Making a p di f-ference - results of the pdif quality improvement initiative

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Purpose of the Call: …

Purpose of the Call:
1.Provide background information about the PDiF initiative, outcomes and key lessons learned.
2.Identify how one organization addressed the obstacles patients face with respect to safe medication management after they are discharged from hospital.
3.Challenge all health care providers to incorporate discharge medication reconciliation into their assessment from the day of admission throughout the patients’ hospital stay.
4.Challenge pharmacists to expand their role in discharge medication reconciliation.

Watch the webinar: http://bit.ly/1ql1O2N

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  • 1. www.saferhealthcarenow.ca Making a PDiF-ference – Results of the PDiF Quality Improvement Initiative March 2014
  • 2. www.saferhealthcarenow.ca Welcome also to our francophone attendees Bienvenue à nos participants francophones Hélène Riverin Conseillère en sécurité et en amélioration Safety Improvement Advisor Bienvenue!
  • 3. www.saferhealthcarenow.ca3 Objectives of today’s call Colleen Cameron: • Describe the PDiF initiative, its outcomes and key lessons learned. • A few practical “challenges” to consider. Marg Colquhoun: The MedRec Journey from 2005 and onwards.
  • 4. www.saferhealthcarenow.ca Please input your Questions All questions will be addressed at the end of the webinar Ask questions or send feedback via the “chat” box • Select “All participants” • Type message • Click “Send” All Participants
  • 5. www.saferhealthcarenow.ca Where to find our webinars…
  • 6. www.saferhealthcarenow.ca6 Please complete our poll
  • 7. Making a PDiF-ference – Results of the PDiF Quality Improvement Initiative Colleen Cameron, RPh, Pharm.D. PDiF Coordinator, Grand River Hospital ISMP Canada/Safer Healthcare Now! April 8, 2014
  • 8. Objectives  Describe the PDiF initiative, its outcomes and key lessons learned.  A few practical “challenges” to consider.
  • 9. WW LHIN (775,000 people) Grand River Hospital St. Mary’s General Hospital Cambridge Memorial Hospital North Wellington Health Care St. Joseph’s Health Centre Groves Memorial Hospital Guelph General Hospital
  • 10. PDiF = Pharmacy Discharge Facilitator
  • 11. Two stories PRE Metformin ASA Atorvastatin Ramipril Bisoprolol POST Metformin ASA Lipitor (Brand) Perindopril Bisoprolol Clopidogrel Lantus Rapid Ezetimibe Esomeprazole Docusate Senokot Nitro Patch $$$ $$$ $$$ - 63 year old male - 3rd cardiac event. - Discharged post-stent insertion.
  • 12. Two stories Losartan 100mg Irbesartan 300mg
  • 13. Losartan 100mg Irbesartan 300mg Two stories 200
  • 14. The most unpredictable variables in the entire equation
  • 15. Pharmacy Discharge Facilitator Project  What is it?  Quality Improvement Initiative  Uniquely included 2 local CEOs in its development  Possibly helped to keep the project’s profile and momentum  January-September 2013  Facilitate medication discharge for high-risk medicine patients with a goal of improving care and outcomes  PDiF team = pharmacist + University of Waterloo pharmacy co-op student
  • 16. Pt Admitted To Hospital BPMH Completed / AMR (Best Possible Medication History/ Admission Med Red) Medication Therapy In Hospital Discharge preparation and coordination Discharge Medication Care Map in Hospital MD Patient Pharmacy
  • 17. Pt Admitted To Hospital BPMH Completed (Best Possible Medication History) Medication Therapy In Hospital Discharge preparation and coordination Discharge MD Patient Pharmacy PDiF 1 On admission – Identify High-Risk Patients Components of PDiF
  • 18. Pt Admitted To Hospital BPMH Completed (Best Possible Medication History) Medication Therapy In Hospital Discharge preparation and coordination Discharge MD Patient Pharmacy Components of PDiF PDiF 2 During hospital stay – Modify medications that will be practical and make sense for discharge
  • 19. Pt Admitted To Hospital BPMH Completed (Best Possible Medication History) Medication Therapy In Hospital Discharge preparation and coordination Discharge MD Patient Pharmacy Components of PDiF PDiF 3 At time of discharge – 1. Communicate with involved health care providers about medication changes and rationale for those changes. 2. Talk to patient/ caregiver to ensure they understand directions.
  • 20. Pt Admitted To Hospital BPMH Completed (Best Possible Medication History) Medication Therapy In Hospital Discharge preparation and coordination Discharge MD Patient Pharmacy Components of PDiF PDiF 4 Post-discharge - Call patient 24- 72 hours post- discharge to see if they are able to follow the instructions we gave them.
  • 21. Outcomes  Qualitative  Patient / caregiver satisfaction  Primary Care Provider satisfaction  Community Pharmacist satisfaction  Hospitalist satisfaction  Quantitative  7, 30 and 90 day ER visits  7, 30 and 90 day readmissions  Conservable Bed Days…unexpected
  • 22. Demographics  # of patients seen – 148 (+)  Average age – 74.2 years  7 patients died during index hospital admission 0 5 10 15 20 25 30 35 40 45 50 20-40 41-60 61-80 81-96 Age Ranges % 79%
  • 23. Age Range % of Patients Heart Failure (# of pts) Diabetes (# of pts) Warfarin (# of pts) 20-40 3.4% (N=5) 0 2 2 41-60 17.6% (N=26) 5 16 9 61-80 35.1% (N=52) 14 23 26 81-96 43.9% (N=65) 20 22 39 Total 148 pts 26% 43% 51%
  • 24. Qualitative Outcomes Did we achieve Patient / Caregiver satisfaction? Did we achieve Primary Care Provider satisfaction? Did we achieve Community Pharmacist satisfaction? Did we achieve Hospitalist satisfaction?
  • 25. Quantitative Outcomes (#, $)  ER/Readmission Rates  7, 30 and 90 day ER visits  7, 30 and 90 day hospital readmission rates  Data disclaimer Historical = All comers – young patients, DKA, pneumonias, acute ingestions, dialysis PDiF patients
  • 26. GRH Readmission Rates - Historical 0 2 4 6 8 10 12 14 16 7 day 30 day 90 day FY 09-10 FY 10-11 FY 11-12 FY 12-13 % CIHI 13.3%
  • 27. GRH Readmission Rates 0 2 4 6 8 10 12 14 16 7 day 30 day 90 day FY 09-10 FY 10-11 FY 11-12 FY 12-13 PDiF % CIHI 13.3%
  • 28. ER Visit Rates - Baseline 0 5 10 15 20 25 30 7 day 30 day 90 day FY 09-10 FY 10-11 FY 11-12 FY 12-13 %
  • 29. ER Visit Rates 0 5 10 15 20 25 30 7 day 30 day 90 day FY 09-10 FY 10-11 FY 11-12 FY 12-13 PDiF %
  • 30. What do these numbers have the statistical power to prove?  Anything? – probably not  Causality? – certainly not  Benchmarking? - maybe  Is that the only information that matters? What if patients subsequently go elsewhere for care?
  • 31. Quantitative Outcomes (#, $)  Hospital Readmissions and ED Visits  At first glance, our PDiF numbers look great…
  • 32. Quantitative Outcomes (#, $)  Hospital Readmissions and ED Visits  At first glance, our PDiF numbers look great… BUT
  • 33. This is bigger than GRH…
  • 34. Quantitative Outcomes (#, $)  Conservable Bed Days  Definition…relevance  Over 9 months, PDiF realized 8 weeks of conservable bed days  Medications involved – Warfarin, Methadone  Unexpected, but fascinating  Consequently – have started targeting patients on medications that are more likely to delay discharge  Warfarin / NOACs  Insulin
  • 35. Top 5 lessons learned… 1. Dare to look at your patients’ experience post-discharge.  Are they seeing their family doctor post- discharge?  Are they getting their prescriptions filled as expected?  Are they going to other local hospitals for subsequent visits?  Follow-up phone calls are quick, and incredibly valuable!
  • 36. Top 5 lessons learned… 2. Drugs delay discharge  Warfarin, LMWHs, insulins, methadone  We now assess 100% of patients on warfarin for timely and safe discharge from Medicine program  Assist with LMWH coordination post-discharge  Educate injection technique while in hospital  Phone call follow ups  Anticoagulation summary of INRs & warfarin doses,  Ensure patient has appt with PCP as well as plans to go to lab
  • 37. Top 5 lessons learned… 2 ½ . Where there is warfarin (or NOACs) there are other medication misadventures looming  Warfarin and NOACs are predictors of other high- risk medications (insulin, digoxin, spironolactone, amiodarone etc)  Most computer systems can search for certain medications.  This is the best place to start!
  • 38. Top 5 lessons learned… 3. Use the hospital admission to optimize chronic medications  Clinical inertia  Look for adherence issues!!!  ODB DPV has picked up on MANY misadventures  Incorporate practical medication discharge assessment upstream
  • 39. Top 5 lessons learned… 4. Medication knowledge transfer contributes to efficient and safe patient care  GRH has an electronic discharge prescription but….  PCPs and Community Pharmacists need information about medications, including rationale and plans of care.  What is your eHealth system?  Fusion software (transcription software)  Clinical Connect (LHIN EHR)  Medication-Focused Discharge Summaries
  • 40. Medication-Focused Discharge Summary One of the most valuable interventions from the PDiF project!
  • 41. Medication-Focused Discharge Summaries Standardized document including  Date of Admission/Discharge  Adherence Issues Identified**  Drug Cost Issues Identified  Numerical List of medications  comment if same, increased, decreased or new  Medications discontinued or held  Additional information  Commentary including plan of care, monitoring plans, concerns  My name and telephone extension
  • 42. Top 5 lessons learned… 5. Discharge medication reconciliation is time consuming!  Track outcomes/stories to strengthen your argument for more funding  Go to your program director with proposal  Develop a business case?  Dr. Schnipper’s data  Be creative in staffing  Pharmacist : patient ratio  Pharmacy students  Pharmacy Technicians Financially: 1 pharmacist ≈ 2 technicians ≈ 4 co-op students
  • 43. Summary Was the PDiF project successful? Did we improve outcomes? Unequivocally Are there simple strategies every hospital can implement to help these patients? Absolutely Medication misadventures We don’t even know the magnitude of the problem yet
  • 44. colleen.cameron@grhosp.on.ca
  • 45. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) The MedRec Journey Margaret Colquhoun, B.Sc.Phm., FCSHP, R.Ph., Project Lead, ISMP Canada http://www.ismp-canada.org/medrec/
  • 46. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Objectives • To talk about the MedRec from 2005 – 2014 • Highlight SHN tools and resources • Highlight your accomplishments • To announce changes in 2014-2015
  • 47. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Thanks to……… • Canadian Patient Safety Institute • 2005 MedRec Intervention
  • 48. MedRec 2005 • Unknown – did not know what we did not know • Systems not in place • Measures not in place • Studies not driving practice change
  • 49. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Things I am Proud of!!! • Creation of new language and knowledge • Being used around the world • Whole country worked together and learned together as a team • Tools and Resources • Webinars, kits, questions • Unbelievable sharing though our network of MedRec teams across Canada
  • 50. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 51. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Action for Safer Medical Care – Medication Reconciliation, CMPA/ACPM, 2103
  • 52. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 53. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 54. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 55. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 56. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 57. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) www.ismp-canada.org/medrecwww.saferhealthcarenow.ca
  • 58. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) www.ismp-canada.org/medrec www.saferhealthcarenow.ca
  • 59. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 60. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) National Team Sharing through Webinars 200-400 lines for each webinar Showcase the Success of our Teams Well received by attendees Relevant and Timely
  • 61. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) London Health Sciences Centre describes: The challenging elements of MedRec implementation in one of Canada's largest, acute care teaching hospitals 1. How LHSC overcame these challenges by focusing on interdisciplinary collaboration 2. How LHSC is evaluating and sustaining the process The Stepping Stones to MedRec Success
  • 62. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Square Peg in a Round Hole: MedRec in Ambulatory Clinics Requires a Different Model Vancouver Health Authority and University Health Network, Toronto • Describe how ambulatory clinic patients require a different system to enable medication reconciliation & review. • Understand the longitudinal team approach to improve accuracy & error reduction through regular review. • Describe two approaches to medication reconciliation in the ambulatory clinic setting. • Identify opportunities of a patient registry as it relates to patient care (medication reconciliation), the organization (drug usage review) and outcomes research. • To share the findings of medication discrepancies and drug therapy problems identified in a post discharge medication reconciliation pilot study.
  • 63. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Different Strokes: Engaging Pharmacy Technicians in MedRec The Moncton Hospital, The Ottawa Hospital, Trillium Health Centre, Peterborough Regional Health Centre Describe the medication reconciliation model developed for pharmacy technicians • Review the training process involved for pharmacy technicians in medication reconciliation • Highlight the role of the pharmacy technician in the Emergency Department and/or the pre-admission clinic
  • 64. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Dr. Jeffrey Schnipper Results of a funded research study into what works and what is the impact of MedRec All past and future webinars available from: SHN website: http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx ISMP Canada website: http://www.ismp-canada.org/medrec/ (Education & Training)
  • 65. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Slide Courtesy of Dr.Jeff Schnipper Safer Healthcare Now! Webinar Jan, 2014
  • 66. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) All past and future webinars available from: • SHN website: http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx • ISMP Canada website: http://www.ismp-canada.org/medrec/ (under Education & Training) MedRec Webinars 2009-2014 Available online
  • 67. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) 2010- National MedRec Summit To accelerate a system-wide strategy to implement medication reconciliation (MedRec) Healthcare CEOs, senior leaders, representatives from national organizations, provincial quality councils, physicians, nurses and pharmacists identified themes that would accelerate and optimize MedRec across the continuum of care
  • 68. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) “Senior leadership commitment is critical to ensuring MedRec is implemented successfully across an organization. Accountability must rest with the CEO with clear reporting expectations at the board level.” REF: Optimizing Medication Safety at Care Transitions: A National Challenge, 2011 http://www.ismp-canada.org/download/MedRec/MedRec_National_summitreport_Feb_2011_EN.pdf
  • 69. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 70. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) PR Campaign from North Bay Regional Health Centre (ON) Consumer Awareness and Tools
  • 71. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Interactive Map Relatively few self-identified “MedRec All-Stars” who have MedRec in place across admission, transfer and discharge
  • 72. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Paper to Electronic Tools/Checklists • Organizational Readiness • Steps to support the safe transition to eMedRec • Ideal features of eMedRec, • Evaluation of eMedRec
  • 73. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) October 2013 was National MedRec Quality Audit Month 2340 patients 29% (acute care) 55% (Long Term Care) • 1906 Acute Care • 329 Long Term Care • Met all 5 quality criteria • Met all 5 quality criteria 103 Organizations
  • 74. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) National Quality Audit Results Summary Comments • MUST critically evaluate admission to ensure quality at discharge • Canadian audit tool results demonstrate need for ongoing and specific improvements • People believe they are doing MedRec but they may not be doing it well • The foundation of the process – the BPMH needs work
  • 75. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) In 2014 we have NOT reliably implemented MedRec!!!
  • 76. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Outstanding Issues in MedRec! Getting to where we want to be • Leadership • Measuring and Monitoring Quality • Role and use of technology • Embedding roles and processes into system • Consumer Engagement • Primary care
  • 77. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Light…. at the end of a lot of hard work The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.
  • 78. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada) Changes in 2014-2015
  • 79. ©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
  • 80. www.saferhealthcarenow.ca80 Questions
  • 81. www.saferhealthcarenow.ca Questions 1. Raise your hand and we may be able to open your phone line 2. Send feedback via the “chat” box • Select “All participants” • Type message • Click “Send” All Participants
  • 82. www.saferhealthcarenow.ca82 Please complete our poll
  • 83. www.saferhealthcarenow.ca Upcoming MedRec Webinars 83 Thank you for attending Join us on May 6, 2014 at 12 noon ET for our next MedRec webinar Safety, Sleuthing and Students: A Novel Collaborative MedRec Event at the University of British Columbia
  • 84. www.saferhealthcarenow.cawww.ismp-canada.org 84 We encourage you to report medication incidents Practitioner Reporting https://www.ismp-canada.org/err_report.htm Consumer Reporting www.safemedicationuse.ca/
  • 85. www.saferhealthcarenow.cawww.ismp-canada.org Medication Safety Self-Assessment® • Hospitals (acute care)(2006) – free for Ontario* • Long-term care (2012) – free for Ontario* • Complex Continuing Care and Rehabilitation (2008) – free for Ontario* • Community and Ambulatory Pharmacy (2007) – free for Ontario* • Operating Room Medication Safety Checklist (2009) – free for Ontario* • Oncology (2012) • Anticoagulant Safety (VTE) – free for Ontario* • HYDROmorphone Safety Self-Assessment (2014) - $50 * Supported by the Ontario MOHLTC For more information visit www.ismp-canada.org/MSSA or email mssa@ismp-canada.org
  • 86. www.saferhealthcarenow.ca Thank you for attending