improving transitions of care from hospital to home or hospital … · 2017-11-27 · improving...

ImprovingTransitionsofCarefromHospitaltoHomeorHospitalto

SkilledNursingFacilities

JohnFanikos,BS,MBAExecutiveDirector,PharmacyBrighamandWomen’sHospital

Boston,MANovember27,2017

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

ConflictofInterestStatement

• Consultant– PortolaPharmaceuticals

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

Objectives• Describepatientflowfromhospitalstolongtermacutecarefacilities(LTACs),SkilledNursingFacilities(SNFs),andhome.

• Identifychallengesinprovidingextendedvenousthromboembolismprophylaxisinthesetransitionsofcare.

• Identifypotentialsolutionstoensurepatientssafety.

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

Outline

• PatientflowfromhospitalstoLTACs,SNFs,andhome.

• TheElectronicHealthRecord(EHR)• EnsuringaccesstoVTEprophylaxis• Patientengagement,education,support,andfollow-up

• Justifyingexpense• Summary

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

PatientcareSettingsinHealthcare

SNF=skillednursingfacility,LTACH=Longtermacutecarehospital

Hospital SNF LTACHLevel ofcare Acutecare Rehabilitation AcutecareTypeofpatient

Complexmedicalorsurgical

Custodialcare Complexmedicalcare

Reimbursement

Medicare,Medicaid,insurance,privatepay

Medicare,Medicaid,insurance,privatepay

Medicare,insurance,privatepay

Lengthofstay

Anyperiod Anyperiod,Medicarestartsaftera3-dayqualified stay

Must beover25days

Locations Freestandingorpartofanintegrateddeliverysystem

Canbeaffiliatedwithcontinuing careretirementcommunity

Freestandinghospital or“hospitalinahospital”

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

DischargeFromtheHospitalandPrescriptionFulfilment

LTAC:LongTermAcuteCareHospital,SNF:SkilledNursingFacility

Risk

Assessmen

tProp

hylaxis

Selection

Discha

rge&

Fulfillm

ent

Compliance

&

Persisten

ceOrig

ination

LTACSNF

Patient

Receives drug from SNF/LTC pharmacy

Patient

Receives drug from inpatient pharmacy

Discharge planner shares discharge instructions with SNF or LTAC

as necessary

Discharge planner completes drug authorization process

Home HealthCommunity

PositiveOutcomesPrior authorization not required or

prior authorization approved

ChallengingResultsof

Prior authorization denied by payor

Product not stocked at retail facility

Patient reverse the prescription

Receives drug from Meds2Beds prior to discharge

Or

Receives drug from retail pharmacy

Patient

Does may not receive drug

Patient

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

EHR-PrescribeVTEProphylaxis

PharmacologicOptions

MechanicalOptions

NoteAlphabeticalordersoBetrixaban islisted1st

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

Question AnswerWhereistheprogram? Theinpatientmedicalunit.

Who is eligiblefortheprogram?

Anypatientnotinanyformofisolation.

Whoalertstheprogramtopatients?

Theadmittingnurseinformspatientsoftheprogramandoffersenrollment.

Howisinformationrelayedtothepharmacy?

IT softwarelinks thehospitalandpharmacycomputersystem.

Who fillstheprescriptions?

Currently,theoutpatientpharmacyisfillingtheprescriptions.

HowaretheRXsrelayedtothepharmacyforfilling?

Prescriptionsareeithere-scriptsorhardcopiesfaxedtothepharmacy.

Whowilldelivertheprescriptions &counsel patients?

RPhs, studentsorinternsdeliverprescriptions. 8

Med-to-Beds

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

• Singlecenter,tertiaryorthopediccenter

• THRTKRtreatedwithrivaroxabanfor14or35days.

• Follow-upat6weekswithpatientselfadministeredquestionnaire.

• Gender,age,BMI,Hemoglobin,allcorrelatedwithnon-compliance.

Carrothers AD.JArthroplasty 2014:29:1463-1467.

PersistencewithDOACsinOrthopedics

9

In-hospitalprophylaxis(n=2947,94%)

Arthroplastycases(n=3145,100%)

CompletedallIn-hospitalprophylaxis

(n=2824,96%)

Tookalldoses(n=2163,83%)

Completed6-weekfollow-up(n=2621,96%)

Convertedtoalternative(n=198,6%)

Didnotcompleteinhospitalprophylaxis,

(n=123,4%)

Didnotattendfollow-up,(n=203,3%)

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

ShoreS.JAMA2015:313:1443-1450.

VeteransHealthAdministrationSites

67sites,4863patients

AnticoagulationorOutpatientClinics

PATIENTFOCUSEDEVENTSonNOAC

Selection• Indication• Adherence

Education• Adverse

events• Misseddoses• Falls• Dailydosing• Interactions

Monitoring• Stroke• Bleeding• Surgery• Missed

doses

Pharmacistsattheperformingsites

Patients %Adherent

Nomonitoring

1042 65.2

Tailored tonon-adherent

1117 79.2

Telephone 1425 75.2

Face-Face 198 84.5

3mos 1176 74.8

> 12mos 405 83.2

PatientFocusedActivitiesandAdherence

0.51.02.0

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

CareDelivery:PreventionofVTE

11Lenchus JD.Adv Ther 2016;33:29-45;BarnesGD.Circ Cardiovasc Qual Outcomes.2016;9:182-185.

AnticoagulationManagementServices

Assistinselectionofoptimumagentand

dose

Minimizeseriousbleeding

complications

Monitorand

encourageadherence

Tailortopatientco-morbidities

andpreferences

Signs&symptoms,interruptions

Access,misseddoses,

challenges

Constantco

ntact&

rapidrespon

se

Consideragent,duration,prescribeappropriateVTEprophylaxis

Patientadmittedtothehospital

Clinicalendpoints

AssesspatientsVTErisklevel,contraindications,adverseevents

MDperformsVTEriskassessment

MDordersappropriateVTEprophylaxis

RNdeliversVTEprophylaxis

Computerlinkspatient’sVTErisktoappropriateVTEprophylaxis

Admiss

ion

Careand

edu

catio

nDischa

rge

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

HeidbuchelH.EuHeartJ2016: pii: ehw058.

Follow-upMonitoringCheckListTask Interval CommentsAssesscompliance

Eachcontact

Bringremainingmedication.Re-educateonimportanceofstrictintakescheduleInformaboutcomplianceaids(specialboxes;smartphone applications,etc.).

Assessforthromboembolism

Signs,symptoms,systemic(peripheral,pulmonary)circulation.

Assessforbleeding

Ifminor(nuisance)bleeding,arepreventivemeasurespossible?(eg.PPI,salinenosespray,etc.).Motivatepatienttodiligentlycontinueanticoagulation.Ifbleedingwithimpactonquality-of-lifeorwithsignificantrisk,ispreventionpossible?

Assessforothersideeffects

AssessforlinktoDOACanddecidewhethertocontinue,temporarilystop,orchangetodifferentanticoagulant.

Assessfornewco-medications

AssessforP-gpinhibitors/inducersordualP-gp/CYP3A4inhibitorsAssessforothermedicationsthatmayincreaseriskofbleedingsuchasanti-platelets.

Assesslabs Asneeded

Hgb,renalandliverfunctionIfclinicallyindicatedforconditionsthatmayimpact

12

150,000dosesperyear$0.83pervial

$124,000annualspend

50,000dosesperyear$3.70persyringe

$185,000annualspend

Heparin5000units Enoxaparin40mg Rivaroxaban10mg

100dosesperyear$9.05pertablet

$1,000annualspend

ComparisonsinUtilization

ProvidedthroughMcKessonConnect

43,406TotalHospitalAdmissions15,760MedicalIllAdmissionsX5.8daylengthofstay91,408hospitaldaysx$9.05DOACperday----------------------------------------------------------$827,242peryearincrementalDOAChospitalspend

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

ApplicationofGlobalPerspectiveModeling43,406Admissions

8,556HighVTERiskMedicallyIll

5,362APEXEligible

997BetrixabanTreatedPatients

22VTEeventsavoided

15Fatalorirreversibleeventsavoided

20%Betrixabanprescribing

ACCPdefined“VTERisk”

Applyinclusioncriteria

$148,692

$478,239

$1,459,660$918,474

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

Enoxaparin Betrixaban

Drug$(hospital) Drug$(post-acute) Event$

ApplyAPEXResults

NetSavings$182,346annually

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

MedicarePart-D:PrescriptionDrugCoverage

EnrolleePays5%Planpays15%Medicarepays80%

Enrolleepays100%

Enrolleepays25%

Planpays75%

$3,700Coveragegap(Donuthole)

$4,950outofpocket)

$3,700totaldrugcosts

$400deductible

40%discountonbrandnameformularydrugs

StandardMedicarePrescriptionDrugBenefitItems that Count Towards the

Gap

• Your yearly deductible

• The discount you get on brand name drugs in the coverage gap

• What you pay in the coverage gap

Items that Don’t Count Towards the Gap

• Your drug plan premium

• Pharmacy dispensing fee

• What you pay for drugs that are not covered

Availableat:www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html.

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

PatientAssistancePrograms•Co-paymentcouponcardorvoucherforpatients.•Patientscanobtainuptotwelve30-daysupplies(over15months).•Patientswithcommercialinsurancepaynomorethan$10-30foreachprescription,withamaximumbenefitof$100permonth.

GrandeD.JAMA.2012;307:2375-2376.Sanger-Katz.NYTimes.Availableat:https://www.nytimes.com/2016/10/13/upshot/drug-coupons-helping-a-few-at-the-expense-of-everyone.html?_r=0.Dafny L.NEJM2016:375:2013--2015

Drug Co-Pay DiscountedCo-pay RetailPrice InsurerCost

Lipitor $360 $48 $2,004 $1,644Crestor $360 $216 $1,872 $1,512Simvastatin $120 $120 $336 $216

New YorkTimes“DrugCoupons:HelpingaFewatthe

ExpenseofEveryone”• Couponsfor23drugswithagenericalternativesresultedinanextra$700millionto$2.7billioninspendingondrugsoverfiveyears.

Sponsor Website Sponsor Website

The Assistance Fund www.theassistancefund.org National Organization of Rare Disorders

www.rarediseases.org

Chronic Disease Fund www.cdfund.org Patient Access Network Foundation

www.panfoundation.org

Healthwell Foundation www.healthwell.org Patient Advocate Foundation

www.copays.org

PatientAssistanceFoundations andFunds

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.

Summary• PatientstreatedwithextendedVTEprophylaxiswillflowfromhospitalstoLTACs,andSNFs.

• EHRfacilitatescommunicatingplanforextendedVTEprophylaxis.

• “Meds-to-Beds”facilitatesandensuresaccesstomedication

• ExtendedVTEprophylaxismustbesupportedwithpatientengagementandeducation.

• Newmedicationsarealwaysviewedasexpensive.ExtendedVTEprophylaxisrequiresexplanationofthebeneficialoutcomesandcostavoidance.

ThereWILLNOTbeoff-labeland/orinvestigationaldiscussioninthispresentation.