Implementation of Clinical Services at Various Institutions

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OBJECTIVES Implementation of • Describe various hospital pharmacy Clinical Services at quality improvement initiatives • List components of the framework Various Institutions necessary for expanding clinical services • Describe methods of utilizing pharmacist- Niki Carver, Pharm.D., UAMS Medical Center extenders in providing clinical services Shannon Hays, Pharm.D., White Co Medical • Discuss the development and Melanie Claborn, Pharm.D., Veterans implementation of clinical pharmacy Healthcare System of the Ozarks/UAMS NW services in primary care at a federal facility

Disclosure

This presenter has no conflicts of interest to Increasing Possibilities for Health- disclose. Systems Pharmacists Involvement

Niki Carver, Pharm.D. Assistant Director for Medication Safety University of Arkansas for Medical Sciences

Objectives Definitions

• Describe various hospital pharmacy ASHP – American Society of Health-System quality improvement initiatives Pharmacists CMS – Center of Medicare & Medicaid Services

1 Health-Systems Pharmacists’ ASHP 2015 INITIATIVE Possibilities • This Initiative is a program to help make medication use in health systems more effective, Readmissions scientific, and safe. There are six key goals and 31 specific objectives to be accomplished by the year 2015. NPSG, Core • The 2015 Initiative is a tool to help health- Measures system pharmacy practitioners achieve the ideals identified in the vision statement. Pharmacokinetic Dosing, • ASHP dedicates itself to achieving a vision for Therapeutic Drug Monitoring, pharmacy practice in hospitals and health systems in IV to PO, Therapeutic which pharmacists

Substitution 7 www.ashp.org/menu/practicepolicy/initiative/2015Initiative.aspx

Goal/Objectives

Goal 1 Increase the extent to which pharmacists help individual hospital Goal/Objectives inpatients achieve the best use of medications. Goal 2 Increase the extent to which health-system pharmacists help individual Objective Pharmacists will be involved in managing the acquisition, upon admission, of non-hospitalized patients achieve the best use of medications. 1.1 medication histories for a majority of hospital inpatients with complex and high-risk medication regimens* in 75% of hospitals. Objective In 70% of health systems providing clinic care, pharmacists will manage 2.1 medication therapy for clinic patients with complex and high-risk medication Objective The medication therapy of a majority of hospital inpatients with complex and regimens*, in collaboration with other members of the health-care team. 1.2 high-risk medication regimens will be monitored* by a pharmacist in 100% of hospitals. Objective In 95% of health systems providing clinic care, pharmacists routinely Objective In 90% of hospitals, pharmacists will manage medication therapy for 2.2 counsel clinic patients with complex and high-risk medication regimens. 1.3 inpatients with complex and high-risk medication regimens*, in collaboration with other members of the health-care team. Objective In 90% of home care services, pharmacists will manage medication therapy Objective Hospital inpatients discharged with complex and high-risk medication 2.3 for patients with complex and high-risk medication regimens*, in 1.4 regimens* will receive discharge medication counseling managed by a collaboration with other members of the health-care team. pharmacist in 75% of hospitals. Objective 50% of recently hospitalized patients (or their caregivers*) will recall Objective In 90% of long term care facilities, pharmacists will manage medication 1.5 speaking with a pharmacist while in the hospital. 2.4 therapy for patients with complex and high-risk medication regimens*, in collaboration with other members of the health-care team. Objective In 90% of hospitals, pharmacists will ensure that effective medication 1.6 reconciliation* occurs during transitions across the continuum of care.

Goal/Objectives Goal/Objectives Goal 3 Increase the extent to which health-system pharmacists actively apply Goal 4 Increase the extent to which pharmacists help individual hospital inpatients achieve the best use of medications. evidence-based methods to the improvement of medication therapy. Objective 90% of health systems will have an organizational program, with appropriate pharmacy Objective In 90% of hospitals, pharmacists will be actively involved in providing care to 4.1 involvement, to achieve significant annual, documented improvement in the safety of all steps in 3.1 individual patients that is based on evidence, such as the use of quality drug medication use. information resources, published clinical studies or guidelines, and expert Objective 80% of pharmacies in health systems will conduct an annual assessment of the processes used consensus advice. 4.2 throughout the health system for compounding sterile medications, consistent with established standards and best practices.

Objective In 90% of hospitals, pharmacists will be actively involved in the development Objective 80% of hospitals have at least 95% of routine medication orders reviewed for appropriateness by a 3.2 and implementation of evidence-based drug therapy protocols and/or order 4.3 pharmacist before administration of the first dose. (*Not including doses required in the context of sets. emergencies or immediate procedures such as surgeries, labor and delivery, cardiac catheterization, etc.)

Objective In 90% of hospitals, pharmacy departments will actively participate in Objective 90% of hospital pharmacies will participate in ensuring that patients receiving antibiotics as 3.3 hospital-wide efforts to ensure that patients receive evidence-based 4.4 prophylaxis for surgical infections will have their prophylactic antibiotic therapy discontinued within 24 hours after the surgery end time. medication therapies required by the CMS hospital quality initiative, Joint Commission Core Measures, and/or state-based quality improvement and Objective 85% of pharmacy technicians in health systems will be certified by the Pharmacy Technician public reporting efforts. 4.5 Certification Board.

Objective In 70% of hospitals, pharmacists will actively be involved in medication- and Objective 50% of new pharmacy technicians entering hospital and health system practice will have 4.6 completed an ASHP-accredited pharmacy technician training program*. 3.4 vaccination-related infection control programs.

Objective 90% of new pharmacists entering hospital and health-system practice will have completed 4.7 an ASHP-accredited residency.

2 Goal/Objectives Goal/Objectives Goal 5 Increase the extent to which health systems apply technology effectively to improve the safety of medication use. Goal 6 Increase the extent to which pharmacy departments in health systems engage in public health initiatives on behalf of their communities. Objective 75% of hospitals will use machine-readable coding to verify medications 5.1 before dispensing. Objective 60% of pharmacies in health systems will have specific ongoing initiatives

6.1 that target community health. Objective 75% of hospitals will use machine-readable coding to verify all medications 5.2 before administration to a patient.

Objective 50% of pharmacy departments in health systems will be directly involved in Objective For routine medication prescribing for inpatients, 70% of hospitals will use 6.2 ongoing immunization initiatives in their communities. 5.3 computerized prescriber order entry systems that include clinical decision support. Objective 85% of hospital pharmacies will participate in ensuring that eligible patients 6.3 in health systems receive vaccinations for influenza and pneumococcus. Objective In 65% of health systems, pharmacists will use medication-relevant portions 5.4 of patients' electronic medical records for managing patients' medication Objective 80% of hospital pharmacies will participate in ensuring that hospitalized therapy.* 6.4 patients who smoke receive smoking-cessation counseling.

Objective In 70% of health systems, pharmacists will be able to access pertinent Objective 90% of pharmacy departments in health systems will have formal, up-to- 5.5 patient information and communicate across settings of care to ensure 6.5 date emergency preparedness programs integrated with their health continuity of pharmaceutical care for patients with complex and high-risk systems' and their communities' preparedness and response programs. medication regimens.

CMS Core Measures AMI

• Acute Myocardial Infarction (AMI) • Order set development and maintenance • Heart Failure (HF) • Identify patients • Interventions • Pneumonia (PNE) • Timely administration of ASA on arrival • Stroke • ACE/ARB at discharge for decreased LVF • ASA/Beta-blocker at discharge • Counsel patients about ASA at discharge ** Many measures are medication-related** • Statin (or HMG CoA reductase inhibitors) prescribed at discharge • Insures nurse is contacted/appropriate documentation occurs

Heart Failure PNEUMOCOCCAL/INFLUENZA • Order set development and maintenance • Patients Assessed and Given Pneumococcal • Concurrent inpatient review Vaccination • Pharmacist screening/ordering • Interventions • Standing orders approved by Medical Staff • Discharge instruction • Nurse vaccinates within 24 hours of admission • ACE/ARB at discharge if decreased • Pneumonia Patients Whose Initial Emergency LVF Room Blood Culture Was Performed Prior To • Smoking cessation advice/counseling The Administration Of The First Hospital Dose Of Antibiotics • Insures appropriate documentation occurs • Pneumonia Patients Given Smoking Cessation Advice/Counseling

3 PNEUMOCOCCAL/INFLUENZA Stroke • Order set development • Pneumonia Patients Given Initial Antibiotic(s) • Interventions within 6 Hours After Arrival • Stroke Patients with Deep Vein Thrombosis (DVT) • Pneumonia Patients Given the Most Appropriate Prophylaxis Initial Antibiotic(s) • Discharged on Antithrombotic Therapy • Order set development and maintenance • Anticoagulation Therapy for Atrial Fibrillation/Flutter • Pneumonia Patients Assessed and Given • Thrombolytic Therapy Influenza Vaccination • Antithrombotic Therapy by End of Hospital Day Two • Seasonal • Standing orders approved by Medical Staff • Discharged on Statin Medication • Stroke Education

Joint Commission Standards Medication Reconciliation National Patient Safety Goals • Obtain information on the medications the patient (NPSGs) is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. • NPSG 03.06.01 • Medication history upon admission • Medication Reconciliation • Compare the medication information the patient • NPSG 03.05.01 brought to the hospital with the medications • Anticoagulation Management ordered for the patient by the hospital to identify & resolve discrepancies. • Admission orders match home meds • Medication therapy appropriateness throughout hospital stay

Medication Reconciliation Anticoagulation Management

• Provide the patient with written information on • Written approved protocols for initiation the medications the patient should be taking and maintenance of therapy when discharged from the hospital or at the end of an outpatient encounter • Evaluate anticoagulation safety practices • Medication counseling upon discharge and take action, and measure • Explain the importance of managing medication effectiveness information to the patient when discharged from • Assess baseline INR for all patient’s the hospital or at the end of an outpatient receiving warfarin encounter. • Written policy addresses baseline and • Medication counseling upon discharge • Assistance with obtaining prescriptions ongoing lab tests for anticoagulants

4 Readmission Rates Evolving Opportunities

• Targets • AMI, heart failure, pneumonia, hip and knee Readmissions arthroplasty, and stroke • Many places target Heart Failure • Medication counseling NPSG, Core • Medication accessibility Measures • Medication compliance Pharmacokinetic Dosing, • Follow-up phone calls Therapeutic Drug Monitoring, IV to PO, Therapeutic

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Contact Information Expanding Clinical Niki Carver, Pharm.D. Services in a Community UAMS Medical Center Phone: 501-686-6694 Hospital 4301 West Markham Street, Slot 571 Shannon Hays, Pharm.D. Little Rock, AR 72205 Clinical Coordinator Email: [email protected] White County Medical Center Searcy, AR

Disclosures Objectives

• This presenter has nothing to disclose. • List components of the framework necessary for expanding clinical services. • Describe methods of utilizing pharmacist- extenders in providing clinical services.

5 Objectives for the Pharmacy Practice Model Initiative • Describe optimal pharmacy practice models that ensure safe, effective, efficient and accountable medication-related care Goal: for patients. Develop and disseminate a futuristic practice model • Identify patient-care-related services that supports the effective use of pharmacists as • Foster understanding of and support for direct patient care providers optimal pharmacy practice models by key groups

www.ashp.org/PPMI

Objectives for the Pharmacy White County Medical Center Practice Model Initiative • 438 bed community hospital serving White, Jackson, • Identify existing and future technologies Woodruff, Lonoke, Independence, and Prairie required to support optimal pharmacy Counties practice models in health-systems • Pharmacy staff: • 20 pharmacists, 13 technicians • Identify specific actions that pharmacists • Central Pharmacy should take to implement optimal practice • Technology • CPSI, Pyxis Connect models • Pyxis Medstation 4000, PHACTS Vertical Carousel • PharmoPack Hi-Speed Medication Packager • Determine the tools and resources need to • Pyxis CII Safe implement optimal practice models • CareFusion MedMined with Patient Event Advisor and NurseLink

WCMC Pharmacy Getting Started

• Drug-distribution-centered model • Establishing relationships • Clinical-pharmacist-centered model • Building the framework • Clinical Coordinator added who handled all clinical activities • Create demand, select projects • Now a comprehensive model • Distributive, generalists, and specialist pharmacists • Provide practice sites for 6 COP faculty (providing specialist services)

6 Getting Started Getting Started

• Establishing Relationships • Building framework • Physicians (rounding, interdisciplinary committees) • Documentation in patient chart • Nurses (core measure teams, inservice • Ordering authority for routine interventions education) (CSF auto-stop, renal dosing, laboratory • Case Managers (core measure teams, protocol development) monitoring) • Colleges of Pharmacy (IPPE, APPE, service • Providing education/building competency of learning, committees) – taking students from 3 pharmacy staff (parenteral nutrition, kinetics, Colleges renal dosing) • Staff pharmacists (streamlining clinical consults, CE, pharmacy policies)

Getting Started

• Documentation in patient chart • Documenting notes in response to consults already in place • Physicians not accepting of documentation in permanent record for interventions • Developed “Pharmacy Care Note” to place non- urgent interventions in chart that are not part of the permanent record • Used for IV to PO, antimicrobial de-escalations, etc. • Once patient is discharged, note is removed from chart and returned to pharmacy. Provides some mechanism for feedback.

Getting Started Getting Started • Ordering authority for routine interventions • Lab monitoring: • Education and skill-building for pharmacy • serum creatinine for renal dosing of antibiotics (Levaquin) and LMWH staff • INR for Warfarin • CBC for LMWH, heparin to monitor platelets • Parenteral nutrition consults (CEs, case • Peak and/or trough for AMG, Vanc studies) • CSF Auto-Stop: • Automatically discontinue CSFs when ANC reaches a certain • Kinetics consults (protocol development, CEs) level • Renal dosing (protocol development) • Renal dosing: • Automatically change dose of Levaquin for renal function • CSF Auto-Stop (protocol development) • IV to PO conversion: • Automatically change IV to PO route for certain medications when specific criteria are met

7 Getting Started WCMC Clinical Services

• Create demand/select project(s) • Parenteral nutrition • Be involved in hospital initiatives (cost savings, patient safety, quality, CMS core measures) • Kinetics • Work in collaboration with other departments • CSF monitoring and discontinuation • Nursing • Case management • Renal dosing • Medical staff • PNA/Flu vaccine protocol compliance • Select project(s) • Anticoagulant monitoring • Meet a need • Start simple • Discharge Follow-Up calls • Outcome that is easily measured • Antimicrobial stewardship • Easy “sell” to Administration, Medical Staff, Nursing, etc. • IV to PO conversion

Keeping it Going Monitor and Report Progress

# Consults • Monitor and Report Progress 900

800 • Utilize Pharmacist-Extenders 770 700

600

500 482 # Consults 400

300

200 193

100

0 2008 2009 2010

Monitor and Report Progress Utilizing Pharmacist-Extenders

• Technicians • Quality Improvement/Core Measures • Students • Quality Improvement/Core Measures (IPPE) • IV to PO conversion (APPE) • Call center (PSL, APPE) • Routine consults (kinetics, parenteral nutrition, renal dosing) (APPE) • Antimicrobial stewardship (APPE)

8 Utilizing Pharmacist-Extenders Celebrate Success

• Expect much from your students • Measure and report • Students are like children; they will live up to your expectations. • Economic outcomes • Be prepared to provide more guidance early in the • Cost savings experience. • Decreased LOS • Adequate training • Availability of preceptor(s) • Patient care outcomes • Accountability • Readmission Rates • To the preceptor • Core Measures • To the department • Patient safety outcomes • Ultimately, to the patient • ADRs reported • Let them see the “big picture” • Committee meetings • Medication Errors (especially “Near Misses”) • Shadowing other departments

Future Directions Questions?

• Residency Program (PGY1) • Ambulatory Care Clinic (Diabetes) • Medication Reconciliation • Continue to expand clinical faculty sites • Cardiology • Surgery • Med/Surg • 340B Optimization • Bedside Barcoding

Contact Information Development and White County Medical Center Implementation of Phone: 501-380-1384 Clinical Pharmacy Services 3214 East Race Ave in Primary Care Searcy, AR 72143 Email: [email protected] Melanie Claborn, Pharm.D. Assistant Professor of Pharmacy Practice University of Arkansas for Medical Sciences Clinical Pharmacy Specialist Veterans Healthcare System of the Ozarks

9 Disclosure Objective

This presenter has no conflicts of interest to disclose. Discuss the development and implementation of clinical pharmacy services in primary care at a federal facility

Background Background

• National organizations have identified the optimal • Practice site management of chronic disease states through • Veterans Health Care System of the Ozarks (VHSO) in Fayetteville education and appropriate pharmacotherapy as a public • Serves 53,000 unique Veterans annually • Outpatient care exceeds 500,000 visits per year and is provided at the health issue Fayetteville campus and six community-based outpatient clinics (CBOC’s) • Pharmacists have been shown to have a positive impact • Affiliated with the University of Arkansas for Medical Sciences (UAMS) on patient care outcomes • Clinical pharmacy at this facility • Monitoring treatment plans • Clinical pharmacists- clinical coordinator, acute care, psych, primary • Educating patients and providers care • Establishing a new clinical pharmacy position • Promoting cost effective therapy • UAMS had identified a need for faculty members in Northwest Arkansas in ACPE self-study

Billups SJ, et al. Assessing the structure and process for providing pharmaceutical care in Veterans Affairs • New position co-funded with UAMS medical centers. Am J Health-Syst Pharm. 2000; 57:29-39 • VA is physically located next to the UAMS NW campus

Implementing the service Information about the service

• Pharmacy management assessed what types of services • Ambulatory Care/Primary Care were needed • Named the pharmcare clinic • Tailored to the type of service the faculty member had an • Clinic protocols were developed interest • Scope of Practice-prescribing authority within the VA • Preferred an employee with residency training in ambulatory care • Disease state management for short term- • Performance measures at the VA were reviewed hyperlipidemia, hypertension, diabetes, anticoagulation • Determined the numbers of patients that could potentially benefit from the service • Follow guidelines for the treatment of the specific disease states

10 Evolution of the service

• Hired a co-funded UAMS faculty member in August 2008 • Scopes of practice approved for three clinical pharmacists in December 2008 Example • Pharmacists presented information about the clinic services at consult the medical staff meeting • Pharmacists were trained in the VA scheduling software • Outpatient consults from primary care providers only • Consult placed in the electronic medical record (CPRS) • Providers receive a notification when patients are scheduled to be seen

Evolution of the service

Example • First patient seen in February 2009 consult • Clinic appointments were originally available four half days per week (continued) • Appointments have now expanded to availability from 8am-3:30pm each weekday • Pharmacists complete appointment and lab scheduling • More difficult to control patients (noncompliance, previous adverse reactions, etc) • Documentation of each encounter in the electronic medical record • Providers are notified of the therapeutic plan • Pharmacy students on APPEs and IPPEs are involved

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Experience With the Service Discussion-Future changes

Anticoagulation, 8% • May add other disease states or pharmacy initiatives • Need administrative help with appointment Hypertension, scheduling and message retrieval 32% Diabetes • Changing consult criteria-restricting to certain Mellitus, 22% patients • Incorporating PCMH/PACT model • Present outcome data • Additional support with a pharmacy resident

Hyperlipidemia, 38% 65

11 Helpful Tips Priceless Benefits

• Obtain support from management • Build trust with the patients • Obtain protocols from other facilities to have a • Establish better relationships with nurses starting point and providers • Start with a pilot program-one provider or one • Enhance patient safety and education disease state • Promote an improvement in patient’s • Obtain outcomes from pilot and expand quality of care

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Summary Contact Information

• Implementation of a new service requires • Veterans Healthcare System of the Ozarks support from all areas of the facility • Phone: 479-443-4301 ext 65249 • Established a better relationship with other • 1100 North College (Pharmacy-119) members of the healthcare team • Fayetteville, AR 72703 • This clinic has become a vital tool for the • Email: [email protected], advancement of pharmacy practice in [email protected] primary care at the VHSO