Transitionofcarefromhospitaltodischargetohomeortorehabfacilities: Do’sandDont’s

JohnFanikos,BS,MBAExecutiveDirector,PharmacyBrighamandWomen’sHospital

Boston,MADecember2,2017

Objectives• Describepatientflowfromhospitalstolongtermacutecarefacilities(LTACs),SkilledNursingFacilities(SNFs),andhome.

• Identifychallengesinprovidingextendedvenousthromboembolismprophylaxisinthesetransitionsofcare.

• Identifypotentialsolutionstoensurepatientssafety.

Outline

• PatientflowfromhospitalstoLTACs,SNFs,andhome.

• TheElectronicHealthRecord(EHR)• EnsuringaccesstoVTEprophylaxis• Patientengagement,support,andfollow-up• Justifyingexpense• Summary

HospitalDischarge&PrescriptionFulfillment

LTC:LongTermCare,LTACH:LongTermAcuteCareHospital,SNF:SkilledNursingFacility

Risk

Assessmen

tProp

hylaxis

Selection

Discha

rge

&

Fulfillm

ent

Complianc

e&

Persisten

ceOrig

ination

LTACSNF

Patient

Receives drug from SNF/LTC pharmacy

Patient

Receives drug from inpatient pharmacy

Discharge planner shares discharge instructions with SNF or LTAC

as necessary

Discharge planner completes drug authorization process

Home HealthCommunity

PositiveOutcomesPrior authorization not required or

prior authorization approved

ChallengingResultsof

Prior authorization denied by payor

Product not stocked at retail facility

Patient reverse the prescription

Receives drug from Meds2Beds prior to discharge

Or

Receives drug from retail pharmacy

Patient

Does may not receive drug

Patient

Hospital

EHR-PrescribeVTEProphylaxis

PharmacologicOptions

MechanicalOptions

NoteAlphabeticalordersoBetrixaban islisted1st

EHR-PrescribeVTEProphylaxis

Labparameters

Abilitytoalterdosing

Question AnswerWhereistheprogram? Theinpatientmedicalunit.

Who is eligiblefortheprogram?

Anypatientnotinanyformofisolation.

Whoalertstheprogramtopatients?

Theadmittingnurseinformspatientsoftheprogramandoffersenrollment.

Howisinformationrelayedtothepharmacy?

IT softwarelinks thehospitalandpharmacycomputersystem.

Who fillstheprescriptions?

Currently,theoutpatientpharmacyisfillingtheprescriptions.

HowaretheRXsrelayedtothepharmacyforfilling?

Prescriptionsareeithere-scriptsorhardcopiesfaxedtothepharmacy.

Whowilldelivertheprescriptionstopatients?

RPhs, studentsorinternsdeliverprescriptions.

7

Med-to-Beds

• Singlecenter,tertiaryorthopediccenter

• THRTKRtreatedwithrivaroxabanfor14or35days.

• Follow-upat6weekswithpatientselfadministeredquestionnaire.

• Gender,age,BMI,Hemoglobin,allcorrelatedwithnon-compliance.

Carrothers AD.JArthroplasty 2014:29:1463-1467.

PersistencewithDOACsinOrthopedics

8

In-hospitalprophylaxis(n=2947,94%)

Arthroplastycases(n=3145,100%)

CompletedallIn-hospitalprophylaxis

(n=2824,96%)

Tookalldoses(n=2163,83%)

Completed6-weekfollow-up(n=2621,96%)

Convertedtoalternative(n=198,6%)

Didnotcompleteinhospitalprophylaxis,

(n=123,4%)

Didnotattendfollow-up,(n=203,3%)

PatientPreferencesinVTEEducation

Popoola VOetal.PlosOne.2016;11:e0152084.

• Nationalsampleofpatientsandfamilymembers

• ReviewofcontentandapproachestopatienteducationrelatedtoVTEpreventionandtreatmentinhospitalizedpatients

0

100

200

300

400

500

MD Video Paper RN RPh

Who

0100200300400500600700

What

28% 23% 33%

23%

Howlong

20min 15min 10min 5min

BordaCo

untW

eighted

Preferen

ces

EducationTopics

MethodorSourceofEducation

BordaCo

untW

eighted

Preferen

ces

PatientEducationProgram

PiazzaGP.AmJMed2012;125,258-264.FanikosJ.AmJMed2010;123:536-541

EducationalScript

1. WhatisVTE?2. Whatdoesthemedicationdo?

3. Whyisitimportanttotakeeverydose?

4. QuestionsandContact.

AdmittoHospital(n=583)

RxforVTEProphylaxis

RPHeducationalintervention

Medicationadherence=

AdministeredDosesScheduledDoses

94%

74%

29% 33%

19%10%

0%

20%

40%

60%

80%

100%ResultsandPatientResponse

10

ShoreS.JAMA2015:313:1443-1450.

VeteransHealthAdministrationSites

67sites,4863patients

AnticoagulationorOutpatientClinics

PATIENTFOCUSEDEVENTSonNOAC

Selection• Indication• Adherence

Education• Adverse

events• Misseddoses• Falls• Dailydosing• Interactions

Monitoring• Stroke• Bleeding• Surgery• Missed

doses

Pharmacistsattheperformingsites

Patients %Adherent

Nomonitoring

1042 65.2

Tailored tonon-adherent

1117 79.2

Telephone 1425 75.2

Face-Face 198 84.5

3mos 1176 74.8

> 12mos 405 83.2

PatientFocusedActivitiesandAdherence

0.51.02.0

CareDelivery:PreventionofVTE

12Lenchus JD.Adv Ther 2016;33:29-45;BarnesGD.Circ Cardiovasc Qual Outcomes.2016;9:182-185.

AnticoagulationManagementServices

Assistinselectionofoptimumagentand

dose

Minimizeseriousbleeding

complications

Monitorand

encourageadherence

Tailortopatientco-morbidities

andpreferences

Signs&symptoms,interruptions

Access,misseddoses,

challenges

Constantco

ntact&

rapidrespon

se

Consideragent,duration,prescribeappropriateVTEprophylaxis

Patientadmittedtothehospital

Clinicalendpoints

AssesspatientsVTErisklevel,contraindications,adverseevents

MDperformsVTEriskassessment

MDordersappropriateVTEprophylaxis

RNdeliversVTEprophylaxis

Computerlinkspatient’sVTErisktoappropriateVTEprophylaxis

Admiss

ion

Careand

edu

catio

nDischa

rge

HeidbuchelH.EuHeartJ2016: pii: ehw058.

Follow-upMonitoringCheckListTask Interval CommentsAssesscompliance

Eachcontact

Bringremainingmedication.Re-educateonimportanceofstrictintakescheduleInformaboutcomplianceaids(specialboxes;smartphone applications,etc.).

Assessforthromboembolism

Signs,symptoms,systemic(peripheral,pulmonary)circulation.

Assessforbleeding

Ifminor(nuisance)bleeding,arepreventivemeasurespossible?(eg.PPI,salinenosespray,etc.).Motivatepatienttodiligentlycontinueanticoagulation.Ifbleedingwithimpactonquality-of-lifeorwithsignificantrisk,ispreventionpossible?

Assessforothersideeffects

AssessforlinktoDOACanddecidewhethertocontinue,temporarilystop,orchangetodifferentanticoagulant.

Assessfornewco-medications

AssessforP-gpinhibitors/inducersordualP-gp/CYP3A4inhibitorsAssessforothermedicationsthatmayincreaseriskofbleedingsuchasanti-platelets.

Assesslabs Asneeded

Hgb,renalandliverfunctionIfclinicallyindicatedforconditionsthatmayimpact

13

150,000dosesperyear$0.83pervial

$124,000annualspend

50,000dosesperyear$3.70persyringe

$185,000annualspend

Heparin5000units Enoxaparin40mg Xarelto 10mg

100dosesperyear$9.05pertablet

$1,000annualspend

ComparisonsinUtilization

ProvidedthroughMcKessonConnect

43,406TotalHospitalAdmissions15,760MedicalIllAdmissionsX5.8daylengthofstay91,408hospitaldaysx$9.05DOACperday----------------------------------------------------------$827,242peryearincrementalDOAChospitalspend

ApplicationofGlobalPerspectiveModeling43,406Admissions

8,556HighVTERiskMedicallyIll

5,362APEXEligible

997BetrixabanTreatedPatients

22VTEeventsavoided

15Fatalorirreversibleeventsavoided

20%Betrixabanprescribing

ACCPdefined“VTERisk”

Applyinclusioncriteria

$148,692

$478,239

$1,459,660$918,474

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

Enoxaparin Betrixaban

Drug$(hospital) Drug$(post-acute) Event$

ApplyAPEXResults

NetSavings$182,346annually

CostAvoidance

0% 5%

10% 15% 20%

2000 2002 2004 2006 2008 2010

Even

tRate(%

)

30-dayReAdmit 30-dayMort In-HospMort

Hospitalizations

U.S.VTETrends-ReadmissionareCommonandCostly

Heparininducedthrombocytopeniawithorwithoutthrombosisisexpensive.

HIT HITT

Age (y) 64.1 63.4

UFH 80.1% 88.5%

UFH SC 38.2% 25%

LMWH 9.2% 1.1%

Mortality 21% 21.8%

Cost $122,191 $112,281

BarolettiSetal.ThrombHaemost. 2008;100:1130-5.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html.

HuangWetal.AmJMed.2014;127:829-39.

HospitalAcquiredConditionsincurPenalties

MedicarePart-D:PrescriptionDrugCoverage

EnrolleePays5%Planpays15%Medicarepays80%

Enrolleepays100%

Enrolleepays25%

Planpays75%

$3,700Coveragegap(Donuthole)

$4,950outofpocket)

$3,700totaldrugcosts

$400deductible

40%discountonbrandnameformularydrugs

StandardMedicarePrescriptionDrugBenefitItems that Count Towards the

Gap

• Your yearly deductible

• The discount you get on brand name drugs in the coverage gap

• What you pay in the coverage gap

Items that Don’t Count Towards the Gap

• Your drug plan premium

• Pharmacy dispensing fee

• What you pay for drugs that are not covered

Availableat:www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html.

PatientAssistancePrograms•Co-paymentcouponcardorvoucherforpatients.•Patientscanobtainuptotwelve30-daysupplies(over15months).•Patientswithcommercialinsurancepaynomorethan$10-30foreachprescription,withamaximumbenefitof$100permonth.

GrandeD.JAMA.2012;307:2375-2376.Sanger-Katz.NYTimes.Availableat:https://www.nytimes.com/2016/10/13/upshot/drug-coupons-helping-a-few-at-the-expense-of-everyone.html?_r=0.Dafny L.NEJM2016:375:2013--2015

Drug Co-Pay DiscountedCo-pay RetailPrice InsurerCost

Lipitor $360 $48 $2,004 $1,644Crestor $360 $216 $1,872 $1,512Simvastatin $120 $120 $336 $216

New YorkTimes“DrugCoupons:HelpingaFewatthe

ExpenseofEveryone”• Couponsfor23drugswithagenericalternativesresultedinanextra$700millionto$2.7billioninspendingondrugsoverfiveyears.

Sponsor Website Sponsor Website

The Assistance Fund www.theassistancefund.org National Organization of Rare Disorders

www.rarediseases.org

Chronic Disease Fund www.cdfund.org Patient Access Network Foundation

www.panfoundation.org

Healthwell Foundation www.healthwell.org Patient Advocate Foundation

www.copays.org

PatientAssistanceFoundations andFunds

Summary• PatientstreatedwithextendedVTEprophylaxiswillflowfromhospitalstoLTACs,andSNFs.

• EHRfacilitatescommunicatingplanforextendedVTEprophylaxis.

• “Meds-to-Beds”facilitatesandensuresaccesstomedication

• ExtendedVTEprophylaxismustbesupportedwithpatientengagementandeducation.

• Newmedicationsarealwaysviewedasexpensive.ExtendedVTEprophylaxisrequiresexplanationofthebeneficialoutcomesandcostavoidance.