Ambulatory Patient Safety Toolkit

2011

Property of HealthPartners A resource for clinicians and staff provided by HealthPartners Ambulatory Safety Program Introduction

HealthPartners is committed to eliminating harm due to error in the delivery of medical care. The HealthPartners Ambulatory Safety Toolkit provides practical tools and suggestions that you may wish to incorporate into clinical operations or adapt to create your own initiatives. We include links to national and local safety resources and protocols, organized by topic. A complete listing of HealthPartners administrative policies can be found on the Provider Portal at healthpartners.com/portal/p178.html.

To date, relatively little research has focused on patient safety in the ambulatory setting. Yet most care is delivered in these settings. Although the ambulatory setting might seem less intense (and less “dangerous”) than an inpatient setting, lapses in safety can and do occur, with adverse consequences.

A “culture of patient safety” is an essential ingredient of the safe health care organization. “Culture” can be understood as habits, attitudes, and beliefs that live in the minds of the people who work in the organization and guide the work that they do. Concepts closely related to “culture” are “environment” and “mindset.”

The knowledge, skill and judgment of the clinician are essential, of course. In the modern group practice, clinic, and outpatient center, the clinician operates through organizational systems and processes, which together produce the desired clinical outcome.

Research has shown that serious errors occur more often from a failure of process and systems, rather than the action of a single individual. Well-designed systems and processes allow the organization to deliver care with reliability, consistency, and resiliency (the ability to detect and quickly recover from an error, before harm occurs).

Our goal with this toolkit is to promote these sorts of systems and processes. Together, we can improve the safety of care delivered in the ambulatory setting. We welcome comments and feedback. We are committed to continually improving this toolkit. Please feel free to contact us by e-mail at [email protected].

Lawrence H. Lee, MD, FACP Associate Medical Director Analytics and Strategy HealthPartners Health Plan

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Table of Contents

Clinic Assessment of Safety Culture ...... 4

Safety Learning Reports ...... 5

Medication Safety

. Medication Sampling ...... 6

. Therapeutic Monitoring ...... 7

. Do Not Use Abbreviations ...... 8

. Medication Reconciliation ...... 9

. Protocols for Use of Hazardous Drugs ...... 11

. Antibiotic Prescribing ...... 13

. Prescription Refills ...... 14

. Generic Prescribing ...... 15

Reporting Results: Follow-up from Tests and Procedures ...... 16

Patient Registries as a Monitoring Tool ...... 17

Falls Prevention ...... 18

Safe Driving ...... 19

Health Literacy ...... 20

Patient Engagement ...... 22

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Clinic Assessment of Safety Culture and Systems

Identify the Safety Risk Figure 3: Medication Safety Culture Meter Evaluation of a culture of safety refers to Figure 4: Clinic Safety Assessment Survey measurement components such as management Figure 5: Ambulatory Site Survey form behaviors, safety systems and employee perceptions of safety. There are a variety of Figure 6: Medical Error Policy and Reporting survey tools that facilities could use to identify form potential gaps and improvement initiatives Figure 7: Creating and Sustaining a Culture of concerning patient safety. While there are many Safety (Patient Safety & Quality Healthcare web surveys that address the safety climate, we site) endorse the Institute for Clinical Systems Improvement (ICSI) survey and HealthPartners Other Resources Ambulatory Site Survey (see sample forms).  AHRQ Perspectives on Safety Suggestions for Improvement  AHRQ Medical Office Survey Toolkit  Clinics should track errors that occur within  AHRQ Patient Safety Toolkit the standard practice of medicine.  ISMP Assessment Tool  A standard error report should be used by all of the staff. All staff must be comfortable in  Harvard Education-Culture of Safety reporting errors.  HealthPartners Policy: Practitioner Office  Review Tools for Incident Reporting. Site Quality Establish a “Safety Learning Report”  HealthPartners Clinic Safety Assessment format. Survey  Consider providing a thank you note and/or a pack of lifesavers when someone submits an error report. Works Cited  Culture surveys assist in identifying comfort The Ambulatory Patient Safety Toolkit is the copyrighted work of the Gunderson Lutheran Medical Center, in this area. A safety officer or committee developed for the Safety Collaborative for Outpatient could review the reports and monitor for Environment (SCOPE) Project, funded by the American trends to prioritize improvement projects. If Medical Group Association (AMGA) in 2003. Portions of a clinic is large enough, the detail could be the Ambulatory Patient Safety Toolkit are reproduced with permission of the Gunderson Lutheran Medical Center and entered into a database to track and assist in will be referenced whenever used in this toolkit. analysis.

 Clinics should have guidelines in place for hand hygiene. The Hand Hygiene Resource Center (http://www.handhygiene.org) is a project of the Saint Raphael Healthcare System and John M. Boyce, M.D. The Center’s mission is to advance the quality of patient care and reduce infection by improving hand hygiene practices in healthcare settings. The Center for Disease Control and Prevention (CDC) guidelines are also available at this site. (Gunderson 15) Sample Forms & Article Figure 1: ICSI Survey on Patient Safety Figure 2: Medication Event Report [4]

Safety Learning Reports

Identify the Safety Risk  Use this analysis to identify and prioritize areas for improvement. Clinics should have systems in place to track errors, “near misses” and “good catches” that  Develop action plans around the outcomes occur with the standard practice of medicine. seen.

 Continue ongoing monitoring of safety Describing them as safety learning reports may culture. minimize the negative connotation of incident reports and promote open dialogue and review (Gunderson 15) of an event from a systems perspective. Even Other Resources near misses could be tracked and collected.  NQF Resources Review of incident reports and near misses  ICSI through safety learning reports can help identify things that may be wrong with the system that  Minnesota Alliance for Patient Safety lead to errors, or may provide detail on what was  Children's MN Safety Learning Reporting right with the system that helped to prevent an error. Works Cited The Ambulatory Patient Safety Toolkit is the copyrighted work of Suggestions for Improvement the Gunderson Lutheran Medical Center, developed for the Safety Collaborative for Outpatient Environment (SCOPE) Project,  Establish and utilize a survey tool to assess funded by the American Medical Group Association (AMGA) in your clinic’s safety culture (see Clinic 2003. Portions of the Ambulatory Patient Safety Toolkit are Assessment of Safety Culture and Systems reproduced with permission of the Gunderson Lutheran Medical Center and will be referenced whenever used in this toolkit. for sample forms).  Use the safety culture results to assess the team’s comfort level in reporting incidents and in reviewing learning reports, near misses and good catches.  If survey results indicate improvement, develop an education tool kit and schedule team building around reporting incidents, near misses, good catches and safety learning.  If you do not have a current safety learning report format (or report for incidents), obtain samples and form a committee to review and select one, or use one and implement updates to it specific to your clinic.  Establish a protocol for safety learning reports. Make sure that the protocol addresses learning reports, near misses and good catches.  Have a safety representative review and compile data on the safety learning events that are identified through reports each quarter. Enter details into a database and monitor for trends.

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Medication Safety: Sampling

Identify the Safety Risk date distributed and the number of sample drugs remaining with a date. The use of samples leads to prescribing and use which may not be the most effective or efficient  Create labels for the samples and attach for patients: them prior to giving to the patient. Sample drugs represent potential risks as  Provide educational handouts on each drug pharmacists are eliminated from the within the sample space and make sure dispensing process. adequate copies are available and easily obtainable for each sample. Place a copy of There is an increased risk of documentation the education piece given to the patient in errors, use of non-formulary drugs, outdated the log and in the medical record. medications and drug interactions.  Make pharmaceutical representatives aware It is recommended that clinics eliminate of your protocol and their roles in ensuring sampling of all prescription pharmaceutical safe sample distribution. Consider a sign products supplied by manufacturers. Clinics in/out log for pharmaceutical representatives choosing to stock and dispense sample to use during every visit. Enter a name, medications must follow safe medication medication(s) delivered, lot numbers, practices consistent with JCAHO standards. quantity and expiration date. Clinic staff HealthPartners identifies sampling of who remove samples should sign them out prescription pharmaceuticals as inconsistent on the same log. with the six aims of quality, primarily due to concerns for patient safety.  Compliance with the protocol should be assessed and evaluated. Regular assessment Suggestions for Improvement for outdated drugs, supplies of drug  Eliminate sampling. information, and compliance with sign in/out log procedure should be performed on  Review or implement a sample drug protocol in your clinic. Form a work group a monthly basis. to assess the protocol (providers, nurses,  Assessments for hidden caches of samples medical assistants). within physician offices or exam rooms should be done regularly, perhaps every  Implement protocol. quarter to every six months.  If sampling is not yet eliminated, set a future date and goal for elimination. (Gunderson 22)  Determine which samples should be Sample Forms maintained, where they should be maintained and the level of security Figure 8: Pharmaceutical Sampling Policy necessary. All samples should be locked in a Other Resources secure place.  AHRQ: Data Collection  Eliminate drug samples from exam rooms  AHRQ: Selecting a Sample and doctors’ offices and store them in a secure location in clear view of a nursing  Harvard Education/Patient Safety Strategies station. Works Cited  Create a written documentation and The Ambulatory Patient Safety Toolkit is the copyrighted work of the Gunderson Lutheran Medical Center, developed for the Safety monitoring system for samples and include Collaborative for Outpatient Environment (SCOPE) Project, duplicate written instructions to keep in the funded by the American Medical Group Association (AMGA) in log and to give to the patient. Include 2003. Portions of the Ambulatory Patient Safety Toolkit are reproduced with permission of the Gunderson Lutheran Medical expiration date and drug details. Center and will be referenced whenever used in this toolkit.  Track the total starting number of samples per drug, the number distributed with the

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Medication Safety: Therapeutic Monitoring

Identify the Safety Risk Suggestions for Improvement Certain medications require annual monitoring  Create or implement a protocol on due to increased risk of harm from drug side- therapeutic monitoring for patients on effects and drug toxicity. Therapeutic persistent medications. monitoring of patients is essential to prevent avoidable adverse drug events related to specific  Incorporate the protocol to align with your high-risk drugs (e.g., Coumadin and use of the HealthPartners registry Amiodarone monitoring). monitoring system. Access to the registry data is available through Ongoing provider monitoring will include the www.healthpartners.com. Health Plan Employer Data and Information Set  Form a work group to assess the policy and (HEDIS) measure Annual Monitoring for include providers, nurses, and medical Patients on Persistent Medications. Performance assistants. information will provide meaningful and useful information to clinicians for therapeutic decision  Evaluate HEDIS results for this measure. making and management.  Review the HealthPartners measurement summary of the HEDIS Annual Monitoring This measure now includes for Patients on Persistent Medications − ACE inhibitors and combination products (Figure 9). − ARBs and combination products − Digoxin Sample Forms − Diuretics Figure 9: HealthPartners Clinical Indicator: − Anticonvulsants Annual Monitoring for Persistent Medications

Figure 10: HPMG&C Amiodarone policy

(example only – HealthPartners health plan does HealthPartners Commercial HEDIS Rates not endorse this specific protocol) Other Resources Annual Monitoring for Patients on Persistent Medications:  American Association for Clinical Chemistry 2009 2010 Results Results  FDA Safety and Drugs 2008 DOS 2009 DOS Works Cited ACE Inhibitors or ARBs 79.3% 82.3% The Ambulatory Patient Safety Toolkit is the copyrighted work of the Gunderson Lutheran Medical Center, developed for the Safety Collaborative for Outpatient Environment (SCOPE) Project, Digoxin 78.2% 86.1% funded by the American Medical Group Association (AMGA) in 2003. Portions of the Ambulatory Patient Safety Toolkit are Diuretics 80.5% 83.1% reproduced with permission of the Gunderson Lutheran Medical Center and will be referenced whenever used in this toolkit. Anticonvulsants 68.8% 68.7%

Total 79.5% 82.3%

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Medication Safety: Do Not Use Abbreviations

 Member interviews and pharmacy reports Identify the Safety Risk are additional resources to use in monitoring HealthPartners and Regions Hospital are part of and validation checks. a metro area-wide effort to eliminate unsafe (Gunderson 10) prescribing practices and reduce medication errors. Our efforts are part of the Safest in Sample Forms America (SIA) and JCAHO initiatives to Figure 11: Medication Discharge Sheet eliminate dangerous abbreviations, acronyms and symbols. We provide this information to Figure 12: Clinic Pharmacy Prescription Sheet encourage the elimination of unsafe prescribing Figure 13: ISMP List of Error Prone practices in all clinical settings. Abbreviations Suggestions for Improvement Other Resources  Establish a protocol and eliminate all hand  HealthPartners Policy and Attachments: Do written prescriptions. Not Use Error Prone Abbreviations  Perform an audit of prescriptions written in  Harvard Education/Patient Safety Strategies the clinic on 20 records to monitor for compliance with your clinic’s protocol. If  Joint Commission Do Not Use List 100 percent compliance is not seen, share

results with providers and set goals for improvement. Works Cited  The Ambulatory Patient Safety Toolkit is the copyrighted work of Continue to monitor for compliance. the Gunderson Lutheran Medical Center, developed for the Safety Consider additional initiatives with Collaborative for Outpatient Environment (SCOPE) Project, providers if 100 percent compliance is not funded by the American Medical Group Association (AMGA) in 2003. Portions of the Ambulatory Patient Safety Toolkit are seen. reproduced with permission of the Gunderson Lutheran Medical Center and will be referenced whenever used in this toolkit.  Obtain examples of poor prescription

writing from pharmacies and have them

block out the names to protect patient

confidentiality. You can show these to providers as examples.  Assess prescription writing practice by assigning a nurse to review all of the prescriptions written in a day as patients exit the clinics (Figure 11).  Collaborate with a pharmacy and provide them with standards and a chart to track a clinic’s prescriptions. Ask them to assess every prescription for one week or one month and give feedback. Review at least 20 prescriptions. Generate provider specific data and give feedback with suggestions for improvement. We suggest monitoring every 3 to 6 months once standards are in place.  If a medical practice has an electronic medical record, an electronic prescription writing platform may already be in place. Create a monitoring system (through EMR data reports) to check for accuracy.

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Medication Safety: Medication Reconciliation

Identify the Safety Risk review their medication list tool and compare it to the list in the chart (Figure 15). Medication reconciliation is the process of comparing a patient's medication orders to all of (Gunderson 4) the medications that the patient has been taking.  Develop scripting messages around This reconciliation is done to avoid medication medication reconciliation to promote errors such as omissions, duplications, dosing consistency, assure a high level of service, errors, or drug interactions. It should be done at help staff to handle difficult situations, and every transition of care in which new set clear expectations. Scripts also promote a medications are ordered or existing orders are verbal commitment and compel people to rewritten. follow through. Commitment influences HEDIS instituted a new measure in 2009 (2008 behavior and may increase compliance. data year) regarding “Medication Reconciliation  Try to include “Elements of Influence” in Post-Discharge”. The specification from CMS the scripting (Cialdini) requires that medication reconciliation occur within 30 days post-discharge from an inpatient Reciprocity exits: give before receiving facility. Even though this measure has a Commitment: greater consistency restricted population, the standard of care should Social proof: ‘everyone’s doing it’ apply to any member with complex medical care Recognition of legitimate authority needs on multiple medications Scarcity of opportunity: makes us want it more Suggestions for Improvement Provide a reason for the request  Establish a spot in the medical record where It helps if they know and like you the current medication list is stored. This  Include a statement in scripting about how should be accessed upon opening a medical the patient’s provider gives recognition of record or on the encounter page in an legitimate authority. For example, “Dr. X electronic medical record (EMR). wants to know your medications and would  Implement a process for obtaining and like you to know them too”. documenting a complete list of each  Consider personal reciprocity in your scripts patient’s medications upon admission to - be nice to people and they will feel clinic and hospital. Establish a obligated to be nice to you. Use words like communication method (fax or EMR) where “will you please…”, and always give the an inpatient facility provides the patient’s patient the opportunity to respond. current list of medications upon discharge from an inpatient facility.  Once you have developed the medication reconciliation script with input from front  Develop a tool for the member to use and line staff, test it in a small group. Make carry with them to bring for each visit to changes as needed. keep medications up to date (Figure 15).

 Consider a pre-visit or a post visit phone call HealthPartners HEDIS Rates: Medical Record to review medications with the patient. Audit of Special Needs Plans Population  Establish an audit review system to check Care of Older Adults 2008 2009 accuracy in the data provided between Medication Review 91.8 96.2 inpatient and outpatient systems. (i.e., do a comparative audit of 20 records each Medication Reconciliation

quarter). within 30 days post-inpatient discharge 77.1 87.6

 Assign a nurse/ medical assistant to choose 20 patients over several days each quarter to

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Medication Safety: Medication Reconciliation, continued

Sample Forms Figure 14: Medication List and Allergy List Accuracy Test Figure 15: My Medicine List Tool Figure 16: Sample Pill Box Distribution Policy Figure 17: HEDIS 2010: Medication Reconciliation

Other Resources

 AHRQ

 MHA

 NIH Seniors and Medication

 Joint Commission Alert/Medication Reconciliation  Joint Commission Alert/Anticoagulants Works Cited  Cialdini Robert B., Influence: The Psychology of Persuasion (New York: William Morrow and Company), 1984, 1993. Note: supported by ICSI

The Ambulatory Patient Safety Toolkit is the copyrighted work of the Gunderson Lutheran Medical Center, developed for the Safety Collaborative for Outpatient Environment (SCOPE) Project, funded by the American Medical Group Association (AMGA) in 2003. Portions of the Ambulatory Patient Safety Toolkit are reproduced with permission of the Gunderson Lutheran Medical Center and will be referenced whenever used in this toolkit.

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Medication Safety: Protocols for Use of Hazardous Drugs

 Form an improvement group of providers to Identify the Safety Risk review the current methods of providing safe Coumadin, Amiodarone, Insulin and controlled care to patients who are on anticoagulants substances are the most common potentially and for patients who are diabetic. Evaluate hazardous drugs prescribed in the outpatient the results and implement change if setting. Research demonstrates that standardized improvement is needed. prescribing of these medications may improve  Update protocols and standing orders as safety. needed to be in compliance with guidelines. Protocols for a Coumadin prescription, along  Perform an audit of 20 records to compare with standing orders for INR determination are with each of the medication guidelines and available through multiple sources, including the orders in your protocol(s). Review product manufacturer. Clinics should have compliance outcomes with your clinic’s standing orders that allow nurses to renew or quality team. alter doses based on lab test results or changes in the patient’s circumstances. Standing orders that  Continue to monitor for compliance against require regular assessment of INR should also be the clinic protocols for hazardous drugs. in place.  If you use an electronic medical record, and Sliding scales for Insulin have improved care by as computers become more common in allowing those at the actual point of contact with exam rooms, incorporate the guidelines, the patient to modify medication orders based on standing orders and other safety tools into point of care testing. Protocols, guidelines and the work flow of patient care. standing orders should be developed to allow  Review the HPMG & C Amiodarone policy nurses to provide the greatest level of patient (Figure 10) care in the safest manner. (Gunderson 25) Use of chronic opioid therapy for chronic nonmalignant pain (CNMP) has increased Sample Forms substantially; therefore effective management is Figure 10: Amiodarone Monitoring Policy considered a major problem in both primary care and out-patient medicine. It presents a major Figure 18: Warfarin Therapy Protocol challenge for both the patient and health care Figure 19: Provider Letter: Controlled provider. Opioids are associated with potentially Medication serious harms, including adverse effects and outcomes related to the abuse potential. Figure 20: Exceptional Use Program

Does your clinic have protocols in place and standing orders for Coumadin, Amiodarone, Insulin and controlled substances (CS)? Are CS locked in a safe place with a sign out procedure? How complete are the protocols for hazardous drugs? Have you compared them to guidelines? How well are the protocols and standing orders followed in your clinic? Suggestions for Improvement  Establish protocols for the use of hazardous drugs in your clinic. Make sure that the protocol addresses standardized daily dosing algorithms, monitoring and management plans. Include details on lock up and sign out procedures for certain medications.

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Hazardous Drugs, continued

Other Resources  ICSI Guidelines: Antithrombotic Therapy Supplement, Diabetes  AHRQ  AAEM Position  OSHA list of hazardous medications  MN Pharmacy Board: Prescription Monitoring Program

Works Cited The Ambulatory Patient Safety Toolkit is the copyrighted work of the Gunderson Lutheran Medical Center, developed for the Safety Collaborative for Outpatient Environment (SCOPE) Project, funded by the American Medical Group Association (AMGA) in 2003. Portions of the Ambulatory Patient Safety Toolkit are reproduced with permission of the Gunderson Lutheran Medical Center and will be referenced whenever used in this toolkit

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Medication Safety: Antibiotic Prescribing

Identify the Safety Risk Sample Forms To reduce risk, monitor the overuse (multiple Figure 21: Pearl of Knowledge: Acute dispensing) of antibiotics and/or inappropriate Bronchitis use of antibiotics. Some potent antibiotics, while Other Resources very effective against certain types of infections, have a high risk for toxicity. This risk is even greater with patients who have impaired renal  AHRQ Antibiotic Report function.  AAP Guidelines When using antibiotics that have a high risk of  Pediatric Abstract article toxicity, such as aminoglycosides and vancomycin, use protocols or other standardized  NY Dept of Health dosing guidelines to assist prescribers in  ICSI Guideline Respiratory Illness selecting appropriate doses based on clinical condition and renal function.  HealthPartners and Flu Shots Ongoing provider monitoring completed by  MN Community Measurement Minnesota Community Measurement includes  Minnesota HealthScores the following measures:

• Appropriate Treatment for Children with Upper Respiratory Infections • Appropriate Testing for Children with Pharyngitis • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Performance information will provide meaningful and useful information to clinicians for therapeutic decision making and management. Suggestions for Improvement  Develop a protocol to follow with antibiotic prescriptions.  Review the Minnesota Community Measurement provider monitoring for the measures listed above.  Use existing guidelines and protocols with appropriate criteria to meet before ordering an antibiotic. If possible, implement these guidelines into your EMR or patient work flow to use when prescribing antibiotics.  Consider creating a tool with criteria to check for quarterly chart audits on children and adults who have received antibiotics. Review results and try to identify if greater action is needed for appropriate use of antibiotics.

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Medication Safety: Prescription Refills

Identify the Safety Risk  Form a work group to assess the audit data (providers, nurses, medical assistants). All providers will have a process for prescription Compare data to the policy parameters. If refills to insure patients receive approvals in a parameters were not met, evaluate if timely and safe manner. Providers should changes are needed in the policy. develop a standing order policy and procedure regarding frequent medication refills.  Review and analyze the other data results. Is there an area where improvement is needed Research studies have proven the effectiveness in the refill process? If so, have the work of automated or electronic prescription writing group develop an improvement initiative. programs to reduce errors in handwritten prescriptions. Examples of electronic  Once the initiative is implemented, evaluate prescription tools include palm pilots, intranet, quarterly until improvement is seen, or until electronic formulary, or online drug information other changes are made. database. E-Prescribing allows for clear,  Continue to monitor for compliance with concise, and legible instructions. HealthPartners your clinic’s prescription refill protocol on encourages the adoption of E-prescribing in all an ongoing basis. clinical settings.  Consider implementing a refill reminder Electronic prescribing can offer enhanced safety system to increase compliance. features for patients. Prescriptions are legible, and pharmacists can eliminate worries over (Gunderson 34) misunderstood phone messages for a Sample Forms prescription or refill of a medication consisting of a sound alike name. Figure 22: Medication Refill (Behavioral Health) Standing Order policy. Online prescription refills is another technology that can reduce errors and improve prescription Figure 23: Medication Refill (Non-Behavioral processing efficiency. With online refills, Health) Standing Order policy. patients can submit their refill requests These policies are for reference only. Please electronically. review and adapt to make your own policy. Suggestions for Improvement Other Resources  Convert your refill process into an e-  AHRQ Article prescribing system.  e Health Initiative-Electronic Prescribing  Create or implement a protocol on prescription refills for your clinic. This  NPSF Pharmacy Safety Consumer Fact could be incorporated into an electronic Sheet medical record or an on-line refill system. Works Cited  Create an assessment sheet for auditing The Ambulatory Patient Safety Toolkit is the copyrighted work of purposes. The assessment could include how the Gunderson Lutheran Medical Center, developed for the Safety Collaborative for Outpatient Environment (SCOPE) Project, the refill was provided, by what provider, funded by the American Medical Group Association (AMGA) in who picked up the order, what pharmacy 2003. Portions of the Ambulatory Patient Safety Toolkit are refilled the prescription, did the member reproduced with permission of the Gunderson Lutheran Medical Center and will be referenced whenever used in this toolkit need to be seen prior to the refill, and, if so, was the member seen?  Integrate the clinic protocol parameters into the assessment. Complete a random audit of 20 members with refills. Use the assessment sheet to track audit results.

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Medication Safety: Generic Prescribing

Identify the Safety Risk  Perform an audit to identify patients who are on the drugs and run a cost summary of the Generics are a safe, effective alternative to many past year. The summary should include cost branded drugs. Generic drugs, because they have of the drug and cost to the patient. been on the market for a long time, have well known side effects and a longstanding record  Create a generic education sheet and making them a more reliable and safe choice describe the medication conversion you are compared to newly introduced drugs. focusing on. Prescription drugs can be a costly medical  Identify 20 patients and flag their medical expense, especially for older people and those record to focus on conversion to a generic who are chronically ill. However, each state has equivalent on their next office visit. a law that lets pharmacists substitute less  Make a follow-up phone call to the patient expensive generic drugs for many brand-name three to five days after the prescription was products. Generic drugs are less expensive written for conversion. because generic manufacturers don't have the investment costs that the developer of a new  Submit a questionnaire to check on drug has. satisfaction and send to patients two months after conversion. Review the satisfaction New drugs are developed under patent outcomes and determine if you can broaden protection. The patent protects the investment - the conversion program. including research, development, marketing and promotion - by giving the company the sole  Re-run the cost analysis data in three to six right to sell the drug while it is in effect. months and again in one year and compare that to the brand cost data. As patents near expiration, manufacturers can apply to the FDA to sell generic versions. Other Resources Because those manufacturers don't have the  FDA Generics same development costs, they can sell their product at substantial discounts. Also, once  HealthPartners.com/formulary generic drugs are approved, there is greater  HealthPartners Clinical Indicators Report competition, which keeps the price down. Generic Drug Use in Primary Care and in Specialty Care are Clinical Indicator measures. The rate represents the percentage of all prescriptions filled with generic drugs for HealthPartners members with a drug benefit. For prescriptions filled the first half of 2010, the generic drug use rate for primary care is 76.0 percent. The generic drug use rate for specialty care ranged from 71.0 percent and 92.5 percent. Suggestions for Improvement  Create a generic drug protocol in your clinic.  Choose one common brand name drug to focus on in your clinic.  Identify patients and target to move them toward generic conversion from the brand name drug to the equivalent generic.

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Reporting Results: Follow up from Tests and Procedures

Identify the Safety Risk  Implement the new process and policy. After one month, perform a random survey All providers will have a process and written of charts. Document results and evaluate if protocol to identify abnormal diagnostic results, any changes need to be made. Resurvey reporting abnormal results to clinicians and compliance on a regular basis. actions taken.  If failure to notify patients in a timely Suggestions for Improvement manner is rare, an annual evaluation should  Examine your practice and review your be sufficient. If you are seeing problems, try current “results reporting” process. Is there a to perform a gap analysis, adjust the process protocol in place? If not, form a work group and update the policy. If problems are noted, to establish a clinic wide results reporting a quarterly audit for compliance may be policy. Questions to answer may include: required. What critical values require phone calls? (Gunderson 31)  What tests require a written letter from the provider? Sample Forms Figure 24: Patient test result notification  What is the turnaround time required for a Figure 25: Patient test follow-up letter test to be completed and reported initially?  What is the turnaround time goal for Other Resources reporting the results to the patient?  Hanna, D, Griswold P, Leape LL, Bates DW: Communicating Critical Test Results:  Is there a difference between a turnaround Safe Practice Recommendations. Joint time or type of notice given for normal Commission Journal on Quality and Patient verses abnormal results? Safety 2005, 31:2 68-80.  Is there a provider back up plan to notify  Baldwin DM, Quintela J, Duclos C, Staton patients of results if the provider who EW, Pace WD: Patient Preferences for ordered them is not available to get back to notification of normal test results: A report the patient? from ASIPS Collaborative BMC Family  Is there a rule about leaving information on Practice 2005, 6:11 1-7. results on answer machines or with other people? Works Cited The Ambulatory Patient Safety Toolkit is the copyrighted work of  What documentation needs to occur in the the Gunderson Lutheran Medical Center, developed for the Safety notification process and who is responsible Collaborative for Outpatient Environment (SCOPE) Project, funded by the American Medical Group Association (AMGA) in for this? 2003. Portions of the Ambulatory Patient Safety Toolkit are reproduced with permission of the Gunderson Lutheran Medical  Try to address all of these issues and define Center and will be referenced whenever used in this toolkit. parameters for the notification process in your clinic policy.  Develop a form letter for reporting normal results to the member to simplify reporting normal results to the patient (Figure 25).  If your clinic uses patient e-mail notification, consider adding detail in the protocol to address reporting results through this process.  Perform a random audit of normal and abnormal result notifications under your current process. Use this as baseline data.

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Patient Registries as a Monitoring Tool

Registries are becoming increasingly important  Identify your interventions, evaluate these to support patient care, ensure adherence to over time and modify them as needed. clinical guidelines and assess provider  Use the registry for visit planning to work performance. “A computerized disease registry with patients when they are seen in the is a software application for capturing, managing clinic. and providing access to condition-specific information for a list of patients to support  Assist patients in receiving the services they organized clinical care.” (California HealthCare need such as mammograms, immunizations, Foundation publication, Using Computerized lab tests and eye exams by communicating Registries in Chronic Disease Care). the needs to the patient through some form Developing, using and maintaining a Registry is of outreach. a standard in NCQA’s Medical Home  Validate the data provided and update recognition program. quarterly. HealthPartners maintains a registry of members  Evaluate your success and refine your who are in need of preventive or chronic care process where needed. treatment and/or testing. These lists may be utilized independently or may augment  Continue ongoing monitoring of patient processes and/or Registries that you already populations and expand improvement efforts have in place for your entire clinic. to other focused areas in patient care. Registries at HealthPartners are updated Other Resources quarterly. Registry data updates are currently  AHRQ: Registries for Evaluating Patient available for Preventive Services, Asthma, Outcomes (2010) Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Cardiovascular Disease  California Health Care Foundation: Using (CVD), Coronary Artery Disease (CAD), Heart Computerized Registries in Chronic Disease Failure (HF), Child and Teen Check-ups (C & Care (2004) TC) and Hypertension.  AAFP: Registries Suggestions for Improvement  Develop a protocol on registry use in your Secured Provider Portal access to registry data is clinic using HealthPartners registry, your available at healthpartners.com. Contracted own clinic registry, or both. providers can obtain access by registering at Provider Registry form  Identify your target population(s). Choose a population of patients with certain chronic diseases. It may be practical to start an For current registry users: Provider Electronic improvement process with one area of focus Commerce support center at 952-883-7505 can from the registry. help with password issues and questions.  Identify who will be responsible for one (or each) registry list and how the work will get done.  Develop base line data using established measures, and evidence based guidelines to define target goals.  Audit at least 20 patient records for completion of the required elements.  Track your efforts to provide the needed services through the registry.

[17]

Falls Prevention

Identify the Safety Risk  Present a case study of the fall description to the partnership committee to prevent falls. Preventing falls is an important issue, especially for the well-being of older adults. Research has  Have a brainstorm session to identify causes demonstrated falls in adults over the age of 65 and possible prevention for the case can result in hip fractures and head injury. Once presented. an elderly patient is hospitalized from a fall,  Come to a conclusion for the cause of the many never return home or live independently fall, and intervene with an education again. It is imperative to identify and assess program for the patients. patients at high risk for a fall in the ambulatory setting. This includes appropriate access points  Engage the patient in your quality in the clinics, use of assistive devices, cameras improvement attempt to prevent future falls. in public areas, appropriate rooming procedures  Provide additional resource tips such as such as a family member or staff member physical therapy, safety tips for use of staying with the confused patient during their crutches, walkers, wheelchairs, etc. visits  Intervene and document education and have Suggestions for Improvement the patient teach back or explain what was  Create a partnership committee to focus on learned. fall prevention. Include physicians, nursing,  Monitor the patient for future falls and audit pharmacy, physical therapy staff and records twice a year for two years post falls. administration.  Evaluate and intervene if falls occur post  Identify that falls can happen from aging improvement initiative. Make changes if and balance problems, environmental necessary. hazards, impairments to vision, hearing, sensory and motor skills, medication effects,  Create a falls assessment and falls toileting requirements and poor judgment. prevention check list for every patient over the age of 65 years of age – also include any  Falls can be prevented through thoughtful patients who may be at risk for falls. strategies designed for individuals.  Keep the check list posted on the admit page  Create a falls assessment sheet to identify if for clinic visits. Provide educational a patient is at risk for falls and include: handouts for falls prevention to these history of previous falls, motor or sensory patients. impairment, orthostasis, dementia, delirium, sedation, elimination (bowel and bladder Sample Forms needs). Figure 26: Fall Safety Checklist  Create a protocol that identifies that the Other Resources team working with patients can recognize, diagnose, evaluate, treat and prevent patient  NIH Senior Health falls.  CDC Falls Fact Sheet  Create or use an education sheet on patient  MN Falls Prevention falls. Make sure to address each of the areas identified as potential risks and provide a key prevention recommendation.  Audit the records of patients who have been seen in clinic and/or admitted to the hospital in the last quarter due to a fall.

[18]

Safe Driving

Identify the Safety Risk Advanced age should not automatically be equated with dangerous driving, because many older drivers are quite capable drivers.

Safe elderly drivers require the complex coordination of many different skills. Physical and mental changes that occur with aging can diminish the abilities of elderly drivers.

Telling elderly drivers that it may be time to stop driving can be one of the most difficult milestones for caregivers. Support and assistance from the patient’s physician can help make this transition less difficult. Other Resources Suggestions to Assess and Counsel the Older Driver:  Aging Solutions  Open communication with the patient and  AAA Roadwise Review family in the office setting can help  How to Assess and Council the Older Driver physicians assess the patient’s risk for a driving accident.

 Working with family and involving

community resources regarding alternative

forms of transportation may be necessary.  Patient with suspected driving difficulty needs to be interviewed and examined thoroughly by the physician.  Determine the importance and uses of driving in the patient’s life.  Provide resources to the patient regarding a formal driving evaluation program or community programs.  If a patient needs to stop driving, present the news slowly and sensitively.  Acquaint yourself with state laws regarding the reporting of a patient with disease or illness that interferes with driving.  Your recommendations should be provided to the patient in writing. Sample Forms Figure 27: AARP elder driver checklist

[19]

Health Literacy

easier to understand and into the primary Identify the Safety Risk language that you have prioritized. Effective communication is the heart of health  care relationships. At least 50 percent of the US Several resources have education materials population cannot understand and use the available in multiple languages that also information provided by their clinicians. provide detail on cultural appropriateness.  Health Literacy is defined as an individual’s Bring in a focus group and a translator to ability to read and comprehend prescription test the materials you have converted. bottle labels, appointment slips and other  Create a calendar to continue to covert essential health related materials required to materials by topic in your clinic over time. successfully function as a patient. Create a shame-free environment and use Research shows literacy is a stronger predictor patient friendly and culturally appropriate of health status than age, income, employment materials. status, education level or racial and ethnic group. (Gunderson 26) Health literacy barriers lead to misunderstood health care instructions, prescriptions and Six steps to improve interpersonal appointment slips (no-shows), poor health communication with patients outcomes and medical errors. 1. Slow down It is now recommended that a universal 2. Use plain, non medical language precautions approach be taken. This means 3. Show or draw pictures approach all patients the same – i.e., all patient education materials, forms and letters are at a 4. Limit the amount of information provided 7th grade reading level and all explanations are and repeat it in plain (nonmedical) language. 5. Use the teach-back or show-me technique Health Literacy affects a person’s ability to 6. Create a shame-free environment and use engage in self-care and chronic disease patient friendly and culturally appropriate management. See the “Patient Engagement materials Section” of this toolkit for additional ideas.

Suggestions for Improvement Sample Forms  When giving instructions or educating the Figure 2 8: Teach-Back supported by research patient about their medical condition, use Figure 2 9: Teach-Back Self-Evaluation & plain, non-medical terminology, focus on Tracking Log one to three key messages, show or draw a Figure 30: Resource List simple picture. Figure 31: Clear Communication Checklist  Ask patients to recall and restate what they Works Cited have been told about medication, what they are to do when they get home, etc. See The Ambulatory Patient Safety Toolkit is the copyrighted work of the Gunderson Lutheran Medical Center, developed for the Safety Figure 24. Collaborative for Outpatient Environment (SCOPE) Project, funded by the American Medical Group Association (AMGA) in  Focus on one topic and/or one ethnic group 2003. Portions of the Ambulatory Patient Safety Toolkit are and review all patient education materials reproduced with permission of the Gunderson Lutheran Medical Center and will be referenced whenever used in this toolkit. used in this area. Compare the materials to a Reading score tool (e.g., Flesch Reading Ease or grade level, SMOG, etc.) and access tools that have already converted education materials to different languages. Convert those materials that are identified as more complex into a lower reading level that is

[20]

Health Literacy, continued

Other Resources  Health literacy and patient safety: help patients understand (AMA Video)  US Dept of Health and Human Services: Quick Guide to Health Literacy  Strategies for Improving Health Literacy  CDC Communication Strategies  National Patient Safety Foundation  Stratis Health  AHRQ Health Literacy Universal Precautions Toolkit  Ethnomed  CDC Plain Language Thesaurus  NPSF Online Patient Safety Resources

[21]

Patient Engagement

Identify the Safety Risk  Provide each patient with copies of their medication lists. There are “apps” that will A critical component of ongoing medical care is show a picture of the medication for people having the patient engaged in self-care. Assess with low health literacy. the patient’s interest level in their own care. Remove health literacy barriers to support your  Patients should be instructed to update the patient/family engagement efforts. Informed clinic with any medications they are taking patients are more engaged and actively involved that are prescribed by other physicians or in their therapy. Patient partnering will involve any other medication changes i.e., providing patients with tools to help them discontinued medications, dosage changes, become more informed. What efforts has your etc. clinic made to involve patients in their own  Urge patients who are unsure about safety? medications to bring in a bag with all of Suggestions for Improvement their medications. Take the time to help clarify the labels and explain the different When providing patients with written materials, th medications to them. Health literacy tip – be sure that they are at the 7 grade reading ask the patient to identify each pill, when level and are in plain language. When explaining they take it and what the pill is for. medical conditions or educating patients, use the “Teach Back Method”. See Health Literacy  Consider implementing a pill box section of this toolkit for additional ideas. distribution system or develop a pill card (Figure 33) for patients who take multiple  Provide all patients with an understanding of medications and/or for those at highest risk the roles of the clinicians, nurses and of missing medications. pharmacists in their care.  Create a protocol for the use and distribution  Have patient brochures available in the of the pill boxes (Figure 16). clinic to engage them in actively managing  Engage patient family members or, if their care with their providers. appropriate, assist the patient in engaging  Create an agreement for patients and home health resources for medication providers to review and sign regarding roles distribution. and responsibilities. Address prevention,  The medication reconciliation tool can help healthy lifestyles, illness, and medication to coordinate improvement efforts (Figure management. Keep the agreement in the 15). front of the medical record and provide a copy for the patient.  Make it a routine part of your care process, to create an after visit summary regarding  Address active patient responsibility at each patients self care and medication safety. clinic visit and give examples related to the visit and follow up. Health Literacy tip – use Sample Forms Teach Back Method, e.g., “What are you Figure 15: My Medicine List Tool going to do when you get home?” Figure 16: Sample Pill Box Distribution policy  Engaged patients may want additional help Figure 31: Medication Therapy Management: when faced with multiple options for care of article, ROSE Resource 2Q 2008 newsletter certain conditions/diseases. Shared decision published by ING Reinsurance. making tools address this need. See “Other Figure 33: Pill Card Template Resources” for more information.

 Discuss the patient’s role in checking their medication carefully and the need to report any side effects to their care providers.

[22]

Patient Engagement, continued

Other Resources  CDC Health Communication Strategies  What Did the Doctor Say?  Joint Commission International Center for Patient Safety  AHRQ Consumer Site  National Cancer Institute Fact Sheet  ICSI Guidelines  AHRQ Pill Card and Instructions  Shared Decision Making  Ottawa Patient Decision Aids  Patient Safety and Quality Healthcare

[23]

FIGURE 5

AMBULATORY SITE SURVEY FOR ONE CLINIC Contact Information Medical Group Name: Surveyor Name:

Date of Survey:

Clinic Site Name & Address: Medical Group Representative & Title: (meets with HP surveyor and receives follow-up recommendations. Note if 2 different individuals.)

Phone: Site Phone: Fax: Site Fax: Email Address: Medical Records Contact: Quality Contact:

Phone: Phone: Accreditation (circle) JCAHO NCQA Other (list) Accreditation Date

If clinic has accreditation, obtain a copy of the survey report that indicates the survey includes the physician’s office and meets HealthPartners quality assessment criteria. If these qualifications are met, the rest of this document does not need to be completed.

Site Survey External Access/Appearance Yes No N/A 1. Building is easily identified and accessible (includes: handicap accessibility) 2. Practitioner’s names are listed near entrance/reception area or printed information is available to patients (i.e.: brochure, business cards) 3. Hours of operation and after hours care are posted near entrance/reception area or printed information available to patients (i.e.: brochure with hours) 4. Adequate patient and handicap parking is available 5. Parking areas and clinic entrance are well lit and well maintained Internal Access/Appearance Yes No N/A

6. Adequate signs/directions to patient care, business office and administrative areas

7. Reception/waiting areas are adequate to accommodate patient flow and volume 8. Exam/treatment rooms are adequate to accommodate appointment scheduling, patient privacy, etc. 9. Patient care areas are handicap accessible 10. Reception/waiting areas and exam/treatment rooms are clean and well maintained General Safety Management Yes No N/A 11. Fire safety procedures and systems are in place (i.e.: unobstructed fire exits/doors, alarms, sprinkler systems) 12. Abusable supplies are appropriately secured (i.e. are not in exam rooms - drugs, syringes, prescription pads) 13. Hazardous waste containers and Sharps containers are present 14. Sample medications are kept in a locked area and logged out when provided to patients

and routinely checked for expiration date (circle if yes)

FIGURE 5B

AMBULATORY SITE SURVEY FOR ONE CLINIC

Site Survey, continued Access Yes No N/A 15. Medical Coverage is available 24-hours/day

16. Written policy exists for appointment availability

17. Preventive Care appointments can be obtained within four weeks

18. Non-Urgent, symptomatic appointments can be obtained within 48-72 hours

19. Urgent Care appointments can be obtained within 24-36 hours

20. Policy exists for answering and returning phone calls

21. Compliance with answering and returning phone calls is monitored Medical Record-Keeping Yes No N/A 22. Medical records are stored in a secure area that is inaccessible to unauthorized

individuals. Area is locked or someone present at all times during open hours. 23. Written policies exist for confidentiality, release of information, and advanced directives 24. Written policy for medical records standards. Compliance with medical record

organization and documentation requirements is monitored 25. Written policy exists for chart availability between practice sites 26. Written policy exists for continuity & coordination of care with other practitioners &

providers (i.e.: hospitals, home cares, nursing homes, specialists)

27. Review medical record or obtain a copy of a list (chart order) showing what’s included in the medical record (i.e.: problem list, immunizations, medication flow sheet). For electronic (EMR) obtain a copy of the policy and procedure manual’s Table of Contents

If you answered No to any of the above questions please explain/comment:

HealthPartners/GHI

Subject Attachments Medical Errors/Incident/Quality Issues Reporting Process Yes No

Key words medical errors; incident report; quality issues Number GHI PI HPMG Ops 01 Category Performance Improvement (PI) Effective Date 4/10

Manual HealthPartners Medical Group and Clinics-Operations Manual Last Review Date 4/10 Issued By Care Innovation and Measurement Department Next Review Date 4/13 Applicable HealthPartners Medical Group and Clinic Staff Origination Date 4/04 or earlier Retired Date

Review Responsibility Care Innovation and Measurement Dept; HPMG Medical Council; Contact Sr. Quality Peer HPMG Clinic Administration. Review Coordinator

I. PURPOSE Reporting of quality issues or medical errors/potential medical errors/incidents and quality of care and service issues to the Care Innovation and Measurement Department is important. Data and information that is collected by the peer review committee is protected from discovery by Minnesota Peer Review Statutes. Reporting is of great benefit to the organization because investigation and peer review can occur when appropriate and tracking and trending of issues can help discover system issues to be corrected. You can contribute to quality care in the workplace and for our patients by reporting.

II. POLICY Medical errors/Incidents and Quality of Care and Service Issues involving patients or visitors should be reported to the Care Innovation and Measurement Department in a timely manner.

III. PROCEDURE(S) Immediate actions: ensure patient/visitor safety including emergency treatment, evaluation by MD./medical staff, notification of supervisor, any corrective actions needed to prevent immediate danger to others. Give appropriate response to patient following the Service Recovery Process, addressing immediate needs.

Reporting: Fill out the Medical Error/Incident form or the Medical Patient Feedback Request form. The forms are found on the ERIC webpage under Work Tools/Forms section/Quality Forms. The forms are also available on EPIC under Links. Instructions are provided on the forms. Give form to the clinic administrative staff or send directly to the Care Innovation and Measurement Department as directed on the forms. The Medical Patient Feedback Request form can be used for reporting patient feedback (complaints or compliments) and also for staff identified quality of care issues.

An alternate method of reporting is the Medical Error/Incident Reporting Hotline at 952-883-6222.

Questions regarding the process can be directed to the Care Innovation and Measurement Department.

GHI PI HPMG Ops 01 4-10.doc 1 of 2

IV. DEFINITIONS Medical Error - failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim. Incident - occurrence which happens to a patient, visitor or property which is inconsistent with proper procedure or routine operations, inconsistent with intended care or injurious or has potential to result in injury, property harm or negative consequences. Quality Issue - a staff member or patient-identified quality issue/complaint with any department. For example, quality of care issues regarding providers, nursing, reception, pharmacy, lab, radiology, etc. This includes issues of Access (wait times, referral availability, appointment scheduling), Communication/Behavior (manner, time spent, explanation/education, communication of results), Coordination of Care, Technical Competence/Appropriateness (diagnosis, competence), and Facility/Environment issues.

V. COMPLIANCE Failure to comply with this policy or the procedures may result in disciplinary action, up to and including termination.

VI. ATTACHMENTS n/a

VII. OTHER RESOURCES Internal n/a

Other n/a

VIII. APPROVAL(S)

Nancy McClure Brian Rank MD Senior VP, HPMG and Clinics Medical Director, HPMG and Clinics

IX. ENDORSEMENT n/a

GHI PI HPMG Ops 01 4-10.doc 2 of 2

Medical Error/Potential Medical Error/Incident Reporting

When should the form be completed?

Whenever a medical error, potential medical error or incident is identified, it should be reported. We define these as follows:

Medical Error - failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim.

Incident - occurrence which happens to a patient, visitor or property which is inconsistent with proper procedure or routine operations, inconsistent with intended care or injurious or has potential to result in injury, property harm or negative consequences.

How can I report these events?

To report it, you can either call the Medical Error Hotline (952-883-6222) or complete this form. The call or form should be completed immediately.

Who should complete the call or the form?

Any HPMG employee or medical staff member who witnesses or becomes aware of an event should report it.

What should I do if the event involves injury to the patient/visitor?

The first and most important thing to do is ensure the patient/visitor is treated by a physician. Additionally you should immediately notify your supervisor of this type of event and on the form indicate the appropriate class for the outcome of the event.

Where should this form be sent?

Send the completed, original form in reroute to:

Care Innovation & Measurement 21101D

How can I get help if I have questions?

Talk with your clinic manager, chief or supervisor or call Care Innovation & Measurement at 952-883-7779.

CONFIDENTIAL – NOT A PART OF THE MEDICAL RECORD This report is directed to HealthPartners Care Innovation & Measurement Department. The contents of this report are confidential in accordance with Minnesota statutes.

Page 1

DO NOT COPY

Medical Error/Potential Medical Error/Incident Form

Name: ______Check one Clinic: ______Date of event: ______ Patient Time of event: ______MRN #: ______ Visitor Specific location

of event: ______DOB (if MR # missing): ______

1. Describe what happened (Be concise, objective, factual, and include any statements of patient/visitor in quotes. Include details surrounding the event and other extenuating circumstances) ______

______

2. Outcome of Event

Check one

Class I – Emergent, Harm * Class II – Urgent, Harm * Class III – Non-urgent, No harm Unexpected, event involving death or Event resulting in injury Event not resulting in injury or serious injury. or change in condition. change in condition.

* Class I & II require immediate attention and response. Contact your supervisor immediately.

Check all that apply:

Abrasions/bruise/contusion Fracture / dislocation Sprain / Strain Allergic reaction Infection Unplanned admission to hospital Burn IV infiltration Unplanned ER visit Cardiac / Respiratory arrest Laceration Unplanned surgery Death Mental status changes Other: ______ Delayed treatment / Diagnostic test No change in condition or outcome Dental related Property damage Dizzy, nausea, headache Repeat test / Procedure

Page 2

M EDICATION RELATED Possible Causes of Event – Check all that apply Prescribing – RX w/incorrect med/dose/freq. (provider only) Lack of training Illegible handwriting Dispensing – Incorrect product (pharmacy only) Verbal miscommunication Transcription incorrect Dosage – Incorrect strength (pharmacy only) Label/packaging Order missed Distribution – Pt. receives another’s Rx (pharmacy only) Name confusion Order not sent to Pharmacy Medication – Incorrect med or dose administered Unfamiliar medication Order sent to Pharmacy but not Reaction – Adverse reaction to meds Med. unavail. at admin. time in stock Inaccurate dose calculation Confusing abbreviation Order misread Other - ______ Other - ______

PATIENT CARE RELATED

Check all that apply

Diagnostic Treatment Preventive Error or delay in diagnosis Error in performance of operation, Failure to provide prophylatic treatment Failure to employ indicated tests test, procedure Inadequate monitoring or follow up Use of outmoded tests or therapy Error in administering the test/treatment Failure or delay in acting or results Delay in treatment or responding to abnormal test of test Inappropriate or not indicated care

Other Possible Causes of Event – Check all that apply Failure of communications New process or task Documentation error Unfamiliar process Computer system error Staffing levels Record availability Lack of training ______ Miscommunication Other: ______

FALL RELATED TRAUMA RELATED

Check one Check all that apply Check one Exam room Floor wet/slippery Burn Self-injury Interpersonal altercation Public area Needed help – did not call Staff with pt/visitors at time Check all that apply Other: ______of incident Was patient impaired Struck by an object Patient impaired at time of Staff involved Struck an object incident Equipment involved Other: ______

M ISCELLANEOUS

Check all that apply

Equipment failure, damage, contamination Facility/property damage Departure before seen Missing article Other: ______

Page 3

3. Person Completing Form

______Name (Please print) Date Dept/Unit Phone/Extension

Witnesses:

______Name (Please print) Date Dept/Unit Phone/Extension

Others (Please print name(s)

4. Physician Report Condition of Patient and Plan of Care: ______

______

Signature of Physician Examining Patient______Date/time ______Refused treatment/care? Yes No N/A

5. Management Follow-up: ______

______

Other Dept(s) CI needs to follow up with: ______

______Signature of Supervisor Date Time

6. Other Department Follow-Up: ______

______

7. CARE INNOVATION & MEASUREMENT USE ONLY: DATE RECEIVED: ______FOLLOW-UP NECESSARY:______

Page 4 September / October 2008 Patient Safety & Quality Healthcare psqh.com Teams & Communication Creating and Sustaining a Culture of Safety

By Stephen W. Harden

Healthcare consumers are increasingly aware of medical error and publicly reported quality measures. Additionally, the Centers for Medicare and Medicaid Services' (CMS) pending refusal to pay for certain "never events," the advent of the Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS), and the work of the Institute for Healthcare Improvement (IHI), the National Patient Safety Foundation (NPSF), and Joint Commission have combined to produce conditions where creating and sustaining a culture of safety is a priority for many healthcare organizations. That was the case for The Nebraska Medical Center (TNMC) in Omaha. The academic medical center realized in 2004 that their patient safety efforts needed a boost to move from very good to great. A focus on quality and safety was one of four CEO leadership priorities, and the focus on quality and safety was incorporated into the hospital's strategic plan with full approval of the Board.

Chief Medical Officer Steve Smith, MD, spearheaded the effort to change TNMC's culture: "We want a safer place to practice medicine with the confidence that all steps necessary to ensure our patients' safety to the highest degree are taken into account for all cases." Based on a recommendation from the chief of surgery, Smith elected to join forces with LifeWings, a consultancy group that works with clients to create a culture of safety by adapting the best practices of aviation and other high reliability organizations.

TNMC chose to follow a five-point plan for creating and sustaining an improved culture of safety. In a 6- month period of 2005 and 2006, the first four steps of the plan were conducted in perioperative services as proof of concept with follow-on implementation planned for other areas after success in the OR.

Step 1. Develop change-initiative skills for key leadership positions and an organizational structure that will support the new culture. Realizing no change would occur without partnership with the institution's physicians, TNMC recruited physician champions, briefed all physicians in perioperative services through monthly meetings and surgery Grand Rounds, and made sure each physician understood the methodology, potential results, and "what's in it for you" for supporting the initiative. This was an important step, as TNMC already had very high levels of patient safety in other areas. Next, key leaders at both the institutional and departmental level were trained on leading change initiatives. Skills learned included:

• responding to difficult questions about the initiative,

• recruiting champions and coaching low performers, and

• conducting rounding for patient safety.

Organizational development to support the initiative included:

• a project oversight and steering committee,

• revisions to policy and procedure manuals,

• alignment of leadership assessment systems to support the culture,

• a data collection and analysis plan for project measurement, and

• making the training and new safety tools mandatory for all physicians and staff — including consequences for non-compliance.

Step 1 was perhaps the most important part of the methodology as research shows that "end user" adoption of culture changing behaviors and tools is primarily a function of effective leadership action.

Step 2. Provide training in teamwork and communication to support desired culture-changing behaviors. Following a site visit, a thorough patient care processes review, and preparation of a teamwork scorecard as part of their needs analysis, LifeWings prepared customized courseware targeting the needs of TNMC and presented it to physicians and staff. The training was interdisciplinary, experiential, and based on healthcare case studies. It provided evidence-based teamwork skill sets based on team training from the aviation industry — called Crew Resource Management (CRM) — and adapted for the needs of the OR team. CRM is based on the best science and research on high performing teams.

Step 3. Create and implement site-specific safety tools to hardwire the teamwork behaviors into daily work life. Using a process based on Lean, a small work group of physicians and staff met to 1) identify points in their workflow where improvements in patient safety were most needed and 2) create safety tools such as checklists, structured handoffs, protocols, and communication scripts to facilitate the needed improvements. An education and implementation plan was created for each tool. Tools were implemented over a period of weeks. The first tool completed and implemented was a Pre-Procedure Briefing (Figure X) for surgical cases that incorporated the elements of the Universal Protocol (which is available online at www.psqh.com/xxx. It also included checklist items to ensure all staff and needed equipment were available and operational, and that the patient was completely ready for the procedure to begin.

Step 4. Collect and analyze data to document results. TNMC created a measurement plan to analyze results by examining safety measures including safety climate surveys, teamwork and communication issues, and process reliability and efficiency.

Step 5. Conduct training for "master trainers." TNMC wanted to bring the culture-changing initiative in- house as quickly as possible and avoid an extended engagement with an outside consultant. To develop their internal capacity, three trainers were chosen in 2006 to learn to provide the teamwork skills training and to create and implement the safety tools. Two trainers were from the Six Sigma department and one was hired externally. Once qualified by LifeWings, these trainers assumed responsibility in 2007 and 2008 for the roll out of Steps 1 through 4 in the emergency department, the cardiac catheterization and electrophysiology labs, and the obstetrics and gynecological services department. TNMC continues to roll out the system in its critical care areas with plans to implement the culture change in its entire hospital.

Results The culture of safety has improved at TNMC. Results of the safety-climate survey administered after the implementation in the areas listed above show dramatic improvement in the perception of staff, physicians, and residents on those indicators related to patient safety in their area (Figure 1). Additionally, the culture has produced multiple examples of "good catches" by the staff as they have intercepted potential errors that might have affected patient safety. In addition to improved patient safety, TNMC has seen an improvement in cases without significant events, reducing unexpected delays (Figure 2). As a result of their culture- changing efforts, TNMC recently won the "Quest for Excellence" award given each year by the Nebraska Hospital Association. The award represents "the highest level of professional acknowledgement in Nebraska's hospital quality improvement arena."

TNMC has proved that though disciplined leadership action, effective interdisciplinary skills training, use of site-specific safety tools that hardwire behaviors, and program-guiding measurement, the safety culture can be changed and improved.

Stephen Harden is the co-founder and president of LifeWings Partners LLC. He is co-author of CRM: The Flight Plan for Lasting Change in Patient Safety (published by HC Pro) and is a nationally known speaker on creating a culture of patient safety. He can reached at [email protected].

HealthPartners/GHI

Subject Attachments Pharmaceutical Sampling Yes No

Key words Number Drug samples, pharmaceutical sampling, drug dispensing, pharmacy GHI EC HPMG Ops 03 Category Environment of Care, Work Service (EC) Effective Date 11/09

Manual HealthPartners Medical Group and Clinic Operations Manual Last Review Date 11/09 Issued By Next Review Date HPMG Pharmacy Committee; HPMG Medical Council 11/12

Applicable Origination Date HPMG and clinic staff 11/90 Retired Date

Review Responsibility Contact HPMG Pharmacy Committee; HPMG Medical Council and clinic operations Dir. of Pharmacy

I. PURPOSE To ensure patient safety as it relates to drug samples.

II. POLICY Individual clinics or care units wishing to continue or initiate storage and distribution of free drug samples must apply to the HPMG Pharmacy Committee for pharmaceutical sampling privileges. Clinics must provide a detailed written plan on how they will comply with outlined procedures. Applications will be reviewed and approved or denied by the Pharmacy Committee. The Chief of Professional Services or Department Head will be responsible for the implementation and compliance of the Pharmaceutical Sampling Policy for his/her clinic and/or department.

III. PROCEDURE(S) Proposal Guidelines: 1. Identify the requesting physician and chief or department head (approving MD). 2. Identify the designated coordinator (oversight for daily operations). 3. Identify the clinic location and specific sample location within the clinic. 4. Describe the purpose for providing pharmaceutical samples. 5. Describe how the proposed sampling practice will meet with the following principles for drug dispensing/distribution:  Safety—the use of pharmaceutical services/agents within our systems will not pose a threat to our patients/members.  Effective—patients/members will receive the most appropriate pharmaceutical interventions, avoiding underuse and overuse.  Equitable—pharmaceutical services/agents will be consistent and fair to all patients/member. Individual personal characteristics will only guide pursuit of optimal outcomes.  Patient Centered—pharmaceutical services/agents will be respectful of individual patient/member needs, preferences and values.  Timely—the delivery of pharmaceutical services/agents will eliminate unnecessary waits and @[email protected] 1 of 3 harmful delays to both patients/members and providers.  Efficiency—pharmaceutical services/agents will be guided by wise stewardship of resources, avoiding waste and inefficiencies. 6. Develop written proposed procedures that are consistent with JCAHO Requirements on Sampling (see below) and includes these at a minimum:  A list of proposed sample medications.  Identify responsible individual “designated coordinator” that will meet with Pharmaceutical representatives, maintain sample inventory, and implement policy.  Provide approach of how to ensure proper storage and disposal of samples, secure locked storage, limited accessibility, and method to dispose of outdated, damaged, recalled drugs. Note: All out dated or discontinued samples are considered hazardous waste and must be placed in the black hazardous waste container in the clinic.  Provide procedure for proper dispensing of drugs, including clarification on who will dispense, labeling of samples, written patient information, documentation in patient’s medical record.  Provide approach to assure quality control of pharmaceuticals, including process to manage drug recalls, process to check for expired drugs, and process for self-audit. Process for documenting lot number and expiration dates will be in a log book.  Specify exact location (s) where samples will be stored.  Designate person in clinic responsible to assure overall compliance with sample program within this clinic.  Outline communication plan to notify all staff of sample procedures and expectations. 7. Forward all applications to the Chair of the HPMG Pharmacy Committee. 8. Any additions/deletions/changes to the Sample Plan and the list of drugs must be provided to the Pharmacy Committee quarterly. 9. Application renewal must be requested annually.

JCAHO DRUG SAMPLES REFERENCE There is a system for the control, accountability, and security of all drug samples throughout the organization. This process should adhere to FDA and other laws and regulations regarding distribution of drug samples, and should be consistent with other organization policies and procedures for medication use. The drug samples are properly stored. Storage of drug samples are under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and safety according to manufacturer’s specifications and law and regulation (e.g. USP and OSHA requirements). Products that require refrigeration should be refrigerated. Stored drug samples should be organized to allow for easy retrieval yet segregated to prevent medication errors. All samples of the same drug should be stored together in the same sample storage area, although multiple storage areas for samples are allowed. Although not required, it is recommended that samples be stored by therapeutic class rather than alphabetically, since the chances of a serious dispensing error are less likely. In any case, throwing all samples of various types into a drawer is not acceptable. Also, OSHA requires that cytotoxic agents (e.g. cancer chemotherapy, gancyclovir, etc) be stored separately from non-cytotoxic drugs with special labeling of the storage area. Drug sample storage areas are routinely inspected. This inspection checks for expired and deteriorated sample medications; samples stored in the wrong place; drugs which can no longer be identified for name, strength, and expiration dates; and other medications that do not belong there. Drug samples for prescription or legend drugs are secure. Drug samples should be kept in an area where unauthorized access is not allowed or which is under constant supervision or surveillance (e.g. behind the receptionist, in a rocked room, in the physician’s private office etc.). If in areas not under constant surveillance by staff, and where visitors and patients are allowed (e.g. patient examination rooms) the drug samples must be locked in a drawer or cabinet. @[email protected] 2 of 3 Drug samples for prescription drugs are labeled and dispensed according to the same standardized method that the organization uses for non-sample prescription medications. The organization’s policies and procedures for dispensing medications to ambulatory patients should be followed. If the same system is not used, the same objectives and outcomes should be achieved. Handwritten and fill-in preprinted prescription labels are acceptable. If the organization normally provides written patient information with dispensed medications, the same should occur for samples. Documentation requirements for sample drugs should be the same as other non-sample medications ordered and dispensed by the clinic or organization. At a minimum, all documentation requirements for prescription drugs in the medical record (e.g. inclusion on the summary list, progress notes, etc.) should be followed. There is no requirement to conduct a perpetual documented inventory of non-controlled substance sample medications, unless such a process is desired or required by organization policy and procedure. There must be an effective recall mechanism for drug samples. There is no requirement to have a log of all dispensed sample medications and lot numbers, unless such a process is desired or required by organization policy and procedure (including pharmacy procedures for outpatient prescriptions). As long as all recalled medications can be quickly retrieved from patients and removed from stock, the process is acceptable. Thus, reviewing each patient’s chart to determine who received the drug under recall, and calling all patients to remove the drug (irrespective of lot number) or verifying with the patient the lot number on the package at the time of calling the patient, is an acceptable method. Many organizations, however, do not want to alarm patients who did not receive the affected lot of drugs, and thus maintain a log of dispensed medications by lot number or document that lot number in the medical record. That way, only patients who received the affected lot of the recalled drug are contacted. However, this is not a JCAHO requirement.

IV. DEFINITIONS n/a

V. COMPLIANCE Failure to comply with this policy or the procedures may result in disciplinary action, up to and including termination.

VI. ATTACHMENTS n/a

VII. OTHER RESOURCES Internal HealthPartners Safety Toolkit at Healthpartners.com/quality

Other JCAHO Standard, TX.3.17

VIII. APPROVAL(S)

Nancy McClure Brian Rank, MD Senior VP, HPMG and Clinics Medical Director, HMPG and Clinics

IX. ENDORSEMENT n/a

@[email protected] 3 of 3

Improving Quality of Care: Annual Monitoring for Persistent Medications

The Opportunity: • Patient safety is highly important, especially for patients at increased risk of adverse drug events from long-term medication use. • Appropriate monitoring of drug therapy remains a significant issue to guide therapeutic decision making and provides largely unmet opportunities for improvement in care for patients on persistent medications. • Persistent use of these drugs warrants monitoring and follow-up by the prescribing physician to assess for side-effects and adjust drug dosage/therapeutic decisions accordingly. The drugs included in this measure also have more deleterious effects in the elderly. o Angiotensin Converting Enzyme (ACE) inhibitors o Angiotensin Receptor Blockers (ARBs) o Digo xin o Diuretics o Anticonvulsants (phenobarbital, carbamazepine, phenytoin, divalproex sodium and valproic acid)

The Measure: • Annual monitoring for select therapeutic agents has been established as a quality measure of the Healthcare Effectiveness and Information Set (HEDIS). • This measure assesses whether persistent users of medications receive timely monitoring to prevent potential harms associated with persistent use of these drugs: o At least one serum potassium (K+) and either a serum creatinine (SCr) or a blood urea nitrogen (BUN) for prescribed ACE inhibitors, ARBs, digoxin and diuretics. o At least one drug concentration level monitoring test for prescribed anticonvulstants (phenobarbital, carbamazepine, phenytoin, divalproex sodium and valproic acid).

The Approach: • Provide comparative performance information on therapeutic monitoring for ACE/ARBs and Diuretics for primary care and specialty providers. • Publish annual comparative performance information in Clinical Indicators Report. • Identify patients on CAD, Diabetes, Heart Failure and Hypertension registries that have been prescribed ACE/ARBs or Diuretics and have not received annual monitoring.

Resources: • HealthPartners Ambulatory Patient Toolkit can be found at: www.healthpartners.com/quality

Who to Contact: For Clinical Questions: Terry Crowson, MD at 952-883-7109 For Measurement Questions: Rene’ Fisher at 952-883-5113

July 2008 original January 2011 revised Annual Monitoring for Patients on Persistent Medications - Angiotensin Converting Enzyme (ACE) and Angiotensin Receptor Blockers (ARB) Primary Care 2010

Description The percentage of members 18 years and older who received at least a 180-day supply of ambulatory medication therapy for ACE and/or ARB during the measurement year and had at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Performance January 1, 2009 through December 31, 2009 Measurement Period Methodology Administrative

Ages Included 18 and older

Products All products

Continuous Enrollment The measurement year

Sample Size Full population

Attribution The medical group of the prescribing provider’s primary location of the most recent script that qualified the member for the denominator. Includes only scripts written by providers with the reported specialty. Sample Method NA

Frequency Annually

Reported Provider eligibility is based on a minimum of 30 unique members for the measurement year. All provider groups are included in the overall rate calculation. Measures Annual Monitoring Rate

Denominator Members 18 and older as of December 31st of the measurement year on persistent medications – defined as members who received at least a 180 days’ supply of ambulatory medication in the measurement year (NCQA's web site at www.ncqa.org provides a list of NDC codes for ACE/ARBS).

To determine continuity of treatment during the 365 day period, sum the number of treatment days (days supply from all the scripts filled during the year) for a total of 180 days.

NOTE: Members may switch therapy between ACE and ARB during the measurement year and have the days supply for those medications count toward the total 180 days supply (i.e. a member who received 90 days of ACE inhibitors and 90 days of ARB’s meets the denominator definition.) Numerator Number of members with at least one serum potassium (cpt 80047, 80048, 80050, 80051, 80053, 80069, 84132) and either a serum creatinine (cpt 80047, 80048, 80050, 80053, 80069, 82565, 82575) or a blood urea nitrogen therapeutic monitoring test (cpt 80047, 80048, 80050, 80053, 80069, 84520, 84525) in the measurement year.

NOTE: The tests do not need to occur on the same service date, only within the measurement year. Rate Calculations Number of members with the required therapeutic monitoring test / Total number of members on persistent medications within each medical group.

HealthPartners Internal Technical Specification Primary Care

Annual Monitoring for Patients on Persistent Medications - Diuretics Primary Care 2010 Description The percentage of members 18 years and older who received at least a 180-day supply of ambulatory medication therapy for diuretics during the measurement year and had at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Performance January 1, 2009 through December 31, 2009 Measurement Period Methodology Administrative

Ages Included 18 and older

Products All Products

Continuous Enrollment The measurement year

Sample Size Full population

Frequency Annually

Reported Provider eligibility is based on a minimum of 30 unique members for the measurement year. All provider groups are included in the overall rate calculation. Measures Annual Monitoring Rate

Denominator Members 18 and older as of December 31st of the measurement year on persistent medications – defined as members who received at least a 180 days supply of ambulatory medication in the measurement year (NCQA's web site at www.ncqa.org provides a list of NDC codes for Diuretics).

To determine continuity of treatment during the 365 day period, sum the number of treatment days (days’ supply from all the scripts filled during the year) for a total of 180 days. Numerator Number of members with at least one serum potassium (cpt 80047, 80048, 80050, 80051, 80053, 80069, 84132) and either a serum creatinine (cpt 80047, 80048, 80050, 80053, 80069, 82565, 82575) or a blood urea nitrogen therapeutic monitoring test (cpt 80047, 80048, 80050, 80053, 80069, 84520, 84525) in the measurement year.

HealthPartners Internal Technical Specification Primary Care

HealthPartners/GHI

Subject Attachments Amiodarone (low-dose) Monitoring Policy  Yes  No

Key words Amiodarone, toxicity Number GHI - PC - HP Nursing xx Category Provision of Care (PC) Effective Date 10/10 Manual HP Nursing Last Review Date 10/10 Issued By HPMG Nursing Administration Next Review Date 10/13 Applicable Ambulatory clinic RN, LPN, CMA and RMA staff Origination Date 3/02 Retired Date

Review Responsibility HPMG&C MTM Pharmacists, Nursing Practice Committee, HPMG Contact Clinical Cardiology Pharmacy Program Manager

I. PURPOSE To provide a uniform and consistent policy for monitoring patients on low-dose amiodarone. Amiodarone is a medication typically used for the treatment of heart arrhythmias.

II. POLICY All HPMG patients on amiodarone should be monitored per this amiodarone policy (these are minimum expectations). RNs can use the Medication Refill Standing Order to order monitoring lab tests and procedures. If laboratory or other monitoring tests are abnormal, the RN will consult the prescribing physician. The physician assumes responsibility for monitoring until the values are within established parameters. This policy focuses on monitoring low-dose amiodarone (< 400mg/ day) - additional monitoring may be recommended during initiation and for higher doses of amiodarone. Unless otherwise agreed upon, the prescribing physician is responsible for this monitoring. If other arrangements are made for follow-up, this plan should be documented in the medical record.

III. PROCEDURE(S) Amiodarone toxicities that need monitoring are: 1. Pulmonary toxicity  Pulmonary function tests should be completed at baseline, including diffusion capacity.  Chest x-rays should be done at baseline and yearly.  Patients should be referred to prescribing physician for additional testing if symptoms of pulmonary toxicity occur (unexplained cough, dyspnea). 2. Liver toxicity  AST (SGOT) or ALT (SGPT) should be monitored at baseline and every 6 months. 3. Thyroid abnormalities  Thyroid function, using TSH and free T4, should be assessed at baseline, 3 months and every 6 months.  Refer to the prescribing physician for more frequent monitoring if thyroid abnormalities are amiodarone monitoring 10-10.doc Page 1 of 3 suspected. 4. Ophthalmic side effects  An ophthalmologic exam, including funduscopy and slit-lamp examination should be completed at baseline.  Refer to an ophthalmologist if the patient has with visual changes. 5. Cardiac effects  EKGs should be done at baseline and yearly.  Refer to the cardiologist if the patient has new-onset arrhythmias or bradycardia. 6. Renal function  Serum creatinine, Bun and electrolytes (K, Mg, Na) should be done at baseline. 7. Interacting medications  In the event of amiodarone dose changes, monitoring protocols should be followed for interacting medications like warfarin (Coumadin) and digoxin. Referrals may be made to anticoagulation nurse, cardiologist, or prescribing physician.  Caution should also be used with simvastatin (increased risk of myopathy), sildenafil (increased levels), cyclosporine (increased levels), antiarrhythmic medications (additive effects), quinolones (increased risk of arrhythmias), antidepressants (increased risk of arrhythmias), and grapefruit (inhibits conversion of amiodarone to the active metabolite).

IV. DEFINITIONS

V. COMPLIANCE Failure to comply with this policy or the procedures may result in disciplinary action, up to and including termination.

VI. ATTACHMENTS Amiodarone Monitoring worksheet

VII. OTHER RESOURCES Internal – Medication Refill Standing Order

Other

VIII. APPROVAL(S) Robert H. VanWhy, Sr. Vice President, Primary Care and Practice Development

IX. ENDORSEMENT Nursing Practice Committee, HPMG Cardiology

amiodarone monitoring 10-10.doc Page 2 of 3 Updated October 2010 Amiodarone Monitoring

Patient Name ______Primary MD ______Amiodarone start date ______ID#: ______Primary Clinic ______Coumadin Y/N ______DOB ______Cardiologist ______Digoxin Y/N ______Patient Phone ______Cardiology Clinic Location ______

Open boxes are required monitoring, shaded boxes indicate routine monitoring is not required but can be completed if clinically indicated. Initial 3 months 6 months 12 months 18 months 24 months 2 ½ years 3 years Date Followed by * Symptoms **

TSH and T4(free) AST (SGOT) ALT (SGPT) Chest x-rays EKG Eye exam *** PFTS **** Creatinine***** BUN***** K ***** Na ***** Mg *****

* Monitoring values are not needed if amiodarone monitoring is done by consultants outside of HPMG. This can be noted with a check mark or the name of the group assuming responsibility for monitoring. ** Patients should be asked about symptoms, both for efficacy and for side effects. Specific questions should address respiratory symptoms, vision problems, thyroid abnormalities, cardiac symptoms, and GI pain. *** Patients should be evaluated for visual impairment/symptoms and considered for annual eye exams. No monitoring values are needed on this sheet. **** Pulmonary function testing is recommended at baseline and for otherwise unexplained dyspnea, particularly in patient with underlying lung disease, and for abnormalities on chest x- rays. ***** Serum creatinine and electrolytes are recommended at baseline and as necessary.

Providers also need to be aware of multiple drug interactions, which include warfarin (Coumadin), and digoxin. This policy focuses on monitoring low-dose amiodarone (<= 400mg/ day) - additional monitoring may be recommended during initiation and for higher doses of amiodarone.

amiodarone monitoring 10-10.doc Page 3 of 3

Clinic Pharmacy Prescriptions

Rx #s______Dates of Rx’s______

# of Rx’s written by prescriber ______

Recommendations (Number of compliance failures) Totals

Use ball point pen-no felt tip

Medication name

Dose

Route of administration

Frequency of use

Purpose of medication

Signature and printed name of prescriber Printed name is almost never present

DEA number on Controlled Substance Rx’s

Write out “unit” – no abbreviations

Write mg, mcg, ml, %, etc.

No drug name abbreviations

Avoid Latin abbreviations (QD, QID, PRN,

BID, TID, etc.)

Use metric measurements

Faxed Rx’s corrected before transmittal

Institute for Safe Medication Practices ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations

he abbreviations, symbols, and dose designations found in this table The Joint Commission has established a National Patient Safety Goal T have been reported to ISMP through the ISMP Medication that specifies that certain abbreviations must appear on an accredited Error Reporting Program (MERP) as being frequently misinterpreted organization's “do-not-use” list; we have highlighted these items with a and involved in harmful medication errors. They should NEVER be used double asterisk (**). However, we hope that you will consider others when communicating medical information. This includes internal beyond the minimum Joint Commission requirements. By using and communications, telephone/verbal prescriptions, computer-generated promoting safe practices and by educating one another about hazards, labels, labels for drug storage bins, medication administration records, we can better protect our patients. as well as pharmacy and prescriber computer order entry screens.

Abbreviations Intended Meaning Misinterpretation Correction µg Microgram Mistaken as “mg” Use “mcg” AD, AS, AU Right ear, left ear, each ear Mistaken as OD, OS, OU (right eye, left eye, each eye) Use “right ear,” “left ear,” or “each ear” OD, OS, OU Right eye, left eye, each eye Mistaken as AD, AS, AU (right ear, left ear, each ear) Use “right eye,” “left eye,” or “each eye” BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime” cc Cubic centimeters Mistaken as “u” (units) Use “mL” D/C Discharge or discontinue Premature discontinuation of medications if D/C (intended to mean Use “discharge” and “discontinue” “discharge”) has been misinterpreted as “discontinued” when followed by a list of discharge medications IJ Injection Mistaken as “IV” or “intrajugular” Use “injection” IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS” HS Half-strength Mistaken as bedtime Use “half-strength” or “bedtime” hs At bedtime, hours of sleep Mistaken as half-strength IU** International unit Mistaken as IV (intravenous) or 10 (ten) Use “units” o.d. or OD Once daily Mistaken as “right eye” (OD-oculus dexter), leading to oral liquid Use “daily” medications administered in the eye OJ Orange juice Mistaken as OD or OS (right or left eye); drugs meant to be diluted in Use "orange juice" orange juice may be given in the eye Per os By mouth, orally The “os” can be mistaken as “left eye” (OS-oculus sinister) Use “PO,” “by mouth,” or “orally” q.d. or QD** Every day Mistaken as q.i.d., especially if the period after the “q” or the tail of Use “daily” the “q” is misunderstood as an “i” qhs Nightly at bedtime Mistaken as “qhr” or every hour Use “nightly” qn Nightly or at bedtime Mistaken as “qh” (every hour) Use “nightly” or “at bedtime” q.o.d. or QOD** Every other day Mistaken as “q.d.” (daily) or “q.i.d. (four times daily) if the “o” is Use “every other day” poorly written q1d Daily Mistaken as q.i.d. (four times daily) Use “daily” q6PM, etc. Every evening at 6 PM Mistaken as every 6 hours Use “daily at 6 PM” or “6 PM daily” SC, SQ, sub q Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in Use “subcut” or “subcutaneously” “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery) ss Sliding scale (insulin) or ½ Mistaken as “55” Spell out “sliding scale;” use “one-half” or (apothecary) “½” SSRI Sliding scale regular insulin Mistaken as selective-serotonin reuptake inhibitor Spell out “sliding scale (insulin)” SSI Sliding scale insulin Mistaken as Strong Solution of Iodine (Lugol's) i/d One daily Mistaken as “tid” Use “1 daily” TIW or tiw TIW: 3 times a week TIW mistaken as “3 times a day” or “twice in a week” Use “3 times weekly” (also BIW or biw) BIW: 2 times a week BIW mistaken ad “2 times a day” Use “2 times weekly” U or u** Unit Mistaken as the number 0 or 4, causing a 10-fold overdose or greater Use “unit” (e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dose given in volume instead of units (e.g., 4u seen as 4cc) Mistaken as unit dose (e.g., diltiazem 125 mg IV infusion “UD” misinter- Use “as directed” UD As directed (“ut dictum”) preted as meaning to give the entire infusion as a unit [bolus] dose) Dose Designations Intended Meaning Misinterpretation Correction and Other Information Trailing zero after 1 mg Mistaken as 10 mg if the decimal point is not seen Do not use trailing zeros for doses decimal point expressed in whole numbers (e.g., 1.0 mg)** No leading zero before 0.5 mg Mistaken as 5 mg if the decimal point is not seen Use zero before a decimal point when the a decimal point dose is less than a whole unit

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (continued) Dose Designations Intended Meaning Misinterpretation Correction and Other Information Drug name and dose run Inderal 40 mg Mistaken as Inderal 140 mg Place adequate space between the drug together (especially name, dose, and unit of measure problematic for drug Tegretol 300 mg Mistaken as Tegretol 1300 mg names that end in “l” such as Inderal40 mg; Tegretol300 mg) Numerical dose and unit 10 mg The “m” is sometimes mistaken as a zero or two zeros, risking a Place adequate space between the dose and of measure run together 10- to 100-fold overdose unit of measure (e.g., 10mg, 100mL) 100 mL The period is unnecessary and could be mistaken as the number Abbreviations such as mg. mg 1 if written poorly Use mg, mL, etc. without a terminal period or mL. with a period following the abbreviation mL

Large doses without 100,000 units 100000 has been mistaken as 10,000 or 1,000,000; 1000000 has Use commas for dosing units at or above properly placed commas been mistaken as 100,000 1,000, or use words such as 100 "thousand" (e.g., 100000 units; 1,000,000 units or 1 "million" to improve readability 1000000 units) Drug Name Abbreviations Intended Meaning Misinterpretation Correction ARAA vidarabine Mistaken as cytarabine (ARA C) Use complete drug name AZT zidovudine (Retrovir) Mistaken as azathioprine or aztreonam Use complete drug name CPZ Compazine (prochlorperazine) Mistaken as chlorpromazine Use complete drug name DPT Demerol-Phenergan-Thorazine Mistaken as diphtheria-pertussis-tetanus (vaccine) Use complete drug name DTO Diluted tincture of opium, or Mistaken as tincture of opium Use complete drug name deodorized tincture of opium (Paregoric) HCl hydrochloric acid or Mistaken as potassium chloride Use complete drug name unless expressed hydrochloride (The “H” is misinterpreted as “K”) as a salt of a drug HCT hydrocortisone Mistaken as hydrochlorothiazide Use complete drug name HCTZ hydrochlorothiazide Mistaken as hydrocortisone (seen as HCT250 mg) Use complete drug name MgSO4** magnesium sulfate Mistaken as morphine sulfate Use complete drug name MS, MSO4** morphine sulfate Mistaken as magnesium sulfate Use complete drug name MTX methotrexate Mistaken as mitoxantrone Use complete drug name PCA procainamide Mistaken as patient controlled analgesia Use complete drug name PTU propylthiouracil Mistaken as mercaptopurine Use complete drug name T3 Tylenol with codeine No. 3 Mistaken as liothyronine Use complete drug name TAC triamcinolone Mistaken as tetracaine, Adrenalin, cocaine Use complete drug name TNK TNKase Mistaken as “TPA” Use complete drug name ZnSO4 zinc sulfate Mistaken as morphine sulfate Use complete drug name Stemmed Drug Names Intended Meaning Misinterpretation Correction “Nitro” drip nitroglycerin infusion Mistaken as sodium nitroprusside infusion Use complete drug name “Norflox” norfloxacin Mistaken as Norflex Use complete drug name “IV Vanc” intravenous vancomycin Mistaken as Invanz Use complete drug name Symbols Intended Meaning Misinterpretation Correction Dram Symbol for dram mistaken as “3” Use the metric system Minim Symbol for minim mistaken as “mL” x3d For three days Mistaken as “3 doses” Use “for three days” > and < Greater than and less than Mistaken as opposite of intended; mistakenly use incorrect Use “greater than” or “less than” symbol; “< 10” mistaken as “40” / (slash mark) Separates two doses or Mistaken as the number 1 (e.g., “25 units/10 units” misread as Use “per” rather than a slash mark to indicates “per” “25 units and 110” units) separate doses @ At Mistaken as “2” Use “at” & And Mistaken as “2” Use “and” + Plus or and Mistaken as “4” Use “and” ° Hour Mistaken as a zero (e.g., q2° seen as q 20) Use “hr,” “h,” or “hour” zero, null sign Mistaken as the numerals 4, 6, or 9 Use the number “0” or the word “zero” © ISMP 2010 **These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an Institute for Safe organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jcaho.org for more information about this Joint Commission requirement. Medication Practices Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited without written www.ismp.org permission. Unless noted, reports were received through the ISMP Medication Errors Reporting Program (MERP). Report actual and potential medication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E).

My Medicine List Fold this form and keep it with you

Name: Date of Birth: Allergic To: (Describe reaction) Emergency Contact/Phone numbers: Doctor(s): Pharmacies, other sources:

Immunization Record (Record the date/year of last dose taken) Flu vaccine(s): Pneumonia vaccine: Tetanus: Hepatitis vaccine: Other:

List all medicines you are currently taking. Include prescriptions (examples: pills, inhalers, creams, shots), over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: nitroglycerin, inhalers). START NAME OF DIRECTIONS DATE NOTES DOSE DATE MEDICATION (How do you take it? When? How often?) STOPPED (Reason for taking?)

www.mnpatientsafety.org Page ______of ______

Directions for My Medicine List How does this form help you?

1. ALWAYS KEEP THIS FORM WITH YOU. You may want • This form helps you and your family members remember all of to fold it and keep it in your wallet along with your driver’s the medicines you are taking. license. Then it will be available in case of an emergency. • It provides your doctors and other providers with a current list of 2. Write down all of the medicines you are taking and list all of ALL of your medicines. They need to know the herbals, your allergies. Add information on medicines taken in vitamins, and over-the-counter medicines you take! clinics, hospitals and other health care settings — as well as at home. • With this information, doctors and other providers can prevent potential health problems, triggered by how different medicines 3. Take this form with you on all visits to your doctor, clinic, interact. pharmacy and hospital.

4. WRITE DOWN ALL CHANGES MADE TO YOUR For copies of the My Medicine List and MEDICINES on this form. When you stop taking a certain a brochure with more tips, visit the Minnesota medicine, write the date it was stopped. If help is needed, ask Alliance for Patient Safety’s Web site at www.mnpatientsafety.org or call (651) 641-1121. your doctor, nurse, pharmacist, or family member to help you keep it up-to-date.

5. In the “Notes” column, write down why you are taking the medicine (Examples: high blood pressure, high blood sugar, high cholesterol).

6. When you are discharged from the hospital, someone will talk with you about which medicines to take and which medicines to stop taking. Since many changes are often made after a hospital stay, a new list may be filled out. When you return to your doctor, take your list with you. This will keep everyone up-to-date on your medicines.

(1/06)

SAMPLE POLICY

. Policy for Pill Box Distribution

Purpose: Increase compliance with prescribed therapeutic regime and reduce the potential for medication errors by distribution of medication boxes to those patients determine to be high risk.

Definition: A person considered being high risk if two or more of the following conditions are identified or present:

• Greater than 5 prescriptions. • Greater than 12 doses of medications per day. • Four or more medication changes in the past 12 months. • More than 3 concurrent disease states. • On a medication that requires therapeutic monitoring (narrow therapeutic index). • History of non-compliance. Policy:

After evaluation by a physician, pharmacist, or nurse, those patients meeting the above criteria of high risk will be offered a medication box to aid in the correct administration of their medications. Education of the proper use of the medication box will be provided for the patient/surrogate/or designated person by the physician, pharmacy, or nurse. The person providing the medication box should note this either in the discharge note or on the patient profile at the pharmacy. The patient or the patients surrogate will need to designate the person responsible for filling and monitoring the medication boxes. It is the patient or the patients’ surrogate responsibility to monitor the status of medication refills and notify the patient’s attending physician when refills are needed

Medication Reconciliation

Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.

Hospital discharge is a critical transition point for all patients. High-risk patients with multiple medical issues and elderly patients are especially vulnerable to the consequences of ineffective discharge handoffs that leave the individual without clear understanding of discharge instructions that likely includes changes or additions to their pre-hospital medication list.

HEDIS Measure:

HEDIS instituted a new measure in 2009 (2008 data year) regarding “Medication Reconciliation Post-Discharge”. This measure continues as one of a select number of measures addressing the special needs of Medicare members enrolled in Special Needs Plans (SNPs). The specification from CMS requires that medication reconciliation occur within 30 days post-discharge from an inpatient facility. Even though this measure has a restricted population, the standard of care should apply to any member with complex medical care needs on multiple medications.

HealthPartners Quality Improvement:

HealthPartners, Inc., as part of their 2009 and 2010 Medical Record Documentation review, assessed the occurrence of medication reconciliation using the HEDIS specifications for a sample of Medicare members at multiple clinics that serve our members. Results showed that an average of 85 – 90% of the charts reviewed indicated post-discharge medication reconciliation was completed within 30 days post discharge.

In 2011, HealthPartners entered a collaborative arrangement with other major health plans on a Performance Improvement Project (PIP) for our seniors. Each health plan will partner with a hospital and provider group to increase the number of members who are discharged from hospital to home that have a follow-up visit with their Primary Care Provider (PCP) within 15 days after discharge. The purpose of this visit is to promote a safe recovery and prevent rehospitalization. . An extremely important component of that is the inclusion of a thorough medication review and reconciliation.

Sheila Dalen, Quality Consultant Quality Measurement & Improvement 02/02/11 SUBJECT: WARFARIN THERAPY DOSE PROTOCOL FOR MAINTENANCE EFFECTIVE DATE: 3/10 APPROVED BY: Beth Averbeck, MD Associate Medical Director, Primary Care Randy Hurley, MD Department Head, Hematology/Oncology Colleen Morton, MD Hematology/Oncology William Nelson, MD Department Head, Cardiology Doug Olson, MD Assistant Medical Director Pathology and Lab Rae Ann Williams, MD Department Head, Internal Medicine Art Wineman, MD Department Head, Family Medicine CONTACT: Beth Averbeck, MD Associate Medical Director, Primary Care John Butler, MD Internal Medicine Jo McLaughlin, RN Director, Nursing and Nutrition Services Colleen Morton, MD Hematology/Oncology SUPERSEDES: 3/09 REVIEW DATE: 3/11

PURPOSE To provide a population based standing order for Registered Nurses to manage anti-coagulation maintenance therapy for established and stable patients who are on an anti-coagulation medication (Coumadin).

POLICY To provide in a safe, efficient manner, guidelines for the RN to manage patients’ dose therapy for their anticoagulation medication. The patient must be established and stable, meaning he/she must have been on anticoagulation therapy for at least one month and have at least three (3) INR readings within their ordered range. All patients should read and sign the Anticoagulant Medications health information sheet (H Ed master 120037). The nurse will review this information with patients with emphasis on patient responsibility, i.e. obtaining INRs as directed and contacting clinic or CareLine if a nurse doesn’t call with results within 36-48 hours. The standing order may be used for clinic visits or telephone encounters. The RN may adjust the patient’s anti-coagulation medication based on a complete and clear standing order originated by a HPMG provider annually and per the following procedure. The RN will use the Epic anticoagulation careplan and SmartForm for documentation.

@BCL@741789C8 Page 1 of 16 Approval for use as a Population Based Standing Order:

Beth Averbeck, MD Date

Randy Hurley, MD Date

Colleen Morton, MD Date

William Nelson, MD Date

Doug Olson, MD Date

Rae Ann Williams, MD Date

Art Wineman, MD Date

@BCL@741789C8 Page 2 of 16 Anti-Coagulation Dose Protocol for Maintenance Therapy

High Range Low Range Other Range First Action Weekly Dose Change Follow-up After Dose Change 2.5-3.5 2.0-3.0 INR Result INR Result INR Result <1.6 Alert ♦ <1.3 Alert ♦ Range minus 0.9 Notify physician; consider risk Per Physician Repeat INR in 3-5 days depending factors in determining action.  upon patient risk. 1.6-2.0 ♦ 1.3-1.5 ♦ Range minus Consider Risk factors and Patient Increase dose after first low reading or Repeat INR in 3-7 days depending 0.8-0.5 INR stability in determining recheck in 3-7 days upon patient risk. action.  and then increase if still low.

Change dose according to large increase column or by 7-14%.

2.1-2.4 1.6-1.9 Range minus If previous INR in range, repeat If 2 consecutive low results, change Repeat INR in 5-9 days or up to 14 0.4-0.1 INR in 5-14 days depending on dose according to small increase days for established pts. at low risk pt. risk factors & INR stability column or by 3 ½ -7 %. who have had stable INRs in the past before changing dose (see low risk definition) 2.5-3.5 2.0-3.0 Ordered range Target Range No Change Repeat INR in 4-6 weeks

3.6-4.5 3.1-4.0 Range plus If previous INR in range, repeat If 2 consecutive high results, change Repeat INR in 5-9 days or up to 14 0.1-1.1 INR in 5-14 days depending on dose according to small decrease days for established pts. at low risk pt. risk factors & INR stability column or by 3 ½ -7%. who have had stable INRs in the past before changing dose (see low risk definition) 4.6-5.0 4.1-5.0 Range plus Hold scheduled dose for one day. Change dose according to large Repeat INR in 5-9 days 1.1-2.0 decrease column or by 7-14%.

>5.0 >5.0 Range plus 2.1 Notify Physician. Hold Per physician Repeat INR in Critical ● Critical ● Or > 5.0 scheduled dose for 2 days. 1-5 days Consider risk factors in determining action. ●

♦ Patients with mechanical prosthetic heart valves who require an INR range of 2.5-3.5 should be placed on enoxaparin (Lovenox) if their INR is <2.  High Risk patients may require heparin or enoxaparin therapy while INR is subtherapeutic or warfarin is held for surgery. ● Risk factors for major hemorrhage include: history of GI bleed or any other major bleed, hypertension, stroke, renal disease, age>75, ASA, or NSAIDS.  Low risk is defined as those patients with no recent venous thromboembolism (>3 months from the event), atrial fibrillation without history of stroke or other risk factors and bileaflet mechanical cardiac valve in aortic position (ACCP guidelines: Chest vol. 126, number 3 supplement, September, 2004) Depending upon risk, low dose Vitamin K may be indicated in non-urgent situations (RN consults with provider, provider orders Vitamin K therapy): INR 5-9 0, 1mg, or 2.5mg by mouth, depending on risk of bleeding. Since the tablet is only available as 5mg, these lower doses are most easily given using the injectable form diluted in a glass of water. Nursing will stock vitamin K vials (Lawson # 801861). INR >9 5-10 mg by mouth, consider fresh frozen plasma Serious bleeding at any elevation of INR 10 mg slow IV infusion and fresh frozen plasma, consider adding recombinant Factor VII for life-threatening bleed RNs may adjust a patient dose up to 7% per week (one daily dose per week) based upon patient history and nursing assessment and then recheck INR within 5-9 days.

@BCL@741789C8 Page 3 of 16 The following guidelines may be useful in Anti-Coagulation dosing flexibility:

 Expect a 15% dose adjustment to result in an approximately 1.0 INR change.

 A 10% dose adjustment will result in an approximate 0.7-0.8 INR change.

 Steady state INR values will not be realized for up to 3 weeks following a dose adjustment.

 Patients with INR values by +/- 0.5% INR out of range should be considered for more frequent monitoring and should have a repeat INR within 7 days.

 The dose response relationship is best interpreted when at least 16 hours elapse between dose and lab draw.

 Any drug has the potential to interact with warfarin; in such circumstances close INR monitoring is required during initiation and discontinuation of the interacting agents. Refer to drug/food interactions tables for selected interactions.

@BCL@741789C8 Page 4 of 16 Procedure for Reporting Low INR Results

PURPOSE To provide a process for reporting low INR results when the clinic is closed  1.6 or below OR  2.0 or below for patients with a mechanical mitral valve as described in the policy.

POLICY INR values of less than 1.6 OR less than 2.0 for patients with mechanical mitral valves are considered on Alert status and should be reviewed for possible adjustments in dosing decisions.  All patients with mechanical heart valves who need an INR range of 2.5-3.5 are high risk patients and need low molecular weight heparin (Lovenox) if their INR is less than 2. This includes mitral valve and any aortic valve patients with additional risk factors. They should be seen emergently at Urgent Care or the ER and covered with low molecular weight heparin until their INR is raised to at least 2.5 or greater. These patients require an expeditious evaluation as to the origin of the declining INR and the INR needs to be rapidly corrected with close follow-up and monitoring.  Patients with mechanical heart valves who need an IRN range of 2-3 are those with aortic valves, without additional risks; do not need low molecular weight heparin (Lovenox) with a low INR. An aggressive plan to raise their INR to an accepted normal range needs to be expeditiously pursued.

PROCEDURE (For clinics that are evaluating INRs at the Point of Care, low INRs will be evaluated and adjusted at that time.) Action: 1. Ask patients, whenever possible, to have their INRs drawn before 1 p.m., Monday through Thursday. If an INR needs to be drawn on Friday, request that the patient comes in on Friday morning to facilitate the process of getting the INR result back to the clinic before the 5:00 closing time. Rationale: Receiving INR results back during the regular clinic hours facilitates communication between the nurse and physician regarding clinical decision making on anticoagulation dosing. 2. Monday-Thursday, INR results of less than 2.0 for patients with a mechanical heart valve that are not reported to the clinic before closing, will be called to the CareLine by Central Lab for follow-up. No action needs to be taken by Central Lab on INR results less than 2.0 for non-mechanical heart valve patients. Rationale: Mechanical aortic valve patients need emergent follow-up if their INR is less than 2.0. Dosing decisions for other patients with INRs less than 2.0 can wait overnight. 3. On Fridays, or the day before a holiday, INR results of less than1.6 OR less than 2.0 for patients with mechanical mitral valves, that are not reported to the clinic before closing, will be called to the CareLine by Central Lab. Rationale: Patients with mechanical heart valves, especially those with decreased LV systolic function and/or atrial fibrillation are a higher risk when exposed to a subtherapeutic INR. Patients with a St. Jude, bileaflet, aortic valve have a low risk for valve related thromboembolism. Notification of CareLine facilitates follow-up for patient management. 4. If a clinic nurse is concerned about dosing for a patient with an unreported INR result at the end of the day, the nurse will notify the CareLine that an INR result, for an at risk patient, has not come back and will provide the CareLine nurse with careplan directions. Rationale: Ensure continuity of care. 5. Document actions taken. 6. CareLine forwards a telephone encounter to the PCP’s clinic RN pool with the report of actions taken. Rationale: Ensure appropriate clinic follow-up.

@BCL@741789C8 Page 5 of 16 Select Warfarin - Drug Interactions (not a complete list) Drug Interaction Management Comments Effect Acetaminophen (Tylenol) Elevations in INR Consider early and frequent Effect is likely related to dose and have occurred within monitoring of INR for several length of treatment. 1-2 weeks of weeks when acetaminophen is initiating added or discontinued. acetaminophen at moderate to high doses (2- 4 g/day Amiodarone (Pacerone, INR increases by 22- Monitor INR at least weekly- Potentiation occurs from 4 days to 2 108% 1st month of combined weeks. May persist up to 4 months Cordarone) Bleeding episodes 2 therapy. Drop warfarin dose after amiodarone discontinued. days to one month by 25% on start of after initiation amiodarone. Daily warfarin needs usually drop by 25- 50%. Carbamazepine (Tegretol, Decrease in INR Monitor INR more closely Induces warfarin metabolism Carbatrol) Cimetidine (Tagamet) Can increase INR Use alternative medication Dose dependents with at least 300- [e.g. ranitidine (Zantac), 800 mg/day famotidine (Pepcid)] Ciprofloxacin (Cipro) Increase INR in 2-16 Monitor INR more carefully Unpredictable but can be clinically days significant, especially in the elderly Levofloxacin (Levaquin) Moxifloxacin (Avalex) Clarithromycin (Biaxin) Increased INR seen Monitor INR closely when within 7 days add or stop clarithromycin or Erythromycin (Erytab, erythromycin Erythrocin)

Clopidogrel (Plavix) Increased risk of Monitor INR more closely Inhibits platelet aggregation bleeding during initiation or discontinuation Corticosteroids (prednisone, May increase INR Monitor INR more closely Onset of INR effect is variable and during initiation or may be anticipated 3-10 days after methylprednisone, others) discontinuation initiating steroid

Dronedarone (Multaq) May increase INR Monitor INR closely when Limited data suggests up to 20% adding or stopping increase in S-warfarin concentration. dronedarone. Is structurally similar to amiodarone. Duloxetine (Cymbalta) Increase in INR Monitor INR more closely during initiation or discontinuation of duloxetine Fluconazole (Diflucan) Slight to 2 fold Monitor every 2 days when increase in INR add or stop fluconazole, Itraconazole (Sporanox) itraconazole, or ketoconazole Ketoconazole (Nizoral) Fluvoxamine (Luvox) Can increased INR Monitor INR more closely for1-2 weeks after fluvoxamine is started. Levothyroxine (Levoxyl, Increased risk of Monitor closely when Increases metabolism of Vitamin K- bleeding add/change levothyroxine dependent clotting factors Synthroid) dose Lovastatin (Mevacor) May increase INR Monitor closely when add or Lovastatin commonly associated stop lovastatin or simvastatin with hypoprothrombinemia Simvastatin (Zocor) Metronidazole (Flagyl) Increase in INR Monitor INR more carefully when starting and stopping metronidazole NSAIDs (Aspirin, Ibuprofen, Increased risk of Monitor INR closely when Inhibits platelet aggregation &gastric bleeding add or stop NSAIDs erosion Naproxen, Diclofenac, Celebrex)

@BCL@741789C8 Page 6 of 16 Drug Interaction Management Comments Effect Nicotine Decrease INR Monitor INR more closely Nicotine induces warfarin when stopping/starting metabolism nicotine replacement therapy or smoking more or less/day Omeprazole (Prilosec) Increase of INR after Monitor INR closely when Dose related a few days add/change omeprazole dose Paroxetine (Paxil) Can increased INR Monitor INR frequently when paroxetine is added Penicillin (Veetids) Increased INR Monitor INR more closely Penicillin reduces GI synthesis of when add or stop penicillin vitamin K Phenobarbital (Luminal) Decrease in INR Monitor INR more closely Induces warfarin metabolism Phenytoin (Dilantin) Decrease in INR Monitor INR frequently for 1 Induces warfarin metabolism, month or more after enhances metabolism of clotting phenytoin added factors Prasugrel (Effient) Increased risk of Monitor INR more closely Inhibits platelet aggregation bleeding during initiation or discontinuation Rifampin (Rifadin) Decrease INR within Monitor INR closely for 1-2 Induces warfarin metabolism 2-4 days weeks after rifampin is added. Sulfamethoxazole Increase in INR Monitor INR more closely Use of sulfamethoxazole is not when starting and stopping recommended if acceptable Sulfamethoxazole alternative exists. Tamoxifen (Nolvadex) Increase in INR. A Monitor INR more closely Use is contraindicated with warfarin 35-60% reduction of during initiation or therapy in high-risk women. warfarin dose may discontinuation be required.

@BCL@741789C8 Page 7 of 16 Select Warfarin - Food/Dietary Supplement Interactions (not a complete list) Drug Interaction Effect Management Comments Alcohol Can increase or decrease INR Caution pts to drink in moderation Acute use may inhibit and to avoid binge drinking; start at warfarin metabolism; lower doses in pt has liver damage chronic use induces warfarin metabolism; Cirrhosis is associated with reduced warfarin metabolism Dong quai Can increase INR Monitor INR more closely when Inhibits platelet activation add or stop. Advise pt to use and aggregation. consistent dose if must use Ginseng Can increase INR Monitor INR more closely when Pts don’t always consider add or stop. Advise pt to use dietary supplements consistent dose if must use medications. Co-Q10 Decrease INR Monitor INR more closely when adding or stopping. Advise patient to use consistent dose if must use. Cranberry Juice (100%) Can increase INR Monitor INR more closely, advise pt to use consistent amount if drink cranberry juice Garlic Can increase INR Monitor INR more closely, advise pt Inhibits platelet aggregation to use consistent dose if must use. Glucosamine/chondroitin Chondroitin may have Monitor INR more closely when anticoagulant activity increasing adding or stopping. Advise patient bleeding time and INR to use consistent dose if must use. Green Tea Potential to increase INR due to Monitor INR more closely, advise pt Inhibits platelet aggregation platelet aggregation inhibition to use consistent dose if must use Contains small amount of Potential to decrease in INR due to Vitamin K Vitamin K content Feverfew Can increase INR Monitor INR more closely, advise pt Inhibits platelet aggregation to use consistent dose if must use Fish oil Can increase INR Monitor INR more closely when May decrease platelet adding or stopping. Advise patient aggregation to use consistent dose if must use. Flaxseed oil Can increase INR Monitor INR more closely when May decrease platelet adding or stopping. Advise patient aggregation to use consistent dose if must use. Gingko Biloba Can increase INR Monitor INR more closely, advise pt Inhibits platelet aggregation to use consistent dose Omega 3 Can increase INR Monitor INR more closely when May decrease platelet adding or stopping. Advise patient aggregation to use consistent dose if must use. Salvia Root (Danshen) Can increase INR Monitor INR more closely, advise pt Inhibits platelet aggregation. to use consistent dose if must use May contain coumarin derivatives. St. John’s Wort Can decrease INR Monitor INR more closely, advise pt Induces metabolism of to use consistent dose if must use. warfarin Vitamin K containing Decrease INR Advise pt to keep diet steady. Consistency and moderation Inform clinic of major dietary is key. foods in large amounts changes. (Leafy greens)

@BCL@741789C8 Page 8 of 16 Anticoagulant Medications

What do anticoagulants do?

Anticoagulants are medications that help keep blood from clotting. Warfarin, Coumadin, Jantoven and Lovenox are common anticoagulants. These medications were sometimes called “blood thinners” in the past. However, they do not make blood “thinner.” They make the blood less able to clot.

What are the possible side effects of anticoagulants?

 Bleeding  Patients on Lovenox must watch for leg  Easy bruising or arm swelling that is new or gets  Diarrhea and decreased appetite are worse, chest pain, difficulty breathing or uncommon side effects of skin breakdown at the site of injections. Coumadin/warfarin If you have any of these, contact your doctor immediately. These may be signs of a serious reaction to Lovenox.

Why do I need to have my blood tested so much?

Your doctor will monitor your blood with a test called an INR. This test is done more often at first. If possible, have the INR test done before1 p.m., Monday-Thursday (unless your doctor gives you other instructions). This is so that you get the results in a timely manner. This test helps your doctor decide how much anticoagulant you should take.

Your doctor may change your dose several times to find what is best for you. A nurse will call you within a day of your test to let you know if you need to change your dose or not. If the nurse does not call you within 36-48 hours of a test, call your clinic or the CareLine (612-339-3663) to check on the results.

Once the dose you need is stable, most of the time you’ll be able to have the test done monthly. It is very important that you take your anticoagulant medication the way your doctor tells you to. It’s also important to get the recommended blood tests.

I agree to follow my doctor’s recommendation about when to have my blood test (INR) done.

______Patient signature

Continued How do I take this drug?

Take the medication at the same time every day. It’s best to take it with your evening meal or at bedtime. Take each dose with a full glass of water. Do not stop taking this medication unless you are told to by your doctor.

What if I miss a dose?

Take it as soon as you remember. You can take your anticoagulant medication up to six hours after the usual time of your dose. After that time, count it as a missed dose. Do not take two doses at the same time. Write down the date of the missed dose and tell your doctor at your next visit. Missing a dose may change your blood test result. If you miss doses on two or more days, call your doctor right away.

When should I call my doctor?

Complications with medications are rare when you are closely monitored. Call your doctor right away if you have any of the following:

 Bleeding, including nosebleeds or  Any changes in diet, activity level, how bleeding gums much alcohol you use, medications  Bleeding that does not stop after an  Cough or difficulty breathing injury  Fast heartbeat  Frequent bruises or bruises that keep  Shortness of breath getting larger  Heavy sweating when at rest  Dark brown or red urine  Chest pain  Vomiting or spitting up blood or  Faintness, dizziness or increased brown material that looks like coffee weakness grounds  A serious fall or injury to the head  Bloody or black, sticky stool  Fever or sickness that gets worse  Severe headache, stomach ache, back  Women: heavier-than-usual periods or kidney pain  Pregnancy or you plan to get pregnant  Swelling, redness, warmth, pain,  Something unusual happens that you firmness or heaviness in an area question  Pain in any part of your leg  If you plan to travel  Small red spots on your skin  Sudden anxiety or restlessness

What you avoid when taking an anticoagulant

Anticoagulants interact with many other medications, vitamins, herbs and certain foods. If any new drugs are prescribed for you, make sure your doctor, nurse and pharmacist know that you take an anticoagulant.

Anticoagulants should not be taken during pregnancy. They may harm an unborn baby. Please discuss plans for pregnancy with your doctor. Then, safer medications may be prescribed.

Continued Aspirin and NSAIDs Do not take aspirin or any nonsteroidal anti-inflammatory drugs (NSAIDs) until you have talked to your doctor. (See list below.) These drugs can increase your risk of bleeding. If you need something for pain, use acetaminophen (Tylenol® ). Do not take more than four extra-strength Tylenol® in a day (2000 mg). If you are unsure of what to do for your pain, ask your pharmacist, nurse or doctor.

Do not take the following drugs while you are on anticoagulant medications.

Generic Name Brand Names Acetylsalicylic Acid *Aspirin, Excedrin, Aspergum, Ecotrin, Bufferin, Ascriptin, Empirin, Midol Diclofenac Cataflam, Voltaren Etodolac Lodine Flurbiprofen Ansaid Fenoprofen Nalfon Ibuprofen Motrin, Motrin IB, Haltran, Midol IB, Nuprin, Advil, Arthritis Foundation Indomethacin Indocin, Indocin SR, Indochron E-R Ketoprofen Orudis KT, Actron, Orudis, Oruvail Ketorolac Toradol Meclofenamate Meclomen Mefenamic acid Ponstel Naproxen Aleve, Anaprox, Naprosyn, Naprelan Oxaprozin Daypro Piroxicam Feldene Sulindac Clinoril Tolmetin Tolectin 200, Tolectin 600, Tolectin DS

*Many medications combine aspirin with another drug. Examples are: Percodan, Empirin with codeine, Fiorinal, Robaxisal, Soma Compound and Ascriptin with codeine. Please ask your pharmacist, doctor, or nurse if you have questions.

Other substances to avoid Do not take any nonprescription drugs, herbal teas or vitamin supplements without talking to your doctor. Some herbs affect how anticoagulants work. Check with your doctor before using any of these herbs: garlic, ginger, fenugreek, feverfew, ginkgo biloba, ginseng, horse chestnut, red clover, and tonka beans. Do not eat large amounts of food with Vitamin K. This can reduce the effect of the anticoagulant. See the handout called “Guidelines for vitamin K intake for patients taking anticoagulants.” Avoid eating or drinking cranberry products.

Continued What can I do to reduce the risk of bleeding when taking an anticoagulant?

 Take your medications exactly the way your health care provider tells you, and at the same time each day.  Keep follow-up appointments for blood tests to monitor clotting times.  Use a soft-bristle toothbrush and floss gently.  Use an electric razor instead of a blade.  Check regularly for bruises.  Avoid contact sports and heavy physical activity that could cause injury.  Tell other care providers about your blood thinner medication.  Check with your doctor before scheduling surgery or dental work.  Get a medical alert bracelet and carry a drug identification card if you will be on an anticoagulant for a long time.  Check with your doctor before taking any other medications.  Avoid alcohol, food fads, crash diets, or changes in your eating habits.  Talk with your health care provider if you become pregnant or plan to become pregnant.  Anticoagulants cause birth defects. You must take precautions against pregnancy while taking an anticoagulant.

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total mg./wk 1 1 1 1 1 1 1 7 1 2 1 1 1 1 1 8 1 2 1 1 1 2 1 9 1 2 1 2 1 2 1 10 2 1 2 1 2 1 2 11 2 1 2 2 2 1 2 12 2 2 2 2 2 1 2 13 2 2 2 2 2 2 2 14 2 3 2 2 2 2 2 15 2 3 2 2 2 3 2 16 2 3 2 3 2 3 2 17 3 2 3 2 3 2 3 18 3 2 3 3 3 2 3 19 3 3 3 3 3 2 3 20 3 3 3 3 3 3 3 21 3 4 3 3 3 3 3 22 3 4 3 3 3 4 3 23 3 4 3 4 3 4 3 24 4 3 4 3 4 3 4 25 4 3 4 4 4 3 4 26 4 4 4 4 4 3 4 27 4 4 4 4 4 4 4 28 4 5 4 4 4 4 4 29 4 5 4 4 4 5 4 30 4 5 4 5 4 5 4 31 January 2000

@BCL@741789C8 Page 13 of 16 2 MG DECREASE WEEKLY DOSE INCREASE LARGE SMALL SMALL LARGE DECREASE DECREASE TOTAL INCREASE INCREASE TOTAL/MG/WK TOTAL MG/WK MG/WK TOTAL/MG/WK TOTAL/MG/WK 7 8 9 7 8 9 10 7 8 9 10 11 8 9 10 11 12 9 10 11 12 13 10 11 12 13 14 11 12 13 14 16 12 13 14 15 17 12 14 15 17 18 13 15 16 18 19 14 15 17 19 20 15 16 18 20 22 16 17 19 21 23 17 18 20 22 24 18 19 21 23 25 18 20 22 24 26 19 21 23 25 28 20 22 24 26 29 21 23 25 27 30 22 24 26 29 31 23 25 27 30 23 25 28 31 24 26 29 25 27 30 26 28 31 January 2000

@BCL@741789C8 Page 14 of 16 WARFARIN 5 MG DAILY DOSE

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total mg./wk 2.5 2.5 2.5 2.5 2.5 2.5 2.5 17.5 2.5 5 2.5 2.5 2.5 2.5 2.5 20 2.5 5 2.5 2.5 2.5 5 2.5 22.5 2.5 5 2.5 5 2.5 5 2.5 25 5 2.5 5 2.5 5 2.5 5 27.5 5 2.5 5 5 5 2.5 5 30 5 5 5 5 5 2.5 5 32.5 5 5 5 5 5 5 5 35 5 7.5 5 5 5 5 5 37.5 5 7.5 5 5 5 7.5 5 40 5 7.5 5 7.5 5 7.5 5 42.5 7.5 5 7.5 5 7.5 5 7.5 45 7.5 5 7.5 7.5 7.5 5 7.5 47.5 7.5 7.5 7.5 7.5 7.5 5 7.5 50 7.5 7.5 7.5 7.5 7.5 7.5 7.5 52.5 7.5 10 7.5 7.5 7.5 7.5 7.5 55 7.5 10 7.5 7.5 7.5 10 7.5 57.5 7.5 10 7.5 10 7.5 10 7.5 60 10 7.5 10 7.5 10 7.5 10 62.5 10 7.5 10 10 10 7.5 10 65 10 10 10 10 10 7.5 10 67.5 10 10 10 10 10 10 10 70 10 12.5 10 10 10 10 10 72.5 10 12.5 10 10 10 12.5 10 75 10 12.5 10 12.5 10 12.5 10 77.5 April 26, 2000

@BCL@741789C8 Page 15 of 16 5 MG DECREASE WEEKLY DOSE INCREASE LARGE SMALL SMALL LARGE DECREASE DECREASE TOTAL INCREASE INCREASE TOTAL/MG/WK TOTAL MG/WK MG/WK TOTAL/MG/WK TOTAL/MG/WK 17.5 20 22.5 17.5 20 22.5 25 17.5 20 22.5 25 27.5 20 22.5 25 27.5 30 22.5 25 27.5 30 32.5 25 27.5 30 32.5 35 27.5 30 32.5 35 40 30 32.5 35 37.5 42.5 30 35 37.5 40 45 32.5 35 40 45 47.5 35 37.5 42.5 47.5 50 37.5 40 45 50 52.5 40 42.5 47.5 52.5 57.5 42.5 45 50 55 60 45 47.5 52.5 57.5 62.5 45 50 55 60 65 47.5 52.5 57.5 62.5 70 50 55 60 65 72.5 52.5 57.5 62.5 67.5 75 55 60 65 70 77.5 57.5 65 67.5 75 57.5 65 70 77.5 60 65 72.5 62.5 67.5 75 65 70 77.5 January 2000

@BCL@741789C8 Page 16 of 16

Date

Dr.«FirstName» «LastName» «Addr1» «Addr2» «City», «State» «ZipCode»

Dear Dr.«Provider»:

In the last month, your patient has been identified through pharmacy claims as obtaining six or more controlled substances, by at least three different prescribers and filled by at least three different pharmacies.

In an effort to ensure your patient is getting appropriate, safe and high quality care, a subset of the patient’s prescription profile representing only the prescriptions you have prescribed has been attached. State privacy laws prevent us from disclosing the full prescription history.

What can you do? • Review the complete patient profile for this patient’s controlled medications by using the Minnesota Prescription Monitoring Program. Minnesota law requires all pharmacies to report the dispensing of all controlled substances to the Minnesota Prescription Monitoring Program. To access this data please visit http://pmp.pharmacy.state.mn.us/. Registration is required. o Many states have similar programs. • If you believe that this patient would benefit from case management services, you can contact HealthPartners Connect (HealthPartners' case management program) to make a referral at 952-883-5469.

If you have questions or suggestions regarding this communication, please contact Pete Marshall, PharmD, directly at (952) 967-5807.

Thank you for your attention and partnership in providing appropriate care for this member.

Sincerely,

Terry W. Crowson, MD Medical Director Medical Management & Government Programs HealthPartners Health Plan

(Optional) Physician Feedback -Fax back to HealthPartners (952) 967-6667  Yes -- I found this information helpful  No -- I did not find this information helpful Comments: To ensure members are getting appropriate, safe and high quality care, HealthPartners developed the Exceptional Use Intervention Program for controlled substances. It targets members who received six or more controlled substance medications prescribed by three or more physicians or obtained from three or more pharmacies.

The member is identified through pharmacy claims; we send a letter to the most recent prescriber describing the Exceptional Use Intervention Program and identifying the controlled substance prescriptions written by that provider. Physicians can re-evaluate the treatment plan and if they need a complete patient profile they can call HealthPartners Pharmacy Benefits Manager, or refer the member to our Case Management Program at the phone number listed below. Minnesota prescribers can log on to the Minnesota Prescription Monitoring Program. Minnesota law requires all pharmacies to report the dispensing of all controlled substances to the Minnesota Prescription Monitoring Program. Some states have similar programs.

Alabama, Arizona, California, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and Wyoming.

Seven states (Alaska, Florida, Kansas, New Jersey, Oregon, South Dakota and Wisconsin) and one U.S. territory (Guam) have enacted legislation to establish a PDMP, but are not fully operational. accessed 1.28.2011.

Reports are compiled monthly and are reviewed for trends. Any member that recurs three times in a rolling 12-month period is automatically forwarded to our Case Management Program for investigation.

If misuse is identified, HealthPartners can request system limitations that restrict the patient to a particular pharmacy or provider. Or, in the case of provider or pharmacy misuse, HealthPartners can restrict that provider or pharmacy or remove that provider or pharmacy from our network.

Acute Bronchitis

Summary Recommendation Antibiotics are NOT indicated in acute bronchitis unless in specific circumstances where pertussis is suspected or in patients with significant medical co‐morbidities.

Introduction

Acute bronchitis is one of the most common conditions encountered in clinical practice and is also one of the commonest causes of antibiotic misuse. Both the Centers for disease control and the American College of Physicians have stated unequivocally that the only indication for antibacterial agents in uncomplicated acute bronchitis is pertussis. Although the usage of antibiotics had decreased in recent years the prescriptions are now slanted towards broader spectrum antibiotics increasing risk for emergence of resistant strains.

Microbiology Viruses are overwhelmingly the main causative agents for acute bronchitis. Influenza A and B, parainfluenza, coronavirus, rhinovirus, and respiratory syncytial virus are the predominant viruses implicated. Apart from pertussis bacterial etiologies are rare unless there are airway violations such as tracheostomy or endotracheal intubation or those patients with structural lung disease or immune suppression.

Natural History

In the first few days the symptoms are similar to any upper airway infection but with acute bronchitis the cough typically persists for 10‐20 days and occasionally for more than 4 weeks. 50% of patient swill report purulent looking sputum. Fever is relatively uncommon and when present may suggest either pneumonia or influenza. Reactive airways and wheezing is not uncommon. In the vast majority of patients symptoms resolve without antibiotic therapy.

Bronchitis is often “under coded” when a diagnosis code is selected. If cough is the predominant feature of an upper respiratory infection, it usually should be coded “Bronchitis” rather than simply “URI or Upper Respiratory Infection.” This is more accurate, and it will make it easier to compare HealthPartners experience to national data.

Diagnostic testing

Pearl of Knowledge: Acute Bronchitis 2.10.10

In the presence of typical symptoms and the absence of abnormal pulmonary findings further testing is usually not indicated. Wheezing alone does not require tests. Specifically sputum gram stain and culture rarely leads to specific diagnosis. Spirometry and chest x rays are also not indicated for initial workup.

Rapid tests can be used to diagnose influenza. PCR testing for pertussis is diagnostic if the typical symptoms are present especially in the presence of a known epidemic.

Treatment Antibiotics are generally not recommended for acute bronchitis . Exceptions include extremes of age, patients with COPD, immune deficiencies, cystic fibrosis, pneumoconiosis or other structural lung disease. A Cochrane review of nine randomized controlled trials showed a significant but minor reduction in duration of cough (0.6 days) and decrease in duration of symptoms by one day. There was a non significant reduction in the number of days feeling ill and a non significant increase in adverse effects attributed to antibiotics. As mentioned both the CDC and the ACP guidelines state that antibiotics are not indicated except in cases of pertussis.

The guidelines from the national institute for health and clinical excellence in the UK advise not treating acute bronchitis with antibiotics with the following exceptions:

1. Preexisting comorbidity (heart, lung, renal, liver or neuromuscular disease or immunosuppression), 2. Patients over the age of 65 with acute cough and two or more of the following or patients over 80 with one or more of the following: admission to the hospital within the prior year, Diabetes, CHF or current use of steroids.

Antimicrobial therapy is indicated to limit transmission of pertussis. A Macrolide would be the first line treatment. Antibiotic therapy should be initiated within the first week where possible but there is no evidence that cough will be less severe or the course less protracted with treatment.

Treatment with oseltamivir or zanamivir decreases duration of symptoms for acute bronchitis due to influenza by only one day and results in a slightly earlier return to work (0.5 days.)

Symptomatic treatment with beta agonists for the cough may be beneficial in patients with airflow limitation. A recent Cochrane review however did not support this recommendation. In practice a short course of inhaled or oral steroids may be tried for troublesome cough. There are no compelling data from clinical trials supporting the use of antitussives or mucolytics in acute bronchitis. There are small studies to show benefit treating cough associated with allergic rhinitis with antihistaminics. A decongestant or antihistaminic could be used for cough associated with post nasal drip in the setting of acute bronchitis. Non specific antitussives like codeine are also prescribed for significant cough in acute bronchitis with very little evidence to support this.

Pearl of Knowledge: Acute Bronchitis 2.10.10

References:

1. Gonzales R, Barltlet JG, Besser RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001;134:521‐529 2. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence‐based clinical practice guidelines. Chest 2006;129:Suppl:95s‐103s 3. Bent S, Saint S, Vittinghoff E, Grady D. Antibiotics in acute bronchitis: a meta‐analysis. Am J Med 1999;107:62‐67 4. Wenzel P, Fowler AA. Acute Bronchitis. NEJM 2006;355:2125‐2130

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All Pearl recommendations are consistent with professional society guidelines,

and reviewed by HealthPartners Physician Leadership.

Pearl of Knowledge: Acute Bronchitis 2.10.10

SUBJECT: MEDICATION REFILL (Behavioral Health) STANDING ORDER EFFECTIVE DATE: July 2010 APPROVED BY: Carol Novak, MD Department Head, Behavioral Health CONTACT: Jo McLaughlin, RN Director, Nursing and Clinical Dietitians Ryan Michels, PharmD BCPS, Clinical Pharmacist SUPERSEDES: July 2009 REVIEW DATE: July 2011

PURPOSE: To provide a process for RNs working in Behavioral Health to review and approve maintenance prescription refill requests for designated medications.

POLICY: To provide in a safe, efficient manner, approval for a supply of medication for patients. The RN is the agent of the prescriber delegated to refill medications as per the following procedure. The prescription must clearly originate with HPMG physicians or other HPMG authorized prescribers.

PROCEDURE: 1. Obtain information from the requesting pharmacy: patient’s name, medical number or date of birth, pharmacy, pharmacy phone number, medication requested, amount requested and the last date the medication was filled. Document the information in an EpicCare Refill Encounter or phone message. A 24 to 48 hour turn-around time on a medication request may be necessary. 2. Review the patient’s medical record for the following areas: a. Review the record for visit compliance. In order to refill mediations, a patient needs to be “current” or as indicated in the plan of the last visit. If the patient is overdue for a visit, contact the patient by phone to schedule a follow-up appointment. If unable to contact the patient to schedule an appointment, the pharmacy is notified that the patient needs to contact his/her provider’s clinic to schedule an appointment so that a refill can be authorized. All communications and outcomes are documented in the patient’s medical record. b. Verify the medication and dosage. The patient must be contacted if any discrepancies are noted, for example, a medication is being refilled too frequently for the way it is prescribed. Also, the patient is contacted for any p.r.n. medications that are being used with increased frequency, for example, benzodiazepines, sleeping pills or stimulants. Identified problems are clearly documented in the medical record. c. Verify that no lab testing/monitoring is required before ordering refills. (See Refill Guidelines attached.) If patient is due for testing/monitoring, a month refill may be provided to allow the patient the opportunity to see his/her provider/complete tests or monitoring. 3. The following medications are excluded from this policy. Refill requests must be routed to a licensed prescriber: a. Scheduled II Controlled Substances (medications such as oxycodone and morphine) b. Medications excluded per careplan c. Indications of non-compliance, including overuse or underuse d. Indications that the patient may be experiencing a side effect or drug interaction e. Specific medications as noted by the ordering prescriber f. Requests to change from a brand name medication to a generic when a physician specified the brand name to be used 4. Determine appropriate refill quantity @BCL@C0040D71 Page 1 of 4 a. If the patient has been keeping his/her appointments and is not overdue for a visit, refills may be given to last until the patient is due for his next visit, not to exceed one year from the last visit. b. If the patient has been keeping his/her appointments and is not overdue for a visit, RNs may increase the quantity from 30 to 90 days supply per patient request or to meet the mail order benefit. c. If the patient is overdue for a visit and the patient has scheduled a visit after being contacted, a refill can be called in by the nursing staff for one month or until the next scheduled appointment if it is beyond one month. d. If a patient’s appointment is canceled and rescheduled, a refill can be called in by the nursing staff for one month or until the next scheduled appointment if it is beyond one month. e. If a client cancels and reschedules a second consecutive time, nursing will only order enough days of non-scheduled medication to last to the scheduled appointment regardless of co-pay status. Further refills of scheduled medications require authorization by the provider. The client will be told at that time that there will be no further refills until he/she is seen. f. If a client cancels and reschedules a third time, there will be no refills until the client is seen by the provider. g. If a client is a no-show, there will be no refills until he/she has rescheduled another appointment, and then a refill of non-scheduled medications can be approved by the nursing staff for one month or until the next scheduled appointment if it is beyond one month. Scheduled medications refills will only be given for exactly the amount needed until the next scheduled appointment unless authorized by the provider. 5. Refills are returned to or called into the pharmacy of the patient’s choice. 6. Document that the medication was refilled per standing order (PSO). 7. The RN may question any medication refill and refer to an ordering provider for review. 8. If the medication refill is denied, the medical record should be routed to the physician for review and to determine if it is acceptable to deny.

Monitoring Parameters for Selected Medications

NOTE: This is not an all-inclusive list. The RN may refill any maintenance medication, including those not included in the following categories, unless it is identified in the exclusions. Although a specific drug may not be listed below, the monitoring parameters apply to all medications in the drug class.

Antipsychotics Older Antipsychotics AIMS or DISCUS every 6 months Haldol (haloperidol) Labs every 2 years: Fasting lipid profiles (total cholesterol, LDL, HDL, Mellaril (thioridazine) triglycerides) Navane (thiothixine) Prolixin (fluphenazine) Thorazine (chlorpromazine) Trilafon (perphenazine) Atypical Antipsychotics AIMS or DISCUS annually Abilify (aripiprazole) Weight, calculated BMI every visit Fanapt, Fanapta Labs at start, 4 months after start, then annually: (ioperidine)  Fasting plasma glucose level Geodon (ziprasidone)  Fasting lipid profiles (total cholesterol, LDL, HDL, triglycerides); if Invega (paliperidone) LDL level > 130 mg/dl increase to every 6 months Risperdal (risperidone) Saphris, (asenapine) Seroquel (quetiapine) Zyprexa (olanzapine)

@BCL@C0040D71 Page 2 of 4 Antipsychotics Clozaril, FazaClo WBC every week for 6 months, then every two weeks. If <3,000 increase (clozapine) frequency of monitoring.

Antidepressants Effexor (venlafaxine) Blood pressure at all visits where the medication was started or raised at the last Prestiq (desvenlafaxine) visit Cymbalta (duloxetine) Blood pressure at all visits where the medication was started or raised at the last visit Remeron (mirtazepine) Weigh at each visit for one year then annually Tricyclics Weigh at each visit for one year then annually amitriptyline Note last blood level clomipramine desipramine doxepin imipramine nortriptyline MAO Inhibitors Blood pressure every visit isocarboxazid phenelzine tranylcypromine SSRI’s n/a Celexa (citalopram) Lexapro (escitalopram) Luvox (fluvoxamine) Paxil, Pexeva (paroxetine) Prozac, Sarafem (fluoxetine) Zoloft (sertraline) Wellbutrin (bupropion) n/a

Serzone (nefazodone) Inquire if patient has signs/symptoms of liver disease such as jaundice, malaise, nausea or anorexia.

ADHD Medications Stimulants Blood pressure at all visits where the medication was started or raised at the last Adderall visit and every 6 months (dextroamphetamine, Weigh every visit under age 16 amphetamine) Height every 6 month under age 16 Concerta, Metadate, Ritalin (methylphenidate) Daytrana (methylphenidate patch) Dexedrine (dextroamphetamine) Focalin (dexmethylphenidate) Provigil (modafinil) Vyvanse (lisdexamphetamine) Strattera (atomoxetine) Weigh every visit under age 16

@BCL@C0040D71 Page 3 of 4

Mood Stabilizers Depakote (valproic acid) Weigh at each visit for one year then annually Labs at one month after start, 6 months after start then annual:  CBC with platelets  SGOT  Valproate level Tegretol (carbamazepine) Weigh at each visit for one year then annually Labs at one month after start, 6 months after start then annual:  CBC with platelets  Na (Sodium)  SGOT  Tegretol level Lithium Weigh at each visit for one year then annually Labs every 6 months:  Lithium level  BUN and Creatinine Annual Labs:  TSH Topamax (topiramate) Labs at 3 months and 6 months after start then annually  Basic Metabolic Panel (CHEM8)  UA Annual eye exam for glaucoma screening

Approval for use as a Population Based Standing Order:

Carol Novak, MD Date

@BCL@C0040D71 Page 4 of 4

SUBJECT: MEDICATION REFILL STANDING ORDER EFFECTIVE DATE: July 2010 Avandia removed 7/21/10 Celebrex & Azmacort removed 8/3/10 APPROVED BY: Debra Johnson, MD Department Head, Pediatrics & Adolescent Medicine Art Wineman, MD Department Head, Family Medicine Rae Ann Williams, MD Department Head, Internal Medicine Beth Averbeck, MD Associate Medical Director, Primary Care CONTACT: Jo McLaughlin, RN Director, Nursing and Clinical Dietitians Ryan Michels, PharmD, Clinical Pharmacist SUPERSEDES: July 2009 REVIEW DATE: July 2011

PURPOSE: To provide a process for RNs and Pharmacists to review and approve maintenance prescription refill requests.

POLICY: To provide in a safe, efficient manner, approval for a supply of medication for patients (this would also include supplies for maintenance medications, for example, insulin syringes). The RN or Pharmacist is the agent of the prescriber delegated to refill medications as per the following procedure. Prescriptions must clearly originate with HPMG physicians or other HPMG authorized prescribers.

Medication Refill SO Policy_2010.doc Page 1 of 10 d. If a medication alert appears when the refill order is placed, verify that the patient has had a previous order for this medication and history of tolerating the medication, and then proceed to refill. If there are any questions or concerns, forward to the ordering provider. 3. The following medications are excluded from this policy. Refill requests including but not limited to the following list must be routed to a licensed prescriber. RN or Pharmacist use “.no standing order” or “.narcotics” for narcotic medications, to document that the request is being routed to a licensed prescriber. a. Controlled Substances b. Oral Steroids c. Cox II inhibitors d. Chemotherapeutic agents e. Antibiotics f. Indications of non-compliance, including overuse or underuse g. Indications that the patient may be experiencing a side effect or drug interaction h. Specific medications as noted by the ordering prescriber i. Requests to change from a brand name medication to a generic when a physician specified the brand name to be used 4. Refills may be given to last until the patient is due for his next visit, not to exceed one year from the last visit. a. RNs or Pharmacists may increase the quantity from 30 to 90 days supply per patient request or to meet the mail order benefit. b. This exludes scheduled medications (II – V) and psychotherapeutic drugs and any medication excluded from this standing order (per section 3). 5. The DISPENSING PHARMACIST may change the quantity and days supply dispensed on maintenance medications, up to a 3-month supply, to meet patient requests or a mail order benefit. This policy excludes all scheduled medications (II – V), psychotherapeutic drugs and any medication ordered by a behavioral health provider. 6. Refills are returned to or called into the pharmacy of the patient’s choice. 7. Document that the medication was refilled per standing order (PSO). 8. The RN or Pharmacist may question any medication refill and refer to an ordering provider for review. If the medication cannot be filled per the standing order, the request should be routed to the physician for review.

Monitoring Parameters for Selected Medications

NOTE: This is not an all-inclusive list. The RN or Pharmacist may review any maintenance medication that falls into the categories below unless it is identified in the exclusions. Although a specific drug may not be listed below, the monitoring parameters apply to all medications in the drug class. For combination products, the RN or Pharmacist will review the parameters for each component. RNs and Pharmacists may also consult the PDR, Facts and Comparisons, or clinical Pharmacy Specialist for drug specific monitoring.

Nonprescription/Over-the-counter (OTC) Medications (not listed elsewhere) Medications Monitoring ALL Review for the following using a reputable drug information source, such as Micromedex or Up-To-Date: • No contraindications for use exist • Lack of significant drug, disease or dietary interactions. • Dosage/usage appropriate • Therapeutic benefit (effectiveness) demonstrated • Lack of significant adverse effects

Medication Refill SO Policy_2010.doc Page 2 of 10

Allergy Medications Monitoring ANTIHISTAMINES (oral) • desloratidine (Clarinex®) • fexofenadine (Allegra®, Allegra-D®) • levocetirizine (Xyzal®) ANTIHISTAMINES (nasal) • azelastine (Astelin®) • olopatadine (Patanase®) NASAL STEROIDS • budesonide (Rhinocort®) • fluticasone (Flonase®) • mometasone (Nasonex®) • triamcinalone (Nasacort®) • ciclesonide (Omnaris®) • fluticasone furoate (Veramyst®)

Antidepressants Medications Monitoring SSRI ANTIDEPRESSANTS • citalopram (Celexa®) • escitalopram (Lexapro®) • fluoxetine (Prozac®) • fluvoxamine (Luvox®) • paroxetine (Paxil®) • sertraline (Zoloft®) SNRI ANTIDEPRESSANTS Annually • duloxetine (Cymbalta®) • BP • desvenlafaxine (Prestiq®) • Heart rate • venlafaxine (Effexor®) • milnacipran (Savella®) Savella – FDA approved only for fibromyalgia TRICYCLIC ANTIDEPRESSANTS Annually • amitriptyline (Elavil®, Endep®) • BP • amoxapine (Asendin®) • Heart rate • clomipramine (Anafranil®) • Weight • desipramine (Norpramin®) • doxepin (Sinequan®) • imipramine (Tofranil®) • maprotiline (Ludiomil®) • nortriptyline (Aventyl HCL®, Pamelor®) • protriptyline (Vivactil®) • trimipramine (Surmontil®) • mirtazepine (Remeron®) Annually • Weight • bupropion (Wellbutrin®)

Anti-herpetics Medications Monitoring ORAL AGENTS Annually in patient’s with known renal insufficiency • acyclovir • BUN • famciclovir (Famvir®) • serum creatinine • valacyclovir (Valtrex®) TOPICAL AGENTS • acyclovir (Zovirax®) • penciclovir (Denavir®) Medication Refill SO Policy_2010.doc Page 3 of 10

Benign Prostatic Hyperplasia (BPH) Medications Monitoring • alfuzosin HCl (Uroxatral®) Annually/dosage change • silodosin (Rapaflo®) • BP • tamsulosin (Flomax®)

Cardiovascular (not HTN) Medications Monitoring All cardiovascular (not HTN) medications • BP annually • amiodarone (Cordarone®) • Baseline, 3 months, and every 6 months: TSH • Baseline and every 6 months: ALT • Baseline and annually (or as needed per symptoms): chest radiograph and EKG • Baseline and as necessary: Cr, BUN, K, Mg, Na, PFT, and eye exam • refill only 6 months • dronedarone (Multaq®) • Baseline and annually (or as needed per symptoms): EKG • Baseline and as necessary: K, Mg • refill only 6 months • isosorbide (Isordil®, Imdur®) • nitroglycerin/ NTG (Nitrostat®, Nitrol®, Nitrek®,

Minitran®) • warfarin (Coumadin®) • INR regularly • Refer to Warfarin standing orders and SmartForm • digoxin (Lanoxin®) • K+, Mg, BP, serum creatinine annually • clopidroget (Plavix®)

• prasugrel (Effient®)

Cholesterol Medications Monitoring FIBRATES Annually/dosage change • gemfibrozil (Lopid®) • ALT • fenofibrate (Tricor®, Lofibra®, Antara™ , • lipid panel Triglide®, others) • fenofibric acid (Trilipix®) STATINS Annually/dosage change • atorvostatin (Lipitor®) • ALT • pravatatin (Pravachol®) Annually/dosage change • simvastatin (Zocor®) • lipid panel • fluvastatin (Lescol/ Lescol XL®) New start or changing dose • lovastatin (Mevacor®, Altocor®, generics) • ALT every 3-6 months for first year • rosuvastatin (Crestor®) • simvastatin/ezetimibe (Vytorin®) • lovastatin/niacin ER (Advicor®) • Ezetimibe (Zetia®) Annually/dosage change • Lipid panel NIACIN Every 6 months • Niacin ER (Niaspan®) • ALT Annually/dosage change • Lipid panel New start • ALT every 6-12 weeks for first year.

Medication Refill SO Policy_2010.doc Page 4 of 10 OMEGA-3 FATTY ACIDS Annually/dosage change • Omega-3-acid ethyl esters (Lovaza®) • ALT • lipid panel

Diabetes Medications Monitoring BIGUANIDES Annually • metformin (Glucophage®, Glucophage XR®) • serum creatinine • ALT • BP • Lipid panel • microalbumin Every three months • HgbA1c INSULIN Annually • insulin (Apidra®, Humalog®, Lantus®, Levemir®, • serum creatinine Novolog®, NPH, Regular) • BP • supplies • Lipid panel • microalbumin Every three months • HgbA1c GLUCAGON-LIKE PEPTIDE 1 AGONIST Annually . Exenatide injection (Byetta®) • serum creatinine . Pramlintide injection (Symlin®) • BP • Lipid panel • microalbumin Every three months • HgbA1c DIPEPTIDYL PEPTIDASE IV INHIBITOR Annually . Saxagliptin (Onglyza®) • serum creatinine . Sitagliptin (Januvia®) • BP • Lipid panel • microalbumin Every three months • HgbA1c SULFONYLUREAS Annually • glimeperide (Amaryl®) • serum creatinine • glipizide (Glucotrol®, Glucotrol XL®) • BP • glyburide (Micronase®, Diabeta®) • Lipid panel • microalbumin Every three months • HgbA1c THIAZOLIDINEDIONES Annually • pioglitazone (Actos®) • serum creatinine • ALT • BP • Lipid panel • microalbumin Every three months • HgbA1c • ALT

Medication Refill SO Policy_2010.doc Page 5 of 10 MEGLITINIDES Annually • nateglinide (Starlix®) • serum creatinine • repaglinide (Prandin®) • ALT • BP • Lipid panel • microalbumin Every three months • HgbA1c • ALT COMBINATIONS • Follow the monitoring guidelines of the medication • metformin/pioglitazone (Actoplusmet®) components. • metformin/rosiglitazone (Avandamet®) • metformin/glipizide (Metaglip®) • metformin/glyburide (Glucovance®) • glimepiride/pioglitazone (Duetact®) • metformin/sitagliptin (Janumet®) • metformin/repaglinide (Prandimet®) BLOOD GLUCOSE TESTING SUPPLIES

Hormone Replacement Medications Monitoring • conjugated estrogens (Premarin®) Annually • conjugated estrogens/ medroxyprogesterone • mammography (Combipatch®, Premphase®, Prempro®) • breast exam • esterified estrogen/ methyltestosterone (Estratest®, • Pap (3 normals then every 2-3 years) Estratest HS®) • estrodiol (Estrace®, Estraderm®, Vivelle®) • ethinyl estradiol/ norethindrone (FemHRT®) • medroxyprogesterone (Provera®) • progesterone (Prometrium®)

Oral Contraceptives Medications Monitoring • various products Annually • BP • Pap (3 normals then every 2-3 years)

Hypertension Ace Inhibitors Medications Monitoring • captopril (Capoten®) Annually/dosage change • benazepril/amlodipine (Lotrel®) • K+ • enalapril (Vasotec®) • serum creatinine • enalapril/HCTZ (Vasoretic®) • sodium (only applies to medications that include a • lisinopril (Prinivil®, Zestril®) diuretic) • lisinopril/HCTZ (Prinzide®, Zestoretic®) • BP Alpha Blockers Medications Monitoring • doxazosin (Cardura®) Annually/dosage change • prazosin (Minipress®) • BP • terazosin (Hytrin®) Alpha/Beta Blockers Medications Monitoring • carvedilol (Coreg®, Coreg CR®) Annually/dosage change • labetalol (Trandate®, Normodyne®) • BP

Medication Refill SO Policy_2010.doc Page 6 of 10

Angiotensin II Receptor Blockers Medications Monitoring • irbesartan (Avapro®) Annually/dosage change • irbesartan/HCTZ (Avalide®) • K+ • losartan (Cozaar®) • serum creatinine • losartan/HCTZ (Hyzaar®) • sodium (only applies to medications that include a • telmisartan (Micardis®) diuretic) • telmisartan/HCTZ (Micardis HCT) • BP Beta Blockers Medications Monitoring • atenolol (Tenormin®) Annually/dosage change • atenolol/chlorthalidone (Tenoretic®) • BP • metoprolol (Lopressor®, Toprol XL) • Heart rate • propranolol (Inderal®) Calcium Channel Blockers Medications Monitoring • amlodipine (Norvasc®) Annually/dosage change • diltiazem (Cardizem®, Cardizem CD/SR®, • BP Dilacor®) • Heart rate (diltiazem, verapamil) • nifedipine (Procardia XL®) long acting • verapamil (Calan®, Calan SR®, Isoptin®, Verelan®) Central Acting Antiadrenergics Medications Monitoring • clonidine (Catapres®, Catapres TTS®) Annually/dosage change • methyldopa (Aldomet®) • serum creatinine • BP Direct Renin Inhibitors Medications Monitoring • aliskiren (Tekturna®) Annually/dosage change • K+ • serum creatinine • BP Diuretics Medications Monitoring • furosemide (Lasix®) Annually/dosage change • hydrochlorothiazide/ HCTZ (Hydrodiuril®) • K+ • chlorthalidone (Thalitone®) • serum creatinine • indapamide (Lozol®) • sodium • spironolactone (Aldactone®) • BP • eplerenone (Inspra®) • triamterene/HCTZ (Dyazide®, Maxzide®) • metolazone (Zaroxolyn®)

Hypothyroidism Medications Monitoring • Levothyroxine (Synthroid®, Levothroid®) Annually/ dosage change (6wks) • TSH sensitive

Medication Refill SO Policy_2010.doc Page 7 of 10

Migraine Medications Monitoring • almotriptan (Axert®) • eletriptan (Relpax®) • rizatriptan (Maxalt®)

• sumatriptan (Imitrex®) • frovatriptan (Frova®) • naratriptan (Amerge®)

Non-Steroidal Anti-Inflammatory Drugs Medications Monitoring • flurbiprofen (Ansaid®) Annually • ibuprofen (Motrin®) • serum creatinine • indomethacin (Indocin®) • Hgb • meloxicam (Mobic®) • ALT (if on sulindac [Clinoril®]) • naproxen (Naprosyn®) • piroxicam (Feldene®) • salsalate (Disalcid®) • sulindac (Clinoril®) • tolmetin (Tolectin®)

Osteoporosis Medications Monitoring BISPHOSPHONATES • alendronate (Fosamax®) • alendronate/ cholecalciferol (Fosamax +D®) • risedronate (Actonel®) • ibraondranoate (Boniva®)

PUD (peptic ulcer)/ GERD (reflux) Medications Monitoring H2 BLOCKERS • cimetidine (Tagamet®)

• famotidine (Pepcid®) • ranitidine (Zantac®) PROTON PUMP INHIBITORS • dexlansoprazole (Dexilant®) • lansoprazole (Prevacid®) • omeprazole (Prilosec®) • pantoprazole (Protonix®) • rabeprazole (Aciphex®) • esomeprazole (Nexium®)

Medication Refill SO Policy_2010.doc Page 8 of 10

Respiratory Medications Monitoring BRONCHODILATOR INHALERS Each refill • albuterol (Proair®, Ventolin HFA®) • Check for refill requests. If requests more • albuterol/ipratropium (Combivent®) frequently than provider ordered, route for provider • ipratropium (Atrovent®) review (may require adding or increasing dose of • pirbuterol (Maxair®) steroid inhaler). • salmeterol (Serevent®) Albuterol th • tiotropium (Spiriva®) • 4 refill request for an albuterol inhaler within 1 yr of the original prescription - RN assesses for increasing asthma severity level and/or need for controller medication. Review with provider. BRONCHODILATOR for NEBULIZER See Bronchodilator Inhaler monitoring • albuterol (Proventil®, Ventolin®) • albuterol/ipratropium (Duoneb®) • ipratropium (Atrovent®) LEUKOTRIENE MODIFIERS

• montelukast (Singulair®) STEROID INHALERS • beclomethasone (QVar®) • mometasone furoate (Asmanex®) • budesonide (Pulmicort®) • fluticasone (Flovent®) • fluticasone/salmeterol (Advair®) • budesonide/formoterol (Symbicort®) STEROID for NEBULIZER

• budesonide (Respules®) THEOPHYLLINE Annually • various products • theophylline level

Seizures Medications Monitoring • carbamazepine (Tegretol®) Annually • phenobarbital (Luminal®) • drug level (carbamazepine, phenobarbital, phenytoin • phenytoin (Dilantin®) and valproic acid/divalproex) • valproic acid/divalproex (Depakote®, Depakote ER • Weight ®) • CBC (carbemazepine only) • gabapentin (Neurontin®) • ALT (carbemazepine and valproic acid) • lamotrigine (Lamictal®) • Sodium (carbamazepine, oxcarbamazepine) • levitiracetam (Keppra®) • BMP (topiramate) • oxcarbamazepine (Trileptal®) • topiramate (Topomax®) • zonisamide (Zonegran®)

Supplements Medications Monitoring • calcium • Vitamin D • potassium Annual/change in dose • K+ level MULTIVITAMINS

• multiple products

Medication Refill SO Policy_2010.doc Page 9 of 10

Topical Agents Medications Monitoring ACNE, ROSACEA, ECZEMA, PSORIASIS Tazarotene should not be used during pregnancy. • adapalene (Differin®) • azelaic acid (Azelex®; Finacea®) • benzoyl peroxide (Benzac®, Brevoxyl®, others) • clindamycin (Cleocin T®) • metronidazole (MetroCream®, MetroGe®l, MetroLotion®) • tazarotene (Tazorac®) • tretinoin (Retin-A®, Retin-A Micro®)

Urinary Incontinence Medications Monitoring • oxybutynin (Ditropan ®, Ditropan XL®, Oxytrol®) • tolterodine (Detrol®, Detrol LA®) • darifenacin (Enablex®)

• fesoterodine (Toviaz®) • solifenacin (Vesicare®) • trospium (Sanctura®)

Miscellaneous Medications Monitoring • acetaminophen (Tylenol®) Annually (with frequent usage) • ALT • serum creatinine • allopurinol (Zyloprim®) Annually • serum creatinine • ALT • CBC • Nicotine patches (Nicoderm CQ®, Nicotrol®) Annually • Heart rate • BP

Drug Information: http://micromedex.HealthPartners.com

Approval for use as a Population Based Standing Order:

Debra Johnson, MD Date

Art Wineman, MD Date

Rae Ann Williams, MD Date

Beth Averbeck, MD Date

Medication Refill SO Policy_2010.doc Page 10 of 10

HealthPartners Family Practice Training Minnetonka, MN 55305 Clinic: 952-546-2500

Date Name Address Address

Dear Name:

I am writing to follow up on your recent visit to our office. I am pleased to report that the following studies were either normal or within acceptable limits.

This is a brief explanation of the above lab tests: {COMMON LAB:7172}

Should you have any questions or concerns, please call my office at the number listed above. Thank you for letting us serve you.

Sincerely,

Name, MD.

Page 1 of 3

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Preventing Falls

Table of Contents

 Topic Overview  Credits

Topic Overview

Every year, thousands of older adults fall and hurt themselves. Falls are one of the main causes of injury and disability in people age 65 and older. People who have had a stroke or have multiple sclerosis or osteoporosis are also at risk. These tips can help you avoid falls.

Take care of yourself

 If you live alone, think about wearing an alarm device that will bring help in case you fall and can't get up. Or carry a cordless or cell phone with you from room to room. Then you can quickly call for help if you need it.  Have your vision and hearing checked each year or anytime you notice a change. If you have trouble seeing and hearing, you might not be able to avoid objects that make you lose your balance.  If you are very weak or dizzy, have someone help you get out of bed, walk, and bathe.  Call your doctor if you have calluses or corns on your feet that need to be removed. If you wear loose-fitting shoes because of calluses or corns, you can lose your balance and fall.  Call your doctor if you are dizzy and lose your balance. You may have a health problem that needs treatment, such as an inner ear problem.

Learn ways to keep your balance

 Exercise often to improve your strength, muscle tone, and sense of balance. Walking is a great way to start. Swimming can be a good choice if you can't walk well. For simple exercises you can try at home, see Quick Tips: Improving Your Balance.  Wear low-heeled shoes that fit well and give your feet good support. Use footwear with nonskid soles. Repair or replace worn heels and soles.  If you use a walker or cane, make sure it is fitted to you. Put rubber tips on it.  If you have pets, keep them in one place at night. Train your pets not to jump or get underfoot. Think about buying a collar with a bell for your pet so you will know when your pet is nearby.

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Learn about your medicines

 Know the side effects of medicines you are taking. Ask your doctor if the medicines you take can affect your balance. For instance, sleeping pills and some medicines for anxiety can affect your balance.  If you take two or more medicines, talk to your doctor about how they work together. Sometimes combinations of medicines can cause dizziness or sleepiness. Either of these can lead to a fall.

Make your home safer

 Remove or fix things you could trip over, such as raised doorway thresholds, throw rugs, or loose carpet.  Keep paths clear of electrical cords and clutter.  Use nonskid floor wax, and wipe up spills right away.  Keep your house well lit. Use night-lights (or keep the overhead light on at night) in hallways and bathrooms.  Put sturdy handrails on stairways. Make sure you have a light at the top and bottom of the stairs.  Store things on lower shelves so you don't have to climb or reach high.  Keep a phone and a flashlight by your bed. Check the flashlight batteries often to make sure they still work.

For a complete list of hazards to look for and fix at home, see this checklist for preventing falls.

Stay safe while bathing

 Install grab handles and nonskid mats in the tub and shower.  Use a shower chair or bath bench. You can also try using a hand-held shower head.  Get into a tub or shower by putting the weaker leg in first. Get out of a tub or shower with your strong side first.

Prevent outdoor falls

 If you live in an area that gets snow and ice in the winter, have a family member or friend sprinkle salt or sand on slippery steps and sidewalks.

Credits for Preventing Falls

By Healthwise Staff Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine Specialist Medical Reviewer Elizabeth A. Phelan, MD, MS - Geriatric Medicine Last Revised February 24, 2010

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Note: The "printer friendly" document will not contain all the information available in the online document. Some information (e.g. cross-references to other topics, definitions or medical illustrations) is only available in the online version.

© 1995-2011 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated. This information does not replace the advice of a doctor. Healthwise disclaims any warranty or liability for your use of this information.

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ELDERLY DRIVERS Is your loved one driving safely?

Are elderly drivers safe? Yes ... for the most part. The same can be said for teen drivers. Do driving skills of decline with age? Yes, but just like other age groups, driving skills vary from one person to another. Telling elderly drivers that it may be time to stop driving can be one of the most difficult milestones for caregivers. Driving represents freedom and independence for the elderly ... the ability to visit friends, go to the movies and shop ... without relying on anyone else. Revoking an elderly person’s drivers license over a certain age is not an acceptable solution. Driving skills vary widely at all ages. It is unfair to punish most elderly drivers for problems caused by only a few drivers. When the question of declining driving abilities becomes personal, the issues involved become very emotional. Elderly drivers might get defensive ... even angry ... when the subject of their driving abilities is raised. Thus, include the elderly person in the decision-making process if at all possible, rather than dictate a decision to them. It can also be very helpful if both you and your loved one discuss the matter together with other family members, doctors, and other people they respect, such as clergy and friends. But, despite your best efforts, you may still have to make the decision to stop for them for their own safety ... and the safety of other drivers and pedestrians. How does aging affect the abilities of elderly drivers?

Safe elderly drivers require the complex coordination of many different skills. The physical and mental changes that accompany aging can diminish the abilities of elderly drivers. These include:

A slowdown in response time

A loss of clarity in vision and hearing

A loss of muscle strength and flexibility

Drowsiness due to medications

A reduction in the ability to focus or concentrate

Lower tolerance for alcohol Taken separately, none of these changes automatically means that elderly drivers should stop. But caregivers need to regularly evaluate the elderly person’s driving skills to determine if they need to alter driving habits or stop driving altogether. A checklist on safe elderly driving

Watch for telltale signs of decline in the elderly person’s driving abilities. Do they:

Yes No Drive at inappropriate speeds, either too fast or too slow?

Yes No Ask passengers to help check if it is clear to pass or turn?

Yes No Respond slowly to or not notice pedestrians, bicyclists and other drivers?

Yes No Ignore, disobey or misinterpret street signs and traffic lights?

Yes No Fail to yield to other cars or pedestrians who have the right-of-way?

Yes No Fail to judge distances between cars correctly?

Yes No Appear drowsy, confused or frightened?

Yes No Have one or more near accidents or near misses?

Yes No Drift across lane markings or bump into curbs?

Yes No Forget to turn on headlights after dusk?

Yes No Have difficulty with glare from oncoming headlights, streetlights, or other bright or shiny objects, especially at dawn, dusk and at night? Yes No Have difficulty turning their head, neck, shoulders or body while driving or parking?

Yes No Ignore signs of mechanical problems, including underinflated tires? (one in 4 cars has at least one tire that is underinflated by 8 pounds or more; low tire pressure is a major cause of accidents.)

Yes No Have too little strength to turn the wheel quickly in an emergency such as a tire failure, a child darting into traffic, etc.? Yes No Get lost repeatedly, even in familiar areas?

If the answer to one or more of these questions is “Yes,” you should explore whether medical issues are affecting their driving skills.

Medical issues to consider

Caregivers need to know if the elderly person: Yes No Has had their vision and hearing tested recently?

Yes No Has had a physical examination within the past year to test reflexes and make sure they don’t have illnesses that would impact their driving?

Yes No Is taking medications or combinations of medications that might make them drowsy or confused while driving? Yes No Has reduced or eliminated their intake of alcohol to compensate for lower tolerance?

Yes No Has difficulty climbing a flight of stairs or walking more than one block?

Yes No Has fallen - not counting a trip or stumble - once or more in the last year?

Yes No Has had a physician told them that they should stop driving?

Adapting to change

Driving is not necessarily an all-or-nothing activity. Some programs exist to help elderly drivers adjust their driving to changes in their physical condition:

AARP (the American Association of Retired Persons) sponsors a Driver Safety Program, which helps older people deal with issues such as how to compensate for vision problems associated with aging. And, the Association for Driver Rehabilitation offers referrals to specialists who teach people with disabilities, including those associated with aging, how to improve their driving.

There are many ways for elderly drivers to adjust so they are not a danger to themselves or others. Among them are:

- 2 - Avoid driving at night and, if possible, at dawn or dusk

Drive only to familiar locations

Avoid driving to places far away from home

Avoid expressways (freeways) and rush hour traffic

Leave plenty of time to get where they are going

Don’t drive alone

Other forms of transportation

Encourage your loved one to rely more on public transportation. This will reduce their time behind the wheel and help prepare them for the day when they can no longer drive. Many cities offer special discounts for seniors on buses and trains, and senior centers and community service agencies often provide special transportation alternatives.

How to get them to stop

If you feel strongly that your parent cannot drive safely, you have little choice but to get them to stop driving. If they agree without an argument, wonderful. If not, you have several options:

Stage an intervention. This approach, commonly used with substance abusers, involves confronting the elderly driver as a group of concerned caregivers. The group should include family members, health care workers and anyone else respected by the senior. The intervention needs to be handled firmly but with compassion in order to break through the senior’s denial of the issue.

Contact the local Department of Motor Vehicles and report your concerns. Depending upon state regulations and your senior’s disabilities, it may be illegal for them to continue to drive. The DMV may do nothing more than send a letter, but this might help convince your parent or loved one to stop.

Take the keys, disable the car or move it to a location beyond the elderly person’s control. Leave the headlights on all night or disconnect the battery to disable the car. But if your loved one is likely to call AAA or a mechanic, you have no choice but to eliminate all access to the car. While this may seem extreme, it can save the lives of seniors, other drivers and pedestrians.

Related resources

AARP offers the highly recommended Driver Safety Program for older people. To find a class near you, visit the AARP Web site at www.aarp.org/drive/home.html, call toll-free at 1-888-227-7669, or write to them at 601 E Street NW, Washington, DC 20049.

The Association for Driver Rehabilitation offers referrals to professionals trained to help people with disabilities, including those associated with aging. Visit their Web site at www.driver-ed.org and click on “Directory” in the left hand menu, or contact them at: P.O. Box 49, Edgerton, Wisconsin 53534, 1-608-884-8833.

The USAA Educational Foundation, AARP, and the National Highway Traffic Safety Administration developed a very informative booklet, “Driving Safely While Aging Gracefully.” (To view it online, visit their Web site at www.nhtsa.dot.gov/people/injury/olddrive/booklet.html.) It describes many of the physical changes associated with aging, and includes tips on coping with them so that older people can remain safe drivers.

- 3 - Teach-back is Supported by Research

● “Asking that patients recall and restate what they have been told” is one of 11 top patient safety practices based on the strength of scientific evidence.” AHRQ, 2001 Report, Making Health Care Safer

● “Physicians’ application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients.” Schillinger, Arch Intern Med/Vol 163, Jan 13, 2003, “Closing the Loop” Health Literacy Universal Precautions Toolkit 149 AHRQ Pub. No. 10-0046-EF Teach-Back Self-Evaluation and Tracking Log

Name: ______Start/end date:_____/_____

Patient # Items Teach Results – Clarification needed? Patient perceptions? What to do ID to do or back Your assessment? differently next time remember used? Yes No 1. Increase X I asked the patient to tell me his medication changes. He understood If I find that many patients evening the addition of Enalapril and the dose, but he forgot how much I can’t recall their insulin dose asked him to increase his insulin dose by. I clarified, and he actually medication changes, I may to 26 units. expressed his appreciation for my confirmation. use a form to write them 2. Start down for all patients. Enalapril 5 mg, take 1 pill every morning.

Health Literacy Universal Precautions Toolkit 160 AHRQ Pub. No. 10-0046-EF Resource List Health Plan Organizational Assessment of Health Literacy Activities

Many questions in the organization assessment inquired about the use of guidelines. To help health plans implement and use guidelines in the future, each guideline topic covered in the assessment is listed below. The guidelines and suggestions listed are resources that have been developed and may be used or built upon to improve existing health literacy initiatives.

Please ote All pages numbers listed refer to the page of the actual document as indicated in the lower right or left corner. The page numbers may or may not correspond to individual pdf file page numbers.

Reading level goals and testing • Simply Put CDC communication guide. It includes directions for completing a Frye Readability Test for written material (Pages 23-28). http://www.cdc.gov/od/oc/simpput.pdf

Font/Size • The Health Literacy Style Manual This manual provides font and size guidelines and examples of proper use (Pages 40-43). http://www.idph.state.ia.us/health_literacy/common/pdf/tools/hlsmchapter4.pdf • Simply Put CDC communication guide. It gives font and size suggestions (Page 9). http://www.cdc.gov/od/oc/simpput.pdf

Clear/Plain Language • Clear & Simple: Developing Effective Print Materials for LowLiterate Readers- Provided by the National Cancer Institute, this is a great resource for creating clear and simple print materials (primarily focuses on disease specific information). It gives the basic steps to develop materials as well as appendices detailing style, layout, visuals etc. http://www.nci.nih.gov/aboutnci/oc/clear-and-simple/allpages • Checklist for use of plain language- http://www.plainlanguage.gov/howto/quickreference/checklist.cfm • Simply Put CDC communication guide. Page 29 provides a checklist for written materials. http://www.cdc.gov/od/oc/simpput.pdf • Plain Language Thesaurus http://www.nphic.org/files/editor/file/thesaurus_1007.pdf • Merck manuals- The Merck manuals are often used as examples of good written health information on a variety of health conditions and diseases. Some examples: Diabetes: http://www.merck.com/mmhe/sec13/ch165/ch165a.html?qt=Diabetes&alt=sh High Blood Pressure: http://www.merck.com/mmhe/sec03/ch022/ch022a.html#sec03-ch022- ch022a-176

Web specific • Guidelines for Health Plan UserFriendly Development and Design AHIP guidelines http://www.ahip.org/content/default.aspx?docid=22867 • Checklist for Evaluating Health Plan Websites for UserFriendliness AHIP guidelines http://www.ahip.org/content/default.aspx?docid=22865 • Document Checklist of Plain Language on the Web This webpage provides some brief guidelines for writing information specifically for web viewing. http://www.plainlanguage.gov/howto/quickreference/weblist.cfm

Identification of medical/scientific jargon to avoid • Plain Language Thesaurus includes medical terminology http://www.nphic.org/files/editor/file/thesaurus_1007.pdf

White space • The Health Literacy Style Manual Suggestions and guidelines for spacing and the proper use of “white space”. Includes examples (Page 47) http://www.idph.state.ia.us/health_literacy/common/pdf/tools/hlsmchapter4.pdf • Simply Put- CDC Communication Guide. Brief layout and design guidelines(Page 17) http://www.cdc.gov/od/oc/simpput.pdf

Graphics/Illustrations • Simply PutCDC Communication Guide. Discusses the use of graphics/illustrations generally as well as putting some focus on cultural appropriateness (Pages 11-16). http://www.cdc.gov/od/oc/simpput.pdf

Verbal Communication (strategies for good communication as well as indications for difficulty understanding) • Quick Guide to Health Literacy Includes information on teachback and examples of the use of this technique (Page 4.5). http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf

Identification of organizational words and phrases • Simple Words and Phrases http://www.plainlanguage.gov/howto/wordsuggestions/simplewords.cfm • Plain Language Thesaurus http://www.nphic.org/files/editor/file/thesaurus_1007.pdf

Regulation of acronyms or nicknames • Keep it JargonFree Lists suggestions for regulating the use of acronyms/abbreviations at the bottom of the page. http://www.plainlanguage.gov/howto/wordsuggestions/jargonfree.cfm

Development of forms • The Health Literacy Style Manual This manual provides many “good” and “bad” examples of forms, identifying appropriate layout and development techniques. http://www.idph.state.ia.us/health_literacy/common/pdf/tools/hlsmchapter4.pdf • Simple Words and Phrases Word suggestions- much of this is the type of language that would be used in forms http://www.plainlanguage.gov/howto/wordsuggestions/simplewords.cfm • Quick Guide to Health Literacy Includes a very brief tip list for form improvement (Page 5.2)http://www.health.gov/communication/literacy/quickguide/Quickguide.pdf

Training Resources • PlainTrain, the Plain Language Online Training Program- free online training for clear writing and material development. http://www.web.net/~plain/PlainTrain/index.html • Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency- An online course for public health professionals to communicate better with patients with poor English skills and limited health literacy. http://www.hrsa.gov/healthliteracy/training.htm

The resources listed above provide basic guidance for the use of health literacy guidelines in your health plan. If you are looking for more in depth, additional, or specific information, there is a comprehensive guide to available resources on Health Literacy available for download at http://www.healthliteracyinnovations.com/home.

Checklist for Creating Easy-to-Read and Easy-to-Understand Communications

Planning the Communication ¾ Know your audience ¾ Know your objectives ¾ Limit content to what’s needed ¾ Focus on the reader, not on HealthPartners ¾ Focus on what the person must do ¾ Always let the reader know how to get more information

Writing Style –Make it Easy to Understand ¾ Write the way you would tell it to someone (use living room language) ¾ Write to the person, not about the person (use “you” and “we”) ¾ Use short words rather than longer ones when possible ¾ Use short sentences (10-15 words) with one idea in each ¾ Use active voice when possible ¾ Use medical, technical and industry terms and jargon sparingly (define if used) ¾ Avoid acronyms (spell out if must use) ¾ Avoid elements like “i.e.” “e.g.” “<” “>” ¾ Keep it simple and friendly ¾ Avoid using long names for staff positions and phone lines (for example Obesity Patient Counseling Nurse)

Format – Make it Look Easy to Read ¾ Use serif font for body copy (Times New Roman) ¾ Can use sans serif font (such as Arial) for heads, subheads, etc. ¾ Use 12-point font ¾ Use upper and lower case text ¾ Be strategic with using bold type – don’t overdo it ¾ Break content into chunks – don’t use large blocks of copy ¾ Use bulleted lists when possible ¾ Provide “road signs” to help people navigate the document (headings, font style, color, etc.) ¾ Use plenty of white space ¾ Provide sharp contrast – text should be dark; background white or very light ¾ Set up flush left – don’t justify type (don’t make it fill the line left to right)

Review your work ¾ Read it out loud ¾ Ask someone who’s not close to your subject to read it and make suggestions to clarify ¾ Check the reading level (aim for 7th grade or lower).

Visuals (illustrations, photos, charts, diagrams) ¾ Only use visuals to help readers understand the message, not just be decorative ¾ Charts should be very simple and limited to what readers need to know ¾ Clearly label all parts of a chart or graph

Medication Therapy Management (MTM),

a Growing Trend in Healthcare By Linda M. Strand, Pharm.D., Ph.D.

Medication Therapy Management (MTM) services help address this urgent public need for the prevention of medication-related morbidity and mortality. This service can enhance patients’ understanding of appropriate drug use, increase adherence to their medication therapy, and empower patients to take an active role in management of their medications and health care. MTM services are currently being delivered in both the public and private sectors. In the public sector, some state Medicaid programs and Medicare D plans are utiliz- ing MTM services. For Medicare Part D, the Centers for Medicare and Medicaid Services (CMS) have mandated that any patient that has $4,000 per year in actual or anticipated drug expense is eligible for MTM services.2 State Medicaid programs vary widely in eligibility criteria, but generally a patient must have at least two chronic disease states and be on at least four or more medications to receive these services. In the private sector, MTM programs are beginning to emerge and are providing services for traditional insured organizations, self-insured employers, managed-care groups, and self-paying individual patients nationwide. Retail pharmacy organizations are developing capabilities for MTM in anticipation of patient needs and payer requirements.

What is Medication Therapy Management (MTM)? Medication Therapy Management is a standards driven service. It is a patient-centered service encompassing an assessment of the patient’s medication-related needs, the development of a care plan to meet these needs and The health care industry has worked hard over follow-up evaluations in order to optimize outcomes. Drug therapy problems are identified, resolved and pre- the past thirty years to improve the quality vented with the patient and the patient’s care providers. of care and stem rising cost trends. In spite This service is designed to facilitate collaboration and of these efforts, economic estimates show that enhance communication between the pharmacist, patient, physician, and other healthcare workers to pro- more than $100 billion is spent on drug related mote safe and effective medication use by the patient. morbidity and mortality.1 Drug therapy problems The pharmacist or qualified provider takes a com- are a significant public health issue within plete medication history, gathers patient-specific information about the patient’s medical conditions, and the healthcare system. More than 1.5 million assesses the medication therapies to determine if there preventable medication-related adverse events are problems. This assessment can help determine if any of the medications are inappropriate, ineffective, occur each year in the United States.2 unsafe or inconvenient for the patient to take as intended. Interventions may include working with the patient or

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MEDICATION THERAPY MANAGEMENT

(Continued from page 4) collaborating with physicians or other healthcare workers intended are that the patient: 1) cannot afford to purchase to resolve the problem. When drug therapy problems are the medications or make the co-payment; 2) did not identified, they can be resolved by changing products, understand the instructions for use; 3) has a significant doses, or educating the patient on how to maximize the number of co-morbidities and is taking a large number effectiveness of the medication. MTM services are proof medications.3 vided to the patient in a private or semiprivate area, as Patients with a potential need for MTM services can be required by the Health Insurance Portability and Account- identified by pharmacists, physicians, nurse practitioners, ability Act (HIPAA), and in accordance with evidenced- case managers or other healthcare workers, and even by based guidelines.2 the patients themselves, when medication-related Which patients may 70 percent of medication users today experience problems are identified benefit from MTM drug therapy problems, which cost the healthcare or suspected. For services? example, case managers 1 All patients who are tak- system more than $100 billion dollars yearly. work closely with ing medications or patients that have should be taking med- chronic conditions and ications can benefit diseases to counsel and from MTM services. teach about their specif- Patients taking multiple ic diagnoses and med- prescription and nonpre- ication regimen. They scription medications, develop care plans and patients who may be goals with the patient experiencing a drug that encourage active therapy problem, regard- participation in their less of the disease-state, care. They collaborate all benefit from MTM with the patient services. Patients who providers and other may be having difficul- healthcare workers to ties taking their medica- promote adherence to tions, patients who are the plan of treatment taking medications that and medications. Case need close evaluation managers can help with (for example, warfarin, early identification of phenytoin, methotrex- patients who can bene- ate), or patients who are fit from MTM services, receiving care from including those patients more than one pre- who continue to demon- scriber, can all benefit from this service. strate non-adherence, or continue to have medication- Patients with chronic conditions requiring them to related problems, despite the teaching and efforts of the take complex regimens throughout the day can benefit case manager. from these services. Some of the medical conditions Health plans and provider systems can use triggers which are most commonly associated with non-adherence such as diagnoses, number of prescriptions, or financial include diabetes (27%), hypertension (15%), hyperlipi- expenditures to identify patients out of larger popula- demia (14%), osteoporosis (12%), and depression (6%). tions that could benefit from these services. Other conditions include gastroesophageal reflux disease, (GERD), asthma, allergic rhinitis, generalized pain, and Examples of the benefits of MTM services COPD/emphysema. The most frequent causes of patients The literature supports the patient benefits of MTM ser- being unwilling or unable to take their medications as vices when provided in a comprehensive and systematic www.ingreinsurance.com page 6 ROSE Resource, Volume 18, Number 2

MEDICATION THERAPY MANAGEMENT

(Continued from page 5) manner. In one study, qualified pharmacists provided Summary MTM services for eleven months to 1122 diabetic patients To prevent medication-related problems, The Institute of in ambulatory practice settings. The majority of the prac- Medicine advocates that healthcare should be safe, effective, tices were clinic-based and the services were provided in patient-centered, and patients should be active participants close proximity to, and in collaboration with, the prescrib- in the healthcare process.2 Pharmacists, practitioners, nurse ing physician. The patients saw the pharmacist an average case managers and other healthcare workers can partner to of 2.5 visits in a year for MTM services. They were being ensure that patients are educated and informed healthcare treated for an average of eight medical conditions includ- consumers, and are aware of the tools and resources avail- ing hyperlipidemia, hypertension, depression, osteoporo- able to promote safe medication practices and reduce risk. sis, pain, GERD, and medication therapy for stroke or Because medications play a major role in over 80 percent myocardial infarction, in addition to their diabetes treat- of treatments, improving their effectiveness and safety ment. The average number of medications being taken by may be the largest opportunity to improve care.5 these patients was 13. MTM services can Seventy-seven percent improve clinical out- Because medications play a major role in over (77%) experienced one comes, medication safety or more drug therapy 80 percent of treatments, improving their and adherence, and problems, 39 percent effectiveness and safety may be the largest reduce healthcare 6 had threee or more and 1 expenditures. Patients 17 percent had five or opportunity to improve care. who receive MTM more drug therapy prob- services achieve their lems identified and resolved during the study period. goals of therapy fifty-two percent (52%) more often than The drug therapy problems were resolved by evaluating when they do not. They are on fewer unnecessary medica- each medication for appropriateness, effectiveness, and tions, have fewer adverse reactions, and experience less safety. When these issues were resolved, the patients were toxicity when they receive these services, avoiding costly more willing and able to take their medications, thus treatment failures. These services also help patients use improving adherence to their medications. For this group more affordable medications and be more compliant. of patients, a return on investment (ROI) of approximately When patients with numerous medications are well 3:1 was achieved. For every dollar invested in providing managed, they will achieve better therapeutic outcomes, MTM services three dollars was saved.3 compliance, and ownership of their healthcare. ■ The Minnesota State Medicaid Program recently reported that pharmacists providing MTM services to Linda M. Strand, Pharm. D., Ph.D. is a Distinguished Professor in the Medicaid patients improved diabetes quality indicators College of Pharmacy, at the University of Minnesota. six-fold over statewide averages. A federal study which included about 160 ambulato- Sources: ry patients over the age of 65, who were prescribed at 1. “Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model”; American Pharmacists least four medications daily, also demonstrated the value Association and National Association of Chain Drug Stores Foundation, of MTM services. Pharmacists provided education March, 2008, pages,3, 4. regarding their medications, and performed assessments 2. “Medication Therapy Management Part Two: Strategies to Improve of adherence and refills. Researchers found that after Quality and Reduce Costs”; David J. McLean, Ph D; Lyceum Associates, December, 2006, page 2. six months in an MTM program, medication adherence 3. “Medication Adherence: Improved Results with Comprehensive increased in these patients (from 61.2 percent to 96.9 Medication Therapy Management Services; Linda M. Strand, percent), resulting in clinically significant improvements Pharm.D., PhD, Robert J. Cipolle, Pharm.D., Mike J. Frakes, Pharm D.; 4 Unpublished White Paper July, 2007, page 7. in blood pressure and LDL levels. 4. “Medication Therapy Management May Finally Enter the Mainstream”, MTM services are demonstrating positive clinical Managed Care Magazine; Martin Sipkof, May 2007, page 2. and economic healthcare outcomes. Reductions in 5. “Medication Therapy Management, Part One The Science of Managing Drug Therapy”; Robert J. Cipolle, Pharm D & Linda M. emergency room visits, hospital days, physician visits Strand, PhD ;Lyceum Associates, November, 2006, page 1. and overall healthcare costs have resulted from pharma- 6. Isetts, et al, J Am Pharm Assoc, 2008, 48; (2): 203-211. cists providing MTM services in various settings. www.ingreinsurance.com Pill Card Template

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