Combining Administrative, Distributive, and Clinical Pharmacy Staff to Provide Hospice Service

Kathleen A. Johnson, Pharm.D.

St. Mary’s/Duluth Clinic Health System
Duluth, Minnesota

There were three goals in the implementation of the Hospice service project. This included integrating a pharmacist into the Hospice Multidisciplinary Team, creating a pharmacy practice change, and demonstrating a drug cost savings. Currently pharmacist activities on the Hospice Team include participating in weekly hospice patient care conferences, thus acting as an drug information source, providing ongoing drug therapy assessment by evaluating drug regimens for clinical efficacy and fiscal responsibility, participating in a selected therapy prior authorization process, and contributing to improved patient care.

The opportunity to provide patient care services allowed for a practice change for SMDC pharmacists. This change needed to provide a practice environment which included an opportunity for ambulatory pharmacy staff to participate in clinical activities, develop clinical skill, and practice pharmaceutical care. Educational resources were needed to support the change as well as motivational strategies to advance and support intradepartmental relationships and reinforce the pharmacy team concept in providing pharmaceutical care.

To be able to provide pharmaceutical care services an initial plan was devised. First, staffing needs were identified. There needed to be clinical and distributive pharmacy input for a two hour weekly care conference. Therefore the pharmacist from the outpatient pharmacy and clinical coordinator attended the care conference while the operations manager fulfilled staffing responsibilities for the pharmacist in the outpatient pharmacy. Second, a care conference preparation process and documentation method was developed. The outpatient pharmacists and clinical coordinator reviewed the patient roster and matched medication profiles to identify areas of concern; the concerns were then communicated to case managers prior to the conference.

The outpatient pharmacist and clinical coordinator both participated in care conference whenever possible. Activities included providing drug information, answering questions, offering therapeutic suggestions, prospectively evaluating costs for potential therapies, and documenting discussions. To ensure good communication among pharmacy staff, the pharmacy patient roster was updated with care conference notes and distributed to all participating pharmacists. Follow-up on questions or concerns were communicated with the hospice case manager.

An analysis of hospice drug use and costs was conducted. The analysis identified high cost/high volume therapeutic drug classes and drugs within the therapeutic classes, matched issues identified during care conferences with utilization data and targeted areas for improvement, developed a list of suggestions to promote cost reductions and improve the efficacy of drug therapy by providing cost comparison data to illustrate and support therapeutic suggestions, and gave the background to establish a hospice drug formulary.

A hospice drug utilization report was prepared after five months from the start of the program to establish a baseline practice and identify areas for improvement. The report was created from the total drug use charged to SMDC Hospice and Palliative Care account. The report was sorted by descending dollar volume and high cost/high volume classes were identified. Each class was sorted by drug in descending dollar volume. High cost/high volume drugs were then identified. Monthly patient reports were created for all patients using the Hospice Election benefit. The reports were sorted by descending dollar volume to identify patients with high cost therapy this included total monthly charges for Hospice Election, total patients receiving benefit, average cost/patient/month, average number of drugs/patient/month, average cost/drug/month and average monthly cost/patient/day were calculated. Targeted therapeutic classes and drugs with classes were identified such as opioids, chemotherapy-related, anti-ulcer, anti-emetics, anti-depressants, anti-convulsants, cardiac, anti-infectives, and COX-2 receptor inhibitors. Cost comparison tables were prepared for drugs within classes. A preliminary hospice formulary was prepared taking into account the SMDC Formulary and additional therapeutic classes such as narcotic analgesics, combination narcotic/analgesics, anti-emetics, sedative/hypnotics, anti-convulsants for pain management, and anxiolytics. Cost containment strategies were then recommended. One method was the implementation of "prior authorization" on selected drug classes or therapies including parenteral drugs, total parenteral nutrition, orphan drugs, chemotherapy agents, and biological agents. Suggestions for drug use were also developed in the use of opioids, chemotherapy, anti-ulcer, anti-emetics, anti-depressants, cardiac medications, and COX-2 receptor inhibitors. The drug use suggestions were then incorporated into the hospice drug formulary

Therapeutic suggestions by drug class include opioids, chemotherapy related agents, anti-ulcer drugs (H-2 receptor antagonists and proton pump inhibitors), anti-emetics, anti-depressants, cardiac medications, COX-2 receptor inhibitors, and miscellaneous agents requiring prior authorization.
SMDC Hospice and Palliative Care chose Pharmacy Hospice Program as their demonstration of Quality Improvement for the JCAHO 2001 Survey. JCAHO requested permission to publish SMDC documents and materials on the clinical monitoring role of the pharmacist in the Joint Commission Resources Good Practices Database.

To measure outcomes, a monthly analysis of the following data occurs: total hospice drug costs, patient census, and cost/patient/day are tabulated, target drug classes and drugs within classes are also monitored, and variations in expected results are discussed with hospice team at care conferences. The Pharmacy Department was able to demonstrate a savings in cost/patient/day once there was pharmacy involvement in the Hospice Care team. The combined cost of retail drugs and infusion therapy went from $11 per patient per day from January-June 2000, to $9.65 per patient per day from July-December 2000, to $5.50 per patient per day from January-June 2001.

Overall, pharmacists have been integrated into the Hospice Team and are recognized as a drug information resource. An opportunity has been provided for pharmacy staff to learn about hospice care principles and philosophy. A practice environment has been created for ambulatory pharmacy staff to participate in clinical pharmacy activities, the pharmacy team concept has been reinforced, and communications with hospice staff has been enhanced. A hospice drug formulary was also developed and pharmacists participate in the review and revision of hospice standing orders. Care conference planning and documentation process was refined. An initial drug utilization evaluation was completed with baseline data for future pharmacoeconomic analysis, areas of opportunity for improvement identified, and suggestions for drug therapy developed. Ongoing drug utilization has demonstrated a notable decrease in hospice drug costs as reflected by the decrease in cost/patient/day. Changes in therapeutic strategies have evolved through use of the formulary and care conference discussions. Two additional regional Hospice teams have been added. The pharmacy model has been adapted to include regional SMDC pharmacies for dispensing: clinical monitoring and drug utilization performed by clinical coordinator. The Pharmacy Hospice Service model has also been adapted to improve pharmacy service and fiscal initiatives in other areas of practice at SMDC.