Douglas Del Paggio PharmD, MPA

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Douglas Del Paggio PharmD, MPA Director of
Pharmacy Services Alameda County Behavioral
Health Care Services Assistant Clinical
Professor UCSF College of Pharmacy
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The Use of Pharmacy Data for Quality
Improvement in a County Mental Health System
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Alameda County Behavioral Health Care Services

• Provides integrated system of mental health and
  substance abuse treatment services
• Outpatient Programs
• 23 mental health
• 100 alcohol and other drug
• Wrap-around services
• inpt/outpt/crisis/vocational/case mgmt/
  conservatorship/criminal justice

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Safety net provider serious persistent mental
illness (SMI) MediCal (70) indigent
(30) Annual budget 250 million 35,000 unique
patients Annual individual visits 1.8 million
per year
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AHRQ (Agency for Healthcare Research
Quality) Statistical Brief 163 Feb 2007
Trends in the Use and Expenditures for the
Therapeutic Class Prescribed Psychotherapeutic
Agents and All Subclasses 1997 and
2004 http//www.meps.ahrq.gov
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Pharmacy Benefit Management Services (PBM) for
Uninsured

• Contracted with PBM (NMHC) 11/96
• increased access
• uniform policies reimbursement
• define formulary, MDs, clients
• Information (Access-based tool)
• from Rx (NCPDP fields)
• drug/dose/cost/pt. profile

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Pharmacy Data Use Programs

• Medication usage
• dose, combos, costs, client med history
• Medication Monitoring Program
• practice guidelines- rational pharmacotherapy
• Clinic/Program function
• is care appropriate? Refining mission
• MediCare Part D
• what is impact on clients County?
• Outcome studies
• pharmacoeconomic
• CalMEND
• MediCal prescription data

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Medication Usage

• Prescribed medications
• Ave doses, Rx, costs etc
• Trending
• Multiple same-class psychotropics
• Medication use patterns

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Medication Usage
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Medication Usage
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Medication Usage
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Indigent Care Medication Program
BHCS MIA Program

• Medication for uninsured patients
• 15 different PAPs
• distributed through pharmacy system
• Patients identified through PBM claims
• No MediCal or secondary coverage
• Monthly monitoring
• patients, meds, cost savings

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Medication Usage
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Medication Usage
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Medication Usage
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Medication Usage
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Medication Monitoring

• Develop Practice Guidelines (2/1997)
• PPC (PT) Committee
• 80 criteria regarding prescribing
  documentation specific
• Implementation
• hiring of clinical pharmacist
• random 10-15 MD caseload annually
• Case specific reviews based on client profile
• medication total daily dose/regimen/combo

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Clinic/Program Function

• Review of prescribed medications
• QI indicators feedback
• Refine program mission/goals

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Clinic/Program Function

• County Jail Facility

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• Psychotropic Medications Misused by inmates
• quetiapine (Seroquel)
• olanzapine (Zyprexa)
• gabapentin (Neurontin)
• bupropion SR (WellbutrinSR)
• TCAs (amitriptyline, etc.)
• benztropine/trihextphenidyl (Cogentin/Artane)
• benzodiazepines (Ativan/Klonopin)

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MediCare Part D
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MediCare Part D

• Assess Benchmark Plans performance
• impact of utilization management
• PA process
• denials/appeals process
• Impact on dual-eligible clients County costs

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MediCare Part D
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MediCare Part D
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Pharmacoeconomic Studies

• Prospective studies initiated 1996
• Naturalistic environment
• Intent to treat
• all patients prescribed ie atypicals
• Mirror-design
• 2 year duration
• Not sponsored by a drug company
• no funds or input

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Pharmacoeconomic Studies

• All indigent patients
• Integration of data sources
• medication usage costs
• service utilization costs
• symptom measure
• ie PANSS

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CalMENDAn MHSA Initiative integrating
pharmacotherapy, quality of care and recovery
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CalMEND An MHSA Initiative

• Effort to develop and implement statewide mental
  health care management program that
• is consumer focused
• is evidence driven
• increases quality and safety
• improves efficiency
• improves health outcomes
• promotes shared decision-making
• supports clients individual wellness/recovery

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Project Team Agencies

• Department of Health Care Services
• Barry Handon, MD
• Pauline Chan, PharmD
• Teresa Miller, PharmD
• Marcia Ehinger, MD
• Department of Mental Health
• Penny Knapp, MD
• Department of General Services
• Greg Doe, PharmD
• County Mental Health Agencies
• Doug Del Paggio, PharmD, MPA

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Project Team CiMH

• Clinical Lead
• Neal Adams, MD, MPH
• Lead Project Manager
• Karin Kalk
• Project Manager
• Julie Cheung
• Recovery Specialist
• Alice Washington
• Recovery Specialist
• Odette Chenoweth

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Project Team CiMH

• Research Psychiatrist
• Anh Thu Bui, MD
• Medical Informaticist
• Cecil Lynch, MD
• Psych Nurse
• Jo Hillard, RN, LCSW
• Cultural Competence Specialist
• Khani Gustafson
• Program Support Specialist
• Miles Murch

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IOM Institute of Medicine

• Institute of Medicine (IOM) of the National
  Academies for science-based advice on matters of
  biomedical science, medicine, and health.
• The Institute provides a vital service by working
  outside the framework of government to ensure
  scientifically informed analysis and independent
  guidance.
• The IOM's mission is to serve as adviser to the
  nation to improve health. The Institute provides
  unbiased, evidence-based, and authoritative
  information and advice concerning health and
  science policy to policy-makers, professionals,
  leaders in every sector of society, and the
  public at large.
• http//www.iom.edu

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IOM Institute of Medicine

• Improving the Quality of Health Care for Mental
  and Substance-Use Conditions Quality Chasm
  Series
• November 01, 2005
• http//www.iom.edu/CMS/3809/19405/30836.aspx

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CalMENDa resource to support transformation
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CalMENDa resource to support transformation

• Counties are receiving
• MediCal Prescription Data (!!)

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CalMENDa resource to support transformation

• Data Test Workgroup Medication
• Polypharmacy (rational vs. irrational)
• intra-class (ie multiple antipsychotics)
• multiple psychotropic agents (ie 5 or more
  agents)
• Dosing
• too high/low doses
• Prescription adherence

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CalMENDa resource to support transformation

• How to proceed
• digestible data
• format accuracy of data
• empty/inaccurate fields ie MD name
• lag period 4-6 months
• intervention authority
• individual case review
• MTM Medication Therapy Mgmt

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CalMENDa resource to support transformation

• What next