1. Lisa Anne Boothby, PharmD, BCPS Director of Pharmacy, Dukes Memorial Hospital

2.  Demonstrate the value of clinical pharmacy services to decrease 30-day readmission rates  Outline the pharmacist’s role in reducing medical waste  Detail ethical issues associated with drug shortage management

3.  Clinical pharmacy services  Inpatient and outpatient settings  Improve patient outcomes

4.  Patient Accountability and Affordable Care Act  Pharmacists are “other healthcare providers”  Social Security Act  Part B versus Part D  Three MTM billing codes  Private insurance reimbursement follows Smock N. Affordable Care Act Regards Pharmacists as Health Care Providers, Not Just Prescription Dispensers. Available at URL: http://www.pharmacytimes.com/publications/issue/2013/January2013/Affordable-Care-Act- Regards-Pharmacists-as-Health-Care-Providers-Not-Just-Prescription-Dispensershttp://www.pharmacytimes.com/publications/issue/2013/January2013/Affordable-Care-Act- Regards-Pharmacists-as-Health-Care-Providers-Not-Just-Prescription-Dispensers

5.  Capitated healthcare precede reimbursement  May decrease need for pharmacy billing  Share in savings once minimum achieved  Accountable care organizations  Not all hospitals have embraced  Pilot programs Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

6.  Providers accountable  Achieving quality  Reductions in rate of spending growth  Physician led with many payer arrangements  National Committee for Quality Assurance  Established ACO criteria  7 categories with 4 levels Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

7. To reach critical mass  Incorporate multiple payers or multiple hospitals  Apply for a CMS wavier to include Medicaid patients Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

8.  Patient centered medical homes  Led by physician  Include pharmacist, nurse and other health care practitioners  Treat patient with chronic conditions  Prevent adverse events and optimize therapy  Team ensures all health care needs are met Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

9.  Improve medication management  Preventing hospital readmissions  Decreases revenue in a traditional hospital budgetary model Daigle L. Pharmacists Role in Accountable Care Organizations. ASHP Policy Analysis. ASHP, 2011.

10.  Keep patients healthy and out of the hospital  VA collaborative practice model  Prescribing privileges  More than 20 years of success  Pharmacist credentialed providers

11.  Medication management  Preventing disease  Maintaining cardiovascular health  Preventing end organ damage  Medication compliance, adherence  Therapeutic drug monitoring  Supportive care

13.  1 month study at Mission Hospital  735 bed community teaching hospital  Asheville, North Carolina  Pre-post design  2 weeks normal routine  2 weeks with clinical pharmacist Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

14.  Drug information  Discharge counseling  Medication interventions  Medication reconciliation  Filling discharge prescriptions  Submit discharge summaries Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

15.  15-day and 30-day readmission rates  Number of ED visits  Employee satisfaction surveys Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

16.  33% vs. 17% readmission within 30 days  11% vs. 2% readmission within 15 days  9% vs. 4% ED visits within 30 days Simone A. Physician-Pharmacist Team Improves Hospital Care. Published June 20, 2013. Available at http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care http://www.pharmacytimes.com/news/Physician-Pharmacist-Team-Improves-Hospital-Care

17.  Prospective cohort  729 patients over three months  Pharmacy medication reconciliation  30-day readmission rate  Polypharmacy and readmission rate Pal A., Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

19.  Med reconciliation and counseling  Decreased 30-day readmission rate  16.8% vs. 26%; p=0.006  Polypharmacy  More than 5 scheduled medications  Associated with increased readmission rates Pal A., Babbott S, and Wilkinson T. Can the use of a discharge pharmacist significantly decrease 30-day readmissions? Hospital Pharmacy 2013;48(5):380-388.

21.  Walgreens program  Reduces readmissions  Pharmacists oversee medication regimens  Transitions of care Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012. http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions

22.  Med review at admission and discharge  Bedside medication delivery  Counseling for patients and their caregivers  Regularly scheduled follow-up post discharge  24-7 support for discharged patients  Ensure follow up with physician  Ensure appropriate self care  Marian General and Lutheran Hospital Walgreens Program Employs Pharmacists to Reduce Hospital Readmissions. November 20, 2012. http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions http://www.pharmacytimes.com/news/Walgreens-Program-Employs-Pharmacists-to-Reduce-Hospital-Readmissions

23.  11 pharmacists  Vanderbilt University  Brigham and Women’s Hospital  Medication reconciliation  Time consuming  Most important contribution  Improving care transitions  Correct the admission medication history Haynes KT, Oberne A, Kripalani S. Pharmacists’ recommendations to improve care transitions. Ann Pharmacother 2012;46(9):1152-1159.

24.  Translation to a rural critical access hospital  Minimal resources  Decreased ED visits decreases admissions  Decreased revenue with traditional models  Next steps?

25. TARGETING TRANSITIONS  Project BOOST: www.hospital-medicine.org  Project RED: www.projectred.org  STAAR initiative: www.ihi.org/STAAR

26.  Medication reconciliation process  Physician and nurse driven  2 to 3 errors per each  Follow-up by pharmacy  Clarify and correct errors  Time intensive  Increased safety risk  Omissions  Delays and duplications

27.  Develop criteria for consultation  Greater than 10 scheduled medications  High-alert medications  Anticoagulants  Core-measure disease states

29. INCOMPATIBLE HAZARDOUS WASTE Aerosols Inhalers Oxidizers Silver nitrate REGULAR TRASH Outside packaging Empty items that once contained medication Shipping packaging Recycle paper, glass, plastic P-LISTED HAZARDOUS WASTE Coumadin plus wrapper Nicotine plus wrapper and peel HAZARDOUS WASTE Insulin Some vitamins and minerals Phenylephrine NON- HAZARDOUS RX WASTE Antibiotics Lidocaine Pitocin Heparin SHARPS Needles and broken ampoules Empty syringes SEWER IV dextrose Potassium Saline Sodium Calcium lactated ringers magnesium CHEMO WASTE Smith CA. Managing Pharmaceutical Waste. Journal of the Pharmaceutical Society of Wisconsin 2002;17-22.

30.  Save money, prevent delays and omissions  Clinical pharmacists know formulary medications  Clinical pharmacists prevent non-formulary and not-available medication orders at admission  Formulary management policies/procedures  Therapeutic interchange programs  Evaluate PAR levels for expired drugs

31.  Outpatient prescribing practices  Polypharmacy  Lack of follow-up  Mail order pharmacies automatic renewals  Three month supplies  Compliance  Adherence  Persistence

32.  Controlled substance regulation  Changes from DEA  Expected in future  Vendors  Stericycle, others …  Environmentally conscious disposal

34.  Therapeutic interchange  Drug classes  Pharmacodynamics of medications  Superior therapeutic alternatives  Evidence based medicine  Avoid grey market distributers

35.  Receive emails for information only  Plan ahead  Keep adequate inventory levels  Medications dispensed daily  Accept small loss with expired medications  To stock adequate levels  Prevent drug shortages from reaching patient

36.  Aminophylline  Sincalade  Nalbuphine  Dextrose 25% and 50% syringes  Furosemide IV  Metoclopramide IV  Fentanyl IV  Potassium phosphate IV

39.  Pharmacists vital part of the healthcare team  Pharmacotherapy experts  Explain how medications work in the body  Suggest therapeutic alternatives  Eliminate therapeutic duplications

40.  Avoid polypharmacy  Teach common side effects  Action for severe side effects  Ethical stewardship  Medical and financial resources

41.  PHARMACY COST CENTER

42.  Collaboration  Rural health hospitals  Payers  Obtain grant money  Research  New practice models  Demonstrate added value

43. Lisa Anne Boothby, PharmD, BCPS Director of Pharmacy, Dukes Memorial Hospital