1. LAYERS AND LEARNERS: LEVERAGING PHARMACISTS, RESIDENTS, TECHNICIANS, AND STUDENTS TO PROVIDE CARE TRANSITIONS SERVICES IN A TWO- HOSPITAL HEALTH-SYSTEM 1 Daniel T. Abazia, Pharm.D., BCPS Clinical Assistant Professor, Ernest Mario School of Pharmacy Clinical Pharmacist, Capital Health Regional Medical Center September 18, 2015

2. Daniel Abazia has no financial disclosures DISCLOSURES 2

3. By the end of this presentation, the pharmacist will be able to: 1.Explain health-system pharmacy’s role in population health. 2.Describe opportunities for pharmacist, resident, technician, and student involvement in transitions of care activities. 3.Identify potential barriers to establishing care transitions pharmacy services. 4.Advocate the use of pharmacy technicians and students in medication reconciliation and post- discharge follow-up. LEARNING OBJECTIVES PHARMACIST 3

4. By the end of this presentation, the pharmacy technician will be able to: 1.Explain population health and the role of health- system pharmacy. 2.Describe opportunities for pharmacy technicians in transitions of care activities. 3.Identify potential barriers to establishing pharmacy technicians in transitions of care activities. 4.Advocate the use of pharmacy technicians in medication reconciliation and post-discharge follow- up. LEARNING OBJECTIVES PHARMACY TECHNICIAN 4

5. LEARNING ASSESSMENT Population health is defined as which of the following? a.Coordination and continuity of health care during a movement from one healthcare setting to another or home. b.A concept for organizing and delivering health care that strives for better care and incentive alignment to outcomes. c.A care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. d.Health outcomes of a group of individuals, including the distribution of said outcomes within the group. 5

6. ACCOUNTABLE CARE 6 www.improvingpopulationhealth.org/blog/what-is-population-health.html. Accessed September 1, 2015. www.nahq.org/education/Q-Essentials/population-health-and-care-transitions.html. Accessed September 1, 2015. National Transitions of Care Coalition. http://www.ntocc.org/Home.aspx. Accessed September 1, 2015. Patient Safety Medication reconciliation and timely follow-up…reduced readmissions Transitions of Care The health of a population requires coordination and bridging across caregivers and levels of care, appropriate engagement of other organizations and services, and consumer engagement. Population Health Health outcomes of a group of individuals, including the distribution of said outcomes within the group.

7. NEW JERSEY: #1 IN READMISSIONS 7 www.nj.com/politics/index.ssf/2015/08/nearly_every_nj_hospital_to_be_penalized_for_high.html. Accessed September 1, 2015.

8.  PPMI recommendation D10: opportunities for technician specialization should be developed  Pharmacy technicians have been utilized for medication reconciliation in a number of settings:  Emergency department  Inpatient/acute care  Mental health  Pediatric cardiology  Preoperative  Requires pharmacist training (“Best Possible Medication History”) and supervision RX TECHNICIAN ROLE: MEDICATION HISTORIES 8 Am J Health-Syst Pharm. 2011; 68:1148-52. Meyers, C. Am J Health-Syst Pharm. 2011; 68:1128-36. Chan C, et al. Can J Hosp Pharm. 2015; 68(1):8-15. Cater SW, et al. J Emerg Med. 2015; 48(2):230-8. Brownlie K, et al. Int J Clin Pharm. 2014; 36(2):303-9. Sen S, et al. Am J Health Syst Pharm; 2014; 71(1):51-6. Van den Bemt PM, et al. Ann Pharmacother. 2009; 43(5):868-74.

9. LEARNING ASSESSMENT Audience Poll – Yes or No Do you currently utilize pharmacy technicians in the medication reconciliation process within your institution? 9

10.  Two-hospital regional health-system that serves Mercer County, NJ and Bucks County, PA  Home to a variety of regional services, including:  Institute for Neurosciences  Stroke & Cerebrovascular Center of NJ (Comprehensive Stroke Center)  Level II Trauma Center CAPITAL HEALTH 10 Regional Medical Center Hopewell Medical Center

11. CAPITAL HEALTH CARE TRANSITIONS 11 Nurse ManagerPharmacist Population Care CoordinatorHealth Coach Care Transitions Team

12. LAYERS & LEARNERS 12 Pharmacist/ PGY1 Resident Student Technician Review activities of tech & student Clinical interventions Patient/caregiver education Post-discharge follow-up phone call Best possible medication history (BPMH) Patient/caregiver education Post-discharge follow-up phone call BPMH/med rec clarification Discharge medication access Post-discharge appointments Post-discharge follow-up phone call

13. RX CARE TRANSITIONS EVOLUTION 13 January 2014 Care Transitions program go-live Focus is on Medicare patients at highest risk for readmission September 2014 Pharmacy Technician - Care Transitions position created Care Transitions becomes a longitudinal learning experience for PGY1 pharmacy residents June 2015 Pharmacy Technician - Care Transitions position evolves into Health Coach Pharmacy Care Transitions team begins seeing ACO and PCMH patients on both hospital campuses ACO = accountable care organization PCMH = patient-centered medical home

14.  Verify and clarify medication intake list (medication reconciliation) during inpatient admission  Perform “best possible medication history” and review with pharmacist or PGY1 pharmacy resident  Verify insurance coverage to determine medication affordability  Schedule post-discharge physician appointment(s) if patient agreeable  Document patient interview and discrepancies in electronic medical record  Signed off by pharmacist or PGY1 pharmacy resident  Communication with Care Transitions Team  Conduct post-discharge follow-up phone call with pharmacist or PGY1 pharmacy resident oversight TECHNICIAN AS HEALTH COACH 14

15. LEARNING ASSESSMENT Which of the following can be conducted by a pharmacist, pharmacy resident, pharmacy technician, and pharmacy student? a.Patient/caregiver education b.Post-discharge follow up phone call c.Duplicate therapy clarification d.None of the above 15

16. BARRIERS 16 Time Pharmacy Resources Development of new processes Competing quality and safety initiatives Technician knowledge & interpersonal skills Sen S, et al. Am J Health Syst Pharm; 2014; 71(1):51-6. Cooper JB, et al. Am J Health Syst Pharm. 2014; 71(18):1567-74.

17.  Medication reconciliation conducted by certified pharmacy technicians (CPhTs) has been shown to be more effective than those conducted by registered nurses (RNs)  RNs had significantly higher admission discrepancy rates per medication (0.59) compared with CPhTs (0.36) and pharmacists (0.16), P <.001. 1  Medication history taking/reconciliation is one of approximately 26 novel roles utilizing pharmacy technicians as per a 2008 ASHP survey. 2  Demand for pharmacy department involvement in transitions of care activities can be alleviated by greater involvement of pharmacy technicians. 3 OPPORTUNITIES 17 1.Kramer JS, et al. Hosp Pharm. 2014; 49(9):826-38. 2.Meyers, C. Am J Health-Syst Pharm. 2011; 68:1128-36. 3.Kern KA, et al. Am J Health Syst Pharm. 2015; 71(8):648-56.

18. CAPITAL HEALTH CARE TRANSITIONS HOW ARE WE DOING?  Six-month pilot program (2014)  High-risk readmission patients  > 1 admission in 6 months  > 7 medications prior to admission  One of the following diagnoses on admission: AMI, COPD, HF, pneumonia  Total Number of patients enrolled: 132  Out of hospital > 30-day success rate: 88.6% or only an 11.4% 30-day readmission rate  The NJ benchmark 30-day readmission rate in all Medicare patients = 14.9%

19. LEARNING ASSESSMENT Audience Poll What is the largest barrier to implementing pharmacy technicians in medication history taking/medication reconciliation at your institution? 1.Time 2.Pharmacy resources 3.Development of new processes 4.Competing quality and safety initiatives 5.Technician knowledge and interpersonal skills 6.Other 7.None of the above 19

20.  Takeaway #1  Involve pharmacy technicians in each step of the development and implementation of your program  Takeaway #2  Dedicate at least one pharmacist or pharmacy residents to your medication reconciliation technician(s) for timely follow-up of discrepancies and clinical interventions  Takeaway #3  Maintain continuous interdepartmental communication – up to the C-suite and down to the dispensing technicians – advertise successes and gain support for additional resources KEY TAKEAWAYS 20

21. QUESTIONS? dabazia@pharmacy.rutgers.edu Thank you!