What s at the Heart of the Matter? Inpatient Pharmacy Services for Heart Failure Patients Jason Williamson, PharmD, BCPS Clinical Pharmacy Manager, PGY1 Pharmacy Residency Director Genesys Regional Medical Center, Grand Blanc, MI The speaker has no actual or potential Conflict of Interest in relation to this presentation. Objectives - Pharmacists At the end of this activity, participants should be able to: - Select services that the pharmacy team can provide to optimize the transition of care for heart failure patients from the inpatient setting to the outpatient setting - Outline an approach for performance improvement for a pharmacyprovided transition of care service for heart failure patients - Identify evidence-based therapies for heart failure associated mortality, symptoms, and associated hospitalizations Objectives Pharmacy Technicians At the end of this activity, participants should be able to: - Select services that the pharmacy team can provide to optimize the transition of care for heart failure patients from the inpatient setting to the outpatient setting - Identify opportunities for performance improvement for a pharmacy provided transition of care service for heart failure patients. - Recognize medications and their corresponding drug classes that can be used in the management of heart failure. Background Information Genesys Regional Medical Center Located in Grand Blanc, MI 400 bed community teaching hospital Clinical pharmacy services - Pharmacokinetic antibiotic dosing - Anticoagulant dosing - Decentralized pharmacy practice - Rounding in critical care areas - Code blue emergency participation Launching new pharmacy residency program in July 2017 4 Background Information Back to the Basics of Heart Failure Care Daily weights Medication management Patient education on heart failure symptoms Discharge Transitions of Care Services for Heart Failure Patients Pilot Project Design and Methods How could pharmacy assist with improving the care provided to heart failure patients?
Project Design Project Design Pilot unit: cardiovascular care (CVC) units Targeted heart failure patients: patients with new diagnoses for heart failure as well as all patients admitted for heart failure exacerbation Three phase launch approach to the pilot project 1 2 Bedside Prescription Delivery Discharge Education from Pharmacists Outpatient Pharmacy Manager Clinical Pharmacy Manager 3 Discharge Medication Coordination Clinical Pharmacy Manager Phase Specific Methods Phase 1 - Metric number of patients who received their prescriptions from our hospital s outpatient pharmacy prior to discharge - Goal 70% of targeted heart failure patients will receive their prescriptions from our hospital s outpatient pharmacy Phase 2 - Metric number of patients who received education about their heart failure education regimen prior to discharge - Goal 90% of targeted heart failure patients will receive education from a pharmacist about their heart failure medication regimen prior to discharge Additional Methods Phase 2 Staff Training A pilot group of pharmacists was trained to educate heart failure patients Pharmacy specific training materials were developed collaboratively with a staff pharmacist and pharmacy interns A consistent form of education documentation was developed for all pilot pharmacists to use in the electronic medical record Live training was communicated by one staff pharmacist and 2 behavioral psychologists A standardized form was developed to facilitate patient education Medication Education Form Evidence-Based Therapies for HF Yancy CW et al. Circulation. 2013; 128(16):1810-52. April 1225, 2017
Beta-Blockers Loop Diuretics - Bisoprolol (Zebeta) - Carvedilol (Coreg) - Metoprolol succinate (Toprol XL) - Bumetanide (Bumex) - Furosemide (Lasix) - Torsemide (Demadex) 13 14 ACEI/ARB/ARNI Sacubitril / Valsartan (Entresto) First in class agent combination of a neprilysin inhibitor and an ARB In PARADIGM trial, combination of medications demonstrated to have significant benefit to mortality and hospitalizations relative to comparator enalapril - ACEI: lisinopril (Zestril, Prinivil), enalapril (Vasotec) - ARB: losartan (Cozaar), valsartan (Diovan) - ARNI: sacubitril / valsartan (Entresto) Recently supported by HF pharmacotherapy guideline update McMurray JJ et al. N Engl J Med. 2014;371(11):993-1004. Yancy CW et al. Circulation. 2016;134(13):e282-93. 15 16 Aldosterone Antagonists Digoxin - Spironolactone (Aldactone) - Eplerenone (Inspra) 17 18
Hydralazine / Nitrates Other Medications for HF Ivabradine (Corlanor) - Add-on therapy for patients with very specific criteria CHF with LVEF 35% In sinus rhythm with resting HR 70 bpm Either on maximally tolerated dose of a beta blocker or have a contraindication to beta blocker use - Hydralazine / isosorbide dinitrate (BiDil) Inotropic therapies - Milrinone (Primacor) - Dobutamine (Dobutrex) Yancy CW et al. Circulation. 2016;134(13):e282-93 19 20 Identifying Heart Failure Patients Targeted heart failure patients are recognized by case management and are designated in the electronic medical record (EMR) Discharge Transitions of Care Services for Heart Failure Patients Logistics Patients identified by case management are designated with an I in the EMR, and this I is changed to a C when education is performed Designation of patients in EMR is being used to drive alerts for pharmacists (e.g., once discharge med rec is complete) 22 Other Means of HF Patient Identification Identifying Pilot Project Pharmacist Team Members We sought pharmacist team members who: - Had past experience in providing discharge education - Were highly motivated to incorporate patient education into their day-to-day workflow - Could motivate and influence other pharmacists to participate in this new service For hospitals with HF education / TOC programs, how do you identify patients for service delivery? - Would provide constructive feedback to contribute to improvement of the education service 23 24
Navigating Pharmacy Workload Issues Utilized shift overlap time to permit education coordination and provision Teamed pilot pharmacists together to have back up assistance Scheduled pilot pharmacists in blocked manner Quality Improvement Strategies Pharmacy Services for HF Patients Quantified time spent by pharmacists coordinating education and providing education 25 April 2625, 2017 PDSA Cycle Example of PDSA Cycle in Action During a monthly meeting with your pharmacist team, a few pharmacists bring up concerns about the pharmacy services you ve recently implemented for HF patients. Despite reaching some patients, many have slipped through the cracks, and pharmacy isn t aware of patient-specific discharge plans. The education program is far from goal attainment (70% educated vs > 90% desired). What can be done to improve this service? Available from: http://www.ihi.org/resources/pages/tools/plandostudyactworksheet.aspx 28 Facilitating Transitions of Care Discussions Tabletop Rounding Service - Meets Tuesday and Thursday afternoons for ~ 30 minutes - Involved team members include HF clinic coordinator, cardiology physician extenders, case management, nursing management, inpatient pharmacist, and outpatient pharmacist - Goal of meeting is to review identified HF patients and discuss barriers to discharge and obstacles to successful transition to next outpatient setting - Meeting attendance, participation fed back to HF transition workgroup for hospital Conclusions/Future Directions The heart failure transitions of care services at Genesys Regional Medical Center have incorporated pharmacists into medication access and medication education roles All decentralized pharmacists at Genesys were trained to educate patients about their heart failure medications and will be educating heart failure patients Future directions include: - Incorporating medication profile review/polypharmacy review into our pharmacists workflow - Involvement of pharmacists in our hospital s outpatient HF clinic 29 30
Questions/Discussion Posttest Questions Pharmacists 31 April 3225, 2017 Question 1 Which of the follow pharmacy services may contribute to the successful transition of a heart failure patient from the inpatient setting to the outpatient setting? A. Bedside prescription delivery B. Heart failure medication education C. Medication profile review for drug interactions / duplications of therapy / medications which may exacerbate HF D. All of the above Question 2 One of the most common strategies to use in health care quality improvement that could be used in improving pharmacy driven HF services is: A. The PDSA method B. The ABCD method C. The HELP method D. The IDK method 34 Question 3 Prior to providing education to a patient about their HF medications, you notice that the patient was recently initiated on sacubitril / valsartan (Entresto). You decide that you d like to effectively communicate the benefits of this medication to this patient with HFrEF. Which of the following is the optimal and most correct communication strategy to use? A. Entresto will keep you from dying but won t keep you out of the hospital. B. This medication won t keep you from dying but will keep you out of the hospital. Posttest Questions Pharmacy Technicians C. Studies suggest that this medication can help you live longer and can help reduce the number of hospitalization you have related to HF. D. None of the above. 35 April 3625, 2017
Question 1 Which of the follow pharmacy services may contribute to the successful transition of a heart failure patient from the inpatient setting to the outpatient setting? A. Bedside prescription delivery B. Heart failure medication education C. Medication profile review for drug interactions / duplications of therapy / medications which may exacerbate HF D. All of the above Question 2 You work in an outpatient pharmacy located within a community teaching hospital. One of your pharmacy s goals is to ensure medication access for patients with high concern for readmission (e.g., HF). The pharmacy has set an aggressive goal of bedside prescription delivery to > 70% of patients identified by the transition of care program, but is only capturing ~ 40% of patients identified. Which of the following may be an appropriate avenue to take for program improvement? A. Assess how prescriptions are transferred to the outpatient pharmacy prior to discharge B. Review reasons why patients choose not to utilize the on site outpatient pharmacy C. Analyze discharge times of these identified patients related to your outpatient pharmacy s hours of operations D. All of the above 38 Question 3 Which of the following is an example of a beta blocker, a medication that is commonly prescribed for HF patients for mortality and hospitalization benefits? A. Ivabradine (Corlanor) B. Digoxin (Lanoxin) C. Spironolactone (Aldactone) D. Bisoprolol (Zebeta) 39