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PARADE: Preventing and Reducing Adverse Drug Events in Care Coordination Communities


PARADE: Preventing and Reducing Adverse Drug Events in Care Coordination Communities Anne Myrka, RPh, MAT IPRO Webinar January 6, 2015 – PowerPoint PPT presentation

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Title: PARADE: Preventing and Reducing Adverse Drug Events in Care Coordination Communities

PARADE Preventing and Reducing Adverse Drug
Events in Care Coordination Communities
Anne Myrka, RPh, MAT IPRO Webinar January 6, 2015
  • Introduce IPRO and the Centers for Medicare
    Medicaid Quality Innovation Network/Quality
    Improvement Organization Program
  • Provide overview of CMS 11th Scope of Work
    Coordination of Care task
  • Describe the Preventing and Reducing Adverse Drug
    Events (PARADE) initiative
  • Describe PARADE Objectives and Strategy
  • Gain Cross-setting Community Commitment
  • Establish the PARADE Timeline
  • Next Steps, Q A

  • The federally funded Medicare Quality Innovation
    Network Quality Improvement Organization
    (QIN-QIO) for New York State.
  • Under contract with the Centers for Medicare
    Medicaid Services (CMS).
  • Leading the Atlantic Quality Innovation Network

Atlantic Quality Innovation Network (AQIN)
  • One of 14 QIN-QIOs across the country working to
    provide quality improvement learning
    opportunities, technical assistance and free
    resources in support of CMS healthcare quality
  • Led by IPRO in New York State.
  • Partners include Delmarva Foundation in the
    District of Columbia and the Carolinas Center for
    Medical Excellence in South Carolina.

QIN-QIO Program
  • Continued commitment to partnering with
    stakeholders on data-driven initiatives that
    increase patient safety, make communities
    healthier, better coordinate post-hospital care
    and improve clinical quality.
  • Grounded in principles that align with the goals
    of the CMS Quality Strategy
  • Eliminating disparities,
  • Strengthening infrastructure and data systems,
  • Enabling local innovation, and
  • Fostering learning collaboratives.

QIN-QIO Program Goals and Initiatives (2014
  • Goal 1 Promote effective prevention and
    treatment of chronic disease by
  • Partnering with physicians to provide more
    effective treatment to patients at risk for heart
    attack and stroke, especially those in
    underserved populations.
  • Supporting self-management education to patients
    with diabetes.
  • Helping physician practices use EHRs to full
    potential and provide patients with preventive
  • Goal 2 Make care safer and reduce harm caused in
    the delivery of care by
  • Working with providers across the continuum of
    care of care to prevent HAI in hospitals and
    other settings.
  • Targeting prevention of HAC in nursing homes and
    facilitating collaboration, innovation and
    enhanced patient and family engagement.

QIN-QIO Program Goals and Initiatives (contd)
  • Goal 3 Promote effective communication and
    coordination of care by
  • Helping community stakeholders, providers,
    patients and families to collaborate for better
    coordination of care transitions, improved
    discharge communication, and better access to
    community services.
  • Sharing evidence-based approaches to reduce
    avoidable hospitals readmissions, especially in
    vulnerable populations.
  • Working with providers and stakeholders across
    settings to reduce potential adverse drug events
    and promoting medication management strategies.
  • Goal 4 Make care more affordable by
  • Helping providers report on measures that assess
    clinical quality of care, care coordination,
    patient safety and patient and caregiver
    experience of care and helping providers improve
    care quality through effective use of healthcare

CMS 11th Scope of Work Task Priorities
  • Essential Functions
  • Results-Oriented Quality Improvement Activities
  • 2. Community Learning and Action Networks
  • 3. Technical Assistance (i.e., Quality
    Improvement Experts)
  • 4. Integrated Communications

Coordination of Care Task Goals
  • Promote Effective Communication and
    Coordination of Care
  • Reduce hospital readmission rates in the Medicare
    program by 20 by 2019
  • Reduce hospital admissions rates in the Medicare
    program by 20 by 2019
  • Increase community tenure, as evidenced by
    increased number of nights spent at home, for
    Medicare beneficiaries by 10 by 2019
  • Reduce the prevalence of adverse drug events
    (ADEs) that contribute to significant patient
    harm, emergency department visits, observation
    stays, hospital admissions or readmissions
    occurring as a result of the care transitions
  • Anticoagulants
  • Hypoglycemic Agents
  • Opioids

  • What is IPROs PARADE Initiative?

Reducing Adverse Drug Events Federal Alignment
of Resources
  • Anticoagulants, Opioids,
  • Hypoglycemics
  • Communication failures
  • Suboptimal management systems
  • Inadequate access to medication lists and lab

PARADE Initiative Pilot study and results
  • Based on an IPRO multi-facility rapid-cycle pre
    (February 2014) and post (July 2014) intervention
    quality improvement pilot study, Medication
    Reconciliation and Anticoagulation Management
    Across Care Settings
  • Four Care Transitions collaboratives comprised of
    hospitals, skilled nursing facilities (SNFs),
    home healthcare agencies
  • Evaluated the discharge communication of 17
    evidence-based requisite anticoagulant-related
    information elements and 5 medication
    reconciliation processes across care settings ? 5
    to 10 charts, retrospectively

PARADE Initiative Pilot study and results
  • Evidence-based system improvements were applied
    according to site-specific baseline results
  • Results
  • Significant improvement in communication of
    requisite anticoagulation-related elements to
    subsequent provider upon transfer/discharge
  • All facilities (16, 95 CI 11.6-20.3)
  • Hospitals (8, 95 CI 1.2-15.2)
  • SNFs (19, 95 CI 12.7- 25.8)
  • Significant improvement in completion of
    medication reconciliation processes upon
    admission in SNFs (21.2,
    95 CI 9.6- 31.9)

Medication Reconciliation Elements
Was an original home medications list collected on admission?
Did the list of original home medications collected at admission include the medication name, dose, route and frequency for each medication? (all elements for all drugs must be present for Yes)
Was the original home medication list reconciled with admission orders in less than 24 hours?
Did the reconciled medication list reside in a dedicated location in the medical record?
Was there is a 11 match for every medication on the home medication list to the admitting orders? (all elements for all drugs must match for Yes)
Requisite Anticoagulation Management Elements Communicated at Transfer/Discharge to Subsequent Provider
Was the primary indication for use of the anticoagulant clearly documented?
Was an assessment of fall risk clearly documented?
Did documentation indicate whether the patient was new to anticoagulation therapy or a previous user?
If new, was start date of anticoagulation therapy provided?
Did documentation indicate whether treatment is intended to be acute (short term) or chronic (long term)?
If acute (short term) was total duration of therapy provided? (was there a stop/end date?)
Date, time, and strength of last dose given documented? (all must be present for Yes)
Date, time, and strength of next dose due provided? (all must be present for Yes)
If on Coumadin (warfarin), was the target INR or INR range documented?
If on Coumadin (warfarin), were the last 2 INR lab results provided (with dates and results)?
If on Coumadin (warfarin), was the date provided for when the next INR was due?
Was the most recent serum creatinine or creatinine clearance evaluation provided (with date and results)?
Was the patient provided with educational material?
Was an assessment of patient/caregiver understanding of the education documented?
Was documentation of patient/caregiver education and understanding communicated to the next provider?
Was contact information provided for the anticoagulation management prescriber/physician?
Was patient referred to an anticoagulation management service? (e.g. Coumadin/warfarin clinic)
  • Requisite Anticoagulation Management Elements
    Communicated at

Link to audit tool http//
PARADE Initiative
  • QIOs are directed by CMS in the 11th Statement of
    Work (11SoW) to
  • Establish relationships and collaborations in the
    community to coordinate provider communication
    and medication management across care settings
    with a patient centered focus
  • Help providers utilize new or existing
    evidence-based tools and practices to improve the
    care of those prescribed high risk medications,
    specifically anticoagulants, diabetic agents and
  • Use health information technology to screen for
    and prevent ADEs in Medicare beneficiaries

  • PARADE Objectives and Strategy

PARADE Objectives
  • To identify patients at risk of experiencing ADEs
    due to high risk medication use following
    hospital discharge
  • To identify hospital readmissions and emergency
    department visits associated with high risk drug
  • To evaluate the post-discharge medication use
    system across care settings and identify
    opportunities for system improvements
  • To facilitate the implementation and serial
    evaluation of evidence-based intervention

PARADE Strategy
  • Process measures All facilities/healthcare
  • Small, low-impact audits of medication
    reconciliation processes and high risk drug
    discharge communication (5-10 charts,
  • Serial evaluation to guide improvements
  • Goal 100 adherence to audit criteria in 6
  • Interventions
  • Evidence based interventions according to
    site-specific results
  • Outcome measures Hospitals only
  • Readmissions due to ADEs using data from
    electronic health record data (hospital) and
    claims data (IPRO)
  • Serial evaluation to identify improvements
  • Goal Demonstrate measureable improvement over 5
    year scope of work

PARADE Strategy
  • Based on 6 month improvement cycles
  • Cross setting work will be achieved within each
    care transition coalition Medication Management
    Committee monthly meetings
  • Cycle 1 is January 6, 2015 June 30, 2015
  • All facilities will focus on Medication
    Reconciliation and Anticoagulation Discharge
  • Educational webinars on management of
    hypoglycemics and opioids will be provided prior
    to the launch of Cycle 2 (which will expand to
    process improvements for hypoglycemics and

PARADE Strategy
  • Cycle 1 January 6, 2015 June 30, 2015
  • All facilities (including those who participated
    in the pilot study) will complete and return a
    PARADE Request for Technical Assistance by
    January 16, 2015
  • Eligible facilities are hospitals, skilled
    nursing facilities (SNF), rehabilitation
    facilities, home healthcare services/agencies
    (HHA), residential facilities, adult homes,
    pharmacies (hospital, community, SNF vendors,
  • Participating individuals are administrators,
    physicians, nurses, pharmacists (including SNF
    consultant pharmacists), quality improvement
    professionals, discharge planners, HHA hospital
    liaisons, etc.

PARADE Strategy
  • Cycle 2 is July 1, 2015 December 31, 2015
  • Continue to work on ADE hospital readmission
    measure, high risk drug discharge communication
    and med rec improvement processes
  • Expand to medication management of hypoglycemics,
    opioids, other (e.g. antibiotics)
  • IPRO is currently convening subject matter
    experts to provide guidance on best practices for
    management across care settings during
  • Subsequent Cycle work will focus on continued
    evidence based improvements, sustainability and
    applicable cross-setting emerging measures

  • PARADE Process Measures Audit Methods

Audit Methods Medication Reconciliation
Audit Methods Medication Reconciliation
  • Audit Methods
  • Anticoagulation Discharge Communication (AC-DC)
    Audit Tool
  • Excel version
  • Preferred method of data collection
  • Calculates performance statistics automatically
    and includes performance dashboard
  • Color coded performance
  • Green gt90 of completed fields as "yes
  • Yellow 60-90 yes
  • Red lt60 yes

Audit Methods Anticoagulation Discharge
Communication (AC-DC) Paper Tool
Link to paper audit tool http//
(No Transcript)
Additional Ad Hoc Anticoagulation Measure-
Warfarin Time in Therapeutic Range?
  • Designed for skilled nursing facilities,
    outpatient clinics and others that serve
    population over long term
  • For more information http//

TTR Rosendaals method
  • PARADE Interventions

  • Policy Procedure improvements
  • Educational programs
  • Clinical tools resources
  • Monthly networking/collaboration through each
    Coalitions Medication Management Committee

Medication Reconciliation Intervention Resources
  • http//

Medication Reconciliation Intervention Resources
Medication Reconciliation Improvement Tools
Anticoagulation ManagementEvidence Based
The Anticoagulation Centers of Excellence
(No Transcript)
Anticoagulation Improvement Tools
  • PARADE Outcome Measure

Outcomes ADE Surveillance Process - Hospitals
  • Baseline measure completion date will be
    individualized per hospital
  • Remeasure quarterly after baseline is completed
  • Secure data transfer protocol utilized

  • Commitments, Timeline, and Due Dates

Organization/Provider Commitments
  • IPROs strategy requires creation of a local
    ADE-specific collaborative comprised of at least
    one hospital and two or more downstream providers
    committed to sharing information and working
    across settings to successfully complete the
    work. Participants will
  • Join your local cross-setting IPRO supported
    Community Care Transitions Coalition by signing
    on to its Coalition Charter
  • Establish an internal team to share project
    responsibility for your organization
  • Commit to collaborate with IPRO for duration of
    the project agree to investigate adverse drug
    events and address performance outliers as part
    of the quality improvement plan
  • Commit to developing and implementing a
    sustainable quality improvement plan to address
    identified deficiencies
  • Implement and evaluate the impact of one or more
    intervention strategies
  • Attend and actively participate in the Medication
    Management Committee convened within your
    communitys Care Transition Coalition and attend
    IPRO coaching support calls as needed

IPRO Commitments
  • Provide technical assistance to support serial
    data collection, analysis, and reporting
  • Perform analysis of prescription drug data at
    baseline and quarterly over each 6 month ADE
    improvement interval (hospitals)
  • Provide detailed reports characterizing at-risk
    population and suspected ADEs
  • Facilitate interpretation and root cause analysis
    to identify priorities for intervention
  • Lead the Medication Management Committee for the
    Community Coalition and facilitate communications
    between partner providers
  • Provide evidence-based clinical tools and
    educational resources for quality improvement
  • Assist in determining effectiveness of
    interventions and support innovative strategies
    that sustain safety goals

Commitments, Request for Technical Assistance and
Completion Date
  • Due January 16, 2015

PARADE Cycle 1 Timeline and Due Dates
Date/Time Topic/Activity
January 6, 2015, 2-3pm PARADE Project Launch Webinar
January 16, 2015 Technical Assistance Request Due Date AC-DC Excel tool will be emailed to participating facilities
January 20, 2015, 2-3pm Webinar PARADE Measures and Audit tool guidance and QA
January 22, 2015, 2-3pm Webinar Reducing Hypoglycemic Events in the Elderly Dr. Medha Munshi
January and monthly thereafter Each Coalition has monthly Med Management Committee Meetings to advance work
February 6, 2015 Baseline audits due IPRO analysis of baseline audit sent to facilities within 2 weeks
February and March Coalition Med Management Committee Meetings interventions/prioritization
March 17, 2015, 2-3pm Coaching Call teleconference only 1-877-287-8135 8949321
March 30, 2015 Remeasure due IPRO analysis of remeasure sent to facilities within 2 weeks
April Coalition Med Management Committee Meetings
May 30, 2015 Remeasure due IPRO analysis of remeasure sent to facilities within 2 weeks
June Coalition Med Management Committee Meetings - Review initial 6 month cycle outcomes create plan for continuing improvements and sustainability expand to hypoglycemic, opioids
(No Transcript)
Summary Next Steps
  • PARADE Request for Technical Assistance Agreement
    due by January 16, 2015
  • SAVE the DATE - Webinar January 20, 2015 2-3pm
    audit tool guidance, QA
  • Audits
  • Excel AC-DC audit tool (preferred) will be
    emailed to facilities after technical agreement
    is signed
  • Paper AC-DC audit tool can be utilized
  • Med rec audit only paper tool is available
  • Fax completed paper audits by due dates to Anne
    at 518-426-3418
  • Email completed Excel AC-DC tool by due dates to
    Anne at
  • Outcome ADE readmission baseline completion date
    will be individualized per hospital

Collaborative Disclosures
  • Project is designed to encourage collaboration
  • Through that effort we will facilitate the
    sharing of facility names, team members and email
    addresses with all involved in project
  • We will not share your individual QI findings or
    QI data with any other organization without your
  • Please contact Anne by January 16, 2015 if you do
    NOT wish to have your contact information shared

  • Questions / Feedback

For more information
  • Anne Myrka
  • Pharmacist Drug Safety
  • (518) 320-3591

Sara Butterfield Senior Director Care
Coordination (518) 320-3504 Sara.Butterfield_at_hcqis
Darren Triller Senior Director Drug
Safety (518) 320-3525
IPRO Care Transitions Web Site http//qio.ipro.or
g/care-transitions/overview IPRO Drug Safety Web
Site http//
Avenue Lake Success, NY 11042-1002 IPRO REGIONAL
OFFICE 20 Corporate Woods Boulevard Albany, NY
This material was prepared by the Atlantic
Quality Innovation Network/IPRO, the Medicare
Quality Innovation Network Quality Improvement
Organization for New York State, South Carolina,
and the District of Columbia, under contract with
the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of Health
and Human Services. The contents do not
necessarily reflect CMS policy.