Curricular Track II—Case Study of Innovative Practice ...

Annual Meeting

Curricular Track II—Case Study of Innovative Practice Models Activity No. 0217-0000-11-087-L01-P (Knowledge-Based Activity) Tuesday, October 18 10:15 a.m.–11:45 a.m. Convention Center: Spirit of Pittsburgh Ballroom B Moderator: Alissa Segal, Pharm.D. Associate Professor of Pharmacy Practice, Massachusetts College of Pharmacy & Health Sciences and Joslin Diabetes Center, Boston, Massachusetts Agenda 10:15 a.m.

Launching an Innovative Practice: A Case Study

Lisa Dolovich, Pharm.D. Research Director, Family Medicine, McMaster University, Hamilton, Ontario, Canada

10:45 a.m. Launching a Similar Innovative Practice: Considerations and Challenges Melissa Somma McGivney, Pharm.D., FCCP Associate Professor and Director, Community Pharmacy Residency, University of Pittsburgh, Pittsburgh, Pennsylvania

11:15 a.m. Integrating Scholarship into Your Innovative Practice Model Patricia M. Klatt, Pharm.D., BCPS Director, Pharmacist Practice Development, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Faculty Conflict of Interest Disclosures Lisa Dolovich: no conflicts to disclose. Patricia M. Klatt: no conflicts to disclose. Melissa Somma McGivney: no conflicts to disclose. Learning Objectives

1. Describe the steps taken to launch and establish an innovative practice model. 2. Based on the experiences described by the previous speaker, describe the process of launching a

similar innovative practice in other settings/patient populations. 3. Explore the considerations and challenges to launching this practice. 4. Examine the process of integrating opportunities for research and scholarship related to

innovative practice development.

Self-Assessment Questions Self-assessment questions are available online at www.accp.com/am

Integrating Scholarship into Integrating Scholarship into Your Innovative Practice Model: Th SCRIPT P jThe SCRIPT Project

Melissa Somma McGivney, Pharm.D., FCCPAssociate Professor of Pharmacy &TherapeuticsDi t C it P ti R idDirector, Community Practice ResidencyUniversity of Pittsburgh School of Pharmacy

Objective

Examine the process of integrating Examine the process of integrating opportunities for research and scholarship related to innovative practice developmentp p

Practice and Research…our view

Integral Integral Sustainability Viability Viability Scalability

Collaborative Collaborative University Hospital Hospital Health Plan

SCRIPT: Goals

Identify the impact of a pharmacist providing Identify the impact of a pharmacist providing care and service in family practice/medical home offices; specifically:; p y

Overall medical/pharmacy expenditure impact

Patient outcomes

Practice efficiencyy

SCRIPT: Planned Analysisy

Economic and Clinical AnalysisEconomic and Clinical Analysis

Qualitative AnalysisQualitative Analysis[Patients, physicians, staff, pharmacists]

Qualitative Analysis: Objective

To determine the acceptance and attitudes of To determine the acceptance and attitudes of family medicine physicians, clinical and nonclinical office staff, pharmacists, and , p ,patients during pharmacist integration into a medical home.

J Am Pharm Assoc 2011;51:173-183

Qualitative Analysis - Team

Planned integration of Planned integration of learners

Partnership with

Co-PI Residents/

P4 Studentp

research consultants Qualitative research

Research Consultants

Family medicine leader

Leveraged strengths of core team

Core SCRIPT

Teamof core team Previous research and

clinical experience


Qualitative Analysis - Timeliney

Timeline

Aug’09Pharmacistsbegin

Oct ’09Datacollection

Jan ’10Interviews begin

Jun ’10Qualitative analysis complete

Oct ’10End data collection


Qualitative Analysis - Results

84 interviews 84 interviews 21 with Family Medicine physicians 26 with patient care staff 26 with patient care staff 13 with patients 9 with non-clinical staff 9 with non clinical staff 8 with office managers 6 with pharmacistsp

5 main themes emerged


SCRIPT: Qualitative Analysis

Initial concerns: “How is this going to affect workflow?” (physician) “Just one more thing to have to think about…”

(physician)(physician) “I was a little skeptical at first, thinking, you know,

‘Is this a waste of time?’” (clinical staff)( )

After 3 months: “It is working so well that I am fearful. I am fearful for

what might happen when the project ends, because having [pharmacist] there has been terrific.” (physician)



Positive overall feeling about pharmacist integration “I think that medicine is a whole team approach,

and the more team members there are the betterand the more team members there are, the better care the patient gets, so it’s very good to have [pharmacist] here.” (physician)

“I think it helps quite a bit.” (clinical staff) “I think it’s just the best thing that happened to this

office ” (non clinical staff)office.” (non-clinical staff) “Oh, I think it’s a wonderful idea.” (patient)


SCRIPT: Qualitative Analysis Clinical, educational, and time-saving

benefits to physicians clinical and non-benefits to physicians, clinical and nonclinical staff, and patients

“They are able to understand more of what the patients y pare doing with their medications, and take the time that we don’t often take as physicians, to do that I think is fantastic.“ (physician)(p y )

“Getting people who can’t afford their medicines some alternatives, or giving the physicians alternatives on what they could order has really helped a lot ” (clinicalwhat they could order, has really helped a lot. (clinical staff)

“We have patients calling all the time now. ‘Is pharmacist there?’ which is great because they have a back up and theythere? , which is great because they have a back-up and they have somebody they can trust.” (office manager)



Challenges understanding the role of the Challenges understanding the role of the pharmacist

“The beginning I wasn’t quite sure, you know, what sort g g q , y ,of things were appropriate to, you know, to use the pharmacist for or when to involve them.” (physician)

“Because the problem is no one really knows what Because the problem is no one really knows what specifically the pharmacist (is) going to do that’s going make a difference and impact to the patients. They’re here to figure that out When they figure it out then theyhere to figure that out. When they figure it out then they can replicate it for other people, and say, hey, “this is the things that we do that benefit the patients and make it more structured” (physician)more structured (physician)



Improved workflow and integration due to Improved workflow and integration due to pharmacist flexibility and motivation

“It does not slow me down at all.” (physician)(p y ) “[Pharmacist] is usually on top of our list. [pharmacist]will

look at patients and already know before we’ve seen them what their meds are what recommendationsthem what their meds are, what recommendations … [pharmacist] does function pretty autonomously” (physician)“[Ph i t] ll ll ith thi Thi b “[Pharmacist] really rolls with things. This can be very chaotic, the office is very busy.” (physician)



Suggestions to increase the pharmacists’ Suggestions to increase the pharmacists time in each office “Selfishly, I would like to have [pharmacist] there y, [p ]

full-time…could we use [pharmacist] more? Sure. Is it good the way it is? You bet.” (physician)“I thi k if [ h i t] h it ld h l ” “I think if [pharmacist] was here more it would help.” (clinical staff)


Quantitative Analysis: Objectives

To determine To determine The drug therapy problems identified through

comprehensive medication consultations with a ppharmacist in a medical home.

The effect on physician practice efficiency with a pharmacist integrated into the medical home.

Quantitative Analysis - Team

Planned integration of Planned integration of learners

Partnership with Resident

PIphospital leadership Finance office Hospital

L d hi EPIC team

Leveraged strengths Core

SCRIPT Team

Leadership

of core team Ability to navigate/negotiate

sensitive information

Team

Quantitative Analysis – Pharmacist i hiPractice Demographics

1494 patients Top Indications 1494 patients 50 years old on avg.

63% female

Top Indications Hypertension n=464 Nutritional supp n=392

63% female 37% male

4.7 meds/patient

Cholesterol n=321 Type 2 Diabetes n=320 Pain n=299p Pain n=299 Cardioprotection n=259 GERD n=220 Depression n=189 COPD n=120

All i hi iti 119 Allergic rhinitis n=119

Quantitative Analysis – Drug y gTherapy Problems (DTP)

3257 t t l DTP id tifi d 3257 total DTP identified 1110 medication reconciliation

1102 li 1102 noncompliance 379 adverse drug reaction

259 dosage too low 259 dosage too low 137 dosage too high 114 needs additional drug therapy 114 needs additional drug therapy 87 needs different drug product 69 unnecessary drug therapy 69 unnecessary drug therapy

Average 2.2 DTP/patient

Quantitative Analysis – Pharmacist Interventions and Outcomes Interventions n=5049 Outcomes n=3500 Interventions n 5049

3.4 interventions/pt. 10% required physician

Outcomes n 3500 347 medication cost ↓ 45 ADR preventedq p y

Top interventions: 1393 physician letter

p 30 physician visit avoided 28 saved additional med

1110 update med list 785 education on device

372 h d

11 saved ER visit 9 saved hospital visit

372 change med 331 change med dose

Next Steps/Questions

Health Plan Hospital Health Plan HEDIS measures STAR ratings

Hospital Practice efficiency Integration into ACO g

Pharmacy specific measures:

G i fill t

gmodel

Application to additional practices Generic fill rate

“High utilizers” Non-compliance

additional practices

School of Pharmacy Growth of practices Continued research

I t ti f l Integration of learners

SCRIPT: Our Success Clear vision

Lead to understanding what can not be accomplished alone

Willingness to understand structure and culture of each institution Need a willingness to look “outside the box”

Administrative leadership key: Administrative leadership key: Setting vision Sustaining partnership Troubleshooting

Core research/project team: Clear vision, Consistent Communication, Colleagues

Launching a Similar Innovative Practice:Launching a Similar Innovative Practice: Considerations and Challenges

ACCP Annual Meeting

Tuesday, October 18

Trish Klatt, Pharm.D., BCPS

Welcome to Pittsburgh!!

Developing Innovative Practice

2 colleagues talking…

Teaching

T hi FM Teaching Can we doTeaching FM residents

Teaching pharmacy students

Can we do this in private

practice?

Needs Assessment

PharmDs, MDs and administrators, What are needs of practice?

Who would be stakeholders of having pharmacists g pin practices?

What would they do?

How could we pay for this?

Finding funding

Options Options Non-profit organization grants

Payor (insurance company) UPMC Health Plan

Highmark

Health System UPMC

Developing a teamProcess

improvement lt t

Process improvement

lt t

Pharmacy residents

H lth Plconsultantsconsultants Health Plan Pharmacists

UPMC HP

ProjectAdministrators

Physician

Project Manager

Dept of Pharmacy

Administrators • UPMC St.

Margaret• UPMC Health

Plan (HP)

Pharmacists• University of

Pittsburgh faculty• Project

pharmacists (2)p ( )

SCRIPT Project Team

UPMC St. Margaret University of Pittsburgh UPMC Health Plan

Joel Merenstein, MD

Trish Klatt, PharmD

School of Pharmacy:Melissa McGivney, PharmD

Chronis Manolis, VP Pharmacy

Douglass Harrison, MBA

Aaron DiFilippo, PharmD

PharmD

Mindy Kozminski, PharmD*

Stephanie Hackett, PhD

Pamela Peele, PhD

Deandra Jones PharmDMaria Osborne, PharmD

Rachelle Busby, PharmD*

School of Medicine:Donald Middleton, MDRichard Zimmerman, MD

Deandra Jones, PharmD

* Qualitative Analysis

Learning from others…

Thanks to Lisa and Barb! Thanks to Lisa and Barb!

Napcrg open meeting Napcrg open meeting

What’s in a name?

SCRIPTSCRIPT

Successful Collaborative Relationships to ImproveRelationships to Improve

PatienT care

Creating a Replicable, Scalable, Sustainable Model of Care

SCRIPT: Successful Collaborative Relationships to Improve

PatienT carePatienT care

Identifying outcome measures

O ll di l/ h t Overall medical/pharmacy cost PMPM

Patient outcomes Admissions

Practice efficiency wRVU

SCRIPT Project

Pharmacist PharmacistPharmacist Pharmacist

Family Practice

Family Practice

Family Practice

Family PracticePractice Practice Practice Practice

Direct Patient CarePractice Management

Standardized Documentation

Practice Management

Selecting practices

Factors to consider Factors to consider

Project team meeting structuremeeting structure

Job role assignment

S t f f db k Set up for feedback

Defining pharmacist role

What unique skills will pharmacist bring to the table?

Medication ExpertsIdentify, Prevent and Solve Drug Therapy P blProblems

Keep an ear to the ground

Be aware of the Be aware of the culture around you

Piggy-back onto ggy“sexy” topics Medical Home

Chronic Care Model

HEDIS Measures

Insertion of pharmacists…

Mechanics Mechanics Laptops, phones, space to sit, schedules,

documentation in medical records

Documention

Electronic Health Record Electronic Health Record

Types of interventions

Demographics of PracticesPractice 1

(Glenshaw)Practice 2

(RIDC)Practice 3

(Penn Plum)Practice 4

(Penn Hills)

N b f 4 h i i 3 h i i 7 h i i 7 h i iNumber of Clinicians

4 physicians- 3 FT, 1 PT1 FT CRNP

3 physicians 7 physicians- 2 FT, 5 PT

7 physicians- 4 FT, 3 PT

Average Age of Clinicians 41 years 45 years 40 years 48 yearsg g y y y y

Daily Patient Load Per Ph i i

32 patients 27 patients 30+ patients 30 + patients

PhysicianStaff 7 MA

6 FT patient information coordinators1 FT practice manager/biller

1 FT practice manager/biller1 FT RN4 FT MA3 patient information

di t

7 FT MA5 FT office Assistant1 FT LPN1 FT biller1 FT ti

1 FT RN1 PT LPN5 FT MA2 FT office coordinators7 FT patient information

coordinators 1 FT practice manager coordinators2 PT patient information coordinators1 FT prescription specialist1 FT biller1 FT medical records clerk1 PT medical records clerk1 PT- medical records clerk1 FT phlebotomist1 FT practice manager

Total Active Patient

10,000 patients 6,000 patients 9,000 patients 12,000 patients

Summary of Observation at all Four Sitesy

DocumentationPt. CareMed‐Rec

Chart Review

DocumentationPatient Care

d

Med Rec

Talk with Staff

Talk with Physician

DocumentationNon‐medRec

Talk with Physician

Other phone calls

Phone Med Rec

Phone Non‐

Phone call Non‐med recChart Review

Phone NonMed Rec

TalkPhone Med Recwith

Staff

Pharmacist Support

Monthly project meetings Monthly project meetings

Weekly case discussions

Drug information questions Drug information questions

IT issues

Key learning points

Maternity leave Maternity leave

Vacation coverage

Creating a need Creating a need

Importance of planning process

Learning curve re: differences in culture between funding sources

Patient Feedback

“UPMC d D t lik D J d d “UPMC needs Doctors like Dr. Jordan and Maria Osborne. These 2 people working together have my diabetes at a good level Ittogether have my diabetes at a good level. It is very important to have people like her and her knowledge working with a busy doctorher knowledge working with a busy doctor trying to save UPMC money and making patients feel important and well.”patients feel important and well.

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