ASHP InterSections ASHP InterSections

September 25, 2013

HENs Offer Opportunities for Pharmacists to Improve Patient Care

 

Hospital Engagement Networks are bringing together pharmacists, physicians, and nurses to improve patient outcomes in areas such as preventable infections, adverse drug events, and preventable readmissions.

A COLLABORATION BETWEEN ASHP and the American Hospital Association is yielding exciting opportunities for pharmacists to improve patient care across the country.

The two organizations are working together to increase pharmacist participation in Hospital Engagement Networks (HENs), part of the Centers for Medicare & Medicaid Services’ (CMS’s) Partnership for Patients program.

Approximately 3,700 hospitals participate in HENs, choosing among 10 areas in which to improve quality measures, including surgical site infections, adverse drug events, central line-associated bloodstream infections, venous thromboembolism, catheter-associated urinary tract infections, ventilator-associated pneumonia, and preventable readmissions.

The hospitals then share their successes with partnering organizations to help others replicate what they have achieved.

Pharmacists are a Natural Fit

Because so many of the primary goals for HENs involve medication therapy, pharmacists are in a perfect position to help as medication experts on the health care team. And when the American Hospital Association’s Health Research and Educational Trust (HRET) received a CMS grant to create a HEN, approaching ASHP seemed like a no-brainer.

The HRET HEN is focused on identifying solutions that are already reducing health care-acquired conditions and disseminating them to other hospitals and health care providers, according to David G. Schulke, HRET’s vice president of research programs in Washington, D.C.

“It was natural to reach out to ASHP because many readmissions are attributable to breakdowns in drug therapy, and pharmacists are well-trained and have tremendous knowledge in that area,” Schulke said. “I’ve worked with pharmacists and ASHP for many years, and HRET wanted to see if we could use that existing relationship to knit pharmacists into the HEN’s implementation teams.”

Beverly L. Black, MHSA, CAE

Beverly L. Black, MHSA, CAE

ASHP then turned to its strong network of state affiliates to reach members who might be interested in participating.

“Depending on what a state affiliate is focusing on, they may be able to recruit pharmacists to get involved,” said Beverly L. Black, MHSA, CAE, ASHP’s director of affiliate relations. She added that pharmacists attend workshops as presenters or participants, work within their health systems to design and implement quality improvement programs as part of the HEN, and forge strong partnerships among state health-system pharmacy groups and state hospital associations.

“These relationships are important because we are common stakeholders in ensuring that patients receive optimal therapy.”

Narrowing the Focus

Developing initiatives relevant to a hospital’s or health system’s needs, measuring outcomes, and sharing information with other providers in the network are major facets of the HRET HEN.

At Purdue University’s Center for Medication Safety Advancement in Indiana, pharmacists collaborated with the Indiana Hospital Association to create the Indiana Medication Safety Alliance. Last November, the Alliance hosted a conference about medication safety, ADEs and readmissions. Now the group has its own website, provides ongoing coaching, and hosts conference calls every other month or so.

The group initially focused on two measures, successful anticoagulation with warfarin and avoidance of hypoglycemia among insulin users, but has since whittled its efforts down to improving anticoagulation.

John B. Hertig, Pharm.D., M.S.

John B. Hertig, Pharm.D., M.S.

Narrowing the focus was essential because the HEN’s guidance offers so many possible areas for improvement, said John B. Hertig, Pharm.D., M.S., the Center’s associate director.

“The HRET HEN’s Encyclopedia of Measures contains more than 100 distinct measures. So, zeroing in on warfarin was a strategic decision because the HEN was looking at patient harm with regard to ADEs and the hospitals in Indiana were reporting [issues with anticoagulation] more than anything else,” Hertig said.

At the University of Arkansas for Medical Sciences in Little Rock, the focus is on reducing readmissions for heart failure patients.

“When Medicaid announced penalties for pneumonia, acute myocardial infarction, and heart failure, we decided to take a look at how that would affect us,” said Niki Carver, Pharm.D., assistant director of pharmacy.

“After working on medication reconciliation for years, I wondered if there was a way the pharmacy could be notified when heart failure patients were admitted so the pharmacy could obtain medication histories for those patients.”

Carver knew such an effort would have an impact on the pharmacy’s workload, so she created an elective rotation for fourth-year pharmacy students that tasks them with obtaining medication histories and assisting in quality improvement efforts. Thus far, reductions in monthly readmission rates for patients with congestive heart failure have ranged from 1.67 to 4.43 percent.

Pharmacists at The Johns Hopkins Hospital are working to improve HCAHPS scores related to educating patients about their medicines. Above, a pharmacist talks to a patient about how to properly use an insulin pen.

Above left, Leigh Efird, Pharm.D., BCPS, clinical pharmacy specialist, The Johns Hopkins Hospital, teaches a patient how to properly use an insulin pen.

Working Smarter, Not Harder

The Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) served as a catalyst for involving pharmacists in the HRET HEN at The Johns Hopkins Hospital in Baltimore, where their goal is to improve HCAHPS scores for medication-related questions.

“When we partnered with the Maryland Hospital Association, they knew we were working on issues related to HCAHPS,” said Meghan Davlin Swarthout, Pharm.D., MBA, BCPS, division director, ambulatory and care transitions.

“We were able to take actionable steps toward our goals and share information with other hospitals about our successes.”

Swarthout said that the hospital has increased its “Always” HCAHPS score from the 48th percentile in the second quarter of FY2013 to the 84th percentile in the fourth quarter for the survey question, “When I left the hospital, I clearly understood the purpose for taking each of my medications.”

Swarthout also stressed the value of sharing information within the network. “Sometimes the goals for quality and safety can be overwhelming. HENs bring in the expertise of your peers, and they can help you target your biggest problems,” she said.

Carver noted that HENs eliminate redundancy. “You hear what other hospitals have done, take what you need for your institution, make changes that fit your setting and implement them, instead of starting something from scratch.”

Pharmacist involvement in the HRET HEN is still fairly sporadic. For example, in a statewide workshop of roughly 250 attendees that Swarthout attended, only about 10 participants were pharmacists. Yet despite the relatively small number of pharmacists there, they made an impact: Once the other participants heard what the pharmacists had to say about safe medication use, many indicated they would promote better use of pharmacists’ skill within their own institutions.

ASHP is hopeful that by encouraging affiliate members to participate in the state-level HENS, other health systems will likewise more fully understand the valuable role that pharmacists play in ensuring patient safety and optimal health outcomes.

“We believe that if more pharmacists knew the benefits of participating in the HENs network, they would be more interested in participating,” Swarthout said. “We all have days when it feels like we’re not making any improvements, and that can be discouraging. But when you hear other people in the HEN talk about the same things, you realize you are not alone. You come away with ideas and external motivation.”

Showcasing Pharmacists’ Skills

HENs are also an excellent way to advance the profession, according to Hertig.

“It’s an opportunity for pharmacists to showcase their skills and abilities as members of interdisciplinary teams,” he said. “But it’s also in line with ASHP’s Pharmacy Practice Model Initiative in that it helps pharmacists work at the top of their licenses. What better avenue to show the impact we can have than a federal program where we work with nurses, physicians, and other professionals?”

Shekhar Mehta, Pharm.D., M.S.

Shekhar Mehta, Pharm.D., M.S.

Shekhar Mehta, Pharm.D., M.S., ASHP’s director of clinical guidelines and quality improvement, agreed.

“ASHP is primarily concerned with patient care, medication-use safety, and ensuring that pharmacists are part of a collaborative care team. So, this initiative supports all those goals,” he said.

“Pharmacists are also the most knowledgeable members of the team when it comes to medication use, and that’s a big issue in health care reform in improving the quality of care and lowering readmissions.”

Ultimately, patients are the ones who benefit most, said Carver.

“Skeptics will say that it’s more work for pharmacists, and it is. But if you’re in hospital pharmacy, you’re in it to improve patient care. And the outcomes you will see with this program are astounding.”

—Terri D’Arrigo

Editor’s Note: Interested in getting involved with an HRET HEN program? Send an email to affiliates@ashp.org, and we’ll put you in touch with the right resources within your state.

 

July 22, 2013

Interprofessional Collaboration: ASHP’s Response to the AMA

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

In June of this year, the American Medical Association (AMA) passed a resolution that caused concern among many of us.  At first glance, it’s no wonder why the policy gave us pause, as it states that “a pharmacist who makes inappropriate queries on a physician’s rationale behind a prescription, diagnosis, or treatment plan is interfering with the practice of medicine.”

While this statement seems to throw up a barrier to the good, productive collaborative relationships that best benefit patients–and that pharmacists, physicians, and patients have all grown to appreciate–it’s important to look at what was at its root: this nation’s drug abuse problem.  The AMA’s statement is a response to the efforts of some pharmacies in light of the federal government’s stepped-up enforcement to prevent diversion and better control the epidemic of prescription drug abuse.

Certain pharmacies, in response to enhanced scrutiny and enforcement efforts by the Drug Enforcement Administration, are calling and faxing to verify the legitimacy of every controlled substance prescription before filling. The burden this has placed on some physicians’ offices gave rise to this new AMA policy.

I recently wrote a letter to the CEO of the AMA that stressed the long history of collaboration that exists between pharmacists and physicians in hospitals, health systems, and ambulatory clinics. My letter confirmed that ASHP would be pleased to work with the AMA and other stakeholders to find solutions to the broader problem of prescription drug abuse, which ideally would include more effective communications and interprofessional collaboration among pharmacists, physicians, other health care providers, policymakers, and law enforcement.

The nature of today’s health care delivery system depends on professional collaboration to make sure our patients are getting the best health care possible.  Over the course of my 35-plus years in practice, and here at ASHP, I’ve seen firsthand how that collaboration has grown exponentially,  and is now widespread, not only in our nation’s hospitals and clinics, but with our community pharmacy partners.

And, indeed, we hear the same from our physician colleagues. In fact, Richard Pieters, M.D., the physician who wrote the draft for the AMA resolution, described his working relationship with pharmacists as “excellent” in an interview with Pharmacy Practice News. He added that “pharmacists are very valuable members of the team.”

Pieters, who is a radiation oncologist at the University of Massachusetts Medical Center and president-elect of the Massachusetts Medical Society, went on to state that, as a physician who is board-certified in hospice and palliative medicine, he finds pharmacists to be “fantastic resources.”

With a strong commitment to getting to the right issues in the right ways, pharmacists and physicians can both be part of the solution to our nation’s epidemic of prescription drug abuse in a way that encourages the interprofessional collaboration that best serves our patients.

July 17, 2013

Novel Missouri MTM Program Benefits Patients, Pharmacists

DC Pro is a feature of the MO HealthNet Medicaid program.

DC Pro is a feature of the MO HealthNet Medicaid program.

A NEW FEATURE OF MISSOURI’S MEDICAID PROGRAM is drawing admiration from health care experts around the country for its ability to bring pharmacists and patients together.

The program in question—Direct Care Pro (DCPro)—provides pharmacists with a database of patients in their area who are eligible for medication therapy management (MTM) and other cognitive therapies.

Gloria Sachdev, Pharm.D., a clinical assistant professor, primary care, at Purdue University, West Lafayette, Ind., and director-at-large of ASHP’s Executive Committee for the Section of Ambulatory Care Practitioners, is one of the program’s admirers.

​“I would love Indiana to one day have the IT infrastructure in place to provide MTM like Missouri does,” she said, calling DCPro “an amazing example of how to operationalize MTM services in a streamlined manner.”

Gloria Sachdev, Pharm.D.

Gloria Sachdev, Pharm.D.

Pharmacists under the Missouri program receive direct reimbursement as health care providers, and a variety of conditions are covered, including asthma, chronic obstructive pulmonary disease, diabetes, gastroesophageal reflux disease, heart failure, hypertension, and hyperlipidemia.

“The number of covered conditions is constantly expanding,” according to Sandra Bollinger, Pharm.D., provider outreach coordinator with Xerox, which manages MO HealthNet. She added that only a handful of states allow pharmacists to bill directly to their Medicaid programs as health care providers.

Helping Patients During Care Transitions

The program is an excellent example of how pharmacists can help patients during transitions of care, according to Justine Coffey, JD, LLM, director of ASHP’s Section of Ambulatory Care Practitioners.

“It’s a great model because it ensures that patients receive the care they need once they leave the hospital and are back in the community setting,” Coffey said, noting that patients receive better care when pharmacists are involved in medication management decisions.

“This program provides both an opportunity for better patient care and new opportunities to advance ambulatory pharmacy practice.”

Opportunities for Intervention

Pharmacists who are registered with MO HealthNet can log into the DCPro system and view a list of all patients who are eligible for cognitive services. The information is based on gaps in Medicaid claims that would have been filed had the patient been keeping up with their care for a particular disease state.

Next, pharmacists select which patients they want to assist and then “reserve” an intervention (many patients are eligible for multiple interventions). They then contact patients and arrange face-to-face consultations. Interventions can take place in outpatient clinics, patients’ homes, or in areas of community pharmacies that are designated for patient care. Once reserved, an intervention must be completed within 30 days or the patient is released back into the database.

For example, consider an MO HealthNet patient who has diabetes, but has not had an A1C blood test for more than 90 days. The MO HealthNet system will detect that a claim for the test has not been filed.

Based on that care gap, the system automatically adds that patient’s name and flags the intervention for which the patient is overdue. A pharmacist seeing the information can provide the test as well as additional counseling.

During an intervention, DCPro guides the pharmacist through questions that must be answered before it allows users to move to the next topic. It also fills in progress notes and submits the billing automatically once an intervention is complete.

Reimbursement (which is based on the amount of time spent with the patient rather than the nature of the intervention) is calculated in 15-minute increments. Payment ranges from $10-$20 per 15-minute period with a one-hour maximum per intervention. There is no limit on the number of intervention hours a pharmacist can bill annually.

“Pharmacists who use the system don’t have to keep their own records regarding which patients are eligible. They can just log in to see a complete list of all eligible patients in their area,” said Dr. Bollinger. The system also handles all recordkeeping and billing.

Justin May, Pharm.D.

Justin May, Pharm.D.

Utilizing Program Results to Increase Pharmacist Reimbursement

Pharmacists at Red Cross Pharmacy’s 15 locations regularly check DCPro for any pending MTM and cognitive therapy claims, said Justin May, Pharm.D., director of pharmacy with the chain, based in Marshall, MO.

“Ideally, we use the system as part of our adherence program,” he explained. “A pharmacist takes a look at a patient’s medications five to seven days before the prescriptions are filled and identifies patients who require cognitive services. Then, they set up intervention times. When patients come in to pick up their prescriptions, we sit down with them to conduct the interventions for whatever health issues are indicated.”

Chuck Termini, B.S. Pharm., RPh, a hospital staff pharmacist and independent clinical pharmacist in Kansas City, MO, connects with many of his MO HealthNet patients through referrals from nursing homes and community pharmacies, who contract with him to provide cognitive services. But he also mines the database for additional interventions.

“I almost always find patients who need help,” Termini said, estimating that he interacts with about 60 MO HealthNet patients each month.

Although pharmacist enrollment in the system has been slow to catch on, Dr. Bollinger is optimistic that the numbers will grow as pharmacists learn of these new opportunities for patient intervention and care.

“My goal is to get every pharmacist in the state enrolled,” she said, adding that growing enrollment will help her make a case to state legislators to increase reimbursement rates. “It may take a little time, but I’m confident they will increase eventually.”

Dr. Bollinger also said that MO HealthNet has been able to demonstrate cost savings resulting from decreased emergency room visits and hospitalizations among patients who participated in the program.

“This is a huge opportunity for health-system pharmacists who can get past the idea that the business comes to them, because it doesn’t,” said Termini. “You have to be proactive in assisting patients.”

–By Steve Frandzel

           

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