The Pharmacist’s Role in Improving the Bottom Line

1. The Pharmacist’s Role in Improving the Bottom Line

2. HCAHPS Overview • Hospital Consumer Assessment of Healthcare Providers and Systems • Provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care • www.HospitalCompare.hhs.gov

3. Goals of HCAHPS Survey • Produce data about patients’ perspectives of care that allow objective comparisons of hospitals on topics that are important to consumers • Incentives for hospitals to improve quality of care • Enhance accountability in health care by increasing transparency of the quality of hospital care

4. HCAHPS Reimbursement Impact • On November 1, 2006 CMS issued a final rule regarding the Outpatient Prospective Payment System that was designed to promote higher quality in outpatient care. • Although the rule is primarily related to the Outpatient Prospective Payment System, it also includes provisions for expanding the quality reporting requirements for hospital inpatient services and links submission of HCAHPS data - beginning with discharges in July of 2007 - to the hospital’s market basket update for the 2008 fiscal year • During the June "2010 ANI: The Healthcare Finance Conference" held in Las Vegas by the Healthcare Financial Management Association, it was estimated that HCAHPS scores would account for 10 percent of each hospital's VBP ranking under the Medicare program.

5. HCAHPS Questions • 4 Screening Questions • 5 Demographic Items • 16 Questions on Patient’s Perspectives • 8 Key Topics • Communication with Doctors • Communication with Nurses • Responsiveness of Hospital Staff • Pain Control • Communication about Medicine • Environmental Cleanliness • Quietness of Hospitals • Discharge Information

6. HCAHPS Questions

7. HCAHPS Questions

8. CMS Rules: Communicating with Patients about the HCAHPS Survey • Hospitals are not allowed to: • Ask any HCAHPS questions of patient prior to administration of the survey • Attempt to influence or encourage patients to answer HCAHPS questions in a particular way • Indicate that the hospital’s goal is for all patients to rate them as a “10”, “Definitely Yes” or an “Always” • Imply that the hospital, its personnel or agents will be rewarded or gain benefits for positive feedback from patients by asking patients to choose certain responses such as a “10”, “Definitely Yes” or an “Always” • Ask patients to explain why they did not rate a hospital with the most favorable rating possible • Offer incentives of any kind for participation in the survey • Conduct any satisfaction or patient experience survey prior to the HCAHPS survey being completed (While an inpatient or post discharge) CMS CAHPS Hospital Survey (HCAHPS) Quality Assurance Guidelines, version 4.0

9. Guidance on Communicating with Patients about HCAHPS • Do not ask patients HCAHPS questions, questions using the same language and/or response scale found in the HCAHPS survey during patient interactions and administrative rounds • Do not wear buttons with the word “Always” on them • Do not place posters about patient satisfaction and experience in areas where the public can view them • Discharge calls should focus on the patients’ clinical condition and not their satisfaction • The new survey process will provide timely feedback on patients’ engagement and perception

10. Pain Management • Discuss patient pain management expectations at admission • Discuss pain management options with patient • Incorporate assessment into nursing hourly rounding • Make pain management changes 24 hours prior to discharge

11. Example Pain Management Tools

12. Medication Communication • Medication administer to >99% of patients.

13. Audience Participation • Question: When should patients be told they are receiving a new medication that they have not taken before? • A. When the physician prescribes the medication • B. When the nurse administers the first dose of the medication • C. Every instance of medication administration • D. When the patient is being discharged • E. All of the above

14. Answer: Audience Participation • Correct answer is E • Medication education is everyone's responsibility • Recognize that the patient’s perception of education may be different than ours • Repeating medication education reinforces the information National Council on Patient Information and Education (2007). Enhancing prescription medicine adherence: A national action plan.

15. Audience Participation • Question: What percentage of patients are aware of potential side effects related to their medication? • A. 1% • B. 27% • C. 51% • D. 74% • E. 99% Patient Education and Counseling 56 (2005) 276-282

16. Answer: Audience Participation • Correct answer is B • Patients may not be aware of the side effects of their medications • Using the word “side effect” clarifies the patient’s understanding and perception of the medication • When patients understand the side effects, they are more likely to take their medication Patient Education and Counseling 56 (2005) 276-282

17. HCAHPS: Medication Administration Role of the Pharmacist: • Become proactive about gathering and providing medication information to patients and nurses • Ask the nurse and the patient questions to stimulate dialog • Work with hospital administration to increase pharmacist/patient contact • Incorporate patient communication skills and new teaching methods into education sessions Am J Health Syst Pharm. 2007 Mar 1;64(5):507-20.

18. Engaging Patient Care Staff • Why is medication education important? • Improves medication adherence / compliance • Increases familiarity with medication side effects • Promotes patient self monitoring • Encourages follow-up with care • The informed patient will understand the side effects of prescribed medications and take them as prescribed National Council on Patient Information and Education (2007). Enhancing prescription medicine adherence: A national action plan.

19. Medication Adherence • 50% of patients report they had forgotten to take a prescribed medication • 31% had not filled a prescription they were given • 30% had stopped taking a medicine before the supply ran out • 24% had taken less than the recommended dose National Council on Patient Information and Education (2007). Enhancing prescription medicine adherence: A national action plan.

20. Barriers to Medication Education- Environment • Patient not in the room • Patient drowsy or unable to understand • Visitors present • Distracting environment Robert M. Smith (1991, April). How people become effective learners. Adult Learning, p. 11. Robert L. Steinbach (1993). The Adult Learner: Strategies for Success. (Menlo Park, CA: Crisp Publications.) http://www.newhorizons.org/lifelong/workplace/billington.htm

21. Barriers to Medication Education--Adult Learning • Patient’s level of knowledge • Patient does not understand the purpose of education • 75% of what is heard is forgotten after 2 days • Patients may be disinterested in medication education • Memorization of information is insufficient to change behavior Robert M. Smith (1991, April). How people become effective learners. Adult Learning, p. 11. Robert L. Steinbach (1993). The Adult Learner: Strategies for Success. (Menlo Park, CA: Crisp Publications.) http://www.newhorizons.org/lifelong/workplace/billington.htm

22. Enabling Medication Education • Begin at a learner’s level • Explain importance of medication knowledge • Patients remember 80% of what they hear, see, and do • Learning must be stimulating • New information must be reinforced with practical application Robert M. Smith (1991, April). How people become effective learners. Adult Learning, p. 11. Robert L. Steinbach (1993). The Adult Learner: Strategies for Success. (Menlo Park, CA: Crisp Publications.) http://www.newhorizons.org/lifelong/workplace/billington.htm

23. Medication Teaching Tools • Drug Information Vendor Partner • Notepad for patient questions • “Sorry I missed you” tent

24. Drug Information Toolkit • Partnering with Medication Information Vendor for Staff Resources • Printed Materials • Cover Letter • Sample MedCounselor patient education sheet • Step‐by‐step sheet for accessing and printing patient education • Order form to request additional printed materials • Printed postcards to promote the online Clinical Pharmacology quiz • Clinical Pharmacology Quick Reference Guides

25. HCAHPS Tools: Medication Administration • Provide a note pad for the patient / family to write down questions about medications

26. Notepad for Medication Questions Medication Questions

27. Scenario A: Mrs. J. Doe • 66 year old female • Presented to ED with heart palpitations • BP = 90/70 Pulse = 150 and irregular • Heart: Murmur audible at the apex • EKG: Atrial fibrillation with LBBB • Digoxin and beta blocker continued • Warfarin initiated (patient has never received an anticoagulant)

28. Audience Participation • What would the next step be in providing education to this patient? • A. Pause, allow the patient to ask questions • B. Ask the patient a question to assess understanding • C. Continue describing side effects; ask the patient to hold all questions until the end • D. Give the patient a handout to reinforce medication education session

29. Answer—Audience Participation • Correct answer is A, B, and D • Always allow patients to ask questions • In order to assess the patient’s understanding, it is important to ask him/her questions • Handouts will help reinforce the medication education

30. Audience Participation • If patients appears not to comprehend the information, what is your next step? • A. Continue teaching and document the details provided during the education session • B. Conclude the session and give them the appropriate patient education handout • C. Conclude the session and contact the physician • D. Continue with education and let patients know that this medication will be discussed throughout their hospital stay

31. Answer—Audience Participation • Correct answer is D • Documenting education is important, however not the complete answer • A handout may provide structure to the education session, however, additional educational sessions may be necessary • Communication should extend beyond the physician to include the entire healthcare team

32. Additional Reference: National Council on Patient Information and Education (2007). Enhancing prescription medicine adherence: A national action plan. PDF available

33. Resources for Patients • www.safemedication.com • http://www.ahrq.gov/qual/pillcard/pillcard.htm • www.tnpharm.org/BlankUML.pdf

34. Summary • Various avenue of opportunity exists for RPhs to improve quality metrics • Ensure that quality measures are met by integrating into the health care team • Assess opportunities within the medication administration process to affect or participate in interactions