Achieving Efficiency and Scalability Through QIN/QIO Partnership in ADE

East Coast ADE Collaborative-Six States, Three QIN-QIOs, One Team

2

QIN/QIO Panel Presenters

• Karen Southard, RN, MHA, State Director, AQIN-SC

• Bonnie Horvath, MSHA, FACHE, CSSGB,

State Director, AQIN-DC

• Cynthia Warriner, BS, RPh, CDE, Medication Safety Pharmacist, VHQC: Maryland/VA

• Adrienne Mims, MD, MPH, FAAFP, AGSF, Vice President and Chief Medical Officer, Medicare Quality Improvement, Alliant Quality: GA/NC

3

Objectives

• Describe the alignment of the QIN/QIO goals and how we united to develop our analytic strategy

• Present an overview of the ADE methodology

• Discuss how the ADE methodology is being used to help recruit community providers and monitor progress at a local level

• Review selected interventions that align to address current data trend

4

Parallel Journey – Story of 3 QIN’s to address ADE

Different level of

Expertise and

Experience

Staff new to QIO

work

Variance in

Resources

5

Southeast Subject Matters Experts- ADE Partnership

• Cynthia Warriner, BS, RPh, CDE VHQC: Maryland, Virginia

• Jennifer Thomas, PharmD AQIN: District of Columbia

• Cheryl Anderson, BS, RPh AQIN: South Carolina

• Michael Crooks, PharmD Alliant Quality: North Carolina, Georgia

6

• Motivation: Recognized shared providers, patients and health systems between DC (AQIN) and MD (VHQC)

• Goal: Consistent reporting and messaging to shared providers and stakeholders. Synergy of resources, experience and spread.

• Growth: VA (VHQC) and SC (AQIN), then contiguous states: GA and NC (Alliant Quality)

• Process: Commitment to the team. Scheduled and ad-hoc calls with SMEs and analysts. Goal-driven timeline to standardize claims-based screening, deliverables, provider reports and interventions

Overview and Collaboration SME = Subject Matter

Expert; Task Lead

7

Advantages of the Partnership

• Opportunity to explore and decide on resources and patient education

• QA of the data- shared among the QIN analytic team

• Interventions can be standardized or unique to each state depending on data trends

• Partnership has evolved into ADE strategy group- open to suggestions and feedback

• Data driven reports helped recruit community providers

8

Where we began…

Data:

Sources &

Definitions

Denominator

(HRMB)

Numerator

(ADE)

AQIN

(DC, SC)

Medicare A ICD code as proxy

for Med use

Medicare A ICD codes from

literature review

Timeframe: 3 months

Coordination on ADE rates: DM only (AQIN & VHQC)

VHQC

(MD, VA)

Medicare A ICD code as proxy

for Med use

Medicare A ICD codes from

literature review

Timeframe: 3 months

Coordination on ADE rates: DM only (AQIN & VHQC)

Alliant Quality

(GA, NC)

Medicare D Medicare A ICD Codes from

TMF/IPRO sharing

Timeframe: 12 months, rolling quarterly updates

Coordination on ADE rates: none

0%

5%

10%

15%

20%

25%

AC-rate DM-rate OP-rate

VHQC AQIN Alliant Quality

July 2015 Calculated ADE Rates

HRMB = High-Risk Med Beneficiary

DM = diabetes agent

AC = anticoagulant

OP = opioid

9

How we got here

Aug 14 - Apr 15

• DC, MD, VA

• Recognized value of alignment due to shared patients and health systems

• Used similar claims- based screening, but state/territory-specific SAS® code

• SMEs scheduled planning calls, but limited analyst involvement

Aug 15 - Oct 15

• DC, MD, VA, SC, NC, GA

• Adopt new, shared definitions for denominator from Part D data and numerator from validated ICD codes, adopted 12-month timeframe

• Scheduled monthly SME calls, formed analyst workgroup to share coding

Nov 15 - Now

• DC, MD, VA, SC, NC, GA

• Continue SME calls

• Finalized method to attribute patients to providers

• Adopted universal SAS® coding

• Conversion of ICD9 to ICD10 coding

• CMS Quality Conf. poster, PCC-IC interview and sharing presentation

Apr 15 - Jul 15

• DC, MD, VA, SC

• Recruited newly hired SME from within QIN-QIO partnership

• Aligned definitions for denominator and numerator

• Saw value to include other contiguous states; NC and GA

ICD = International

Classification of Diseases;

diagnosis code

10

Where we are now

• Universal, Shared SAS® Coding: - Part D to identify denominator - Part A - ICD Codes for numerator - 12-month timeframe - Part A, B, D to attribute to providers

• Consistent Reporting: - Describes patient experience, not

provider causality or blame - State-wide, community, provider-level - Same method for any care setting

• Maintain QIN-QIO Flexibility: - Targeted providers, care setting - Community, provider focus on

medication classes, disease states

11

Where we’re going next

• Data: Opportunities for deeper-dive and reporting - Patient demographics, diseases and medication use - Provider setting, size and location - Impact of ICD-9 to ICD-10 conversion

• Teamwork: Collaboration on education and interventions - Webinars, resource sharing, and writing journal articles - Med Bags, Med Rec, and MTM/TCM/CCM training

• Mutual Support: Regular calls enhance problem-solving, brainstorming ideas, networking, and motivation

MTM = Medication Therapy Management

CCM = Chronic Care Management

TCM = Transitional Care Management

12

Scalability

• SC

Incorporating Medication Reconciliation and Immunization education with targeted patient engagement medication bag events co-sponsored with Walgreens.

13

Interventions and Partnerships

• Standardizing Medication Reconciliation

• Share developed tools and best practices with recruited partners

• Inpatient (hospital) monthly chart reviews

• Promote the adoption of Pharmacy Home

• Sharing medication accessibility tool with recruited partners to create safety net medication provisions

for low income patients upon discharge.

• Collaborating with academia and a recruited geriatric provider to reduce hospital admissions related to Opiate Related Aspiration and Pneumonia while raising awareness of Opioid related ADEs.

14

Provider Education Campaign to Address Opioid Abuse

Equip South Carolina prescribers and dispensers of controlled substances

with:

1. the SCORxE toolkit

– risk assessments for substance use disorders

– urine drug screenings

– opiate agreements

2. education and training on proper use of the SCRIPTS program

– legislation

– online trainings

3. academic detailing on "Gold Standard" practices

– prioritized by need and targeted areas

4. education of project to pharmacy community through established SCPhA contacts Small Doses, Journal, RxAlerts

15

Scalability

• DC Incorporating ADE review and reporting within the medication

reconciliation audit

Providing AQIN-DC ADE reports with NCC ADE reports and “hotmaps” to recruited providers,

Compare and contrast with the providers internal reports i.e. hospital , home health agency ADE reports

Raises awareness of potential harm and differences/disparities across the wards and the ranking of the District high risk medicine use and potential harm as compared to other states

Results have been used as part of the justification for a Transitions of Care Pharmacist position in one hospital and the movement forward on an opioid safety team in a hospital

Sharing of methodology and results in discussion across other payers – DC Medicaid

16

Alliant Quality- Case Presentation

• A 79-year-old man comes to the office with his wife. He complains of weakness and hematuria. He was seen last week by urology for dysuria. He has a history of hypertension, stable renal insufficiency, Afib, CAD, with MI 2 years ago (ejection fraction, 35%).

• Meds: aspirin 81 mg/day, warfarin 5 mg qd, furosemide 20 mg b.i.d., metoprolol 25 mg b.i.d., pravastatin 40 mg qd, Lisinopril 20mg qd. Cipo 500 bid for 14 days

• Labs – INR 7; WBC 10,000; Hct 32; UA Many RBC’s

17

RISK FACTORS FOR ADEs

– 6 or more concurrent chronic conditions

– 12 or more doses of drugs/day

– 9 or more medications

– Prior adverse drug reaction

– Low body weight or low BMI

– Age 85 or older

– Estimated CrCl < 50 mL/min

18

Indications for Long Term Warfarin

• Atrial fibrillation

• PE & venous thromboembolism

• Selected patients post-CVA or TIA

• Left Atrial diameter > 5.5 cm with emboli

• Cardiomyopathy with EF< 25%

• Prosthetic valves

• Mechanical aortic and mitral

• Caged ball or disk valves

19

Warfarin

• A leading cause of hospital admission for ADE *

• Half life is 31-51 hours – steady state in 5-7 days post adjustment

• Drugs may increase or decrease the INR when used with Warfarin

• INR should be checked q 4-6 weeks

• Home INR monitoring available

20

Warfarin Drug Interactions – 818 drugs

http://www.drugs.com/drug-

interactions/warfarin,coumadin

.html

21

Medication Reconciliation

Three Step Process • Compile a list * of current medications from patient

history, list, bag (incl. OTC)

• Compare list * to prescribed medications from chart, orders, consultant notes, hospital records

• Resolve any discrepancies

Success – Current, Complete & Communicated to All

* Name, strength, dose, frequency, route, indication

22

Medication Reconciliation

When to Perform: – Hospital admission

– Hospital discharge or transfer

– New patient to your practice

– Patients return from consultant care

– Annually (at least)

Success – Current, Complete & Communicated to All

23

Supporting Medication Reconciliation- My Meds

Bags

• Following up on success in 9th SOW with My Med Bags

• Alliant Quality continues to spread this proven intervention to support medication reconciliation

• Recent pilot test of direct-to-beneficiary mailing of bags and supporting materials to users of warfarin, a medicine with high-risk for Adverse Drug Events

• Intent is to encourage patients to review their medicines with primary care provider

24

My Meds Bags - Materials

• Med Bags sent to 1823 community-dwelling patients of 160 physician partners in NC and GA

• Beneficiaries kit included: Med Bag + Explanatory Letter + Simple Med List + postage-paid Feedback Postcard

25

My Meds Bags

MD Letter

26

My Meds Bags - Evaluation

• PCP completes during office visit

• Simple, low-effort, no-cost method to asses the uptake, perceived value & impact of the intervention

• Of 9 returned cards,

8 patients brought

all medicines, 8 providers valued the review

and 8 found medication discrepancies

27

My Meds Bags – Next Steps

• 4 practices have requested additional Med Bags

• 2 are implementing a QI project to track and measure use of bags

• Alliant Quality will make available to any other care provider who wants to use and measure improvement

• Will distribute through Diabetes Empowerment Education Program

• Will consider other audiences for direct-to-beneficiary distribution

28

Partnership Makes A Difference-

• Care Coordination: Three QIN-QIOS Collaborate to Improve Medication Safe . . .The 2015 Quality Improvement Organization (QIO) Program Progress Report from the Centers for Medicare & Medi . . .

http://qioprogram.org/sites/default/files/progress-report-2 . . .

29

Questions- Contact Us

• Karen Southard ksouthard@thecarolinascenter.org

• Bonnie Horvath horvathb@delmarvafoundation.org

• Cindy Warriner cwarriner@vhqc.org

• Adrienne Mims adrienne.mims@gmcf.org