2.11 Conduct Medication Management University Medical Center Health System Lubbock, TX Jason Mills, PharmD, RPh Assistant Director of Pharmacy

Project Options Evidence-base interventions that put in place the teams, technology and processes to avoid medication errors. This project option could include one or more of the following components: a) Implement a medication management program that serves the patient across the continuum of care targeting one or more chronic disease patient populations b) Implement Computerized Physician Order Entry (CPOE) c) Implement pharmacist-led chronic disease medication management services in collaboration with primary care and other health care providers d) Conduct quality improvement for project using methods such as rapid cycle improvement.

Rationale Approximately 1.5 million preventable ADEs occur annually as a result of medication errors Cost more than 3 billion per year 1 in 5 patients discharged from hospitals suffers an adverse event 72% are related to medications 76% of Medicare readmissions in 2007 were potentially preventable billion in readmission costs may be preventable Pharmacist-provided medication therapy review and consultation in various settings resulted in reductions in physician visits, ER visits, hospital days, and overall health care costs Uniquely positioned to help increase medication safety and compliance in patients across the continuum of care

Rationale Diabetes is a complex, increasingly common chronic condition that remains one of the most serious health problems in Lubbock County and Texas 6 th leading cause of death in Texas 21.9% of adult diabetics do not have health insurance in Texas Lubbock BRFSS data indicate that 10.7% have diagnosed diabetes Death rate from diabetes in Lubbock is 38.6/100,000 compared to 26.5/100,000 in Texas Approximately 1.8 million adult Texans have type 2 diabetes and 460,000 are undiagnosed 4 th leading cause of death for African Americans and Hispanics One study found that a decrease in diabetes medication adherence resulted in a 58% increase in hospitalizations and 81% increase in all- cause mortality

Project Description Provide medication management for adult diabetes mellitus patients across the continuum of care Age 18 and older Approximately 5000 total patient visits per year with about 1000 visits being Medicaid or uninsured Establish a patient-centric medication management program that includes the following components: Written medication management plan focused on medication safety Clearly defined roles for interdisciplinary participants Process and criteria to screen for adult diabetic patients Standardized medication reconciliation process and counseling by a pharmacist Utilization of patient friendly education and medication management tools Patient access to outpatient prescriptions on site at UMC Outpatient Pharmacy Targeted post-discharge follow-up

Project Process Population-based screening Identify targeted adult diabetic population Admission assessment Best Possible Medication History (BPMH) Compliance Lack of efficacy Adverse drug effects Discharge counseling Comprehensive review of discharge medication list and counseling by a pharmacist Individualized patient education Comprehension of medication instructions and therapy plan Coordinate the filling and delivery of discharge prescriptions to the patient’s room Post-discharge Follow-up Phone call by a pharmacist Assess compliance, identify ADEs, and answering any patient questions

Project Goals Reduce medication errors and adverse drug events Increase adherence to an appropriate medication regimen Cost saving to the health system Provide access to outpatient medications Decrease unplanned visits to the ER Decrease hospital’s diabetes 30 day readmission rate (IT-3.3) Improve patient satisfaction regarding issues and questions about their medications Regional Goals Improve access to care and medications Address the high incidence of diabetes mellitus Provide a specialist to assist in the treatment of diabetes mellitus

Expected Outcomes DY2 (10/1/12 – 9/30/13) Develop criteria and identify targeted patient populations Develop written medication management plan Implement an evidence based program based on best practices for medication reconciliation to improve medication management and continuity between acute care and ambulatory setting DY3 (10/1/13 – 9/30/14) 20% or about 1000 patients receive medication management therapy DY4 (10/1/14 – 9/30/15) 40% or about 2000 patients receive medication management therapy DY5 (10/1/15 – 9/30/16) 60% or about 3000 patients receive medication management therapy

Challenges Complex disease state and co-morbidites Engagement and education of patients History of poor medication compliance Lack of understanding of the severity of their disease state Collaboration with other services and departments Case Management Social Services Nursing Physicians Pharmacist education and training Pharmacist staffing Hospital census

CQI Pharmacy medication management team meets internally at least every two weeks Lessons learned Project impacts Challenges Pharmacy medication management team meets with IT monthly to discuss issues and improvements Pharmacy medication management team meets routinely with case management, social services, and nursing Medication errors, ADEs, and compliance are continuously monitored for trends and areas of improvement

June 1, March 22, 2014 YesNoNot Indicated Total% Admission Assessment 2,2452,0124, % Discharge Counseling 1,8901,1471,2194, % Follow Up Phone Call 1,4061, , % Success at all three markers 1,2393,0184, %

October 1, 2013-March 22, 2014 YesNoNot Indicated Total% Admission Assessment 1,3241,2312, % Discharge Counseling 1, , % Follow Up Phone Call , % Success at all three markers 8961,6592, %

Readmissions Total Patients Total Readmissions Readmission Rate Decrease from Previous Year % %21.37% %38.04%