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Transforming Patient Care Paramount Issues and Opportunities in Pharmacy Practice

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon), FASHP

Chief Executive Officer

ARKANSAS ASSOCIATION OF HEALTH-SYSTEM PHARMACISTS

ANNUAL FALL SEMINAR – OCTOBER 2, 2014

SPEAKER: Paul W. Abramowitz, Pharm.D., Sc.D. (Hon), FASHP

Chief Executive Officer, ASHP

TITLE: “Transforming Patient Care: Paramount Issues and Opportunities In Pharmacy Practice”

MEETING: Arkansas Association of Health-System Pharmacists

Annual Fall Seminar – October 2, 2014

Disclosure Information

I have no relevant financial relationships to disclose.

• Discuss future pharmacy practice models and new methods of care delivery to improve outcomes of care

• Describe a focus on the full continuum of medication therapy and pharmacy-driven transitions of care to eliminate silos of care

PRACTICE MODEL

CHANGE

New Methods of Care

• Discuss the need for pharmacists to be members of all ambulatory healthcare teams, and the role they play in improving care outcomes, providing primary care, and reducing healthcare costs

• Describe key factors and models for ambulatory care delivery and integration models

• Outline ASHP’s efforts to date to help advance ambulatory care practice through practice model change and education

DEFINING AND

ADVANCING

AMBULATORY

CARE PHARMACY

PRACTICE

Objectives

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• Describe the importance of and process for pharmacists to obtain provider status at the federal, state, and local levels

• Provide an update on the efforts of the Patient Access to Pharmacists’ Care Coalition (PAPCC)

• Describe ways in which members and affiliates can get involved to rally congressional support of H.R. 4190

• Discuss ways to enhance the public’s understanding of the vital role of the pharmacist in their care

OBTAINING

PROVIDER

STATUS FOR

PHARMACISTS

Yes, It is Important

• Discuss increasing pharmacist prescribing privileges to improve the delivery of healthcare

PHARMACIST

INTERDEPENDENT

PRESCRIBING

Optimizing Patient Outcomes

Objectives

New Methods of Care

What is a Practice Model?

• Defines important types and levels of patient care services

• Allows for:

o Application of best practices

o Standardization of care

o Judgment of pharmacist and individual patient needs

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Imperatives for Practice Model Change

o Medication use and its outcomes are far from optimal in the U.S.

o Admissions and readmissions to hospitals due to medication therapy are too high

o Provision of primary care and management of chronic disease is inadequate to meet needs

o Wellness and prevention do not receive adequate attention

o Estimated waste in the healthcare system each year = $765 BILLION1

o Estimated cost of medication-related hospital admissions each year = $198 BILLION2

Current Silos that Exist in the Pharmacy Practice Continuum

o Lack of effective transition-of-care mechanisms

o Less than optimal division of responsibilities

The

Patient

Hospitals &

Health

SystemsClinics

Home Care

Long-Term

Care

Specialty

PharmacyCommunity

Pharmacies

Urgent Care

Insurers

INTER- and INTRA- Professional Care

Health care will become increasingly

inter-professional, team-based

Medication preparation, distribution,

& dispensing should be

more centralized &

automated

Vast majority of

pharmacists’ time must be

spent providing

direct patient care

in allsettings

Need for a well-trained technician

workforce to provide

more complex

medication-use roles

Increased definition & standard-ization of pharmacy direct care services

offered for all patients

is necessary

Principles for Practice Model Redesign3

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Every patient should receive a comprehen-

sive pharmaco-

therapy plan

Expect the public to insist on additional requirements

for credentialing & privileging

of pharmacists in

general & specialty practices

More and more

pharmacists will be

practicing in clinics

Collaborative practice will

evolve to include greater

pharmacist responsibility

for prescribing as part of

coordinated health care teams in all

settings

Primary care and adherence must receive a much greater emphasis by pharmacists

Principles for Practice Model Redesign3

ASHP’s vision is that medication use will be optimal, safe, and effective for

all people all of the time.

“Expanded pharmacy practice models in collaboration

with the physician or as part of a health team improve

patient and health system outcomes and optimize primary care access and delivery.”

-- Dr. Regina M. Benjamin, U.S. Surgeon General (Ret)4

IMPROVING HEALTH – OPTIMIZING OUTCOMES

In response to the U.S. Public Health Service’s report: Improving Patient and Health System Outcomes through Advanced Pharmacy Practice: A

Report to the Surgeon General 2011, by Rear Admiral Scott F. Giberson, Acting Deputy Surgeon General, USPHS

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• 1960s – Indian Health Service5

o Began refilling prescriptions, based on medical record information

• 1979 – Greifenhagen and Pearlman6

o Created a system to screen ambulatory patients with:o Respiratory disorderso Dermatologic complaintso Hypertensive concerns

o Established protocol where pharmacist:o Interviewed and examined patientso Ordered lab tests and developed treatment plano Referred patient to physician for confirmation of pharmacist’s

treatment plan

• 1981, 1982 – Helling7a,b

o Developed principles/constructs of family practice pharmacy services

Early Pharmacy Ambulatory Clinic Practice

• 1985 – Gray et. Al8

o Researched benefits of pharmacist-managed anticoagulation clinics

o Findings of clinics:o Therapeutic prothrombin times were effectively maintainedo Reduced the incidence of hospitalization; 0.048 days per year in

pharmacist group versus 3.22 days per year in physician groupo Reduced hospitalization costs per year by $211,776.00 for 26

patients treated

• 1987 – Veterans Affairs (Cheung et. al)9

o Developed a multi-institutional pharmacy system; including inpatient and ambulatory care practices

• 1989 – Koecheler et. Al10

o Identified six prognostic indicators o Quickly identify ambulatory patients who may benefit from

pharmacist monitoring

Early Pharmacy Ambulatory Clinic Practice

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• 2014 and beyond – Many more pharmacists will be working in ambulatory clinics3:

o Embedded in clinics and/or pharmacist-directed clinics

o Criteria-based patient selection

o Allocation of physician, pharmacist and, nurse time

• Clinic Locations11

o Hospital and health-system clinics

o Patient-Centered Medical Homes (PCMH)

o Community medical centers

o Community pharmacies

o Physician office practices

Ambulatory Clinic Practice of the Future

• ASHP Ambulatory Care Summit and Conference

• March 3-4, 2014 -- Dallas, TX

• Consensus-building processo 40-member consensus panel

o Domainso Defining ambulatory care pharmacy

practice

o Patient care delivery and integration

o Sustainable business models

o Outcomes evaluation

o Iterative process with large group (>400) all participated

o Followed by survey to all members

Outcomes:

o 25 Visionary and forward-thinking recommendations

o High percentage of participant agreement

o Percentage of ASHP member agreement

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Major Recommendations12:

o Defining Ambulatory Care Pharmacy Practice

o Recommendation 1.5: Pharmacists who provide ambulatory care services should articulate and promote a standardized pharmacist patient care process

o Patient Care Delivery and Integrationo Recommendation 2.2: Pharmacists who provide ambulatory care

services must collaborate with patients, caregivers, and healthcare professionals to establish consistent and sustainable models for seamless transitions across the continuum of care

Major Recommendations12:

o Sustainable Business Models

o Recommendation 3.4: Services provided by pharmacists who provide ambulatory care services should achieve a set of quality and cost measures, be supported by payment model(s), and be valued by demonstrated improvements in patient outcomes

o Outcomes Evaluation

o Recommendation 4.6: At every level (community, state, national), pharmacists who provide ambulatory care services should participate in healthcare policy development related to improving individual and population health outcomes

ASHP’s Next Steps:

o Proceedings published - AJHP 8/15/14

o Mobilize the profession

o Create tools and resources to assist in implementation

o Advocacy efforts to achieve Summit recommendations

o Ambulatory Care Conference – 2015 Summer Meetings

• ASHP Ambulatory Care Summit and Conference

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• Make the healthcare and business case

• Start with establishing transitions of care pharmacy services

• Identify clinics and patients where drugs are a major component of care of ambulatory care

• Pilot new clinic services

• Expand based on successes

What YOU Can Do at Your Hospital?

Yes, It is Important

What is Provider Status?

• Being listed in section 1842 or 1861 of the Social Security Act as a supplier of medical and other health services

• Becoming a “provider” in the Social Security Act means that pharmacists can:

o Participate in Part B of the Medicare program

o Bill Medicare for services that are within their state scope of practice to

perform

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Provider Status is About Patients

• Achieving provider status is about giving patients access to care that improves:

� Patient safety

� Healthcare quality

� Outcomes

� Decreases costs

Why is it Important for Pharmacists?

• Absence reduces visibility � Implies secondary role � Impedes care provision

• Extensive documentation of need and improvement in outcomes, safety, cost, and access when pharmacists provide clinical services

• Pharmacists practicing in clinics and the expansion of services offered in community pharmacies will require financial support

• Need for pharmacists to provide primary care and manage chronic disease

• Inappropriately aligned incentives constrain pharmacists

• Section 1861 of the SSA remains the reference point for which practitioners are eligible to participate in current, new and emerging delivery systems, and payment models (e.g., ACOs and Medical Homes)

Fundamental issue for full professionalization

Who Has Provider Status Now?

• Physicians

• Nurse practitioners

• Physician assistants

• Certified nurse midwives

• Psychologists

• Clinical social workers

• Certified nurse anesthetists

• Speech-language pathologists

• Audiologists

• Registered dietitians

• Physical therapists

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• Introduced by Representatives Guthrie (R-KY), Butterfield (D-NC) and Young (R-IN) March 11, 2014

• Bipartisan bill; over 100 congressional

cosponsors include two physicians: Reps. Roe (R-TN) and Bera (D-CA)

• Refers back to state scope of practice

• Applies to medically underserved areas, populations, or shortage areaso Represents a large part of the U.S.o Urban and rural areas

What is House Resolution 4190?

H.R. 4190 Specifics

• Amends Section 1861(s)(2) of the Social Security Act to include:o Pharmacists services furnished by a pharmacist licensed by state law

o In setting located in/for and defined in federal law:o Medically underserved areao Medically underserved populationo Health professional shortage area

• Why does H.R. 4190 only cover under medically underserved communities?o Help meet unmet health care needs

o Increase accesso Improve qualityo Decrease costs

• Why this approach?o Provides a foot in the door; limits opposition and brings down legislation costso Other health professionals have taken a similar approach (e.g., Nurse

Practitioners and Physician Assistants)

Where are the Medically Underserved Communities?

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Patient Access to Pharmacist’s Care Coalition (PAPCC)

• Formed January 2014

• Group of more than 20 organizations representing patients,

pharmacists, pharmacies and other interested stakeholders

• Drafted H.R. 4190 to

expand medically-underserved patients’ access to pharmacist services consistent with state scope of practice

Members

American Society of Health-System

Pharmacists (ASHP)

Albertsons

American Association of Colleges of

Pharmacy (AACP)

AmerisourceBergen

American Pharmacists Association (APhA) Bi-Lo Pharmacy

American Society of Consultant

Pharmacists (ASCP)

Cardinal Health

International Academy of Compounding

Pharmacists (IACP)

CVS Caremark

National Alliance of State Pharmacy

Associations (NASPA)

Food Marketing Institute

(FMI)

National Association of Chain Drug Stores

(NACDS)

Fred’s Pharmacy

National Community Pharmacists

Association (NCPA)

Fruth Pharmacy, Inc.

Rite Aid

Safeway

SuperValu Pharmacies

Thrifty White Pharmacy

Walgreens

Winn Dixie

Why Do Pharmacists Want Provider Status When Fee-For-Service is Going Away?

• Traditional fee-for-service is not the model of the future

• However, Social Security Act (SSA) remains the reference point for eligibility to participate in:o Delivery systems o Payment models (see ACO example)

• Pharmacists need to be listed in the SSA to fully participate

Does H.R. 4190 require pharmacists to be residency trained, Board certified, or possess other credentials?

• No. H.R. 4190 requires pharmacists to be licensed by a stateo State legislature and board of pharmacy, health care organizations, and

private health plans determine requirementso Examples:

� CA: “Advanced Practice Pharmacist” � NM: “Pharmacist Clinician”

Why isn’t ASHP calling for credentialing requirements given that ASHP started pharmacy residencies and supports Board certification?

• ASHP supports these concepts, but they do not belong in federal lawo Credentialing and privileging requirements are for states and

organizations to decide through:� State pharmacy practice acts� Private health plan requirements� Credentialing and privileging requirements by hospitals and health

systems

What will a pharmacist provider be referred to when H.R. 4190 is signed into law?

• Pharmacist

• No need to create a new category of pharmacist in federal law

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State Scope of Practice

• Provider status at the federal level will only allow a pharmacist to:

o Participate in the Medicare program

o Bill for services that are within their state scope of practice

• State scope of practice will determine what pharmacists can actually do in terms of the provision of service

• As provider status at the federal level is achieved, continued efforts by states to ensure scope of practice for pharmacists is sufficiently robust will be vital

How Can State Affiliates Support H.R. 4190?

• Urge co-sponsorship of H.R. 4190; focus on state members:o Energy and Commerce Committee o Ways and Means Committee

• Seek Senate sponsors for companion bill

• Organize in-state/in-district meetings with elected officials and/or staff

• Coordinate hospital/health system facility tours

• Reinforce/supplement ASHP Grassroots Calls to Action

• Profile Member Advocacy in Newsletters, etc.

• Attend Campaign Fundraiser & other Events

• Recruit individual health systems to support of H.R.4190

• Solicit the support of other state-level health professions

How can YOU support H.R. 4190?

• Visit elected officials/staff in your home district

• Encourage your colleagues to get involved

• Utilize social media to talk about provider status; share ASHP material and updates

• Attend political rallies, town halls, and fundraising events

• Write editorials or op-eds in local newspapers

• Congressional leaders listen when constituents speak

• Educate your patients and the public

• ashp.org/providerstatusteam

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Enhance the Public’s Understanding of the Vital Role of the

Pharmacist in Their Care

https://www.youtube.com/watch?v=152dfgadI7U&feature=youtu.be

Optimizing Patient Outcomes

Evolution of Collaborative Drug Therapy Management (CDTM)

• Changing delivery of care model as it relates to prescribing14

o Current model: � Vertical� Dependent

Pharmacist and physician, working together with other members of the healthcare team, and forming a strategic partnership to optimize

patient outcomes with medications.

o Proposed model: � Horizontal� Interdependent

Changing the Scope of Practice - Maximizing What Pharmacists Can do for Patients

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Proposed Horizontal Model14

• Makes initial diagnosis

• Treats and monitors patient

PHYSICIAN

• Based on physician diagnosis, selects & designs drug therapy regimen

• Writes prescription or medication orders

*PHARMACIST • Reviews and monitors patient’s drug therapy for efficacy and adverse events

PHYSICIAN / PHARMACIST /

NURSE

• Changes medication orders, consulting with physician and nurse as needed

PHARMACIST

*In specific patients and specific situations

previously determined by both the physician and

the pharmacist

OUTCOME: Improved outcomes and reduced costs. Better utilization of physician, nurse, and pharmacist’s time.

Existing International Models• U.K.15:o Able to prescribe all drugs for any medical condition within their competence

• Canada – Effective October 2012, Ontario16:o Independent prescribing based on a collaborative relationshipo Initiate therapy for smoking cessationo Emergency prescribingo Renew and adapt prescriptionso Administer injections or inhalation (for education and demonstration)o Administer the flu vaccineo Quebec allowing pharmacists to prescribe medications that do not require a

diagnosis, i.e.17:

o Antimalaria medications for travelers

• Australia: Currently in developmento National prescribing competencieso Scope of practice

We need an increased emphasis on care basics, such as adherence, design of affordable drug therapies, elimination of unnecessary drug

use, chronic disease management, wellness, and primary care.

Pharmacists in different sites of care must work together to provide the full spectrum of care.

We need to educate the public as to the role of the pharmacist in patient care.

Final ThoughtsPutting it All Together

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Staying focused on what is right for the patient will always be our best strategy.

Our models of practice must change significantly to achieve the above.

There should be an increased pharmacy presence in clinics, medical homes, ACOs, etc.

Final ThoughtsPutting it All Together

References1. IOM, 2012, Best Care at Lower Cost.

2. The Advisory Board Company. 2014 Health System Pharmacy Survey, March-April 2014.

3. Abramowitz P. The evolution and metamorphosis of the pharmacy practice models. Am J

Health-Sys Pharm. 2009; 66:1437-1440.

4. Benjamin R. Letter to Scott Giberson, Chief Professional Officer, Pharmacy, U.S. Assistant Surgeon General. Dec. 14, 2011.

5. Church RM. Pharmacy practice in the Indian Health Service. Am J Hosp Pharm. 1987; 44:771-5.

6. Greifenhagen R, Pearlman JJ. Pharmacy system for screening ambulatory patients. Am J Hosp Pharm. 1979; 36:916-20.

7a. Helling DK. Family practice pharmacy service: part 1. Drug Intell Clin. Pharm. 1981;

15:971-7.

7b. Helling DK. Family practice pharmacy service: part 2. Drug Intell Clin. Pharm. 1982; 16:35-48.

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References8. Gray DR, Garabedian-Ruffalo SM, Chretien SD. Cost-justification of a clinical pharmacist-

managed anticoagulation clinic. Drug Intell Clin Pharm. 1985; 19:575-80.

9. Cheung A, Sleight SM, Sisson NM. Pharmacy practice in the Veterans Administration. Am J Hosp Pharm. 1987; 44:747-54.

10. Koecheler JA et al. Indicators for the selection of ambulatory patients who warrant

pharmacist monitoring. Am J of Health-Sys Pharm. 1989;46:729-732.

11. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated care teams. Health Affairs (Millwood). 2013;32:1963-70.

12. ASHP/ASHP Foundation. Ambulatory Conference and Summit. Consensus

Recommendations. Retrieved on June 13, 2014 at http://www.ashpmedia.org/amcare14/docs/preliminary_recommendations_2014-03-04.pdf

13. Medically Underserved Areas. Rural Assistance Center. Retrieved on March 18, 2014 at http://www.raconline.org/racmaps/mapfiles/mua_muptype.png

14. Abramowitz P, Shane R, et al. Pharmacists interdependent prescribing: A new model for optimizing patient outcomes. Am J Health-Sys Pharm. 2012;69:1976-81.

References15. Department of Health. Nurse and pharmacist independent prescribing changes announced.

Retrieved at https://www.gov.uk/government/news/nurse-and-pharmacist-independent-prescribing-changes-announced

16. Ontario College of Pharmacists. Understanding your pharmacist’s expanded role. Retrieved

March 18, 2014 at http://www.ocpinfo.com/Client/ocp/ocphome.nsf/object/Brochure/$file/Exp_Role_Letter.pdf

17. Legislative change in Quebec gives pharmacists expanded authorities. Can Pharm J.

2012;145:7