Outpatient Antibiotic Stewardship Initiative “Open Office Hours”

Matt Lincoln, MBA Director, Administrative Operations

Health Services Advisory Group (HSAG)

Thursday, December 7, 2017

Objectives

At the conclusion of this webinar, attendees will be able to: • Identify common barriers to implementing the Centers

for Disease Control and Prevention (CDC) Core Elements of Outpatient Antibiotic Stewardship (AS).

• Apply best practices recommended during the webinar.

• Request additional individualized technical assistance offered by HSAG staff members, peers, or other subject-matter experts.

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What is a Quality Innovation Network-Quality Improvement Organization (QIN-QIO)?

Funded by the Centers forMedicare & MedicaidServices (CMS)– Dedicated to improving health

quality at the community level– Ensures people with Medicare and

Medicaid get the care theydeserve

– Improves care for everyone– Largest federal program

dedicated to improving health quality at the community level

Department ofHealth & Human

Services

CMS

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HSAG’s QIN-QIO Territory

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Nearly 25 percent of the nation’s Medicare beneficiaries

HSAG is the Medicare QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands.

Quality Innovation Network-Quality Improvement Organization (QIN-QIO)

AS is the Effort to…

• Improve prescribing by clinicians and use by patients so that antibiotics are only prescribed and used when needed.

• Minimize misdiagnoses or delayed diagnoses leading to underuse of antibiotics.

• Ensure that the right drug, dose, and duration are selected when an antibiotic is needed.

• Measure antibiotic prescribing.

The goal of AS is to maximize the benefit of treatment while minimizing harm to individuals and communities.

5Sources: 1. CDC. MMWR, vol.65. No. 6, Nov. 11, 2016. https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6506.pdf. 2. CDC. Antibiotic resistance threats in the United States, 2013 [Internet]. Atlanta, GA: US Department of Health and Human Services, CDC; 2013.3. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51–77

Project Timeline

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2016 2017 2018

Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

Recruitment

Baseline Self-Assessment

Kickoff Webinar

Monthly “Office Hours”

Quarterly Check-in

“Bite-Size” Webinars

Today

Suggested Project Timeline*

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CommitmentSeptember 2017

Action for Policy and

PracticeNovember 2017

Tracking and ReportingMarch 2018

Education and Expertise

May 2018

* Timeline is not evidence-based and is provided for discussion purposes only.

CDC Core Elements of Outpatient AS (November 2016)

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• Provides a framework for AS for outpatient clinicians and facilities that routinely provide antibiotic treatment

• Augments existing guidance for other clinical settings:– Core Elements of

Hospital AS Programs (2014)

– Core Elements of AS for Nursing Homes (2015)

Source: CDC. MMWR, vol.65. No. 6, Nov. 11, 2016. https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6506.pdf.

Core Elements of Outpatient Antibiotic Stewardship

Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety.Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.

Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians or have clinicians asses their own antibiotic use.

Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing and ensure access to needed expertise on antibiotic prescribing

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Core Element #1 Commitment

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Core Element #2 Action

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Viral Prescription Pads

14 Source: CDC: https://www.cdc.gov/antibiotic-use/community/pdfs/aaw/CDC-AU_RCx_Relief_for_Viral_Illness_sm_v8_508.pdf

Delayed Prescribing

15 https://www.cdc.gov/antibiotic-use/community/pdfs/aaw/CDC-AU_RCx_Delayed_Prescribing_lg_v9_508.pdf

Watchful Waiting

16 https://www.cdc.gov/antibiotic-use/community/pdfs/aaw/CDC-AU_RCx_Watchful_Waiting_lg_v10_508.pdf

CMA Foundation Project AWARE

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CMA Foundation AWARE. Compendium Aware 2017-Acute Respiratory Tract Infection Guidelines. https://itunes.apple.com/us/app/aware-compendia-app-toolkit/id913606319?mt=8&ign-mpt=uo%3D4.CMA Foundation AWARE. Acute Infection Guideline Summary brochure.2016. http://www.thecmafoundation.org/Portals/0/assets/docs/Physician-Resources/AWARE/compendium-adult-2016-11x17-final-web.pdf?ver=2016-12-14-090913-470

Core Element #3 Tracking and Reporting

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Steps to Track Antibiotic Prescribing

Overview:• Chart review and

assessment are fundamental to improving healthcare quality.

• This sheet is designated as a “bare minimum” guide to auditing appropriate antibiotic use for acute bronchitis in otherwise healthy adults.

Source: CMS. https://www.hsag.com/contentassets/a4089e467b61495c9fdb701b86e854db/bronchitis_self-audit_20170825_fnlv2_508.pdf19

Four Key Components Audit Process

1. Pull visit charts with diagnosis of acute bronchitis, and apply inclusion and exclusion criteria

2. Determine the number of uncomplicated bronchitis visits in which antibiotics were prescribed

3. Calculate prescribing rates for acute bronchitis

4. Compare observed prescribing rate to recommended prescribing rate

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Example Sheet for Tracking Antibiotic Prescribing for Acute Bronchitis

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Antibiogram Toolkit

• Cumulative antibiogram report is used to guide initial empirical antimicrobial therapy decisions when definitive microbiological susceptibilities are unavailable for the infecting pathogen(s).

• Toolkit provides direction for clinicians involved in creating the cumulative antibiogram report and educating clinicians on its use.

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Core Element #4 Education and Expertise

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“Bite-Size” Webinars

• Practical strategies to improve infection prevention and AS

• Common barriers that lead to deviation from best practices

• Identifying high-priority conditions for intervention

• Using clinical practice guidelines to establish expectations for appropriate prescribing

• Strategies to improve provider patient communication

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Patient Education Resources

25Sources:English: http://consumerhealthchoices.org/wp-content/uploads/2015/02/3AntibioticsTri-Fold_DownloadGenericFINAL.pdfSpanish: http://consumerhealthchoices.org/wp-content/uploads/2015/02/3AntibioticsTri-Fold_DownloadGenericSpanish_Final.pdf

Patient Education Resources (cont.)

26 Source: https://www.cdc.gov/antibiotic-use/community/pdfs/aaw/AU_viruses-or-bacteria-Chart_508.pdf

Waiting Room Video Now Available!

27https://www.youtube.com/playlist?list=PLfm1t1zOVVIMvxtMUCx0z-pBwB8Qe1ap9

Online CME Course—“To Prescribe or Not To Prescribe? Antibiotics and Outpatient Infections”• Communication training activity

from Stanford University• Provides practical approach to

management of common outpatient infections

• Uses both instructional and interactive videos and patient role plays

• 1.75 CME credits offered

https://med.stanford.edu/cme/courses/online/improving-antibiotics-pcs.html

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Continuing Education Opportunities

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Available from the CDC• Healthcare Professionals

• https://www.conversationsforhealth.com/antibiotics/

• Medical Students

• http://www.wakehealth.edu/School/CAUSE/Get-Smart-About-Antibiotics.htm

• Pharmacists

• https://www.cdc.gov/getsmart/community/for-hcp/pharmacists-ce-courses.html

Main CDC Link: https://www.cdc.gov/getsmart/community/for-hcp/continuing-education.html

Provider Education Resources (cont.)

30 Source: LACDPH. 2016. http://publichealth.lacounty.gov/acd/docs/ABPoster3.pdf.

Next Steps

• Attend monthly “office-hours” coaching calls every first Thursday at 12 Noon PT next call—January 4, 2017.

• Schedule quarterly check-in call with HSAG specialist before December 22, 2017.

• Contact HSAG at any time to be connected with AS subject-matter experts for coaching or troubleshooting.

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Poll Question #1

Which CDC Core Element of Outpatient AS would you like to focus on during the next Open Office Hours Webinar?

A. Commitment

B. Action

C. Tracking and Reporting

D. Education and Expertise

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Thank you!Matt Lincoln, MBA,

Director, Administrative Operations, Health Services Advisory Group (HSAG)

mlincoln@hsag.com

Joseph De Veyra, DNP, RN, PHN, PCCN, CNLExecutive Director, HSAG

jdeveyra@hsag.com

Keith Chartier, MPHAssociate Director, HSAG

kchartier@hsag.com

Mary Fermazin, MD, MPA Chief Medical Officer, Vice President, Health

Policy and Quality Measurement, HSAGmfermazin@hsag.com

Eli DeLille, RN, BSN, CICQuality Improvement Specialist/Infection

Preventionist, HSAGedelille@hsag.com

Please complete the evaluation at:

https://goo.gl/ekLmWGIf you registered online for this event, you will also receive the link via email.

A recording of today’s session will be available at:www.hsag.com/events

(Click on today’s event date to access the recording link)

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department

of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C.3.10-11302017-02.