Developing a Model to Evaluate Risk and Workload with DOAC Patients - PowerPoint PPT Presentation

Developing a Model to Evaluate Risk and Workload with DOAC Patients Walter J Moulaison Jr, MSN, MBA, RN, NE-BC Co-Director, Anticoagulation Management Service Massachusetts General Hospital Boston, MA, USA September 15, 2017

Evolution of the AMS: The Medication Safety Clinic • Developed to provide safe and effective care for warfarin- treated patients requiring laboratory monitoring and dose adjustment by expert providers • Need for expanded role – Assistance with selection of most appropriate anticoagulant and dose – Minimize risk of serious bleeding complications – Peri-procedural management – Encourage on-going medication adherence

Why is measuring work important Barriers Drivers • Greatest challenge is • Changing payment landscape financing • Focus on holistic strategies to • Studies of cost-effectiveness improve care and reduce for DOACs do not include costs of clinic support expenses • Greatest need for support is • Responsibility for costs of care, up front; requires a change in not just fee-for-service costs culture, early consult for assistance is a change in • Strategies to reduce adverse drug practice for most providers events financially beneficial

Primary Functions • Provide a safety net for patients taking anticoagulant drugs with critical safety profiles • Act as an informational resource and decision support service • Assure appropriate drug selection and dosing given renal or liver impairment and concurrent medication use; ongoing monitoring is often overlooked • Spend quality focused time with patients to answer questions or concerns; ongoing relationships will likely improve DOAC adherence • Reduce harm from bleeding; inappropriate dosing, peri- procedural periods • Rapidly incorporate and implement new clinical evidence

Top Priority For Patient-Centered Care • Serving a broader need • Reduce costly emergency visits and hospital admissions • Improve patient satisfaction • Central role in standardized peri-procedural bridging and reductions in the use of frequently overused heparins • Potential for longitudinal medication monitoring in patients taking other cardiovascular medications

Robust Data is Lacking • Assessment of patient outcomes is important • Assessment of clinic function and costs is important • Assessment of cost avoidance is impor tant

Budgeting; not simply a plan for doing what we’ve always done • Goals of budgeting – constantly get better at what we do • Benchmarking – Technique to find best practices • Productivity measurement – Cut fat rather than lean, guard against the motivation to sacrifice the mission • Cost benefit/cost effectiveness analysis – The key to working smarter not harder lies in changing processes

Goals • To measure the relative amounts of resources consumed in providing specific services for patients • To consider RN time and care intensity in the measurement • To provide an analytical method for measuring productivity • To use historical data for deriving meaningful benchmarks • To remove subjectivity • To bring credibility to requests for equipment and staffing

Leveraging the Warfarin RCA RVU Model Weighted Risk Class Assessment Relative Value Units • Grouping patients on basis of • Analytical method for measuring common clinical characteristics productivity and level of resource use – Removes subjectivity – Requirement for nursing care • Critical indicators predict – Adjusts for variations among intensity of care needs patients – Quantification of nursing care resources – Captures major work drivers • Direct observation and time – Informs understanding of studies – Method for calculating staffing patient needs and changes in for required nursing hours the population • RVU model

Measuring Workload Warfarin Patients � Warfarin dose authorization � � � Authorizations Bridging Induction Maintenance Controlled (0-25) 68 5 4962 Low Watch (26-50) 28 103 1316 counts in each class taken High Watch (51-75) 16 107 655 Complex Care (>75) 31 114 497 directly from the dB Times Bridging Induction Maintenance Controlled (0-25) 10 15 5 � � � � Standard times in minutes Low Watch (26-50) 15 20 8 High Watch (51-75) 20 25 12 Complex Care (>75) 25 30 15 RVU � sum of all minutes � � � Controlled (0-25) 680 75 24810 Low Watch (26-50) 420 2060 10528 High Watch (51-75) 320 2675 7860 Complex Care (>75) 775 3420 7455 61078 Dosing Work Units 1018 * Teaching Work Units 80 Converted to hours Total Work Units 1098 *One hour per face-to-face visit is added to dosing work units to comprise total work units

Measuring Productivity Calculating Relative Value Units • Paid direct care FTEs taken from payroll reports is compared with budget targets RVUs = Direct FTES Month Hours Worked FTES * Month Hours = Avg. Hrs./RVU RVU

Productivity (RVU) Warfarin Only Efficiency Above Budget Below Budget Efficiency 2009 2010 2011 2012 2013 2014 2015 2016 2017 Fiscal Year

Active Warfarin Patients Versus Average Hours Per RVU 4800 1.8 1.6 4600 1.4 Budget 1.3 4400 1.2 Average Hours Per RVU Active Patients 4200 1 0.8 4000 0.6 3800 0.4 3600 0.2 3400 0 FY'09 FY'10 FY'11 FY'12 FY'13 FY'14 FY'15 FY'16 FY'17 TD Fiscal Year Active Patients Av Hrs/RVU Linear (Active Patients) Linear (Av Hrs/RVU)

As we work to improve productivity in health care, we must always guard against motivation to sacrifice the mission.

Patient Care Quality Measures 100.00% 90.00% 80.00% 70.00% 70.00% TTR 60.00% Compliance TTR Target 50.00% Compliance Target Linear (TTR) 40.00% Linear (Compliance) 30.00% 20.00% 10.00% 0.00% FY'10 FY'11 FY'12 FY'13 FY'14 FY'15 FY'16 FY'17 TD

DOAC Risk Elements Severity / Warning Level • Risks • DOAC Risk - 27 – Age =>75 • DOAC Risk – 9 or Resolved 0 – Non-Adherence • DOAC Risk – 27 or Resolved 0 – eGFR<41% • DOAC Risk – 27 or Resolved 0 – Hct drop =>6 • Minor (Report No F/U – 11 • Events • Moderate (Medical Attention) – 26 – Bleeding • Major (Hospitalization/Transfusion) – 51 – Thromboembolic • DOAC Contact – 11 – Incoming Calls • Contact/Lab/QNR/Adherence – Outgoing Calls • Procedures • Pre and Post Duration – Variable • Age – Age =>65 • All Patients – 10 • New Patient Score • DOAC Patients - 27 – 8 weeks or less

Drugs

DOAC Events* Event Description Event Severity DOAC Event - Bleeding DOAC Event - Thromboembolic DOAC Incoming Call DOAC Outgoing Call Grand Total DOAC Adherence (condition related) - 26 1 1 DOAC Adherence (economic) - 26 2 2 DOAC Adherence (forgetfulness/ed need) - 26 9 9 DOAC Adherence (side effects/fear) - 26 2 1 3 DOAC Contact - 11 19 27 46 DOAC Contact LAB - 11 1 6 7 DOAC Contact QNR - 11 10 10 Minor (Report No F/U) - 11 7 7 Moderate (Medical Attention) - 26 1 2 3 Grand Total 8 2 34 44 88 *Duration on all events is 14 days

Adherence # Missed Dose/Time Period Dose Regimen (20% = Add Non-Adherence Risk) • 1 out of 7 days • Daily • 3 out of 2 weeks • 6 out of 4 weeks • 12 out of 8 weeks • Twice daily • 3 out of 7 days • 6 out of two weeks • 12 out of 4 weeks • 24 out of 8 weeks

Application to DOAC Medications Aug-17 Risk Classes Enrollment Education Initial QNRs Follow-up QNRs Call Events DOAC Standard Risk <527 0 2 1 4 2 DOAC Non-Adherhence Watch <527 0 0 0 0 0 DOAC High Risk >526 4 6 5 6 12 DOAC High Risk - Dose Adherence >526 0 0 0 0 0 Grand Total 4 8 6 10 14 Time Study Enrollment Education Initial QNRs Follow-up QNRs Call Events DOAC Standard Risk <527 60 30 20 20 5 DOAC Non-Adherhence Watch <527 60 30 25 25 10 DOAC High Risk >526 60 30 30 30 5 DOAC High Risk - Dose Adherence >526 60 30 30 30 10 RVU Enrollment Education Initial QNRs Follow-up QNRs Call Events DOAC Standard Risk <527 0 60 20 80 10 DOAC Non-Adherhence Watch <527 0 0 0 0 0 DOAC High Risk >526 240 180 150 180 60 DOAC High Risk - Dose Adherence >526 0 0 0 0 0 Work Units (minutes) 980 Work Hours 16

More to come….