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

• Greatest challenge is

financing

• Studies of cost-effectiveness

for DOACs do not include costs of clinic support

• Greatest need for support is

up front; requires a change in culture, early consult for assistance is a change in practice for most providers

Drivers

• Changing payment landscape
• Focus on holistic strategies to

improve care and reduce expenses

• Responsibility for costs of care,

not just fee-for-service costs

• Strategies to reduce adverse drug

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 important

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

• Grouping patients on basis of

common clinical characteristics and level of resource use

– Requirement for nursing care

• Critical indicators predict

intensity of care needs

– Quantification of nursing care resources

• Direct observation and time

studies

– Method for calculating staffing for required nursing hours

• RVU model

Relative Value Units

• Analytical method for measuring

productivity – Removes subjectivity – Adjusts for variations among patients – Captures major work drivers – Informs understanding of patient needs and changes in the population

Measuring Workload

Warfarin Patients

Authorizations Bridging Induction Maintenance Controlled (0-25) 68 5 4962 Low Watch (26-50) 28 103 1316 High Watch (51-75) 16 107 655 Complex Care (>75) 31 114 497 Times Bridging Induction Maintenance Controlled (0-25) 10 15 5 Low Watch (26-50) 15 20 8 High Watch (51-75) 20 25 12 Complex Care (>75) 25 30 15 RVU 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 Total Work Units 1098

• sum of all minutes

Converted to hours

*One hour per face-to-face visit is added to dosing work units to comprise total work units *

• Warfarin dose authorization

counts in each class taken directly from the dB

• Standard times in minutes

Measuring Productivity

Calculating Relative Value Units

• Paid direct care FTEs taken from payroll

reports is compared with budget targets

RVUs Month Hours = Avg. Hrs./RVU = Direct FTES Worked FTES * Month Hours RVU

2009 2010 2011 2012 2013 2014 2015 2016 2017

Efficiency Fiscal Year

Productivity (RVU) Warfarin Only

Above Budget Below Budget Efficiency

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 3400 3600 3800 4000 4200 4400 4600 4800 FY'09 FY'10 FY'11 FY'12 FY'13 FY'14 FY'15 FY'16 FY'17 TD

Average Hours Per RVU Active Patients Fiscal Year

Active Warfarin Patients Versus Average Hours Per RVU

Active Patients Av Hrs/RVU Linear (Active Patients) Linear (Av Hrs/RVU)

Budget 1.3

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

70.00% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% FY'10 FY'11 FY'12 FY'13 FY'14 FY'15 FY'16 FY'17 TD

Patient Care Quality Measures

TTR Compliance TTR Target Compliance Target Linear (TTR) Linear (Compliance)

DOAC Risk

Elements

• Risks

– Age =>75 – Non-Adherence – eGFR<41% – Hct drop =>6

• Events

– Bleeding – Thromboembolic – Incoming Calls – Outgoing Calls

• Procedures
• Age

– Age =>65

• New Patient Score

– 8 weeks or less

Severity / Warning Level

• DOAC Risk - 27
• DOAC Risk – 9 or Resolved 0
• DOAC Risk – 27 or Resolved 0
• DOAC Risk – 27 or Resolved 0
• Minor (Report No F/U – 11
• Moderate (Medical Attention) – 26
• Major (Hospitalization/Transfusion) – 51
• DOAC Contact – 11
• Contact/Lab/QNR/Adherence
• Pre and Post Duration – Variable
• All Patients – 10
• DOAC Patients - 27

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

Dose Regimen

• Daily

# Missed Dose/Time Period (20% = Add Non-Adherence Risk)

• 1 out of 7 days
• 3 out of 2 weeks
• 6 out of 4 weeks
• 12 out of 8 weeks
• 3 out of 7 days
• 6 out of two weeks
• 12 out of 4 weeks
• 24 out of 8 weeks
• Twice daily

Application to DOAC Medications

Aug-17 Risk Classes Enrollment Education Initial QNRs Follow-up QNRs Call Events DOAC Standard Risk <527 2 1 4 2 DOAC Non-Adherhence Watch <527 DOAC High Risk >526 4 6 5 6 12 DOAC High Risk - Dose Adherence >526 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 60 20 80 10 DOAC Non-Adherhence Watch <527 DOAC High Risk >526 240 180 150 180 60 DOAC High Risk - Dose Adherence >526 Work Units (minutes) 980 Work Hours 16

More to come….