steve simenson bpharm, faca, fapha -...

©2017 American College of Apothecaries

Collaborative Practice in a Community Based Pharmacy

PracticeSteve Simenson BPharm, FACA, FAPHA

CEO – Managing PartnerGoodrich Pharmacy. Inc


Disclosures

Steve Simenson has no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.”

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The American College of Apothecaries is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

©2017 American College of Apothecaries3

“Collaborative Practice in a Community Based Pharmacy Practice” – has been approved for1.5 contact hours (0.15 CEUs) of continuing education credit. Attendees will be required to complete an online evaluation for each CE session they attend to verify attendance and acquiretheir CE. Attendees must provide their NABP e‐Profile ID and birthdate (MMDD) to receive credit

for any ACPE‐accredited CPE session.

It is the responsibility of the CPE taker to give correct information. If incorrect information is provided, the record will be rejected by the CPE Monitor and the CPE credit will not be awarded. If you complete an online evaluation for each CE session you attend at the conclusion of the conference, your CPE credits will be uploaded to the CPE Monitor System within 60 days of completion. If you do not see CPE activity displayed for a session that you attended and it has been more than 60 days since you submitted the CPE to the provider, please contact your CPE provider.

All sessions carrying the ACPE program number are approved for continuing education credit. The American College of Apothecaries, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. “Collaborative Practice in a Community Based Pharmacy Practice” session is co‐sponsored by the American College of Apothecaries.


Learning Objectives

At the conclusion of this program, the participating pharmacist or technician will be able to:

– Identify the changing Payment model Landscape– Discuss the opportunities for Community Based

Pharmacy Practitioners– State the need to develop the tools, Collaborative

Practice Agreements, EMR/EHR Access and HCP Relationships to provide Quality Patient Care

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Our Story Welcome to Goodrich Pharmacy

Thank you for choosing us!


Goodrich PharmacyAnoka, Andover, Blaine, Elk River and St. Francis Minnesota

• Community Pharmacy partnering with HP Riverwayand MultiCare Clinics

• EST 1884 Patient Care Services Launched 1996

• Number of FTE RPh: 14 • Pharmacy sites: 6• Partnering Clinics: 5• 11 CPA’s• Unique CMM, CMR and MTM

patients served in 12 months: – Onsite (Pharmacies): 900 unique

CMM patients and 700 unique DS-MTM patients.

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Evolution of Patient Care Practices– Therapeutic Substitution …Clinic requested– Blood Pressure monitoring and Management– Lipid Management research Project– Prescription Refill Management with Clinic– Pharmacist and Resident in Clinic– Immunizations…Influenza– Collaborative Practice Agreements– Patient Needs– Fill a Need or Solve a Problem


Patient Care Services Offered• Univ of Minn COP Teaching and Residency Site• Board and Care Facility medication Consulting• Immunizations• Medication Therapy Management• Comprehensive Medication Reviews• Blood Pressure Monitoring and Management• Home Delivery, Adherence Packaging, Med Sync• Compounding Services• Practice Based Research • 11 Collaborative Practice Agreements…In

Pharmacies and in Clinics

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Why Now?

• “Meaningful Collaboration with Pharmacists to Improve Quality and Meet Patient Needs”


Alternative Payment Models(APM)

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• What is driving the transition away from Fee for Service (FFS) towards APM?₋ APM reward high quality and cost effective care

which supports the delivery of high value healthcare

₋ “Volume to Value” with Value = outcomes/cost₋ APM encourage providers to invest in areas with

the greatest return


Transforming care requires a transformed business model

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Strategic Aim: 75% of all care will be reimbursed via Alternative Payment Models (APM)


Patient‐centered system by 2020 will provide care under a different mix of

payment models

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Best path to consistently describe our journey.

Fee‐for‐Service

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Full‐risk / Capitation

Loosely Integrated

Care

Highly Integrated

Care

Traditional Model

Future State


The journey to value based payment requires deep focus and vigilance.

Fee‐for‐Service

Full‐risk / Capitation

Highly Integrated

Care

Future State • With each initiative, ensure thatthe interventions and initiativesare aligned

• Success is defined clinically and financially

• Models are created that allow flexibility yet remain consistent as possible for patients and providers

• Diverting from the center path results in financially unsustainable models, putting our mission at risk

Loosely Integrated

Care

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Health Care is inherently Local

• There are things that can be performed centrally that can ease administrative burden and simplify implementation

• All of us can move down this path faster and moreeffectively together than we can separately

No one is in a better position to to embrace this new potential for care collaboration than Community Based Pharmacy Practice


The Business Case: Value is Created by Better Episode Management through

Care Redesign

Cost

(revenu

e)

Traditional fragmented delivery

Value creation

Portion of savings to payer

New Model of CareTime

Availablemargin forgainsharing

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Collaboration with Pharmacists

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Integrating Pharmacist’s intoPatient Centered Health Care

• Do the right things well.

• Structure. Process. Outcomes.

• Align the Incentives,

• Improve the Outcomes,

• Control the

• Costs

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Build RelationshipsCreate Opportunity

Solve a Problem Fill a NeedDevelop CultureObtain Tools

CollaborateDevelop WorkflowAdd ValueMeasure Outcomes

Idea

PharmacistImproved Team BasedPatient Care

“The Best way to predict the future is to invent it” Alan Kay


Benefits to Clinic Health Care Providers

• Improved Patient Outcomes raise Community Measure Scores

• Timely monitoring and follow up • Availability to HCP’s for Medication Consultation• Ability to tackle difficult Medication problems• Ability to improve Immunization Goals …add to EMR,

triage which specific type referred to which practice• Ability to help other HCP’s be more efficient, increases

capacity to see more patients• With coming MACRA driven pay for performance, fill

Gap’s in expertise• ………

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Pharmacists Meeting Patient Needs

• Improved Patient Satisfaction with all HCP’s• Improved Medication Adherence and Outcomes,

through med synchronization, monitoring and adherence packaging

• Empowers Patients to be Partners in Therapy• Improves communication of progress to HCP’s• Detects and Prevents more Medication ADR’s• Lowers overall Health care costs

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Best PracticesPhysicians and other Health Care Providers don’t want Pharmacists to bring them problems we can’t resolve… Pharmacists need the authority and tools to implement the solutions we recommend.

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Necessary Tools to Succeed:• Use EMR as other HCP’s in Clinic• In Pharmacy use EMR to:

• Check last Clinic Visit and Care Plan• Check Med list in Transitions of Care• Check for/add Immunizations • Check for New or D/C’d Medications• Schedule Patient appointment or refer to HCP’s• Research for patient Pharmacist Visit

• Use Collaborative Practice Agreements• Credentialing and Privileging


Pharmacist’s Role in Team Based Care

• Pharmacist sees patient in Clinic and multiple times in Pharmacy to Monitor Progress.

• Communication channels are open to Clinic Staff and Pharmacy Staff with a single care plan and Goal & Outcome progress.

• Patient visit before or after patient Clinic HCP visit

• Pharmacist triages Patients and schedules patient visit or refers to appropriate HCP

• Goodrich Pharmacists Manage & Monitor Medications and Educate Patients on there use

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• Roles in and Out of Clinic

• Scheduled patient visits • Clinic Staff Consulting• Referals to other Health

Care Providers• Patient Follow up• Ordering necessary Labs• Documenting care in EMR• Managing patients

through Collaborative Practice Agreements


Support From Innovative Health Systems

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• “There is so much potential in the use of medications”

• “I think of the growth in the cost of prescription medications and I think that medications are the #1 resource in treating chronic conditions”

• “I still think the pharmacist has been the least effectively used member of the health care team”

• “There are lots opportunity to connect pharmacists more effectively with patients then there has been in the past”

• With Chris Farrell Economic Journalist MPR News Presents November 3, 2015

“We are doing a lot of work changing the role of the Pharmacist as a member of the health care team”


“Meaningful Collaboration with Pharmacists to

Improve Quality and Meet Patient Needs”


Types of Services• Medication management services

– Chronic diseases– Hospice, palliative care and pain management– Mental health– Specialty clinics– Polypharmacy clinics– Refill clinics

• Wellness and prevention– Medicare Wellness Visits– Tobacco cessation– Immunizations including travel clinics– Weight management

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Patient Care Delivery• Settings:

– Community pharmacies– Physician’s office– Outpatient clinics– Patient’s bedside– Worksite health– Pharmacist consultant practice

• Delivery mode--Face-to-face• Appointment-based• “On the fly”

– Telehealth

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Example Programs Where Pharmacists Are Impacting Quality Measures

• CMS Programs– Quality Payment Program (QPP): MIPS/APMs– ACOs: Medicare Shared Savings Program (MSSP),

Next Generation ACO– Comprehensive Primary Care Plus– Part C and Part D Star Ratings Programs

• Private sector value-based ACOs and Medical Home programs

• Accreditation, certificate and recognition programs (e.g. NCQA for PCMH)

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Example High Priority MIPS Measures• Effective clinic care

– Diabetes: Hemoglobin A1C Poor Control > 9%– Controlling high blood pressure– Medication management for people with asthma

• Patient safety– Documentation of current medications in the medical record– Adherence to antipsychotics medications in schizophrenia– Use of high-risk medications in the elderly

• Communication and care coordination– Medication reconciliation post discharge (>65yrs)

• Community/population health– Pneumococcal vaccination status for older adults – not high priority– Preventive care and screening: influenza immunization – not high

priority

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Eric Hoffer…Learners and the Learned

“ In a time of drastic change it is the learners who inherit the future. The learned usually find themselves equipped to live in a world that no longer exists”

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Why aren’t we practicing

like we learn?

Scope of PracticeScope of Practice Payment for Services

Payment for Services

Health Information Technology


Workflow/Time Restraints


Public Perception/Support

Public Perception/Support The Big One...The Big One...


Patient‐Specific CPA

Population‐Specific CPA

Statewide Protocol

Unrestricted (Category‐Specific)

Continuum of Pharmacist Prescriptive Authority

Adams AJ, Weaver KK. The Continuum of Pharmacist Prescriptive Authority. Annals of Pharmacotherapy. June 2016.


Collaborative Practice Agreements

Establishes a formal

relationship

Delegated patient care

functionsNegotiated conditions


Statewide authorityStatewide authority

Allows pharmacists to

prescribe

Allows pharmacists to

prescribe

Address public health goals

Address public health goals

Do not require differential diagnosing

Do not require differential diagnosing


Prevalence

States with CPA Provisions

HI

AK

MO

WV

MS

NC

FL

KY

WA

SC

OH

CA

TN

MAN

Y

IL

VT

MI

ME

MNOR ID

MT ND

SD

NV U

T

AZ

NM

TX

WY

CO

NE

OK

KS*

IA

WI

IN

PA

VA

AR

AL

GA

LA

Based on data collected by NASPA (updated Dec 2015)

NH

RICTNJDEMDDC

Have CPA authority to somedegree

*Kansas is awaiting rule promulgation. Their law is vague regarding services and calls for rules to be issued

Prescribing Under a Statewide Protocol* or Unrestricted (Category‐Specific) Authority

HI

AK

MO

WV

MS

NC

FL

KY

WA

SC

OH

CA

TN

MAN

Y

IL

VT

MI

ME

MNOR ID

MT ND

SD

NV U

T

AZ

NM

TX

WY

CO

NE

OK

KS

IA

WI

IN

PA

VA

AR

AL

GA

LA

Based on data collected by NASPA (updated August 2016)

NH

RICTNJDEMDDC

One statewide protocol for pharmacists

Two statewide protocols for pharmacists

Three or more statewide protocols for pharmacists

*Includes statewide standing orders


Collaborative Practice Authority• State law authorizes pharmacist to enter into an agreement or protocol

with a provider• Collaborative practice agreement (CPA): A voluntary formal agreement in

which a licensed provider makes a diagnosis, supervises patient care, and refers a patient to a pharmacist under a protocol or agreement that delegates specific patient care functions to the pharmacist beyond the pharmacist’s regular scope of practice:– Functions can include initiating, modifying, and discontinuing patients’

medication therapy and ordering laboratory tests• Terminology* for the agreement varies in state law • Variability between states regarding types of functions, practice settings,

patient populations, and requirements for the agreement

*Collaborative drug therapy management agreement, collaborative pharmacy practice agreement, consuagreement, physician-pharmacist agreement, standing order or protocol, simply physician delegation

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Collaboartive Practice Agreements

• Date, Professional Supporters• Patient Population• Treatment Algorithm• Medication Ordering• Lab Monitoring• Patients Excluded• Triage and Referral Mechanism


CPA Examples

• Broad – Less detailed….Diabetes one page plus signatures…. Diabetes

• More focused…more detailed…8 pages plus signature page…Hypertension

Current Applications

Naloxone (11)

General Authority (3)

TB Testing (2) Fluoride (1)

Immunizations (17)

Smoking Cessation (4)

Epinephrine (1)

Contraceptives (3)

Limited Formulary (1)

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like we learn?









Washington State

California

Not to mention…


Part D Enhanced Medication Therapy Management Model

• Testing if payment incentives and regulatory flexibility for Part D MTM can improve patient outcomes and lower Medicare costs


like we learn?









Health Information Technology –

So What?


like we learn?









Patient Care Activities

Technician Activities

Potential Advanced Roles for Technicians

PDMP Check

Verbal orders/ transfers

Clinical Support

Tech‐check‐tech


• Tech-Check-Tech (TCT) is a strategy to delegate the task of final product verification to specially trained technicians

• Typically limited to: – Refill prescriptions– Automated filling

machines– Unit-dose repackaging– Unit-dose carts


TCT technicians typically/always do NOT perform:

• Clinical/DUR checks• Verification of

compounded or controlled medications

• Verification of their own work


Demonstrated safety

Results of Same‐Sample Tech‐Check‐Tech Studies

Facility Practice Situation Sample Size

Accuracy Rateb Error Detection Ratec pa

Tech RPh Tech RPh

Tertiary care institution

Checking unit dose envelopes

15,252 99.9 99.8 97.0 94.3 <0.05

Specialty pharmacy

Checking pre‐filled syringes

10,608 99.83 99.86 …d … NS

Children’s hospital

Checking unit dose cart fills

8,645 98.95e … 100 100 …

a NS=not significant b Percentage of orders checks that were free from error c Percentage of errors in sample that were detected by the checker dNot reported e Calculated by authors

A meta‐analysis of all published

studies consistently show technicians to be

at least as accurate as pharmacists.

Where TCT is allowed now


like we learn?










But that is changing!

• Increased utilization of pharmacists has been supported by:– The National Governor’s Association – The US Public Health Service– The American Public Health Association – Independent research organizations– CMS & CDC– CDC– AAFP, ACP,ACOG and other Physician organizations– MMA (July 2017!)


• Fear to leave the counter• Fear of physicians• Fear they are

incapable/incompetent• Fear of making a mistake• Fear of the unknown


Impact of Pharmacists Beyond the Four Walls of the Community Pharmacy

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Multiple Locations


Taking the First Step

• Our Organizations must establish recognition of the unique value of pharmacists in the eyes of other health care providers.

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Exploring Financial Models

Contract for Pharmacist Time…Clinic contracts for Pharmacist Services

delivered in Clinic and in Pharmacy

Shared Staff… Split time …Employee of Both Clinic & Pharmacy…Pay for hours worked at each site by location

Bill for Pharmacist Services…MTM, CMM or CMR’s

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Pharmacists Improving Quality

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” Pharmacists are establishing recognition of the unique value they provide in the eyes of Patients and other

health care providers.

Surveys reveal that our patients are satisfied with our programs. With annual scores consistently averaging above 85% .Annual Physician/HCP satisfaction is also high, above 80%. In our contracted clinics, satisfaction has trended upward the longer our pharmacists are in the clinic.Physicians and clinics are asking for more hours of in clinic Pharmacist time every year.It shows our Physician colleagues value us.


Pharmacists Improving Quality (cont’d)

(14 Medical Directors)


What Can You Do?

Advocate

Teach

Support

Learn


Provider Status &Why It

Matters


The Patient Access to Pharmacists’ Care Coalition (PAPCC)

• Publically announced early March 2014• Currently more than 29 organizations and growing• Representing patients, pharmacists, and pharmacies, as

well as other interested stakeholders


PAPCC – H.R. 592 and S. 109

Scope of Proposal• Pharmacists – State-licensed pharmacists with a B.S. Pharm. or Pharm. D.

degree who may have additional training and certificates depending on state laws

• Services – Services authorized under state pharmacy scope of practice laws• Patients – Services provided in/ for Medically Underserved Areas (MUA),

Medically Underserved Populations (MUP), or Health Professional Shortage Areas (HPSA)

• Reimbursement – Consistent with Medicare reimbursement for other non-physician practitioners, pharmacist services would typically be reimbursed at 85% of the physician fee schedule

Are only a limited number of pharmacists eligible under

the federal bill?


“You never fail until you quit

trying”


• A special Thanks to KRYSTALYN WEAVER, PHARMD

• VICE PRESIDENT, POLICY & OPERATIONS

• NATIONAL ALLIANCE OF STATE PHARMACY


Need More Information?Steve Simenson

CEO – Managing PartnerGoodrich Pharmacy, Inc

[email protected]…….Place holder

Check out www.NASPA.us for more information!

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steve simenson bpharm, faca, fapha -...

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