Preventing and Reducing Adverse Drug Events in Care Coordination Communities: Cycle 1 Results

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Preventing and Reducing Adverse Drug Events in
Care Coordination CommunitiesCycle 1 Results
Anne Myrka, RPh, MAT IPRO July 30, 2015
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Objectives

• Describe IPROs CMS 11th Scope of Work Priorities
  and Goals
• IPRO Drug Safety work overview
• Describe the Preventing and Reducing Adverse Drug
  Events (PARADE) initiative Objectives and
  Strategy
• Provide Cycle 1 (January June) results
• Highlight facility specific interventions and
  experiences guest speakers
• Next Steps, Q A

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• Thank You!!!

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Coordination of Care Task Goals

• Promote Effective Communication and
  Coordination of Care
• Reduce hospital readmission rates in the Medicare
  program by 20 by 2019
• Reduce hospital admissions rates in the Medicare
  program by 20 by 2019
• Increase community tenure, as evidenced by
  increased number of nights spent at home, for
  Medicare beneficiaries by 10 by 2019
• Reduce the prevalence of adverse drug events
  (ADEs) that contribute to significant patient
  harm, emergency department visits, observation
  stays, hospital admissions or readmissions
  occurring as a result of the care transitions
  process
• Anticoagulants
• Hypoglycemic Agents
• Opioids

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IPRO Drug Safety overview

• NYS Anticoagulation Coalition
• Appropriate DOAC use included in utilization
  reports
• Effective EHR utilization manuscript published
• Peri-procedural utilization of all anticoagulants
  MAP tool (app under development)
• Pain Management Task Force
• Reducing opioid-related adverse drug events
  (ADEs)
• Hypoglycemia agent Task Force
• Reducing hypoglycemia-related ADEs

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• What is IPROs PARADE Initiative?

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PARADE Initiative 2014 Pilot study and results

• Evidence-based system improvements were applied
  to Anticoagulation Discharge Communication and
  Med Rec on Admission according to site-specific
  baseline results
• Significant improvement in communication of
  requisite anticoagulation-related elements to
  subsequent provider upon transfer/discharge
• All facilities (16, 95 CI 11.6-20.3)
• Hospitals (8, 95 CI 1.2-15.2)
• SNFs (19, 95 CI 12.7- 25.8)
• Significant improvement in completion of
  medication reconciliation processes upon
  admission in SNFs (21.2,
  95 CI 9.6- 31.9)

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PARADE Initiative

• QIOs are directed by CMS in the 11th Statement of
  Work (11SoW- 2015-2019) to
• Establish relationships and collaborations in the
  community to coordinate provider communication
  and medication management across care settings
  with a patient centered focus
• Help providers utilize new or existing
  evidence-based tools and practices to improve the
  care of those prescribed high risk medications,
  specifically anticoagulants, diabetic agents and
  opioids
• Use health information technology to screen for
  and prevent ADEs in Medicare beneficiaries

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• PARADE Objectives and Strategy

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PARADE Objectives

• To identify patients at risk of experiencing ADEs
  due to high risk medication use following
  hospital discharge
• To identify hospital readmissions and emergency
  department visits associated with high risk drug
  exposure
• To evaluate the post-discharge medication use
  system across care settings and identify
  opportunities for system improvements
• To facilitate the implementation and serial
  evaluation of evidence-based intervention
  strategies

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PARADE Strategy

• Process measures All facilities/healthcare
  providers
• Small, low-impact audits of medication
  reconciliation processes and high risk drug
  discharge communication (5-10 charts,
  retrospective)
• Serial evaluation to guide improvements
• Goal measureable improvement in adherence to
  audit criteria
• Interventions
• Evidence based interventions according to
  site-specific results
• Outcome measures Hospitals only
• Readmissions due to ADEs using data from
  electronic health record data (hospital) and
  claims data (IPRO)
• Serial evaluation to identify improvements
• Goal Demonstrate measureable improvement over 5
  year scope of work

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PARADE Strategy

• Based on ?6 month improvement cycles
• Cross setting work will be achieved within each
  care transition coalition Medication Management
  Committee monthly meetings
• Eligible facilities hospitals, skilled nursing
  facilities (SNF), rehabilitation facilities, home
  healthcare services/agencies (HHA), residential
  facilities, adult homes, pharmacies (hospital,
  community, SNF vendors, etc.)
• Participating individuals are administrators,
  physicians, nurses, pharmacists (including SNF
  consultant pharmacists), quality improvement
  professionals, discharge planners, HHA hospital
  liaisons, etc.
• Cycle 1 was January 6, 2015 June 30, 2015
• All facilities focused on Medication
  Reconciliation and Anticoagulation Discharge
  Communication

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PARADE Strategy

• Cycle 2 is September 2015 February 2016
• Continue to work on ADE hospital readmission
  measure, high risk drug discharge communication
  and med rec improvement processes (expanding to
  discharge)
• Expand to medication management of hypoglycemics,
  opioids, other (e.g. antibiotics)
• IPRO is currently convening subject matter
  experts to provide guidance on best practices for
  management across care settings during
  transitions
• Subsequent Cycle work will focus on continued
  evidence based improvements, sustainability and
  applicable cross-setting emerging measures

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• PARADE Process Measures Audit Methods

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PARADE Process Measures Audit Methods

• Medication Reconciliation on Admission Audit
• Medication Discrepancy Tool
• Anticoagulation Discharge Communication Audit
• Anticoagulation Information Discovery Tool

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Additional Ad Hoc Anticoagulation Measure-
Warfarin Time in Therapeutic Range?

• Designed for skilled nursing facilities,
  outpatient clinics and others that serve
  population over long term
• For more information http//qio.ipro.org/drug-saf
  ety/collaborative-partners/analytic-services

TTR Rosendaals method
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• Cycle 1 Results

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Anticoagulation Discharge Communication
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Medication Reconciliation
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Outcomes ADE Surveillance Process - Hospitals

• Remeasure quarterly after baseline is completed
• Secure data transfer protocol utilized

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ADE Surveillance Hospital Engagement

• Total hospitals engaged 27
• Already sharing complete data 6
• Represents 22,380 unique Medicare Fee for Service
  Beneficiaries discharged from participating
  hospitals on 1 high risk drug and screened for
  ADEs
• Anticoagulant potential ADEs - 104
• Opioid potential ADEs - 55
• Hypoglycemic potential ADEs - 9
• Beginning test data query 4
• Agreed to share data 17
• ?Hospitals currently participating in CT
  communities

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• PARADE Interventions

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Medication Reconciliation Improvement Tools
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Anticoagulation Improvement Tools
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• Facility Specific Interventions

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HealthAlliance of the Hudson Valley, Kingston, NY

• Medication Reconciliation Risk Reduction
  Strategies Identified
• ASU staff were provided additional training on
  how to enter home medications in the EMR to
  generate a clean medication reconciliation. No
  free texting!
• Orthopedics -aggressive education with Medical
  Staff on steps to complete medication
  reconciliation utilizing the EMR. Informatics
  staff assisted MD with 11 concurrent training
• Set up touch points with MD to address any
  concerns identified with use of medication
  reconciliation process
• Sole use of the EMR for medication
  reconciliation. No more paper!

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HealthAlliance of the Hudson Valley, Kingston, NY

• Medication Reconciliation Risk Reduction
  Strategies Identified continued
• The Emergency Department created dedicated
  resource called Clinical Data Specialist
• This position is staffed with an a Pharmacy Tech
  or LPN. They are required to enter into the
  hospital EMR all of the Home Medications for
  all patients admitted.
• Two sources must be utilized to reconcile the
  list of home medications
• The patients list
• Call pharmacy
• Calling the patients MD
• Reviewing the list from the ER EMR

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HealthAlliance of the Hudson Valley, Kingston, NY

• Medication Reconciliation Opportunities for
  Improvement
• CHF patient post discharge phone calls
  identified need for clearer patient instructions
  on home medication resumption or discontinuation.
  Not always evident in the medical record.
• Pharmacy medical record application does not
  allow pharmacist to view MD reason for
  stopping/discontinuing medications.

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HealthAlliance of the Hudson Valley, Kingston, NY

• Blood Thinner Adverse Events Risk Reduction
  Strategies Identified
• Orthopedics physicians managing post operative
  course of blood thinner or conferring with
  patients cardiologist.
• Orthopedics - plan to pilot a sequential
  compression biomechanical device (SCBD) replacing
  the use of utilizing blood thinner medications

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HealthAlliance of the Hudson Valley, Kingston, NY

• Blood Thinner Adverse Events Opportunities for
  Improvement
• Multiple places in EMR where information
  regarding high risk blood thinner medication may
  be documented.
• Auditing difficult due to inconsistent
  documentation. Sub-group identified location of
  possible documentation evaluating possibility
  of creating a blood thinner tab in EMR for
  centralized documentation.
• Information needed for transition of care not
  summarized.

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HealthAlliance of the Hudson Valley, Kingston, NY

• Medication Reconciliation High Risk Medication
  Discharge Process Audit
• Audit 35 charts utilizing IPRO medication
  reconciliation discharge tool to obtain baseline.
  
• Audits to be completed no later than July 31,
  2015
• Charts to be audited by discharge location
• 5 - SNF, Rehab, Acute Care
• 5 ED
• 5 Orthopedics
• 5 General Home
• 5 Endo
• 5 Hypoglycemic agents
• 5 CHF

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Albany Memorial Hospital, Albany, NY

• Anticoagulant-related high priority elements
  highlighted for hospitalists in real time during
  discharge summary dictation facilitated by case
  management at time of discharge
• Kaizen done regarding standardization of
  discharge practices
• Patient teach back
• Identifying high risk patients
• ED med rec by pharmacist
• Contact PCP on admit
• Identify caregiver/family by day 2
• Rapid summaries for high risk drugs

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Evergreen Commons, East Greenbush, NY

• Initiated the Blood Thinner Safety Plan  
• Complete med list printed from Omniview
  indicating drug, dosage and time of next dose due
• Most recent fall risk assessment faxed to
  community PCP
• Resident PT/INR flow sheet faxed to community PCP
• Medication Reconciliation home meds
• Developed a discharge check list

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Home Healthcare

• Dominican Sisters Family Health Services
• Multiple PDSAs and PARADE huddles weekly
• Business Development Managers and Liaison
  Champions
• Standardized New Electronic Referral which
  includes  mandatory fields to capture
  Anticoagulant high priority elements
• Collaboration with hospital readmission teams
• Access to hospital electronic medical record
  attained
• Nurse education
• Cross-setting pilot of Blood Thinner Safety Plan
  - planning for next cycle.

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Home Healthcare

• VNA of the Hudson Valley
• Evidence Based Patient Education Protocols and
  Materials including BTSP, INR Worksheet, RN Pt.
  Teaching Plan Checklist, Guidelines for Lovenox
  Administration/Precautions Patient self-test re
  learning achieved
• Guidelines for  Home Health Intake Coordinators
  Baseline transfer information
• Anticoagulation information to be sent  to PCP
  upon discharge from homecare Transfer summaries
  to reflect status of anticoagulation therapy
• Nurse education

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Home Healthcare

• VNS Westchester Putnam Branch
• Implementing intake template revision to capture
  salient anticoagulation information for use by
  Home Health Intake Coordinators and Liaisons
• Piloting Blood Thinner Safety Plan and Warfarin
  Dose and INR flow sheet
• Developing Discharge Summary Form for patients on
  AC therapy to be sent to the PCP or other
  provider upon discharge from home care services
  to include diagnosis requiring need for AC
  therapy, flow sheet account of past INR readings,
  corresponding AC medication changes, s/s
  bleeding, related teaching, etc.
• Working with local hospital readmission task
  force for access to patient portal and other
  options to obtain most current accurate discharge
  medication and other pertinent data related to AC
  therapy last 3 INRs, reason for AC therapy,
  identification of patients new to AC therapy,
  therapeutic level, etc.
• Working with Director of Pharmacy at local
  hospital for identification of patients on AC
  therapy at risk for complications and in need of
  home care follow-up.
• Developing process for standardized, mandatory
  clinician education on the assessment and
  pharmacology aspects of the anticoagulated
  patient.

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Next Steps

• Webinar PARADE Cycle 2 Launch
• Wednesday, September 9, 2015 200pm 300pm
• This webinar will serve as an introduction to
  IPROs Preventing and Reducing Adverse Drug
  Events (PARADE) initiative for new communities
  and provide information for those communities
  entering PARADE Cycle 2.
• Click or Copy and Paste this URL to your web
  browser https//qualitynet.webex.com
• Password IPRO
• Dial in number is 866-209-5917. The access code
  is NO CODE NEEDED.

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• Questions / Feedback

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For more information

• Anne Myrka
• Pharmacist Drug Safety
• [phone]
• Anne.Myrka_at_area-i.hcqis.org

Sara Butterfield Senior Director Care
Coordination [phone] Sara.Butterfield_at_area-
i.hcqis.org
Darren Triller Senior Director Drug
Safety [phone] Darren.Triller_at_area-i.hcqis.
org
IPRO Care Transitions Web Site http//qio.ipro.or
g/care-transitions/overview IPRO Drug Safety Web
Site http//qio.ipro.org/drug-safety/overview
IPRO CORPORATE HEADQUARTERS 1979 Marcus
Avenue Lake Success, NY 11042-1002 IPRO REGIONAL
OFFICE 20 Corporate Woods Boulevard Albany, NY
12211-2370 www.atlanticquality.org
This material was prepared by the Atlantic
Quality Innovation Network/IPRO, the Medicare
Quality Innovation Network Quality Improvement
Organization for New York State, South Carolina,
and the District of Columbia, under contract with
the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of Health
and Human Services. The contents do not
necessarily reflect CMS policy.
11SOW-AQINNY-TskC.3-15-25