All right. We'll go ahead and get started. Good morning, everyone. We have a debate as to whether it's better to be the session right before lunch or right after lunch, and I'm not sure. We'll find out here soon whether we're on the winning end of that or not. Thank you for joining this session. This is a meds to bed session, and it'll be about a culture shift in this organization, and there's two wonderful people that'll be presenting it, and it's Lindy Sane here, who is a STEMI coordinator, and Anna Reichard, who is a pharmacist, both at Methodist Healthcare in Germantown, Tennessee. So welcome. Thank you, guys. Thank you. Thank you, Bobby, for that lovely introduction. We're actually here, just exactly what you said. We're here to talk about meds to beds and changing the culture in our healthcare system. I want to also introduce our other presenter, who's not here, John Sigma. He's our cath lab director. He wanted to be here, and Dr. Brian Burkowski as well. So why are we here today? And before we get started, you know, we should be experts now on enhancing the patient care for meds to beds, but go ahead and get your phone out and scan the QR code, because this is one of the things I love about ACC is, like, we love polls, and we love to answer questions. So let's get to know each other a little bit. So I'm going to introduce Lindy Sane and ask her the reason why she's here. Hey there again. My name is Lindy Sane. I'm the STEMI coordinator at Methodist Germantown. This, I keep going back, was probably the hardest slide to get information on, because I had to take a deep dive as to my true why. And my why coordinates with how my career has transformed. I started out at 19 years old, literally pulling paper charts for Arthur Sutherland, who is a prestigious cardiologist in Memphis, who even has his name on the side of the building. And here I was, a 19-year-old pulling paper charts, but I took it a step further. And I would read those charts, and I would try to learn, because I didn't know what I wanted to be when I grew up. So I just took the opportunity. That morphed into billing, coding. I worked at the front desk. I did the call center. I ended my career under Dr. Sutherland, going into the cath lab, I mean, excuse me, as the pro-time lab as a medical assistant. And then I did nuclear medicine, and then lost my mind and decided to go back to nursing school. So when I got out of nursing school, everybody told me I had to work med-surg, and I did, but I wasn't happy. It wasn't my passion. So Dr. Borkowski came on board back at the clinic, and the nurse manager, who hired me at 19 years old, called me back, and she's like, Lindy, we need a nurse. So I onboarded, and I was Dr. Borkowski's nurse, and then went on to being the clinic manager. And then Dr. Borkowski pushed me out of the nest to be the STEMI coordinator at Germantown. All that to say, my true why is it's been stair-stepped as far as I've taken all my experiences and built it, and tried to look at different perspectives and those experiences to put it into a process on how we can enhance patient care. And it was applicable to this meds-to-beds process. So that is my why. So I think I'm the only pharmacist here, and you know, I am very proud to come here. You know, this is your 75th anniversary for ACC, and I feel like I'm a member of ACC. And I guess my surface why, you know, being here in the convention, I can see a lot of passion just to do through the whole health care system. But the first thing about why am I here, so this actually is a picture of me. And I'm not the adult in there, that's my mom. And my two boys were visiting my parents, and they went into this room, and you know, as your parents' room, or their house, right, there's this room where there's a portal to your childhood. And they found this picture, and like, mom, you're holding a Coke, you don't drink Coke. And I laugh at this because I'm the girl on the left with the red-rimmed glasses. And you know, being in that age, you know, I don't know if you guys remember, like, the first talk show host, Sally Jesse Raphael, that's my glasses. So for the Millennials and Generation Z, you know, I tell my interns, please go Google who that is. So why am I talking about this, about Mom Eats Last? Well, I do a lot of reading, and one of my passions is reading about leadership and guiding my team. And one of my, kind of, the guide I go to is Simon Sinek, and he wrote the book about Leaders Eat Last. Now, in this book, he talks about how great leaders will sacrifice their interests for the greater good of their team, and that the best organizations, like ACC, right, will foster this care of, like, trust and safety. And my mom was at safety. Now, not to downplay any dads, and I was joking with Bobby because he brought his kids, the moms in the room, we always eat last, right? We're the last ones to sit down at the table. We're the last person that turns out all the lights in the house and go to bed. My mom was that person. So why am I telling you this? So I was the first person in my family to go to college. My parents were immigrant parents that we immigrated here from Thailand. My dad had $200 in his pocket, two suitcases, and three kids, and a wife. And they worked, like, two, three jobs so I can go to the best school in Germantown. I was 13 years old when I first grabbed those glasses, and I remember my mom talking to the optometrist because we were self-paid, we were uninsured, and she told him, it's like, I'm having trouble seeing. An optometrist happens to have a glucometer and tests her sugar. She was diabetic. It was 300. And at 13 years old, I didn't kind of understand what that meant until I took her to the doctor, and the doctor's prescribing horse insulin, and I'm translating all the information on how to take the meds, and I could see in her face that she was calculating how much it was going to cost, or how much it was going to cost us in the household if she was going to be able to afford it. And we would drive all the way out to Fraser, and if you're not familiar with the Memphis area, it's a northern part of Memphis, it's very dangerous, and she would go and see Roy, and he was our independent pharmacist. And I hated going to the pharmacy because I was standing in line, and my mom would have to pick and choose what medicine she could pay for that month. And I remember the technician, the cashier, just rolling his eyes because he knew he had to put some of those medications back. So that's kind of like my why of why I'm here, because even though we live in the part of Germantown, the prestigious part of Germantown, we couldn't afford those meds. And my mom is a good example of why sustainable, good health care comes with a price, a price at which she's going to feed her kids that day. So just going to go ahead and do your question number one. So get out your phone, don't be sad, this is supposed to be a fun time. My mom is still with me, and you know, she's been very successful. So question one, does your hospital health care system has a meds to vets program? So let's cue some music, right? No music? Okay. All right. She has some 80s music. Where's my team? Jeopardy music, something. Yeah. All right. Wow. This is amazing. So 60% of you guys have a meds to vets program in your hospital. Well, this is great, because you know what, I was excited that this was going to be a case, because you guys already understand the struggles and the progression of meds to vets. All right. So basically, question number two, what percentage range of discharged patients from the hospital have poor medication adherence due to the lack of transportation, high medication costs, long pharmacy wait time, and health literacy? Excellent. You guys know this. If you guys get anything from ACC summit today, the cost and the adherence of the medication is a big topic in the world. Good, 25, 50%. All right. Question number three. What percentage of certain patient populations have a disruption of DAP therapy related to non-compliance? Let me reiterate, this is not due to bleeding. This is just non-compliance. Do, do, do, do. Thank you, Bobby. Thank you. I was waiting for the backup singers. There's no wrong answers, please. Okay, that's, it's 10%. I know, that was shocking to us too. But 10%, that's one in 10 too many. We noticed that with this, when we really drill down, it's your older population, those who are at an educational level that's pretty low, and then rural areas. So Anna and I go a long ways back when I was first starting as Dr. Borkowski's nurse, and it was one of my patients. And I'd heard Anna's name, but we like to tell this story. And I cold called her, and I'm like, what do you mean this patient didn't get their medications? Anna has a different version of the story. I thought I was the gentle, giant, nice, like, what happened, Anna? So I'll let her tell it, but that was over six years ago. And we laugh about this, you know, because I think the story has morphed a couple of times. And we laugh at this because pharmacy gets blamed for everything. The medication wasn't ordered right. We didn't get it there on time. So it was something that it was kind of taken back a little bit. We had shared a patient that we thought we took care of everything for him. We did the procedure right, took the meds right, and guess what, he went to the pharmacy and they didn't have the meds, and he forgot to take it. How many of those stories do you guys resonate with? A lot, right? So with that, we decided at that point over that conversation that we would establish one goal, one process, and one culture within our program that we were trying to resurrect at our hospital. So with that, we always try to hone in on a story because we feel like we can throw data at you, or we can, you know, but when there's a story attached to something, it really hits home. And I will never forget that as a new STEMI coordinator, this patient came in, apparent MI, we took him to the cath lab, we opened his LAD, and you never forget the eyes of that patient when they're at their scariest moment in their life. Everything went well. It looked great on paper. We had checked all the boxes. We thought he knew what he was doing. We fast forward a month later, code STEMI over the speaker. I go down to the ER and I'm like, I know that face, that same fear in his eyes. So we took him back to the cath lab, reopened the stent we had put in, and turns out he just didn't get his medication refilled. And I sat down with him at bedside and I was trying to drill down, like, what happened? We thought we had done all the right things, but truly, what happened? And his words will stick with me. I truly didn't know. I just didn't know. Or, you know, something like this that happens too. As pharmacists, we at Methodist Healthcare, we make sure that the patient can afford their medication. So we'll do the prior authorization for the P2Y12. The patient can afford it. You know, it's December, it's $47. He got his first month free. And guess what? January hits and he's a Medicare Part D patient. He is deductible to me, right? So he can't afford those meds. So these are things that, you know, we have to talk about, not just as a system, but also in healthcare. So what do we do now? So Anna and I set out, what did we want to do? How did we want to make a change? So we decided that with the Meds to Beds program would be part of the patient intake in the same day B holding area where we take all of our pre-cath procedures, where we put IVs in, where we do the HMP, go over meds, things like that, where we just interview the patient. So we started to initiate the verbage of Meds to Beds on the front intake. Our goal was to obtain a 50% program participation by quarter four, 2023, with a 95% program participation by quarter two, 2024. We set the standard high because we knew that our team could do it and we believed in them. Patients would receive medications prior to discharge. And we're not talking just a transactional encounter. They would actually have the medications, but it would be accompanied with education by a pharmacist, a pharmacy tech, a pharmacy intern. Somebody would sit down at bedside and build that relationship. Then patients who are unable to afford them the P2Y12 specifically speaking, we through grant money, coupons, things like that, we were able to get them a 30 day free voucher to get them out of the hospital because we all know our census is booming and to get them on their way while in the background, Anna and her team, because she's our pharmacy fairy godmother, would work her magic for prior authorizations. And then we would work it out after the patient was home while talking with the cardiology clinic. And so it was all a collaborative effort. So something that we have discussed quite significantly and you know, like for me, in the background at Harris is something that we don't talk about. We don't see on the news. You know, when a patient dies from an MI, it doesn't say death due to non-adherence, right? But according to the World Health Organization, 50% of our patients do not take their medication as prescribed by a physician, 50%. Medication non-adherence, especially in patients with cardiovascular comorbidities, cost $100 billion to the healthcare system. So it is a huge deal. So when we're talking about why this is important, this is it. End disruption, you know, dual anti-plate therapy, you guys know to do non-compliance can be detrimental to PCI. I heard it somewhere and I can't remember where I heard it. You know, non-adherence can be a situation between life and death. And like we said, you know, in our poll, non-adherence can cost one in 10 patients to stop DAP therapy. And then bleeding can cost one in 20 to stop DAP therapy, if that's the case. Now, during the session for ACC, I heard a lot about the need for non-adherence. I heard a lot about FTEs and C-suite. And you don't get anything out of this. Take this slide, because I've used this slide in some form or fashion, probably in the last couple years. When I go up on, you know, the pharmacy is always in the basement. I don't know why we put us there. We don't have any windows, you know? And my team knows when I'm dressed up like this, that means I'm going upstairs to ask for money, right? This non-adherence, I'm usually in scrubs, you know, like we almost miss our connection because we were slow. And Lindy said, pretend it's a coat semi. I did. And so we made it. But the point of this slide of non-adherence, right, is because we want to reduce readmission. We want to decrease length of stay. And because of non-adherence, it lowers the patient satisfaction score, right? And this is why it hits the C-suite people. One out of $9 of total healthcare spend waste is due to non-adherence. It's not a pretty picture. Nobody, you know, kind of write articles on it. It's not on Newsweek, but it's something that's a concern because if you look at the data, one-third to two-third of hospitalization is due to somebody not taking their medication correctly. So what are the two barriers to medicated adherence? There's patient-related barriers and treatment-related barriers. Patient-related barriers can be a couple things. There's lack of motivation. I'm going to take on Dr. Borkowski because he's probably one of the two physicians in here, right? So he tells me all the time, you know, sometimes patients just don't want to do it. That lack of motivation, right? And if you guys don't know, right now our whole healthcare system is dealing with mental health and depression comes in part and denial. We see a lot of patients that have come to Methodist Le Bonheur Healthcare who weren't taking anything and all of a sudden they are now on a scheduled PCI. There's some cognitive impairment. There's drug or alcohol use and low education level and a culture issues. Now, if it was up to me, everything would be highlighted. Lindy had to control my highlighting yellow, all right? So the three top reason patient-related barriers for us is denial, low education level and culture issues. In the Memphis area, in the population that we're dealing with, we had to change our patient education about medication to a third grade level. Naturally, everything is written in a fifth grade level. And I remember as a pharmacist, I was like, this is not gonna be helpful for us. If our patients don't understand what they're reading, they're not gonna take their medication ready. And culture issues. You heard about my mom. I was joking with Liza. I came from the Asian Pacific Islander background. My mom would never told the doctor in that appointment, even at 13, that she could not afford their medication because she was embarrassed. They asked for a sample, that's embarrassing, all right? So there's a culture issue to a barrier as well for adherence. Treatment-related barriers for medication adherence, the complexity of treatment, right? Getting diagnosed with a heart disease, it's hard to kind of grasp that concept. And side effects. Oh gosh, as a pharmacist, there's so many urban legends about statins. And then when we changed the guidelines to high-intensity statins, it was like, no, my mother's neighbor's dog said this, you know? It was just like, what, right? And the inconvenience, right? We, I heard it, you know, when I'm part of ACC now and you're on your team, you know, can't be the only pharmacist on your team. The inconvenience of being sick, right? Trying to get the appointment, trying to get your drugs, and the costs. Cannot explain this, you know? My husband was like, don't talk about politics. I go, well, it's election year. We've got to talk about this. The Inflation Act of 2026 is coming. It was just announced in August. So Medicare Part D patients will now be able to get their medication at a lower cost. So what does that mean? I was in a lecture yesterday with Dr. Baja, or actually it was the audience, and he said that annually, a Medicare Part D patient will spend $2,000 out of pocket, all right? The Inflation Act, which is coming out, is going to affect us. You know, I hate to say this, but politics and healthcare are so intertwined. Our ACC president said it. She's going up to the hill. Of the list of those medication, of those 10 medication, six out of 10 of those medications are heart medication. We have spent $1.5 billion, our patients, on getting these medications. So I'm gonna get off my soapbox, okay? I'm in time. Now, barriers to medication adherence. Their poor clinic-clinician-patient relationship. I kind of sometimes agree with that. You know, I had dinner with Dr. Murkowski, and he said, you know, ideally, I would love to see nine to 10 patients a day. It doesn't happen in real life. We're seeing 20, 30 patients a day in Southern Cardiology, all right? And transportation. Transportation in Memphis area is horrible. The public transportation is horrible. And this is something that we have talked about for a long time. It's long wait times in the pharmacy, all right? Long wait times in the pharmacy to get your prescriptions filled, all right? And long wait times in the pharmacy to actually get that prescription to fill. So what does that mean? The average time to fill a prescription post-discharge. I love this slide. You know, we pharmacists, and you know, Lindy's like this, she was so color-coded. This is something I wanted to really stress, all right? The average time to fill a prescription post-discharge. 40% of patients actually go to the pharmacy at the day of discharge to fill their medication. 20% of those patients go to one to two days post-discharge. 18% of those go three to nine days post-discharge to fill their meds. And then 22% goes, oh, I feel better. Dr. B fixed me up. They didn't fill their medication at all. You do the math. 60% of our patient that we handed their prescription did not get their medication filled. You just had a, what, post-PCI, right? Two days without your medication, shortness of breath, I'm getting chest pain, I'm right back to where I started. I just didn't know. Right. So is Meds to Beds the answer to all our problems with the P2Y12 adherence at MLA Germantown? I don't know. It's a moving process. It's a process that we have to kind of look at every single day, almost. So the perception pitfalls of Meds to Beds. It was a very loose term that was occasional delivery. And I own this as accountability. The pre-procedure area of my hospital in the beginning of this project was the hardest one to kind of like fall into our Meds to Beds program. Because it was a hospital-wide department that we weren't aware of the service. Because our EMR system did not talk to our pharmacy EMR system. We have five systems at Methodist that don't talk to each other. And it's gonna change, right? And there's lack of patient participation. There was a lot, it was insufficient buy-ins from the executive leadership. Like, why do we need more FTEs with Meds to Beds? Physicians and nurses. It was a lot going on. So, we're going to change that. And something flipped. Agreed, something did flip. I was listening to a podcast and actually this quote was stated and it really stuck out because, I want you to read it, take it in. Only those who risk going too far can possibly find out how far they can go. So what does that mean to you? If you're told no, are you just gonna stop? Are you gonna wait till the next patient gets harmed? Not, you know, on purpose or anything, but what are you willing to do to push your program forward? And so, that's where Anna and I took the bull by the horns. And I like to call it the squeaky wheel method. Call it annoying, call it what you will. But we kept on until we were heard. At Methodist Germantown, we do the PDSA, Plan, Do, Study, Act model. This is how we, when we establish a new process, we give this to our C-suite because they want short and simple. As a good friend in the audience says, she says, the KISS method, keep it simple, stupid. And so that's what we, not that we're calling anybody stupid, but you've gotta keep it very concise to sell your product, basically, in the name of patient care. So we started with a plan. What was our plan? We wanted 90 days of the P2Y12 that are prescribed post-PCI on the order set. It was previously just a 30-day supply. So we all know, as Anna alluded to earlier, appointments and getting into cardiologists, you cannot get them in within 30 days, typically. We're trying to change that and open up more slots and utilize nurse practitioners and APPs in, you know, more efficiently. However, the 30 days was just not cutting it. So we planned to change that. As we reflect back on the story I told, we were like, we've gotta incorporate more people. We can't just tell the patient when he's in post-op holding and he's had his little cocktail, like, here's your medicines, this is what you wanna take. So we changed the way we delivered our message about the medications post-PCI. Then we educated the staff on the option to enroll and that meds-to-beds had been used so loosely and that term was basically just handing over a coupon and shout out to Kevin Worley who is a navigator who said that's not meds-to-beds but that really got us thinking because we were like we've really got to amp this up we've got the resources let's amp it up so we had to educate the staff on what they thought meds-to-beds was to what our vision was becoming and then our plan was definitely to increase adherence by educating the patients like I said on the front side and it didn't it didn't mean just the patients we had to educate staff physicians and everybody so what did we do this brings me to our do it was a total multidisciplinary approach it wasn't just Anna Wendy and Borkowski set in the world on fire trying to implement this no we did we used pharmacy we use physicians cath lab clinic anybody that would listen to us we we gave our spill because we knew that it would enhance patient safety I'm gonna turn it over to Anna to explain the outpatient pharmacy strategy so I'm glad that you guys have been a meds-to-beds program I just want to raise your hand how many pharmacists is on part of this team okay okay some so how I got I don't want to say voluntold I volunteer because I'm really passionate about you can tell from my story so I love how I heard about this so Dr. Borkowski calls me he has his own ringtone and I need to change it cuz I let that loose it I know when he's calling me on my cell phone right he's calling me and I pick up and I can hear him washing his hand I'm thinking are you done with the procedure is this it and then I see our cath lab director John comes you know I'm down the basement right no one ever comes see me unless it's a patient right so here's the dawn coming and here's Karen our nurse leader and here comes Lindy gun the caboose trying to come and tell me about this project like we really really want that's the best program to be part of our accreditation so what is outpatient pharmacy do we're a really fun group you guys have come down Memphis you really have to come see us we developed a pharmacy medication form in the EMR and pharmacy system to document meds-to-beds in their counseling notes and education this way when Lindy and her team go and look if the patient got the meds they see a documentation we also ought to generate a pharmacy task for patients in the pre-procedure area so you already knew the list of patients are going to come that day for a procedure and this is the key now for those don't have a pharmacy you pick one and I know I'm really good at picking out people you pick the pharmacies that ask the most questions you know why because they're the most creative they're gonna make it work so they call what we do we'll call the high-risk patients after we go back lab procedure so how do we change his meds-to-bed culture strategy so I told my team all right pharmacists all right interns we've got to ask the three same probing questions for education and counseling how are you doing on your medication all right where are you having effects all right when is your appointment with your doctor tell me about that and we keep saying again during our education counseling you cannot stop taking this medication if you have trouble obtaining your medication will you please call our pharmacy for assistance you don't remember anything else I said if you run in trouble you call me so then we'll take it over to the physician strategy that's the only picture I could capture of dr. burkowski and his lead before he was going to a procedure because he's so hard to catch but the first thing that we did was like I said earlier we had to modify the order set that took a great deal of effort because it was not just one physician it was a multitude of physicians but not just one group it was a you know several groups within our system we educated the physician with the emphasis on the order set to make it easy clicker friendly because we didn't want more clicks and then we actually had physician champions at the invasive council meetings within the cardiology clinics to actually speak to the meds-to-beds process because we wanted to get the word out and have the verbiage the same across the system and then there was post procedure communications in the clinics EMR and I think that's where my growing up in the clinic I still had access and I knew a lot of the physicians and the nurses so if I saw a high-risk patient come across my radar I could be like dr. burkowski I feel like this patient you know may get into some trouble and I would send his nurse a task so we were all in this together talking about the greater good for the patient this is a picture of the order set and what's highlighted is it's a pop-up that if you do not prescribe the p2 y12 it is a hard stop on the physician side why you have to document a reason and then you have to put it in the chart too so we just didn't take no for an answer I just forgot about it no this was the hard stop and we have the pop-up this was the hardest thing it did I think it took the team a year and a half to get every physician on board if this was okay this is 90 days and I remember writing and as a pharmacist I'm really about all the geekiness of side effects and drugs and plastic grill when you prescribe plastic grill it pops up and says please make sure that is in the original container on the comments in the prescription now I'm gonna tell you as a pharmacist I get this a lot then patients when I'm counseling a plastic grill it has to be in the original bottle it is temperature and heat sensitive light sensitive you know we tell our patients to please put all the pills in their pill box right that's a grill is the only one you can't do that so I tell patients if you're prescribed price ago you make sure when you go back and get refills is an original container not the orange by all pretty ones the original container and it's not you tell me your hospital pharmacist says it has been original container please go look at the packaging search and I remember dr. Berkowski going I had no idea where is this this is amazing and at one point I was like my gosh I'm smart about dr. Berkowski and one thing so I had him print out the package insert and I how I did yellow and it was like a funny thing you guys can go home take that take that knowledge and you know make sure that it is you know the patient understands that so then we have the nurse strategy these are our same day be nurses are our pre holding area where we take the cath patients prior to their procedure and we education I cannot hit home enough education a big feat was getting IT involvement because we the nurses started noticing that some of the physicians didn't have access to e-scripts and so we were like wait a minute and it was just something in Cerner that IT had to you know flip the switch but the nurses took the bull by the horns with that one and they would sit down one-on-one with a physician and say hey can I show you how to do this in our EMR constant reiteration and staff huddles I cannot say that if you were in earshot we were talking about it to the point of nausea and I think and they were sick of seeing us and then like I said the biggest thing from the nursing strategy was taking somebody who was in the holding area and placing them to actually do the interview and intake with the patient and their family member on the very front end so we had to totally displace an FTE and move it to another part of the cath lab so that we could get this person who she would while she's starting the IVs they're in there talking about the medications that you could potentially get and that we have this service so that it wasn't just fresh material we wanted it you know on everybody's brain so with that said Anna and her team produced this pamphlet or flyer and it's really great because you know what when you're trying to start anything new all right it's hard to kind of guide the conversation if you don't understand our service so you use this pamphlet or flyer to give out to the patients and the nurses use it too as a kind of a template to talk about our meds to beds like one more time we're open and we also did express pickup so if they had refills that they wanted to pick up at our outpatient pharmacy we had curbside delivery so it wasn't just like one and we're done right if we're trying to carry on this transitional care model where you know we're taking care of an inpatient we're going to take your outpatient and you know like when you say you know handing somebody out a coupon to fill their p2i 12 it's not the same thing so this flyer is great you guys want to use it definitely use it so in the cast lab we basically did the same thing with talking to everybody making sure that all the doctors were on board all the nurses knew but I would like to say that when you're on the other end of patient care and you become the patient instead of the nurse or the caregiver unbeknownst to us has happened to one of our members and the patient was they were just so grateful because they got to see our process from door to discharge discharge to pharmacy pharmacy to clinic and onward so that was just a testament to it was kind of like a secret shopper that we didn't know was a secret shopper it is and you know and she felt really proud you know she took you didn't know it was my parent that was under the table there right on the table but you took care of him like if they had one dollar in their pocket versus a million dollar in her pocket correct then like I said earlier we went to the clinic and with the clinic we basically just wanted to get the message out there so that there was familiarity so when our study it was a very very very very manual process there was no easy way to gather these metrics with the database that we have so we did chart reviews and in this chart review we would get like a census every month of the same day PCI patients and I would literally go in and I would look at the doctor did they have a stent placed or no and then I would try to find trends in the data as to why these patients would or would not use the meds to vets process and in these chart reviews we noticed that the statin a high-intensity statin was actually not on the order set so that was a positive outcome that came from this as well so before 2023 the pre meds to beds program we would just you know like I said it was very transactional after that and I made the decision to really take this forward we decided to instill pharmacists pharmacy techs people that that handled medications to go like I said to bedside so that they could really form trust and a bond with these patients because we just didn't want it to be one and done and like Anna said earlier a week later the patients are called we have to make sure that you know they understand because we inundate these patients was so much and we want to make sure that there's if there's any clarifying questions they had they truly understand it and if they don't we're gonna get them the resources and the people to contact so let's take a look at our results the next slide is going to show you quarter by quarter the results and we adjusted our goals we started out with nothing so we had 0% we stair-stepped our goal by 25% with I mean ultimately yes we'd like to be at a hundred percent participation rate with the meds to beds but we all know that's not going to happen so we plateaued out at 95% so we adjusted the goals every quarter as we observed improvement or if we saw need for improvement we would go back to the drawing board so we although we set the standard high we still we wanted to hear from our staff who were actually utilizing it so here we are like I said we started with nothing in quarter 4 of 2023 we were gangbusters everybody was on board quarter 1 2024 again like I we stair-stepped our goals 25% over quarter over quarter we were at 66% we did see a drop in that because there was shifts in staffing at the hospital the denominator was lower in the cath lab for elected PCI's so even though it did drop and it is above goal we still wanted to know the why behind it again quarter 2 staffing started to solidify more we got you know our ground back and then if you look at quarter 3 there is a slight drop-off and so I can explain that in the next slide again this is just month after month in July that was the quarter 3 I was speaking to previously in our denominator we had the set of patients and we had the outliers and we couldn't figure out like was it our process so Anna are always going back like we take accountability well what we did notice with these people that that did not use the program it was rural areas we live in Southern State Memphis we get Mississippi Arkansas and people are very very loyal to their mom-and-pop pharmacies they trust them and here we are we just presented this new process to them so they didn't they didn't want to use us and rightfully so so that didn't stop us from you know accepting this we still made sure and followed through that they still had a follow-up appointments and that they were still getting their medications so Lindy kind of alluded to this like how the patients hold the key to meds the beds a reason for nose like loyal to their pharmacy they weren't sure to do with their refills and that was something that was the hardest thing to sell and I stuck here forever I live 30 miles away you know it's like no you take those refills you take it to the pharmacy and we can transfer that prescription there's a thought about delaying discharge and a lot of patients didn't have form of payment there you know there's a copay and there's a misconception a lot about our patient pharmacy in the hospital paying more now the hospital team also who's the key to success of meds to beds we have to be consistent and like Lindy said there's accountability one of the things that we learned through this process is that we're not perfect it's a chip is a culture right we're learning from our stakes our meds to beds program has like morphed it and and reinvent us I feel like Cher every five years I got to do something different right the Backstreet Boys are coming back you know outpatient pharmacies coming back this is huge right so one of the things we found out you know when a patient gets admitted to our hospital we can't deliver meds until there's a discharge placed by a physician well the cardiologist thought the hospitals was gonna do it the hospitals thought the cardiologist do it and I'm like I still have the meds right I can't go out there legally yet so these are things that we have to talk about so our meds to bed culture strategy like you have to establish a culture of care from c-suite to the door if you want to start your medicine program you start with a strategic floor where the need is all right where is the floor that needs the most with the lowest patient satisfaction pick the hardest one pick the hardest floor the reason why you show one floor that you could do the meds to bed program really well everybody will follow you know so I love this slide because when I'm talking about meds to beds because not only do in Germantown we also do in other hospitals that don't have an outpatient pharmacy like Olive Branch and it's good it's kind of one sheet it tells you exactly what we do and why we do it so if you don't have an outpatient pharmacy what's the solution I get this a lot although 60% of us do there's still a couple lesson well you know I'll learn about this you can actually partner with a national retail chain that's how I started I was on maternity leave and my boss says guess what we're gonna do meds to beds from Methodist Le Bonheur healthcare and then he gave me a binder and it was empty and I remember actually having my technician drive to the hospital round with the team bring the prescription actually fax the prescription, this is the old day before e-scribing, and we would fill the medication, and then I would FaceTime the patient at the hospital about their meds. Or you can rent a space. This is something huge too, and that's FTE that you don't have to pay for. It's paid by a chain. So you can also partner with an independent pharmacy. We love our moms and pops, right? 70% of the hospitals do this. And I was like almost geeking out because I never knew about a closed door employee pharmacy until I met one of our colleagues at ACC, Jersey Shore from Hackenshack. They have a closed door employee pharmacy. Okay, what does that mean? So I was a secret shopper. I called them, right? And I said, hey, can anybody come here? And they're like, no, we only take care of associates, and we only take care of patients that are being discharged. And it was great for them because you know why they started the closed door pharmacy? Because they want to increase patient satisfaction in their hospital. And it's something for C-suite people. If you're a contracting 340B entity, and I can talk about this in a lecture that won't bore Lindy or the group, it can actually be financial money or income for the hospital as well. So what are our key takeaways? If we can hit anything home, it's to match the goals of your hospital and what you want to accomplish with your resources and what you have at hand. You keep seeing the words culture and process. You have to instill a culture of allies to use the Meds to Beds program to make the patient's lives better. But we look at it as safety too, and be realistic, creative, and don't be scared to fail when you're implementing a new process. All right, I think that's important. We show our why's, right? We show our slide. We show when we, you know what? We didn't do so well that month. What happened? We can do all the time. We are great. We are, I know for our healthcare professionals here, we're great at like planning, doing, and reviewing, but we're not best at reviewing. We don't know why. And there's that accountability issues that we have to take up on upon ourselves. So this was a story when I tell you that we go literally from the field, and I think this upholds the ACC's methodology too. This was an EMS story. This patient that you see, and yes, we have her permission. It's HIPAA compliant. She coded four times before we got her on the table. She was one of those 82 years old, not supposed to make it. Dr. Borkowski's senator. We didn't know her neuro status. She was on the vent a couple of weeks. We didn't know her renal status. She was discharged the day before her birthday. When I found that out, I remember checking her chart the night before I went to bed. I found that out. I started making phone calls. You can see in the picture, EMS showed up. We had her a birthday cake. We got permission from her significant other, so we just didn't show up at the door, and we sang her happy birthday because it was such a testament, and I get a lump in my throat, but it was such a testament of how our community is so involved. It's not just us behind the scenes. It's everybody from EMS on throughout the whole system, and then we even took it a step further because of her story. She has gone public, and that's Dr. Borkowski right there. This publication will go out to every single business in Germantown and every single household in Germantown to raise awareness, and I love the title, A Journey of Recovery and Hope. So in conclusion, when we first started this, we just encompassed a process and made it, ultimately made it the culture and how we wanted to treat patients. With guidance from the ACC, the gold standard practices are outlined, but we use these as a compass to how we would perfect our program for our system, but one thing that I would like to ask each of you in this room at the end of the day, can the awards on the wall support the care that you're giving to the patients that's laying in that bed? This is my motto when Bobby and I first started talking about this. I think I surprised y'all because I was just sitting there and I was like, it's more than a process. It's a culture, and I know we've said that 100 times, but if you can go away with anything, don't just do it to check a box. Do it to make a difference. Thank you. All right. So I can say definitively that pre-lunch is better. We've got about three pages of questions here. So we'll try to get through this. All right. The first question here is, our state law restricts inpatient pharmacies from dispensing meds. How can you accomplish getting patients meds 24-7 before discharge? So that's a good statement, because in Tennessee, we require to educate face-to-face, and it's considered steering to we force you to take their meds. So for the inpatient pharmacy, that's something you have to talk to your legislator about. Talk to your pharmacist. Like, how can we do this in an inpatient setting? Set small goals first. I think the best thing to do is talk to your pharmacist and the team. Come up with a plan. We can't do it inpatient. Can we collaborate with a retail chain or an independent pharmacy of some sort? But yes, it depends on your local state law. So I think there's something about ACC we can ask, too, of how many other entities or hospitals use their inpatient setting. Because we actually do in Tennessee, we actually, for our south hospital, we actually could give their meds, a three-day supply of the meds, during emergency-wise. But that's a good question. That's hard for me to answer, too, because every state law is different. All right. Next one here. Do you have an outpatient pharmacy within the hospital, or do you use a third party? So we have an outpatient pharmacy in the hospital. There's actually three of us. There's an outpatient pharmacy in Germantown, there's one at University, and there is one at Le Bonheur Children's Healthcare. But because of our work with our meds to beds and our work with our AMI-PCI patients, it has gotten all trickled down to the top. I'm like, you know what? We need to open another one. We need to invest this in another hospital, because we see the value in it. You remember that non-adherence page, we reduce re-admission? This is how we sell our service, and not just for patient care, but as a financial revenue for the hospital as well. All right. Now, any tips on how to convince pharmacy partners to get on board with meds to beds program and involving them with the patient education? Okay. Everybody is busy. Everybody is busy. I think it starts with the why. Why are we doing this? Not just for accreditation, because I know everybody who goes in pharmacy has that story of the reason why. Like I said, you pick one that answers the most questions. There are times that I got pushback, even from my own team, like we don't have the FTE to do this, Anna. Why are you volunteering to do this? I said, because it's the right thing to do. So that's a hard thing to say to your peers, but we start small. You find that person that comes to all your quality meetings, and ask their questions, and recruit there. Do you have any suggestions, Wendy? I was going to say, yeah, you just use your resources that you have available, and pick each other's brains, because everybody's got a different perception on how they can help, and then you collaborate. And this process, do you initiate it on admission, or when do you start the meds-to-beds process? It's when the patient actually, now again, let's get grounded. This was just elective PCIs to start out with. So when that patient rolled in through same-day surgery, we initiated it then. We would start the conversation at the very beginning, hey, while you're waiting for the doctor to call you back, we're waiting for your table time, read this pamphlet, or this flyer that's on the wall, but let me just tell you about the service we have, so you don't have to make an extra stop when you're going home to get your medications in the event that something is prescribed. So we started it on the very, very front end. And then, Anna, you had mentioned high-risk patients, and so how do you determine if patients are considered high-risk? Okay. That's a good question. So when we first started this, we would have the caretaker come down and pick up the meds in the pharmacy. And what I found out was when we don't include the patient in the education, we don't kind of hit home on how important it is, because there's a lot going on. People are not listening to that. So when I see a high-risk patient, and you know, my pharmacist now, I've been doing this for 20 years, they're not listening or, you know, a lot's going on in their process, and they're trying to determine when they're going home. So those are the patients I kind of put in my note, like I need to talk to them a little bit more. Or they're uninsured, or they have five different comorbidities, they're diabetic, they're COPD, this is not their first time in the hospital. Those are the patients I really target. And we also have a transitional care pharmacist that is at our Methodist LeBaron Health Care that we also collaborate as well. But those are the high-risk patients we actually have a consult that kind of triggers in the pharmacy. But you know, as a clinician, you're like, I'm going to have to call this patient again, right? From my standpoint, I do the concurrent reviews on the charts. So I'm looking at these patients basically in real time, and if I see something that flags me, I'll go ahead and call Anna. I mean, we've done that multiple times. Hey, this patient's been in here six times, this is their third, you know, event this month. I'm exaggerating, but you know what I mean. If they're a frequent flyer, and we're like, maybe they need a little more education, maybe they need, you know, some more resources. So I've always got my fingers in the chart trying to figure out, and constant talk, whether it's with the doctors, the nurses, the techs, whomever. It's just, I mean, full transparency. Yeah, and this patient says coded, uninsured, or self-pay. It's highlighted yellow guys in my mind, because these are the patients that they're going to need me more, because they're more likely to come back and be re-admitted because they can't afford their meds. All right, there's actually several questions regarding the seven-day phone call process. Who calls the patient? How successful are the calls? Any issues on those? Sure. It's old school, guys. I've told my interns this, and they're like, can we text them? I'm like, no, we got to make the phone calls. I think, you know, in the process of seven days, we first were like, we're going to do two or three days afterwards, but it didn't work for us, because the patients were still kind of coming back to their old regular life, and we would ask the kind of same questions. The pharmacist would call, and if we didn't, we'd leave a message, you know, and then I would always tag team by team. It's not a only-me person. Lindy's calling, too. I'm like, hey, I haven't heard from this person, you know, is he doing okay on his meds? People get excited. You know, I do one, remember, this is elective surgery, so they already knew that they had to get this procedure. They'll call me back and say, yes, I am doing okay on the meds. It's the people that call me back immediately, it's like something happened. They went to the pharmacy, and it's outrageous, you know, what do I do? You told me not to take that medication, that link, but I do have the resources to help with that. We also instilled in our cath lab, too, that just like any same-day procedure, the cath lab crew, they call within 24 hours just to make sure their site's okay, to make sure that everything, it's a very broad, blanketed conversation, but it's a first point of contact within 24 hours, and then we kick it off to her team. All right, we'll try to knock out a couple more here. You kind of touched on this in the presentation, but for inpatients, who's responsible for patient discharge med rec, post-PCI, hospitalist, cardiology? Oh, God, the million-dollar question. Who answered that question, so I'm going to go and hug you, because I want to know. That's a hard one to answer, because it depends on which rotation, we talked about this with somebody earlier, who's coming on rotation, did one doc do it the day before, and a new doc is coming on, so that's something that we are forever working on, and then we've had a total change of guard as far as new ED, our cardiology group is pretty sustained, but hospitalists, they've turned over, too, so it's basically just, you know, cultivating a relationship and a teamwork approach amongst everybody in the team, so I do not have a definite answer for that, because there's not one, it depends, the doc of the day and things like that, if we're being completely honest. And everybody knows the meds to bed, so when we call them, and I tell my pharmacist intern, never be afraid to talk to a physician about patients, and they know about the meds to beds, and it's something just like, okay, we're going to do this, and so that's a culture, if you can tell me how to answer that question, I'll just give you a big high five, because that's something that is always in the back of my mind, like, how can I change this process and make it to a culture, so I see that. All right, we'll get one more question, and for the other questions that are in here, we'll work on getting answers sent out to you, but how would you describe the hospital culture before the change to meds to beds, and the culture after? It was very siloed, it was very, we had this term, but we didn't truly know what the term meant, and then when we drilled down and truly figured out the process, there was a reason behind it, again, we keep going back to the why, there was the why behind it, so before all this, it was just, I would say, very abstract, I think is a good way to describe it. Yeah, I laugh, because, you know, they didn't even know we were going to open out patient pharmacy. There was conversation from the C-suite to me, now it's been a while, too, because I've been there a long time, like, we didn't know you guys were going to be open, like, my own pharmacy team, the inpatient didn't know they had an outpatient, so it's trying to getting from, starting from the top, the C-suite and the executive people has got to understand why we're here, and it kind of trickles down, I mean, there are times, Lindy and I would like ask the secretary and admin, like, when does so-and-so come out of the bathroom, or next meeting, and we'll, like, jump up and, like, hey, we're going to talk about this, right? It's us. And it's being, it's being there, showing up, and, you know, when the team asks, like, how can we improve, where is our need, and that's important, too, is finding that niche. The respectful, squeaky-well method for the greater good. It just takes one floor, guys, one floor. All right. Thank you all for attending, and thank you, Amanda. Thank you, guys, so much. Thank you.

Meds to Beds

medication adherence

discharge processes

multidisciplinary approach

healthcare system

patient education

hospital integration

healthcare policy

patient outcomes