Upload
vanhuong
View
215
Download
1
Embed Size (px)
Citation preview
Annual Meeting
Curricular Track II—Pearls from Innovative Practice Models Activity No. 0217-0000-11-106-L04-P (Knowledge-Based Activity) Wednesday, October 19 10:15 a.m.–11:45 a.m. Convention Center: Rooms 302 & 303
This session is available for elective credit for the ACCP Career Advancement Certificate Program. For more information, visit the ACCP Web site at www.accp.com/academy.
Moderator: Alissa Segal, Pharm.D. Associate Professor of Pharmacy Practice Massachusetts College of Pharmacy & Health Sciences and Joslin Diabetes Center, Boston, Massachusetts Agenda 10:15 a.m. Pearls from Innovative Practice Models : Pharmacy Practice in an
Obstetric Care Clinic Denise D. Ragland, Pharm.D., CDE Associate Professor of Pharmacy Practice, College of Pharmacy University of Arkansas for Medical Sciences, Little Rock, Arkansas
10:35 a.m. Pearls from Innovative Practice Models: Pharmacist-Managed Latent Tuberculosis Infection Clinic Julie P. Last, Pharm.D. Clinical Pharmacist and Ambulatory Clinic Coordinator, Hospital of Saint Raphael, New Haven, Connecticut
10:55 a.m. Pearls from Innovative Practice Models: Local and National
Programs Integrating Comprehensive Pharmacy Services into Medical Homes Steven W. Chen, Pharm.D., FASHP Associate Professor, Department of Clinical Pharmacy & Pharmaceutical Economics and Policy; Hygeia Centennial Chair in Clinical Pharmacy; Director, Pharmacy Practice Residency in Primary Care; Distinguished Faculty Fellow, Center for Excellence in Teaching University of Southern California; Co-Chair Emeritus, HRSA Patient Safety & Clinical Pharmacy Services Collaborative; University of Southern California, Los Angeles, California
11:15 a.m. Panel DiscussionSteven W. Chen, Pharm.D., FASHP Julie P. Last, Pharm.D. Denise D. Ragland, Pharm.D., CDE
Annual Meeting
Faculty Conflict of Interest Disclosures Steven W. Chen: no conflicts to disclose. Julie P. Last: no conflicts to disclose. Denise D. Ragland: no conflicts to disclose. Learning Objectives
1. Recognize potential practice sites or patient populations in need of pharmacy services. 2. Identify common challenges that threaten the development of an innovative practice, including
health care reform. 3. Identify key steps in building a successful and innovative practice.
Self-Assessment Questions Self-assessment questions are available online at www.accp.com/am
Pearls from Innovative Practice Models Pharmacy Practice in an Obstetric Care ClinicyOctober 19, 2011 Denise D. Ragland, Pharm.D., CDEAssociate Professor of Pharmacy Practice, College of Pharmacy University of Arkansas for Medical Sciences, Little Rock, Arkansas
Objectivesj
1. Recognize potential practice sites or patient populations in need of pharmacy services. p p p y
2. Identify common challenges that threaten the development of an innovative practice.the development of an innovative practice.
3. Identify key steps in building a successful and innovative practiceand innovative practice.
Campus-wide meeting announcedp g
UAMS to apply forUAMS to apply for Women’s Health
Center of Excellence
UWC receives state-wide referralsUWC receives state wide referrals
d dOvercrowdedUnderstaffedUnderstaffed
Wh ?Why? Drug in pregnancy info Diabetes educationg p g y Drug in lactation info Medication histories
Causes of GDM Medical nutrition therapy
Gl t t i i New Rx counseling Depression screening
I i ti
Glucometer training Injection teaching BG log review
Immunizations Contraception
counseling
g Hypoglycemia
instruction Insulin dosingcounseling
Telemed consults Medication assistance
Insulin dosing Postpartum evaluation Access to DM supplies
Diabetes education cannot be done in five minutes or less
Observation l d tleads to
opportunitiesopportunities
Observation OpportunityObservation UWC nurses trained
needle-phobic
pp y Pharmacist, CDE
has time to provide ppatients by “sticking” pillows
pproper training
Student pharmacistsp Student pharmacists have opportunities to practice skillsp
Observation OpportunityObservation Overwhelmed
patients are
Opportunity Screenings to rule
out depressionpatients are noncompliant with diabetes self-
out depression
diabetes selfmanagement
What percent of women will experience a What percent of women will experience a depressive disorder while pregnant?
A 1 4%A. 1-4%
B. 5-8%
C. 9-13%
D. 14-23%
Obstetrics & Gynecology 2009 14(3):703-713Obstetrics & Gynecology 2009,14(3):703-713
Only 17% of patients with severe depression symptoms received tx
200 t d ith B k D i 200 pts surveyed with Beck-Depression Inventory-II 100 w/ diabetes: 19 T1DM, 41 T2DM, 40 GDM
100 without diabetes
Pts were referred for mental health consults
Research opportunity for studentsy
Prevalence of comorbid depression in women with diabetes during pregnancy 5th International Symposium of Diabetes in Pregnancy
Depression and diabetes: establishing the pharmacist’s role in detecting comorbidity in
tpregnant women J Am Pharm Assoc. 2010;50:195-199.
Presence of depression s mptoms in pregnant Presence of depression symptoms in pregnant women with and without diabetes J Reprod Health Currently in review J Reprod Health. Currently in review
What percent of U S pregnancies were What percent of U.S. pregnancies were reported as unintended in 2001?
A 23%A. 23%
B. 34%
C. 49%
D. 86%
Perspectives on Sexual & Reproductive Health 2006,38(2):90-92p p , ( )
Observation Opportunity Overcrowded teen
pregnancy clinic
pp y Contraception
counseling by
Few patients had received reproductive
student pharmacists
health education
Retrospective study at UWC
269 patients surveyed & counseled on 269 patients surveyed & counseled on contraception
86% unintended pregnancy rate 86% unintended pregnancy rate
54.6% (n=147) unaware of EC
68% (n=100) willing to use or would consider using EC in the future
Impact of EC status on unintended pregnancy: observational data from a women’s health practice. Pharmacy Practice 2010:8(3);173-178.
To assess impact of counseling on patient knowledge of EC
12 question survey pre- & post-test
10 min counseling session with flipchart
EC counseling: an opportunity for pharmacists.J Am Pharm Assoc Accepted Feb 2011J Am Pharm Assoc. Accepted Feb 2011
Which is true regarding levonorgestrel Which is true regarding levonorgestrel emergency contraception?A It is contraindicated in pts with h/o DVTA. It is contraindicated in pts with h/o DVT.
B. It is not available without a prescription.
C It works by disrupting an implanted ovumC. It works by disrupting an implanted ovum.
D. It may be effective taken 5 days after unprotected intercourseunprotected intercourse.
ACOG Position Statement No 69 2005ACOG Position Statement No. 69, 2005
Fluzone® is a live influenza vaccine that Fluzone is a live influenza vaccine that should NOT be administered during pregnancypregnancy.
A. True
F lB. False
Observation OpportunityObservation 2005: Severe
shortage of flu
Opportunity 2006: AR Board of
Pharmacy allowsshortage of flu vaccine
O h lf f ll
Pharmacy allows immunization-certified students One-half of all
vaccines ordered f UWC
certified students to administer if directly supervisedfor UWC go
unused
directly supervised by preceptor
2007‐2008Number of vaccines administered
t UWC t i l !at UWC triples! Protected patients Protected patients
Relieved nurses
Empo ered st dent pharmacists Empowered student pharmacists
What are the key steps in buildingWhat are the key steps in building an innovative practice?
Observation leads to opportunity
Innovate collaborate evaluate Innovate, collaborate, evaluate, disseminate
Persistence pays off
On going ProjectsOn‐going Projects Association of mid-trimester serum vitamin D Association of mid trimester serum vitamin D
level & depression during pregnancy and the puerperiump p
Clinical usefulness and patient acceptance of continuous glucose monitoring in pregnancycontinuous glucose monitoring in pregnancy
Patterns of contraception use in women receiving prenatal care at an academic healthreceiving prenatal care at an academic health care center
Obstetrical Opportunities: Will Pharmacy Ever Realize Them?
Ragland D, Briggs G, Wasik M, Kelsey J, Ferreira E, Abe-Fukushima W, Forinash, A, Kelly B, Nageotte M
Currently in review
Latent Tuberculosis Infection Clinic
Julie P. Last, Pharm.D.Hospital of Saint Raphaelosp ta o Sa t Rap ae
New Haven, CTOctober 19, 2011
H i l f S i R h lH i l f S i R h lHospital of Saint RaphaelHospital of Saint Raphaelo 511‐bed community,
teaching hospital Newteaching hospital, New Haven, CT
o Leader in Cardiac, Cancer, Stroke, and Joint Replacement Servicesp
oo Affiliated with University Affiliated with University of Connecticut School of of Connecticut School of Pharmacy and Yale Pharmacy and Yale University School of University School of M di iM di iMedicineMedicine
oo Pharmacy Services 24/7, Pharmacy Services 24/7, fivefive pharmacy satellites, pharmacy satellites, and cand computerized physician order entryphysician order entry (CPOE), profiled profiled automated dispensing automated dispensing cabinets (ADC)cabinets (ADC)
L i Obj iLearning Objectives
o Recognize potential sites or patient populations
o Identify key elements in creating a successful practice
o Identify common challenges in development of a new program
D fi i iDefinitionsL T b l i I f i (LTBI) A Latent Tuberculosis Infection (LTBI) – An infection in which an individual has dormantMycobacterium tuberculosis organisms but is y ba e u ube u o ga s s but sasymptomatic.
Active tuberculosis disease – Progression from h l f dthe latent TB infection to active TB disease caused by Mycobacterium tuberculosis overcoming the defenses of the immune system overcoming the defenses of the immune system and beginning to multiply, causing the patient to experience signs and symptoms associated i h b l i with tuberculosis.
Centers for Disease Control. 2005. The difference between latent TB infection and active disease. TB Elimination. Document # 250101
EpidemiologyEpidemiologyWorldwide – Approximately 1.7 billion people worldwide are considered to be infected with Mycobacterium tuberculosiso On average 10% of LTBI patients progress to o On average, 10% of LTBI patients progress to active disease
o Overall risk of developing active disease ranges p g gfrom 5% to 15% annually
o HIV patients – lifetime risk is 50%o Countries with low TB incidence – active disease comes mainly from reactivated LTBI
Ah d S P h i I l dAhmad, S. Pathogenesis, Immunology, and Diagnosis of Latent Mycobacterium tuberculosis Infection: Review Article. Clinical and Developmental Immunology 2011; 17 pages
Epidemiology
United States – National public health concerno 14,871 cases reported nationwide in 2003A i l /o Approximately 5.1 cases/100,000
Prevalence is due to:Prevalence is due to:o Increased immigrationo HIV epidemicL i i o Low socioeconomic status
o Insufficient public health infrastructure for the control of LTBI
Ioachimescu, O., Tomford, J.W. Tuberculosis. The Cleveland Clinic. [Online]. 2004; 1-15Horsburgh C.R. and Rubin, E..J. Latent Tuberculosis
Infection in the United States. NEJM. 2011;364:1441-8
dhAdherenceRisk of progression from latent infection to active diseaseo Approximately 5 to 15% total LTBI patients are at risk of o Approximately 5 to 15% total LTBI patients are at risk of converting to active tuberculosis
Non adherence to LTBI therap can reach up to 0%o Non‐adherence to LTBI therapy can reach up to 50%o Urban areas are on the high end of the spectrum
o Once active, patients become infectious
o Risk increases if LTBI therapy is not completedo Risk increases if LTBI therapy is not completedo Development of drug resistance
Adherence (cont.)Demographic and epidemiologic factors for non‐compliance
M l do Male gendero Homelessnesso Alcohol abuseo Alcohol abuseo Residence in urban areaso Low socioeconomic statuso Adverse drug reactions and drug interactionso Asymptomatic nature of infection
Centers for Disease Control. 2005. Treatment of latent tuberculosis infection: Maximizing adherence. TB Elimination. Document # 25003.
State Department of Public Health
Connecticuto Requires all patients with a positive tuberculosis test to b t d t th D t t f P bli H lth (DPH)be reported to the Department of Public Health (DPH)
o Responsible for any patients lost to follow‐up fromtuberculosis clinics
o Concerned with controlling possible outbreaks by tracking patients diagnosed with LTBI
Potential patient populationPotential patient populationUrban vs. suburbanU ba vs. subu bao Different pharmacy services may be required based on settingo In‐patient protocols vs. ambulatory programs
o Different incidence for various disease stateso Insured vs uninsuredo Insured vs. uninsured
o Reimbursement rateo State vs. private insuranceo Private insurance reimbursement rate is generally higher than state or federal coverage
o Different socioeconomic status
LTBI Cli i P ti t l tiLTBI Clinic – Patient populationUrban settinggo Low socioeconomic statuso High immigration rate – third world countrieso Many non‐English speaking patientsMostly Medicaid/Medicare patients
LTBI d b TB o LTBI treatment covered by state TB programo Visit reimbursemento Free medication o Free medication o State does not pay for liver function tests ‐‐‐‐ have to charge patient’s insurance
S i d ti tSome uninsured patientso Patients have to pay for labs out of pocket
Pharmacy Practice SettingRetail vs. hospital vs. long‐term care facilitieso Different settings have different requirementso Different patient population
o Age, comorbidities , concomitant medications
Similar practice setting in close proximityo May provide analogous servicesy p go May create competitiono May decrease reimbursement/revenue from your services
LTBI Clinic – Pharmacy PracticeHospital settingo Referrals from outpatient primary care clinics onlyo Patients’ PCP is a medical resident overseen by anattending physicians
Another large hospital Another large hospital o Yale‐New Haven Hospital within 1 mile radiuso Offers many comparable servicesy p
Needed a form of service that would distinguish us
Key elements in creating a successfulKey elements in creating a successful practice
1. Overview2. Description of Pharmaceutical Services3. Duties and Responsibilities3 p4. Return on Investment (ROI)5 Summary5. Summary6. References
Key elements (cont.)1. Overview:
oIdentify a sense of urgency for the projectoIdentify a sense of urgency for the projectoPresent data supporting the statement of urgencyurgency
oDescribe an example of your project from h ’ iothers’ experience
LTBI Clinic – OverviewPre‐Clinic Data ‐ 2004 Pre‐Clinic Data ‐ 2005o 69 patients total o 66 patients total
o 32 adultso 37 children
o 16 patients completed
o 27 adultso 39 children
o 19 patients completed p ptherapy
o 2 adults o 14children
9 p ptherapy
o 5 adultso 14 childreno 14children
o 23% completion rateo 77% lost to follow‐up
o 14 childreno 28% completion rateo 72% lost to follow‐up
Key elements (cont.)2. Description of Pharmaceutical Services:oIdentify role of the pharmacist oExplain how the role of the pharmacist
ill i h ti l will improve pharmaceutical careoDetermine scope of practice for the pharmacist pharmacist o Protocol basedo Collaborative practiceo Co abo a e p ac ce
LTBI Clinic – Description of Pharmaceutical ServicesServices
Pharmacist’s roleo Pharmacist managed tuberculosis clinic has been o Pharmacist managed tuberculosis clinic has been shown to improve therapy completion rate (Tavitian, 2003).
o Educate patients on the importance of adherence, safety, and efficacy of the medication
Scope of practice for the pharmacisto Physician‐directed treatment Protocol
Key elements (cont )Key elements (cont.)3. Duties and responsibilities:
oDevelop a job description oDevelop competency based evaluation oDevelop competency based evaluation toolAssess additional educational material oAssess additional educational material o CertificationsS lf d d lo Self‐study modules
o Patient education materials
LTBI Clinic Duties and ResponsibilitiesLTBI Clinic – Duties and Responsibilities1. Implementation of a computerized patient tracking system for those lost to follow‐uptracking system for those lost to follow up
2. Patient educationa. Pathology of LTBI a. Pathology of LTBI b. LTBI treatmentc. Importance of compliance
3. Monitoring for hepatotoxicitya. Liver function tests – AST and ALTb d ll f h k db. Jaundice – yellowing of the skin and eyesc. Nausea/vomitting; abdominal pain; diarrhead Fatigue/Weaknessd. Fatigue/Weaknesse. Loss of appetite
LTBI – Duties and Responsibilities (cont.)4. Refer patient to PCP if
a. Liver function tests are abnormal b. Patient experiences adverse drug reactions
i Peripheral Neurotoxicity tingling sensationi. Peripheral Neurotoxicity – tingling sensationii. Hepatotoxicity
5. Process all required documentation5 qa. Connecticut’s Department of Public Health TB form 32 b. Document all appropriate information in medical chart
6. Establishment of proper reimbursementprocedures
I id t t h i i billia. Incident to physician billing
Key elements (cont.)4. Return on Investment Opportunity:o Costs
Th l f d i i l di i o The total spent for goods or services including money, time and labor.
o Revenueo The entire amount of income before any deductions are made.
o Profito The excess of revenues over outlays in a given period of time (including depreciation and other non‐cash expenses).
LTBI Clinic – Return on Investment
Costs – Total: $27,580o Labor
o Salary of the pharmacy staff (4 hours) – $16,640 oBenefits – $4,160N d ti ti $ 6oNon‐productive time – $2,496
o Space requirementsoOffice rental space and office equipment – NoneoOffice rental space and office equipment None
o Miscellaneous o Laboratory tests – $4,284y 4, 4
LTBI Clinic – Return on InvestmentLTBI Clinic – Return on Investment (cont.)
Revenue – Total: $44,321o Visits
o $39,780
o Miscellaneous – Reimbursement for any laboratory tests required for therapy monitoring q py go $4,541
LTBI Clinic – Return on InvestmentLTBI Clinic – Return on Investment (cont.)
Net Profit : $16,741
o Revenue minus cost
o 44,321 – 27,580 = 16,741
o Pharmaceutical services – cost justified
LTBI Clinic – Return on Investment (cont.)
Costs Hours/Week
Annual Expenses
LaborClinical Pharmacist,
4 Salary $16,640
Revenue Visits/Year
Annual Revenue
Visits 612 $39 780PharmD 1 Pharmacist Tuesdays – 8am
to 12pm
Benefits $4,160
Non Prod. $2,496
Total
Visits 68 patients – 9
monthly visits $65/visit
612 $39,780
Total $23,296
Non LaborSpace RequirementsLiver Function Tests
None$3,276Total
Liver Function Tests
68 patients – 9 visits
$7.42/visit
612 $4,541
68 patients – 9 visits
$7 for hospital to perform the test
$4,284
$7.42/visit
Total revenue $44,321
Net Profit $16 741Total Cost
$27,580
$16,741
Key elements (cont.)5. Summary:
oRecap the overviewoRecap the overviewoReiterate the description of the pharmaceutical servicespharmaceutical services
oReview pharmacist’s responsibilitiesoSummarize cost justification requirements
LTBI Clinic ‐ SummaryP Cli i d t f t ( d )o Pre‐Clinic data for two years (2004 and 2005):o Therapy completion rate – 26% o Loss to follow‐up rate – 74% o Loss to follow up rate 74%
o Clinic opened in October 2006o Has been open for 5 years
After two years (October 2006 October 2008):o After two years (October 2006 – October 2008):o Therapy completion rate – 74%o Loss to follow‐up rate – 26%p
Key elements (cont.)6. References:
oEssential for evidence‐based medicineoEssential for evidence based medicineo Justifies statements that are madeGi ifi bl f i d f i ioGives verifiable facts instead of an opinion
Limitations/DifficultiesLimitations/DifficultiesLack of Project Championj po May be more difficult to sell to specialty areas,
o such as Infectious Disease and HIV ClinicsLimited resourceso Are there other costs associated with services (i.e. rent)?
l f di Prevalence of disease stateo Are there enough cases in the demographic area to support the services provided?support the services provided?
Non‐adherenceo No patients, no services, no reimbursementp
Limitations/Difficulties (cont.)Potential lack of reimbursemento No profit, no serviceso Private insurance vs. state coverage
o Different coveragego Not all ICD‐9 codes reimbursed
o Example: smocking cessation is not covered p gby the state of Connecticut
LTBI Cli i Li i iLTBI Clinic ‐ LimitationsLack of retrospective datao Data from previous years is not very well documented
o Discrepancies between hospital and state recordsDiffi lt t o Difficult to assess
Patients’ non‐complianceo Due to asymptomatic nature of infection and potential y p padverse reactions of the medication
Patients visit covered by stateD bill i ’ io Do not bill patient’s insurance
o Does not cover lab costso Private insuranceo Private insuranceo Patients out of pocket
Patient Protection and Affordable Care Acto Grant Programs
o Grant programs for collaborations between physician and pharmacistsp
o Integrated Care Modelso Pharmacists involved in medical homes, accountable care organizations communities and home based programs organizations, communities, and home based programs
o Transitional Care Activitieso Pharmacists involved in medication reconciliation, discharge
l i h i ’ f dplanning when patient’s care gets transferedo Medicare Advantage Plan Incentive
o Pharmacist involved in care for chronically ill, high‐cost patientsy g po Polypharmacy in ambulatory setting
C l iConclusiono Patient population required for the new service
o Urban vs. suburban ‐‐‐ low income vs. moderate to highincome
o Is the practice setting appropriate for the program o Is the practice setting appropriate for the program planned
o Identify key elementso What constituents are required for the new program
o Sense of urgency, description of the services, duties and responsibilities, ROI, summary and references
o Be cognizant of all possible challenges when creating a new practice model
Any resistance from other health care professionalso Any resistance from other health care professionalso Potential lack of reimbursement
References1. ASHP statement on the pharmacist’s role in infectious control. American Society of Health‐
System Pharmacists Inc. 1998. 2. Centers for Disease Control. 2000. Targeted Tuberculin Testing and Treatment of Latent
Tuberculosis Infection. M.M.W.R. 49 (No. RR‐6):1‐51.3. Hirsh, C.S., Johnson, J. Treatment of Latent Tuberculosis Infection: New U.S. Guidelines. 3. Hirsh, C.S., Johnson, J. Treatment of Latent Tuberculosis Infection: New U.S. Guidelines.
Infectious Diseases in Clinical Practice. 2001; 10:93‐99.4. Michalets, E.L., Williams, E. Reimbursement for pharmacists' cognitive services in the
inpatient setting. American Journal of Health‐System Pharmacy. 2001; 58: 164‐166.5. Tavitian, S.M., Spalek, V.H., Bailey, R.P. A Pharmacist‐managed clinic for treatment of latent
tuberculosis infection in health care workers American Journal of Health‐System tuberculosis infection in health care workers. American Journal of Health System Pharmacists. 2003; 60:1856‐1861.
6. Centers for Disease Control. 2005. The difference between latent TB infection and active disease. TB Elimination. Document # 250101.
7. Jasmer, R.M., Nahid, P., Hopewell, P.C. Latent Tuberculosis Infection. NEJM. 2002; 347:1860 1866347:1860‐1866.
8. Horsburgh C.R. and Rubin, E..J. Latent Tuberculosis Infection in the United States. NEJM.2011;364:1441‐8
9. Centers for Disease Control. 2005. Treatment of latent tuberculosis infection: Maximizing adherence. TB Elimination. Document # 25003.C f Di C l T d T b li T i d T f L 10. Centers for Disease Control. 2000. Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection. M.M.W.R. 49 (No. RR‐6):1‐51.
References (cont.)11. Centers for Disease Control. 2003. Treatment of Tuberculosis. M.M.W.R. 52 (No. RR‐
11): 1‐77. 12. Connecticut state law.13. American Thoracic Society. Targeted Tuberculin Testing and Treatment of latent
tuberculosis infection Am J Crit Care Med 2000; 161:S221 S247 tuberculosis infection. Am J Crit Care Med. 2000; 161:S221‐S247. 14. Kaufmann, S.H.E. New issues in tuberculosis. Ann Rheum Dis. 2004; 63 (Supplement
II):ii50‐ii56. 15. Centers for Disease Control. 2005. Treatment options for latent tuberculosis infection.
TB Elimination. Document # 250004.5 416. Centers for Disease Control. 1996. Update: Adverse event data and revised American
Thoracic Society/CDC recommendations against the use of rifampin and pyrazinamide for treatment of latent tuberculosis infection, United States. 2003. M.M.W.R. Weekly. 2003. 52 (31): 735‐739.
17 Ahmad S Pathogenesis Immunology and Diagnosis of Latent Mycobacterium 17. Ahmad, S. Pathogenesis, Immunology, and Diagnosis of Latent Mycobacterium tuberculosis Infection: Review Article. Clinical and Developmental Immunology 2011; 17 pages.
18. Ioachimescu, O., Tomford, J.W. Tuberculosis. The Cleveland Clinic. [Online]. 2004; 1‐15
Pearls from Innovative Practice Models:
Local and National Programs IntegratingLocal and National Programs Integrating
Comprehensive Pharmacy Services into p y
Safety Net Medical Homes
Steven W Chen Pharm D FASHP FCSHPSteven W. Chen Pharm.D., FASHP, FCSHPHygeia Centennial Chair in Clinical Pharmacy
Associate Professor, USC School of PharmacyDirector, Pharmacy Practice Residency in Primary Care
Distinguished Faculty Fellow Center for Excellence in TeachingDistinguished Faculty Fellow, Center for Excellence in TeachingCo-Chair Emeritus, HRSA Patient Safety & Clinical Pharmacy Services Collaborative
[email protected] (323) 442-1556
Intent of this sessionIntent of this session
To discuss local and national models of
pharmacist-managed patient care for
underserved populations
Questions to run onQuestions to run on…
How can you identify a potential safety net site and a population of focus in need of pharmacy services?
What are the challenges / barriers to developing a pharmacy service in the safety net setting, and how does healthcare reform fit?
What are key steps in building a successful pharmacy program in the safety net setting?
OutlineOutline
What is the safety net?
Key steps for developing a safety net pharmacy program Key steps for developing a safety net pharmacy program
Barriers, challenges, and healthcare reform
S f t N t Cli iSafety Net Clinic
"Th id / titi th t i d d li "Those providers / entities that organize and deliver a significant level of health care and other health-related services to uninsured Medicaid and other vulnerableservices to uninsured, Medicaid, and other vulnerable patients.”
Providers of healthcare regardless of ability to pay Providers of healthcare regardless of ability to pay Rural safety net: 20% of Americans, 11% of physicians “If you’ve seen one safety net clinic, you’ve seen one
safety net clinic.”
Institute of Medicine
Initial USC School of Pharmacy Safety Net Partners
Demographic T.H.E. Weingart South Central QueensCare LADemographic Characteristics
T.H.E.
Clinica
Weingart Medical Clinicb
South Central Family Health
Centerc
QueensCare
Clinics dLA
County e
Ethnicity: (%)
Black 59 49 5 4 9Hispanic 21 40 90 25 45White 1 9 2 62 47White 1 9 2 62 47Asian / Pacific Islander 16 2 3 13 13Education and Income:
<12 years education (%) 56 70 25 23 25Median Family income $21,038 $2,500 $23,554 $34,267 $51,315Unemployment rate (%) 12 96 7 5 5<100% of Federal poverty level (%)
75 100 92 29 24
Receiving Public 25 100 18 na 7gassistance (%)
Uninsured in the U SUninsured in the U.S.
49.9 million Americans Ethnic minorities (L,B, others), 41% < HS education Limited healthcare providers available Wide range of support staff competency Fragmented medication lists, greater risk for med safety problems Needs: More healthcare professionals, subspecialties Better disease management and prevention Focus on medications (1st-line for ~90% of chronic illnesses)
Covertheuninsured.org, RWJ Foundation; U.S. Census Bureau, Sept 2011
Comprehensive Diabetes Care
$1 of every $5 spent on healthcare goes toon healthcare goes to diabetes care
2010 State of Healthcare Quality Report
OutlineOutline
What is the safety net?
Key steps for developing a safety net pharmacy program Key steps for developing a safety net pharmacy program
6-Step Process for Establishing a Safety Net Pharmacy Program in Safety Net Clinics
1. Find a clinic, form your team2 Identif ser ices and pop lation of foc s2. Identify services and population of focus3. Develop a proposal & protocol4. Establish key measures of success5. Pilot service, collect measure day 1y6. Share results with stakeholders for sustainment and
spreadp
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
1. Find a Clinic, Form a Team,
Potential clinic partners• Local primary care associations
• Health profession schools
• Consultants
• HRSA Patient Safety & Clinical Pharmacy Services Collaborative
Forming your team• Pharmacy expertise: Safety net laws / regulations, ambulatory y p y g , y
care clinicians, grant / data managers, public health
• Physician champion / advocate
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
University of Oklahoma at Tulsa
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
2. Identify Services and Population of Focus
Refine formulary (PAP, 340B)
Pharmacy vs. Dispensary vs. Contract with retail pharmacy
Provide disease state / medication therapy management (DSM, MTM) to high-risk patients
Improve medication safety
Align with clinic’s quality improvement efforts (Medical Home, Meaningful Use, etc.)
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
2. Identify Services and Population of Focus
Patients with chronic illnesses known to be poorly managed Patients with chronic illnesses known to be poorly managed according to national measures (e.g., NCQA SOHC, HRSA PSPC)
Review available quality / utilization reports (e.g., registries, UR, P&T)
What are perceived to be the most significant disease / medication-l t d bl ?related problems?
Take opportunity you’re given (e.g., refills, reconcile meds, anticoagulation)anticoagulation)
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
3. Develop Proposal and ProtocolDiffers from state to state; flow chart recommendedDiffers from state to state; flow chart recommended
Physician / PA / NP appointment
Drug-related problem(s)1 and/or poor chronic disease control?ug e a ed p ob e (s) a d/o poo c o c d sease co o ?
Yes No
ENDcontinue usual care
Schedule CPS appointment
PHYSICIAN / NP / PA
CLINICAL PHARMACIST
Pharmacist evaluation1, screen for drug-related problems
Drug-related problem(s)1 identified?
Modify drug therapy per approved protocols, follow-up2
Yes
g p ( )No
Modify drug therapy per approved protocols, follow up
Drug-related problem(s) resolved?No Yes
4. Establish Key Measures of Success Establish measures immediately Align with national standards (National Quality Forum, NCQA,
Medical Home, Meaningful Use, etc.) for relevance, bench-marking
Quality of life survey
Treatment targets, Satisfaction survey
appropriate selection of drugs, medication
safety
Resource utilization (e.g., drug expenses, PharmD vs. ( g , g p ,PCP visits, hospitalizations, urgent care)
The Joint Commission Journal on Quality Improvement 1996;22(4)The Joint Commission Journal on Quality Improvement 1996;22(4)
Grants for Program Initiation or Expansion
http://www.foundationcenter.org/findfunders/ HRSA: $140,000 grant (2003) Community Pharmacy Foundation: $50,000 (2004) QueensCare Foundation:
• $300,000 for 3 years (2004)• $1,100,000 for 3 years (2006)
UniHealth:• $405,000 for 3 years (2004)• $405,000 for 3 years (2005)• $350,000 (2010)• $300,000 (2011, in submission)
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Medication cost savings (1 FTE pharmacist serving 3 clinics)
Practice-Based Research: Return on Investment
Medication cost savings (1 FTE pharmacist serving 3 clinics)• PAP utilization + 340B purchasing• > $700,000 in annual medication costs saved,• Access to critical medications previously thought to be
unattainable Extension of pharmacy services with the help of students
• Student assistance in dispensary → 10-20 additional hours of disease state management timeof disease state management time
Physician time saved
• Access complex patients not needed to dispense meds etc• Access, complex patients, not needed to dispense meds, etc.
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Practice-Based Research-Disease Management / Medication Therapy Management
Patient Visits, 10/04-9/08
TotalPatient Referrals 2,779
Unique Patients Seen 2,235
Patient Visits 15,904
Diabetes
Hypertension
13,267
9,452
Dyslipidemia
Asthma
Other
8,720
975
1 403Other 1,403
Benefits of partnering
Blood Pressure Management (n=242)
Majority of patients with DM (BP goal < 130/80)
Baseline152
126140
160BaselinePost-enrollment
-26 mmHg SBP)) 126
120
140 g
re (
mm
Hg
re (
mm
Hg
83
180
100
12 H DBPod P
ress
urod
Pre
ssur
71
60
80
SBP DBP
-12 mmHg DBP
Blo
oB
loo
SBP DBP
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
A1C ( 225)11.312
A1C (n=225)
11
12
9
10 --3.7 %3.7 %
c (%
)c
(%)
7.6
8
A1c
A1c
6
7
Baseline Post-enrollmentBaseline Post-enrollment
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Overall Impact of Pharmacist Intervention on Individuals with Diabetes (N=484)on Individuals with Diabetes (N 484)
Variables Change in A1CAdj.R2 = 0.4093
Likelihood of Achieving A1C < 7
Likelihood of Achieving A1C < 8
Estimated Effect
(% A1C)
p-Value Estimate Effect
(Odds Ratio)
p-Value Estimate Effect
(Odds Ratio)
p-Value
Intercept 7.760 <0.0001
Intervention group -1.38 <0.0001 4.037 <0.0001 5.129 <0.0001
Gender (male) 0 292 0 0770 0 586 0 1167 0 819 0 3931Gender (male) 0.292 0.0770 0.586 0.1167 0.819 0.3931
Age (in years) -0.025 0.0018 0.986 0.3655 1.021 0.0687
Insured (1=MediCal + other) 0.358 0.2719 - - - -
Hispanic (1 = Black + other ) 0.403 0.0717 0.819 0.6486 0.978 0.9437p ( )
Smoker (1=yes) 0.080 0.8783 1.622 0.2348 0.832 0.5584
Baseline A1C level -0.721 <0.0001 0.874 0.2069 0.824 0.0123
Days between first /last A1C -0.0002 0.5708 1.000 0.9004 1.001 0.0724test
Ann Pharmacother December 2010 vol. 44 no. 12 1877-1886
3 Severity Rating Categories for ADE/pADE
28
http://www.medicare.gov/NHCompare/static/related/incdrawlevelofharm.asp?language=English&version=default
Problems identified by category (N=2 085 9 4 medication related problems per patient)(N=2,085, 9.4 medication-related problems per patient)
CPS / MTM at local, state, and national levels
Most Common Quality of Care P bl (N 1 657)Problems (N = 1,657)
80%80%80%80%
# of Problems
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Interventions Provided by Pharmacists(N = 2 480 11 1 per patient)(N = 2,480, 11.1 per patient)
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Start small, pilot with a single physician if possible5. Pilot service, collect measures day 1
, p g p y p
6. Share results with stakeholders for t i t d d
Payers / Health plans
sustainment and spread
Administrators / Senior leaders
Medical team Medical team
Patients
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Community (public, legislators)
USC School of Pharmacy Affiliated Safety Net Clinics (3 to 12 sites in 7 years)( y )
Clinicas Del Camino Real
SCHFC
LACHC
CHOC Breathmobile
Teaching / Service OpportunitiesSHARE Community Education / ServiceSHARE Community Education / Service
Patient Education Classes
Counseling
TranslationData Collection
Medication Reconciliation
Health FairsData Collection
Immunizations
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Physician Satisfaction / FeedbackJWCH Institute Weingart Clinic
"The USC Pharmacists provide our patients and clinic a comprehensive package of health education drug information disease management and dispensing
JWCH Institute, Weingart Clinic
of health education, drug information, disease management and dispensing assistance."
"We are able to provide a wider range of services to a greater number of patients due to the PAP software and assistance that the USC School of Pharmacy has yprovided.“
"Our disease management indicators have improved dramatically as a result of the assistance we have received from the USC Pharmacy clinicians.“y
"Patient satisfaction has never been better thanks to the USC School of Pharmacy.”
"Our patients have consistently provided positive feedback about how the pharmacy services have increased the quality of care at the clinic and made their healthcare experience more satisfying."
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
2009200920092009
2007 APHA2007 APHA
20082008
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
Scholarship and Public RelationsLegislative/Policy Agenda
Visits to Congressional OfficesIn Washington DC to discuss value of
Legislative/Policy Agenda
In Washington DC to discuss value of supporting clinical pharmacy service integration in safety net clinics
Representative Lucille Roybal-Allard
SacramentoState LegislatureR itiRecognition
6-Step Process for Developing Clinical Pharmacy Services in Safety Net Clinics
OutlineOutline
What is the safety net?
Key steps for developing a safety net pharmacy program Key steps for developing a safety net pharmacy program
Barriers, challenges, and healthcare reform
What we have supporting the spread of clinical pharmacy services….
Published evidence clarifying the value of CPS Pharmacist support Allied health profession support Government support Tremendous needs among the underserved with few
answers Alignment with healthcare reform (PCMH, ACO)
Barriers, Challenges, and Healthcare ReformBarriers, Challenges, and Healthcare Reform
What we need….
More…
Evidence of CPS value published in medical journals Pharmacy professional organization unity Interprofessional education P t d t t i i Postgraduate training Collaboration, external endorsement Tuition repayment Tuition repayment Establish our domain, clarify our product, and create demand
for clinical pharmacy services among the public
Changes in…
Reimbursement limitations for clinical pharmacy services The perception of community pharmacy
Barriers, Challenges, and Healthcare ReformBarriers, Challenges, and Healthcare Reform
Aim of HRSA’s Patient Safety &Aim of HRSA s Patient Safety & Clinical Pharmacy Collaborative
“Committed to saving and enhancing thousands of lives a yearthousands of lives a year
by achieving optimal health outcomes and eliminating adverse drug eventsand eliminating adverse drug eventsthrough increased clinical pharmacy
i f h i ”services for the patients we serve.”
Barriers, Challenges, and Healthcare ReformBarriers, Challenges, and Healthcare Reform
Who is eligible to form a team?Who is eligible to form a team?
Consolidated Health CentersComprehensive hemophilia diagnostic
Federally Qualified Health Center, or FQHC look-alikes
Family planning (Title X)
Comprehensive hemophilia diagnostic treatment centers
Native Hawaiian health centersFamily planning (Title X)
Ryan White Care Act (Parts A, B, C, D) grantees
Black lung clinics
Urban Indian organizations
Certified tuberculosis clinicsBlack lung clinics
Healthcare reform additions:
Sole comm nit and
Certain disproportionate share hospitals (>11.75%)
Certified sexually transmitted disease Sole community and critical access hospitals, rural referral centers, and free standing cancer centers
Certified sexually transmitted disease clinics
Children’s Hospitals
HRSA & Other Local / National Efforts to Spread CPSHRSA & Other Local / National Efforts to Spread CPS
Patients with Health Status
Patient Safety & Clinical Pharmacy Patient Safety & Clinical Pharmacy SvcsSvcs Collaborative National Performance StoryCollaborative National Performance Story
Under Control vs. Out of Control, September 2009 (Baseline)
ms
Team
Out of Control
0 20 40 60 80 100
Number of Patients
Patients with Health Status
Patient Safety & Clinical Pharmacy Patient Safety & Clinical Pharmacy SvcsSvcs Collaborative National Performance StoryCollaborative National Performance Story
"Under Control" vs. "Out of Control" through August 2010
ms
Team
Under Control
Out of Control
0 20 40 60 80 100 120
Number of Patients
Patient Safety Breakthroughs
Patient Safety & Clinical Pharmacy Patient Safety & Clinical Pharmacy SvcsSvcs Collaborative National Performance StoryCollaborative National Performance Story
Patient Safety Breakthroughs
Teams are working to drive rates ofTeams are working to drive rates of potential adverse drug events (pADEs) and adverse drug events (ADEs) to zero
Average team improvement after 11 months
pADE rates ↓ 60% (0.86/patient to 0.34/patient)
ADE rates ↓ 49% (0.12/patient to 0.06/patient)
PSPC SpreadPSPC Spread
PSPC 1 0 PSPC 2 0 PSPC 3 0
PSPC SpreadPSPC Spread
PSPC 1.0 PSPC 2.0 PSPC 3.0
Organizations 209 350 445Teams 68 110 13568 110 135CHCs 57 79 118Hospitals 30 43 43Hospitals 30 43 43Schools of Pharmacy 24 53 98
Barriers, Challenges, and Healthcare ReformBarriers, Challenges, and Healthcare Reform
Additional Support for the Spread of Integrated Clinical Pharmacy ServicesIntegrated Clinical Pharmacy Services
FDA: Funding, use of broadcast headquarters CDC AHRQ: volunteer faculty CDC, AHRQ: volunteer faculty CMS: State Quality Improvement Organizations (QIOs) must
engage 5-10 new teams into PSPC, minimum 100 Medicare / dual g geligibles each
Affordable Care Act• Expanding Authority to Bundle Payments (1/13)• The Community Based Care Transitions Program (CCTP): Goal of reducing
hospital readmissions, testing sustainable funding streams for care transition services, maintaining or improving quality of care, and documenting measureable savings to the Medicare program.
F i f tiFor more information:http://www.hrsa.gov/patientsafety/
Barriers, Challenges, and Healthcare ReformBarriers, Challenges, and Healthcare Reform
Multidisciplinary IPE Program at California Hospital Medical Center and LAC-USC
Brian Prestwich, MDZain Al-Shamiyeh (Pharm Student)Hillel Bocian (Med Student)( )
Barriers, Challenges, and Healthcare ReformBarriers, Challenges, and Healthcare Reform