collaborative practice successes in primary care- final

COLLABORATIVE PRACTICE SUCCESSES

IN PRIMARY CARE

KPhA Annual MeetingSeptember 7, 2014

Tiffany R. Shin, PharmD, BCACPLyndsey N. Hogg, PharmD, BCACP

Objectives

Describe basic concepts of collaborative practice

Review recent changes in the Kansas Pharmacy Act relating to collaborative practice

Discuss how collaborative practice impacts patient care

Provide examples of collaborative practice successes in primary care clinics

Introduction to Collaborative Practice

Audience Poll

What is your experience with collaborative practice agreements?

A. I have a collaborative practice agreement (CPA)B. I have heard of other pharmacists with CPAsC. I am interested in implementing a CPAD. None, I want to learn about CPAs

Traditional Healthcare:Insufficient Collaboration

Limited communication between healthcare professionals, health-systems, and payers Fragmented care Lack of coordination – acting in “silos”

Consequences may include: Increased time to care Duplication of care Increased costs Decreased safety

Crabtree BF, et al. Ann Fam Med. 2010;8:S80-S90. Crossing the Quality Chasm, 2001 IOM.

Cooperation among clinicians is a priority

Core Competencies for Interprofessional Practice

Domain 1 - Values/Ethics for Interprofessional Practice Domain 2 - Roles/Responsibilities Domain 3 - Interprofessional Communication Domain 4 - Teams and Teamwork

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

Collaborative Practice

Key terms/phrases:Mutual respectUnderstanding other’s roles and abilitiesPlanned approach to patient careFrequent communicationTeamwork

Collaborative Drug Therapy Management (CDTM)

A collaborative practice agreement between one or more providers and pharmacists in which qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility

Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.

Potential CDTM Delegated Functions

Perform patient assessments Conduct counseling Place referrals Order laboratory tests Administer drugs and immunizations Select, initiate, monitor, continue, and adjust

drug regimens


Collaborative Practice Agreements (CPAs)

A formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions


CPA Complexities and Levels of Responsibility

Broad to specific scope Medication or disease state limitations

Levels of management Provision of education or recommendations to

collaborative modification of therapy Specific requirements

Training, experience, certification, competencies

Milestone in Kansas Pharmacy Law

Audience Poll

As of 2012, how many states did not have laws explicitly authorizing pharmacist collaborative practice?A. None B. 4 statesC. 8 statesD. 16 states

Laws on Collaborative Practice, 2012


Senate Sub. for HB 2146

Amended Kansas Pharmacy Act Effective July 1, 2014

Added definitions Collaborative drug therapy management (CDTM) Collaborative practice agreement (CPA) Practice of pharmacy (definition expanded)

Created ‘Collaborative Drug Therapy Management Advisory Committee’

Collaborative Drug Therapy Management

“A practice of pharmacy where a pharmacist performs certain pharmaceutical-related patient care functions for a specific patient which have been delegated to the pharmacist by a physician through a collaborative practice agreement.”

-Senate Sub. for HB 2146

Collaborative Practice Agreements

“A written agreement or protocol between one or more pharmacists and one or more physicians that provides for collaborative drug therapy management. Such collaborative practice agreement shall contain certain specified conditions or limitations pursuant to the collaborating physician’s order, standing order, delegation or protocol. A collaborative practice agreement shall be: (A) Consistent with the normal and customary

specialty, competence and lawful practice of the physician; and

(B) appropriate to the pharmacist’s training and experience.”


Practice of Pharmacy

“performance of collaborative drug therapy management pursuant to a written collaborative practice agreement with one or more physicians who have an established physician-patient relationship”


CDTM Advisory Committee

For the purpose of promoting consistent regulation and enhancing coordination between Board of Pharmacy & Board of Healing Arts

Chair (non-voting) Jim Garrelts, PharmD, FASHP Kansas Board of Pharmacy

3 Licensed Pharmacists

Rick Couldry, MS, RPh, FASHPLyndsey Hogg, PharmD, BCACPTiffany Shin, PharmD, BCACP

KU Medical CenterVia Christi HealthKU School of Pharmacy

3 Licensed Physicians

Determined by Kansas Board of Healing Arts

Collaborative PracticeAcross the Country

Mountain Area Health Education CenterAsheville, NC

Family medicine resident training program Level III Patient-Centered Medical Home (PCMH)

Interdisciplinary collaboration Physicians & residents Pharmacists (3 + 2) Nurses Nutritionists

Pharmacotherapy, anticoagulation & osteoporosisScott MA, et al. J Am Pharm Assoc. 2011; 51: 161-166.

Care managers Behavioral medicine

specialists Spanish translators

Pharmacist CP Impact on Patient Care

Clinical outcomes Increased number of patients achieve treatment goals Improved adherence to medication regimens Fewer adverse drug events and medication errors

Humanistic outcomes Improved patient satisfaction, quality of life,

improvements in patient knowledge Economic outcomes

Decreased medication costs, medical costs, and visits to emergency room or hospital

Draugalis, et al. AACP Argus Commission Report. 2009-2010.Haines SL, et al. Am J Pharm Ed. 2010; 74(10): Article S5.

The Minnesota Experience

Intervention Medication management provided by pharmacist

in collaboration with primary care providers

Patient selection BCBS health plan beneficiaries At least 1 of 12 medical conditions Intervention (n=285): patients seen/managed by

pharmacists Control (n=126): patients selected from clinics

without pharmacist collaborative services

Isletts BJ, et al. J Am Pharm Assoc. 2008; 48:203-211.

Minnesota Experience: Clinical Outcomes

637 drug therapy problems resolved(285 intervention patients)

Improvements in percentage patients meeting HEDIS goals


Intervention(n=128)

Control (n=126) P value National

Avg (2001)

Hypertension 71% 59% 0.03 51%

Cholesterol (LDL) 52% 30% 0.001 53%

Minnesota Experience: Economic Outcomes

Intervention group, n = 186 31.5% reduction in total annual health

expenditure (p < 0.001)

Return on Investment (ROI) = 12:1


Before Intervention$ per person-year,

mean + SD

After Intervention$ per person-year,

mean + SD

11,965.27 + 48,969.64 8,197.33 + 10,551.02

Collaborative Practice Successes at Via Christi Clinic (VCC)Lyndsey N. Hogg, PharmD, BCACP

Beginning of Ambulatory Care at VCC

October 2012 CPA signed by physicians & administrators 1 pharmacist began in clinics (3 half days/week)

3 clinics, 7 teams, 25 providers Began PCMH transformation process Aug 2012

Referral-based pharmacy services Providers, nursing staff, care coordinators Variety of disease states

VCC Collaborative Practice Agreement

Broad scope

Collaboratively modify therapy

Currently no pharmacist training/experience requirements included*


4) Order appropriate laboratory tests to aid in monitoring medication therapy

5) Evaluate patients’ medication regimens based on efficacy, safety, tolerability, drug interactions, cost, patient preference and professionally recognized clinical guidelines

6) Initiate, discontinue, or adjust dosesof medications as clinically indicated based on professionally recognized clinical guidelines and patient-specific factors


8) Provide patient education regarding disease states, self monitoring, and medication therapy

11) Maintain close communication with patient’s primary care physician, acting at all times as an additional expert member of the patient’s medical home team and an agent of the physician

10) Document patient encountersin the electronic medical record

Pharmacotherapy Clinic Workflow

•From provider, care coordinator or nursing staff•Pharmacotherapy appointment scheduled by clinic staff

•Chart review (labs, provider encounters, etc.)•Comprehensive medication review•Prepare anticipated educational materials as necessary

•Medication reconciliation•Vitals & limited physical assessment•Patient interview•Assessment of barriers to care•Education (chronic diseases, medications, lifestyle)•Therapy modification as indicated

•Note to provider through EHR•Face-to-face consult with provider if indicated•Complete referrals (as needed)•Pharmacotherapy follow up appointments as needed

Referral

Prior to appointment

Appointment

After Appointment

Overview of Patients

Nov 2012 – June 2014 (PCMH only)

Diabetes management Total patients = 56 Average A1C

Initial 3 mo. 6 mo. 9 mo. 12 mo. 15 mo. 18 mo.No. pts 56 40 29 22 15 5 3avg A1C 9.8% 8% 8.1% 7.8% 7.4% 6.9% 7.2%

Number unique patients 274Total patient visits 491Number drug therapy problems 843

Improvements in DM Control

Months since initiating CDTM

Num

ber o

f pat

ient

s

0

2

4

6

8

10

12

14

16

Initial 3 6 9 12

A1C < 8% A1C 8-8.9% A1C > 9%

A1C Changes in Select Patients

6

7

8

9

10

11

12

13

14

15

Initial 3 6 9 12 15

Avg all pts Patient 1 Patient 2 Patient 3

Months since initiating CDTM

Hem

oglo

bin

A1C

Patient Case- RH

59 y/o Caucasian male PMH: T2DM, HTN, hx DVT, depression Uncontrolled T2DM and labile INR

Collaboration between PCP, PharmD, RN, care coordinator

Patient barriers identified Low health literacy Finances Lack of family support

Regular appointments with PharmD scheduled INR obtained same day Written instructions

Patient Case- Outcomes

Improvement in A1C During CPINR Stabilization

Date INR7/29 2.2

10/30 1.31/21 1.21/31 9.82/7 2.7

Date A1C1/31/14 11%4/25/14 9.6%

Date INR3/6 3.8

3/13 2.93/20 3.13/28 2.34/3 2.5

4/10 2.14/23 35/8 2.6

5/30 2.1

Before CPFluctuating INR

CP = collaborative practice

Keys to Success at VCC

Physician champion Leverage established resources and processes

Clinic rooms Scheduling process EHR and communication systems

Integration into clinic culture Utilization of clinic reports

Geriatric polypharmacy Uncontrolled diabetes

Collaborative Practice Successes in a Residency ClinicTiffany R. Shin, PharmD, BCACP

Via Christi Family Medicine Resident Clinic

Joined clinic and residency faculty in September 2013 No prior ambulatory care clinical pharmacist

presence 4 half-days per week 40% of clinical faculty responsibilities

Participation in clinic/residency meetings and committees

Collaborative practice agreement approved May 2014

Pharmacy Referral Services

Any clinic patient may be referred Referred by PCP, other providers, or clinic staff

Scheduled individual visits with patients Phone call encounters Documentation in the EHR routed to PCP Verbal communication with PCP

Focus on patient co-management

Pharmacy Referral Services

Pre-MD Visit MD Visit PharmDVisit

Follow-up

Physician/PCP X X XPharmacist X XStudent Pharmacist

X X

MD Resident or Attending Patient

Pharmacist

Collaborative Care Planning (Pharmacy consults)

Pro-active Referred patients Chart reviews

Re-active Medical Resident

preceptingEvaluate resident’s plan

Questions from providers Answer drug information

questions Potential Outcomes:

Therapeutic recommendation or education Patient evaluation or education by pharmacy Referral for co-management

Collaborative Care Planning

Pre-MDVisit

MD Visit MD Resident Precepting

Follow-up

Physician/PCP X X X XPharmacist X X X If referredStudent Pharmacist

X X X If referred

MD Resident

Patient

Pharmacist

+ MD Resident

Pharmacist

+

MD Attending

+

Collaborative Care Planning Results

Data from 27 clinic half-days*: 218 patients precepted and/or charts reviewed 29 (13%) pediatrics 29 (13%) obstetrics 130 (58%) adult

112 total contributions or recommendations from pharmacist 56 pharmacist-initiated recommendations

*Does not include individual pharmacist visits or phone follow-up encounters

Patient DM – Prior to Collaboration

48yAAM with uncontrolled Type 2 DM Other PMH: HTN, stroke, glaucoma,

adenocarcinoma of colon, hx of falls Barriers to care: Low health literacy Poor memory Poor dexterity Finances Lives alone

Patient DM – Prior to Collaboration

13.2% 8.3% 12.9%

Legend

MD Visit

MD + PharmDVisit

PharmDPhone

PharmDVisit

Insulin dose increase

Jul Aug Sept Oct Nov Dec Jan Feb

Insulin startedpo med

Patient DM - During Collaboration

March 2014 during PCP visit PCP asks clinic pharmacist to provide patient

education on meter use Identify difficulty of checking blood sugar at home

Referral to pharmacist for DM co-management

Patient DM - During Collaboration

6.8%13.4%

March April May June July

Legend

MD Visit

MD + PharmDVisit

PharmDPhone

PharmDVisit

Insulin dose increase

Keys to Success

Strong physician and clinic staff relationships Multiple options for communication High risk patient population Foster long-term patient relationships Academic teaching environment Being both proactive and reactive

Conclusion

Collaborative practice is occurring in Kansas and across the US

Communication and building relationships is key to collaborative care

Successful implementation can improve patient outcomes

More guidance to come from the CDTM Advisory Committee

COLLABORATIVE PRACTICE SUCCESSES

IN PRIMARY CARE

KPhA Annual MeetingSeptember 7, 2014

Tiffany R. Shin, PharmD, BCACPLyndsey N. Hogg, PharmD, BCACP

collaborative practice successes in primary care- final

Documents