Exam 2 Flashcards
Why do we need pharmacists?
Medication Use Healthcare Reform Physician shortages Increased healthcare costs Population health
What is the US healthcare system performance rating?
Last in most things
Healthcare reform
Fee-for-service (FFS) -pay for outcomes IHI triple/quadruple aim goal- to improve individual healthcare and experience along with that of communities and populations Improve patient experiences Increase population health outcomes Reduce costs Care team well being
Pharmaceutical care
Introduced in 1990
Patient-centered, outcome-oriented pharmacy practice
Principles- professional relationship with patient must be established and maintained
Medical information must be collected and evaluated
Pharmacists assures that the patient has all supplied, information and knowledge necessary . Pharmacists reviews, monitors therapeutic plan
Medication therapy management (MTM)
Officially recognized by the Medicare Prescription Drug, Improvement, and Modernization act of 2003
Required Med part D to establish MTM programs
MTM patient eligibility
Multiple chronic disease states (2-3)
Take multiple part D drugs (2-8)
Likely to incur $4,376 for covered part D drugs
5 core elements of MTM
Medication therapy review Personal medication record Medication-related action plan intervention or referral Documentation and F/U
Comprehensive Medication Review (CMR)
Annual
Collecting patient specific information
Assessing medication therapies and identifying medication-related problems.
Developing prioritized list of med-related problems.
Creating a plan to resolve problems
All meds are addressed to determine appropriateness, effectiveness, safety, able to be taken by patient
Targeted Medication Review (TMR)
Quarterly
Addresses specific or potential medication related problem
Examples- adherence, cost savings, new or changed therapy, inappropriate dose or duration
Pharmacists patient care process (PPCP)
Collect- subjective and objective info Assess- analyzes clinical effects of pts therapy Plan- Implement Monitor and Evaluate
Medication management services (MMS)
Encompasses ALL collaborative pharmacy services focusing on:
medication appropriateness, effectiveness, safety, adherence
Hospital pharmacy models
Community vs academic health centers
Centralized vs decentralized
Virtual
Specialized vs general
Community pharmacy models
Independent vs chain
Clinical initiatives
Flip the pharmacy (ftP)
ACT collaborative/CPESN
CPESN
Focus on getting reimbursement for clinical services by forming a group and negotiating with payors
FtP
Focuses on implementation, workflow, etc. of innovations for CPESN pharmacies
ACT collab
Brings faculty together with CPESN pharmacies to unite, mobilize and amplify community pharmacy transformation efforts
Ambulatory Care Definition
Ambulatory care pharmacy practice is the provision of integrated, accessible healthcare services by pharmacists who are accountable for addressing medication needs and sustained partnerships with patients, and practicing in the context of family and community.
Ambulatory care is accomplished through
Direct patient care Medication management Long-term relationships Coordination of care Patient advocacy Wellness and health promotion Triage and referral Patient education and self-management
Ambulatory care models
Pharmacists run clinics Vs. Provider run clinics Collaborative practice agreements Hospital based Physician group Specialty vs generalized Federally qualified health centers
Benefits of am care pharmacists
Clinical- improved outcomes and markers
Economic- decreases healthcare costs
Humanistic- patient reported satisfaction improves. Provider burnout is reduced.
Specialty pharmacy
Meds are high cost, high complexity, high touch
Transitions of care
Coordination and continuity of healthcare between different settings
Most effective if f/u is done after hospital stay
PAI goal
PAI is a group of recommendations developed by ASHP to drive pharmacy change at a local level
PAI domains
Patient centered care Pharmacy technician role Pharmacist role Technology and data science Leadership
Steps to develop a clinical practice
1.) Define scope 2,) Build support 3.) Demonstrate value 4.) Determine practice model 5.) Identify resource requirements 6.) Anticipate and manage growth
Define scope
Complete a needs assessment and focus on services that provide the most value and is the most feasible.
Service needs to align with your skills AND the needs of the institution.
What attributes should you consider when you define scope?
Valuable- quality divided by cost
Scalable- can easily grow to accommodate demand
Reproducible
Sustainable
Needs assessment questions
- ) What is the current state of the proposed service?
- ) What is the current standard of care?
- ) What current and future developments may impact the success of this service?
Comprehensive Medication Management (CMM)
All of a patients medications are individually addressed to determine: Appropriateness Effectiveness Safety Able to be taken by the patient.
PPCP
Collect, assess, plan, implement, monitor and evaluate
Steps to developing a clinical practice
- ) Define scope
- ) Build support
- ) Demonstrate value
- ) Determine practice model
- ) Identify resource requirements
- ) Anticipate and manage growth
Steps for other providers to implement a pharmacist into their team
Identify roles
Decide how the practice could benefit
Find a pharmacist and tech match
Prepare and set expectations for your team and pts
Determine the resources the pharmacist needs and the impact on the physicians workflow
Measure impact
4 key attributes to scope
- ) Valuable- quality divided by cost
- ) Scalable- can easily grow to accommodate demand.
- ) Reproducible- can be replicated
- ) Sustainable- able to be maintained at a high level.
High risk medications or requiring frequent monitoring
Warfarin Insulin Digoxin Anticonvulsants Lithium Antiarrhythmics
Potential services for ambulatory care clinics
Patient education Prevention and wellness Medication reconciliation Immunizations Transitions of care Comprehensive medication management MTM Point of care testing
Performing a needs assessment, what 3 questions should you ask?
- ) What is the current state of the proposed service?
- ) What is the standard of care currently?
- ) What current and future developments may impact the success of this service?
Key stakeholders for am care clinics
Patients, physicians. NP/PAs, nurses, medical assistants, office managers, care coordinators
Steps for ambulatory care: Build support
Include people that are initially skeptical
Get everyone engaged early
Use supporting information from outside pharmacy organizations
Steps for ambulatory care clinic: Prepare and set expectations for your team and pts
Designate a physician champion
Delineate roles and responsibilities
Manage up the pharmacists to patients (create introductory letter, do a “meet and greet”)
How do you demonstrate value of an ambulatory care clinic?
Use evidence!
Internal- other pharmacy services within your organization, pilot study.
External- similar orgs/competitors, similar services.
Select evidence that clearly supports a PHARMACIST completing the service
Steps for ambulatory care clinic: how can the practice benefit from a pharmacist
Reviews considerations for how to include a pharmacist
- cost of hiring a pharmacist
- share with another practice
- collaborate with community pharmacist
Consider the physical space of a ambulatory care practice
Integrated in the clinic- desk space, availability to team, pt room
In another location- how to communicate? EHR
Practice model
Patient interactions- face-to-face, telephonic, team visits
Special agreements- collaborative practice agreements, protocols, standing orders
Ambulatory care- integrating into the clinical team
Inclusion of stakeholders early-improves perception of service.
Keep provider goals in mind and align with your goals.
Remain flexible.
Consider providing disease state management presentations or clinical guideline updates.
Elevator speech
“Face Time”
Create a document for providers on what they can expect when they consult you.
Keys to integration into a clinical team
Visability and accessibility
Ambulatory care clinic- how to determine demand for service/patient volume
Start with billing officers -ICD codes to determine pt diagnoses -Services provided -Insurance/payer mix -Basic demographic information EHR- show rate, obtain basic lab information
Referral system
Automatic= more patients
Provider initiated= fewer patients
Time for appointments
Pharmacists
8-12 patients per day for CMM
15-30 patients per day for targeted disease state management
FTE
Full time equivalent
Maximum number of compensable hours an individual will work in a year= 2080
Financial potential of service
Reimbursement (billing)
- incident-to
- MTM services
- Value-based contracts
Cost-avoidance (“soft dollars”)
Care efficiency- improving the productivity of other providers who can see more patients and generate additional revenue.
What resources does the pharmacist need and the impact on the physicians workflow?
Clinic desk space
Patient room space
Reimbursement
Co-signing notes
Anticipate and manage growth when making a am care clinic
Keep services within your means
Maintain patient volume
payer/payor definition
Insurance company including commercial insurance, Medicare, Medicaid
Why is sustainability important?
Best practice does not equal sustainable practice.
Service MUST be AT LEAST cost neutral
4 Pillars of sustainable practice
Leadership
Staffing
Information Technology
Compensation
4 pillars of sustainable practice: Leadership
Advocates for pharmacy Nurtures stakeholder relationships Stays informed about local management changes Staffing Writes BP
4 pillars of pharmacy leadership: Staffing
Establishing training needs.
Are current pharmacists qualified to offer new service?
Maximize efficiencies- ensure that everyone practices at the top of their license.
Strategies used to ensure pharmacists practice at the top of their license
Integrate into current workflows, establish own workflows that are efficient
Advantages/disadvantages of pharmacy learners
Advantages- rewarding for current staff, identification of future employees, inexpensive labor, financial benefits.
Disadvantages- may or may not be consistent
Requires time for current employees.
Information technology
Always changing
Assess current technology before investing in new
Opportunities- workload tracking, clinical reports
Appoint someone to be the IT expert on the team,
Compensation of ambulatory care clinic
Diversify
-billing for services
-pay-for-performance
cost savings and cost avoidance
Cost savings and cost avoidance
Cost savings= real dollars
-Not lost due to financial penalties imposed by a payer
Cost avoidance= “soft” dollar
-Avoided by avoiding an event (hospitalization, thromboembolic event, etc.)
Do CFOs want to see cost savings or cost avoidance?
Cost savings
Do payers prefer cost savings or cost avoidance?
Cost avoidance
Cost savings example
HRRP
-Financially penalizes hospitals for high readmission rates
Measuring readmission rates
Before and after service implementation
Among similar populations with and without a pharmacist
Between organizations (competition)
How to demonstrate value over time?
Select quality measures to demonstrate value over time
ECHO model
-Economic- costs
-Clinical- lab values, adherence measures
-Humanistic- patient, provider, staff satisfaction
Measure impact of ambulatory care
Clinical outcomes Impact on process metrics Med adherence Change in costs Utilize current measures, if possible
Pay for performance
Local pay for performance initiatives
5 star ratings
Value based purchasing
PCMH, ACO
Accountable Care Organizations (ACO)
Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve.
CMS
MANY different programs
Patient Centered Medical Home (PCMH)
Transforming how primary care is organized to improve health in America.
5 functions- comprehensive care, patient-centered, coordinated care, accessible services, quality and safety
Reimbursement for services traditionally not reimbursed
Star Ratings
Measures= outcomes, intermediate outcomes, patient experience, access to care, process
Reimbursed based on star rating
Examples of measures
Screening measures- osteoporosis screening, cancer screenings
Medication use and adherence- statin, ACE/ARB, oral diabetes agents
Monitoring- glycemic control, INR monitoring
Revenue
Payment for services provided
Payment for downstream services
Product sales
Potential grant support
What does billing depend on?
Clinical practice site location
Payer mix (government, self-payed, commercial)
Type of service
Billing for sustainability
One aspect of revenue
Likely will not be enough to completely cover costs
Become familiar with potential billing opportunities, but do not completely rely on this income.
Provider status will influence in future.
Measuring success
Traditional pharmacy benchmarks- number of interventions, patients seen
Aligns with measures for physicians or the group as a whole.
Challenges in measuring success
Ability to obtain data
Accuracy of data
Timeliness of data
Too much data
Return on Investment (ROI)
Clinical value of pharmacists must be translated into economic value
Consider partnerships
Collaborative practice agreements
Establish a formal relationship
Delegate patient care functions
Contain negotiated conditions
Functions delegated to the pharmacist for chronic disease management.
What requires a CPA?
Authorization of refills
Chronic disease management
Laboratory test
Therapeutic interchange (modify/start/discontinue therapy)
What does not require a CPA?
Referrals
Medication reviews
Disease screenings
Patient and provider counseling/DI questions
Protocol
Law allows a pharmacist to work under a standing order from a physician to dispense to anyone without a prescription
Privileging
Organizations allow individuals to perform a clinical services within a defined scope of practice.
Who can pharmacists enter CPAs with?
Certified nurse practitioners Certified nurse-midwives Certified Clinical Nurse specialists PAs Physicians
CPA law
Ongoing physician-patient relationship
Scope of practice
Trained within specialty
Evolving a CPA
Identify areas of need for the population
Build a relationship/trust with the provider
Create the legal agreement/collaboration
Advancing growth of CPA within clinic
Who can terminate a CPA?
Pharmacist
Practitioner
Patient whose therapy is being managed
Billing for CPA appointments
CMS rulings
Medicare Part B
Contracts with private payers
Provider status?
Senate bill 265
NPI number
Advocating for the profession
Benefits of CPAs
Measuring patient successes
Building relationships
Expanding and growing pharmacy services
Credential
Documented evidence of professional qualifications
Privilege
Permission or authorization granted by a healthcare organization to an individual health professional to perform certain patient care services
Credentialing
Process of granting a credential
Process by which an organization obtains, verifies, and assesses a health professionals qualifications to provide pt care
Privileging
Process after credentialing where a healthcare organization authorizes an individual to perform a specific scope of pt care
Purpose of C&P
Ensure capabilities and competence of healthcare professionals
Promote ongoing quality improvement in individual performance via periodic peer review
Lessen risk for malpractice suits
Credentialing- document and demonstrate
Privileging- assure stakeholders that the healthcare professional has the competencies and experience for specific services
Purpose of C&P for pharmacists
As pharmacists move to more clinical roles, it became necessary to further verify credentials
Gain credibility on an interprofessional team
Provide consistency and increases understanding among providers, insurers, and health systems
Council on credentialing in pharmacy (CCP)
Provides leadership, guidance, public information, and coordination for credentialing programs relevant to pharmacy
Types of credentials
Certificates, statement of continuing education, certification, practice-based CPE activities
Pharmacists credentials
Doctor of pharmacy degree
Entry-level credentials= NAPLEX, MPJE, State license
Voluntary credentials
CCP Guiding principles
Licensure should ensure entry-level knowledge. Post-licensure credentials should build on this foundation
Credentialing programs should be established through a profession-wide, consensus-building process and should be base don patient and societal needs
