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traduction madelung Inge is a pharmacist with the visiting nurse services of Newport and Bristol counties in Portsmouth Rhode Island following graduation from MC PHS University in May of 2015 she completed a community pharmacy residency with the University of Rhode Island and with Rite Aid pharmacy she's a certified diabetes outpatient educator and cardiovascular disease outpatient educator her professional experience includes working with patients in home health care nursing homes and community pharmacy settings her interest include transitions of care and the role pharmacists have in optimizing medication therapy to improve patient outcomes reduce readmissions and most importantly improve patient quality of life so we're delighted to have you thank you thank you very much for an introduction again my name is Madeline thank you all for attending I know it's the last session of the day and the Sun is out and it's beautiful outside I do appreciate you all coming to my presentation titled integration of a pharmacist on the home health care team to address medication related hospitalizations first and foremost I do not have any financial interests or arrangements to disclose today I'll be discussing three learning objectives the first is explained a partnership between the University of Rhode Island College of Pharmacy and the visiting nurse services of Newport in Bristol counties secondly I would discuss the role of the pharmacist on vns service and how they complement the care provided by the VNS interdisciplinary team third I will review results from the van Buuren charitable foundation your one grant awarded to add a part-time pharmacist to the VNS care team my practice setting again is located at the visiting nurse services of new porn Bristol counties for all intensive purposes I will be referring to them as the VNS just to save time and so I don't tongue tie myself during this presentation we are an independent nonprofit organization serving patients of all ages we have home care rehabilitation hospice and community health services and uniquely we do also have telehealth monitoring offered to our patients there were no pharmacy services prior to our first Farm the resident on the care team which I will explain a little further in the next few slides so the program began with the University of Rhode Island College of Pharmacy clinical associate professor ginger LeMay in July of 2013 since then we've had twenty five six-year pharmacy students completing an ambulatory care rotation at the VNS throughout the state we have partnered with numerous home health care agencies including the BNs and students have the opportunity to gain experience in medication reconciliation and medication teaching in the home care setting this has been an extremely fulfilling and valuable experience for the students since they have limited experience throughout the curriculum to be part of an interdisciplinary team with nurses physical therapists and occupational therapists to apply the clinical knowledge that they've learned in pharmacy school along with the pharmacy students we have had four Pharmacy resident at the visiting nurse service as well Tom Calista was our first pharmacy resident in 2013 and the next resident was Corrine I was a third pharmacy resident and our fourth pharmacy resident is Kathryn Corsi she is currently completing her residency right now at the VNS graduating in July of this year Pharmacy residents are licensed pharmacist pursuing additional training and clinical experience after graduation pharmacy school the residency is a one-year commitment with University of Rhode Island and Rite Aid pharmacy however the visiting nurse service is an additional ambulatory care site for the residency the rotation is a longitudinal rotation at the visiting nurse service which means that from July to June the pharmacy resident is at the visiting nurse service one to two days a week providing home visits and additional services for the nurses physical therapists occupational therapists a requirement for the residency as well is the development and implementation of a year-long research project we are allowed to come up with a topic of our own develop it and implement it in a site we choose as you can see there have been three research projects that have been based out of the visiting nurse service the first project was Tom's project based on heart failure medication adherence and rehospitalization the next research project was my research project on telehealth monitoring and lastly the current project that Catherine our current resident is implementing is revolved around medication therapy management and this is a very exciting presentation and I will discuss this further because this will give us ways to fully support hopefully a full time pharmacist at the visiting nurse service so just because I like to put faces with names this is a picture of ginger lemon Tom Calista our first resident and myself last year a little bit about our program history the visiting our service likes to utilize Facebook to appeal to their masses so this is a picture of Corrine on the bottom left and Kathryn our current resident on the right so to start off i'd like to present some data that we have collected with our students at the visiting nurse service we do ask the pharmacy students on rotation to document the type of visit that was provided and the intervention provided especially for high-risk medication classes all information of course has been de-identified and is HIPAA compliant each student is paired with a nurse or physical therapist so they are exposed to a wide range of patients at the VNS the students and nurses will often switch off every week so that they are paired with a different nurse and a different physical therapist as the caseloads are different between all therapists the data is served so that we can not only see what type of patients are on service but also so we can understand the impact of the pharmacy profession can have on patients and interpret interdisciplinary team in the home care setting as you can see on this slide we started collecting data in spring of 2014 so here this is the highest number of patient visits because at that time we had a lot more sites included but here on the top line you can see the amount of patient visits the students have seen per semester the next line the blue line here shows the amount of reconciliation that was provided ideally every single patient that was seen should have a medication reconciliation perform however a lot of times the nurses have the same patience so week after week a medication reconciliation haven't had any changes in medications lastly the Green Line shows the amount of med teaching that was provided to the patients and as you can see it's been fairly consistent year after year semester after semester the type of interventions and outcomes are listed here on this slide if the patient's provided adherence support they would let us know there have been total of 387 opportunities for adherence support the red line here shows the amount of interventions just in the past year so in fall 2016 other interventions include preventive and additional prescription order preventing a physician visit prevented ER visit reduced medication costs prevented a hospital admission and also prevented a life-threatening situation the students are asked to assess the type of interventions provided so therefore a lot of these are subjective in 2014 the National Action Plan developed to identify common preventable and measurable adverse drug events that may result in significant harm I identified three drug classes most commonly implicated in average drug events for Medicare beneficiaries these include these specific drug classes the anticoagulants diabetic patients as well as opioids we ask students to identify how many of their patients are taking any medications in these classes if a patient was on a medication in any of these classes the student was asked to further and more thoroughly assess the patient for the potential of an adverse drug event or an actual drug event occurring in the patient for example as you can see in the opioid section there was 150 total patients range of these total 150 patients there were 32 patients identified for a potential adverse drug event an example of a potential drug event is a patient who is taking opioids medication say vicodin or percocet but have no bowel regimen on board as we know opioids have a high risk of causing constipation in many of their patients on the other hand for was reported to have an actual I'm sorry 8 was reported to have an actual adverse drug event so what this means is that perhaps the patient was actually impacted and has it hasn't had a bowel movement in a long period of time that is an actual drug event therefore requiring medical intervention a common question that I'm always asked is what role does the pharmacist have at the visiting hour service and now that we have discussed the role of pharmacy students in home care I think this is a good time to transition to what a licensed pharmacist can do in the home first and foremost we provide home visits to the patients we are involved in telehealth monitoring as you will see in the next slides when I discuss my research project we are part of the hospice and palliative care team every two weeks the pharmacist will meet with the hospice group to discuss every single patient on Hospice and the pharmacist is valuable in essence discuss medications that could help or possibly harm the patient on hospice any recommendations on doses or how to prevent a drug event and of course to make the patient as comfortable as possible the pharmacist also does community outreach last spring I teamed up with the the community outreach nurse at the visiting our service and visited senior homes to discuss healthy aging and discuss how to better manage your medications we also provide diabetes education in Rhode Island we have a lot of patients on servers I have diabetes so we have community outreach that diabetes education groups for these patients we are of course the drug information specialists we provide medication therapy management for patients as well as primary care case conferences and to discuss the home visit process I'd like to open up with a patient case so mr. a is an 86 year old male he is widowed he lives alone his family is out of state his past medical history is significant for CHF diabetes COPD and hypertension in the winter of 2016 in the last snowstorm he went outside to shovel his driveway and fell and broke his hip he was sent to the hospital while he was in the hospital his metformin was discontinued because his kidneys started to decline his insulin regimen was increased his a1c was found to be 12% which suggests non-compliance to his medications he got better and was sent to a skilled nursing facility at the skilled nursing facility he was found out of edema on his ankles so his lasix was increased there was a planned discharge date set up and the day before he developed pneumonia and was started on antibiotics now because of his insurance they found that pneumonia is not a reason to lead him skillett also he's actually sent home with the antibiotics to finish the course and the school nursing facility luckily provides medications for the patient to go home with so the next day the visiting nurse service goes and visits this patient at home they find blister packs bags and bags of blister blister packs from the skilled nursing facility they find old medications because of course he is put on a 90-day supply at his community pharmacy he set on automatic refill as well which is why he has held up medications in his cabinets and in the drawers he has expired this including expired insulin which may suggest why his a1c was so high as well as why they had to increase the insulin measurement in the hospital the medications are not matching on a skilled nursing facility discharge sheet to what he has at home and to top it all off he has a cabinet full of over-the-counter medications that he's accumulated the present family and this is usually the part of the admission where I will get an email or a phone call saying Madeline please help there is a lot going on with this patient so as you can see in this patient he would benefit mostly from a medication reconciliation so this is to review the medications that he was sent home from from the skilled nursing facility medication teaching because maybe he doesn't know that influent expires and that's why he's been using expired influenced adherence support so if he's on a 90-day supply with automatic refills he probably shouldn't have a year's worth of medications at home of he was adherent to his medications we are also community and community pharmacy referral and liaison so maybe I thought how we will called pharmacy to let them know that there's been a change in the medication and - please stop filling all the medications automatically and lastly we can provide community prescriber communication interface so most importantly in this patient I would call his primary care physician his endocrinologist and probably his cardiologist to let them know that this patient and within the hospital sent to the skilled nursing facility and is now home but has a lot of medication changes and this is just a classic example of one patient many a very very common patient that I see however sometimes the patients are not as complex as this one but as you can see this one patient could benefit from every single thing on this slide so this patient that I also have told you about would be a good candidate for telehealth monitoring at the visiting nurse service and this is what I base my research project on last year activist taking our service as we know telehealth monitoring is an in-home monitoring program allowing nurses to monitor patient vital signs high-risk patients are selected by the visiting nurse service the visiting nurse service nurses to be monitored using telehealth technologies the patient's weight blood pressure heart rate and oxygen saturation are collect and transmitted daily through a secure server the values are then analyzed by scientists or providers at the home healthcare setting subjective questions related to patient's health can also be programmed into the machine my study was a prospective study approved by the University of Rhode Island institutional review board with the primary objective to determine the etiology of medication related problems identified through telehealth monitoring systems the telehealth monitoring system that we use at the VNS is the whole med monitor the home and monitor can be set to have specific alert limits so the weight is patient specific we have specific limits on systolic and diastolic blood pressure as po2 as well as heart rates so when the value goes above or below these values then we would get an alert at the visiting our service medication related home med monitor alert questions were scheduled to be answered by the patient every Tuesday so I asked for the machines to be programmed to have these three questions go off every Tuesday for the patient to answer these questions include are you out of any of your medications are you having difficulty taking any of your medications as well as have there been any changes in the medication you're taking so if a patient had a vital sign alert out of range and also answered yes to any of the medication related questions the patient would be contacted for inclusion a home visit would be scheduled so every single patient in my study was seen by myself informed consent was provided and obtained I interviewed the patient as well as categorized their medication related problem the interview questions consist of six subjective questions very quick the first one how are you feeling today the second question assess how many patient how many medications prescription and non-prescription medications was the patient on the third question assess how they were taking the medications was it one time during the day everything all in the morning or was it throughout the day the fourth question asked how many times a week did they forget to take their medications the fifth question and the six uestions are both very important in my perspective the fifth one asks do you understand what your medications are used for and number six do you feel differently now than you did before you started your medications the enrollment period was very short it was December 2015 to March 2016 I had a total of ten patients roll into study now we have to remember that this was a very limited time that I had my research designed and also implemented as well as the time constraint as a pharmacy resident the mean age was seventy five and a half and the mean number of medications which is alarming was sixteen point four medication so on average patients had sixteen point four medications prescription and non-prescription medications it's the ones that I found on reconciliation the primary diagnosis as you can see most patients had CHF some patients also had COPD a fib one patient only had high blood pressure the youngest patient that was included in my study was 35 years old the oldest was 93 years old and in terms of number of medications the highest amount of medications that one patient had was 28 and this includes a lot of over-the-counter supplements the home med monitor alerts were then categorized into these percentage so as you can see most patients had a weight that was out of range three patients had a reported weight outside of range as you know in patients with CHF this is something that we need to take a look at and to call the doctor to perhaps increase the lasix many patients also had a blood pressure blood pressure out of range five patients reported that they were out of their medications thankfully only one person admitted that they were having difficulty taking any of the medications and this was because the pills were too big and he couldn't swallow pills the last question have there been any changes in the medications you are taking nine patients that that yes they had a change in the medication that they were taking when asked to interview questions the most percentage of patients who reported that they forgot to take their medications during the week was one time week and five patients reported up they would forget at least once as you can see six patients did not understand what the medications were used for in these six patients they just said well my doctor told me I need to take this medication I'm not really sure why but I trust my doctor so I'm just going to take my medications the last questions you feel differently now than you did before you start your medications many patients did say that yes they do feel better they do feel different now that they've started the new medications the medication related problems were they categorized into these seven categories first is adverse effects fear anxiety no refills on current prescriptions care transition resulting in confusion to medication regimen complexity of regimen forgetfulness and lack of understanding as you can see this is how I categorize the different medication related problems so if a patient said yes I'm out of my medications I correlated this to a patient had no refills if a patient responded yes to having difficulty taking any of their medications this was categorized into having fear or an anxiety if there were any changes in the medications they were taking I result of this as care transition confusion and going into my interview if a patient had many medications and were taking medications several parts of the day I correlated this to regimen complexity if a patient forgot to take their medications during the week that was correlated with forgetfulness number five if the patient did not understand what their medications used for that's lack of understanding and number six you feel differently now than you did before you start your medications this was a way for me to to see if the patient was experiencing any adverse effects so the medication related problems are seen here so zero percent of patients had any adverse effects from their medications but as you can see seven patient both had a very complex regiment and also admitted to forgetfulness five four five patients again had no refills on their current current prescription and six patients had lack of understanding other medication related problems identified during the visit that was not in my category I could put was inaccurate fill an inaccurate pillbox so patients who were supposed to take medications two times a day maybe had some in morning noon and night time a patient taking medications one time a day accidentally maybe had two tablets in the morning spot many patients also did not know how to use their inhaler or glucometer correctly which is alarming a patient with COPD or diabetes and many patients were using expired medications because they didn't know medications could expire so a patient with a 90-day supply who keeps getting it refilled with just keep using old medications without realizing that that bottle had been filled two years ago and at that point that medication is probably not good to use anymore in conclusion medication related problems are prevalent amongst patients admitted to the visiting nurse service the patient data collected through telehealth monitoring may be utilized to assess patient progress and pharmacist in the home healthcare setting can impact patient care and outcomes the next research project I will be discussing is the first research project so Tom's project which focuses on heart failure it's the most common principal discharge diagnosis among Medicare beneficiaries is the second most expensive condition billed to Medicare 30-day heart failure related readmissions as the Centers for Medicare and Medicaid Services CMS performance standards so as we know if a patient is readmitted to the hospital for heart failure they will not get reimbursed now there are a lot of benefits for adding a pharmacist onto a care team for a patient with heart failure so that includes a 25% relative risk reduction for readmission a 13% relative reduction in all cause mortality and improved quality of life and no increase in cost of care his project was also a prospective study approved by the University of Rhode Island IRB it took place from December 2013 to April 2014 the primary objective is to determine if home health pharmacy service improved patient medication adherence as well as reduces hospital admissions patients were included if they were discharged to B&S with the primary diagnosis of heart failure they were referred for inclusion within one week of admission they had to be willing and able to give informed consent they were excluded of course if they were unable to give informed consent and if they were entirely dependent on a care giver from medication management the primary outcome looked at adherence and the Moreschi eat item medication adherence questionnaire was utilized to see change from baseline secondary diagnosis was a 30-day heart failure related readmissions included patients versus agency-wide patients this is an example well this is the more risky eighth item medication adherence questionnaire as you can see this is a validated adherence assessment it is reproducible and feasible to replicate throughout pharmacies including the community pharmacy setting it is an adherence assessment tool that is subjective to patient response so as you can see these are yes and no questions and patients are trained to give us the right answers because they don't want their caregivers to worry about them so even if they may forget to take their medications they know that the right answer is to say that they don't forget to take their medications so therefore that is a limitation and as you can see the score here is how tom measured adherence so the score was over two it indicated low adherence to medications one or two medications medium adherence as well as zero is high adherence so his method was measured in an in-home visit and then telephone follow-up so the in-home visit was anywhere between 60 to 90 minutes long and this included medication reconciliation as well obtained consent at the visit there was a baseline assessment questionnaire medication reconciliation was provided as well as medication disease State Education so as you can see the visits are lengthy but they are very very thorough telephone follow-up occurred one and four weeks post visit it was a call between five to ten minutes the same questionnaire was provided for reassessment of adherence the patient's progress was monitored as well as looking at the readmission rates ten patients were enrolled in his study and three were unable to complete follow-up as you can see the mean age is eighty one point four and again the mean number of medications fifteen point nine so that doesn't really change between you know my study or his study it seems that a lot of patients are on just a lot of medications now as you can see - there was a percentage of nya shake class 70% were in class three and 30% were in class four this is a graph to show the patients in each adherence category so the bottom is the amount of weeks post in-home visit as you can see 0 weeks there was one patient who had high adherence and as the week's went on that high adherence would increase between patients because there were stations that were unable to follow up that's why the N decreases over time but as you can see over time there are no patients who have low adherence to their medications in terms of heart failure related readmissions one out of 10 enrolled patients was readmitted to the hospital however agency-wide July 2013 to February 2014 38 of 99 patients were we hospitalized so that's correlated 38.4% the conclusion to his study is that pharmacist community pharmacists provided in-home medication teaching can improve medication adherence can lower 30-day harfa related readmissions and also provides an innovative unique pharmacy service received exceptionally well and beneficial for all involved Tom and ginger the studies were so exceptional that it was actually published and the successful completion of this research project and subsequent publication paved the way to allow for further pharmacy services within the agency and this includes further residences more students and with the generous support of the van Buren Charitable Foundation of pharmacists physician ginger LeMay was a principal investigator of this application title expanding the College of Pharmacy and VNS partnership we have seventy thousand dollar grant awarded and funded again for a second year to study the benefits of a pharmacist the delivered medication reconciliation and medication teaching inpatients at higher risk for rehospitalization the project began February 1st 2016 and today I'll be presenting the perspective data collection with interim results from the first twelve months this is the press release stating that we have a grant that allows visiting nurse services to expand pharmacist services in Portsmouth Rhode Island the home visit process is the safe medication reconciliation provides every patient every patient visit is truly different so it depends on what the patient's primary concern is if their primary concern is that their advair inhaler is too expensive and it can't be covered by insurance then that focus of that visit is to see if they can be on a cheaper inhaler it if not inhaler that I nebulizer solution if a patient's primary concern is that they don't check their blood sugars every day like they should maybe they check it once a week because of fear of having to test that the goal of that visit will be to provide support and education so that a patient can test their blood sugars every day so every visit is really different but medication teaching is always provided every single time I go into a home visit I do sit down with the bottles in front of me and I say all right so this is listener pearl can you tell me what this is used for and it's a patient you can't tell me what it's used for then that's when I will explain this is for your blood pressure and at the end teach-back always occurs so that they can teach it back to me and here is support is provided we do provide our patients with a pillbox if that's how they want to provide if that's how they want to organize some medications a lot of times I will sit with the patient and make sure that they can fill the pillbox correctly correctly because there's no use in providing a pillbox if they can't show you that they can use a toolbox i've also teamed up with other pharmacies that provide medications in med packs so that the patients don't have to worry about having to fill a pillbox every week again the community pharmacy referrals and liaisons occur as well as prescribe a communication and interface if I feel like a patient needs a dose reduction or dose increase I will call the doctor to recommend that nowadays my concern is with the opioids so a lot of patients who are taking a pain medication and also maybe a sleep medication and a muscle relaxant are at highest risk for respiratory depression so in these patients I will recommend narcan so the interventions are endless they're very unique depending on each patient because every patient truly needs something different but I'm happy to do it all so with the addition of a pharmacist to the VNS team we expect a decrease in 30-day hospital readmission rates and edy visits and increase inpatient medication adherence and increase in nursing time by removing the medication burden an increase in patient quality of life and satisfaction with pharmacy service an increase in patient referrals from the community and physicians with the goal to reduce hospital readmission rates by five to ten percent for high-risk patients the mean age in our patients with seventy four point seven years of age again the mean number of medications is sixteen point one most of our patients are female and here are the diagnosis of the patients that we see in service most patients have hypertension followed by diabetes and psychiatric disorders and this is just to put into a chart the Medicare VNA diagnosis as you can see majority of the patients are admitted for cardiopulmonary assessment followed by disease management education and this is the primary diagnosis the major diagnostic criteria based on Medicare severity the diagnosis related groups again the highest patient the highest amount of patients were seen for circulatory reasons followed by respiratory and then skin and soft-tissue infections on average there were 5.2 medication discrepancies seen in the patient in the patient visit and this includes wrong dose wrong medication wrong directions this also includes if the medication reconciliation was incomplete so maybe the nurse who admitted the patient didn't realize that they had a cabinet full of over-the-counter medications in our patients we had four point five percent of patients readmitted to the emergency room or seen in the emergency room and thirteen point six of our patients were unfortunately hospitalized again we this was focused on high-risk patients so high-risk patients have multiple comorbidities taking multiple medications so these are patients that are very very ill after every patient visit we always ask for our pharmacists faction survey to be completed because we like to get an idea of what the patients think of having a pharmacist on service it sounds like a great idea we have data to support that it's a great idea but we really want to know what the patients think as you can see many patients were satisfied with the service a lot of patients appreciated the idea of having someone come sit down with them took over their medications especially if they live alone have no car to go to the pharmacy so they don't have the opportunity to go pick up the medications and speak to the pharmacist at their Walgreens or Rite Aid or CVS and how would the pharmacist know that mr. a is at home with no support and doesn't know what medications he's taking as you can see a lot of patients to appreciated having a better understanding of the medications that they're taking it's important to me as a pharmacist that every patient knows why they're taking their medication so these are some of the comments that were left about the pharmacist visits there was no bribery intended in any of these surveys these are all truthful and confidential so lastly I'd like to talk about pharmacist program sustainability because as we know this is a great service but pharmacists have a high cost although at the end it is worth it if we prevent hospital readmissions so our last resident our current resident actually is pursuing her research project on sustainability so currently no pharmacist practices in the home health care model are established within the state of Rhode Island and with the progress we have been able to make at the visiting nurse service practices stainability is important since we have shown benefit to incorporating pharmacists on the interdisciplinary teams this research project is centered around medication therapy management and Medicare beneficiaries and the possible channels for payment with the completion of a patient medication review along with investigating reimbursement potentials the study will help us understand what types of medication related problems affect the home health population Blue Cross Blue Shield of Rhode Island blue chip for Medicare currently partners with outcomes MTM services to Bill MTM claims and analyze cost savings through pharmacist interventions cost savings from these MTM Billings is how this insurance company is justifying incorporating pharmacist into inventory care settings such as the VNS if the cost saving ratio is above the threshold of 1 / 3 there is potential for pharmacists employment so this is a great Avenue to explore in this particular study the inclusion criteria includes 65 years and older for patients who were at this age range they were admitted to visit nurse services of new form Bristol counties they had blue chip Blue Cross Blue Shield of Rhode Island blue chip for Medicare beneficiary which is a majority of patients in Rhode Island this plan already offers billable MPM services for this group of beneficiaries the Blue Cross has not incorporated home health MPM to any of their services thus far the group represented in the study reflects the high-risk patients we often serve at vns so again the patient population is there at our fingertips it's just accessing this MTM cost savings program into the homecare services that we provide once the patients were identified from VNS admission data they were contacted to schedule a home MCN visit with the pharmacist the pharmacist completed a patient interview and medication interview with the goal of identifying and acting on medication centered interventions that would benefit patient therapy data collected include reason for VNS admittance number of comorbid diagnosis the number of prescriptions and over-the-counter meds as well as the type of pharmacist intervention along with the outcome of that intervention intervention categories were assigned to coordinate with current billable outcomes MTM claim categories and that's listed here on this slide the enrollment period is from July 2017 to April 2017 as of April 1st 2017 we have she has 16 patients enrolled average age is AD 1.5 years of age most of the patients were male primary diagnosis have included in myocardial infarction heart failure COPD wound care Falls Alzheimer's disease UT is and also surgical aftercare this data represents the type of pharmacists initiated medication therapy interventions discovered during home MTM sessions these correlate with potential cost savings depending on their severity as you can see a majority of the patients 18.4% needed immunization so whether that be flu or pneumonia or the shingles vaccination or Tdap 15.1% of patients were identified for inappropriate admission administration or technique so for adherence claims 11.8% had new or change over-the-counter therapy 12.5% had new or changed prescription therapy each identified medication related problem from the previous slide is associated with an intervention severity level when the claim was submitted the severity helps peers determine the cost savings from the therapy intervention provided with the interventions recorded the severity levels assigned to each claim are shown on the slide in total there was over 2,500 dollars in healthcare savings associated with just 15 patients there was also an additional patient that was omitted from the cost savings reported due to a unique circumstance this particular patient had seven medication interventions that prevented a life-threatening situation outcome her billing alone would have acquitted to an additional $93,000 contributing to a total of 119 thousand dollars for all study participants seen so this is a huge Avenue that can be explored for pharmacists in the homecare setting as you can see we have had great success integrating pharmacy in home care heart failure patients and patients with home and monitors are just two small examples in a large patient population who are on the VNS service as a pharmacist I'm humbled and I'm honored to be able to work with these patients to help them manage the medications and their current disease states so the next steps we will of course continue the pgy one confirma C resident and pharmacy student program the van Buuren funded pharmacists is in place through July I'm sorry January 31st 2018 we are going to continue to analyze the Blue Cross Blue Shield of Rhode Island Medicare claims data for MCM billing for sustainability and we would like to fund a full time pharmacist post grant front post grant funding lastly I'd like to acknowledge three important people at the visiting nurse service Candice Sharkey our CEO sue Dugan our director of quality as well as Charlene Eggman our quality and compliance clinical supervisor for supporting the pharmacy services since we first started in 2013 lastly these are my references and I would be happy to take any questions at this time yes sure yes so we utilize the FHP report who identifies for us high-risk patients as well as moderate risk patients they their formula is based off of how many disease states they have as well as the amount of medications they are on mm-hm sure so again it depends on the type of patience it is if it's a patient that is newly admitted to service and they need everything listed in that slide then that visit can take anywhere up to an hour and hour and a half so in a day four to five four patients may be total for patients who need follow-up or any adherence education or support and those visits are going to be a lot shorter so in my experience visits have taken up to thirty to thirty minutes and as much as two hours and that's not including if I have to call the doctor or the pharmacist and get follow-up calls back and all of that so again it depends on the type of patient it is so if it's a new patient who wants to get started on using a pillbox and that's a patient I will see two or three times just to make sure that they are adherent to their medications and they can fill the pillbox themselves as long as the patient is still on vns services I am allowed to see the patient as many times as I want and provide as much follow-up as I feel is needed for the patient of course of course yes the nurses love our notes just because we're so thorough and talking about what we assess but we do it soap note format so that every single clinician that takes care of that patient will have access to see what we've talked about and when the patient was seen by the pharmacist everything is documented through our EMR system yes exactly exactly and sometimes the patients won't have skilled nursing services sometimes they're only admitted for PT services it is recommended that every single time someone goes into the house on medication reconciliation is performed and it is it's just a complete medication review that is occurring on top of the medication reconciliation exactly exactly so I try to present myself in a way where I'm there to help them and of course like you said I can't go searching through every part of their house but generally when I explain to them that you know I'm not here to judge them or I'm not here to take anything away that they don't want me to take just to review the medications that are in the house they'll say go ahead you know I keep things in the bathroom if you want to look in the cabinet that's fine or I'll ask is there anywhere else you're keeping your medications just so I can take a look at yes exactly exactly or the cabinet a lot of patients have told me that they have their own CVS in their home usually that means their own closets full of over-the-counter medications and they'll say you can have at it if you want to go look through that oh of course of course yes so that's part of the interventions that that is provided so if a patient is on a medication that is on the beers list and is inappropriate and I will make a call to the primary care physician yes absolutely exactly right so exactly right exactly so the beers lists also any interactions that come up those are all the interventions that I take a look at for every patient mm-hmm right yes absolutely so chance your first question the the nurses I work with are extraordinary I mean they're angels to these patients but I think that the way pharmacists are trained to look at medications and to assess how medications work in your body and interactions is it's a little different than how nurses for change we're trained and especially if you take a patient who was admitted for wound care okay and they have an hour of nursing services and they spend 30 to 45 minutes on that wound change and then they only have that 15 minutes to provide medication teaching that's an opportunity for pharmacists to go in with a nurse or after the nurse to provide additional training and help for the patient I'm sorry your second question following yes yes so a lot of times that occurs with over-the-counter medications so a lot of times patients see something on TV or dr. oz has something on TV so they go out and buy the product a lot of patients may not need over-the-counter medications especially since we're not really sure what they're using it for so that's one particular area that I try to simplify medications sometimes - what I see is that a patient is on a medication that causes an adverse effect and then the doctor will add a medication to treat that vers effect so if a patient is on a heart medication and one of the adverse effect is that it causes edema then the patient will have an order for lasix to treat the edema when really it was the heart medication that was causing the edema so simplifying the medication regiment in that way - has been something that I will call their prescribers for as well so thankfully thankfully in Rhode Island we have integrated Pharmacy into a lot of different care settings including primary care physician offices so I haven't experienced a lot of pushback I think when you present yourself in a way where you're working as part of a team for the patient's benefit then they tend to perhaps listen a little bit harder and to you know to say that you have some validity so I haven't had a lot of pushback but you know in that case right right right exactly and and then if that's the case and that would be an area where I would call just to let them know that perhaps they don't know what's going on in the home yes yes that's an area that's absolutely worth exploring absolutely absolutely so you know hopefully with this position taking off and having MTM services on board that will be an area that will also incorporate into our pharmacy services yes so we are a relatively small facility we have about 170 total nurses physical therapists occupational therapists and that includes any of the assistants as well at this time yes exactly exactly but hopefully with the medication therapy management component at at all we'll be able to build for some of these services that we already do exactly exactly exactly all right thank you very much thank you