Patient Safety & Clinical Pharmacy Services Collaborative

Problem Statement

The Health Resources and Services Administration (HRSA) is the nation's federal agency for improving access to healthcare services for people who are uninsured, isolated or medically vulnerable. HRSA-supported safety-net providers serve populations that have a higher prevalence of chronic diseases compared with other populations of similar age and gender, making patient safety and effectiveness at least as salient for them as for other providers. In a community where components of the safety net are fragmented, a significant percent of complex patients may not be achieving the health outcomes that are possible and many will suffer from medication errors and adverse drug events as a result.

Many patients live with multiple chronic conditions that require them to be in contact with a number of health care providers and institutions. The scale of this at-risk population is enormous and growing, and the opportunity for improvement is great:

• 47% of Americans have a chronic condition
• 22% have multiple chronic conditions
• Less than 50% of patients with chronic conditions have satisfactory levels of disease control.

The U.S. healthcare system relies heavily on the use of prescription medications to bring chronic conditions under control. Patients are likely to be taking many medications for different conditions, often prescribed by different providers. 1

• 82% of the U.S. population reported using at least one prescription medication, over-the-counter medication, or dietary supplement in the previous week.
• 30% reported using five or more of these drugs in the previous week
• In 2006, the pharmacy industry dispensed over 3.4 billion prescriptions in the US.

The Institute of Medicine 2 found that the safety and quality risk associated with medications are severe:

• Adverse healthcare events continue to be a leading cause of death and injury.
• 1.5 million people are injured each year as a result of medication
• Nearly 25% of ambulatory patients reported adverse drug events (ADEs)
• “…for every dollar spent on ambulatory medications, another dollar is spent to treat new health problems caused by the medication.”

The U.S. population is living longer, and the prevalence of chronic disease is increasing. A number of other dynamics will also make outpatient drug use much more complicated and risky, including:

• The trend of delivering more health services in the outpatient setting
• The development of potent new prescription medications
• The increase in the type and number of medications a patient takes

With these trends, the number and costs of outpatient adverse drug events (ADEs) will also increase unless effective interventions to improve healthcare system delivery and outpatient safety are implemented.

Opportunity for Impact

Because medications play an integral role in improving patient care and related health outcomes, the primary emphasis in this Collaborative is on the improvement and integration of healthcare delivery systems which maximize use of clinical pharmacy services and safe medication practices that ultimately result in improved patient outcomes. This includes transitions and handoffs between provider organizations, such as between outpatient health center care and inpatient hospital care settings.

A key component of the Collaborative is to increase awareness of the benefits of clinical pharmacy services among healthcare providers and to promote the integration of clinical pharmacy services into the interdisciplinary healthcare team which includes building effective partnerships amongst both the public and private sector. For the purposes of this Collaborative, clinical pharmacy services are defined as patient-centered services that promote the appropriate selection and utilization of medications to optimize individualized therapeutic outcomes.  Clinical pharmacy services are provided by an inter-disciplinary professional health care team through individualized patient assessment and management. These services are best provided by a pharmacist or by another healthcare professional in collaboration with a pharmacist.

The PSPC is focused on the community situation where complex patients with multiple medications are served by a number of providers. Here, the patient faces “system risks” associated with service delivery design and practice:

• Care coordination among the providers involved
• Management of the medication process
• Patient self-management
• Information control for service and management.

Experience has shown that the associated risk can be reduced dramatically:

• Community health centers have shown that the “Care Model” 3 can be followed to improve a patient population's health outcomes: from 10 – 30% of the population achieving target levels to 80 - 90% achieving target levels.
  
  
• Community health centers have shown that safe medication practices and aggressive medication system management can reduce safety shortfalls:
  - Medication error rates fall (e.g., Level 1, most serious, from 0.1% to 0.03%)
  - Adverse drug reactions fall (e.g., fewer emergency department visits due to adverse drug reactions)
  - Gaps in health literacy are filled and patient medication control is increased.

Collaborative Aim

“Committed to saving and enhancing thousands of lives a year by achieving optimal health outcomes and eliminating adverse drug events through increased clinical pharmacy services for the patients we serve.” Central to this aim is providing safety-net organizations and their community-based partners with the tools and skills to improve care, decrease errors and realize cost savings. This Collaborative will improve quality of healthcare by spreading the leading practices of “high performers” that have achieved outstanding health outcomes for their patients by employing interdisciplinary, patient-centered approaches to integrate the provision of clinical pharmacy services and safe medication practices at each point of care.

Collaborative Goals

The transformational goal of the PSPC is to integrate the healthcare delivery system, across multiple healthcare partners, to create a service delivery system for high-risk patients that will produce breakthroughs in the following three areas:

1. Improved patient health outcomes
2. Improved patient safety
3. Increase cost-effective clinical pharmacy services

The Collaborative focuses on one very significant risk arena: the experience of high-risk patients as they encounter multiple providers and different medication practices within these systems. The highest payoff for the PSPC is expected to be with patient populations that have the following high risk characteristics:

• One or more chronic conditions
• Encounters with multiple service providers and prescribing opportunities
• Use of high risk medications
• Use of multiple medications
• Poor patient medication control and self management or low health literacy.

A national score card will track performance on the multiple performance aims that each community-based team will set for itself to meet the overall Collaborative goal. Quantitative and qualitative goals for the collaborative will be ambitious and will be achieved through true systems change.

Collaborative Methods 4

The Collaborative is made up of community-based teams with members from partnering provider organizations. Team members will represent the critical service providers such as: primary health care homes, clinical pharmacy services, specialty services, hospital services, educational systems and more. The flow of patients, especially uninsured and low income patients, will be a key factor in determining which organizations should participate together as a Collaborative team.

The Collaborative uses an “action learning system” designed to spread leading practices that have been shown to produce the intended results. In an 18 month process, improvement efforts are organized around regular Learning Sessions where teams come together for several days to learn about leading practices.

A “Change Package” details the leading practices that result in successful performance. The Change Package has been developed through site visits to “high performing” organizations. It serves as the catalogue of the leading practices that teams will adapt in an accelerated improvement process.

Action Periods follow the Learning Sessions where teams return home to apply what they have learned. Teams use the Model for Improvement, 5 a fast paced, iterative improvement method. Continuous, small scale, rapid testing leads to adaptation of leading practices to fit local conditions.

Collaborative Leadership

The Collaborative is being co-led by HRSA's Center for Quality and the Healthcare Systems Bureau's Office of Pharmacy Affairs. Nationally recognized leaders comprise the expert faculty drawn from the safety-net community and individuals experienced in primary health care, and those who have participated and implemented successful disease management system design improvements. Their work is guided by experts from world-class organizations and those with a proven track record of conducting collaboratives that generate results of this magnitude. In addition, many national and state based organizations (pharmacy organizations, federal partners, quality organizations, nursing organizations, safety-net organizations, educational institutions and others) are partnering with HRSA on this effort.

Readings

National Quality Forum (NQF), Safe Practices for Better Healthcare: A Consensus Report, Washington, DC: NQF; 2003.

IOM, Patient Safety: Achieving a New Standard for Care, Washington, DC: National Academies Press; 2004.

“Meeting Payer Needs for Pharmacist-Provided Services:  The Time is Now!” (PDF - not a U.S. Government Web site) – Prepared by Comstock Consulting on behalf of NACDS, 2007.

Shin-Yi Wu and Anthony Green.  Projection of Chronic Illness Prevalence and Cost Inflation.  RAND Corporation, October 2000.

“Beyond the Basics:  Another Look at The Care Model”, MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative, Ed Wagner. Available at http://www.improvingchroniccare.org/ (not a U.S. Government Web site).

Footnotes

1. "Outpatient Drug Safety: New Steps in an Old Direction" Daniel S. Budnitz and Peter M. Layde, Pharmacoepidemiology and Drug Safety 2007.

2. Institute of Medicine (IOM), To Err Is Human: Building a Safer Health System, Washington, DC: National Academy Press; 2000.

3. Care Model (not a U.S. Government Web site) Ed Wagner, MD.

4. The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston : Institute for Healthcare Improvement; 2003. Available on www.IHI.org (not a U.S. Government Web site).

5. Model for Improvement – Associates in Process Improvement (not a U.S. Government Web site).