Coordinated Pharmaceutical Therapy In Chronic Care

Coordinated Pharmaceutical Therapy in Chronic Care Five Innovative Programs

September 2000

The National Pharmaceutical Council is an education association supported by the leading research-based pharmaceutical companies. NPC conducts research on the appropriate use of pharmaceuticals and the clinical, fiscal and economic aspects of pharmaceutical care. The Council prepares education and information resources for public and private payers and health care policy makers.

© 2000 by the National Pharmaceutical Council. All rights reserved.

OVERVIEW Numerous studies indicate the limitations of a componentbased, line item approach to the management of pharmaceuticals. Although some savings in the drug budget may occur, treatment outcomes may be compromised and overall expenditures are often increased. A much greater potential for improved treatment and overall cost savings lies in the direction of improved coordination of pharmaceutical care, especially for elderly and other chronic care patients. These groups consume a disproportionate share of health care expenditures, including pharmaceuticals. They usually have several coexisting diseases and are at risk for adverse consequences due to their compromised physiological status, and for interactions of prescriptions from several physicians. Their pharmacological needs require access to a broad range of medications and an individualized approach to care.

Successful models of coordinated pharmaceutical care for these and other patients at high risk for suboptimal treatment must be identified. This collection of five diverse approaches illustrates that coordinated pharmacotherapy can be implemented effectively across a variety of health care organizations. Many of the programs have resulted in improved outcomes and/or reduced overall costs of care. This report provides detailed descriptions of the development and operation of these programs. These approaches may, with appropriate modifications, be applicable at other care sites, and can represent a blueprint for organizations wishing to implement coordinated pharmaceutical care.

TA B L E O F C O N T E N T S Overview ....................................................................................................................................................................................... 3 Introduction ................................................................................................................................................................................. 5 Case Studies Protecting the Vulnerable Elderly During Transition from In-patient to Home Care Crozer-Keystone Health System ................................................................................................................................................... 6 New Technologies in Burn Care Require Coordination of Pharmaceutical Therapy Alta Bates Hospital Burn Care Center.........................................................................................................................................16 Coordination of Pharmaceutical Care in High-Risk Patients with Coagulation Disorders Johns Hopkins Bayview Medical Center ......................................................................................................................................24 Centralized Accountability for Coordinated Pharmaceutical Care in a Multi-Specialty Clinic Palo Alto Medical Foundation Clinic ..........................................................................................................................................32 Education Improves Medication Management, Regimen Knowledge, and Outcomes in HIV/AIDS Patients San Francisco Department of Public Health...............................................................................................................................40 What the Case Studies Have Taught Us ....................................................................................................................................46

Coordinated Pharmaceutical Therapy in Chronic Care 3

INTRODUCTION Pharmaceutical innovation has greatly improved treatment outcomes and quality of life for many patients. However, the full potential of pharmaceutical therapy is seldom reached due to the prevalence of uncoordinated care. Chronic care patients, especially the elderly, are most affected by uncoordinated care due to the complexity and multiplicity of their conditions and drug regimens, and their reliance on multiple care providers.

• Ongoing assessment of drug regimens and proper prescribing and use of drugs • Centralized knowledge of the patient’s full medical history and all currently prescribed medications • Effective communication and feedback among care providers, especially across sites of care • Education and involvement of the patient in the treatment plan • Evaluation of the effectiveness of coordinated care programs

The Need for Coordinated Pharmaceutical Care As the pace of innovation in pharmaceuticals, diagnostics, and medical practice quickens, the “practice gap” between the availability of important innovations and their most effective use is widening. The advent of “disease management,” which has brought many important advances beyond episodic and uncoordinated care, has resulted in increased cooperation and information-sharing among providers. However, additional coordination of pharmaceutical care is often required because disease-by-disease approaches may neglect interactions among diseases and their treatments. Additional factors contributing to the increased need for coordinated pharmaceutical care include increased numbers of medical specialists and sub-specialists, and the rising population of fragile, elderly patients with comorbidities. Complicating the situation further is the movement by patients through different services and sites of care of newly merged health systems. Principles of Coordinated Pharmaceutical Care One impediment to the realization of coordinated pharmaceutical care is the ambiguity regarding the definition of this concept and its principles. In 1999, the National Pharmaceutical Council (NPC) joined with the National Chronic Care Consortium (NCCC), an alliance of the nation’s leading non-profit health systems, to articulate a vision and framework for coordinated pharmaceutical care, and to outline some key principles. Ten of the most important principles are as follows: • Commitment, leadership, and support for coordinated pharmaceutical care from upper management • Alignment of financial incentives and clinical goals across sites of care and service sectors • Management by interdisciplinary teams of physicians, pharmacists, and other care providers • Centralized responsibility and accountability for the totality of pharmaceutical care for the individual patient • A system for identifying patients at high risk for undiagnosed disease and suboptimal therapy

These and other aspects of coordinated pharmaceutical care are further described in a NPC/NCCC brochure entitled Integrating Pharmaceutical Care: A Vision and Framework, which is available free of charge from NPC (www.npcnow.org).

Case Studies The challenge now is to put these principles into practice in the real world of care delivery. Clearly, resource constraints limit what can be accomplished in mounting new programs that may require coordinating activities across sites of care, building teams, and assembling patient-level databases. Despite this, a variety of innovative coordinated care programs have sprouted up across the country. Five of these programs are profiled here, as examples of successful approaches taken by different types of provider organizations. These programs embody many of the principles of coordinated pharmaceutical care developed by NPC and NCCC. These case study profiles were based on interviews with individuals who designed, championed, managed, or participated in the programs. These individuals also provided written descriptions of program details as well as information on program results. Their sense of pride and accomplishment in launching these programs was apparent during these communications. NPC is grateful for their help in codifying this information. Through distribution of this booklet, we hope to make these innovative programs more widely known so that others may be encouraged to implement programs of their own. Contributors include: Sydney Hecker, MD, Robert Scheidtman, PharmD, Bruce Bienenstock, MD, Lori Reisner, PharmD, Kathy Korbholz, Edward Casey, RPh, Peter Daley, RPh, Alan J. Ross, Jerold T. Kaplan, MD, June M. Buckle, ScD, Mary G. Meyers, RN, MS, Phillip Zieve, MD, Burt Finkelstein, PharmD, Charles Twilley, PD, MBA, and Mathew Sharp.

Coordinated Pharmaceutical Therapy in Chronic Care 5

Case 1 Protecting the Vulnerable E l d e r l y D u r i n g Tr a n s i t i o n f r o m In-patient to Home Care Crozer-Keystone Health System D e l a w a r e C o u n t y, PA w w w. c r o z e r. o r g

CONTENTS Overview................................................................................. 8 Pharmaceutical Care Assessment Program.............................. 8 Disease Management and Home Care Create Program Need... 8 The Program’s Genesis............................................................ 9 An Innovative Partnership with a Pharmacy School................. How the Program Works......................................................... Rotation Training.............................................................. The Pharmacy Risk Assessment – A Standardized Tool..... In-Home Pharmaceutical Regimen Assessments............... Intake and Planning.................................................... Recommendation Documentation, Communication, and Follow-up....................................................... Program Results......................................................................

9 9 9 11 11 12 13 13

Three Case Examples.............................................................. 14 Lessons Learned and Keys to Success...................................... Physician and Nurse Manager Acceptance........................ Anticipate Growth and Maintain Flexibility........................ Assessment and Data Collection Tools...............................

14 14 15 15

The Crozer-Keystone Health System......................................... 15

Coordinated Pharmaceutical Therapy in Chronic Care 7

Overview The Pharmaceutical Care Assessment Program at Crozer-Keystone Health System provides a real world approach to delivering coordinated pharmaceutical services to patients with complex drug regimens. The Program’s focus is on serving elderly patients during their time of greatest need: the transition from in-patient care to home care. The Program is staffed through an innovative arrangement with a nearby pharmacy school and provides enhanced coordinated pharmaceutical services for no additional cost to patients or the health care system. This Program reflects many principles of coordinated pharmaceutical care. Coordinated therapy for high-risk elderly patients is provided during their transition from hospital to home care. In-home visits allow patients and pharmacists to work together to assess the patient’s pharmaceutical coordination requirements and individual pharmaceutical needs. A complete medical history is retrieved from the health system’s computer. A tailored treatment plan is developed which considers the patient’s self-care capabilities, medication regimens, and needs for education. Prescription and non-prescription drug regimens are confirmed, patient knowledge of drug regimens and diseases is determined, and appropriate education is provided. A comprehensive drug interaction and medication management review is also conducted. The results of the visit are entered into Crozer’s computer system to become part of the patient’s permanent medical record. After the visit, a telephone follow-up is conducted to review any medication or regimen changes, and to answer additional questions. An interdisciplinary management team has integrated the program into the operations of Crozer’s home care agencies. Comprehensive education and training of the pharmacists making in-home visits ensures a consistent standard of service.

Pharmaceutical Care Assessment Program The Pharmaceutical Care Assessment Program was developed to address pharmaceutical coordination issues for high-risk, elderly patients transferring from inpatient facilities to home care status. High-risk patients include those with multiple diseases and who require multiple medications. Special attention is given to potential interactions among prescribed medications and between these medications and over-the-counter (OTC) products. Patients entering any of Crozer-Keystone’s three home care programs are eligible for this assessment program. An initial pharmacy assessment is made by the home care admitting nurse during the first visit to the home. Patients with high-risk scores on a standardized risk assessment intake tool are referred to the Program for a more complete in-home assessment

8 Coordinated Pharmaceutical Therapy in Chronic Care

by a pharmacist or board-eligible fifth year Doctor of Pharmacy student. During this (voluntary) home visit, the patient’s pharmaceutical care plan, self-care capabilities, medication regimens, and pharmaceutical education needs are assessed. The results of the assessment and any pharmaceutical coordination recommendations are reported to the primary care nurse and the patient’s admitting physician on a written form or through Crozer-Keystone’s home care medical record system. The Program team, consisting of the Program Preceptor (a clinical pharmacist who is the Program manager) and all current pharmacy students, reviews the results and recommendations and makes appropriate regimen modifications and education interventions, or enrolls the patient in additional disease management programs (see below).

Disease Management and Home Care Create Need During the 1990’s, Crozer-Keystone, like most integrated delivery systems, implemented a broad-based disease management and wellness program offering individuals and their families the latest treatment options, technology, education, and resources. Primary care physicians are provided with updated information from specialists and specialty professional organizations regarding new treatments, medications, and care guidelines for specific diseases. Developing these disease management and wellness programs spanning the entire care continuum highlighted the need for increased focus on effective transitions between inpatient care and home care. The multidisciplinary team that implemented the congestive heart failure (CHF) program included physicians, inpatient nurses, and home care nurses. The CHF team quickly recognized the need for pharmaceutical coordination during the transfer to home care. Furthermore, in 1997, Medicare regulations required nonpharmacy-trained health care professionals (e.g., physical, speech, and occupational therapists) to provide a complete assessment of patient care, including pharmaceuticals. These regulations strengthen the need for pharmacy-trained personnel to participate or intervene when necessary in cases where no nursing involvement is present.

The Program’s Genesis The CHF team, together with Edward Casey, RPh, Director of Pharmacy Services, worked with one of Crozer-Keystone’s three home care agencies to launch a pilot program, staffed by a pharmacist from Crozer-Keystone and a pharmacy student from the Philadelphia College of Pharmacy and Science. The pilot program was, in part, a response to the launch and projected growth of Crozer-Keystone’s Medicare Risk program. Under the program, the health system was assuming global financial responsibility for an elderly patient population with many complex medical and pharmaceutical needs. The pilot program fit the goals and objectives of total quality improvement and cost management required to build a successful Medicare Risk program. In this pilot phase, a first-generation pharmaceutical care risk assessment tool was used, and patient referrals and informal assessments were conducted. The home care administrators responded favorably, and there was evidence of positive clinical impacts in the first twenty-five patients (see chart below). This resulted in program expansion and improvement of the tools, processes, and personnel to manage and conduct the program on a larger scale.

Program expansion began with the addition of the Program Preceptor, a full-time clinical pharmacist, with 50% of his time allocated to the Program. Further expansion to all three of CrozerKeystone’s home care agencies required a substantial increase in pharmacy staff resources. This need was met through a formal partnership with the University of the Sciences in Philadelphia (U.S.P.).

An Innovative Partnership with a Pharmacy School Crozer-Keystone and the University of the Sciences in Philadelphia agreed to support a rotation of U.S.P. pharmacy students through the Program. This innovative partnership enabled both organizations to meet their goals, while providing patients with a substantial benefit at no additional cost to the patient or the Health System. U.S.P. was pleased to provide its pharmacy students with the opportunity to gain valuable experience in an ambulatory care setting. The students work directly with patients in their homes and gain insight into real-life drug therapy challenges faced by patients with complex chronic diseases.

How the Program Works

12

The Program is managed by the Program Preceptor, Peter Daly, RPh, a clinical pharmacist who reports directly to the Director of Pharmacy Services. Under Dr. Daly’s leadership, a management team representing all facets of the health system has effectively integrated the Program into the operations of Crozer-Keystone’s three home care agencies. The Program is comprised of four main components: rotation training, use of a pharmacy risk assessment tool, in-home assessments, and recommendations and follow-up.

Received home consults Compliance problems

12 3

Rotation training

Received education Drug-related admissions Drug therapy recommendations

5 2 9

R E S U LT S O F P I L O T P R O G R A M Program Details Total patients in pilot Patients qualifying for program (intake score >15)

• Five meds discontinued at $325/month (three for one pt.) • One added drug treatment, one change in drug regimen schedule, and one request for lab tests

Number of Patients 25

During the course of the year, ten groups of pharmacy students rotate through the Program. Each group consists of three pharmacy students working under the direct supervision of the preceptor for a total of ten weeks. Each pharmacy student is assigned to one of Crozer-Keystone’s home care agencies. Comprehensive pharmacy student orientation and training was implemented to ensure a consistent standard of service. The orientation consists of one day of intensive formal training, followed by at least three days of observation with home care nurses, hospice nurses, or physical therapists. The orientation session covers a variety of administrative and technical topics.

Coordinated Pharmaceutical Therapy in Chronic Care 9

Administrative topics include: • The Program’s mission, vision, and philosophy • Risk and safety management strategies • Clinical information systems • Confidentiality guidelines • Program documentation requirements • Hospice program objectives and services Technical topics include: • Supportive care Screening Tool

10 Coordinated Pharmaceutical Therapy in Chronic Care

• Heart Success Program • Medication administration and medication errors • Adverse drug reactions • Pain management • Intravenous and parenteral therapy at home • Infection control • Disease management guidelines for gastroesophogeal reflux disease, asthma, arthritis, CHF pain management, and other diseases • Drugs to be used with caution in the elderly

Upon completion of the orientation, the student enters field training under the supervision of the home care nurses and guidance of the Preceptor. The student is required to complete ten field visits to pass the rotation. Recommendations or changes in patient therapy require prior discussion and/or approval of the preceptor. Pharmacy risk assessment: a standardized intake screening tool The interdisciplinary team that developed the Program also developed a standardized intake screening tool to assist home care nurses in assessing the patient’s pharmaceutical regimen complexity and determining the need to refer a patient to the Program. The basic home care Pharmaceutical Care Assessment Screen (PCAS) shown on page 10 uses eight primary categories to assess a patient’s overall pharmaceutical regimen risk profile. Any patient scoring fifteen or more total points is referred to the Program for an in-home pharmacy assessment.

In-home pharmaceutical regimen assessments Once the patient is referred to the Program, the pharmacy student, with support from the Preceptor and other Program students, completes an eleven-step patient assessment process, the schematic of which is shown below. The objective of the assessment is to increase pharmaceutical effectiveness by confirming prescription and non-prescription drug regimens, assessing the patient’s knowledge of drug regimens and diseases, and providing appropriate education when warranted. In addition, a comprehensive drug interaction and medication management review is conducted. Recommendations are often made to modify existing regimens, change dosing, delete unnecessary medications, add additional drugs, and simplify the patient’s understanding of complex overall drug therapies. The multi-step assessment process is comprised of three sets of tasks: 1) intake and planning, 2) in-home assessment, and 3) recommendation, documentation, communication, and follow-up.

Coordinated Pharmaceutical Therapy in Chronic Care 11

1. Intake and planning a. The referral is logged into the program tracking system and the patient is assigned to a pharmacy student or program pharmacist. b. The pharmacy student uses the Health System’s Delta computer system to retrieve a complete medical history and all patient demographic information. c. The pharmacy student contacts the patient to schedule an in-home appointment for the pharmaceutical assessment. The student inquires about anyone assisting the patient with medication administration (friend, relative, etc.) and if

12 Coordinated Pharmaceutical Therapy in Chronic Care

necessary includes that person in the appointment. Once scheduled, the student notifies the primary care nurse of the appointment date and time. d. If the patient refuses the visit, the student prepares a refusal form and submits it to the Preceptor. The refusal is then copied to the home care nurse making the referral and documented in the electronic medical record. e. Prior to the visit, the student prepares a patient review plan highlighting specific issues for discussion. Educational materials are assembled and potential drug interactions are checked based on known existing prescriptions.

2. In-home assessment f. The student and patient meet in the patient’s home for about one hour to complete the pharmaceutical assessment. The student checks the contents of the medicine cabinet and the patient’s pill box. They discuss the patient’s understanding of each prescription, when it should be taken, what it is for, special instructions, and potential adverse drug reactions. The patient is also encouraged to discuss any side effects experienced and to ask questions regarding medication regimens. g. The home visit is documented using a standardized Pharmaceutical Care Assessment Form (see below). This form includes demographic information, medical history, medication lists, visit observations, and vital sign/lab report results. The form is completed with a succinct list of prioritized problems and recommendations for regimen modification, additional patient education, patient assistance, and other pharmaceutical interventions. h. The entire Program team meets weekly with the Preceptor to review all assessment forms and recommendations. The assessment is modified to reflect team conclusions, and a final copy is delivered to the Preceptor and the home care nurse. A formalized tool, the Pharmaceutical Care Assessment Health Care Communication Form supports the in-home assessment. This form (shown on page 12) documents key patient data, medical problems, all prescription and OTC medications, patient observations, and recommendations. Upon completion of the form, it is

reviewed and approved by the Preceptor, and formal recommendations are made to the patient’s home care nurse and physician. 3. Recommendation documentation, communication, and follow-up i. The home care nurse is informed, in person or by voice mail, about the results of the visit, potential or existing problems, and important recommendations. Critical issues found while the pharmacist is still at the home are communicated to the primary care nurse and Preceptor via pager, and corrective action is taken immediately. j. The student records the patient visit and any recommendations directly into the Health System’s Delta computer system, which communicates the results of the visit to all the patient’s providers including his physician, nurses, etc. and becomes part of the patient’s permanent medical record. k. A follow-up telephone visit is conducted to review any changes in medications or altered regimens and to answer additional questions. The follow-up call is documented in a report and submitted to the Preceptor and home care nurse. Program Results Although formal outcome studies measuring the cost benefits of the Program have not yet been completed, process results and anecdotal patient results indicate the program is effective. A study of 166 referrals during the period January 1998 to February 1999 noted the following pharmaceutical regimen improvements resulting from the Program (see table below). The acceptance of 33 patient-specific recommendations for

P R O G R A M R E S U LT S

Referrals Received home consults • Required intervention Recommendations made Drug therapy recommendations • Recommendations accepted

Number of patients

Percentage of patients

166

100%

53

32%

51

96%

146

100%

118

81%

33

29%

Coordinated Pharmaceutical Therapy in Chronic Care 13

the 166 referrals indicates the intake assessment tool is working effectively to select appropriate patients for the Program, and the in-home pharmaceutical assessments are effectively identifying a wide variety of therapy improvement opportunities. During the three-month period from April 1, 1999 to June 30, 1999 the Program received 420 referrals. Compared to the 166 referrals received from January 1998 to February 1999, this represents an annual growth rate of over 1,000%. The Program’s dramatic growth during 1999 indicates an overwhelmingly positive response from the home care nurses and primary care physicians. As the Program advances in the future, Crozer-Keystone plans to complete a comprehensive outcomes assessment and to constantly monitor the effectiveness of the intake assessment tool and other Program features. Three Case Examples Provide Evidence of the Program’s Effectiveness: • Case 1. A 77-year-old woman was referred to the Program due to her recent myocardial infarction and history of multiple medications. During the home visit, the student noted a duplication in therapy with clopidogrel plus aspirin –– a combination that resulted in an increase in bruising. Also, the patient was without a clinically indicated drug (ACE inhibitor) proven to decrease morbidity and mortality in post myocardial infarction patients. Furthermore, the patient, who also has a history of asthma, was prescribed an antihypertensive agent but was suffering from bronchoconstriction and difficulty in breathing. The antihypertensive has been shown to have bronchoconstrictive properties. The Program recommended the duplicate drugs be removed from the patient’s regimen and an ACE inhibitor added. The patient’s physician agreed with the recommendations and implemented them immediately, avoiding a potentially dangerous drug interaction. The patient has not been re-admitted to the home care program or hospital. • Case 2. A 76-year-old woman, referred to the Program due to “excruciating pain” from arthritis and spinal stenosis, was noted to be suffering from inadequate pain control and insomnia. The student suggested an immediate-release narcotic for break-through pain control, combined with a continuous-release narcotic for long-acting pain control. A change in dosing schedule for the diuretic furosemide was also suggested – the dose was to be given earlier in the day instead of just prior to sleep to prevent frequent nocturia. The recommendations were approved by the patient’s physi-

14 Coordinated Pharmaceutical Therapy in Chronic Care

cian and resulted in improved pain control and decreased nocturia, significantly improving the patient’s quality of life. • Case 3. A 74-year-old woman with a history of chronic airway obstruction, heart failure, bronchitis, and arthritis was referred for an in-home pharmacy consult because her drug therapy included multiple medications with possible drug-drug interactions. During the visit, the student noted several duplications of therapy such as for her pain control. The patient was also prescribed two corticosteriod inhalants while only one is clinically indicated for the treatment of chronic airway obstructive disease. Furthermore, the patient was prescribed guaifenesin/phenylpropanolamine and amitriptyline. Concurrent use of these medications may result in hypertension, cardiac arrhythmias, and tachycardia. The Program recommended discontinuing four medications. The recommendations were implemented, drastically reducing the potential for adverse side effects (especially falls) and potential drug interactions. Lessons Learned and Keys to Success Three essential lessons were learned as Crozer-Keystone implemented this program over the course of four years. Physician and nurse manager acceptance A critical factor leading to implementation of the Program was the support and acceptance of the health system’s physicians, and particularly the primary care nurses (case managers) at the home care sites. Gaining support was accomplished by leveraging other health system programs like the CHF disease management program. The leadership team of the CHF disease management program helped identify the need for the Program; designed it to fit the needs of the physicians and primary care nurses; and built initial support for the implementation of pilots. The pilot program was used to fine tune Program tools, demonstrate Program effectiveness, and broaden the support base.

Anticipate growth and maintain flexibility Pharmaceutical coordination programs that are well designed, have physician and provider support, and target well-defined patient needs are likely to experience phenomenal growth and create the potential for unmet demand. Maintaining initial success and momentum does not require anticipating every detail from the outset, but rather a mindset that embraces flexibility and creativity. By effectively anticipating the potential growth of the Program, Crozer-Keystone was able to expand capacity through creative partnerships with pharmacy colleges, and through “controlled release” of the Program into the system’s two additional home care agencies. By maintaining positive momentum throughout its growth, Crozer-Keystone ensured the Program’s long-term success. Assessment and data collection tools The importance of designing and utilizing consistent, effective tools to perform home care intake and in-home pharmaceutical assessments cannot be underestimated. Nurse case managers and any other health care professionals opening a case can use the intake tool as a guideline to make effective referral decisions. Similarly, the structured format of the assessment form maintains consistency of reporting, and guides inexperienced pharmacy students to make comprehensive assessments and recommendations. Both tools can be used as a starting point for health systems interested in implementing a similar program, and they can be tailored to meet the specific needs of the health system, home care program, and patients.

The Crozer-Keystone Health System Crozer-Keystone Health System’s network of facilities and physicians provides residents of Delaware County, Pennsylvania and surrounding communities with easy access to primary care and specialty services. Crozer-Keystone consists of five hospitals with 1,088 licensed inpatient beds and 649 sub-acute and skilled nursing beds in its seven long-term care and transitional care units operated by 1,128 medical staff. The health system includes 36 primary care sites staffed by 147 physicians conducting over 200,000 office visits annually. In addition, Crozer-Keystone operates three centers for occupational health, a sports club, and centers for family health in each of its primary service areas.

In summary, the Program provides a rational approach to delivering coordinated pharmaceutical services to patients with complex medication regimens. In-home visits allow patients and pharmacists to work together in a comfortable, private setting to assess the patient’s pharmaceutical needs and to take appropriate corrective action. Through an innovative arrangement with pharmacy schools, the Program can be implemented at little or no cost to the health system or its patients.

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Case 2 N e w Te c h n o l o g i e s i n B u r n C a r e Require Coordination of Pharmaceutical Therapy Alta Bates Hospital Burn Care Center San Francisco Bay Area, CA w w w. a l t a b a t e s . c o m

CONTENTS

Overview ............................................................................ 18 “Blended Medicine”........................................................... 18 Pharmaceutical Coordination in Burn Care........................ Effective Dosage Levels in Pain Control ........................ Effective Dosage Levels in Antibiosis............................. Dietary Concerns and Impact of Diet on Pharmaceutical Effectiveness ...................................... Pharmaceutical Challenges in Discharge Planning........

18 18 19 19 19

Coordinating Pharmaceutical Care..................................... 19 The Burn Coordinator is the Hub of the Coordination Wheel ................................................. 20 Role of Pharmacists in Coordination............................ 20 Lessons Learned and Keys to Success................................. 20 Unique patient circumstances heighten need for pharmaceutical coordination .................................... 20 Nurse Coordinator role enables pharmaceutical coordination ......................... 21 Information and communication systems leverage hospital-wide resources............................. 21 The Alta Bates Hospital....................................................... 21 Appendix: Advances in Burn Care ...................................... 22

Coordinated Pharmaceutical Therapy in Chronic Care 17

Overview

“Blended Medicine”

The Alta Bates Hospital Burn Care Center is located in the San Francisco Bay area of Northern California. The Center employs “blended medicine” with a core of multi-specialty professionals to deliver coordinated services, including pharmaceutical care, to burn patients. The blended medicine approach ensures the effective management of these high-risk, high-cost patients.

The Burn Center is a six-bed facility occupying 3,000 square feet within a 310-bed hospital. Eighty to one hundred patients are treated yearly by a core of multi-specialty professionals, who draw upon the resources of the hospital in their practice of “blended medicine.” Although burn patients occupy a relatively small percentage of hospital beds, these intensive care patients require high levels of staff support and hospital resources.

Coordination of pharmaceutical therapy enables the Center to take full advantage of recent advances in burn care pharmaceutical and service technologies. Coordinated therapy extends from emergent care through inpatient and outpatient rehabilitation and into extended care planning for the patient’s return to normal activities of daily living (ADLs). The burn coordinator, discharge planner and hospital clinical pharmacist provide a nucleus of professionals focused on developing and implementing coordinated pharmaceutical care processes to address the unique needs of burn care patients. These processes include: establishing effective dosage levels for pain control and antibiosis; managing relationships between pharmacotherapy and diet; and discharge planning that provides individualized pharmaceutical regimens. Many key principles of coordinated pharmaceutical care are evident in the operation of the Burn Center. High-risk burn patients require complex, precise pharmaceutical therapy and careful, ongoing assessment of drug regimens. The complexity of pain control in these patients, plus their need for drugs compatible with their nutritional status, necessitates a coordinated approach to prescribing, dosage titration, and monitoring. Coordination extends across service sectors. An interdisciplinary team (including surgeons, nurse coordinators, therapists, and the clinical pharmacist) develops and implements coordinated strategies and shares information at weekly “plan of therapy” sessions. The clinical pharmacist takes responsibility for centralized pharmaceutical care by overseeing pharmaceutical use and maintaining communication with burn specialists to determine effective dosage levels for optimal wound care. A data system enables the pharmacist to monitor pharmaceutical use and laboratory indices. Abnormalities associated with improper use and dosages of medications are flagged for follow-up.

18 Coordinated Pharmaceutical Therapy in Chronic Care

Burn Center Director Jerold T. Kaplan, MD is trained in bacteriology and orthopedics –– fields vital to managing burn patients. Under Dr. Kaplan’s leadership, the Center has effectively implemented a coordinated approach to pharmaceutical treatment that extends from emergent care through inpatient and outpatient rehabilitation and into extended care planning for the patient’s return to normal activities of daily living. The Center’s medical professionals and therapists rely on frequent meetings and close communication to optimize patient care. The charge nurse, occupational therapist, surgeon, and clinical dietitian pool their efforts in a coordinated fashion. The charge nurse and discharge planner play a central role in guiding treatment and coordinating therapeutic regimens. This is the essence of blended medicine. Central to burn care and blended medicine is the coordinated use of pharmaceuticals at every level of therapy. As a member of the care team, the clinical pharmacist oversees pharmaceutical use and dispensing, and maintains communication with burn specialists in determining effective dosage levels for optimal wound care.

Pharmaceutical Coordination in Burn Care The introduction of improved pharmaceutical therapies for controlling pain, treating infection, and restoring bodily functions in the burn patient has raised four primary challenges in the current management of burn patients.

Effective dosage levels in pain control Pain control is idiosyncratic, varying from burn patient to burn patient. In addition, the significant disruption of tissues and organ systems in moderate second and third degree burns calls for creative measures on the part of the physician. The use of various adjuvant medications such as Phenergan or Vistaril, which potentiate the effectiveness of narcotic analgesics, can serve to reduce analgesic dosage levels. Lower levels of narcotic analgesics and derivatives reduce the potential for habituation, which requires increasingly higher dosage levels.

Titration of analgesic dosage levels must take into account the patient’s vital signs, respiratory rate, hematological and respiratory status, body language, idiosyncratic drug reactions, and neuromental and neurologic status. The complexity and interdependency of these issues requires a coordinated approach to pharmaceutical prescribing, dosage titration, and monitoring.

Effective dosage levels in antibiosis To achieve effective levels of antibiosis to prevent infection, one must rely upon clinical wound examination as well as such timehonored methods as antimicrobial susceptibility testing or disc sensitivity testing. Proper wound culture methods are essential for effective isolation and treatment of wound contaminants. Coordination of pharmaceutical prescribing with wound culture methods ensures that patients receive optimal antibiotic treatment while minimizing the risk of antibiotic drug resistance.

Dietary concerns and impact of diet on pharmaceutical effectiveness Moderately to severely burned patients require more protein and calories to compensate for what is sometimes the loss of ten percent of body weight or more at the time of injury. A delicate balance exists between intravenous fluid intake and protein intake as well. The registered clinical dietitian and medical staff should take electrolyte disturbances and fluid-volume disturbances into account. Where intravenous nutrition is not effective, hyper-alimentation remains an option at all times. The clinical dietitian must remain vigilant in adjusting dietary needs for burn victims with preexistent diabetes, liver disease, or hypertension to ensure the continued effectiveness of their existing therapeutic regimens during recovery from the acute burn trauma.

Pharmaceutical challenges in discharge planning Oral medications may be used unless the patient has a venous catheter in place for continuing intravenous home therapy. Such patients require daily home nursing care and periodic alteration of the intravenous site to avoid infection and skin maceration. Hence, patients lacking the means for home care nursing must sometimes make do with oral medications exclusively. Moreover, the administration of topical wound medications and bandaging often is beyond the scope of self-administered patient care. Appropriate discharge planning integrates the pharmaceutical needs of each patient with his or her individual self-care capacity, financial constraints, and caregiver circumstances.

Lastly, oral analgesics are often substituted for intramuscular analgesics at the time of discharge. The monitoring of analgesic effectiveness and drug interactions is more problematic when patients must monitor their own responses to oral medications without recourse to vital signs and other indices of therapeutic response. Each of these issues heightens the need for coordinated pharmaceutical care, which considers each patient’s circumstances when selecting and administering pharmaceutical regimens across the rapidly changing care continuum. As the patient moves from in-patient emergent care to outpatient rehabilitation and finally to home care, the professional team must constantly assess a complex, interdependent array of medical, social, psychological, and financial considerations to ensure optimal pharmaceutical treatment. To ensure the availability of resources required to support this effort, the Center Director insists that third party administrators and reviewers provide these burn patients with all necessary services and adequate rehabilitation time to recover from their injuries. The Alta Bates Burn Care Foundation provides additional support for medical care.

Coordinating Pharmaceutical Care The Center fulfills the following therapeutic goals and commitments regarding pharmaceutical care of burn patients: • The appropriate use of pharmaceuticals in wound care • The selective and specific use of medications • The selection of appropriate doses of analgesics early on to reduce drug dependency • The reduction of antibiotic drug resistance through shortterm, aggressive therapy • The coordination of pharmaceutical therapies throughout the care continuum The Center maintains close adherence to these principles of therapy and provides for the specialized needs of its patients by integration of pharmaceutical therapy through its well-coordinated care team. Although burn patients require relatively few basic medications (e.g., opiates, Benadryl, silver sulfadiazine, furacin, and various antibiotics), drug interactions and iatrogenic complications are possible. These complications can result from the patient’s existing therapies for chronic conditions such as diabetes, liver disease, arthritis, and hypertension. The focus of the clinical pharmacist on the totality of drug therapy has minimized such adverse events.

Coordinated Pharmaceutical Therapy in Chronic Care 19

The Burn Coordinator is the hub of the coordination wheel The Center is a model of multi-specialty or “blended care” medicine. Core team members, including surgeons, nurse coordinators, therapists, and the clinical pharmacist, meet weekly at “plan of therapy” sessions to discuss therapeutic options for their patients. These meetings also serve to keep all team members absorbed and involved in individual patient care. While these meetings ensure that all members are involved in developing coordinated therapeutic plans for the patients, daily pharmaceutical coordination is the responsibility of the Burn Coordinator. At Alta Bates a specialized Nurse Coordinator (NC) performs the burn coordinator function. The NC is responsible for dressing changes, skin and wound care, tube feeding, and emergent care for respiratory crises, in addition to responsibility for coordinating all pharmaceutical care. Specialized wound care training, and often ACL certification, enables the NC to maintain control of these multiple tasks. Along with the physician, the NC has the responsibility of titrating intravenous, intramuscular, and oral medications to achieve effective pain control among patients with different pain thresholds. The Burn Coordinator must also adjust for age and health status in administering pain medications at effective dosage levels. Burn severity and organ and body functioning impacted by the burn trauma also influence drug dosing. The NC assumes the role of discharge planner. The NC must choose the proper setting for continuing burn care and rehabilitation, whether at home, in a skilled nursing facility, or at a board and care facility. The NC must wean the burn patients from hospital care while acclimatizing them to an adequate level of self-sufficiency in ADLs. This includes adequate self-care at home, psychosocial adjustment, and ability to use assistive aids such as casts, splints, crutches, canes, or wheelchairs. The most difficult problem the NC faces is the lack of sufficient community safety nets and resources available to the post-burn patient. Months of painstaking burn care and rehabilitation can be reversed by an absence of transitional services and housing for burn patients with chronic and permanent after-effects of their injuries.

Role of pharmacists in coordination The management of medications in burn therapy at the Center is the province of the hospital’s clinical pharmacist. The pharmacist is assisted by a software program that monitors hospital patients for pharmaceutical use and laboratory indices, and that also serves as a pharmaceutical screening device.

20 Coordinated Pharmaceutical Therapy in Chronic Care

When the computer notes systemic abnormalities associated with medications, the pharmacist will “flag” the findings and send a notation to the burn physician and to the patient's chart. The pharmacist will suggest that the physician consult with him to determine what adjustments in dosage may be necessary or beneficial. Thus, the hospital’s coordinated information system allows the pharmacist to effectively support the care team and Nurse Coordinator in the Burn Center without being dedicated to the Center on a full-time basis. The blended medicine model takes full advantage of the spectrum of hospital resources without significant cost to the Burn Center. The clinical pharmacist also closely monitors changes in body chemistry, noting renal, hematologic, hepatic, and auditory status concurrent with antibiotic usage. The burn patient on aminoglycoside therapy to combat gram-negative organisms will have frequent auditory testing. Changes in blood levels are noted and flagged for the physician's attention. In addition, the pharmacist monitors the concentration of the antiseptic furacin used in topical wound care.

Lessons Learned and Keys to Success Over the past ten years, the Burn Center has constantly evolved its practices to incorporate a blended medicine approach to all burn care. Through the efforts of the surgeons and nurse coordinators, this coordinated approach to patient care incorporates each of the critical components of burn care therapy. Three keys to success enabled the effective coordination of pharmaceutical therapy into the blended medicine approach.

Unique patient circumstances heighten need for pharmaceutical coordination Burn victims present many immediate and long-term challenges requiring a comprehensive approach to care coordination from emergent care to a variety of home care settings. Many challenges were realized during the initial emergent care stage, such as the fact that wound debridement and re-hydration take precedence over pharmaceutical issues. However, overall treatment success relies, in part, on effective use of pharmaceutical therapies. Therefore, it is critical to recognize the interdependent role of pharmaceutical therapies and the impact other patient circumstances may have on their effectiveness. Explicitly recognizing these issues provides the basis for developing a coordinated pharmaceutical therapy approach and for complementing the blended medicine team with appropriate pharmaceutical support.

Nurse Coordinator role enables pharmaceutical coordination Recognizing the unique needs of burn care patients, a burn center must centralize and clearly delineate responsibility for coordinating all patient activities. Effective coordination of pharmaceutical therapy relies on the coordinator being close to the patient at all times and physically located on the Burn Center ward. Although the Hospital’s clinical pharmacist provides support and expert input to the pharmaceutical coordination process, primary day-to-day responsibility is maintained at the Burn Center and is coordinated by the Nurse Coordinator. Clear delineation of the NC’s role as the coordinator of therapeutic interventions ensures the pharmaceutical therapies are monitored and adjusted in a coordinated fashion with other patient-specific therapy and planning, such as wound debridement, dietary changes, and discharge planning.

The Alta Bates Hospital Alta Bates Medical Center has a 90-year history of providing excellent medical care and services to the East Bay Area in Northern California. Founded in 1905 by Nurse Alta Bates, the hospital is located on three major campuses in Berkeley and Oakland, and is the major referral center for the East Bay Medical Network. Areas of excellence include : • Burn Center • Rehabilitation Services • Occupational Health • 24-hour Emergency Center • Mental Health Services • Bone Marrow and Kidney Transplant Programs • Heart & Vascular Services

Information and communication systems leverage hospital-wide resources Information systems can extend the knowledge and expertise of hospital personnel at low incremental costs. The systems at Alta Bates Hospital support the coordination of the burn team by monitoring patients and providing feedback to team members. This is especially important for members who are not full-time employees of the Burn Center. In particular, these systems allow the Center to leverage the Hospital’s clinical pharmacist as an integral member of the team, and also convey his knowledge and support to others without his daily presence at the Center.

In summary, Alta Bates Hospital and the Burn Center Director recognized the unique needs of burn care patients and forged a coordinated approach to treating these patients throughout their recovery and transition back to activities of daily living. The Hospital’s information systems and support departments facilitated this approach through creative leveraging of the Hospital’s resources. Through the efforts of the Burn Center Director and the Nurse Coordinator, the Burn Center ensures these high-risk, high-cost patients receive the highest quality care.

• Comprehensive Cancer Center • Family Birth Center • Perinatal Center • Women and Infants Services

The 555-bed Medical Center has 2,700 employees and 900 physicians on staff. Its medical staff is distinguished by the fact that more than 90% of its active physicians are board certified. The Medical Center supports many community programs including the East Bay AIDS Center, Adult Sickle Cell Anemia Program, Mentoring Program for Teens, Primary Care Access Clinic, Breast Health Access for Women with Disabilities, Audio Health Library, and other free public health education classes. Alta Bates Medical Center is part of the Alta Bates Health System, a non-profit organization dedicated to serving the East Bay. Its mission is to provide high-quality, accessible, affordable health care in a comfortable setting for families. It is affiliated with Sutter Health, which is comprised of 5,000 physicians and 25 hospitals in Northern California.

Coordinated Pharmaceutical Therapy in Chronic Care 21

Appendix: Advances in Burn Care Burn care medicine has advanced significantly from the field hospitals and “Medevac” teams who cared for burn victims in the Korean War. MASH team surgeons would debride burn sites, amputate when necessary, and skin graft when appropriate. At that time a limited array of antibiotics was available to fight complicated wound infections. Gram-negative infection or wound sepsis were dreaded events. Patients were bathed frequently with full body immersion as a prelude to extensive debridement and topical care. Orthotists and prosthetists crafted bulky splints and braces in attempts to avoid joint contractures and to restore joint mobility. Morphine, Demerol, and Percodan were the mainstays of pain control. Introduction of the sulfonamides in wound care antisepsis marked a major stride in the treatment of partial and full thickness burns. Topical Sulfamylon cream proved quite effective in wound surface antisepsis by combating various gram-positive and gram-negative surface wound contaminants including Pseudomonas aeruginosa and some fungi. Physiotherapists provided most of the post-burn rehabilitation, using overhead slings and pulleys to mobilize the burn victim as soon as possible. Strengthening and flexibility exercises were used to preserve functional capacity and mobility. Over the last 25 to 30 years, significant advances in burn care have taken place. The sulfonamide derivative, silver sulfadiazine, has largely supplanted Sulfamylon among sulfonamide-based creams in topical wound care. This cream is well absorbed into the tissues and facilitates wound decontamination so that effective skin grafting and wound granulation can take place. It is partially effective against superinfection and wound contaminants, including many yeasts and fungi. In addition, a powerful array of antibiotics, such as the aminoglycosides gentamycin, and tobramycin along with the penicillin derivative Geopen (disodium carbenicillin), have been formulated to combat the gram-negative wound contaminants such as Pseudomonas and Bacteriodes. Extended spectrum antibiotics, along with heparin locks and central venous therapy, have further increased antibiotic effectiveness. New medications in respiratory medicine have contributed significantly to progress in dealing with burn after-effects or sequelae such as smoke inhalation, pulmonary edema, atelectasis, pulmonary obstruction, bronchospasm, and pneumonia. Bronchodilating medications such as albuterol and Atravent

22 Coordinated Pharmaceutical Therapy in Chronic Care

expand airways and dry respiratory tissues. Steroid inhalants such as sodium medrol are used extensively to offset bronchospasm and airway compromise. The progression beyond disc sensitivity methods for establishing effective Mean Inhibitory Concentrations (MICs) of antibiotics has been startling. Today, modern laboratories can use an automated system which examines tube-dilutions of wound bacteria grown on enriched media. Effective pharmaceutical dosage levels and identification of microorganisms is greatly accelerated. Hence, effective wound debridement and irrigation has progressed in lock step with more effective pharmaceuticals. Advances in orthopedics have been significant for total joint replacement and reconstruction. Monoarthrodial and biarthrodial joint surfaces can frequently be salvaged through plastic and metallic implants, which restore joint mobility and function. Occupational therapists (OTs) have in many instances supplemented physiotherapists within burn centers. The OT tries to preserve, maintain, or restore lost functional capacity and also serves as a monitor for standards of patient autonomy and self-determination.

Coordinated Pharmaceutical Therapy in Chronic Care 23

Case 3 Coordination of Pharmaceutical Care in High-risk Patients with Coagulation Disorders

The Johns Hopkins Bayview Medical Center Baltimore, MD w w w. j h b m s . j h u . e d u Prepared by: June M. Buckle1, ScD; Mary G. Myers2, RN, MS; Burt Finkelstein3, PharmD; Charles Twilley4, PD, MBA 1 Associate, Health Policy & Management, The Johns Hopkins University Department of Health Policy and Management, School of Hygiene and Public Health. At the time this program was developed, Dr. Buckle was Senior Director, Care Management and Outcomes Evaluation, The Johns Hopkins Medical Center. 2 Director of Case Management. 3 Director of Pharmacy Services. 4 Clinical Coordinator of Anticoagulation Service

CONTENTS

Overview............................................................................. 26

Forging a New Approach to Care........................................ 26 The Care Management Program: Framework and Governance .............................................. 26 The Care Management Executive Oversight Group........ 27 The Executive Quality Management Council.................. 27 Advances in Anticoagulation Therapy Underlie the Need for Coordinated Care....................... 27 The Anticoagulation Service (ACS): An Example of Successful Pharmaceutical Coordination ...................... Goals........................................................................ Coordinated Pharmaceutical Care............................ Guidelines................................................................ Comorbidities .......................................................... New Patients............................................................. The Case Manager.................................................... Coordination of Anticoagulant Care Across Settings . Evaluation of the Program........................................ Impact of the Program.............................................

28 28 28 28 29 29 29 29 30 30

The Johns Hopkins Bayview Medical Center....................... 31

Coordinated Pharmaceutical Therapy in Chronic Care 25

Overview

Forging a New Approach to Care

The Johns Hopkins Bayview Medical Center in Baltimore, Maryland has established an interdisciplinary care management program that serves patients across the Center’s care delivery settings. The goal is to provide a coordinated array of services and continuity of care as patients move among services and providers. To accomplish this, interdisciplinary teams were organized as part of a general re-engineering of care processes and staff functions. This enabled improved management of care by linking the core functions of the various service entities.

The Bayview staff now practices coordinated, patient-centered care, within a care delivery system that puts patients at the locus of all activities. A new acute-care hospital, the Bayview Pavilion, was designed with this model in mind. The hospital offers a comprehensive, coordinated array of services on the patient care units ranging from rehabilitation to X-ray to pharmaceutical services. This efficient system not only improves staff productivity but also allows patients to be treated without disruption or a trip to a distant, centralized department for testing or therapy.

As one of its initiatives, Hopkins Bayview initiated an anticoagulation service (ACS) for high-risk in-patients and outpatients who require close monitoring of medications and lifestyles. The ACS provides continuity of pharmaceutical care, prevents sequellae, and manages overall costs for high-risk patients with various diagnoses, including atrial fibrillation, cardiomyopathy, congestive heart failure, and other conditions requiring anticoagulation therapy and services.

In order to achieve this coordinated status, the Johns Hopkins Bayview Medical Center needed to “reinvent” itself. In doing so, it was often necessary for major service departments to abolish old structures and approaches. This was necessary to make room for the development of new practice models made possible by linking the core functions of the various service sectors.

After one year of operation the patients in the ACS were better able to attain and maintain therapeutic prothrombin levels. They required fewer trips to the service and were regulated with less frequent testing of prothrombin levels. A reduction of 20% in total costs resulted from a decreased need for monitoring and blood tests. Several principles of coordinated pharmaceutical care are evident in the operation of the anticoagulation service at Hopkins Bayview: Top management was seriously committed to the coordination and continuity of pharmaceutical care for all patients, especially for those moving among services and providers. Management aggressively abolished old structures to enable the linking of core functions of the various services. Patients can now obtain therapy without a trip to a distant, centralized department. An interdisciplinary team of physicians, pharmacists and other providers oversees and assumes centralized responsibility and accountability for pharmaceutical treatment of anticoagulation patients. The service’s longitudinal database enables continuous monitoring of drug regimens, medical history, and all currently prescribed medications. The service also provides education to patients, providers, and caregivers. The service coordinates pharmaceutical care for anticoagulation patients across the continuum of services and treatment sites. For example, the service works with Hopkins Home Care to enable switches in anticoagulation therapy to be made at home that would normally be performed in the hospital. Lastly, the service performs research to determine the effectiveness of its programs.

26 Coordinated Pharmaceutical Therapy in Chronic Care

Rethinking and redesigning work processes was necessary to achieve dramatic improvements in critical measures of performance including quality, cost, service, and efficiency. This required managers to become change agents, and front-line staff to become empowered to redesign their work environments. It necessitated staff from various departments to form interdisciplinary teams to resolve common patient-focused problems. Redesign also included new approaches to coordinating care management activities. For the pharmacy service this involved the redesign and coordination of high-quality pharmaceutical care, while selecting the most cost-effective approaches. The new care management framework and its governance are described below. An example is then provided of how an interdisciplinary team was able to coordinate pharmaceutical care to establish a successful service for anticoagulation patients, especially those with complex medical needs. The Care Management Program: Framework and Governance Care management at Bayview, and throughout Hopkins’ multiorganizational system, is an interdisciplinary program focused on wellness and health promotion and empowering patients through self-care and education. The program reflects the belief that prevention and early intervention produce higher quality care while minimizing cost. Therefore, the program seeks to support individuals at the least intense level of service and in the most appropriate setting. This is accomplished while striving for quality outcomes and assuring continuity of care across the continuum.

The program is designed to be applied to groups of patients as well as individuals in a variety of health care delivery settings and to create smooth transitions from one site of care to another. Therefore, new roles and new services have been created and provided, and mechanisms for evaluating quality- and value-based care have evolved. The Care Management Executive Oversight Group The Oversight Group oversees the care management program, which is an integral component of Bayview’s quality management structure. Group members include physicians, case managers, administrators, and representatives of all clinical departments including laboratory, radiology, and pharmaceutical services. The Group’s objectives include establishing strategic direction for care management; integrating all clinical services into care processes; developing guidelines and extended care pathways; overseeing all clinical practice improvement initiatives; and evaluating outcomes of care. The Group oversees the development of regular guideline reports that coordinate the clinical and financial outcomes of care for each condition under study. The Executive Quality Management Council The Oversight Group reports to the Council, the committee at the highest level of the organizational structure that evaluates the quality of clinical care. Council members include Bayview’s chief executives (e.g., President, Chief Financial Officer, Vice President for Medical Affairs, physician chiefs, administrators, and clinical department directors). The Council oversees the coordination of care across the continuum, secures resources to advance clinical practice, and assures economies of scale across various committees in the organization. The Council receives regular reports from the Oversight Group that reflect continuing progress towards achieving improved clinical outcomes, patient satisfaction, and coordination of new roles and services. Reports from the Council are forwarded to the Board of Trustees. As a result of the commitment of these top executives to the care management program, a greater emphasis was placed on advanced, independent service roles for health care professionals designed to meet the special needs of high-risk patients. Therefore, the activities of case managers (advanced practice nurses) and pharmacists were integrated into the care management program to manage high-risk populations of patients with specific chronic conditions over time and care setting. The case managers focus on specific conditions, such as congestive heart failure, and pulmonary and neurological problems. They also participate in guideline development, pharmaceutical care, and social services, and are integral to the anticoagulation program described below.

Advances in Anticoagulation Therapy Underlie the Need for Coordinated Care The development of new medications, and new clinical knowledge regarding the mainstay agents aspirin and warfarin, has facilitated therapy for patients at risk for thromboembolism. Although warfarin has long been used to prevent thromboembolic disease, studies continue to discover and refine techniques to augment its safety and effectiveness. New drugs for acute-care therapy include the low molecularweight heparin agents, an advance over unfractionated heparin, which requires intravenous administration. These agents, developed in the 1990s, are smaller pieces of the heparin molecule and can be given by subcutaneous injection. They can usually be administered once daily, in a weight-based dose, without subsequent monitoring or dose adjustment. Other advances include thrombolytic agents (t-PA, streptokinase, and others) for heart attacks, stroke, pulmonary embolism, and deep vein thrombosis; and agents for heparin-induced thrombocytopenia (danaparoid and recombinant hirudin). However, therapeutic gains from these advances in acute-care therapy can be offset by improper transition to oral, long-term anticoagulant agents, mainly warfarin. Although warfarin is an effective anticoagulant, it has a complex dose-response relationship. Due to its narrow therapeutic index, significant changes in clotting time can result from as little as a 15% change in dose. Even slight underdosing can result in thrombosis, and too much can lead to serious bleeding. The reported combined rate of major hemorrhage and thrombosis is between 10% to 20%. However, warfarin prevents 20 strokes for every bleeding episode that occurs. In addition, up to five days are required after any dose change (or diet change affecting vitamin K levels) to reach the new antithrombotic state. Elderly or debilitated patients often require lower daily doses of medication; and drug interactions with warfarin are not always known or predictable. For these reasons, blood clotting time for patients on long-term anticoagulation therapy must be closely monitored, and a variety of tests have now become available for this purpose. One crucial advance over the last decade is the standardization of prothrombin time testing from one laboratory to another. In addition, the ability to test for prothrombin times at home, using whole blood from capillaries, now enables patient self-testing and self-management of anticoagulant dose adjustments. Despite the potential for improved therapy associated with these new medications and tests, anticoagulant therapy is often inadequate – especially when care is not coordinated and prescribers

Coordinated Pharmaceutical Therapy in Chronic Care 27

and patients are not educated on best use of medications. For example, an American College of Cardiology study reported a 30% drop-off in compliance with anticoagulant therapy after one year. Often, anticoagulation therapy is not prescribed, or is underdosed. Although warfarin is an effective anticoagulant in atrial fibrillation, one study reported that only 38% of women with this condition were treated properly with warfarin. Since atrial fibrillation is a leading cause of stroke, coordination of pharmaceutical treatment, involving both provider and patient participation, can have a great influence on treatment outcomes and costs.

and in-patients who require oral or parenteral anticoagulation. Emphasis is on achieving maximum benefit while minimizing cost, improving quality of life, and increasing patient and provider satisfaction.

Pharmaceutical care management for this patient population means: • Providing monitoring and dose modifications for chronic anticoagulated patients; • Assuring optimal anticoagulation while minimizing untoward effects;

The Anticoagulation Service (ACS): An Example of Successful Pharmaceutical Coordination The ACS at Bayview was created in response to the need for coordinated anticoagulation therapy. The Service was designed by an interdisciplinary team led by members of Bayview’s Departments of Medicine and Pharmacy. Phillip Zieve, MD and Burt Finkelstein, PharmD, collaborated to gain full support for the team from the medical staff and also gained the administration’s approval for funding of a full-time pharmacist position. Dr. Zieve is Physician Chief and Professor of Medicine at The Johns Hopkins University, and a practicing clinical hematologist. Dr. Finkelstein is Director of Pharmacy Services at Bayview. His responsibilities include helping to define how pharmaceutical services are managed across the System and overseeing the pharmaceutical requirements for all in-patients and ambulatory patients. Dr. Finkelstein and the Clinical Coordinator of the ACS, senior staff pharmacist Charles Twilley, PD, MBA, are empowered to lead the interdisciplinary team as ACS services become increasingly integral to the new practice model. The ACS is administered with the philosophy that anticoagulation therapy is woven into patients’ lives; and with education, knowledge, and understanding about their conditions, the patients will be able to better manage their therapy.

• Assuring attainment of desired therapeutic outcomes, with minimal adverse effects and sequellae using evidence-based guidelines; • Assisting in the transition from chronic oral to short-term parenteral anticoagulation when medically indicated; • Providing education to patients, caregivers, and providers; • Conducting ongoing outcomes-oriented research; • Providing coordinated pharmaceutical care across the continuum of services.

Coordinated pharmaceutical care Planning and designing the ACS program reflected Bayview’s three-fold mission of patient care, education, and research. Planning included developing interdisciplinary performance improvement activities, contributing to the literature through devising and maintaining a database, and creating coordinated evidence-based practice guidelines. To further ensure coordination of pharmaceuticals in the care management processes, an interdisciplinary team developed standards for documentation, education, and accountability for pharmacotherapy.

Guidelines Goals The goal of the ACS is to serve high-risk anticoagulation patients who require close monitoring of their medicines and lifestyles in order to enhance quality of life and prevent sequellae. The ACS is designed to further coordinate pharmaceutical care through care management processes, including monitoring and consultative services to physicians and health care providers. The Service oversees continuity of care for the Medical Center’s outpatients

28 Coordinated Pharmaceutical Therapy in Chronic Care

Integrating pharmaceutical care necessitated that the ACS Clinical Coordinator play a critical role in the development of evidencebased therapy management guidelines that optimize functional and medical outcomes and minimize disability progression. The coordinator led the interdisciplinary guideline team, and worked with the Medical Center’s Director of Guideline Development to ensure that the guidelines were fully coordinated across care delivery sites. The current literature was reviewed for standards of care, and current medication practices were defined.

The ACS longitudinal database contains patient, clinical, satisfaction, and financial information. Data are maintained on primary and comorbid diagnoses, concomitant drug therapy, and recent history of anticoagulant dosing for the conditions seen in the clinic (e.g., atrial fibrillation, cardiomyopathy, congestive heart failure, and other coagulopathies). From the database, reports about drug usage practices and costs were presented to the interdisciplinary team to identify opportunities for performance improvement. The benefits of specific drugs were discussed (e.g., low molecularweight heparin) and drug protocols were reviewed before determining the final evidence-based guideline.

A letter is provided so that the testing can be performed at any facility.

Comorbidities

The case manager

Among the elderly population with multiple comorbidities seen at the clinic, coordinated pharmaceutical care plays an essential role in identifying and managing issues of polypharmacy. Guidelines address initiation and maintenance of therapy, assessment of interactions among multiple medications, dosing modifications, acute transition from oral to parental anticoagulation, chronic monitoring of therapy, and treatment of supratherapeutic INR values. The ACS collaborates closely with physicians of patients with multiple comorbidities, who are often the patients at greatest risk.

When high-risk cardiac patients are admitted to the Medical Center, they are either screened for automatic referral or are referred by another professional to the cardiology case manager. During the intake assessment, the case manager obtains a detailed medication history and current usage calendar. If the patient has been on outpatient anticoagulation therapy with complications in management (i.e., unable to obtain a therapeutic prothrombin time), the care manager makes an additional assessment to consider current issues and lifestyle risk factors. For example, a patient may be noncompliant with the standard medication regimen because it interferes with his or her work schedule. The case manager also obtains information from the insurer about coverage issues.

New patients The intensity of anticoagulant therapy for all new patients is determined by their primary care physician (PCP) or referring physician. If the desired therapeutic range is not specified, it is determined by the ACS physician consultant or the ACS pharmacist. Each new patient and his family or caregiver meets initially with ACS staff. At this time, relevant education materials about therapy and initial laboratory values and their meanings are discussed. For non-English speaking patients, the service facilitates access to educational materials in the patient’s native language. For providers, the ACS subscribes to the newsletter Anticoagulation Forum, which can be e-mailed to all on-line providers as an element of continuing education from the service. Subsequent patient visits involve obtaining laboratory testing, adjusting dosages, and providing follow-up care. Changes in therapy, in accordance with established guidelines, are conveyed to the patient by telephone or in person when the patient is scheduled for the next test. The ACS communicates with the patient frequently on issues such as information on drug therapy, diet, and dose changes based on altered health status. In addition, to ensure continuity of care, vacation planning is offered to patients who require monitoring and who are leaving the area for an extended period.

The ACS also begins documentation for the medical records, which are always available for review by providers. On-line elements of the electronic record give providers with security access the ability to gather information across the health system. In addition to the ACS comprehensive database, documentation about the clinical needs and responses to therapy is maintained for the patient’s in-patient or outpatient medical record. Also maintained are copies of other correspondence to the patient (e.g., reminder letters, vacation letters) and correspondence to the PCP.

All of this information is then presented to the ACS pharmacist who determines if the patient should receive the services of the ACS. Specifically, he assesses if quality of care could be enhanced and complications reduced if the patient were constantly monitored, had further education about self-care, and had stable therapeutic values maintained. The case manager also presents her findings to the patient’s PCP, orients him to the ACS service and facilitates the PCP’s agreement to delegate anticoagulation management to the ACS. Coordination of anticoagulant care across settings The ACS provides services that integrate pharmaceutical care across the continuum of services provided by the system. For example, the ACS works in concert with Hopkins Home Care when a transition from warfarin to heparin is needed for a patient who has developed deep vein thrombosis. Such cases usually require brief hospitalization, but the ACS is able to perform this transition in the patient’s home. The patient saves a minimum of $2,400 in out-of-pocket expenses for hospital room and board since the insurer will likely deny the procedure as an in-patient charge.

Coordinated Pharmaceutical Therapy in Chronic Care 29

Evaluation of the Program

Impact of the Program

The ACS was evaluated one year after its inception, a critical step in determining early successes and future directions. Data were maintained on the number of patients visiting the ACS and the number of prothrombin time (pT) laboratory tests ordered. This allowed comparison of quality and cost factors before and after the patient entered the ACS (the intervention). The table below presents the changes in monitoring, testing, and percentage of patients in the therapeutic range for the 300 patients remaining in the program after one year.

The results of integrating pharmaceutical care into care management processes at the ACS have been well received by management, and the Bayview cardiology service has plans to develop an integrated pharmaceutical service for patients with congestive heart failure. In addition, ideas are currently being formulated for added services for Bayview’s population of frail, often elderly patients with multiple comorbidities. Since aggressive management of such patients decreases the potential for drug interactions, close monitoring and patient education could improve quality of life and decrease costs of care for these patients.

The table shows that the pre-intervention mean number of prothrombin (pT) tests was 30 per patient per year. At the end of year one, this figure dropped to 19. From a quality perspective, patients were able to attain and maintain therapeutic levels, decrease the number of trips to the anticoagulation service, and be regulated with less frequent testing through close communication with the service. The table also shows that the total costs of pT tests decreased by 36%, and other monitoring costs, including additional laboratory testing (e.g., urinalysis), decreased by 74% for an overall decrease in monitoring costs of 61%. In addition, the average number of patients who were maintained in therapeutic range increased by 14%. The total cost savings per patient was $332.98, representing an annualized savings of $115,212 for these 300 patients. Utilization and costs for office visits, hospital and nursing admissions, emergency services, and pharmaceuticals were not determined.

Program Results A N N U A L P R E - A N D P O S T- I N T E R V E N T I O N VA L U E S F O R M O N I T O R I N G , T E S T I N G , A N D E F F E C T I V E N E S S O F A N T I C O A G U L AT I O N C A R E ( N = 3 0 0 ) Program Details

Pre-Intervention

Post-Intervention

% Change

30

19

-36%

Cost of pT tests

$431.96

$277.32

-36%

Other monitoring costs

$241.56

$63.22

-74%

Total monitoring costs

$673.52

$340.54

-61%

43

57

+14%

Avg. number of pT tests/patient

Avg. % patients in therapeutic range

30 Coordinated Pharmaceutical Therapy in Chronic Care

The Johns Hopkins Bayview Medical Center (JHBMC) JHBMC has a long history of employing performance improvement approaches when addressing systems issues, especially for chronic care patients. The three-fold mission of JHBMC focuses on excellence in patient care, teaching, and research. A state-of-the-art, hospital-based outpatient facility was completed in 1999, ensuring that patients have access to and receive quality care across the health care continuum. The JHBMC offers a comprehensive array of clinical services for persons with chronic conditions, including hospital, primary care, prevention, and specialty care services to the Southeast Baltimore community, the greater Baltimore metropolitan community, as well as an international population. JHBMC is a full-service, 700-bed community teaching hospital and long-term care facility housing Maryland’s only regional burn center, and an area-wide trauma center; as well as centers for renal dialysis, a neonatal intensive care, and a sleep disorders center. Johns Hopkins Geriatrics Center is one of the national demonstration sites for the Program of All-Inclusive Care for the Elderly (PACE). The Center provides residential and outpatient day and respite care, home and office-based assessments, and house calls. The National Institute on Drug Abuse and the gerontology section of the National Institute of Aging are also located on the campus. JHBMC staff works closely with Johns Hopkins Bayview Physicians, PA, a not-for-profit, multi-specialty practice whose physicians are full-time faculty of Johns Hopkins School of Medicine. JHBMC is also a major teaching site for the School of Medicine, and has its own teaching programs in medicine and geriatrics.

Coordinated Pharmaceutical Therapy in Chronic Care 31

Case 4 Centralized Accountability for Coordinated Pharmaceutical Care in a Multi-Specialty Clinic

Palo Alto Medical Foundation Clinic Palo Alto, CA w w w. p a m f . o r g

CONTENTS Overview................................................................................. 34 Coordinating Pharmaceutical Care.......................................... 34 Managed Care Fuels Need to Coordinate Pharmaceutical Care 35 The Path to Pharmaceutical Coordination............................... 35 An Innovative Funding Model Leads to Implementation .......... 36 Quality Improvement and Pharmaceutical Coordination......... Pharmaceutical Coordination through Disease Management of Depression........................... Pain, Lipid-lowering, and Anticoagulation Clinics............. Frequent Visitor Program..................................................

36 36 37 38

Benefits of Accountability for Pharmaceutical Coordination.... 38 Lessons Learned and Keys to Success...................................... Focus on Pharmaceutical Coordination to Achieve Competitive Advantage................................ Link Pharmaceutical Utilization with Outcomes to Enable Process Improvement................................. Centralize Responsibility for Pharmaceutical Coordination to Facilitate Process Improvement..............................

39 39 39 39

The Palo Alto Medical Foundation........................................... 39

Coordinated Pharmaceutical Therapy in Chronic Care 33

Overview This case study examines the driving forces that led to centralized responsibility for pharmaceutical coordination at the Palo Alto Medical Foundation Clinic, and how pharmaceutical coordination is key to the effectiveness of various quality improvement projects. Management’s assumption of responsibility for pharmaceutical coordination has enabled an increased focus on the role of pharmaceuticals in care improvement initiatives. Adding pharmaceutical coordination to these ongoing initiatives has resulted in performance improvement throughout the Clinic’s patient population.

Many principles of coordinated pharmaceutical care are evident in this case study: The Clinic has aligned its financial incentives and clinical goals through its focus on coordination of drug therapy. The Clinic believes that although aspects of coordinated pharmaceutical care, such as education and improved compliance, may result in increased prescription use and costs, overall costs are likely to decrease due to reduced use of services. A key feature of this program is its emphasis on centralized responsibility for pharmaceutical coordination. Top management assumed this responsibility and assigned cross-service accountability for this function to a clinical pharmacist, who reports to senior management. Accurate pharmaceutical and clinical databases provide vital support to the Clinic’s quality improvement programs. A robust prescription database enables analysis of physician prescribing, identification of areas for improvement, and the targeting of follow-up education efforts. These databases remove the Clinic’s dependency on its HMO contracting partners for critical information. The Frequent Visitor Program identifies high-risk patients who require additional attention and a high level of provider coordination. Using the prescription database, a number of critical conditions were identified, including asthma, depression, diabetes, and other chronic diseases. The database also identifies patients who would benefit from further pharmaceutical coordination efforts, including patient education, counseling, and compliance support. High-risk, chronic care patients are also served by disease-focused clinics that provide ongoing education, counseling, and condition monitoring. It is anticipated that these efforts will increase medication compliance, identify drug interactions, and support lifestyle habits that complement drug therapies.

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The disease-focused clinics are managed through a team approach involving a combination of providers and educators, including pharmacists, nurses, and physicians. Linking activities in these clinics with each patient’s primary care physician ensures maximum coordination of pharmaceutical therapies. Physician education is provided by the clinical pharmacist, who develops and delivers follow-up education to targeted physicians. The pharmacist also maintains Clinic-wide physician education programs. This education is essential to the success of the Clinic’s disease management programs. Patient education is enhanced by the Clinic’s web site, which provides answers to frequently asked questions.

Coordinating Pharmaceutical Care The Palo Alto Medical Foundation is a multi-specialty group practice that operates three primary clinics in the Silicon Valley. More than 186 physicians and 848 nurses and support staff deliver pediatric, family practice, internal medicine, and OB/GYN services. Over 50% of the Clinic patients are managed care enrollees. The Foundation’s clinics (collectively referred to as “the Clinic”) have implemented many initiatives designed to coordinate and improve patient care. Coordinating pharmaceutical care is an essential element of these efforts. Several key factors underlie the Clinic’s success in pharmaceutical coordination and resultant benefits. Top management has assumed responsibility for pharmaceutical coordination, and has assigned centralized, cross-service accountability for this function. This has provided a framework for successful implementation of many quality improvement programs. In addition, the linkage of pharmaceutical utilization data with treatment outcomes data has facilitated treatment process improvement. This linkage and other elements of pharmaceutical coordination have provided knowledge of drug utilization patterns and their relationships with treatment outcomes and costs. This information is especially important in projecting costs for contracts based on global capitation. The impetus for the program and key stages of its evolution are examined in this case study which describes the implementation of Palo Alto’s depression disease management, anticoagulation, and frequent visitor initiatives. Multi-specialty clinics like the Palo Alto Medical Foundation are well-suited to leading the pharmaceutical coordination effort with the assistance of their health plan contracting partners and other health care industry participants. The linchpin of the Clinic’s success in coordinating pharmaceutical care has been the centralized accountability for pharmaceutical coordination. This accountability rests with the Clinic’s clinical

pharmacist who reports to the Assistant Director of Health Plans, a member of the senior management team. The clinical pharmacist is responsible for supporting all quality improvement initiatives that have pharmaceutical aspects across all three clinics. This case study examines the driving forces that led to centralized responsibility for pharmaceutical coordination, and how pharmaceutical coordination is key to the effectiveness of various quality improvement projects. The assumption of responsibility for pharmaceutical coordination, and assigning this responsibility to the clinical pharmacist, has enabled an increased focus on the role of pharmaceuticals in care improvement initiatives. In addition, the Clinic has assembled the prescription databases necessary for developing and monitoring quality improvement initiatives. These databases remove the Clinic’s dependency on its HMO contracting partners for critical information. Adding pharmaceutical coordination to its ongoing care improvement initiatives, and supporting them with a clinical pharmacist, has resulted in accelerated performance improvement throughout the Clinic’s patient population.

Managed Care Fuels Need to Coordinate Pharmaceutical Care As managed care growth skyrocketed in Northern California in the 1990s, the need to manage the quality and cost of medical care became increasingly important to the Clinic’s managed care customers. Most California health plans eventually included a prescription benefit, and these plans sought to control prescription spending through a host of benefit design features such as generic switching, restrictive formularies, and prior authorization. The health plans also asked the Clinic for assistance in managing physician prescribing patterns. Thus, the Clinic was driven by its customers to analyze, monitor, and alter prescribing, believing that this would lower drug costs. The Clinic does not directly benefit from any drug cost savings that have accrued from these efforts; the financial risk for the pharmaceutical benefit is currently borne by the health plan, and is managed by a PBM or the plan itself. Although global risk contracts are increasingly common, the Clinic receives fixed (capitated) payments only for professional services. However, the Clinic realizes the value of taking responsibility for managing the total cost and quality of care, including pharmaceuticals. Thus, the Clinic is coordinating and managing pharmaceutical care despite its inability to benefit from any reductions in drug costs. Such reductions may result from its programs targeting inappropriate use of resources (e.g., the Frequent Visitor Program

described below). Implementation of other coordinated care programs, including clinical guidelines, education, and improved compliance, may increase prescription use, although overall costs are likely to decrease due to reduced use of services. Increased drug costs accompanied by lower overall costs may result from the Clinic’s coordinated programs for depression, pain, lipid, and coagulation disorders (see below). Underuse of medications, resulting in compromised outcomes, is common for all of these conditions. By focusing on pharmaceutical coordination, the Clinic believes it will increase its knowledge of pharmaceutical utilization issues, create more coordinated health care service models, and increase the overall effectiveness of care. The competitive advantage that is gained from this knowledge will help the Clinic estimate risk for the drug budget component of global risk arrangements in the future.

The Path to Pharmaceutical Coordination In 1990, Medical Director Sydney Hecker, MD, and Director of Pharmacy Robert Scheidtman, PharmD, began coordinating pharmaceutical care at the Clinic. They soon realized that the prescribing patterns of its physicians were extremely diverse and could not be easily analyzed due to a lack of valid, useful prescribing data. Although the Clinic received reports of physician prescribing patterns from the various HMOs, the reports came intermittently; in different formats; on small patient populations; and were based on comparisons to each HMO’s unique formulary. Therefore the reports were inadequate for analyzing the true prescribing patterns of the Clinic’s physicians. Using the reports as a basis for coordinating pharmaceutical care throughout the Clinic proved ineffective and became the genesis for the Clinic’s current efforts. Hecker and Scheidtman set out to coordinate pharmaceutical care using a three-pronged approach: • Develop useful physician prescribing profiles based on a database of reliable, complete, and timely prescribing data for all patients served by the Clinic, • Create a prescribing guideline designed to meet the objective of delivering cost-effective, high-quality medical care, and • Increase focus and accountability for coordinating pharmaceutical care by creating a clinical pharmacist role as a resource for professional teams. Hecker previously chaired a pharmacy and therapeutics committee for an association of physician groups, and the committee

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developed an objective pharmaceutical guideline as a tool. Hecker initially used this guideline to assist the Clinic in developing and evaluating disease management programs. The guideline served as a standard against which all pharmaceutical performance could be measured, and effectively replaced the various formularies used by the managed care plans to create physician-prescribing reports. The Clinic subsequently developed its own guideline, specifically to encourage and measure the quality of pharmaceutical prescribing by the Clinic’s physicians. Simultaneously, Scheidtman began building broad-based support for creating a clinical position to coordinate pharmaceutical care throughout the Clinic’s many quality improvement initiatives. This position was ultimately filled with a clinical pharmacist, using an innovative funding model that leveraged both public and private funds.

An Innovative Funding Model Leads to Implementation Although there was a groundswell of support for the clinical pharmacist position and the need was clearly recognized, garnering management approval for creating the position was challenging since it was difficult to quantify the hard-dollar return on the investment. Scheidtman proposed creating the position with primary funding from nine pharmaceutical company partners. These firms contributed a total of $65,000 toward funding the clinical pharmacist position. In addition, the Clinic struck a partnership arrangement with the University of California San Francisco School of Pharmacy. Under the arrangement, UCSF would place a clinical pharmacist at the Clinic and assume responsibility for 50% of the salary. This provided real-life experience in a medical group setting as part of the UCSF curriculum. The combination of pharmaceutical company funding and the partnership with UCSF allowed the Clinic to create the position on a provisional basis. After the first year, the return on investment from the position was clear, and management approved the position on a permanent basis. The clinical pharmacist has facilitated the coordination of pharmaceutical care within this large clinic, especially through activities associated with its disease management programs. Such activities include: • Networking with pharmaceutical company representatives to identify the most recent clinical studies in the disease area • Identifying, researching, and analyzing the most relevant clinical and pharmacoeconomic studies in the disease area • Analyzing practice patterns and interviewing physicians to develop a primary care physician needs assessment

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• Assisting process improvement teams to develop cost-effective, high-quality clinical guidelines tailored to the needs of Clinic physicians • Delivering follow-up education to targeted physicians • Developing and delivering Clinic-wide physician education programs • Developing and maintaining a prescription database that can be used to monitor the program’s effectiveness

Quality Improvement and Pharmaceutical Coordination Pharmaceutical coordination is evident in the operation of three of the Clinic’s quality improvement initiatives: disease management programs, lipid-lowering and anti-coagulation clinics, and the Frequent Visitor Program. These programs rely on the establishment and maintenance of accurate clinical databases, analysis of clinical patterns, management of care delivery teams, and education of providers on pharmaceutical care. These functions are best carried out within a framework of centralized accountability for pharmaceutical coordination.

Pharmaceutical coordination through disease management of depression The Clinic is implementing a number of disease management (DM) programs as part of an overall effort to improve patient care. These programs focus on complex patient populations that require a high degree of service coordination to maximize the quality and cost-effectiveness of care. The depression initiative clearly demonstrates the value of DM programs that coordinate pharmaceutical care. The DM program for depression focuses on developing and implementing a depression treatment guideline for patients in primary care. Bruce Bienenstock, MD, head of the Clinic’s psychiatry services, initiated the depression DM program by gaining approval from the Quality Assurance and Clinical Improvement Board. The proposed program included four primary components: 1) documentation of current treatment patterns and primary care physician needs; 2) development of a depression treatment guideline; 3) education of primary care physicians on the guideline; and 4) monitoring results. Documenting current disease treatment patterns and primary care physician needs enabled the clinical pharmacist, Dr. Lori Reisner, to perform chart reviews and credibly discuss treatment alternatives and education needs with the primary care physicians. After numerous meetings with primary care physician groups,

Drs. Bienenstock and Reisner had a clear understanding of physician needs related to identifying and treating patients with depression in their practices. This needs assessment assisted them in gathering information for guideline development. Such information included clinical studies, reviews, AHRQ and other guidelines, and DM programs. These were used to build an evidence-based treatment guideline for high-quality care, tailored to the needs of the Clinic’s primary care physicians. Dr. Reisner played an important role in assembling and assessing the information upon which the guideline was based. Dr. Bienenstock said, “Dr. Reisner brought unique skills to the team and an ability to effectively interface with pharmaceutical company representatives to gather clinical evidence.” In addition, her perspective added value to the analysis of various studies and algorithm options. The final algorithm summarized the preferred treatment regimen on one page, accompanied by a compendium of supporting facts and studies. Although algorithm development is critical, the most important step in the program was educating primary care physicians on the benefits of SSRI antidepressant medications and other recommended treatment options. The clinical pharmacist delivered most of the training on depression, as well as specific information delineating drug products, to the primary care physicians. The clinical pharmacist’s role as an educator is essential to successful implementation of DM programs within the medical group setting.

methods are applied in all disease areas to effectively coordinate pharmaceutical care for all Clinic patients. For example, the monitoring and measurement tools developed for the depression program, particularly the prescription database, will be applied universally to all disease management programs.

Pain, lipid-lowering, and anticoagulation clinics As part of the Clinic’s ongoing effort to coordinate care for high-risk, chronic conditions, disease-focused clinics are being developed to provide pain management, lipid-lowering, and anticoagulation services. The goal of these new clinics is to provide education, counseling, and condition monitoring to patients on an ongoing basis, relying heavily on proper pharmaceutical care. Therefore, coordinating pharmaceutical care within these clinics is anticipated to increase compliance with drug regimens, to identify drug interactions, and to influence lifestyle habits that complement drug therapies, thereby improving overall quality of care and reducing total system costs. Each clinic will be established by the clinical pharmacist and managed by a combination of providers and educators, including pharmacists, nurses, and physicians. Linking activities in each of these clinics with each patient’s primary care physician will ensure maximum coordination of the total care plan, including pharmaceutical coordination.

Finally, no clinical performance improvement process is complete without a thorough measurement and monitoring system in place. Dr. Reisner oversees this system using a robust prescription database developed by combining the numerous data feeds received from its managed care partners. After initiating a process to collect the data on a regular basis, Dr. Reisner and a programmer designed an analysis tool to enable her to monitor the DM program, using the prescription database to analyze physician prescribing, identify areas for improvement, and target follow-up education efforts. Using the physician prescribing profiles from the database, together with the Clinic’s own pharmaceutical guideline and its depression guideline, she conducted one-on-one education and training sessions with the primary care physicians. In Phase II of the measurement program, the Clinic will link guideline usage to clinical outcomes using its newly implemented electronic medical record system. In addition to depression, the Clinic is currently implementing DM programs for several other chronic conditions, including diabetes, asthma, and congestive heart failure. The clinical pharmacist plays a key role in each of these efforts and ensures that consistent

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Frequent Visitor Program In 1997, Kathy Korbholz, Senior Administrator, ordered a report listing a specific patient’s visits over a twelve-month period. She was alarmed to discover that the patient had made over 190 appointments during the period. The patient had cancelled and rescheduled over 50 visits and had seen 24 different physicians in 16 different departments. A chart review uncovered no chronic medical problems, identified numerous tests, and provided no real answers. Believing she had stumbled across the rare patient, Ms. Korbholz nevertheless ordered a report for all patients having more than 20 visits during each of the past two years. The resulting report identified over 4,000 patients with more than 20 visits; the original patient was relegated to page 12. Clearly, many patients were not having their medical needs met despite extensive use of Clinic services. Together with a care management team of physicians, administrators, nurses, and the clinical pharmacist, she set out to improve the coordination of care for these patients by initiating the Frequent Visitor Program. In 1997, over 4,200 patients, or 3.59% of all Clinic patients, were identified as frequent visitors. They consumed approximately 20% of the Clinic’s services. An analysis derived from the newly developed prescription database identified a number of critical areas for attention, including patients with chronic diseases such as asthma, depression, and diabetes. The analysis also identified those patients who could benefit from further pharmaceutical coordination efforts, including patient education, counseling, and compliance support. The Clinic instituted a number of programs in 1998 to better manage frequent visitors, including: • Flagging patient charts to identify those requiring additional attention, continuity of provider, and a high level of provider coordination, • Creating a frequent visitor check list to be completed at each visit, • Building social support groups through “group visits” for patients with similar ailments, and • Posting answers to frequently asked questions on the Clinic’s web site to provide medical information without the need for an office visit.

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The clinical pharmacist enabled the care process improvement teams to increase their performance by: • Having better access to pharmaceutical prescribing data, • Bringing an in-depth knowledge of pharmaceutical therapies and their pitfalls to the team, • Analyzing possible pharmaceutical-related causes for frequent visits, and • Assisting the team to develop and deliver effective education on pharmaceutical issues.

Benefits of Accountability for Pharmaceutical Coordination Focusing on pharmaceutical coordination and creating a clinical pharmacist role charged with overseeing pharmaceutical coordination has brought many benefits to the Clinic, including: • Developing a comprehensive prescription drug database that can be used to enable a variety of clinical improvement programs, • Facilitating and supporting the design, implementation, and monitoring of disease management programs in diabetes, asthma, and depression, • Providing valuable pharmaceutical knowledge to all clinical process improvement teams, • Developing expanded roles for pharmacists by planning and founding pain, lipid-lowering, and anticoagulation clinics, and most importantly, • Achieving more effective pharmaceutical utilization throughout the system.

The clinical pharmacist function and related pharmaceutical coordination efforts are still in their infancy at the Clinic. These efforts form the platform for the many clinical improvement programs that are now operational. These programs are successful in terms of process. Significant improvements in clinical outcomes and patient satisfaction are expected and will be assessed.

Lessons Learned and Keys to Success During the course of the past three years, as the Clinic implemented its pharmaceutical coordination program, three essential lessons were learned:

Focus on pharmaceutical coordination to achieve competitive advantage A provider organization should focus on pharmaceutical coordination, even if it is currently not at risk for the drug budget. In doing so, the organization will increase its knowledge of pharmaceutical utilization issues, create more coordinated health care service models, and increase the overall effectiveness of care. Such organizations will be better prepared to understand and accept financial risk for pharmaceutical care from HMO contracting partners who are increasingly preferring global risk contracts.

Link pharmaceutical utilization with outcomes to enable process improvement Information is the key enabler in implementing almost any clinical process improvement program. Analyzing and implementing pharmaceutical treatment often requires a comprehensive prescription database linked to outcomes and other patient information. Although most clinics do not have timely access to such information, as electronic medical records become more common in the clinic setting, pharmacists and process improvement teams will be better able to assess and implement improvement initiatives, education efforts, guidelines development, and performance monitors. The Clinic invested substantial time and resources to develop the prescription database they needed to move these processes forward. The Clinic will continue to improve utilization of information by linking pharmaceutical use and protocol compliance to outcomes and other service use. By the continued use of an electronic medical record, the Clinic will acquire additional knowledge to further improve the coordination of pharmaceutical care.

Centralize responsibility for pharmaceutical coordination to facilitate process improvement Clearly identifying a person or department accountable for coordinating pharmaceutical care can facilitate many clinical process improvement programs. Once the Clinic created the clinical pharmacist role and held the pharmacist accountable for pharmaceutical coordination efforts, other members of the organization sought out her support and knowledge to help them with pharmaceutical aspects of their process improvement initiatives. This accountabili-

ty not only aided in the coordination of pharmaceutical care, but also enabled overall service coordination at the Clinic. The key is not necessarily who is responsible for pharmaceutical coordination, but rather that responsibility is centralized and therefore recognized throughout the health care system. In summary, clear accountability, accurate and comprehensive prescription data, and recognition of the importance of outpatient pharmaceutical care can be achieved by creating a role specifically responsible for coordinating pharmaceutical care. At the Palo Alto Medical Foundation, this position was filled by a clinical pharmacist and resulted in effective implementation of a variety of innovative programs throughout the organization.

The Palo Alto Medical Foundation The Palo Alto Medical Foundation for Health Care, Research & Education is a not-for-profit, tax-exempt public charity nationally recognized for leadership in health care delivery. The Foundation pioneered the multi-specialty group practice of medicine and outpatient services as ways to improve the quality and cost-effectiveness of health care. The Foundation was one of the first organizations in the country to embrace the concept of a coordinated health care delivery system in a managed care setting as a superior approach to improving health services. In 1987, using community philanthropy, long-term financing, and a multi-million dollar gift from its physicians, the Foundation acquired the assets of the Palo Alto Clinic Partnership (founded in 1930). Together with the former Palo Alto Medical Research Foundation (founded in 1950) and a new education division, they created a truly coordinated health care delivery system. The Foundation operates three primary clinics in the Silicon Valley with over 186 physicians and 848 nurses and support staff. In addition to the 69 researchers and staff at the Research Institute and the 17 educators in the education division, the Foundation employs over 1,100 health care professionals. In 1993, the Foundation became an affiliate of the Sutter Health System based in Sacramento, California. This allied the Foundation with a very strong health system. Like the Palo Alto Medical Foundation, Sutter is a not-for-profit organization comprised of more than 30 health-related entities, including hospitals, other medical foundations, an insurance company, and support organizations. Through Sutter, the Foundation recently joined with the California Health Care System to form a statewide health care network, Sutter Health.

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Case 5 Education Improves Medication Management, Regimen Knowledge, and Outcomes in HIV/AIDS Patients

San Francisco Department of Public Health San Francisco, CA w w w. d p h . s f . c a . u s

CONTENTS

Overview of the HIV/AIDS Treatment Education Certification Program (TECP)........... 42 Complex Treatment Regimens for HIV/AIDS Patients............... 42 The Path to TECP Implementation........................................... 42 Elements of the Program......................................................... 43 Results and Benefits................................................................ 44 Knowledge Base of Counselors Improved ............................ 44 Improved Drug Therapy, Treatment Outcomes, Quality of Life................................................................. 44 Expanding and Improving the Program................................... 45 Lessons Learned and Keys to Success...................................... 45 Additional Information on the Origins of TECP....................... 45

Coordinated Pharmaceutical Therapy in Chronic Care 41

Overview

Complex Treatment Regimens for HIV/AIDS Patients

The Treatment Education Certification Program (TECP), sponsored by the San Francisco Department of Public Health, enhances basic knowledge regarding HIV/AIDS care and treatment. TECP is offered to non-medical service providers, including treatment advocates, case managers, peer advocates, mental health and substance abuse counselors, and others who work directly with low-income HIV-positive clients. If necessary, the trainees interact directly with the medical professionals who provide care for these clients.

Dramatic progress in our ability to suppress HIV replication through powerful new medications has resulted in widespread optimism that HIV can become a long-term manageable disease. However, with a multitude of antiretroviral drugs now available and in development, HIV treatment regimens have become increasingly complex.

This training program enables these non-medical providers to better assist their clients in meeting the challenges posed by their complex therapeutic regimens. The program also helps these providers in identifying inappropriate or conflicting drug therapies. The core of the program is a three-day course on HIV/AIDS, its many comorbidities, and the complex treatment regimens faced by these patients. Once certified, trainees provide patients with the support and education necessary to ensure compliance with their treatment regimens and to maximize the value of their pharmacotherapy. The trainees are not intended to replace the physician. Rather, they provide a baseline of information, together with emotional and practical support, for a complex patient population with multiple social and physical challenges. Case reports indicate that the program has been successful in improving pharmaceutical therapy in HIV/AIDS patients. This innovative program demonstrates how public health officials and not-for-profit programs can be essential forces in the coordination of pharmaceutical care. Several principles of coordinated pharmaceutical care are exemplified in this program that serves clients who have multiple coexisting diseases and who often receive prescriptions from several physicians. Effective communication and feedback among caregivers was an essential element of the program, and patients were educated and involved in the treatment plan. Strong leadership by individuals within participating organizations promoted success and rapid acceptance of the program. In addition, the peer-to-peer training fostered a sense of teamwork that built a strong support network for the future.

In addition to receiving treatments designed to suppress HIV replication, most patients are also treated for common clinical manifestations of HIV disease, such as AIDS wasting, HIV-associated psychiatric disorders, pneumococcal infections, pneumocystis carinii pneumonia, cytomegalovirus, and other bacterial infections. Many patients also require therapy for other comorbidities, such as cardiac conditions, diabetes, and asthma. The combination of these regimens confronts the AIDS patient with one of the most complex treatment regimens in medicine. TECP was created in response to this challenge. Program participants help guide patients through prescribed drug regimens. TECP also provides participants with the knowledge necessary to help patients effectively use available pharmaceutical treatments, and addresses the need to integrate education, treatment advocacy, and support in the HIV/AIDS community. TECP ensures that patients have qualified professionals to answer their questions regarding treatment options, results, side effects, and appropriate usage.

The Path to TECP Implementation TECP was made possible by federal funding provided to state and local public health agencies under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. The funds provided to San Francisco’s Department of Public Health were used to create and support public health and wellness programs throughout the city. The programs are administered through a complex array of agencies. TECP is managed by two of these agencies, the Asian and Pacific Islander Wellness Center (API) and Project Inform. TECP was designed with three primary goals: 1) to initiate marketing, public relations, and advocacy effort within CARE program managers and the general public; 2) to develop program management tools; and, 3) to develop training curriculum and resource materials. API hired the program coordinator and master trainer and began developing the marketing, outreach, and administrative materials. Project Inform took primary responsibility for developing the curriculum and training materials. A three-fold approach was used to market the program to the

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local Ryan White CARE-funded programs. First, a program brochure was posted at all Ryan White CARE-funded sites in San Francisco in order to attract interest from individual non-medical providers. Second, TECP Coordinator Mathew Sharp visited program managers of Ryan White CARE agencies to personally introduce them to TECP. This one-on-one outreach resulted in significant interest. Third, the program was marketed through the media. For example, on December 1, 1998 the San Francisco Chronicle ran a story on TECP, which extended interest in the program beyond the local agencies. These efforts resulted in a strong demand for the training courses; training sessions were often over-enrolled. In addition, agencies outside the San Francisco Department of Public Health’s purview became aware of TECP and enrolled their providers through a tuition-based program that was added to respond to the strong market demand. API also took the lead in developing tools necessary to effectively manage the overall program, including tools for intake, screening, scheduling and follow-up with training course participants. API designed participant tracking systems, eligibility certification procedures, and all data entry forms used to monitor the progress of the program and individual program participants.

Project Inform led all curriculum design efforts and, together with API, managed the overall design of the three-day curriculum, including pre- and post-training certification examinations, instructional materials, and an HIV Treatment Education Briefing Book for distribution to all participants.

Elements of the Program The training curriculum and accompanying HIV Treatment Education Briefing Book include sections on: HIV treatment training philosophy; HIV pathogenesis; standards of care; anti-HIV treatments and therapies; opportunistic infections; research, clinical trials and access issues; compliance issues and strategies; strategies for working with multiply diagnosed clients and underserved populations; and sources for updated treatment information. The three-day training course forms the centerpiece for TECP. Each three-hour course was attended by eighteen participants and was led by Project Inform. The training course is augmented by an annual treatment education update, provider work group sessions and one-on-one consultations for participants who need additional individualized training. Five provider work group sessions, lasting three hours each, were held during the year. Each session focused on a topic of interest that could not be covered in sufficient detail during the three-day training. Each session also featured a guest lecturer from the San Francisco HIV/AIDS research and treatment community. These work group sessions, together with the treatment education updates and the core training sessions, form a powerful yearround training program. Individual tutoring was provided for participants having difficulty with the pace or volume of content covered in the training. These consultations focused on areas such as treatment options, HIV pathogenesis, and other complex topics. These tutoring sessions proved particularly valuable for participants who were having difficulty passing the certification exam.

During the program design phase, Project Inform and API conducted a focus group with a number of non-medical providers to establish a baseline for program planning, evaluation, and standards for certification, and to collect input for curriculum design. In addition, a panel of advisors and experts was asked to help guide overall program development, particularly the curriculum.

Coordinated Pharmaceutical Therapy in Chronic Care 43

Results and Benefits The program had positive effects on both the counselors and their client patients.

Knowledge base of counselors improved Analysis of the results from the first year of TECP demonstrates that the program clearly improves the level of HIV/AIDS knowledge in service providers. During TECP’s first year, nine training sessions were held with a total of 152 participants. The participants represented 41 agencies and clinics in the San Francisco area, and they performed a wide variety of non-medical jobs within the agencies as indicated in the figure below.

Profile of Participants

A total of 122 participants, or 80%, passed the certification examination. In addition to taking the final exam, participants completed a pre-test prior to the training session which was used to measure changes in knowledge level. There was nearly a 90% improvement in base-level knowledge about the disease and its treatment alternatives. Ninety-two percent of participants rated the course as very useful or better. Improved drug therapy, treatment outcomes, quality of life The most important measure of the program’s impact would be the improved health and well being of the clients in contact with TECP participants. This information proved difficult to obtain, due to patient privacy concerns and technical issues associated with measuring impact. However, the three case examples below document improvements in the quality of life and treatment outcomes and costs: • Mr. A, a mid-twenties male patient of Pacific Islander descent is diagnosed with AIDS and is prescribed a complex therapeutic regimen including protease inhibitors in a cocktail. Mr. A does not

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speak English well, resulting in numerous unanswered (and unasked) questions regarding the regimens. Consequently, he was incorrectly administering the cocktails and his retroviral load was not improving. While waiting in the lobby of the Asian and Pacific Islander Wellness Center, Mr. A began conversing with the front reception area staff in his native language. He asked many of his questions regarding the drug regimens and other related issues. The reception staff, having been certified in TECP, were able to properly identify potentially serious non-compliance issues and direct Mr. A to a Center counselor who could more fully address his concerns. This effort resulted in increased compliance with the prescribed medications and details of the regimen leading to reduced retroviral loads and improved overall health and well being. • Mr. B, a 37-year-old man diagnosed with AIDS, is currently undergoing a complex treatment regimen of antiretroviral drugs, including agents for the treatment of various AIDS-related events such as Kaposi’s sarcoma and treatments for other non-AIDS related events, such as asthma. During counseling sessions with a TECP-certified social services counselor, Mr. B indicated concern over his continued weight loss and the impact it was having on his appearance. As a result of the TECP training, the counselor immediately recognized that Mr. B might have been in the early stages of AIDS-wasting syndrome. He recommended that Mr. B see his doctor immediately to discuss augmenting his treatment regimen to include a therapy specifically designed to delay or prevent the onset and debilitating effects of wasting. Mr. B’s primary care physician confirmed the lay recommendation and began an aggressive prevention/treatment regimen that resulted in significant improvement in Mr. B’s lean body mass and also increased his ability to avoid serious AIDS-related events. • Ms. C, a 32-year-old woman who recently relocated to the San Francisco area and is currently being treated for AIDS, was meeting with a TECP-certified counselor. The counselor noted the difficulty Ms. C was having maintaining compliance with the multiple pharmaceutical therapies she was currently taking. After a complete “brown bag review,” the counselor determined that Ms. C had been prescribed two overlapping antiretroviral therapy cocktails and could be at risk for unexpected drug-drug interactions. Upon the recommendation of the counselor, Ms. C’s medication profile was immediately reviewed by a clinical pharmacist at a nearby institution, and it was deemed necessary that her physician reassess and adjust the overall therapeutic regimen. As a result, one of the overlapping regimens was discontinued, providing both the health system and the patient substantial cost savings while reducing the risk of dangerous side effects.

Expanding and Improving the Program TECP will build upon its core strengths and expand to include additional trainees. TECP’s success has spread to agencies and organizations throughout the greater Bay Area and beyond; therefore, TECP has created a tuition-based enrollment option for providers from outside San Francisco. TECP is also working with the federal government’s Health Research and Services Administration (HRSA) to fund a national rollout of TECP to cities and agencies throughout the country. According to Mathew Sharp, TECP Project Coordinator, “The foundation is in place to build a powerful nationwide training program to teach non-medical providers to assist HIV/AIDS patients with their treatment regimens.”

Lessons Learned and Keys to Success Development and implementation of TECP has yielded insight into many keys to success in building and integrating a training program for counselors of patients with a complex chronic medical condition. First, chronic care patients with complex diseases, such as HIV/AIDS, need knowledgeable service providers at every point of contact within their sphere of influence. Often this advice is sought in less formal venues than the physician’s office, including friends, fellow patients, case managers, treatment advocates and others working in the system. Providing potential contacts with the indepth knowledge and resources to answer these questions and serve as a safety-net resource for HIV/AIDS patients improves patient compliance with treatment regimens and quality of life. TECP trainees can now answer routine questions with confidence and recognize issues that are best handled directly by the patient’s physician. TECP has given non-medical providers important baseline information to help patients cope with the complex treatment regimens resulting from their disease. Second, successfully launching a training program like TECP requires a focus on specific diseases and the challenges faced by chronic care patients. TECP benefited greatly from San Francisco’s strong HIV/AIDS community and a well-established network of Ryan White CARE-funded organizations. Starting a similar program in other communities where the agency network is not as strong would present additional marketing and organizational challenges. Similarly, other chronic conditions with less developed support networks and patient communities would require additional marketing and grass roots activism.

tions. The leadership provided by API and Project Inform was from within the Ryan White CARE-funded agency community and resulted in rapid acceptance of TECP. In addition, the peer-to-peer training concept fostered a sense of teamwork that builds a strong support network for the future. Combining this informal sense of community with the formalized, ongoing training of the provider work groups and treatment education updates builds a support network of HIV/AIDS non-medical providers who can embrace and lead continuous improvement throughout the non-profit agency system.

Additional Information on the Origins of TECP In San Francisco, the Ryan White CARE Act funds programs that are administered by the AIDS Office of the San Francisco Department of Public Health (SFDPH). The SFDPH has tasked the San Francisco Ryan White HIV Health Services Planning Council to assess community needs and prioritize services to be supported with federal HIV/AIDS dollars. The 1998 efforts of the Planning Council recognized the need to assist its more than 15,000 HIV/AIDS clients in gaining access to, interpreting, and evaluating their treatment options so they can make informed choices. In addition, the Planning Council wanted to hold its nearly 300 non-medical AIDS workers accountable for establishing and maintaining a high standard of competence in a rapidly evolving field. The Planning Council recommended funding a program like TECP, and called for proposals from the area’s Ryan White funded agencies. The Asian and Pacific Islander Wellness Center, the largest non-profit HIV/AIDS agency dedicated to Asians and Pacific Islanders in the United States, together with Project Inform, the nation’s leading HIV/AIDS treatment information and advocacy source, developed a grant proposal for submission to the Department of Public Health. The collaboration of these two leading HIV/AIDS organizations fit the Planning Council vision perfectly, and the Treatment Education Certification Program was funded and launched in September of 1998. The collaboration brought together Project Inform’s unique skills of treatment advocacy and training program design with the day-to-day operational understanding of a large non-profit HIV/AIDS wellness center. The combined expertise of these two organizations was well suited to implementing this complex program across all 68 Ryan White agencies in the San Francisco Metropolitan Area.

Third, strong leadership from within the organizations receiving the training can promote success among participating organiza-

Coordinated Pharmaceutical Therapy in Chronic Care 45

What the Case Studies Have Taught Us The five programs profiled in this report provide insights on successful strategies and approaches for achieving coordinated pharmaceutical treatment.

cal care across care sites of the parent health system. These hospital-based clinics have extended coordinated services into the ambulatory care setting and home care.

Leadership and Management

Education

A commitment by top management characterized many of these successful programs. Management often acted on this commitment by assigning accountability for the coordination function to an individual or a team.

The pace of progress in pharmaceutical technology has heightened the need for both provider and patient education. Educating and providing feedback to physicians and patients is essential for optimal use of advanced pharmaceutical technologies, such as those for patients with HIV/AIDS.

A “champion” with a vision of coordinated care, often the medical director or staff pharmacist, is needed to spearhead the initiative and, most importantly, to engage the interest and cooperation of clinicians. A pharmacist was often the key driver for the development and implementation of the coordinated care process. The pharmacist often worked in partnership with the “champion” (if he or she was not the champion). Nurses often proved to be effective coordinators of the day-to-day operation of the program. These new roles for health care professionals provided added value for the organization. Partnerships Successful partnerships between provider organizations and pharmacy schools have resulted in win-win situations for both parties. Pharmacy students or interns who assumed integral roles in program implementation received valuable experience; the provider organization received low-cost professional assistance in operating the program. Information Systems Acquisitions of nursing homes, hospitals, and other sites of care delivery by health systems have generally resulted in fragmented information systems in which prescribing data are not linked to treatment outcomes data. Although integration of medical charts across sites and a fully computerized medical record are rare, this has not prevented many of the case study sites from linking enough information to implement an effective level of coordinated pharmaceutical care. Coordination Across Sites of Care Specialty clinics within hospitals – e.g., for burn care or anticoagulation – can be a central focus for coordination of pharmaceuti-

46 Coordinated Pharmaceutical Therapy in Chronic Care

Evaluation Improvements in treatment outcomes and costs were noted in those coordinated pharmaceutical programs that engaged in some measurement of program effects. However, since such programs often evolve as resources permit, rigorous and comprehensive cost/benefit evaluations are rarely performed. In addition, recent cutbacks in operating budgets make such evaluations less likely. However, pharmacy professors or graduate students in search of interesting, relevant research projects could perform such analyses. Demonstration of a net economic gain to the organization will help maintain support for the program and justify funding for expansion. Some of the evaluations that were done indicated that drug expenditures may rise as a result of coordinated pharmaceutical care, especially in those programs focused on reducing undertreatment or improving medication compliance. However, in some of these programs, increased drug costs were accompanied by lower overall costs as well as improved quality of care. This is illustrated in the coordinated programs for depression, pain, lipid, and coagulation disorders. Competitive Advantage Coordinated pharmaceutical care programs can be useful even to those provider organizations not currently at risk for drug expenditures. In addition to increasing the overall effectiveness of care, improved pharmaceutical coordination will also help such organizations enhance their knowledge of pharmaceutical utilization patterns. Substantial competitive advantage may result from this knowledge. In addition, improved knowledge of drug usage patterns will help provider organizations entering global capitation arrangements to better estimate drug budget risk.