Patient Care Final

Set Standards & Subsequently Accredit Thousand of Hospitals, Home Health Care, Long-Term Care, & other Organizations Based on those Standards

CMS (Centers for Medicaid & Medicare)

• AMI (Acute Myocardial Infarction)
• HF (Heart Failure)
• Pneumonia Care
• Surgical Care
• Childen's Asthma Care
• Inpatient Psychiatric Service
• VTE (Venous Thromboembolism) Care
• Stroke Care

• Find a Process to Improve
• Organize a Team Who Understands the Process
• Clarify Current Knowledge of the Process
• Understand the Causes of Variation in Process
• Select the Improvement that Needs to Take Place
• Plan Imporvement Based on Studying the Opportunity
• Do the Improvement
• Check the Result by Collecting & Analyzing Data
• Act to Hold the Gain if Process was Imporved OR go Back to the Drawing Board & Try Something Else While Going thru Cycle Again

to Maintain Superior Pharmaceutical Care, You must Keep up with Continuous Quality Improvement

• For a Group or Population
• Comprised of Individual Encounters w/ the Health System

• For an Individual
• Responsible Provision of D Therapy for the Purpose of Achieving Definite Outcomes that Improve a Patient's Quality of Life

• Curing Disease
• Reducing or Eliminating Symptoms
• Arresting or Slowing of Disease Process
• Preventing Disease or Symptoms

• Untreated Indication
• Improper D Selection
• Subtherapeutic Dosage
• Failure to Receive a D
• Overdosage
• Adverse D Rxn
• D Interaction
• D Use w/o Indication

• Economic
• Clinical
• Humanistic
• Outcomes

• *Direct Cost:
• ~Prevention, Detection, & Treatment (Hospitalization, Immunization, Lab Tests, Ds, etc.)
• *Indirect Cost:
• ~Morbidity or Mortality due to Disease (Time away from School/Work
• *Intangible Cost:
• ~Pain, Suffering, or other Non-financial Aspects of Care

Medical Events that Occur as a Result of Disease or Treatment

• Resuls of Disease or Treatment on Patient's Functional Status or Quality of Life
• Measured as Phsical or Social Functioning, General Health Perceptions, Well-Being

• 1. Inappreopriate Prescribing
• ~Inap. Regimen (D, Dosage Form, Dose, Route, Dosage Interval, or Duration)
• ~Unnecessary Regimen

• 2. Inappropriate Delivery
• ~ D not Available when Needed b/c of:
• (1)Economical Barriers (Pharmacy doesn't stock, Patient Can't/Won't Purchase)
• (2)Biopharmaceutical Barriers (Inappropriate Formulation)
• (3)Sociological Barriers (Institutional D Distribution or Patient Caretaker Fails to Administer D)
• ~Dispensing Error Involving
• (1)Incorrect or Inappropriately Labeled Rx
• (2)Incorrect or Missing Patient Info or Advice

• 3. Inappropriate Behavior by Patient
• ~Compliance w/ Inappropriate Regimen
• ~Noncompliance w/ Appropriate Regimen

• 4. Patient Idiosyncracy
• ~Idiosyncratic Response to D
• ~Mistake or Accident

• 5. Inappropriate Monitoriing
• ~Failure to Detect & Resolve an Inappropriate Therapeutic Decision
• ~Failure to Monitor Effects of Treatment Regimen on Patient

Insurance Company (Entity) that Pays

• 1.) Determine Price of Product
• *Provider (pharmacy) determines based on cost of D
• *will not necessarily be paid by provider
• 2. Claim is Sent from Provider to 3rd Party Payer...Online Billing Begins
• *NPI, NDC, Cost, Dispensing Fee
• *Patient Contract Info (3rd Party Reviews Contract w/ Patient & Provider)
• 3. Reimbursement "Promise" Sent to Provider
• *Provider Receives what 3rd Party agrees to Pay

• *Collect Data for Each Payer
• *Reimbursement & Reconciliation
• *Discrepancies
• *Re-file Discrepancies

• *Look for Statistical Outliers (ex. 6oo test strips, 30 day---not realistic) or charging too much for product
• *If provider is outside norm, payer can conduct audit
• *Create Chargebacks

Medicare Rx D, Improvement, & Modernization Act of 2003 (Medicare Modernization Act) created Medicare Part D which is required to have some form of MTM

Medicare Beneficiaries =20% of All Health Care Spending

• Multiple Chronic Diseases
• Multiple Part D Covered Ds
• likely to Incure Annual Costs for Medicare Part D covered Ds > $4,000

Pharmacists or Other Qualified Providers

Optimize Medication Usage to Reach Target Therapeutic Outcomes & Reduce Adverse Effects & D Interactions

• 1. Enhanced Understanding of Appropriate medication Usage & Adverse D Events thru Patient Edu
• 2. Increase Adherence to D Regiments
• 3. Detection of Adverse D Events & D Over/Under Use

• 1. Providing Patient Edu & Training
• 2. Health Status Assessments
• 3. Developing or Formulating Rx D Regimens
• 4. Evaluating & Monitoring Patient Response to D Therapy
• 5. Coordinating Care w/ the Patient's Health Care Team

• 1. Consistent Documentation & Charting Process
• *SOAP Note Format (Subjective Data, Objective Data, Assessment, Plan)
• *Methods for Collecting Objective Data
• *Methods for Communicating w/ Physicians
• 2. HIPAA Paperwork (to obtain Patient's Paperwork)
• 3. Dedicated Sit-Down Edu Area
• 4. Address Workflow Issues w/ Staff...MTM Sessions should NOT be Interrupted
• 5. Set Aside Dates for MTM Appt. (no Mon or 1st of Mth)

• 1. Medication Therapy Review
• *Brown Bad of all Ds (including OTCs)
• *Prevent, ID, & Resolve all D-Related Problems
• *Each D:duplicate, indication, adverse, expired, directions, dose, route, time, generic, any untreated disease
• 2. Personal Medication Record
• *Patient has list of all Ds (Dosage, Route, Time, Indication, Special Instructions, Start/Stop Date), Dr & Pharmacists info
• 3. Medication Action Plan (1 for Patient & 1 for Dr)
• *Patient(D issue, steps to resolve, method for measuring outcome, follow up method)
• *Dr (SOAP/SBAR note format for patient visit SBAR note format (Situation, Background, Assessment, Recommendation), elements of patient action plan, recommendations for D adjustments, thereapeutic sub., request lab data, any add. recommendation)
• 4. Intervention &/or Referral
• *PhD addresses Med. Issues, Communicates w/ all Health Providers, & Refers Appropriate Provider
• 5. Documentation & Follow-Up
• *Consistent Documentaion w/ All Patients (keep for 10 years...Medicare Requirement)