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Future of Pharmacy in the Healthcare Setting

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Paul W. Bush, PharmD, MBA, BCPS, FASHP

Chief Pharmacy OfficerDuke University Hospital

Clinical ProfessorUniversity of North Carolina Eshelman School of Pharmacy

Professor of Pharmacy PracticeCampbell University College of Pharmacy and Health

Sciences

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Learning Objectives

1. Describe the characteristics of an optimal pharmacy service

2. Differentiate medication therapy management models

3. Understand the evolution of pharmacy practice models

4. Identify the pharmacy team’s role and deployment in population health management

5. Review future medication management demands and workforce trends to ensure a successful pharmacy service line.

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DisclosureDisclosure

I do not have (nor does any immediate family member have):

– a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity

– any affiliation with an organization whose philosophy could potentially bias my presentation

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Duke University Health System is a world-class hospital and health care network supported by outstanding and renowned clinical faculty, nurses and care teams. Duke's services span the full continuum of care, from primary care to medical and surgical specialties and subspecialties, all dedicated to putting our patients at the forefront of everything we do.

Duke University Hospital Duke Regional Hospital Duke Raleigh Hospital

#FSHP2019Duke University Hospital• Academic medical center of the Duke University

Health System which includes 3 acute care hospitals as well as services such as primary care, home care and hospice, diagnostic services, & health & wellness

• Provides an environment to facilitate research and education activities as services to our patients, their loved ones and each other

• Over 8,000 employees inclusive of 950+ residents, 40 hospitalists, and over 2000 volunteers

• In partnership with over 1,400 physicians that are employed by the faculty practice group, PDC

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#FSHP2019Duke University Hospital

• Care across the life continuum including highly specialized, complex care, such as:

• Stem cell/bone marrow transplant• Pediatric cardiac intensive care• Comprehensive Cancer Center• Level 1 Trauma Center• Solid Organ Transplant• TJC Disease specific accreditation for VAD and stroke

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DEPARTMENT OF PHARMACY

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Annual Report

pharmacy.duke.edu

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Duke Pharmacy Mission and Vision

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CHARACTERISTICS OF AN OPTIMAL PHARMACY SERVICE

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Patient-Centered Staff Deployment

• Inpatient• Team-based• Service-based• Unit-based

• Clinic• Interdisciplinary team-based• Pharmacist-based clinics• Refill management

• Population health

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Clinical Services

• Admission and discharge care transitions• Medication history and reconciliation• Discharge coordination and education

• Anticoagulation • Therapeutic drug monitoring• Comprehensive medication management• Rapid response and resuscitation• Antimicrobial Stewardship• Clinical pharmacogenomics service

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Pharmacies

• Ambulatory prescription dispensing pharmacies• Specialty pharmacy• Ambulatory surgery pharmacies• Clinic support pharmacy• Infusion center pharmacies• Investigational drug/research pharmacy

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Programs and services • Center for Medication

Policy and Safety• Controlled Substance

Diversion Prevention• Nutritional support• Transplant pharmacy

services• Antimicrobial

Stewardship• Compounding Service• Repackaging Service

• Prior authorization service

• Medication assistance program

• Meds to Beds• Pharmaceutical

utilization management program

• Revenue management• Information systems –

Willow and Beacon teams

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Committees• Pharmacy Credential &

Privileging Committee• Pharmacy Research

Committee• Pharmacy Education

Committee• Pharmacy Technician

Professional Development

• Work Culture Committee• Employee Activities

Committee• Quality Oversight

Committee• Shortage Management

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Health System Committees• Pharmacy Governance• Pharmacy and

Medication Management

• Formulary and Informatics

• Medication Safety• Sterile Preparations

Oversight Committee

• Pharmaceutical Contracting and Supply Chain Value Analysis Committee

• Smart Pump Quality and Utilization Oversight Committee

• Residency Program Directors

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Training and Education Programs

• ACPE-approved continuing education• Residency training program• Technician training program• Student clerkship experiential training

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Layered Learning Extends Services • Pharmacists precept pharmacy

residents, who teach and precept pharmacy students

• Pharmacy residents and students deliver direct patient care

• Increases the staff resources available to provide services such as medication histories and reconciliation, facilitating bedside delivery of discharge medications, and patient education on new and high risk medications

• Results in higher quality of patient care for a greater number of patients and increased patient satisfaction

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Research

• Program designed to enhance Pharmacy staff and resident knowledge and participation in research

• Identify and arrange extra-departmental research support resources for Pharmacy staff and residents

• Statistical consulting services• Site-Based Research/Institutional Review Board• Other support, as needed

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MEDICATION MANAGEMENT

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Medication Management Services• A spectrum of patient-centered, pharmacist provided,

collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes

• Includes the following elements:• Patient‐centered approach to care – the service

is individualized for a specific patient, focuses on the patient's needs and concerns, and involves the patient in the care process

• Assessment of medication appropriateness, effectiveness, safety and adherence. Consideration should be given to accessibility and cost of medication

• Collaborative approach to care that involves the patient, caregiver(s), pharmacists, and other healthcare providers

• Focus on health outcomes• Pharmacists deliver Medication Management Services using the

Pharmacist's Patient Care Processhttps://jcpp.net/wp-content/uploads/2018/05/Medication-Management-Services-Definition-and-Key-Points-Version-1.pdf

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Pharmacist’s Patient Care Process

Joint Commission of Pharmacy Practitioners – May 2014

#FSHP2019Comprehensive Medication Management• Defined as the standard of care that ensures each patient’s

medications (i.e., prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended

• CMM includes an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes

• This all occurs because the patient understands, agrees with, and actively participates in the treatment regimen, thus optimizing each patient’s medication experience and clinical outcomes

https://www.accp.com/docs/positions/misc/CMM%20Brief.pdf

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#FSHP2019Comprehensive Medication Management

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PRACTICE MODELS

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• Manner in which pharmacy department’s staff is distributed to fulfill:

- the departmental mission of ensuring that patients achieve optimal outcomes from the use of medicines

- the departmental responsibility for leading improvements in the medication-use process

• How pharmacists, pharmacy technicians, and other pharmacy staff:

- spend their time- interface with patients, health professionals outside of

pharmacy, hospital executives, information systems, devices, and vendors

Pharmacy Practice Models#FSHP2019

Models• Drug distribution centered model

• Mostly distributive pharmacy with limited clinical services• Clinical specialist centered model

• Separate distributive and clinical specialist roles• Patient centered integrated model

• Clinical generalist model with limited differentiation of roles—nearly all pharmacists have distributive and clinical responsibilities

• Comprehensive model• Similar to the Patient Centered Integrated Model but recognizes

the clinical pharmacist specialist as an indispensable member of the pharmacy team

AJHP 2009: 66;926-46 AJHP 2011: 68;1396-1397

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PRACTICE CHANGE

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• Health care reform• More patients, increased demand• Value based care models that tie payment to

performance• Movement away from transactional payments• Pressure to reduce costs, reward performance

• Health care systems are challenged to improve quality and cost of care

• Health care executives require pharmacy department operations to be more efficient and contribute to improved care

Factors Driving Practice Change

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• Financial pressures are forcing health systems to pursue significant changes in how pharmacy resources are used

• Health care executives expect that pharmacists will: • ensure that medications will be used in the most cost-

effective manner• help ensure compliance with quality-of-care standards• participate in care management

• Pharmacy departments need to organize their workforce and services so that pharmacists can increase their contribution to the overall health of their health system

Factors Driving Practice Change#FSHP2019

Factors Driving Practice Change

• Professional leadership• Professional education/development• Practice standards• Changes in pharmacy education/residency

training• Advances in drug therapeutics• Growth in medication-related technologies• Practice initiatives• Changes in payment for health care• Accreditation standards

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Current State of Pharmacy Practice

• Pharmacists are widely involved in direct patient care• Pharmacist involvement in ambulatory care clinics growing• Automation/technology in medication use is

commonplace• Pharmacy technician development is underway, and

deployment is continuing• Residency training/certification continue to grow• Specialty pharmacy is growing, especially at larger

hospitals• Bigger focus on sterile compounding and hazardous drugs• Transitions of care receiving a great deal of focus

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Practice Transformation

• Considerations for 2019• Expanding role of pharmacists• Expanding role of technicians• Realizing the benefits of technology• Specialty pharmacy• Collaborative practice/Provider status • Health care reform – expansion of value-based care

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Expectations for Inpatient Care• Assure a complete and

accurate medication history• Reconcile medication in the

emergency department; upon admission, transfer, and discharge

• Develop the medication-related patient care plan and discuss it with the patient

• Participate in patient care rounds

• Review medication orders before the first dose is administered

• Review patient‐specific medication profiles

• Monitor the patient’s response to medication therapy

• Adjust medication doses based on patient response or pharmacokinetic characteristics of the medication

• Monitor critically important medication serum concentrations and other clinically important laboratory analyses

• Establish processes to ensure medication‐related continuity of care for discharged patients

• Provide discharge education to patients

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Expectations for Ambulatory Care

• Drug therapy management (DTM) is available from a pharmacist for health system outpatients

• Pharmacist resources are deployed based on medication complexity

• Collaborative practice is utilized to define responsibility and authority

• Resources are focused on facilitating continuity of care

• Health system/regional pharmacist networks assure patients are referred for follow-up in their local area

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POPULATION HEALTH MANAGEMENT

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Population Health Management

• Explicit efforts of health systems to improve the health status of the population of patients they serve (not simply to provide sickness care)

• Concomitant goal is to reduce the cost of caring for the population they serve

• Pharmacists, and their ability to impact cost and outcomes through effectively managing the medication continuum across levels and sites of care, are critical to the success of the healthcare system

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Population Health Strategies

•Effective medication management•Preventative care• Improve post-acute care• Integrate behavioral health and primary care

•Engagement in community health• Mobile technologies can be key tools for patient

engagement and shared decision-making

#FSHP2019Population Health Program Design

#FSHP2019Population Health Management Pharmacy Services

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#FSHP2019Quality Measures – Population Health Approach

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Measure Description

ACO-12 Medication Reconciliation Post-Discharge

ACO-14 Preventative Care and Screening: Influenza Immunization

ACO-15 Pneumonia vaccination status for older adults

ACO-42 Statin Therapy for the Prevention and Treatment of CVD

ACO-30 IVD: Use of Aspirin or Another Antithrombotic

ACO-34Stewardship of Patient Resources• Data collected through CAHPS survey• Whether care team discussed medication Rx costs

ACO-27 DM: A1c Poor Control

ACO-28 Hypertension (HTN): Controlling High Blood Pressure

ACO-8 Risk-Standardized, All Condition Readmission

ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure

ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes

ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure

ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

Sample Medication-related MSSPQuality Measures

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MEDICATION MANAGEMENT DEMANDS AND WORKFORCE TRENDS

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Promoting a Resilient Work Environment and a Healthy

Work - Life Balance

#FSHP2019 #FSHP2019Caring for PatientAvoiding Harm Respecting Patient AutonomyStriving for Justice

Growing Demands

Burdensome Tasks

Increased Stress

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Burnout

Begins with a high and persistent levels of stressthat can eventually lead you to feel irritable,cynical, and disengaged

Three hallmarks of burnout are:• Emotional exhaustion• Depersonalization• Lowered sense of self-worth which leads to

decreased productivity and effectiveness

Ultimately, burnout can produce hopelessness, feelings of failure, and resentment

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Burnout is Not…

• Having a bad day at work• Feeling overwhelmed for a day or two• Experiencing a bad mood• Wanting time-off from work

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Why?

• Time pressure, • Lack of control over work processes, • Role conflict,• Poor relationships between groups and with leadership,

• Combined with personal predisposing factors, and the emotional intensity of clinical work put staff at high risk

#FSHP2019Drivers of Burnout in Healthcare Professionals

Risk Factors Associated With BurnoutAm J Health-Syst Pharm. 2017; 74:e576-81

Risk Factor Example

Workload Job demands exceeding human limits; limited time to rest, recover, and restore.

Control Role conflict; absence of direction in the workplace

Reward Inadequate financial, institutional, or social reward in theworkplace; lack of recognition

Community Inadequate opportunity for quality social interaction at work; inadequate development of teams

Fairness Perception of equity from an organization or leadership

Values Organizational values are incongruous with an individual’spersonal values or beliefs

Job-person incongruity Personality does not fit or is misaligned with job expectations and coping abilities

#FSHP2019Burnout is a Patient Care Problem

Bodenheimer T, Sinsky C. From triple aim to quadruple aim: care of the patient requires careof the provider. Ann Fam Med. 2014;12(6):573-6.

#FSHP2019Quality and Safety• Medical Error

- ~8000 surgeons

• Medical Malpractice Litigation- ~7000 surgeons

• Health-care associated infections

- Mean burnout hospital nurses independent predictor

• Patient mortality ratios

• Teamwork scores- Mean EE physicians & nurses

ICU

Burnout Medical Error

Bi-directional relationship

Higher levels of burnout associated with increased odds of reporting a medical error in subsequent 3 monthsSelf-perceived medical error associated with worsening burnout & depressive symptoms

Shanafelt Ann Surg 2009; Balch J Am Coll Surg 213; West JAMA 2006, 2009; Jones J Appl Psychol 1988; Cimiotti Am J Infect Control 2012; Welp Front Psychol 2015; Welp Crit Care 2016

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Health Care Costs

↑Medical Errors↑Malpractice claims↑Turnover

• 1.2-1.3 x salary ($82-$88,000 per RN in 2007)• $500,000 to >$1 million

↑Absenteeism↓Job productivity↑Referrals ↑Ordering

Jones J Nurs Am 2008; Fibuch Physician Leadersh J 2015; Buchbinder Am J Manag Care 1999; Kushnir, Fam Pract 2014; Bachman Soc Sci Med 1999; Parker J Behav Med 1995, Toppinen-Tanner Behav Med 2005, Hilton J Occup Environ Med 2009

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Evidence of Burnout

#FSHP2019Maslach Burnout Inventory -Human Services Survey Tool• Medical Personnel

• Emotional exhaustion• Measures feelings of being emotionally overextended and

exhausted by one’s work• I feel emotionally drained from my work

• Depersonalization• Measures an unfeeling and impersonal response toward

patients• I don’t really care what happens to some patients

• Personal Accomplishment• Measures feelings of competence and successful

achievement in one’s work• I have accomplished many worthwhile things in this job

• Response options (frequency): never, a few times a year or less, once a month or less, a few times a month, once a week, a few times a week, every day

#FSHP2019Burnout: Clinical Pharmacists

#FSHP2019Burnout: Clinical Pharmacists• Durham and colleagues measured burnout in health

system clinical pharmacists (n=329)• 53.2% reported scores indicating a high degree of burnout

on at least 1 subscale of the MBI-HSS• 8.5% had scores indicating burnout on all 3 subscales.

• Emotional exhaustion 22.9%• Depersonalization 6.2%• Reduced personal accomplishment 36.3%

• Conclusion: more than half of health-system pharmacists assessed themselves as being at risk for burnout.

Durham ME, Bush PW, Ball AM. Evidence of burnout in health-system pharmacists AJHP.2018:; 75 (Suppl 4) e801-8

#FSHP2019Burnout: Pharmacy Technicians

• DeAngelis and colleagues measured burnout in pharmacy technicians (n= 879)

• Certified pharmacy technicians (PTCB)• 67.7% reported a high degree of burnout on at least one of

three subscales of the MBI-HSS• Emotional exhaustion 53.5% • Depersonalization burnout 38.8%• Reduced personal accomplishment 30.1%

• Conclusion: Higher prevalence of burnout than other health care workers such as physicians and health-system pharmacists

DeAngelis JT, Kelm M, Bush PW. To be published

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#FSHP2019Burnout: COP Faculty• El-Ibiary and colleagues measured faculty burnout in

US College of Pharmacy (n=758)• 41.3% exhibited high emotional exhaustion scores• Women had significantly higher emotion exhaustion and

lower personal accomplishment scores than men• Faculty who had a hobby had significantly lower

emotional exhaustion scores, lower depersonalization score, and higher personal accomplishment scores

• Faculty working in newer Colleges of Pharmacy (est. < 5 years) were associated with lower deperson-alization and lower personal accomplishment scores.

Am J Pharm Educ. 2017;81(4):75

#FSHP2019Clinician Well-being and Resilience• Well-being

• The presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning.

• Physical well-being (e.g., feeling very healthy and full of energy) is also viewed as critical to overall well-being.

• Resilience• The set of individual skills, behaviors, and attitudes that

contribute to personal physical, emotional, and social well-being, including the prevention of burnout.

• These can include self-care strategies, safety nets for crises, organizational support, peer support, financial management, life-needs support, and other forms of health promotion.

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Organizational Strategies

#FSHP2019Strategies to PromoteEngagement and Reduce Burnout

Mayo Clin Proc. 2017;92(1):129-146

#FSHP2019Policy on ClinicianWell-being and Resilience

• To affirm that burnout adversely affects an individual's well-being and healthcare outcomes; further,

• To acknowledge that the healthcare workforce encounters unique stressors throughout their education and careers that contribute to burnout; further,

• To declare that healthcare workforce well-being and resilience requires shared responsibility among healthcare team members and between individuals and organizations; further,

• To encourage individuals to embrace resilience and well-being as a personal responsibility that should be supported by organizational culture; further,

• To encourage the development of programs aimed at prevention, recognition, and treatment of burnout, and to support participation in these programs; further,

• To encourage education and research on stress, burnout, and well-being; further,

• To collaborate with other professions to identify effective preventive and treatment strategies at an individual, organizational, and system level.

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Supporting Pharmacy Technicians#FSHP2019

Why Expand Technician Roles?

• Improved patient care• Enhanced nursing/pharmacy communication• Improved business processes• Operational efficiency• Increased technician job satisfaction

#FSHP2019Activities of PharmacyTechnicians

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Facilitating Transitions of CareMedication Assistance Program

Tech-check-techMedication histories

Tech supervisionIT system management

Controlled Substance mgmtQA activities / unit inspections

Chemo CSP (if applicable)Billing

Non-chemo CSPPackagingPurchasing

Cart fill (if utilized)Restock ADC or floor stock

% HospitalsSource: 2018 ASHP National Survey of Hospitals

#FSHP2019Emerging Technician Roles and Responsibilities

• Prescription clarification

• Quality assurance and quality improvement initiatives

• ACA Marketplace Certified Application Counselors

• CMS‐CMMI Grant Projects (Innovations Center)

• Community outreach programs

• DUE/ADR monitoring

• Informatics

• Medication safety initiatives

• Telepharmacy

• Medication reconciliation• Medication therapy 

management• Immunization• Indigent care prescription 

programs• Sterile & non‐sterile 

compounding• Clinical technicians (e.g., 

chronic care, appt. scheduling, medication adherence, smoking cessation, vital signs measurements, data management, etc.)

• Prior authorization• Tech‐check‐tech

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Ultimate Goal• A well-qualified and trained workforce

• Improved patient safety

• Standard knowledge base in technician workforce

• Trained technician workforce that can assume more pharmacy-based technical and business tasks

• Less turnover in pharmacy technician positions

#FSHP2019Pharmacy Technician Shortage• Technician workforce demand commonly exceeds supply• Shortage must be addressed so we can achieve our

aspirations to improve care of patients• Possible solutions

• Improve work environment -> decrease turnover• Enhance compensation • Increase education/training capacity

• Health system - technical school/community college partnerships

• Health system (employer-based) program

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pharmacy.duke.edu/duhs-pharmacy-technology-training-program

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Questions?

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