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Improving Healthcare Quality and
Safety While Reducing Costs Through
Clinical Pharmacy Service Integration
Steven W. Chen ...
Agenda
• Comprehensive Medication Management at
AltaMed Health Services
• The “Business Case” for Comprehensive
Medication...
Medication Safety Problems in U.S.
• 1.5 million people are injured each year
due to medications
• ~25% of ambulatory pati...
$12 Million USC / AltaMed CMMI Project: Specific Aims
UNIVERSITY OF
SOUTHERN CALIFORNIA
National Conference on Best
Practi...
USC Patient Targeting and Management Strategy
Clinical Pharmacy
Comprehensive
Medication
Management
Clinical pharmacy
tech...
Outcome: Recruit high risk patients
• Enrolled 6,000 patients since Oct 2012
• Predominantly Hispanic, non-elderly women
•...
Outcome: Improvement in Clinical Markers
125
130
135
140
145
150
155
Baseline 3 Months Most
Recent
Systolic Blood Pressure...
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
Less than 7 7 to 8 8 to 9 9 to 10 Greater than 10
A1C Levels
Baseline ...
Outcome: Hospitalizations are declining
Control Group Selection
Propensity scoring to match CPS enrollees (treatments) to similar patients
receiving care at non-t...
Clinical results
HbA1C average change in 6 months, uncontrolled at baseline
BP % under control in 6 months, uncontrolled a...
Untreated (Cohort) vs. Treated Patients,
USC CMMI Program
Mortality rates
- 25.7%
absolute
difference
0.01
0.009
0.008
0.0...
Medication-Related Problems Identified Through
CMMI Clinical Pharmacy Program
67,169 problems among 5,775 patients (Avg 11...
Top Actions Taken by Pharmacists to Resolve Medication-
Related Problems (excluding education)
2,665
3,847
4,230
5,554
14,...
Physician Satisfaction
Average score = 9.6
Average score = 9.7
Patient Satisfaction
Patient Engagement / Retention Keys
Engagement Retention
Make room for walk-ins / “warm hand-offs”  
PCP endorsement to ...
USC Pharmacy Program Recognitions
Clinical Pharmacy Impact
1. Innovation Challenge Finalist in the Let’s Get Healthy Calif...
Agenda
• Comprehensive Medication Management at
AltaMed Health Services
• The “Business Case” for Comprehensive
Medication...
WHY DO THIS?
Clinical Pharmacy
WHY DO THIS?
Clinical Pharmacy
WHY DO THIS?
• Doctors don’t like to follow protocols …
• Pharmacists manage drug therapy better
through collaborative pra...
OVERCOMING ANXIETY
• Can pharmacists do this?
• Will they communicate?
• Why did I go to medical school?
Clinical Pharmacy
IMPACT
• Staff Satisfaction
• Patient Satisfaction
• Quality Goals
• Reduction in ER and Hospital Utilization
• Unexpected...
MAJOR CHALLENGE
Clinical Pharmacy
BUSINESS CASE
• Does clinic pharmacy save money?
• Is clinical pharmacy a high-value service?
• If yes, how do we pay for ...
OPTIONS
• Billing policy changes
• Pay for performance
• Health Home Demonstration
• More risk-bearing, capitated payment
...
Our Team
28
David Goldstein, MD Michael Hochman, MD, MPH Rachel Lim
Welmoed van Deen, MD, PhD
Faculty
Rusha Modi, MD
Facul...
• Collaborate and partner with local health
systems
• Help implement best practices
• Develop sustainable innovations
• Ad...
• The “Triple Aim”
• Quality/Experience
• Population Health
• Efficiency
• Co-development with health systems
• Sustainabl...
Projects in Development
31
• Getting hospitalized patients out of bed
• Evaluating “Whole Person Care” waiver
• Medication...
Gehr Innovation Awards
32
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Improving Healthcare Quality and Safety while Reducing Costs through Clinical Pharmacy Service Integration

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Published on

Apr 6, 2016
Drs. Steven Chen and Michael Hochman, of USC, presented as part of a seminar series on UCLA CTSI Dissemination, Improvement and Implementation Research.

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Improving Healthcare Quality and Safety while Reducing Costs through Clinical Pharmacy Service Integration

  1. 1. Improving Healthcare Quality and Safety While Reducing Costs Through Clinical Pharmacy Service Integration Steven W. Chen PharmD, FASHP, FCSHP, FNAP Associate Professor and Chair Titus Family Department of Clinical Pharmacy and Pharmacoeconomics and Policy William A. Heeres and Josephine A. Heeres Endowed Chair in Community Pharmacy Co-Chair Emeritus, HRSA Patient Safety & Clinical Pharmacy Services Collaborative Michael Hochman, MD, MPH Director Gehr Family Center for Implementation Science Keck School of Medicine of USC
  2. 2. Agenda • Comprehensive Medication Management at AltaMed Health Services • The “Business Case” for Comprehensive Medication Management • The Gehr Family Center for Implementation Science
  3. 3. Medication Safety Problems in U.S. • 1.5 million people are injured each year due to medications • ~25% of ambulatory patients experience adverse drug events • 90% of chronic diseases require medications as first-line therapy • “…for every dollar spent on ambulatory medications, another dollar is spent to treat new health problems caused by the medication.” Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System, Washington, DC: National Academy Press; 2000.
  4. 4. $12 Million USC / AltaMed CMMI Project: Specific Aims UNIVERSITY OF SOUTHERN CALIFORNIA National Conference on Best Practices and Collaborations to Improve Medication Safety and Healthcare Quality Feb 20-21, 2014 Resident and technician training for expansion Web-based pharmacist training and credentialing OUTCOME MEASURES  Healthcare Quality  Safety  Total Cost / ROI  Patient & provider satisfaction  Patient access Telehealth clinical pharmacy10 teams Pharmacist + Resident + Clinical Pharmacy Technician
  5. 5. USC Patient Targeting and Management Strategy Clinical Pharmacy Comprehensive Medication Management Clinical pharmacy tech “check-ins” every 2 months Yes Unstable No Treatment Goal Reached? High cost patients Frequent and recent acute care utilizers 48 EHR-embedded triggers to detect high risk patients MD referrals
  6. 6. Outcome: Recruit high risk patients • Enrolled 6,000 patients since Oct 2012 • Predominantly Hispanic, non-elderly women • 3/4ths have hypertension, 36% uncontrolled • 2/3rds have diabetes, 60% uncontrolled • High rates of hospitalizations
  7. 7. Outcome: Improvement in Clinical Markers 125 130 135 140 145 150 155 Baseline 3 Months Most Recent Systolic Blood Pressure 72 74 76 78 80 82 84 86 88 Baseline 3 Months Most Recent Diastolic Blood Pressure * Among those with uncontrolled hypertension at baseline
  8. 8. 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% Less than 7 7 to 8 8 to 9 9 to 10 Greater than 10 A1C Levels Baseline 6 months Most Recent Outcome: Improvement in Clinical Markers
  9. 9. Outcome: Hospitalizations are declining
  10. 10. Control Group Selection Propensity scoring to match CPS enrollees (treatments) to similar patients receiving care at non-treatment clinics (controls) in three steps: • Wave 1 treatment patients • PACE treatment patients from Wave 2 • Non-PACE treatment patients from Wave 2 Covariates used to model the propensity score: • Demographics • Health status • Utilization • Other
  11. 11. Clinical results HbA1C average change in 6 months, uncontrolled at baseline BP % under control in 6 months, uncontrolled at baseline -11% -9.3% Utilization results (Probit Analysis) Readmissons per year per patient (6 month panel) Readmissions per year per patient primarily attributed to medications (6 month panel) -16% -33% Summary of Difference-in-Differences Results (Treatment – Control) http://www.careinnovations.org/uploads/USC.C EPC.pharm_webinar_FinalV.pdf
  12. 12. Untreated (Cohort) vs. Treated Patients, USC CMMI Program Mortality rates - 25.7% absolute difference 0.01 0.009 0.008 0.007 0.006 0.005 0.004 0.003 0.002 0.001 0 1 2 3 6 9 12 Months after enrollment Untreated Treated Preliminary analysis, data on file USC Schaeffer Center for Health Policy & Economics
  13. 13. Medication-Related Problems Identified Through CMMI Clinical Pharmacy Program 67,169 problems among 5,775 patients (Avg 11.6 per patient) 9,222, 14% 22,229, 33% 13,352, 20% 14,059, 21% 8,267, 12% Medication Nonadherence Safety Issues Appropriateness / Effectiveness Misc Insufficient Patient Self-Management http://www.careinnovations.org/uploads/USC.CEPC.pharm_webinar_FinalV.pdf, Updated July 2016
  14. 14. Top Actions Taken by Pharmacists to Resolve Medication- Related Problems (excluding education) 2,665 3,847 4,230 5,554 14,981 Substitute Medication Discontinue Medication Order test Add Medication Change Dose or Drug Interval
  15. 15. Physician Satisfaction
  16. 16. Average score = 9.6 Average score = 9.7 Patient Satisfaction
  17. 17. Patient Engagement / Retention Keys Engagement Retention Make room for walk-ins / “warm hand-offs”   PCP endorsement to targeted / enrolled patients   Match team member language skills   Clinical pharmacy technicians   Align appointments   Engage family and caregivers   Consider selective home visits   Extended hours / weekend clinics   Transportation support if possible   Flyers explaining program benefits in lay terms  Consider peer-led group appointments  Continuity of pharmacist / tech provider 
  18. 18. USC Pharmacy Program Recognitions Clinical Pharmacy Impact 1. Innovation Challenge Finalist in the Let’s Get Healthy California Goal Area of “Lowering the Cost of Care”! - January 26, 2016, Innovation Conference, Sacramento 2. Los Angeles Times article: http://www.latimes.com/local/great-reads/la-me-c1-pharmacists-clinics- 20150406-story.html 3. Selected for inclusion in the AHRQ Health Care Innovations Exchange: https://innovations.ahrq.gov/profiles/pharmacy-teams-use-telepharmacy-provide- medication-management-risk-patients-safety-net 4. Recognized as Exemplar Innovator, UCSF Center for Excellence in Primary Care and Center for Care Innovations: https://innovations.ahrq.gov/profiles/pharmacy-teams-use-telepharmacy-provide- medication-management-risk-patients-safety-net 5. Interviewed for article in California Healthcare Foundation’s Center for Health Reporting: “Prescription for Success: Caring”- http://www.losangelesregister.com/articles/metcalfe- 597822-chen-eat.html 6. Cover story for Pharmacy Today: “Chen, colleagues provide MTM in L.A.’s most vulnerable neighborhoods, (http://www.pharmacist.com/node/49949)relate 7. Pharmacy Times article: “Effectiveness of Clinical Pharmacy Services to be Tested”, (http://www.pharmacytimes.com/news/Effectiveness-of-Clinical-Pharmacy-Services-to-Be-Tested) 8. Semi-Finalist, Harvard Business School / Harvard Medical School Health Acceleration Challenge - https://openforum.hbs.org/challenge/hbs-hms-health-acceleration-challenge/refinement/good- medicine-medication-therapy-management-and-saving-the-health-care-system-millions 9. Pinnacle Award, American Pharmacists Association: https://pharmacyschool.usc.edu/steven-chen- receives-2013-pinnacle-award-in-washington-dc/ 10. Innovator Award, Health Resources and Services Administration (HRSA) Patient Safety and Clinical Pharmacy Services Collaborative (PSPC)
  19. 19. Agenda • Comprehensive Medication Management at AltaMed Health Services • The “Business Case” for Comprehensive Medication Management • The Gehr Family Center for Implementation Science
  20. 20. WHY DO THIS? Clinical Pharmacy
  21. 21. WHY DO THIS? Clinical Pharmacy
  22. 22. WHY DO THIS? • Doctors don’t like to follow protocols … • Pharmacists manage drug therapy better through collaborative practice agreements! Clinical Pharmacy
  23. 23. OVERCOMING ANXIETY • Can pharmacists do this? • Will they communicate? • Why did I go to medical school? Clinical Pharmacy
  24. 24. IMPACT • Staff Satisfaction • Patient Satisfaction • Quality Goals • Reduction in ER and Hospital Utilization • Unexpected benefits: - patient assistance programs - help with medication errors - staff education Clinical Pharmacy
  25. 25. MAJOR CHALLENGE Clinical Pharmacy
  26. 26. BUSINESS CASE • Does clinic pharmacy save money? • Is clinical pharmacy a high-value service? • If yes, how do we pay for it? Clinical Pharmacy
  27. 27. OPTIONS • Billing policy changes • Pay for performance • Health Home Demonstration • More risk-bearing, capitated payment arrangements Clinical Pharmacy
  28. 28. Our Team 28 David Goldstein, MD Michael Hochman, MD, MPH Rachel Lim Welmoed van Deen, MD, PhD Faculty Rusha Modi, MD Faculty
  29. 29. • Collaborate and partner with local health systems • Help implement best practices • Develop sustainable innovations • Advance knowledge in care delivery Mission 29
  30. 30. • The “Triple Aim” • Quality/Experience • Population Health • Efficiency • Co-development with health systems • Sustainable • Scientifically important data • Engages University and local communities • Trainees can participate Principles 30
  31. 31. Projects in Development 31 • Getting hospitalized patients out of bed • Evaluating “Whole Person Care” waiver • Medication assisted therapy for high utilizers • Preventing readmissions from primary care perspective • Scaling Comprehensive Medication Management
  32. 32. Gehr Innovation Awards 32

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