1. Patient Safety & Clinical Pharmacy Services Collaborative
Rebecca Cheek
Director of Pharmacy
White House Clinics

2. Questions to Run On
How can you implement Clinical Pharmacy Services at your site?
Do you have a method in place to track Adverse Drug Events (ADE’s) and potential Adverse Drug Events (pADE’s)?

3. PSPC Similar to other HRSA sponsored collaboratives
All Teach, All Learn environment
Starting 3rd year in October 2010
White House Clinic has been involved since the beginning-August 2008

4. Our Collaborative Team
Clinical Pharmacy Service Providers at the Primary Health Care Home
Becky Cheek, PharmD
Pharmacy Director
Collaborative Lead
Sharon Davidson, PharmD
Steven Wagers, PharmD
Other Providers at the
Primary Health Care Home
Melissa Zook, M.D.
Family Physician
Medical Director
Sandra Dionisio, M.D.
Internist

5. PSPC Collaborative AIM
To Save and Enhance thousands of lives each year by:
Achieving optimal health care outcomes and
Eliminating Adverse Drug Events through
Increased Clinical Pharmacy Services for the patients we serve
The Goal of Collaborative Services is to:
Improve patient safety
Improve patient health outcomes
Integration of cost-effective clinical pharmacy services

6. Our PSPC Aim Statement
White House Clinics will strive to provide clinical pharmacy services to high-risk patients in an effort to decrease adverse events while encouraging those patients to become active partners in the management of their health condition.

7. What are Clinical Pharmacy Services?
CPS are patient-centered services that promote the appropriate selection and utilization of medications through:
Medication access*
340b formulary
Recommending generic alternatives
Patient Assistance Programs
Patient counseling *
Rx pick-up (required by OBRA-90)
Phone calls
Medication Therapy Management (MTM)*
Poly-pharmacy management
Recommendations given to patient or provider
Changes to therapy after DUR/ADE

8. CPS Services cont. 5. Drug Information Services to Patients*
4. Preventive Care Programs
BMI or blood pressure
Immunizations
Drug Information Services to Patients
5. Drug Information Services to Patients*
Drug information leaflets
Disease state pamphlets
Medication Reconciliation Services
Having 1 accurate medication list

9. CPS services cont. Retrospective Drug Utilization Review*
7. Provider Education*
Pharmacist provides evidence based drug information to provider
Retrospective Drug Utilization Review*
Review patients on certain meds or with certain disease states to assess quality and safety
Disease State Management*
Medications managed to obtain health outcomes and improve safety
Labs ordered and evaluated

10. CPS services cont Prospective chart review and provider consultation*
Review chart before visit and make recommendations to provider team
*Clinical pharmacy services that we provide at WHC

11. Why Are We Doing This Work?
Increase in multiple chronic conditions
Institute of Medicine Report: ADEs are leading cause of death and injury
Every $ spent on a RX = a $ spent on an ADE
Aging population/chronic disease – leading to high prevalence of poly-pharmacy
Lack of integration of clinical pharmacy services
Alignment with HRSA Core Measures

12. Key Benefits It’s the Right Thing to Do for the Patients We Serve
Safer
Increased and Better Pharmacy Services
Improved Health Outcomes
Reduces/Manages Risk – and Risk is Increasing
Builds on and Takes Prior Knowledge Base and Experience to a New Level
Takes HRSA Collaborative Experiences to the Next Power

13. Key Benefits Integrates Services to Maximize Community Health
Reduces Inappropriate Use of Poly-pharmacy – Better Medication Management
Helps Create New Partnerships & Synergies Across Provider Organizations
Exposure to Cutting Edge People and Methods on Quality Improvement, Leadership & Change Management
Opportunity to be a Part of a Major National Movement in a Rewarding All Teach, All Learn Environment

14. Examples of Disease States in Collaborative
Diabetes-HgA1C
Hypertension-blood pressure
Hyperlipidemia-LDL, triglycerides
Asthma-peak flow, ACT test, controller meds
Anticoagulation-INR in range
HIV

18. PSPC Outcomes: Improvements in Health Status
49% improved from health status “out of control” to “under control”
Across a range of chronic diseases, using standardized measures — such as A1C levels, blood pressure, LDL, INR ranges, depression scores, and viral load
Average team improvement through July 2010

19. What did we need to do for the collaborative?
We needed to choose a Population of Focus (POF)
We needed to track ADE’s and pADE’s to improve safety

20. 2% of Patients Can Benefit from CPS on One of the ISMP High-Alert Medications
833,936 pat/year
Total Patient Population
16,284 pat/year
Total Population of Care that could benefit from CPS
315 pat/yr 75
Total Population of Focus
(Anticoagulant Treatment)
Current PSPC teams:
Even as they’re starting out small, PSPC will have big impact through spread.
These numbers show us that we have an opportunity to reach and spread this work to more and more patients.
PSPC Population of Focus 20 20 20 20 20 20

21. White House Clinics Improvement Story
Population of Focus – Patients receiving Coumadin® (Warfarin) therapy referred to the Coumadin Clinic for anticoagulation management
Baseline data unavailable as no data tracking methods in place
After enrolling, developed plan to collect data-manual, EMR template, EMR reports

23. Population of Focus Indications Patient Age Setting CVA – 6%
Atrial Fibrillation – 61.4%
Mitral Valve Replacement – 10.8%
Deep Vein Thrombosis – 13.3%
Pulmonary Embolism –8.4%
Patient Age
<50 = 11
50 – 65 = 24
65 – 74 = 22
75 – 84 = 20
85 – 94 = 3
Setting
Ambulatory – 75
Home Health - 5

24. High Risk Qualities in POF Panel
Medications per Patient – 7 to 8
Providers per Patient – 3
Largest Safety Issues – Bleeding, Thrombotic Event
Largest Health Status Problems – Hypertension, Atrial Fibrillation, Diabetes

25. Anticoagulation Management Data
%INR values within range (goal )
Usual medical care with physician: 29.6%
Pharmacist-run Anticoagulation Clinic: 64%
Chiquette E, Amato MG, and Bussey HI. Comparison of an Anticoagulation Clinic with Usual Medical Care. Arch Itern Med ; 158:

26. White House Clinics INR In Range >80%

27. Improving Safety and Eliminating Adverse Events Tracking ADEs & pADE
ADE – Adverse Drug Event
Events that result in harm or injury to the patient due to medication use
Example – Bleeding as a result of Coumadin® (Warfarin) administration
pADE – Potential Adverse Drug Event
Potential harm that was identified and avoided with appropriate interventions before reaching the patient
Example – Pharmacist catches an allergy to Penicillin and calls the physician to change Amoxicillin to Azithromycin prior to dispensing
Example – A Pharmacist notices a duplication of drug therapy (Lisinopril & Ramipril) and intervenes to have one of the medications discontinued before the patient receives the medication

28. ADE’s & pADE’s No tracking prior to starting collaborative
Through the collaborative many organizations have observed a significant amount of ADE’s and pADE’s due to a lack in tracking data
Clinical Pharmacy Services have allowed these same organizations to see a decline in them over time

29. How We Should Identify ADEs/pADEs
Medication
Reconciliation
Nurse/CMA
Physician
ADE/pADE
Pharmacy
Patient
ER/Hospital

30. How Do We Plan On Collecting Data on ADEs/pADEs
Information concerning ADE’s and pADE’s will be collected from all available venues
The Patient
The Pharmacy
Medication Reconciliation
Nurse/CMA
Physician
ER/Hospital Visit
The data will be evaluated by the provider then entered into an EMR note. This data is easily extracted from EMR for reporting.

31. pADE’s and ADE’s for White House Clinic POF
pADE’s-low or high INR ranges, drug interactions, interruptions in therapy
ADE’s-bleeding, thrombosis

32. Example of pADE/ADE
22 y.o female dx: hypercoagulable state, s/p DVT/PE x5
Patient referred by primary care physician after INR had been followed by cardiologist. She could no longer afford to have INR monitored at cardio office. INR at initial visit =1.2. After CPS, we were able to bring her INR in range in a month. She was also determine to conceive. We assisted her with a Patient Assistance Program to get Lovenox and educated her on its use during pregnancy. We also provided counseling and an option to receive Chantix to stop smoking. She has been able to achieve appropriate anticoagulation levels and is now 3 months pregnant. Hopefully, our service avoided potential adverse drug events and actual adverse drug events for the patient and her unborn child.

33. White House Clinic pADEs/ADEs

34. Institute for Healthcare Improvement Assessment Scale
The Assessment Scale is divided into the following categories:
1.0 — Forming team
1.5 — Planning for the project has begun
2.0 — Activity, but no changes
2.5 — Changes tested, but no improvement
3.0 — Modest improvement
3.5 — Improvement
4.0 — Significant Improvement-White House Clinic
4.5 — Sustainable Improvement
5.0 — Outstanding sustainable results

35. IHI Assessment Scale

36. PSPC 1 Awards Health Outcomes Management Award
Successfully gathered data and reported it
Life Saving Patient Safety Award
Established systems to identify and prevent ADE’s and have an example of a life threatening ADE that was resolved
PSPC Performance Award
Showed overall excellence during the collaborative

37. PSPC 2.0 Awards
Health Outcomes Management Award

38. How did we do it? Better, more focused education for patients
Closer patient follow-up
Better data tracking methods
Quality improvement efforts such as Byeth and CHADS2 scores
Collaborative competition
Communicated data to our providers
Required continuing education in disease state

39. The Next Step…PSPC 3
Spread of anticoagulation management to other sites
Asthma-working with pediatrician
Diabetes-working with Physician Assistant

40. What do we need?
Time
Hard to balance with other duties of a pharmacist
Staff
Hiring a new pharmacist
Resources
Pharmacy Expansion Grant, provider status for billing services, other funding
Support of our providers

41. Contact Information
Rebecca Cheek, PharmD
Office of Pharmacy Affairs
Healthcare Communities