ENGAGING PHARMACISTS IN 1305 UTAH EXAMPLES NICOLE BISSONETTE, MPH, MCHES EPICC PROGRAM MANAGER
UTAH PROJECTS INVOLVING PHARMACISTS Prior to 1305 Select Health Pharmacist Hypertension Management Team Based Care University of Utah Population Management Approach to Diabetes and Hypertension Care Utah Navajo Health System Clinical Pharmacist Diabetes Care Healthcare Extenders/DSME Smith s/community Health Center, Inc. Collaborative Diabetes Medication Management Other Clinical Pharmacy Environmental Scan
SELECT HEALTH Background Completed as part of Heart Disease and Stroke Prevention Program FY13 Utah law allows for collaborative practice agreements where a physician or group of physicians can develop an agreement with a pharmacist or group of pharmacists allowing the pharmacist to manage the patients medications adjusting doses, types, etc. - based on an agreed upon protocol with the physician Select Health is the health insurance arm of Intermountain Healthcare (IHC) - a large integrated health system UDOH contracted with Select Health on this project, but both Select Health and IHC pharmacists participated Project Overview Goal: Improve hypertension management and antihypertensive medication dose titration using a team based approach to care Physicians refer challenging hypertensive patients to pharmacists using shared EMR Pharmacist follows up with patients via phone or in person, documents BP readings, assesses medication adherence, encourages lifestyle modifications, makes drug/dose adjustments (based on an agreed upon protocol with the primary provider), orders follow-up labs, and follows up with patient every 2 weeks until they are at goal All pharmacist encounters are documented in EMR
SELECT HEALTH, CONTINUED Outcomes of initial pilot 40 patients with difficult to control hypertension participated in pilot 75% at goal at project completion.92 Average number of medication titrations to achieve goal Expansion While we re not getting regular data updates anymore, as of Feb. 2014, clinical pharmacist support for hypertension and diabetes medication management has been expanded to a total of nine clinics, and 87% of referred hypertensive patients were at goal after an average of 2.4 encounters with a pharmacist. Currently, this is provided by IHC as a free service to clinics to help them improve their outcomes. Physicians appreciate the service, and other clinics are now asking for pharmacist support. Lessons Learned The main barrier identified was staffing levels, especially as Select Health added additional product lines. Also, pharmacist time is expensive. Coordinating between IHC and Select Health pharmacists was challenging, and it was easier for IHC pharmacists who had a more direct connection to clinics to recruit referrals. IHC began sending reports to physicians to actively recruit patients this was quite successful.
1305 PROJECTS We are currently contracting with three organizations to pilot projects incorporating pharmacists into hypertension/diabetes care. These projects are just getting underway, so we don t have any evaluation data yet. Team Based Care projects - Incorporating pharmacists into a team based approach to Diabetes and Hypertension Care University of Utah Utah Navajo Health Systems University of Utah Piloting in two clinics Diabetes and HTN focus Population based approach to care Utah Navajo Health System Expanding pilot project (2-3 additional locations) Diabetes focus Referral to pharmacist care
1305 PROJECTS CONTINUED Healthcare Extenders/DSME CHC, Inc./Smith s (Kroger) Establishing a connection between an FQHC and a retail pharmacy chain Emphasis on diabetes care CDSME referral system Evaluation project partners will submit the following information to help evaluate the projects, but since the 1305 projects are just getting underway, we don t have this data yet. Number of patients enrolled Proportion of patients with most recent BP/A1c at goal, and percent change from previous month Number of encounters with pharmacists Improvement in enrolled population Potential and actual drug therapy problems identified and adjusted Average proportion of days covered (a medication adherence measure) over project period, and improvement in proportion of days covered (PDC) over project period Subjective description of barriers and benefits to project implementation
ENVIRONMENTAL SCAN Connected to both Domain 3 and Domain 4 Project Overview Goal: Identify current Utah projects related to pharmacist clinical services Identify facilitators to the provision or expansion of pharmacist clinical services Identify barriers to the provision or expansion of pharmacist clinical services Focus on pharmacists practicing in outpatient settings clinics, retail, not hospitals Key Informant Interviews Survey
KEY INFORMANT INTERVIEWS 17 informal interviews Health Plans (N=9), including large integrated health systems, self-funded insurers, Medicaid funded Accountable Care Organizations, and small insurers. Titles of interview participants included: Clinical Pharmacy Director, Quality Improvement Specialist, and Director of Medical Quality as examples. Pharmacists (N=8), with representatives from retail pharmacy, independent pharmacists, and pharmacists practicing within large integrated health systems. Interviewees had titles such as Pharmacy Director, Clinical Coordinator of Pharmacy Ambulatory Care Services, and Clinical Pharmacist. Current Projects an example of what interviewees were working on Telemonitoring patients monitored BP and A1C remotely; pharmacist reviewed information and provided follow-up care accordingly Use of collaborative practice agreements to manage medications Use of collaborative practice agreements fairly common in Utah s two large, integrated health systems Retail pharmacists focused on maximizing MTM Medicare part D reimbursement Pre-visit planning: Pharmacist IDs patients using EMR who have multiple chronic conditions and evidence they are not well managed and have a scheduled visit with their PCP in the next couple weeks. Pharmacist schedules an appointment to update medicine list and labs information then communicated to PCP Including pharmacists as part of interdisciplinary care teams that review challenging cases
BARRIERS/FACILITATORS Facilitators Most common = A trusting and respectful relationship with other healthcare providers A shared EMR to facilitate communication with other healthcare providers Increasing evidence that pharmacist involvement in patient care can improve outcomes Reimbursement opportunities such as Diabetes Self Management Education and Medication Therapy Management for certain Medicare patients. Organizational support such as scheduling two pharmacists at a time and investing in private space to talk with patients Barriers Most common = $ Pharmacists lack provider status and are not typically reimbursed for providing non-dispensing services, so these services tend to be lower organizational priorities Several pharmacists interviewed mentioned that while provider status would be great, they were more excited about outcomes based reimbursement models like shared savings that could allow compensation for improved patient outcomes without the headache of medical billing Time/Staffing levels to provide services Time to research and test new models (from a health plan) Standardizing and integrating clinical services into workflow Pharmacist skill motivation to do something new interviewees saw this mainly in older pharmacists who have been in practice for a long time and are more likely to have a bachelor s degree in pharmacy (the current standard is a PharmD)
LESSONS LEARNED All of the pharmacists interviewed were interested in expanding their role in patient care and very supportive of public health efforts in this area For the most part, people were happy to meet with me In addition to gathering information (and possibly more importantly), interviews gave me a reason to reach out to new potential partners and meet with them Connections made from interviews have been helpful in developing and promoting RFP opportunities, getting input on projects, and being able to ask additional questions that have come up periodically
SURVEY Background Used information from the interviews especially the possible facilitators and barriers to develop a survey 5 of the interviewees also piloted the survey Survey emailed to a list of 1,627 licensed pharmacists from the Department of Occupational and Professional Licensing 331 pharmacists completed at least some of the survey it was a pretty long survey Survey Asked about 7 clinical services Asked if respondent had provided the service in the past year and if it was integrated into workflow. Number of services integrated into workflow was used as Clinical Services Score and used in analysis Individual Facilitators: Asked about their confidence, interest, and whether each service would be helpful for patients Organizational facilitators: Asked about a series of things that previous research has suggested support pharmacist clinical services Community Facilitators: Asked about relationship/communication with other healthcare providers Demographics Urban (88%) Educated (70% had a PharmD. Based on a national sample from 2012, about 22% of practicing pharmacists have a PharmD). About ½ of respondents practice in a retail setting, which is pretty comparable to the national sample.
CURRENT SERVICES Most respondents reported having provided a non-dispensing service in the past year, fewer had these services integrated into their workflow. Service Provided in the past year Integrated into workflow (of respondents who provided service in past year) Medication Therapy Review 74.77% 66.37% Patient Education 87.03% 67.94% Follow up 38.8% 68.42% Collaborative Practice 53.18% 88.61% Healthcare Referrals 57.82% 72.35% Community Referrals 20.21% 75.41% Diabetes Self-Management Education 28.37% 67.07%
INDIVIDUAL FACILITATORS Confident in ability to provide service Most respondents were confident in their ability to provide all of the clinical services we asked about 90% reported feeling confident in their ability to provide Medication Therapy Review and patient education Only 64% reported feeling confident in their ability to provide community referrals Helpfulness to their patients Most respondents agreed that the clinical services we asked about would be helpful for their patients Over 85% of respondents thought that medication therapy review, patient education, and collaborative practice agreements would be helpful for their patients. Only 72% thought that community referrals would be helpful for their patients Interest in providing clinical services Over 85% of respondents were interested in providing, or providing more frequently, medication therapy review, patient education, and collaborative practice agreements 65% were interested in providing community referrals
ORGANIZATIONAL FACILITATORS Respondents who reported practicing in a pharmacy that is integrated with a clinic or in an independent pharmacy had higher average clinical services scores Agreeing with any of the below statements was associated with a higher clinical services score(p-value <.05) Question My organization allows me to build time into my schedule to provide clinical services e.g. non dispensing services My organization provides incentives for improved clinical outcomes such as medication adherence or blood pressure control * Pharmacy techs in my organization have time to schedule and follow up with patients * I have access to private space to discuss medication issues and to provide clinical services My organization supports my continued professional development around clinical services My organization syncs medications so that patients can pick all medications up at one time * Respondents who agreed with these statements had the highest clinical services score
COMMUNITY FACILITATORS Most pharmacists (85%) agreed with the statement, I have a respectful relationship with other healthcare providers in my community. There was not a difference in clinical services score compared to respondents who did not agree. Pharmacists who use face to face communication, a shared EMR, and the chie (the state designated health information exchange) sometimes or often had higher average clinical services scores than respondents who never use these forms of communication. Few pharmacists reported using the chie (46), however pharmacists who did had the highest average clinical services score. OPEN ENDED 32 respondents chose to submit additional comments related to clinical services. Most reiterated that they would like to provide clinical services, but they face barriers in doing so. Financial barriers were the most common. Pharmacists reported that because these services do not directly generate revenue, they tend to be de-emphasized by organizations, and it is difficult to integrate them into workflow. One pharmacist described the financial struggle in this way, Reimbursement for these services would definitely incentivize my employer(s) to facilitate providing services. Right now, we are rarely paid for helping patients and therefore the emphasis is still on dispensing...
NEXT STEPS Using information from environmental scan to develop a more comprehensive plan around how UDOH can promote pharmacist involvement in management of chronic conditions Figuring out how to leverage any positive outcomes or lessons learned from current 1305 projects to encourage adoption on a larger scale
UTAH EPICC CONTACT INFORMATION Nicole Bissonette, MPH, MCHES EPICC Program Manager 801-538-6228, nicolebissonette@utah.gov Teresa Roark, MPH Health Systems Team Based Care Health Program Specialist 801-538-9215, troark@utah.gov