National Forum Podcast July 2014 Brian J. Isetts, RPh, PhD, BCPS, FAPhA Professor, University of Minnesota.

Working with Pharmacists to Improve Medication Management

National Forum Podcast

July 2014

Brian J. Isetts, RPh, PhD, BCPS, FAPhAProfessor, University of Minnesota

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Our Speaker:Brian J. Isetts, RPh, PhD, BCPS, FAPhAProfessor, University of MinnesotaCollege of Pharmacy

Dr. Isetts is a practitioner, researcher and educator dedicated to building a medication use system we deserve. Brian recently returned from a three-year sabbatical serving as a Health Policy Fellow at the Centers for Medicare & Medicaid Services in the CMS Part D Program and at the CMS Innovation Center.

Objectives

1. Understand the comprehensive patient care process for achieving drug therapy treatment goals 2. Describe the evidence supporting team-based medication management3. Build a true medication use system aligned with our 3-part aims

Program Agenda

1. Review the consequences of our dysfunctional medication use system

2. Describe efforts to build a medication use system based on the way patients take medications

3. Understand the outcomes of integrating pharmacists in new care delivery and financing models

Questions to Run On

What would a rational medication use system look like from the patient’s perspective? What are the responsibilities of pharmacists in a redesigned

medication use system?

Power of the Patient’s Perspective in Improving Health Care

“We would all be far better off if we professionals

recalibrated our work with patients and families

not as hosts in the care system, but as guests in

their lives.”

Don Berwick, M.D. (former CMS Administrator), Institute for HealthCare Improvement

This is Reality in Homes across America

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Patient Ownership of Comprehensive Team-based Medication Management

How can we accelerate progress toward a medication use system in which patients routinely achieve their drug therapy treatment goals with zero tolerance for preventable medication harms?

How can we engage patients and families in team-based medication management in a system of care built around the manner in which patients use medications in their homes?

Absence of a Medication Use System

Drug-related Morbidity/Mortality-a National Crisis

Spend ~$300 billion/year due to the ineffective and unfortunate consequences of medication use Largest category of hospital acquired conditions Most common cause for hospital readmissions 3 categories of drugs related to over 70% of costs (Anti-coagulants, Hypo-glycemics, Opioid analgesics)

Approximately 10 people die every HOUR from preventable medication consequences

So why has it taken so long to do something about this national crisis?

Some Root Causes to Consider

We haven’t applied a standard care process to the way patients take medications We don’t have a good idea of a patient’s

medication needs across care settings In a traditional fee-for-service system there are few incentives ensuring medications are indicated, effective, safe and can be taken by the patient THAT IS – Until Now!!

Expectations of Comprehensive Medication Management in the Health

System we Deserve

It is difficult to be an Accountable

Care Organization (ACO) if you’re

not accountable for what happens

when patients take medications

Medication Therapy Management

Official Health Reporting Nomenclature (CPT®) assigned by the American Medical Association

A practice in which a pharmacist takes responsibility for all of a patient’s drug-related needs and is held accountable for this commitment

Separate and distinct from dispensingSystematic patient care process

(assessment, care plan and evaluation)

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THE PATIENT CARE PROCESS

ESTABLISH A THERAPEUTIC RELATIONSHIP

What are the patient’s needs &

preferences?

What am I going to do

with the patient?

How will we know if

it is working?

Continuous Follow-up

ASSESSMENT CARE PLAN EVALUATION

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Basis of a Therapeutic Relationship

Accept responsibility to identify all

of a patient’s drug-related needs,

and commit to working with the patient to meet those

needs

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PHARMACIST RESPONSIBILITIES

To ensure that all of a patient’s drug therapy is appropriately indicated, the most effective available, the safest possible, and the patient is able to take

their medications.

The identification, resolution, and prevention of drug therapy

problems.

Drug Therapy Treatment GoalsAre established for each indication managed with

drug therapyAre used to evaluate effectiveness and safety of

drug therapyCollaboratively set with patients and care-giversObservable, measurable, realistic with time

framesAligned with patient preferences & motivating

eventsAre abundantly more achievable when the patient

knows you’re non-judgmental and in it for the long run as their life champion

It’s the journey as much as the destination

Establishing Goals of Therapy Within each medical condition for which patients are

taking a medication (if 5 medications for 3 conditions = 3 goals of therapy)

1) Like to have both objective and subjective measures 2) Must be observable, measurable, and realistic 3) Have a desired value & specific time frame in which

the goal is to be met.

When we collaborate to achieve goals of therapy patients are empowered to take control of their medications, rather than medications controlling their lives

Identifying Drug Therapy Problems

Drug therapy problems are undesirable events or risks that the patient

experiences that inhibit or delay him/her from achieving the desired goals of

therapy.

They are identified during the assessment process, so they can be resolved through

individualized changes in the patient’s drug therapy regimens.

The Pharmacy Dilemma: Proving we Save Money before being Paid

to Provide Care

● 56,000+ studies of care by pharmacists ● Meta-analysis published in 2010● Clinical outcomes: % of goals of therapy achieved, improved care (A1c, BP, LDL, etc)● Humanistic outcomes: Quality of life, patient satisfaction, reduced sick days● Economic outcomes: Total cost of care↓, fewer hospitalizations; R.O.I. = $4:1 to $12:1

Redesigning Systems to Support Pharmacists

Expectations Shift from F-F-S to Value-based $ Pharmacists' Outcomes Studies Lessons from Patient-centered Homes &

Accountable Care Organizations Transitions of care focus on helping

patients manage their medications Urgent national call to action – alignment

with our 3-part national aims

Better Carefor Individuals

Better Health forthe Populations

Lower CostThrough

Improvement

A Three-Part Aim

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Key Questions in Team-based Care

What would a rational medication use system look like from the patient’s perspective when we all work together? What are the responsibilities of all care-givers in a redesigned medication use system?

This is What We Do TogetherFirst is a therapeutic alliance, because patients

don’t care what you know until they know that you care

Use a systematic patient care process to assess all of a patient’s drug related needs

Clear care plan responsibilities so each of us are held accountable for work to achieve goals

We follow-up to evaluate progress toward goals, and the resolution of drug therapy problems, because if you don’t follow-up – you don’t care

We document care – because if you don’t document, it didn’t happen

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Comprehensive Team-based Medication Management

All team members help set patient-specific drug therapy goals for each medical condition:

Assessment of intended use, effectiveness, safety, and adherence embedded across the care continuum

When patient is not achieving goals of therapy there is more efficient and effective use of pharmacists

Coordination of care as pharmacists conduct comprehensive assessments of drug-related needs

Patients/care-givers help team define “high-risk” as core element of the patient-centered health home

Open Letter to the Natl. Quality Forum

Dear Health Care Experts:We request your guidance in establishing a medication use system focused on helping patients and families find the answers to three essential questions: 1) What is the intended medical use for each of my medications? 2) What are the realistic, patient-specific goals for the

medications used to treat each of my conditions? 3) What are the unique safety concerns specific to my

mix of conditions & medications?We look forward to your response,

Sharon and Edward Jungbauer, Maplewood, MN (11/30/2012)

The Medication Use System We Can Have

Key Characteristics Every drug in use in America is assessed to ensure: it

has an intended medical use, is effective and safe, and can be taken by the patient as intended

Patients, family members, and care givers contribute to establishing realistic, achievable goals of therapy

Clear care plan responsibilities for achieving goals

Patients will Demand our Health System Help Them: 1) Describe the intended medical use of each medication 2) Set realistic, patient-specific goals of therapy 3) Understand safety for their co-morbidities & medications

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Lessons Learned Along the Journey

Value-based financing is good news for patients who take medications

We have a second chance to make a first impression in designing a medication use system we deserve

Can’t be an ACO if not accountable for medicationsOutcomes of medication management can

facilitate progress toward our 3-part national aimsPatient demand will accelerate progressAll team members help set patient-specific goals

Key Aspects of the SPCC Innovation

Pharmacists are functionally integrated into electronic medical records

Pharmacists are paid through the MN-Medicaid Medication Therapy Management Care Law

The Univ. of MN-College of Pharmacy & the MN Pharmacists Assn. will work with pharmacists to ensure service delivery expectations

This will serve as a national exemplar of the medication use system our patients deserve consistent with our 3-part national aims!

Discussion

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