Pharmacy Innovations That Improve Care Quality, Cut Costs: A Q&A With Jose Guzman Garcia, PharmD, MHA, BCCCP

Pharmacy-led initiatives at UC Davis Health are helping to improve care quality while also cutting health care costs, explains Jose Guzman Garcia, PharmD, MHA, BCCCP, associate chief pharmacy officer, UC Davis Health.

From outpatient antibiotic stewardship to advanced medication reconciliation and targeted support for vulnerable populations, UC Davis is setting new standards for value-based care and measurable clinical success.

This interview was lightly edited for clarity.

The American Journal of Managed Care^® (AJMC^®): How was the UC Davis Acute Care Pharmacy Services initiative developed, what were the operational and clinical considerations involved, and what was the impact on both patient outcomes and overall cost of care?

GARCIA: We, as a leadership team, identified a need to consolidate leadership within our acute care clinical and operational teams. Really, the goal was to create synergy and to create alignment between those 2 teams. In addition to that, we really wanted to be able to create a bridge to our ambulatory care services as well. We were able to do that, and I think the biggest gains there were that we were better able to align all of our resources to be able to execute on our initiatives. In addition to that, we were better able to make sure that we were using all of our resources in a cost-effective way.

AJMC: How does the outpatient parenteral antibiotic therapy (OPAT) program operate in practice, and how does it integrate with the antibiotic stewardship program to ensure optimal drug selection, duration, and monitoring?

GARCIA: The way our OPAT program works is, essentially, we have specially trained pharmacists who are trained in stewardship and infectious disease, and they monitor all of the acute care parental antibiotic therapies. What they do is they identify patients who are candidates for ambulatory administration with these antibiotics. They make recommendations to the care team, and then they also help facilitate their discharge. The role that antibiotic stewardship program, plays, is that the antibiotic stewardship program is the one that develops the guidelines and the criteria to help those pharmacists better identify the most appropriate patients.

AJMC: For the OPAT program, what role does pharmacy play in coordinating safe transitions to home or outpatient care, and what measurable impacts have you seen on length of stay, readmissions, and overall cost savings?

GARCIA: The biggest thing that our team does is really identify the patients, and then once those patients are identified, they tailor the therapy in order to best facilitate the disposition of that patient, whether that patient is going home, whether they're going to assisted living, whether they're going to our ambulatory infusion services, or they're going to our home infusion services.

They make recommendations in terms of drug selection, route of bed administration, duration of therapy, monitoring parameters, and really just kind of tailor that therapy so that the patient has the highest likelihood of success within the disposition setting that they're going to be going to. In terms of outcomes, we've seen tremendous success with this program. We average about 400 patient days that we save per year. We're able to avoid about 40 central lines every year. In addition to that, we're able to increase revenue for both our ambulatory infusion service line and also our home infusion service line, because we're able to funnel those patients into those programs, which generates revenue for the organization, but also it improves the continuity of care, because now all of that patient's care is housed within the UC Davis system.

AJMC: How does the High-Risk Medication History and Discharge Medication Reconciliation tool support pharmacy interventions that align with value-based care principles, and what measurable impact have you seen on outcomes such as adverse drug events, readmissions, and medication adherence?

GARCIA: The initial goal of our Med History and our Discharge Medication Reconciliation Program was to see all of our patients, to see 100% of our patients, but logistically, that was very, very hard. It was hard in the sense that we just didn't have the resources to be able to do that. What we realized was that specifically for medication histories, we were getting a medication history for 100% of our patients, but really, sometimes that took us up to 72 hours; so understanding that the value of that medication history is really at admission and not 72 hours after the patient has been admitted.

What we did is we developed a tool that was pharmacy-focused. Essentially, it took components that pharmacy actually had direct control over, and we developed a scoring system that allowed us to identify the patients who most had that need or for whom we were able to make the greatest impact. I think from an outcomes perspective, the thing that was really surprising to us was that about 62% of the patients who were admitted had inappropriate meds for their age. The literature tells us that potentially inappropriate meds have a tremendous burden, not only on the clinical outcome of that patient, but the overall cost of care of that patient. We've been able to put programs in place to be able to eliminate those potentially inappropriate medications and really have a significant impact on the patient's care, not only while they're in the hospital with us, but also after they get discharged.

AJMC: How has the Inpatient Long-Acting Injectable Antipsychotic Administration Program reduced hospital readmissions, lowered the total cost of care, and improved access to treatment for this vulnerable population? What role does pharmacy play in sustaining these outcomes?

Garcia: As we know, uninsured patients with mental health diagnoses are the primary drivers of unfunded hospital stays but also overuse of our emergency departments. What we found was that we had a tremendously high readmission rate for the patients who were being discharged out of our acute care behavioral health floor; the readmission rates were over 10%, so over 10% of the patients who were discharged were readmitted. Really the driver of those readmissions was that there are just no resources. There are very limited resources on the ambulatory side for these patients. Our patients would come in, we would stabilize them, we would discharge them, but then because of that lack of resources on the ambulatory side, they weren't able to get into an acute ambulatory provider, and therefore they would readmit.

Historically, long-acting injectables haven't been part of acute care formularies because they're really seen as maintenance therapy. But what we did is we started a program where our pharmacists screened all of our patients who were admitted into our behavioral health unit to understand which ones were appropriate to start long-acting injectables. What that did is it kind of gave our case managers and our social workers a buffer for us to be able to get these patients into ambulatory care once they were discharged. We were also able to offset the cost of those long-acting injectables by utilizing industry-sponsored hospital-free drug programs, and we've had tremendous success with that program as well. Our 30-day readmission rate, we were able to cut that down by 80%.

The next phase of that program is that we noticed that our 60-day and our 90-day readmissions were still, although lower, significantly higher. Therefore, the next step of that program is to really work with our ambulatory pharmacy colleagues to be able to expand that and perhaps do something on the ambulatory side for perhaps a second dose of long-acting injectable to just give us an even bigger buffer to be able to facilitate that transition of those patients into ambulatory care.

AJMC: How has the Inpatient Discharge Methadone Dispensing Program contributed to lowering the total cost of care and improving patient outcomes for this vulnerable population, and what role does pharmacy play in ensuring safe, timely access to therapy?

GARCIA: In the same vein as our long-acting injectable program, really focusing on these vulnerable populations. What we noticed was that we had substance use disorder patients who would get admitted for whatever reason, and we were having a really hard time discharging them. Because, specifically, our patients who are on methadone, in order for them to receive methadone, have to go to methadone clinics, which is a challenge after hours, on the weekends, and on holidays. What would happen was that we would discharge these patients, they weren't able to get access to their methadone, and they would either readmit or they would have to come into our ED. Again, driving a lot of unfunded care and a lot of ED overuse.

What our team was able to do is we were able to lobby our state legislature to be able to issue an exemption for hospital pharmacies to dispense a 3-day supply of methadone directly to patients. We were able to successfully do that. We instituted that program, and the role that our pharmacists play is that we have a substance use intervention team, so they're a participant upon that team, and they help identify patients who would be appropriate for this program. Again, we've had a lot of success with the program. We're avoiding about 400 patients, about 100 patient-days per year on average. We treat about 60 patients every year, and the cost savings associated with that work is close to $1 million a year.

It’s very successful, and it's also very impactful on our patients. Because these patients are either A, going to get readmitted, or B, they're going to use alternatives in place of that methadone. It really impacts their outcomes and their lives.

AJMC: Can you explain how the Inpatient Drug Spend Analysis and Reduction Program balances cost containment with maintaining or improving patient outcomes, and what strategies have been most effective in achieving these goals?

GARCIA: The biggest mechanism that we use to be able to balance outcomes and cost is really by looking at everything we do through the lens of, how do we create value? And value can be a subjective thing. We try to create objective parameters to it. The way we look at value is we look at patient outcomes, patient experience, provider experience, regulatory compliance, all over cost. Then, what do we do to be able to impact all of those parameters within that equation, per se? What we found was that 9 times out of 10 when you improve a patient outcome, it usually is a result of cost-effective care. The overall cost of that care is lower, that’s how we balance the 2.

In terms of what are the effective mechanisms that we use to be able to achieve these goals is a couple of things. Awareness: it's just having data, and then also key performance indicators that we can share, not only with our frontline staff, but then also with our with our leaders and our nonpharmacy partners. Really just creating that awareness goes a long way. In addition to that, I think just creating focus. We have a very systematic way of going about identifying these are the top drugs that are driving our drug spend, and then creating teams based on the particular drug. If it's antibiotics, then we engage our average sales price and our ID teams, and we create very specific initiatives that we then share broadly. We also put a lot of focus in terms of accountability, by bringing those back, either through patient navigation teams, through executive committees, and then sharing our outcomes and our results with our frontline staff really to maintain that engagement.

AJMC: Looking broadly at UC Davis Acute Care Pharmacy Services’ approach, what is your overall strategy to maximize value-based care within pharmacy services, and what key operational or clinical levers do you consider most impactful for driving meaningful patient outcomes and cost efficiencies?

GARCIA: I think it goes back to value; really understanding that what we're trying to achieve is create value for our patients, create value for our organization, and create value for our community. Understanding those components of value and how can we impact each of those. Like I said before, really 9 times out of 10 when you improve a clinical outcome, it's always usually associated with the decreased cost of care in terms of levers that we pull. Again, it's just creating awareness, being data driven, and having data available to us, and then at the end of the day, creating accountability. The initiatives that we develop by querying our data, we build those into our performance evaluations, for our leaders, for our frontline staff. We also share that broadly so that there's a lot of eyes on it, and when there's a lot of eyes on stuff, it creates accountability. That's really kind of how we go about making sure that we're creating value again, for our patients, for our organization, and for our communities.