Karen Pellegrin, PhD, MBAkaren3@hawaii.edu

Daniel K. Inouye College of PharmacyCenter for Rural Health Science

University of Hawaii at Hilo

CMS INNOVATION CENTER

Established in 2010 via the “Affordable Care Act” (aka “Obamacare”)

“Congress created the Innovation Center for the purpose of testing ‘innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits.’”

https://innovation.cms.gov/About

OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY (ONC)

ONC scope of work mandated in the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, including:

State Health Information Exchange Cooperative Agreement Program

Regional Extension Centers

Workforce Development Program

Beacon Community Program

https://www.healthit.gov/topic/laws-regulation-and-policy/health-it-legislation

U.S. CONTEXT: COST BURDEN

U.S. CONTEXT: THE “SILVER TSUNAMI”

U.S. CONTEXT: COST OF HOSPITAL CARE VS. DRUGS

HAWAII CONTEXT

*Pellegrin KL, Miyamura J, Taniguchi R, Ciarleglio AE, Barbato A, Holuby RS. Using ICD codes to track medication-related hospitalizations of older adults. Journal of the American Geriatrics Society (JAGS); 2016, Vol. 64(3), 651-653.

*This project was supported by a grant from the U.S. Department of Agriculture, National Institute of Food and Agriculture (NIFA) Rural Health and Safety Education Competitive Grants Program (USDA-CSREES-RHSE-002255), Medication Safety Education for Elderly in Rural Areas (award #: 2009-46100-06032). The content is solely the responsibility of the authors and does not necessarily represent the official views of the USDA.

0.9%

3.4%

6.8%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

0-17 18-64 65+

AGE GROUP

% of hospitalizations that are "medication-related" per ICD codein Hawaii, 2010*

WHAT IS “MEDICATION-RELATED”?

ICD codes used by AHRQ & CMS Innovation Center:357.6 (neuropathy due to drugs)

692.3 (contact dermatitis due to drugs and medicines in contact with skin)

693.0 (dermatitis due to drugs or medicines taken internally)

960.0-964.9, 965.02-969.5, 969.8-979.9 (poisoning by drugs, medicinal and biological substances, including overdose of these substances and wrong substances given or taken in error)

E850.1-E858.9 (accidental poisoning by drugs, medicinal substances, and biologicals, including accidental overdose, wrong dose given or taken in error, and drug taken inadvertently)

E930.0-E934.9, E935.1-E949.9 (drugs, medicinal substances, and biologicals causing adverse effects in therapeutic use, including correct drug properly administered in therapeutic or prophylactic dosage as the cause of any adverse reaction including Allergic or hypersensitivity reactions)

THE VISION OF PHARM-2-PHARM

Leverage underutilized pharmacist expertise across the continuum of care to achieve the three-part aim of the CMS Innovation Center: • Better care• Better health• Lower total costs

“Pharm2Pharm” = “Hospital Pharmacist to Community Pharmacist” care transition and coordination model focused on medications

IDENTIFYING PATIENTS AT RISK: INCLUSION CRITERIA

1: Patient is on 15 or more medications

2: Patient is on 10 or more medications AND at least one of those is high risk (i.e., narrow therapeutic index and/or commonly implicated in medication-related hospitalizations)

3: Current acute care episode is due to a drug therapy problem

4: Two or more previous acute care visits (ER, hospitalization, or observation stay) for uncontrolled chronic condition within past 3 months OR any previous hospitalization for uncontrolled chronic condition within past 12 months

5: Newly diagnosed Acute Coronary Syndrome, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and/or Diabetes AND being discharged on a new home medication regimen for the condition(s)

6: Age less than 65 with all 5 of the following OR age 65 or older with at least 4 of the following

- Use of 1 or more medication with narrow therapeutic index

- Use of 1 or more medication commonly implicated in medication-related hospitalizations

- Five or more medications

- Three or more chronic conditions

- Any ED use or non-elective hospitalization/observation stay within past 12 months

See details in Standard Operating Procedures

DEFINITIONS

rrow Therapeutic Index (NTI) drugs are defined as those with less than a 2-fold difference between median lethal dose and median effective dose1

ugs commonly implicated in medication-related hospitalizations: Warfarin, oral antiplatelet agents, insulins, oral hypoglycemic agents, digoxin, opioid analgesics2

ug therapy problems: Indication (i.e., untreated indication or unnecessary medication), effectiveness (i.e., dose too low or more effective alternative available), safety (i.e., adverse drug reaction or dose too high), adherence (i.e., patient non-compliant)3

ronic condition is defined as a condition that lasts a year or more and requires ongoing medical attention and/or limits activities of daily living.4

1 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_part3.pdf2 Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2001-12.3 Pharmaceutical Care Practice – The Patient Centered Approach, Cipolle, Morley, and Strand, 3rd Edition, McGraw Hill, 20124 http://www.hhs.gov/ash/initiatives/mcc/#_edn3

NTIFYING PATIENTS AT RISK: EXCLUSION CRITERIA

Not a full-time county resident

No reasonable expectation of being discharged to home or short-term rehab (SNF status)

Severe dementia

Active psychosis

Hospitalization related to a suicide or homicide attempt

Leaves facility against medical advice (AMA)

See details in Standard Operating Procedures

PHARM-2-PHARM MEDICATION PROCESSES*

f C C

See details in Standard Operating Procedures

PHARM-2-PHARM MODEL IMPLEMENTATION

Launched sequentially in all 4 counties in Hawaii, starting with 3 rural counties

> 2,500 high risk patients enrolled by Hospital Consulting Pharmacists and handed off to Community Consulting Pharmacists

Implemented:

- As an all-payer, population health intervention

- Using a continuous quality improvement approach, including…

ocedures

ols/templates

aining

TRAINING NOW AVAILABLE ONLINEhttp://pharmacy.uhh.hawaii.edu/ce/irdtp.php

HEALTH INFORMATION TECHNOLOGY: GUIDING PRINCIPLES*

1. The Pharm2Pharm model would be independent of and implemented before the supporting health IT. This ensured that the model itself could be replicated in any environment and that the health IT was designed based on experience with the model.

2. The health IT implemented to support the Pharm2Pharm model would add value to the healthcare system beyond that model to make the best use of the investment in health IT.

HEALTH INFORMATION TECHNOLOGY PRIORITY NEEDS IDENTIFIED BY PHARMACISTS*

HEALTH INFORMATION TECHNOLOGY IMPLEMENTEDBY HAWAII HEALTH INFORMATION EXCHANGE*

CS MEDICATION RECONCILIATION ND DECISION SUPPORT TOOL

obust data sources including but not limited to:

PBM’s MedCo, Caremark, Catamaran, ExpressScripts, Argus

Pharmacies CVS, Walgreens, Safeway

nsurance HMSA, Wellpoint, Aetna, Humana

Surescripts

HCS MEDICATION MODULE VIA HHIEdinal fill history screen shot: shows gaps in med use

HCS MEDICATION MODULE VIA HHIEted Med Rec Screen Shot: shows “inactivated med’s” (previous doses and regimens),

n-added OTC’s and herbals

HCS MEDICATION MODULE VIA HHIEe Completed Med Rec: shows dose, route, frequency and recommended changes.

HCS MEDICATION MODULE VIA HHIEtifier

HCS MEDICATION MODULE VIA HHIEon checker identifies drug-drug, drug-disease, duplicates and drug allergy interactions.

HCS MEDICATION MODULE VIA HHIEe Patient Education Materials

MANY PROCESS MEASURES, INCLUDING

- Med rec completed

- Drug therapy problems identified / resolved

- Patient education

- Days between discharge and first visit

- # visits per month

- Contacts with prescribers

- Satisfaction with Pharm2Pharm- Patient- Physician- Pharmacist

- Reason for readmission

OUTCOME EVALUATION DESIGN

Interrupted time series design with:

- quarterly outcome measure: medication-related hospitalization rate among 65+

- 3-year baseline period

- different launch times across hospitals

- all 11 non-federal, general, acute care hospitals with 50+ beds comparing:

- 6 Pharm2Pharm hospitals

- 5 hospitals without Pharm2Pharm

Handley MA, Lyles CR, McCulloch C, Cattamanchi A. Selecting and improving quasi-experimental designs in effectiveness and implementation research. Annual review of public health. 2018 Jan 12(0).

Care transition dox via secure message

HCS med rec

LAN,R&R

CommunityHealth Record

COST SAVINGS DUE TO PHARM2PHARM / ROImedication-related admission rates 2014-Q4:

mparison group rate per 1,000 admissions 72.14

ervention group rate per 1,000 admissions 45.83

erence between comparison group and intervention group rates (A-B) 26.31

number of admissions among those age 65 or older at intervention hospitals 2014 14,966

ed number of avoided medication-related admissions per year among those age 65 or older

d with the intervention (C x (D / 1,000))393.75

cost of a medication-related hospitalization for a patient age 65 or older across intervention

n 2014 based on Medicare cost-to-charge ratio$16,830.02

ted annual cost of avoided medication-related admissions among those age 65 and older

d with the intervention (E x F)$6,626,913

annual cost of pharmacist services to deliver the intervention $1,820,454

return on investment in pharmacist services ((G – H) / H) 264%grin, Krenk, Jolson-Oakes, Ciarleglio, Lynn, McInnis, Bairos, Gomez, Benitez-McCrary, Hanlon, amura. Reductions in Medication‐Related Hospitalizations in Older Adults with Medication gement by Hospital and Community Pharmacists: A Quasi‐Experimental Study Journal of the

American Geriatrics Society, 7 OCT 2016 DOI: 10.1111/jgs.14518

ACKNOWLEDGEMENT OF FEDERAL FUNDING

The project described is supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation.

Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.