Clinical Service Networks

Re-Engineering Your Pharmacy Practice BootcampAugust 13, 2016

Ashley Branham, PharmD, BCACPJoe Moose, PharmD

Disclosures

• Ashley Branham is receiving an honorarium for this program. The conflict of interest was resolved by peer review of the slide content.

• Joe Moose is receiving an honorarium for this program. Joe Moose is a board member of the NCPA Innovation Center. The conflict of interest was resolved by peer review of this slide content.

Objectives

1. Discuss common characteristics of pharmacies in a community pharmacy enhanced service network.

2. Discuss the role of community pharmacy in providing medication management resources to the highest risk populations.

3. Describe how pharmacies are positioning themselves to integrate with care teams to lower health care costs and participate in new models of care and reimbursement.

$100 Total Healthcare Spend

$10

$90

Pharmacy Spend

Non-pharmacy Health Care Spend

The Opportunity: A Fundamentally Different Approach to Payment & Delivery

“How we got to where we are…”(… our community pharmacy experience)

>32,000 Individuals received CCNC Transitional Care Support in 2015(24 different steps, 3 of which are medication optimization oriented)

Dilemma: How to Scale Team-Based Medication Optimization Efforts?

Breaking Out of the Bubble…”

(… our Policy Experience trying to Sell Community Pharmacy“)

Care Team HIT focus less important

Care Team-Based HIT focus extremely

important

What Is a CPESN℠?

Community Pharmacy Enhanced Services Network

Enhanced Pharmacy Services - Services that transcend

conventional requirements of an outpatient pharmacy programcontract that are focused on improving clinical and global patient outcomes

Examples include, but are not limited to:• In-home delivery with patient status review• medication synchronization with clinical review, • Adherence packaging with patient coaching; and • Care management services.

Opportunity Knocks…

CCNC

Enrollees

CCNC

Enrollees

with total

medical cost

> $10,000

Enrollees on

CCNC

Priority list

Enrollees on

TC Priority

list

Enrollees on

Medication

Management

Priority list

Total number of members 1,348,229 112,529 17,753 153,241 6,377

Total medical cost 4,078$ 27,527$ 23,813$ 18,215$ 25,345$

# of Inpatient visits 0.11 0.52 1.41 0.45 1.04

Inpatient costs 369$ 3,464$ 5,337$ 2,924$ 6,456$

# of mental health inpatient visits 0.01 0.04 0.04 0.04 0.04

ED visits 0.67 1.65 2.94 1.74 3.05

ED cost 178$ 745$ 1,262$ 816$ 1,657$

Outpatient visits 4.30 9.43 12.04 8.70 12.28

Mental health outpatient visits 0.62 1.88 1.04 1.53 1.14

PCP visits 2.09 2.91 2.53 2.65 3.52

Pharmacy visits 4.97 19.63 16.95 23.05 35.03

Pharmacy costs (Pre Rebate) 721$ 5,177$ 3,342$ 4,298$ 6,183$

What Does CPESN℠ NC look Like?

North Carolina Medical Home LandscapeNeighborhood

Growth of the NC CPESN℠

Community Pharmacy Enhanced Services Network

0

50

100

150

200

250

300

CPESN workgroups, initial collaboration

card, common informatics platform,

and care team relationship building

Payment for services standardized/required

documentation, performance,

measurement, quality assurance

NC CPESN℠ Distribution

Geographic Representation of CPESN Pharmacies as of December 1, 2015

NC CPESN℠ Participation Criteria• Current registration with the BOP in good standing

• Current NC Medicaid pharmacy provider

• A signed agreement with CCNC that defines scope of work and CPESN participation

• Use of CCNC’s PHARMACeHOME application

• Agreement to provide a minimum set of enhanced services:

1. Proactive waste management program

2. Patient counseling and adherence coaching

3. Assistance with medication reconciliation

Types of Enhanced Services

24 Hour EmergencyServices

Adherence Packaging

Collection of Vital Signs

Compounding

ComprehensiveMedication Review

Home Delivery Home Visits Long-ActingInjections

Med Synchronization Program

Multi-Lingual Capability

NaloxoneDispensing

Nutritional counseling

Point of Care Testing

Smoking Cessation StandardizedAssessments (PHQ-9)

Disease State Management Programs

The Collaboration Card

24 Hour Emergency Service/On Call (Dispensing) X X X X X X X X

24 Hour Emergency Service/On Call (Non-Dispensing) X X X X X X X X X X X X X X

Adherence Packaging X X X X X X X X X X X X X X X X X X

Clozapine Dispensing and Monitoring X X X X X X X X X X X X X X X X

Collection of Vital Signs X X X X X X X X X X X X X X X

Compounding (Non-Sterile) X X X X X X X X X X X X X X X X X X

Compounding (Sterile)

Comprehensive Medication Review X X X X X X X X X X X X X X X X X X X

DME Billing (Medicare and Medicaid) X X X X X X X X X X X X X X X

Home Delivery– (Free) X X X X X X X X X X X X X X X X X X X

Home Delivery (Fee Applies) X

Home Visits X X X X X X X X X X X X X X

In Depth Counseling/Couching X X X X X X X X X X X X X X X X X

Long-Acting Injections X X X X X

Med Synchronization Program X X X X X X X X X X X X X X X X X X X

Multi-Lingual Capability X X X X X X X X X X

Naloxone Dispensing X X X X X X X X X X X X

Nutritional Counseling X X X X X X X X X X

Personal Medication Record X X X X X X X X X X X X X X X X X X

Plan of Care Development/Reinforcement X X X X X X X X X X X X X X X X

Point of Care Testing X X X X X X X X X

Pre-filling Syringes for Oral Administration X X X X X X X X X X X X X

Presumptive Eligible (Medicaid) Medication Dispensing X X X X X X X X X X X X

Smoking Cessation Program X X X X X X X X X X

Specialty Pharmacy Dispensing X X X X X X X X

Standardized Assessments (pain assessment, PHQ-9) X X X X X X X X X X X X X X X

Immunizations (Non Medicaid) X X X X X X X X X X X X X X X X X X

Disease State Management Programs X X X X X X X X X X X X X X X

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0 The Pharmacy

Locator Application

Importance of Targeting and Channeling Patients to High Performing Pharmacies

ONC National Meeting, January 24, 2014

Three Project Aims

• Test New Payment Models for Community Pharmacy

• Test New Relationship Models with Medical Homes

• Determine What IT Needs are Needed for Community Pharmacy

What Does CPESN℠ Iowa Look Like?

CPESN℠ Highlights: Iowa

IPA has hosted a “Building a Community Pharmacy Enhanced Services Network” Webinar Series

Live Meeting on February 12

- Establish Work Groups

Participation at the CCNC Pharmacy Home Annual Meeting

Regular Work Group Meetings and participation engagement

Live Meeting Schedule for June 18 in Des Moines

Progress in Iowa

Core vs. Optional Service Sets

Roles & Responsibilities

Participation Agreement

Iowa CPESN℠ Participation Criteria• A signed agreement that defines roles & responsibilities with

CPESN participation– Current registration with the BOP in good standing– Respect patient’s right to choose their own practitioners and

pharmacies– Use secure data platforms and applications, when applicable

• Agreement to provide a minimum set of enhanced services1. Medication Reconciliation2. Clinical Medication Synchronization3. Adherence Packaging4. Immunizations5. Complete Medication Reviews with Chronic Care Management

Why CPESN℠ Supports Product Reimbursement

The Objective

The Opportunity: In Economic Terms to Medical Benefit

The Opportunity: In Economic Terms to Pharmacy

• Typical Referred Patient 10 Rx/Pt/Month

• Profit per Rx ~$10

• How it Breaks Down– ~100-300 pts/day/referred to NC CPESN

– $1200/pt/yr X 200 pts = $240,000 in annual net profit per day

“we are worried about reductions in reimbursement rates to community pharmacies….we work with a few that are essential for our patients….with special needs

and circumstances…if they went out of business it would be really hard on the practice and the patients”

- Primary Care Physician (CCNC Practice)

A Day in the Life of a CPESN℠

Pharmacy

CPESN℠ Example Workflow

Adherence Technician

Clinical Pharmacist

Administrative Assistant

Consultation Room

Inventory

Input Technician

Fill Technician Pharmacist Cashier

Delivery

CPESN℠ Example WorkflowInput Technician

Input Technician

Key Responsibilities- Determine if patient is on

attribution list- Assess profile for adherence when

processing prescriptions - Clean up medication lists

(discontinue medications)- Document identified DTPs on DTP

Short Form

Technician Tool: DTP Short Form

• Form placed at technician work station

• Technician to complete form if potential DTP’s are identified

• Technician to send form in basket to the pharmacist

• Pharmacist investigate the issue and takes necessary steps to resolve DTP

• DTP documented in platform

CPESN℠ Example WorkflowFilling Technician

Filling Technician

Key Responsibilities- Accurately prepare medications

for dispensing- Answer phone - Identify potential DTPs - Document identified DTPs on

DTP Short Form- Alert pharmacists if consultation

is needed

CPESN℠ Example WorkflowAdherence Technician

Adherence Technician

Key Responsibilities- Call patients on monthly basis- Point of contact for medication changes

during the month (Transition of Care)- Handle Referrals from Provider(s)- Determine medication lists to be sent to

PASS machine

Monthly Follow-Up Calls

• Patients called prior to synch date each month to assess adherence and changes in medication regimen

– Standardized script to fully assess

• Problems with medications

• Changes to medication regimen

• Review of each specific medication

• Evaluation of need of PRN medication

Evaluation of Adherence

• Integrate additional technology in dispensing process to access a comprehensive database for patient-specific prescription fill history, provider, pharmacy and adherence measures to prescribed therapy

CPESN℠ Example WorkflowDispensing Pharmacist

Pharmacist

Key Responsibilities- Final verification on all medications - Review medication history- Counsel patients - Maximize encounters with attributed

patients- Alert Clinical Pharmacist when CIPA is

needed- Identify DTPs - Resolve medication-related problems

through care coordination

CPESN℠ Example WorkflowClinical Pharmacist

Clinical Pharmacist

Key Responsibilities- Prioritize attribution list - Perform Comprehensive Initial Pharmacy

Assessments (CIPA)- Identify Drug-Therapy Problems (DTPs)- Home Visits- Perform Transition of Care Assessments- Documentation and follow up with

patients

CPESN℠ Example WorkflowAdministrative Assistant

Administrative Assistant

Key Responsibilities- Prioritize attribution list - Perform Comprehensive Initial Pharmacy

Assessments (CIPA)- Identify Drug-Therapy Problems (DTPs)- Home Visits- Perform Transition of Care Assessments- Documentation and follow up with

patients

Administrative Assistant

Attribution List received by pharmacy

Request PCP med list, specialist med list, etc.

Review PH to ensure patient not reviewed

recently

Call patients to schedule Face-to-Face CMR or complete CMR

via telephone

Complete CMR with patient/caregiver

Complete Matrix in PH noting any non-clinical

DTPs

Review Matrix entered in PH, noting clinical

DTPs

Complete CMR Summary Note and Publish all Materials

Work with healthcare team to resolve any

DTPs

Technician/Support Staff

Pharmacist

Comprehensive Initial Pharmacy Assessment (CIPA) Work Flow Process

CPESN℠ Example WorkflowCashier

Cashier

Key Responsibilities- Review system flags with

patients- Notify pharmacist to counsel

when DTP is identified- Identify when medications are

not picked up and alert pharmacists (especially if patient is enrolled in the adherence program)

Cashier

CPESN℠ Example WorkflowDelivery

Cashier

Key Responsibilities- Deliver medications to

patient’s home - Provide instructional video(s)

through iPad- Notify pharmacists through

Face Time for consultations- Report back signs of poor

adherence to pharmacist(s)Delivery

Summary of Moose Pharmacy Learnings• Frequently discuss initiative with entire team to create a

culture of providing value-based care– Frequent Team Meetings– When you stop talking about it, staff resume “old” practices– Encourage everyone to work at the top of their degree

• Be efficient at dispensing medications • Complex patients require time away from the workflow

– Invest in resources when appropriate to assist with workflow

• Relationship building is key to successful intervention

Report on the Multi-State Pharmacy Collaborative (MSPC)

Supporting the Development of Community Pharmacy Enhanced Services Networks (CPESN)℠ Beyond North

Carolina

Multi-State Pharmacy Collaborative (MSPC)

• Facilitate expansion of high-performing networks*

• Provide a venue to connect pharmacists and other pharmacy stakeholders who have interest in delivery of financially sustainable, patient-centered care beyond traditional dispensing services

* High Performing Pharmacy Network to coalesce pharmacies based on the principle of providing value beyond selling drug product to effectuate health trajectory

Goals

• Provide Launch Support for CPESN Implementation

• Explore opportunities for collaboration between value purchasers and CPESNs

• Support development of Pharmacy Locator Application/Collaboration Site

• Develop communication strategy for Multi-State Pharmacy Collaborative (MSPC) engagement

The Big Picture• Form a nationwide “Network of Networks”

• Increase, Develop and Sustain High Performing Networks of Pharmacies that provide enhanced services offerings

• Create Marketplace Presence of CPESN℠ Networks

• Create Marketplace Dependency on CPESN℠ Networks

• Facilitate local value propositions to other care team members to establish margin positive referral patterns

• Create care team dependency on clinical activities performed by community pharmacies to mitigate against risk narrow networking or reimbursement reductions on product distribution

• Establish Relationships and Reimbursement models with Medical Benefit side of payer infrastructure

Requested Webinars & On Site Visits

On Site Visit

Webinar

Where We Are: Emerging CPESNs℠

October 2015 December 2015

June 2016 Contact established

Emerging CPESN℠

Active CPESN℠

Next State(s) to Launch CPESN℠

CO

OK

NY

TN

MS

AR

GA

Contact established

Emerging CPESN℠

CPESN℠ Fall Launch

PA

CPESN℠ Highlights: Baptist Memorial Health Care

• Large health center covering 3 states (MS, AR, TN)

• Expressed interest in collaborative effort between BMHC and CPESN℠ in coverage area

CPESN℠ Highlights: Mississippi

MIPA has hosted Webinar

Participation at the CCNC Pharmacy Home Annual Meeting

Live Meeting held on May 14

Live Meeting with pharmacists and Baptist May 24

CPESN℠ Highlights: Kentucky

• Wellcare Pilot Program (6 months)

• KY CPESN℠ to provide NPI’s of participating pharmacies

• Wellcare to provide patient attribution list with highest cost.

Launching a CPESN℠

Phase 3: Preparing to Launch

Phase 2: Develop Network Framework

Phase 1: Determining Interest

Step 1: Determining Interest • Identification of potential participating

pharmacies – Webinar, Live Meeting, One-on-one discussion with

targeted community pharmacists– Potential luminaries

• Organize Voluntary Work Groups – Collectively determine the posture of your CPESN– Schedule live meeting for network decision making

CPESN℠ Work Groups

• Service Sets

• Input on standard and optional services and how those are defined

• Input on the education and communication about services to providers/stakeholders (i.e. Pharmacy Locator App)

• Network Operations & Communications

• Establish, monitor and grow the CPESN

• Input regarding interactive processes and communications needed for collaboration with CPESN community pharmacies around the care of specific patients

• Identify funding & sustainability opportunities

• Quality Assurance & Performance Measurement

• Guidance about appropriate measures and measure definitions needed to monitor overall performance and quality of CPESN network

Step 2: Develop Network Framework

• Determine entity that will organize the CPESN– Non-profit, For-profit entity, CCNC assistance

• Determine name of your CPESN

• Determine value proposition of your network

• Determine intent of pharmacy participation by Letter of Commitment or Participation Agreement

Step 3: Preparing to Launch• Identify Network Administrator• Survey participants to determine enhanced services

offering(s)• Finalize minimum participation criteria

• Outline required and optional service sets• Inclusion criteria

• Engage Potential Partnerships (SOP(s), Vendors, etc.)• Branding/Logo Development• Establish deadline for Letter of

Commitment/Participation Agreement

Work Group Kick Off Meeting • Brainstorming session &

reporting of work groups

• Define owners of work group

• Selection of 1 or more luminaries

• Determine strategy for next follow up

Which Level of Support Will Your CPESN℠ Need?

- Mentorship/Advice on network framework

development

- Resources when requested

- Assistance accessing Pharmacy Locator

App/Collaboration Site

-Mentorship/Advice on network framework

development

- Administrative support as needed

Resources when requested

-Assistance accessing Pharmacy Locator

App/Collaboration Site

-Mentorship/Advice on network framework

development

-Administrative Support (webinar scheduling, create meeting agendas, recording

minutes, organize list of participants)

- Assistance developing network tools, resources,

materials, branding

-Available to attend Work Group Meetings/Live Meetings

Light Medium Heavy

Overview of CPESN℠ Training Modules

• CPESN Training Module Components– Introduction & Learning Objectives– Primary Video (10 minutes)– Practical Application (10 minutes)– Resource Link– CE Assessment

• Priority Topics– Community Pharmacy Care Management Roles– Community Pharmacy Care Management Workflow– Motivational Interviewing: Initial Patient Engagement– Motivation Interviewing: Developing a Patient-Centered Care Plan– Building Provider Relationships and Communication Patterns

CPESN℠ Website Preview

Pharmacy Locator Application

Summary of Network Launch Learnings

Technology Platform-Documentation Tool

A technology platform is not required to organize around a CPESN. While technology is an enabler of services and quality assurance and improvement, it is peripheral to the goals of establishing a CPESN.

Identifying “The Luminary”

One of the first steps for CPESN development is organizing around self-determined high performing pharmacies. In order to do this, you need one or more luminaries to bring other high performing pharmacies to participate. A luminary must be able to tell the story, communicate to other pharmacists why participation is important to be successful in the value-driven model.

Identifying payment for services before CPESN development

Do not wait for a value purchaser to approach you before starting the process of organizing a community pharmacy network. If you do, you will likely, experience a missed opportunity to work with a payer.

What’s Driving This?

• It’s all about pivoting toward payers & alternative primary care providers

• Desire to not be dependent on PBM’s

• $1,000,000,000,000 CMS

• Quadruple AIM

Call to Action

Contact Information

Ashley Branham, PharmD, BCACP

Director of Clinical Services, Moose Pharmacy

ashley@moosepharmacy.com

Joe Moose, PharmD

VP, Moose Pharmacy

Lead Community Pharmacy Coordinator,

Community Care of North Carolina

joe@moosepharmacy.com