Medical Delivery Network

Transcription

1 Medical Delivery Network PATH TO EXCELLENCE THROUGH TEAM CARE AND ENHANCING THE ROLE OF THE PHARMACIST Karine Azizian, PharmD Director, Pharmacy Services Rachel Mashburn, PharmD Pharmacy Program Coordinator

2 Cedars- Sinai Health System Cedars- Sinai Medical Center Medical Delivery Network Educa<on and Research Physician Billing Services (PBS) Cedars- Sinai Medical Network Services (MNS) Medical Provider Network for Workers Compensa<on Cedars- Sinai Medical Group Cedars- Sinai Health Associates Inpa<ent Specialty Prac<ces California Heart Center Tower Hematology Oncology Medical Group Los Angeles Cardiology Associates The Cedars-Sinai Medical Group (CSMG) is a multispecialty group of physicians serving the community at eight sites throughout Los Angeles. The approximately 130 physicians have formed a company dedicated to serving a wide range of medical needs for all patients. The Cedars-Sinai Health Associates (CSHA) is a network of individual physicians with independent offices throughout Los Angeles. These physicians have come together to form an independent physician association (IPA) to serve the community s managed care medical needs. C li n ica l I n t e g r a t i o n Inpatient Specialty Practices (ISP) is a medical group comprised of Hospitalists who provide inpatient services to our patients at Cedars-Sinai Medical Center. California Heart Center consists of cardiologists that specialize in pre and post transplant services that deliver comprehensive, individualized care; offering the latest in diagnostic testing and access to the newest research advances. Tower Hematology Oncology Medical Group (THOMG) consists of ten physicians specializing in high quality and comprehensive hematological and oncological cancer care including conventional, innovative and investigational modalities. THOMG has an excellent reputation in the community for their cancer care and ongoing leadership in clinical trials. Los Angeles Cardiology Associates (LACA) consists of 10 physicians who specialize in all of the major disciplines of cardiology including electrophysiology, interventional cardiology and noninvasive cardiology. Their primary offices are located in Downtown Los Angeles with outreach throughout Los Angeles and San Bernardino Counties.

3 Cedars-Sinai Medical Group 130 multi-specialty physician group located in Beverly Hills, CA 35 Internal Medicine physicians Pharmacist involvement since Clinical Pharmacist FTEs 7 Pharmacy Support Specialists (pharmacy technicians) to support the Refill Center and medication purchasing and distribution

4 Discussion Points for Today Clinical pharmacist services provided for Cedars-Sinai Care Foundation Goals of the Patient-Centered Medical Home project at CSMG Care Management strategies to reduce pharmacy-related total cost of care

5 Clinical Pharmacist Credentials Doctor of Pharmacy Degree (PharmD) California Registered Pharmacist license Completed Residency Training DEA Certificate NPI Other certificates: Certified Asthma Educator (AE-C) Certificate in Travel Health (Certified by International Society of Travel Medicine) Certified Diabetes Educator (CDE) Basic Life Support Certificate

6 Pharmacists in a Medical Group ü Developed drug therapy management (DTM) protocols according to nationally accepted guidelines ü Established Collaborative Practice Agreements with physicians ü Physicians place a patient specific order when referring for DTM Pharmacist Interventions under Protocol: Educate patients regarding disease, medications and treatment goals. Provide patient education/ self management materials/kits, Rx compliance boxes, etc. Initiate, substitute, titrate and/or DC medications under protocols Ensure immunization series completion and timeliness Identify significant ADR s; drug interactions; drug/vaccine duplications; CI s; and/ or allergies Order and monitor labs Panel management role: proactively reaching out to patients on P4P lists in a systematic approach to improve DM and cholesterol

7 Evolution of Pharmacist Services at CSMG Anticoagulation Asthma Hyperlipidemia Hypertension Polypharmacy Diabetes Injection Center Pyxis Patient Centered Medical Home Pharmacist Decentralized Post Discharge Clinic Chronic Hepatitis C Smoking Cessation Travel Medicine Refill Center Transitions of Care Heart Failure DOT

8 Anticoagulation Program January March 2013 Coumadin (warfarin) initiation and titration under protocol LMWH initiation and patient self injection technique education/training Bridging with LMWH when indicated POCT (Coaguchek XS) Monthly no show report for patients lost to follow up ANTICOAGULATION CONTROL: ATTAINMENT OF INR GOAL 1 (n=1,438 INR RESULTS 2 ) 80% 60% 77% 40% 20% 0% INR Within Goal 17% INR Below Goal 6% INR Above Goal 1: INR goal is defined as no less than 0.2 below the lower limit and no greater than 0.5 above the upper limit of the PCP-designated INR target range 2: INR results obtained within 30 days of Anticoagulation Clinic enrollment (n=304) are not included

9 Chronic Hepatitis C Educate patients with chronic Hepatitis C on their disease and treatment regimens Initiate and monitor chronic Hepatitis C drug therapy Manage and treat adverse events from therapy Order appropriate labs throughout the course of treatment

10 Chronic Hepatitis C 200 Number of Patients Ø 194 patients referred since Ø 58 patients: declined treatment; were referred to clinical trails; or had acute Hepatitis C 100 Ø 136 patients treated/treatment ongoing* 50 Ø 106 patients completed treatment and follow up ( ) Total Patients Seen Patients Treated Ø 68 patients (64%) had SVR ( cured ) Total SVR National vs. CSMG Hepatitis C Clinic 80% 60% 55% 64% SVR 40% 20% 0% National CSMG Hep C Program

11 Smoking Cessation One on one consultation to provide individualized smoking cessation plan Strategies for behavior modification and how to control cravings/withdrawal symptoms Prescription for medications or nicotine replacement therapy when appropriate Carbon monoxide level monitored at each visit

12 Travel Consultation and Immunization Program Jan 2011 June 2013 Travel Clinic Enrollment (Number of new patients seen per month) TRV 2012 TRV 2013 TRV Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Education and recommendations for disease prevention Personalized Travel Health Booklet Appropriate immunization administered per CDC and WHO recommendations Prescriptions provided as needed Yellow Fever 11% Typhoid 29% Td/Tdap 7% Vaccine Use 2013 BayGam 1% Rabies 0% Polio 7% Flu 4% MMR 0% Hep A 29% Hep B 6% Meningococal 3% Japanese Encephalitis 3%

13 Heart Failure Program Initiated pilot November 2012 Interdisciplinary team: 2 Cardiologists 1 Pharmacist- part time 2 Nursing staff Program Goals Decrease CHF hospital admissions and 30 day readmissions Decrease total cost of care Improve quality of care

14 Heart Failure Program Management Patient education and care coordination Medication optimization Medication adherence and safety monitoring Medication reconciliation BNP guided diuresis, IV diuretics Bed-side ultrasound Cardiovascular co-morbidity management Nutrition consultation Nurse practitioner house call and home health Supportive care and advanced directive

15 Overall % of Hospital Admission for Patients Pre and Post Enrollment in the Heart Failure Program 80%% 70%% 60%% 50%% 40%% 30%% 20%% 10%% 0%% 74%% PRIOR%TOTAL% n=138 patients Distribu(on+of+Admissions+ 26%% POST%TOTAL% PRE/POST% 74%% 26%% n% 114% 41%

16 12 month pre- and post-enrollment admissions and readmissions for Heart Failure Patients Axis%Title% 35# 30# 25# 20# 15# 10# 5# 0# 12# Mth# Prior# 11# Mth# Prior# 10# Mth# Prior# 9#Mth# Prior# Distribu.on%of%Admissions/Readmissions%by%Month% 8#Mth# Prior# 7#Mth# Prior# 6#Mth# Prior# 5#Mth# Prior# 4#Mth# Prior# 3#Mth# Prior# 2#Mth# Prior# Non6readmit# 17# 4# 4# 4# 4# 4# 3# 10# 2# 5# 17# 24# 6# 3# 1# 7# 4# 1# 2# 1# 1# 3# 0# 10# Readmits# 3# 0# 0# 0# 0# 0# 1# 0# 1# 2# 4# 5# 0# 0# 1# 1# 0# 0# 0# 0# 0# 0# 0# 0# SUM# 20# 4# 4# 4# 4# 4# 4# 10# 3# 7# 21# 29# 6# 3# 2# 8# 4# 1# 2# 1# 1# 3# 0# 10# 1#Mth# Prior# 1#Mth# Post# 2#Mth# Post# 3#Mth# Post# 4#Mth# Post# 5#Mth# Post# 6#Mth# Post# 7#Mth# Post# 8#Mth# Post# 9#Mth# Post# 10# Mth# Post# 11# Mth# Post# 12# Mth# Post# 16 readmissions pre-enrollment vs. 2 post-enrollment in Heart Failure Program *Known deceased patients have been removed from both pre and post counts

17 Heart Failure Program- Next Steps March 1 st Rollout Open to other cardiologists in group and IPA Assign Cardiology Pharmacist Full time Add additional members to the team: Dietician Case Manger LVN coordinator Develop Heart Failure Registry Develop clinical research program

18 Goals of the Injection Center: Injection Center Quality Ø Appropriateness of the drug, dose, frequency, dosage form, route of administration, and duration Ø Check for drug-drug interactions and duplications Ø Review side effects prior to administration Ø Order appropriate labs prior to administration Patient Safety and education Proper coding and documentation Decrease wasted/expired medications

19 Injection Center Directly Observed Therapy (DOT) Program Implemented Protocol June 2012 Overseen by Pharmacist Services Physician refers patient to Injection Center for Directly Observed Therapy of INH + RPT regimen Patient seen weekly for 12 weeks and directly observed taking medication regimen Educate patient and monitor for possible ADRs of treatment and/or disease

20 Secrets to our Success! Great team! Physicians and pharmacists work well together Achieve High Patient and Provider satisfaction scores Scores consistently >90% for program and individual pharmacists Very Accessible Frequent patient follow-up via telephone or office visits Good panel managers Several reports assure patients are not lost to follow up Return patient to PCP/specialist management when patient goals are attained

21 Patient Centered Medical Home Refill Center Medical Home Overview Clinical Pharmacist in PCMH

22 Refill Center Pharmacists authorize continuation of medications for chronic diseases under protocol 22 refill authorization protocols and 4 conversion protocols Quality Assure patients are seen by their PCP annually Chronic medication lab monitoring, i.e. annual BMP for patients on ACE-Inhibitors Identify patients with above goal LDL and HgA1Cs. Collaborate with physicians to have their patients reach LDL and HgA1C goals Resource Utilization Therapeutic Conversions Statins ARBs Intranasal Steroids Proton Pump Inhibitors Prior Authorizations

23 Volume of Prescriptions Processed Refill Center - continued Refill Period Total # of Rx s Protocol Rx s Non-Protocol Rx s Jan Dec ,467 54,911(64%) 31,556 (36%) Prior Authorizations for Protocol Medications Year Total Submitted Approved Denied Changed to formulary alternative Denied and changed to formulary alternative (83%) 18 (4%) 19 (5%) 29 (8%) Conversions (Jan-Dec 2013) - Statins, ARBs, Nasal Steroids & PPIs Statins ARBs Nasal Steroids PPIs Converted 9 (16%) 25 (64%) 24 (45%) 31 (46%) Not Converted 48 (84%) 14 (36%) 29 (55%) 36 (54%) Total Reasons for Not Converting: -Cost is not an issue -Hx of intolerance to generic alternative -Lipids/BP/GERD not controlled -Unable to reach patient -Want to speak to my doctor -No dose equivalent

24 Generic Drug Utilization Rates Pre Refill Center Post Refill Center 2010 Q Q1 Statins 67.9% 92.2% ARBs 31.3% 68.2% Nasal Steroids 57.4% 85.3%

25 Overarching Project Goals: PATIENT CENTERED MEDICAL HOME 25 Ensuring: Maintain/improve quality while improving clinical efficiency and lowering the cost of care IN ORDER TO: - Reduce 30- day readmission rate - Reduce admissions/ Reduce ED visits/ Increase pa<ent access Coordinate and standardize transi<ons of care ü Maximum PCP and care team efficiency and adoption ü Scalability ü Minimum physician disruption Reduce the PCP burden Improve popula<on health management

26 Hot Spotter Program - Ambulatory Case Manager - Post discharge house calls - Medication reconciliation - SNF coverage - Advance Care Planning - Biometric monitoring The Most Fragile Chronic Disease Management Pharmacist Health Coach Panel Management Medication reconciliation MyCSLink Patient Portal Chart Prep, Huddles Intake Refill Center Check-out w/avs Panel Management MyCSLink Patient Portal Routine Medical Care Wellness Promotion & Preventive Services

27 Clinical Pharmacist in PCMH Starting in 2011, one clinical pharmacist to 6-7 physicians Pharmacist located in or near physicians office Huddle with Care Team weekly Services provided: Drug Therapy Management Programs Diabetes, Hypertension, Dyslipidemia, Asthma, Smoking Cessation, Polypharmacy Paired visits with physicians or independent consultations Medication reconciliation Post discharge medication reconciliation Panel management using various registries and reports Drug information to physicians and staff Collaborates with NP that does patient home visits P4P Quality Measures (LDL, BP, DM, Persistent Medications)

28 P4P Quality Measures Diabetes CSMG 2012 Rate MY th Percentile A1C Screening 95.3% 92.2% A1C <8 70.6% 65.8% A1C <7 58.8% 45.1% LDL Screening 90.6% 89.0% LDL < % 54.6% Nephropathy Screening 93.8% 91.3% BP Control 79.6% 69.6% Cholesterol Mgmt for CVD CSMG 2012 Rate LDL Screening 95.6% 95.2% LDL < % 75.3% MY th Percentile Miscellaneous CSMG 2012 Rate MY th Percentile Persistent Medications 93.7% 86.5%

29 Medication Reconciliation Programs Transition of Care Program ISP physicians and in-patient pharmacists identify high risk patients during admission. PTA and admission meds are reconciled by an in-patient pharmacist. Pt is referred to a CSMCF out-patient pharmacist for post-discharge med review and reconciliation. CSMC Daily Discharge List Medical Home clinical pharmacists receive the daily CSMC patient discharge list. Clinical pharmacist will provide medication review and reconciliation within 3 days of discharge. Polypharmacy Program Any patient referred by their physician to be seen by a clinical pharmacist for medication review and reconciliation. *Prior to admission

30 Pilot starting February 2014

31 Total Cost of Care Pharmacy Tactics Specialty Medications Oncology Initiatives Pharmacy Tactics Generics DAW Report Sample Use Policy Target Medications

32 Aligning Processes and Initiatives with TCC Goals MD Workflow Use of Samples Dispense as written Pay Plan Alignment Medical Home Dashboards Pt level interventions Medication level interventions 32

33 NEURO, $280, Specialty Medication Expenditures Medventive Jan-June 2013 MS, $271, PSYCH/, $476, Other Specialti es Expense s IM, $585, HIV, $2,061, ONC PULM NEURO/ RA, $678, TX ID ENDO, $701, GAUCHE R PAIN GI

34 Opportunities to Improve Performance-Generics P4P Goals Generic prescribing rates for: Antidepressants, Antihyperlipidemics, Anti-ulcer agents, Cardiac (hypertension and cardiovascular), Nasal Steroids, Diabetes, Anxiety/sedation (sleep aids), anti-migraine and Overall Generic Drug Rate for all prescriptions Rates determined from health plan pharmacy data Current Practice Dispense as Written Utilization Sampling permitted in specialty practices Patient Expectations Recommendations Implement Sampling Policy across all practices limiting use to best practices with P&T Committee approval Implement Best Practice Alert (BPA) to discourage Dispense as Written (DAW) prescribing MD and PharmD patient education re: generics as part of patient visits Develop patient-centered brochure 34

35 Opportunities to Improve Performance Current Practice MD and patient specific data at drug level based on HMO patients -report cards previously and currently provided to Pods and MDs Reports consist of lists of patients to convert by MD Drugs targeted for reduction integrated into Refill Center 50% conversion rate due to patient demand Recommendations Establish alignment of goals for TCC Pharmacy and Physician Performance Specialty medications- Note: RA guidelines in progress Identify champions for each specialty Develop and implement guidelines and utilization system Concurrent RX and MD review for use outside of guidelines Target medications Order questions in CS-Link-pending Jan 2014 P&T approval Medical home MA support to flag patient on target drugs Pharmacist best practice checklist: reduce overuse; target drugs; med rec, etc 35

36 Thank you! 36