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.