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Hudson Headwaters Launches Clinical Pharmacy Program Focusing on High-Risk Patients at Transitions of Care

Preventing harm from medications, or adverse drug events (ADEs), remains a top patient safety priority across the continuum of patient care. Implementing medication reconciliation during all care transition points has proven to be an effective strategy for preventing ADEs.

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against a physician’s admission, transfer, and/or discharge orders, with the goal of accurately providing medications to the patient.

Hudson Headwaters Health Network (HHHN), with innovation funding support from the AHI PPS (Performing Provider System), launched the Clinical Pharmacy Services and Education Program in July 2019 for high-risk patients transitioning from hospital to the home, and skilled nursing facilities to the home, the most vulnerable of all populations for ADEs. The goal of the program is to increase the quality of care and improve patient outcomes in this identified high-risk population.

The initiative is a pilot involving HHHN and Fort Hudson Health System. HCR Home Care and Glens Falls Hospital are also project partners and recently the group was approached by Warren County Public Health to get involved. According to Kate Shmulsky, PharmD, Director, Population Health Programs and Quality at HHHN, that development was gratifying in that it confirmed the program could be used as a model that could be expanded to include additional partners.

Prior to program launch, HHHN, in May 2019, hired Ryan Armstrong, PharmD, Clinical Pharmacist, to coordinate the program. Armstrong was charged with getting the program off the ground, first looking at workflow efficiency and effectiveness, and then providing in-service education to clinicians, nurses, home health care managers and others involved in patient care. That process took approximately six weeks and went smoothly according to Armstrong. “We conducted pre- and post-training testing and participant’s scores increased dramatically,” shared Armstrong.

Currently, Armstrong is communicating with Fort Hudson and Warren County home health programs to identify Hudson Headwaters patients who are admitted to Glens Falls Hospital scheduled for discharge with home health services. This allows him to proactively review a patient’s medications and identify any discrepancies between the hospital discharge medication list and the medication list maintained by the patient’s primary care provider. The home health nurse will call Armstrong after visiting the patient in the home and the two will collaborate to identify any issues between the medications the patient is taking at home and what has been prescribed upon discharge. Armstrong then communicates any medication changes, discrepancies found, and additional recommendations to the patient’s primary care provider for their review. “The goal is to try and catch potential medication errors that may happen during transitions of care. With new medications being added and current medications being changed or stopped, it is vital to make sure the patient is not only taking the correct medications but is also on the most appropriate medications. We feel that adding a pharmacist review to the process gives us an added security measure to help prevent medication errors from happening.”

Armstrong shared an anecdote to illustrate this point. “A patient was discharged from a hospital with numerous medication changes and upon reconciling them with the home health nurse it was discovered the patient received medication from the pharmacy in bubble packs. Bubble packs are a convenient solution to help patients take their medications at the appropriate times and increase adherence to complex medication regimens. A patient’s medication regimen is packaged in separate ‘packs’ or ‘bubbles’ that are grouped together based on the time of day the medication is to be taken and a few weeks of medication are packaged for the patient at a time,” explained Armstrong. “This particular patient had numerous medication changes which meant that if they were to continue taking the bubble packs at home, they would have been taking the wrong dose, as well as medications that were discontinued. To resolve this, extra coordination was needed between the PCP, home health nurse, and pharmacy to ensure the patient received the correct medications.”

“In addition to medication reconciliation, there’s a second, equally exciting piece of this project and that’s our upcoming implementation of a new medication decision support software,” shared Shmulsky. After conducting thorough research, HHHN contracted with Tabula Rasa HealthCare®, Inc. to license MedWise™ technology to identify patients at high risk for medication-related problems by an assigned medication risk score that is based on accumulative multi-drug interactions to help manage a patient’s medications. The platform can provide point-of-prescribing medication decision support tools to help improve outcomes so that if a risk is identified, providers and pharmacists can work together to make changes. The chance to use these tools for more targeted interventions is exciting,” said Shmulsky.

The program has been useful for patients and providers alike. In addition to medication reconciliation and medication therapy management reviews, HHHN providers have also been able to request pharmacy consults within their electronic medical records that are routed directly to the clinical pharmacists. Both Armstrong and Shmulsky agree that focusing on high-risk patients who are undergoing transitions of care has proved helpful for everyone, and they are optimistic about the future of the program.

“Hudson Headwaters works to provide the best care, and access to that care, for everyone in our communities,” said Jane Hooper, Community Relations Manager at HHHN. “Working to ensure that patients also receive the best possible care during transitions from one care setting to another is another way that we partner with other organizations to keep the patient’s well-being and safety at the center of each decision made along the way.”

The AHI PPS-funded portion of the program was initially scheduled to sunset at the end of 2019 but has been extended through March 2020. Beyond that, the organization has made a commitment to sustaining the Clinical Pharmacy program even after innovation funding runs out.

Transportation Programs Provide Rides to Good Health

Each year, 3.6 million Americans do not obtain medical care due to transportation challenges. These issues include a lack of vehicle access, long distances and lengthy times to reach needed services, and transportation costs. Because it touches many aspects of a person’s life, adequate and reliable transportation services are fundamental to healthy communities.

According to a report, Pathways to Progress, published by the Adirondack Gateway Council, transportation challenges are exacerbated in the North Country because of its expansive and mountainous geography and low population density. Additionally, the area has become automobile-dependent due to limited alternatives in large parts of the region. Indicator reports on the HealthyADK website show transportation costs are typically the second-largest budget item for most families and 8.5 percent of households in the region lack a vehicle.

Transportation can also be a vehicle for wellness and thanks to an influx of innovation funding from the Delivery System Reform Incentive Payment (DSRIP) Program, AHI Performing Provider System partners are making great progress tackling transportation challenges.

Uplift Warren Washington

Cassandra Fleury likens her role as Transportation Coordinator for the Uplift Warren Washington initiative to that of a care manager. “The personal interaction aspect of my program is really what makes it work,” asserts Cassandra. The free program, which kicked off at the end of May 2019 for residents of Warren and Washington counties, promotes preventative health through increased access to services. “Care management is more of an art than a science. I believe we need to work with people as individuals to meet their needs. If they are struggling with transportation to get to places to begin with, asking them to come to an appointment with me seems unrealistic. So, I will travel throughout the region to meet people and to connect them with transportation to get the services they need,” said Cassandra. “I try to be health proactive. It’s better if I help people access services before they get sick, rather than struggling with their recovery needs.”

Partnering with 820 River Street (The Baywood Center), Greater Glens Falls Transit, Tri-County United Way, Warren-Washington Association for Mental Health, Glens Falls Hospital, Hudson Headwaters Health Network, and many other organizations, the program has been providing transportation to and from venues not covered by Medicaid transportation, such as grocery store and pharmacy visits, care management and Department of Social Services appointments, and community-based support group meetings.

To date, Cassandra has distributed nearly 700 transportation vouchers to individuals for such things as taxi cab rides, gas cards, and bus passes. “I help by connecting people to transportation for services and then it’s up to them to take ownership of their own health. I want people to be empowered by eliminating this barrier to health,” stated Cassandra.

Cassandra singled out two cab companies – Queensbury Taxi and Eagle Cab – for their cooperation and commitment to the success of the program. “Queensbury Taxi has been fantastic. They’re available 24/7 and have a wheelchair-accessible van. They are always willing to help get someone to where they need to go, often on short notice,” said Cassandra. “Eagle Cab has been earnest and a pleasure to work with. I’ve been using them for long-distance travel. They once drove someone all the way to Ogdensburg for a procedure, but rather than dropping him off and leaving, they waited around for the all-clear. When the patient wasn’t admitted due to an error, they were there for him and able to drive him back home. They don’t just transport people – they make sure people are okay.”

Another story involved a little boy who was receiving psychiatric services at Glens Falls Hospital who had then been transferred to an inpatient unit in Syracuse. The boy needed his father to attend a discharge planning meeting in Syracuse for him to go back home, but the father couldn’t afford to attend. The program paid for Eagle Cab to transport the dad to the meeting and then brought the father and child home.

Perhaps the most heartwarming story shared by Cassandra involved a young woman struggling with drug and alcohol use issues who was living on her own for the first time. “She had SNAP to purchase food, but because she didn’t live near a grocery store, she was buying her groceries at Dollar General. At one point, she ran out of SNAP before the end of the month and was worried about how she was going to be able to get food to eat,” explained Cassandra. Cassandra provided the woman with vouchers to take advantage of the Salvation Army’s “food gleaning” program, an effort involving local markets in the region donating food to be provided free of charge to folks in need. She then went the extra mile and met the woman at the site to help her through the shopping process. “She was anxious about going alone, and anxiety often sets people back in their recovery, so the fact that I was there helped a lot,” said Cassandra.

“The program has been instrumental in helping people,” concluded Cassandra. “By providing transportation, we truly are giving people a ride back to health.”

For more program information, contact Cassandra at [email protected], or 518.320.6692.

Rides to Healthier Strides

A wheelchair-bound elderly woman in Olmstedville couldn’t afford ambulette transportation. She had been in the hospital and upon release needed to have follow-up appointments with her doctor. Because she couldn’t afford transportation, she went for three months without an appointment. With the advent of the Rides to Healthier Strides program, the woman is now able to make it to her appointments.

This success story is just one of many shared by LeAnn Java, Transportation Navigator, Mental Health Association in Essex County, who oversees the program which has been making tremendous strides in maximizing transportation services for the Medicaid population and those at risk for becoming an Asset Limited, Income Constrained, Employed (A.L.I.C.E.) household.

Working with such agencies as the Essex County Department of Public Works, Essex County Mental Health Clinic, Adirondack Community Action Programs, Inc., the Essex County Office for the Aging, Homeward Bound Adirondacks, Mountain Lake Services, the Community Services Board, Hudson Headwaters Health Network, and the University of Vermont Health Network – Elizabethtown Community Hospital, the program has gotten off to a fast start. The initiative, which commenced on July 10, has already received requests from and helped more than 420 people through its first five months.

LeAnn, who assists consumers by linking them to transportation services, providing travel training, managing vouchers, and handling gas card and other reimbursements among participating agencies, stated, “It’s been extremely gratifying to help so many people in so many different ways and I know there will be many more to come.” LeAnn illustrated the program’s assortment of services by sharing stories of transporting an individual to a food shelf for shopping after a grocery store in Port Henry closed, assisting a woman get to a job interview, and helping a person get to St. Joseph’s Addiction Treatment & Recovery Center for in-patient rehabilitation. “We even helped a frail 73-year-old woman who recently moved to Lake Placid from New York City get a ride back to the city for a doctor’s appointment,” shared LeAnn.

“Another situation involved a homeless mother and child. We transported the woman to work and her child to school with the help of Mountain Lake Services. “It was great because the two of them were eventually able to move into an apartment,” said LeAnn.

“The partners have been great to work with,” said LeAnn. “I also have to mention that American Taxi out of Ticonderoga, Brant Lake Taxi, and We Care out of Plattsburgh have been fantastic for our ambulette needs.”

“This program’s impact has been astonishing. It’s greatly needed, as well as appreciated,” stated LeAnn. “With this funding and all our collaborative efforts, we’ve been able to fill a lot of gaps.”

For more program information, contact LeAnn at [email protected], or 518.412.6186.

St. Lawrence County Access to Care Program

The St. Lawrence County Access to Care program has received nearly 2,500 referrals involving more than 1,100 unique clients since its inception in April 2019.

An authorized transportation service program for Medicaid beneficiaries to travel to and from service destinations not eligible for funded transportation, the initiative has helped people in a multitude of ways. “We help people pick up groceries, obtain their prescriptions from the pharmacy, and attend chronic disease self-management, early parenting, and other continuing education courses,” explained Cassy Dodd, Director, Partner Engagement, St. Lawrence Health System, who, along with colleague Rachel LaPoint, the health system’s Quality Improvement Coordinator, oversee the program. “In addition, the program has assisted clients with transportation to and from work and to sign up for essential services such as SNAP, WIC, HEAP, and more.”

The program is a collaborative partnership of St. Lawrence Health System, the Community Health Center of the North Country, the St. Lawrence County Department of Labor, the St. Lawrence County Department of Social Services, the St. Lawrence Health Initiative, St. Lawrence County NYSARC, St. Lawrence County Public Transit, the Seaway Valley Prevention Council, Transitional Living Services, United Helpers, and the Volunteer Transportation Center of the North Country.

Christine Richardson, Program Director, Volunteer Transportation Center, explained, “Clients can be assisted in different ways depending on their situation. Some are provided gas cards, some are paid mileage reimbursement, and some ride the public bus without paying the $2 ride fee. We also offer the First Mile, Last Mile program where volunteer drivers provide car rides for people to and from their homes to the bus stop.”

“Let’s say, for instance, you’re a diabetic, but you haven’t gone grocery shopping lately and everything in your cupboard is either full of carbohydrates or is processed. That’s going to play a significant factor in your health and wellness,” said Rachel. “Our program can get that person to a store that has healthy food options.”

Clients who have received transportation services have been tracked to determine a correlation between providing rides and admission and readmission rates to the hospital. So far, it’s having an impact on reducing those numbers. “The program has really been working well and we’re so proud of our accomplishments so far,” concluded Cassy. “We look forward to helping many more people in need.”

For more program information, contact Cassy at [email protected], or 315.261.2129.

Rides to Healthier Options

Transportation services have been expanded for those in need in Franklin County by way of the dissemination of bus tickets, gas cards, assistance with minor vehicle repairs, and ride assistance from taxi cabs companies and other providers for non-medical needs.

According to Lee Rivers, Executive Director, Community Connections of Franklin County, the Rides to Healthier Options program has been a huge success and an eye-opener. “Throughout this entire process, what was so simple to see was that individuals living in rural populations do not have enough money to pay for transportation services. This is a catch-22 because transportation companies have a hard time making it without riders,” said Lee.

To date, the program has provided more than 3,300 bus passes, 460 gas cards, and nearly 500 rides for medical, behavioral health, dental, and eye care appointments, grocery store and pharmacy visits, support group meetings and transportation to and from work. It’s also paid for 19 vehicle repairs.

In addition to Community Connections of Franklin County, the initiative involves partner organizations The University of Vermont Health Network – Alice Hyde Medical Center, JCEO, the Franklin County Office for the Aging, St. Joseph’s Addiction Treatment & Recovery Centers, the Franklin County Department of Social Services, Citizen Advocates, Adirondack Health, and Franklin County Public Transportation.

“A program like this only works if everyone works together,” said Lee. “In this case, our efforts have been successful in that every stakeholder knows and plays its role.”

For more program information, contact Lee at [email protected], or 518.521.3507.

Fulton County Transportation Project

“One of the largest deterrents to health care in our region has been transportation. Fulton County is a very rural community with a limited transportation network. For years, many of our residents have been unable to get to their health care appointments and other important destinations,” stated Kathy Calabrese, Children and Family Services Director, The Family Counseling Center. Kathy, Coordinator of the Fulton County Transportation Project, added, “With innovation funding and the launching of this project, we’ve been able to help recipients get to their appointments, pick up medications at the pharmacy, and take care of other needs that otherwise would have resulted in a further decline in one’s wellness if left unmet.”

In addition to The Family Counseling Center, participating organizations include Nathan Littauer Hospital & Nursing Home, Planned Parenthood Mohawk Hudson, The Community Health Center, HFM Prevention Council, and the Mental Health Association of Fulton and Montgomery Counties. Each partner has received a supply of vouchers to share with patients and clients.

At the outset of the project, collaborators anticipated distributing approximately 3,100 taxi cab vouchers, 3,700 bus tokens, and 600 gas-only gift cards to individuals in need over a two-year period. To date, according to Kathy, nearly 600 vouchers have been circulated.

“This program has given us the ability to bridge large gaps in transportation resources,” said Kathy. “We are extremely excited to be able to offer this service to those who have struggled with this challenge for such a long time. It has been a very beneficial and practical resource to be able to offer individuals as we continue to build a healthier community.”

For more program information, contact Kathy at [email protected], or 518.725.4310, ext. 109.

Area Schools Participate in Great American Smokeout®

Many local school districts participated in the Great American Smokeout® on November 21, 2019, with the assistance of Adirondack Health Institute’s Advancing Tobacco-Free Communities/Reality Check program.

Below is a list of school activities:

South Glens Falls High School

Reality Check students collected more than 70 signatures from peers on a banner in support of restricting tobacco industry marketing efforts during week-long tabling activities at the school. A wheel was set up at the table for students to spin to learn tobacco facts. The group also placed signs around the school with facts and statistics about vaping, along with cessation information to support those looking to quit.

Oliver W. Winch Middle School

The school promoted “” by placing signs around campus with such messages as “Tobacco companies spend more on marketing than the junk food, soda, and alcohol industries combined,” and “The U.S. Surgeon General reports that tobacco marketing in stores is a primary cause of youth smoking.”

Schuylerville High School

Students created a colorful banner encouraging peers to “Ditch JUUL.” Banner colors were selected to represent the flavors and bright coloring used by certain tobacco products to draw the attention of young eyes. A table was set up at the school to provide a venue for supporting students to sign and place thumbprints and stamps on the banner. Students hope to share the banner with local legislators and take it to legislative events. In addition, signs encouraging students to quit smoking for a day and perhaps for good were placed around the school and informational tobacco facts were announced between classes.

Burnt Hills-Ballston Lake High School

Students held a day-long tabling event in the school’s cafeteria. A wheel was set up for students to spin to learn tobacco facts and receive cessation information. Students also created a banner for peers to sign in support of tobacco marketing reduction. In addition, AHI’s Reality Check Specialist Merry Rudinger spoke to health classes about the risks associated with tobacco use and vaping, educating them on how they could become involved in creating the first tobacco-free generation by joining the Reality Check movement.

Waterford-Halfmoon Union Free School District

Students participated in educational activities on November 13 in recognition of the tobacco 21 law going into effect in the state. Youth wore matching shirts that read “Ask me about T21,” and when prompted, explained the new law and how it will impact future generations. They also spoke about issues that remain a concern, such as flavored tobacco products, deceptive tobacco industry marketing tactics, and the portrayal of smoking and vaping in movies.

The American Cancer Society sponsors the Great American Smokeout® annually on the third Thursday of November, challenging smokers to give up cigarettes for 24 hours.

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