Mental Health Clinical Pharmacy Services and Pilot at Regions Hospital Craig Harvey, Director of Pharmaceutical Services Meg Moen, Clinical Pharmacy Resident Dan Rehrauer, MTM, HealthPartners Regions Hospital, Saint Paul, MN February 19, 2014

Objectives Regions and current Pharmacy operations Pilot design and initial objectives Preliminary results What we learned along the way MTM Services Future *This was a quality assurance project and any results obtained are not intended for generalized application/knowledge

Regions Hospital 460 Bed hospital Level 1 Trauma Center 79,000 ED visits in 2012. Disproportionate Share Hospital (DSH) – 340B 100 Mental Health Inpatient beds 24 x 7 Pharmacy Discharge Pharmacy with bedside delivery Regions Hospital

Regions Mental Health New 2012, 100 private inpatient rooms Provide acute mental health services for inpatients Care delivered by team of psychiatrists, nurses, occupational therapists, pharmacists, and medicine physicians Crisis staff for emergency evaluations in Emergency Center Outpatient services offered at a variety of HealthPartners clinic locations Regions Mental Health Inpatient facility, Saint Paul, MN

RARE How can Pharmacy help to improve patient care AND reduce readmissions?

Current Model - IP Clinical Pharmacist (DCP) spends 5 hours daily to consult and review of 100 MH patient profiles. The mental health department has the highest patient to pharmacist ratio of any clinical pharmacist position DCP works remotely - little to no direct interaction between pharmacist and patient, provider, or nurse. DCP is not involved in the discharge process. Patients not routinely referred for MTM at discharge

Current Model - OP 82% of MH discharge Rx’s filled at Regions, delivered to patient’s nurse prior to discharge. Regions is 340B – lowest drug cost available. Pharmacy bills insurance if available. Bills patient co-pay or retail price after patient leaves the hospital. If “too early”, “not covered”, “PA” or need to expedite - 30 days supply billed to nursing unit.

Pre-pilot data Progress notes average 0.97 per patient case Average number of medications per inpatient: 17.5 Average number of doses per inpatient: 73 doses per patient per stay Average cost of medications billed to MH floor at discharge: $5,000 - $7,000 monthly Can already see where our opportunities are Greater attention to patient care and reduction in polypharmacy WHERE are the medication billings coming from? What’s our opportunity?

Patient Nursing Clinical Pharmacy Discharge Pharmacy Psychiatry Social Work Medicine MTM Clinic Admin The Players Collaborative, team-oriented initiative necessary to make quality patient impact

Pilot Objectives November 11th – December 13th 2013 Identify potential impact of full-time clinical pharmacist services – measure interventions, cost- savings and satisfaction with services provided. Identify areas for patient care improvement. Determine justification of a dedicated mental health pharmacist resource.

Expanded Clinical Pharmacist Role Increased direct interactions with MD and nursing with recommendations Profile review to reduce polypharmacy Increase pharmacist involvement in discharge medication reconciliation. Place MTM referrals for high-risk patients Track interventions Reduce monthly cost of medications billed to MH units. Participate in team rounding Improved med patient safety Expanded Clinical Pharmacist Role Continued adherence to current role expectations with additional duties.

Interventions Over the course of 24 days: 360 interventions Clinical Pharmacy Over the course of 24 days: 360 interventions 92.8% of recommendations accepted by psychiatrist *Preliminary data from clinical surveillance software system – no eMAR results yet Nursing Interventions Medicine Important to understand in our model – our pharmacists were already doing many of these interventions – they were now just asked to track what they couldn’t track in the eMAR, were given an extra 3 hours daily, and asked to give additional time to certain interventions Psychiatry

Interventions Most common interventions: Clinical Pharmacy Most common interventions: Discontinue inappropriate therapy (72) Change in Drug Formulation Recommendation (46) Medication reconciliation upon discharge (39) Alternative therapy recommendation (18) Antibiotic therapy recommended (16) Greatest cost savings: Antibiotic therapy recommendation Discontinue inappropriate therapy Alternative therapy recommendation Nursing Interventions Medicine Important to understand in our model – our pharmacists were already doing many of these interventions – they were now just asked to track what they couldn’t track in the eMAR, were given an extra 3 hours daily, and asked to give additional time to certain interventions Psychiatry

Graphs from theradoc- we tracked a great deal of interventions

Key Interventions

Pilot Savings

Pilot Savings Over the course of 24 days: Pilot savings: $99,301 Clinical Pharmacy Over the course of 24 days: Pilot savings: $99,301 Potential annual savings: $1.5 million *Preliminary data from clinical surveillance software system – no eMAR results yet Nursing Pilot Savings Medicine Important to understand in our model – our pharmacists were already doing many of these interventions – they were now just asked to track what they couldn’t track in the eMAR, were given an extra 3 hours daily, and asked to give additional time to certain interventions Psychiatry

Discharge Medications Clinical Pharmacy Some patients have their home medications stored in pharmacy upon admit Discharge medications sent up WITH home meds Pharmacist reconciled patients home meds with discharge meds and identified: Duplicates New medications Discontinued medications Opportunity: Pharmacist review meds personally with patient Reduce med costs (patient and institution) Intuitively this may improve compliance Nursing Discharge Medications Discharge Pharmacy Where can our players make an impact? Psychiatry

Clinical Pharmacy HealthPartners Clinics offer unique opportunity for MTM coordination of care Most pilot interventions occurred on floors where patients were working towards discharge Established process for DCP to easily place an MTM order This was a challenge MTM Clinic MTM Referrals Patient Where can our players make an impact? Social Work

Clinical Pharmacy Current order instructs patient to contact appointment line Patients may not call to make an appointment Many patients may not keep their appointment Opportunities identified: Can we enable social work to make MTM appointment prior to discharge Can we establish outpatient MTM services at Regions Hospital to increase convenience to our patients MTM Clinic MTM Referrals Patient Where can our players make an impact? Social Work

Medication Therapy Management (MTM) Why do we want to promote this service? An outpatient service that optimizes pharmacotherapeutic outcomes for individual patients. Are the medications indicated, effective, safe and convenient When offered by a pharmacist the service has been shown to improve clinical outcomes and reduce adverse drug effects from medications for chronic conditions. Dramatic increase in psychotropic medications and complexity of medication regimens makes MTM essential Pre and post discharge education, medications reconcilliation/education and transition managers have been demonstrated to reduce risk of readmission by up to 37%

Who would benefit People on multiple medications (>4) Patients who see multiple prescribers Patients who mention concerns with costs of their medications Patients who are confused about their medications Patient that aren’t taking their medications the way they are supposed to (non-adherence) Everybody!

Patient Nursing Clinical Pharmacy Discharge Pharmacy Psychiatry Social Work Medicine MTM Clinic Admin Perceptions Post-pilot survey distributed to mental health professionals to gauge perceptions of pharmacist services

Perceptions

Perceptions

Perceptions

Perceptions

Impact opportunities (What we learned) Discharge medication process MTM and transitions of care Interprofessional relationships Cost savings Other areas: Are patients getting re-admitted due to cost/administration of long-acting injectables? Other areas: These are thoughts that came up throughout the pilot- we had a team focused on this area and the ideas and experiences bouncing around exposed opportunities for impact

Future Model – IP Hiring 1 FTE BCPP (Board Certified Psychiatric Pharmacist) 2nd quarter 2014. Focus at start Admission Med List – accurate and complete Formulary Management – clinical and cost effective Education – staff and patient focused with indications for Rx Discharge Med Rec – insurance, formulary. Patient home meds – reconcile with discharge orders Use where appropriate – patient safety, cost savings for all All MH patients leave with 30 days supply of meds to improve med compliance, reduce readmissions.

Future Model – IP continued Refer high risk patients to MTM post-discharge ED Clinical Pharmacist partners with MH pharmacist Measure Results of Pharmacist Interventions – Cost Savings, formulary compliance, polypharmacy reduction Outcomes – LOS, reduced readmissions Patient AND staff satisfaction Reduced patient days

How can Pharmacy help to reduce Mental Health Readmissions at Regions? Medication Optimization Medical and psychiatric Medication Reconciliation Accurate, verified medication list upon admission Discharge to home with current meds only Patient Education “Why” this med is important – “indication” on bottle, MTM where needed – reinforces, educates after discharge Transitions of Care Recommending patients for MTM with scheduled appointment Accurate discharge med list on patient discharge summary (AVS) Access to medication Meds in hand when discharged Trouble shoot compliance issues - affordable, reminders Evaluate if strategy works? Measure results.

Thank You Questions?