linda brocato, rph pharmacy manager westerly hospital mark rogers, pharmd, cdoe clinical pharmacy...
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Linda Brocato, RPhPharmacy Manager
Westerly Hospital
Mark Rogers, PharmD, CDOEClinical Pharmacy Supervisor
Westerly Hospital
Kevin Emond, PharmD Candidate ‘16University of Saint Joseph School of Pharmacy
“A Patient Safety and Improved Outcomes Initiative”
Objectives
Pharmacist Objectives
Examine the relationship between accurate medication reconciliation and positive patient outcomes
Identify the impact of pharmacy driven home medication verification
Explain the connection between medication reconciliation and cost avoidance savings
Objectives
Technician Objectives
Describe the impact that pharmacy technicians have on home medication verification
Understand the importance of medication reconciliation during transitions of care
Background
Over 110 million ED visits annually in the United States Approx. 45 visits per 100 persons
Research shows increasing trends in the usage of Emergency Departments as sources of Primary Care
BOTTOM LINE: Larger patient volumes and transitions of care may lead to
increases in adverse reactions, poor patient outcomes, and increased cost of interventionsNana B, Lee-Such S, Allen G. Initiation of an emergency department pharmacy program during
economically challenging times. Am J Health-Sys Pharm. 2012;69:1682-86.
Background
Westerly Hospital strives to achieve positive health outcomes and meet or exceed standards set by regulatory institutions Joint Commission - NPSG compliance 03.06.01 Centers of Medicare and Medicaid Services Affordable Care Act
Home Medication Verification (HMV) program
Medication Reconciliation
Studies have shown that Med Rec (MR) decreases rates of adverse drug events as well as increases positive patient outcomes
Nana et al. demonstrates the benefits of proper MR by highlighting associated positive outcomes
Reduced rates of adverse effects Timely provision of medications Increased adherence to evidence-based guidelines Increased use of cost-effective drug therapies
Nana B, Lee-Such S, Allen G. Initiation of an emergency department pharmacy program during economically challenging times. Am J Health-Sys Pharm. 2012;69:1682-86.
Medication Reconciliation
Nana et al. also strongly advocates for pharmacy driven MR, stating, “It is a critical component of an accurate patient evaluation during any admission”
90.2% of admission medication reconciliations performed by pharmacists were accurate, compared with only 66.7% accuracy of those performed by nurses
Nana B, Lee-Such S, Allen G. Initiation of an emergency department pharmacy program during economically challenging times. Am J Health-Sys Pharm. 2012;69:1682-86.
Medication Reconciliation Nursing
Lack of expertise and time to devote to comprehensive HMV
Physicians Inefficient use of resourcesContributed to patient admission delaysCPOE challenges
PharmacistsBurdened with clean-up after orders writtenDelayed patient medication delivery
History of MR at Westerly Hospital Initiation of Pilot Program (1/7/13 -
2/14/13)
Objective: Collect data in order to demonstrate the significance of accurate Home Medication Verifications (HMV)
19 day trial: 140 completed HMV
7.37 average HMV per day (7:00 am to 3:30 pm)
Westerly Pilot Program
Staffing Structure
6th-Year APPE Pharmacy InternsUtilized on day shifts Monday-FridaySenior interns fully capable of completing
HMV tasks
Replaced nurses, physiciansPharmacists are the drug expertsRealignment of disciplines to capitalize on
key strengths
Westerly Pilot Program
Pros Results illustrated a growing need for increased
pharmacy involvement during patient admissions Identified need for standardized HMV forms and
procedures
Cons High staff turnover and retraining of interns Shift coverage challenges (nights,
weekends/holidays) Narrowed APPE experience (lack of time for students
to participate in other experiential objectives) Efficiency lag with new student trainees
Pilot Program By The NumbersCompleted Medication Reconciliations in the Emergency Department
Red: January 2013, Blue: February 2013; 19 total days, Daily average: 7.37 Med Recs
Pilot Program Results
Illustrated the significant need for a better program with more reliable/efficient staffing coverage
Highlighted the importance of pharmacy led HMVError rate 54% with nurse-driven HMV
Paid student support approved for weekday evening shifts and weekends/holidaysTwo per diem students hired in April, 2013
Per Diem Student HMV Program April 2013 – October 2014 Initially two 6th-Year Interns hired for HMV
position 2nd shift coverage during weekdays
o Start time varied based on APPE rotation schedule
Single-shift coverage on weekends (12 – 8:30 pm) Provided excellent service and enforced the value
of pharmacy-driven HMV
Setbacks Staffing holes due to lack of trained pharmacy
staff to cover all shifts PD Student positions were not officially
legitimized into department staffing model
Per Diem Student HMV Program Ongoing “improvements”
May 2014, received FTE Committee approval to hire an additional 6-10 PD students to cover all shifts
Transitioned to four 8-hour weekend shift positions (days and evenings on Saturday and Sunday)
Continuous coverage on weekdays and during times without APPE students on weekdays
Unforeseen complicationsoDifficult to coordinate schedules
Transition Plan From PD to FT Staff Started in October 2014
Goal was to transition away from intern positions on weekdaysFT staff needed to sustain and legitimize the
program Program could not continue to operate on
students alone Insufficient resources for pharmacist staff
Oversight of HMV was lacking, leading to a false sense of safety by providers
Pharmacist resources needed in the ED to address complex clinical questions
Initial FTE Requests denied
Per Diem Student HMV Program: The Dark Days
The Perfect Storm: November 2014 Scheduling nightmare APPE student breaks Midyear Holidays Student vacations Final/Core exams Job offers/Commitments Medical Leave (broken knee) FTE Committee request process revamped and not available to WH management!
Pharmacy could not staff committed HMV shifts Program shut down for over 1 month…all hell broke
loose! Nursing grossly unprepared for completing HMV
The Battle For Legitimacy Current Hospital Environment
WH just emerged from receivership with limited resources/staffing/building investment
L+M had labor strike causing massive financial loss
Consultants hired with objective to cut costs
L+M did not have a HMV program
Business Plan Proposal
Proposed plan for FTE Committee approval2 FTE Pharmacy Technicians (7 am – 11:30 pm
coverage)1 FTE RPh position (8 am – 4:30 pm)0.8 FTE weekend coverage with paid student interns
Bets anyone???
Data collection was key to justifying needCost Avoidance calculations
Business Plan Proposal
Data collection was key to justifying the program Cost Avoidance calculations Categorized interventions per month: Meds added/removed, free
text conversions Time spent per patient Adverse Drug Reactions prevented Allergy/Immunization updates Verification sources
Outcomes compared to published literature articles Cost avoidance from HMV interventions
achieved staggering results
HMV Associated Cost Avoidance
*Total calculated cost avoidance from Dec 2013 through October 2014 - $1,663,470
Business Plan Proposal
Support and momentum grewHospitalists and President of Medical Staff
lobbied for approval of positions through written statements describing importance of Pharmacy HMV
Plan proposed again to FTE CommitteeThis time we had letters of support from
providers
Final approval granted in February, 2015
Current HMV Positions
HMV Pharmacy Technicians2 full time positions, Weekdays hired 2/2015
7:00 am to 3:30 pm 3:00 pm to 11:30 pm
Weekend and Holiday coverage with PD positions Technicians and Paid Interns (two shifts/day)
HMV PharmacistFull time position Weekdays
8:00 am to 4:30 pmOff shift supervision provided by Staff
Pharmacist
HMV By The Numbers
2013: Blue, Pilot Program 2014: Red, Hired Per Diem Interns 2015: Green, Full time Positions Approved (2/2015)
HMV Documentation
HMV Activity FormWorksheet for technicians/students
collecting HMV data Dr. First Report
Used to verify retail pharmacy dispensing history obtained via data feeds from community pharmacies and PBMs
Patient-Provided Lists, SNF MARs SBAR Communication Form
Home Medication Verification SBAR Communication Form Objective is to communicate discrepancies
identified during HMV to Med Rec providers
Examples: o Patient reports taking Lisinopril ½ tab daily; CVS verifies
Rx directions state 1 tablet daily
o Patient prescribed three HIV meds, but patient states that they haven’t taken meds in 3 months
Home Medication Verification SBAR Communication Form Sections include SBAR problem
communication and a field for provider response
All supporting documentation attached to SBAR form and retained as part of the permanent medical record
Completed by Pharmacy (nursing completes on 3rd shift)
Employee Satisfaction
Nursing “[Home Med Verification] by Pharmacy is the best thing
that has happened to nursing in a long time” Physicians
“…with pharmacy students the process of Med Rec instantly improved and greatly advanced the quality and safety of care for patients...”
Pharmacy Technicians Provides direct patient care connection Professional development, confidence, respect
Pharmacists Expands the scope of influence and respect of the
profession to be part of “the solution” Allows the pharmacist to go beyond the bench and
provide direct patient care
Future HMV Program Opportunities Implementation of pharmacy Pre-Op
patient HMV review
Chief of Emergency Medicine requested that the Pharmacy Tech/Pharmacist be relocated to the central nursing station in the ED
Discharge counseling
Program expansion to L+M main campus
