’t understand the difference between long-acting insulin and short-acting insulin. Some patients are unclear how — and when — to test their blood sugar, or why it is important that a patient log this information for their doctor to review at follow-up appointments.

“Taking the time that is required to effectively review a medication list is time-consuming,” said Dr. Westmoreland. “That’s where a pharmacist has the skill set to come in and effectively look at the medications and provide recommendations for eliminating some drugs that may not be necessary, or optimize doses to make things better for the patient.”

Amy Westmoreland, Pharm.D., BCGP

Closing the Care Gap
Dr. Westmoreland said the program also addresses the disconnect that often exists between specialists and a primary care physician, especially when a patient’s doctors are not all contained in one facility — meaning there may be more than one electronic medical system where the patient’s records are kept.

“There’s a huge gap in care, in my opinion, without having the pharmacist on the care team for every patient,” said Dr. Westmoreland. “I think we’re at a crossroads in healthcare with having the pharmacist on the care team. Pharmacists have a unique knowledge of the medications, and they understand what a normal dose would be and what an exorbitant dose would be. They could look at a prescription and realize something is off or not correct, whereas nurses and doctors may not be looking at the medication lists in the way that pharmacists do.”

A3 Adds Value
Melanie Smith, Pharm.D., BCACP, DPLA, Director of ASHP’s Section of Ambulatory Care Practitioners, serves as a staff liaison for the A3 Collaborative. She noted that the collaborative allows ASHP members to test out great ideas that could help keep patients out of the hospital. “Many of our members are being tasked with setting up a clinic or setting up a service in an ambulatory care setting,” said Dr. Smith. “Participating in a program like the A3 Collaborative provides them with essential coaching and mentoring, and helps provide a foundation and the bridge they need to transition the clinical practice from inpatient to outpatient.”

Dr. Westmoreland, for her part, hopes the success of the program will demonstrate the value of adding pharmacists to patient-care teams. “We’re trying to be very proactive before the point of discharge.” It’s important, she said, for patients to have someone they can turn to when their diabetes management becomes overwhelming, or they can’t afford their prescriptions, or their doctor is not readily available to answer questions. “I would like others to see there’s enough value in this program for it to be expanded across the system and across the nation.”

 

By Jessica Firger

 

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December 18, 2018

ED Pharmacists Keep Opioid-Naive Patients Naive

ED pharmacists Zachary Brent, Pharm.D., BCPS, and Julie Bennett, Pharm.D., MBA, BCPS, discuss opioid metrics.

IN THE EMERGENCY DEPARTMENT (ED) of Baptist Memorial Hospital in Memphis, Tenn., an innovative opioid stewardship program is showing real promise in keeping opioid prescriptions to a minimum while making sure patients are comfortable and pain-free. The program’s primary goal is to keep opioid-naive patients naive.

Opioids in the ED

“Opioids are an increasing problem in the ED, not because pharmacists are seeing so many more overdoses — those are often treated by EMTs — but because the ED is often where a patient is first exposed to opioids,” explained Julie Bennett, Pharm.D., M.B.A., BCPS, a pharmacist who works in Baptist Memorial Hospital’s bustling ED. “We realized that if we could find a way to eliminate that first exposure, then we could make a significant impact on the opioid crisis.”

With the full support of Baptist Memorial’s ED physicians and leadership, Dr. Bennett and Zachary Brent, Pharm.D., BCPS, also an ED pharmacist at Baptist Memorial, set out to create an opioid stewardship program that offers opioid alternatives to patients.

The two pharmacists, both members of ASHP, began the project in January 2017 by collecting data on opioid usage in Baptist Memorial’s ED. They chose milligrams of morphine equivalents per 100 emergency department patient visits as the primary metric. The data showed that in January 2017 the ED staff was giving 120 mg morphine equivalents per 100 ED patient visits. “This was sobering,” said Dr. Brent. “We were giving a dose of opioids to one out of every four patients in the ED.”

Opioid Alternatives

To reduce opioid dispensing, the hospital’s pharmacy team created an opioid stewardship program based on a program implemented at the Swedish Medical Center in Englewood, Colo. First, the Baptist Memorial pharmacy team identified five conditions that are typically treated with opioids: chronic abdominal pain, headache/migraine, renal colic, extremity fractures/joint dislocations, and musculoskeletal pain. The team then provided physicians with non-opioid alternative treatment options for each condition.

Dr. Bennett orders medications from an automated dispensing system.

“Treatment options are broken down into first-, second- and third-line options,” said Dr. Brent. “For example, first-line treatment for headache/migraine might include a liter of saline plus oxygen, ketorolac, ketamine, or lidocaine injections. A physician might choose one, two, or even three of these options.”

He noted that many of the first-line options are common OTC pain medications, but in IV form. “All of the treatment options are built into our computer physician order entry system so our physicians can easily access and order these alternative pain medications,” said Dr. Brent. “Most of the alternative options are also stocked in our automated dispensing cabinets in the ED to allow for quick retrieval by nurses.”

If an opioid is needed, then the pharmacy team will try to use the lowest effective dose. “If patients come in on opioids, that’s fine, but it doesn’t necessarily mean that we are going to give them opioids while they are in our ED,” said Dr. Brent. “The alternative medications we use tend to work quicker and more effectively to alleviate patients’ pain.”

For example, Dr. Bennett recalled a recent situation where a patient who used morphine and oxycodone at home for a certain condition wanted a prescription from the ED pharmacist to alleviate pain caused by her shoulder bursitis. “She already had topical lidocaine patches and creams and every other alternative I could think of at home,” said Dr. Bennett, who ultimately recommended a nonsteroidal anti-inflammatory drug called ketorolac. The patient remembered that she received ketorolac for a dental procedure and that it had really helped with the pain.

Communication and Education

Soon after rolling out the new opioid stewardship program, the pharmacists experienced a bit of pushback from physicians who were used to ordering opioids and from patients who expected to get them. The pharmacy team used a combination of communication and education to demonstrate why opioid alternatives can often be a better option.

ED physician Katrina Hutton, D.O., and Dr. Bennett talk about opioid alternatives for a patient being discharged.

On the patient side, the pharmacy team assisted nurses with answering patients’ questions about the alternative medications and made sure that patients’ pain needs were always being met. “There were many times when I was called to a room to explain to a patient how the alternative medication works and why it is better than an opioid,” explained Dr. Brent. “Sometimes the patient was satisfied with the explanation, and other times they weren’t.” He believes the conversations with patients helped them understand that the providers in the ED were trying to do what was best for them, instead of just defaulting to using opioids.

Although the physicians were excited about the change and enthusiastic about providing more appropriate care for their patients, “it was still difficult for them to curb their opioid use, since it was a habit for them to order opioids,” said Dr. Brent. “Once our providers knew they had support [from hospital leadership], and we provided them with the order sets and educated the nurses about opioid alternatives, they were all in.”

Satisfied Patients, Satisfied Providers

As a result of implementing the opioid stewardship program in the ED at Baptist Memorial, opioid use decreased by 73 percent. Where previously one out of four patients received a dose of an opioid in the ED, the number has now dropped to 1 out of 10. Patient satisfaction with how they felt their pain was being addressed increased by around 30 percent.

Dr. Brent believes the entire team of ED pharmacists, physicians, and nurses at Baptist Memorial has done a great job of communicating to the patient why they are being given an opioid alternative. “We are all focused on taking care of patients effectively and efficiently,” said Dr. Brent. “Through the opioid alternative program, pharmacists are providing physicians and nurses with the support to do that. ED pharmacists are in the perfect position to partner with our providers to give them the tools needed to take care of patients appropriately.”

 

By Ann Latner

 

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