1 Morgan Pendleton, PharmD, BCOP Hematology/Oncology Clinical Pharmacist Wake Forest Baptist Health Administrative Update: How to Implement Discharge Pharmacy Services (DPS) Objectives Evaluate the need for discharge pharmacy services Discuss the role of the oncology pharmacist and technician in discharge pharmacy services
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Morgan Pendleton, PharmD, BCOPHematology/Oncology Clinical Pharmacist
Wake Forest Baptist Health
Administrative Update: How to Implement Discharge Pharmacy
Services (DPS)
Objectives
Evaluate the need for discharge pharmacy services
Discuss the role of the oncology pharmacist and technician in discharge pharmacy services
2
Question
Does your hospital utilize discharge pharmacy services ?
A) Yes
B) No
C) For high risk patients only
Journal of Hospital Medicine. 2008;3(1):12-19
Background
3
Question
A study in 2008 found that ____ percent of patients who reported medication issues after hospital discharge did not pick up their prescribed medications.
A) 5-10%
B) 15-20%
C) 50-60%
D) > 70%
Journal of Hospital Medicine. 2008;3(1):12-19
Background
2008 evaluation via patient survey
N = 31,199 patients
7.2% (2,253) reported prescription-related issues 48-72 hours post discharge
Journal of Hospital Medicine. 2008;3(1):12-19
Prescription-Related IssuePercentage of
Patients (n=2,253)n (%)
Not picking up prescribed discharge medications
1,797 (80)
Not knowing if prescriptions were picked up 55 (2)
Admitted not taking the medications 154 (7)
Not understanding how to take the medications
247 (11)
4
Background
Poor medical adherence
Poor health outcomes
Increased healthcare costs
$100-300 billion dollars per year
Rates have not changed much in the last 3 decades (despite all initiatives)
20-50% of patients are non-adherent to medical therapy
American College of Preventive Medicine. 2011
Background
Pharmacy Quality Alliance (PQA)
Member-based organization (providers, payers, and pharmacy organizations)
Develop quality measures that pertain to effective use of medications
Primary medication non-adherence (PMN)
Patient is prescribed a medication but fails to obtain and take the medication
Includes “newly initiated” medications
Medications not prescribed within the previous 180 days
Network for Excellence in Health Innovation. 2014.
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Background
PMN rate based on patient not picking up a new prescription within 30 days of it being prescribed
List of chronic medications based on prior PQA metrics (based on Accountable Care Organization contracts)
PMN rates for treatment of chronic diseases ranges from 10-30%
Underestimation
Electronic prescribing has increased accuracy
Network for Excellence in Health Innovation. 2014.
Background
“Reducing PMN: Should Pharmacies Take the Lead?”
Access to data and providers
Knowledge to counsel and answer questions
Follow up by pharmacists in the outpatient setting has not been found to be effective
Time
Resources
Reimbursement
Network for Excellence in Health Innovation. 2014.
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Background
Initiate the process at discharge
Cost effective
Prior-authorizations or issues
Deliver medications so PMN rates decrease
Educate
Form relationships
Utilize face to face pharmacy or clinic encounters
Education, questions, refills, support, etc.
Network for Excellence in Health Innovation. 2014.
Question
Pharmacists are the appropriate team member to take the lead for discharge pharmacy and medication services based of their expertise, knowledge, and access to appropriate resources.
A) Yes
B) No
C) For high risk patients only
Journal of Hospital Medicine. 2008;3(1):12-19
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WFBH Experience
Wake Forest Baptist Medical Center
Academic medical center
Comprehensive Cancer Center
Brenner Children’s Hospital
Winston-Salem, NC
Nationally ranked by
U.S. News and World Report
17th in Cancer
8
Nationally
50% of patients experience medication errors when transitioning from hospital to home
Discharge Pharmacy Service (Cancer Center and Main Outpatient Pharmacy:New Prescriptions and Total Patients per Month
Pilot started
via resident project Dec
2012
Pilot started
via resident project Dec
2012
House-wide expansion via integration with MOC
initiative
House-wide expansion via integration with MOC
initiative
Change to “referral”
enrollment strategy
Change to “referral”
enrollment strategy
Creation of Transitions of
Care Technician role
Creation of Transitions of
Care Technician role
0
200
400
600
800
1000
1200
1400
1600Prescriptions
Patients
Average$/Patient
DPS Data: Cancer Center Pharmacy
2014 2015
18
Average Day for DPS Technician
67
3329
23
14 13 12 11 105 4 3 1
0
10
20
30
40
50
60
70
80
Times per Day for Each
Task
Role of Key Team Members in DPS
Success
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Technician Role
Enrollment (in person or via phone)
Test prescriptions
Relay information to pharmacist
Prior authorizations (PA) and enrollment in drug assistance programs
Deliver medications and receive payment (or set up payment plans as necessary)
Pharmacist Role
Enrollment and prior authorizations as necessary
Solicit test prescriptions
Make therapeutic recommendations based on availability of medications at discharge
Set up delivery of medications through specialty or mail order pharmacies
Mandatory discharge medication reconciliation
Prepare education document and counsel
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Social Work/Case Manager Role
Handle all prescription communication with the VA
Enrollment in medication assistance programs as necessary
Determine eligibility for charity care, crisis control ministry, cancer services, cancer patient support, and other resources
Patient Role
Maintain open communication about affordability
Provide appropriate tax or income information
Follow up with assistance programs or mail order pharmacies
Be accountable
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Workflow: is one way better than the other?
Cancer Center Pharmacy
Pharmacist or Technician enrolls in DPS
Pharmacist or Technician notifies the other team member via
pager/phone
Pharmacist and technician communicate via pager/phone
about test prescriptions
Pharmacist notifies technician via pager/phone that prescriptions
are on the way and to prepare for delivery
Main Outpatient Pharmacy
Pharmacist enrolls in DPS
Pharmacist notifies technician through EMR
Pharmacist and technician communicate via EMR about test
prescriptions
Pharmacist notifies technician via EMR that prescriptions are on the
way and to prepare for delivery
Summary
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Is it Worth the Time and Effort?
• Medications in hand at discharge• Education document with valuable information• Counseling with familiar face• Questions answered prior to getting home
Patient
• Know cost and availability prior to prescribing• Know patients have medications in hand• Can communicate with pharmacist about any issues and concerns
to focus on during education
Physician
• Integral part of patient’s transition of care• Use delivered prescriptions to assist in discharge education• Have pertinent information available (next dose, indication, etc)• Develop fundamental relationships with the patients and providers• Have resources to educate and develop plans for illiterate patients• Have translators available for those who don’t speak English
Pharmacist
Is it Worth the Time and Effort?
• Medications in hand at discharge• Education document with valuable information• Counseling with familiar face• Questions answered prior to getting home
Patient
• Know cost and availability prior to prescribing• Know patients have medications in hand• Can communicate with pharmacist about any issues and concerns
to focus on during education
Physician
• Integral part of patient’s transition of care• Use delivered prescriptions to assist in discharge education• Have information available via EMR and providers (next dose,
indication, etc)• Develop fundamental relationships with the patients and providers• Have resources to educate and develop plans for illiterate patients• Have translators available for those who don’t speak English
Pharmacist
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Morgan Pendleton, PharmD, BCOPHematology/Oncology Clinical Pharmacist
Wake Forest Baptist Health
Administrative Update: How to Implement Discharge Pharmacy
Services (DPS)
References American College of Preventive Medicine. “Medication Adherence – Improving Health
Outcomes.” 2011.
Hubbard T. “Ready for Pick Up: Reducing Primary Medication Non-Adherence. A New Prescription for Health Care Improvement.” The Network for Excellence in Health Innovation. 2014.
Hume A, Kirwin J, Bieber H, et al. “Improving care transitions: current practice and future opportunities for pharmacists.” Pharmacotherapy 2012;32(11);326-337
Kripalani S, Price M, Vigil V, Epstein K. “Frequency and Predictors of Prescription-Related Issues after Hospital Discharge.” Journal of Hospital Medicine. 2008;3(1):12-19
National Association of Chain Drug Stores. “Pharmacies: Improving Health, Reducing Costs.” July 2010.