Ascension Columbia St. Mary's Hospital-Ozaukee

Practice setting

Ascension Columbia-St. Mary's Health System is comprised of four hospitals and more than 60 primary and specialty clinics throughout the greater Milwaukee area. Columbia St. Mary's Hospital- Ozaukee is a 120-bed community hospital located in Mequon, WI. A full range of inpatient and outpatient services are available at the hospital, including cardiac diagnostic services, cardiac catheterization, cardiothoracic surgery, electrophysiology and cardiovascular rehab. The cardiac and pulmonary rehab program at Columbia St. Mary's Ozaukee had the program in 2016. Each patient has an average of 24-36 visits (2-3 times per week for 6-12 weeks). Each patient meets with a staff member for an individual appointment once and then joins a class of up to 12 patients for their remaining visits. The pharmacist provides services to the patients one full day per week. The pharmacist meets with each patient individually at least twice during the course of the program, more if medication-related problems arise.

Why was the pharmacy service developed?

This service was developed at the request of the cardiac and pulmonary rehab staff. Prior to the ambulatory pharmacist’s arrival in January 2011, a pharmacy technician had been performing medication histories one hour per week. The staff desired to add a pharmacist to the program because of the pharmacist’s unique knowledge and skills related to medication therapy. Many patients had detailed medication-related questions that the staff could not fully answer as they were taking care of a high volume of patients. The pharmacist also is able to address barriers to adherence and provide education to each patient.

What training, certification, credentialing, and practice agreement is utilized by the practice site?

Pharmacists who practice in the cardiac and pulmonary rehabilitation settings should have a good working knowledge of the most common conditions and procedures for which patients qualify for the program. These include: acute myocardial infarctions, coronary artery disease, coronary stenting, coronary artery bypass grafting, cardiac valve replacement, transluminal aortic valve replacement (TAVR), heart failure, peripheral arterial disease, restrictive lung diseases, chronic obstructive pulmonary disease, and asthma. The pharmacist who practices in this setting is residency-trained in ambulatory care, is a board certified pharmacotherapy specialist, and is BLS/ACLS certified. Collaborative practice agreements are not utilized in this setting; however a good relationship with the cardiologists and pulmonologists is important to achieve a high acceptance rate of the pharmacist’s recommendations.

What outcomes are being measured to evaluate the model's success?

The American Association of Cardiovascular and Pulmonary Rehab (AACVPR) registry tracks quality measures for cardiac and pulmonary rehabilitation programs. This is a requirement of program certification. Outcomes measured include: percentage of patients who are taking guideline-recommended medications at program entry and graduation, A1c, fasting lipid measurements, blood pressure, quality of life, exercise capacity, six-minute walk test distance and dyspnea.

How have you made this service sustainable?

Cardiac and pulmonary rehabilitation programs are provided by an interprofessional team of health care professionals including nurses, exercise physiologists, respiratory therapists, dietitians, pharmacists, and others. The health system receives a fixed amount for each cardiac or pulmonary rehabilitation session that the patient attends. The pharmacist services for this program are currently provided by Concordia University Wisconsin School of Pharmacy faculty member Laura Traynor.

On July 1, 2017, Medicare will likely begin the cardiac episode payment model and bundled payments for patients who have an acute myocardial infarction or coronary artery bypass grafting for select service areas. This is similar to what has already occurred for hip and knee replacement in 2016. This is a single payment from the date of hospitalization until day 90 and would include cardiac rehabilitation. There will be an incentive payment for each cardiac rehabilitation session attended. Part of this incentive payment could be used to offset FTE for a pharmacist involvement.

How did you gain support of administrators, providers, and other key stakeholders?

The service had the full support of the cardiopulmonary rehab department and the pharmacy department from the beginning. Gaining the support of the cardiologists and pulmonologist took some time. In addition, many medication-related problems that are identified are within the purview of primary care, so developing good relationships with the many primary care physicians within the health system is also important and is ongoing.

What are some lessons learned while implementing your practice model that you would like to share?

The role of the pharmacist within the program has evolved over the past 6 years. In addition to performing medication reconciliation, addressing medication related problems, assessing inhaler technique, and providing education, the pharmacist also assists with blood pressures, pulse oximetry, blood glucoses, and other patient assessments. This helps to expedite the intake process as patients begin their exercise session. This provides additional value to the interprofessional team. In addition, having the pharmacist available to provide education to staff about the most recent developments in the treatment of cardiac and pulmonary diseases has been helpful to improving the quality of care that the team provides to our patients.