1220 wk 5-6
Ambulatory Care Pharmacy 2
Access services or care coordination · Chronic disease state management · Comprehensive medication management · Drug information · Healthcare provider education · Immunization screenings and administration · Medication reconciliation · Medication Therapy Management (MTM) · National Committee for Quality Assurance (NCQA) reporting · Ordering, interpreting, and monitoring laboratory tests · Participate in transitions of care, annual wellness visits, and group visits Participate in Physician Quality Reporting System (PQRS) · Patient education and counseling · Preventative care or wellness screenings · Prospective or retrospective chart reviews · Refill authorization · Research & clinical trials · Shared visits with other healthcare providers (i.e. physicians, nurses, behavioral health specialists)
HEALTHCARE PROFESSIONS
All applicants have to complete a 4-year undergraduate degree All PA programs are master level (the bachelor and certificate programs did exist but, all the programs have switched over to master level about a decade ago). The PA curriculum is modeled off of medical school; we usually take the same classes as the 1st year medical students and in some university's we are in the same classes with the MS1's First 12-months are didactic (similar to MS1 ie: biochemistry, pharm, anatomy, immunology etc. ) Students have to pass their OSCE and an end-of-the-year exam in order to progress in to their second year Second 12-months are clinical rotations (ie: FM, IM, Surgery, ED, Ob/Gyn, Peds, psychiatry 2-electives....some schools have a geriatric rotation) Rotations are either 4 or 6-weeks in length After every rotation the students have to come back to campus to take an end-of-the-rotation exam (they have to pass) and they perform an OSCE. They have to pass all components to advance to the next rotation. Schools vary with the OSCE....some require a case write-up but, all have the end-of-rotation exams Prior to graduation, all students have to sit for a 4-hour exam that prepares them for the national examination (PANCE) for their boards; they have to pass this in order to graduate PA schools are between 24-30 months; the 30-month programs have an additional 6-month rotation specific 'residency' (ie: 6-months rotations just in peds, or surgery, or ED) **After graduation, some PA's go on to complete an additional 1-year residency program in that specialty area (ie: ED, surgery/ortho are the top ones). These are quite competitive and are usually 1-year in length. These residency programs are usually at prestigious schools like Yale or Cleveland Clinic** After graduation, all PA's have to take their boards (6-hours in length) and pass to practice medicine; this is what the "C" designates at the end of the PA (PA-C) All certified PA's are required to recertify (ie: sit for their boards either in FM or IM) every 10-years (this just changed; it used to be 7-years). I don't know if surgery PA's still have to sit for their surgery board separately in addition to the general board exam (I never worked in surgery). I do know in TX, in order to practice in psychiatry, there is a psychiatry boards in addition to the normal PA boards that is required to practice. These psychiatry boards are very similar to the psychiatric resident's boards so you train with the residents in preparation for them. There is no degree for DScPA (that is a NP thing) PA's who usually go into academics obtain their PhD or DHs (I have heard PA schools will soon be requiring all their faculty to have a doctoral degree) but it is not required as of yet. PhD will take 5-7 years whereas a DHs degree takes 4-years. But, these degrees are totally separate from the PA training (whereas the NP program incorporate this into their program). PA's are required to complete 100 CME/2-years How PA and NP training differ: Nurses who apply to NP school automatically get in to the program Training on-line (all PA programs are 'brick-and-mortar' except Yale now has the option to do some training online) NP's certify once; they do not have to re-sit for their boards They are required to have 100 CME /2-years
Pharmacists also have the opportunity to incorporate 3-5 years of clincial experience crammed into 1 year by completion of a residency program. There are 1st year residencies in health system and community pharmacy practice. PGY2 or 2nd year residencies build upon this experience but are in specialty areas: cardiology, ID, oncology, critical care, amb care, etc. This is the preparatory step for most faculty positions but also clinical pharmacy specialist and other management positions.
Fellowship training is usually pursued after 1-2 years of residency. These programs are shrinking in number primarily due to the fact that funding is problematic with only a fellowship as opposed to documentation of a formal additional degree such as a masters in clinical research. The masters in research programs are becoming the preferred route to gain additional skills/knowledge in research.
Ambulatory Care Pharmacy Bottom Line
It involves being an integral part of an outpatient, interprofessional healthcare team to improve quality and patient outcomes by focusing on medication management.
STATE VS FEDERAL LEVEL OF PRACTICE
§Practicing at the top of your license" •Federal system recognizes credentialed & privileged pharmacists as "mid-level healthcare providers" ~ NP, PAs •Collaborative drug therapy legal drug therapy prescribing protocol with physician -"Scope of practice" •May include laboratory tests, diagnostic tests •Pharmacists maintain their own independent clinic visits with patients •Documentation co-signed by physician •Prescribe, adjust, monitor meds as needed •State level of practice •Collaborative drug therapy protocols allowed as dictated by state pharmacy practice acts
Clinical Rounding Teams in Hospitals (Often Academic Institutions)
PharmD on teams can vary depending on health system and funding. Examples: ICU, ID, Internal Medicine, Psych Pharmacist on a team will work up patients prior to collect and assess, then will bring up recommendations to the team. Other professions will also communicate their recommendations. Then as a whole we make a plan and follow-up (PPCP). Often the team will communicate prior to seeing the patient (aka sit-down rounds). Then will discuss with patient (aka walk-rounds) Don't forget patients and their care givers are part to the team. Dr. Higbea rounds ½ day a week inpatient with her Family Medicine Team. She also rounded on various teams during residency including ICU, Surgery, Geri, and ID.
Independent Community Pharmacy
Pharmacist-owned, privately held business Encompass 43% of nation's drugstores 23% of independent pharmacy owners own 2 or more pharmacies Average independent owner owns 1.5 pharmacies Dispense 1.3 billion prescriptions annually §41% of the retail prescription market
Chain Pharmacy: Utilizing Technology
Pharmacists send > 5,000 computer generated email & text prescription refill and compliance reminders daily Patients can order nonprescription and refill medications on-line or by text Patient education accessed through websites "Ask the pharmacist" email access available for disease and drug questions
Which professions do you think most commonly interact with?
Physicians pa np nurse Often community pharmD communicate via telephone or electronically. Remember PharmD's are the medication expert. If something is not clear or concerning, it should be communicated in a respectful and non-judgmental manner. You both have the same goalà patient care.
WHAT DOES "HEATHCARE TEAM" AND "TEAM-BASED CARE" MEAN?
TEAM Physician Bedside Nurse Nursing Case Manager Nurse Practitioner or Physician's Assistant Dietician Pharmacist Clinical Social Worker Physical Therapist
•IPEC Core Competencies
1. Values/ethics of interprofessional practice •Honesty, integrity, confidentiality, dignity with patients & families 2. Roles/responsibilities for collaborative practice •Communicate own role & that of other healthcare professionals 3. Interprofessional communication •Choose effective communication tools including technologies to enhance team function 4. Interprofessional teamwork & team-based care •Engage other professions in problem solving & quality improvement
Transitions of Care
60% of all medication errors occur during transitions of care. To provide patients with accurate medication information, pharmacists should perform medication reconciliation upon transitions of care. PharmaD's are integral to evaluating the appropriateness of med use, ensuring info is updated in the health record, and verbally communicating accurate information to other health professionals. An increased risk of medication errors occurs when a patient transitions from the hospital to the ambulatory care setting if complete information is not avail- able and if multiple health professionals are providing care.10 Failure to implement safeguards within care transitions can lead to adverse events and higher rates of rehospitalization.11 Poor communication during transitions of care is responsible for roughly one-half of all hospital-related medication errors and one- fth of all adverse drug events.12 During care transitions, inadequate communication can lead not only to medication errors but also to delays in care, inappropriate monitoring, overall confusion about the care a patient is receiving, and increased health care expendi- tures.7
Ambulatory Care Pharmacy
Ambulatory care pharmacy practice is the provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. This is accomplished through direct patient care and medication management for ambulatory patients, long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self-management. The ambulatory care pharmacists may work in both an institutional and community-based clinic involved in direct care of a diverse patient population. (APhA)
Pharmacist Consultation: Chain Pharmacy
Chain community pharmacies are more likely to have consultation windows for pharmacist-patient discussions
Compounding Laboratory
Compound suspensions, rectal suppositories, oral slurries Primary customers are pediatrics, veterinarians, adults who cannot swallow, or who require creams, ointments for topical skin ailments or diseases Selection of colored capsules for making compounded medications Selection of ointment containers for creams and ointments
Pharmacist Consultation: Community Pharmacy
Consultation room where a meeting between patient and pharmacist can be held in privacy Computer access to input the prescription order or access patient education information
Chain Community Pharmacy
Corporation-owned Many stores located regionally or nationally §Usually hundreds to thousands of stores §Some independently owned franchises which share same name as corporate-owned stores •Medicap pharmacy Most offer 24-hour and/or drive-thru service for convenience All pharmacies are open evenings and weekends Most chains offer drive through refill and new prescription service Walgreen's chain §One drive thru window in 1990 §2,130 drive thru windows in 2004
•Provider Status" is not necessarily "Payment for Services"
How do I get paid? Be Proactive. Let you and the services you can provide be found by claiming your Pharmacy Profiles profile. CPhA has partnered with Pharmacy Profiles, a subsidiary of APhA, to provide pharmacists a FREE tool to help you maintain all of your professional information in one place. Claiming your profile is easy, takes just minutes, and positions you to be found by payers. Continue providing the best care for your patients and share your profession's impact in improving health outcomes and reducing costs. As demand for pharmacists' services increases, increased pressure will be put on payers to cover these pharmacist services
INTERPROFESSIONAL TEAM STRATEGY
Institute of Medicine (IOM) Working Group on Team-Based Care •Team-based healthcare proposed to improve health outcomes & provide care at a sustainable cost •Organized a physician, registered nurse, physician assistant, pharmacist, social worker, patient advocate to issue guidance on implementing successful healthcare teams Interprofessional healthcare teams have been shown to reduce all-cause hospital admissions, readmissions, medical costs & improve survival rates of patients
PATIENT-CENTERED CARE: 2001 era - present
Institute of Medicine (IOM) definition •"Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions." Patient-centered care is the practice of caring for patients (and their families) in ways that are meaningful and valuable to the individual patient. It includes listening to, informing and involving patients in their care. The IOM (Institute of Medicine) defines patient-centered care as: "Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions."
CHANGING TERMINOLOGY
Interface between MTM Core Elements with JCPP Patient Care Process creates MTM Service Model; pharmacists work within an interprofessional care team to accomplish MTM/CMM. Pharmaceutical care was the first term coined to describe the pharmacists patient care process. The new terminology is focused on patient-centered care, where the pharmacist is the focus, not the drug product. This is the process of collecting patient information, assessing the info, developing a plan, implementing the care plan, then following up/monitoring to make adjustments is the Pharmacists patient care process. MTM or medication therapy management is a term that was coined when the Medicare Part D program was made into law which afforded seniors with prescription drug coverage plans. Medication therapy management is a billing term used to describe a process that a pharmacist gets reimbursed for in order to provide clinical services such as drug regimen review, polypharmacy review, and counseling. Wellness visits to the pharmacy also are counted under this and can be billed to insurance for Medicare patients for pharmacist reimbursement for clinical services. Comprehensive medication management (CMM) is the New term to describe a more comprehensive pharmacist where we want to evolve in the pharmacy profession. It is not yet reimbursed by insurance companies such as medicare but essentially is defined as a pharmacist managing a patient and ALL of of their disease states and medications, not just 1 thing like "anticoagulation" in an anticoagulation clinic. Research is being conducted into these programs to determine clinical outcomes as a result of pharmacist intervention but it is not yet reimburseable.
Day in the Life of Dr. Higbea In a Interprofessional Family Medicine Clinic
Monday: (all day) •Individual appointments and team prn (i.e. med rec, DI, patient teaching) •Diabetes, Hyperlipidemia, COPD, Smoking Cessation, Anticoag, Medication Management/Polypharmacy •Population health project, Diabetes Chart Reviews Tuesday: (prn) •Sometimes will teach in the physician residency didactics and/or meetings Wednesday: (all day) •AM: Inpatient Rounds, PM: Complex Care Clinic Thursday: (AM only) •HTN clinic (collaboration by PharmD and NP) Friday: (prn) •Morning COVID call/meeting
COLLABORATION WITH OTHER HEALTHCARE PROVIDERS
Multidisciplinary team doesn't take into account the talents of the team members effectively and doesn't bolster communication skills, continuity of care
PRINCIPLES FOR HIGH-FUNCTIONING HEALTHCARE TEAMS
Put a high value on open communication within the team, including transparency about aims, decisions, uncertainty, and mistakes. Carry out roles and responsibilities even when inconvenient, and seek out and share information to improve even when it is uncomfortable. Be excited by the possibility of tackling new or emerging problems, seeing errors and unanticipated bad outcomes as potential opportunities to learn and improve. Recognize differences in training but do not believe that 1 type of training or perspective is uniformly superior; recognize that team members arehumanand will make mistakes. Delight in seeking out and reflecting on lessons learned and using those insights for continuous improvement. Have clear expectations for each member's functions, responsibilities, and accountabilities. Earn each other's trust, creating strong norms of reciprocity and greater opportunities for shared achievement. Prioritize and continuously refine communication skills using consistent channels for candid and complete communication. Work to establish shared goals that reflect patient and family priorities and that can be clearly articulated, understood, and supported by all members.
STANDARDS OF PRACTICE FOR CLINICAL PHARMACISTS
Qualifications Process of Care Documentation Collaborative team-based practice & privileging Professionalism & Ethics Professional Development Maintenance of Competence Research & Scholarship Other responsibilities
PRINCIPLES FOR INTERPROFESSIONAL COLLABORATION 2
Stage 0: Professional awareness: traditional pharmacist-physician working relationship—exchanges are discrete & minimal—only interact if have a Q/intervention Stage 1: Professional recognition: involves pharmacists effort to establish a relationship w/ physician—educates/informs physician on the services the pharmacist can provide. Important step in establishing collaborative relationship. Goal at this stage is trust Stage 2: Exploration & trial: requires commitment (low level) by physician beyond stage 0 & 1. Pharmacist is still the initiator of the action; physician may refer a patient or two to the pharmacist to determine if can handle the requested action. Tests pharmacists ability to deliver quality & quantity of care desired. Stage 3: Professional relationship expansion: pharmacist still has more responsibility of being initiator of the relationship/refeerrals; Pharm seeks feedback on past performance & communicates benefits derived from pharmacist presence Stage 4: physician is convinced that benefits of collaborative relationship outweigh risks.
CONTINUITY OF CARE: NEW PARADIGMS
The goal of the Quadruple Aim is to enhance patient experience, improve population health, reduce costs, and improve the work life of health care providers, including clinicians and staff. The Quadruple Aim is widely accepted as a compass to optimize health system performance.
Medication reconciliation is
a formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication orders.
Pharmacists Reimbursement for Services
•"Provider Status" is not "Prescriptive Authority" •"Provider status" is catchy term for reimbursement (by health plans) for pharmacists patient care processes •"Prescriptive authority" is pharmacist prescribing medications •Term seen as contentious turf battle with other healthcare groups with prescriptive authority •Pharmacist prescribing under collaborative drug therapy management protocols in 48 states •Legal agreement with physician to prescribe limited drugs & lab tests under protocol APhA, ASHP, and most other pharmacy professional organizations affiliated with the Joint Commission of Pharmacy Practitioners (JCPP) started lobbying in about 2014 for "provider status" --this is a catchy term that signifies that they are advocating for pharmacist reimbursement for clinical services provided in all settings (primarily ambulatory care & community pharmacy)- if recognized as healthcare providers the pharmacists can bill under Medicare part B in these settings for services rendered. 2 bills were launched, 1 in house and 1 in senate. They have died 2x now in committee after receiving 100% support in the House (much less supported on the Senate side)...primarily due to the price tag on the bill if pharmacists were to start billing for services for every patient they see & impact somehow—too expensiev even though the bills were limited to "Underserved populations" which included inner city & rural areas. "Prescriptive authority" is a contentious term with other health professions as it is seen as pharmacists desiring INDEPENDENT prescripitve authority, working outside of the context of physician or a medical team. But in reality, this term can be used to describe the scope of practice given to pharmacists legally under a collaborative practice agreement with a physician or physician group. Prescripitve authority—the ability to write prescriptions that a patient can fill at a pharmacy, has NOTHING to do with reimbursement for the clinical services provided that led to that prescription being generated. Therefore, it is seen as less valuable than having "provider status" or reimbursement privileges for medicare part B & other commercial insurance plans.
SCOPE OF PRACTICE
•"The procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional licensure" •Guided by state law "pharmacy practice act" definitions •Texas Board of Pharmacy •Defined in a legal collaborative practice agreement Pharmacists who desire to enter into a legal collaborative practice agreement with a physician in a health system, along with all other healthcare providers who desire a certain scope of practice within medicine to prescribe medications & see patients independently (physicians, nurse practitioners, physicians assistants etc) undergo a credentialling and privileging process to obtain these authorities. Credentialling is a process by which an organization verifies the credentials of an individual to ensure they are not fraudulent. Privileging is the process by which a healthcare org authorizes a practitioner to obtain a certain scope of clinical practice corresponding with training and competencies passed.
TEXAS DEFINITION OF PHARMACY PRACTICE
•(33) "Practice of pharmacy" means: (A) Providing an act or service necessary to provide pharmaceutical care; (B) Interpreting or evaluating a prescription drug order or medication order; (C) Participating in drug or device selection as authorized by law, and participating in drug administration, drug regimen review, or drug or drug-related research; (D) Providing patient counseling; (E) Being responsible for: (i) dispensing a prescription drug order or distributing a medication order; (ii) compounding or labeling a drug or device, other than labeling by a manufacturer, repackager, or distributor of a nonprescription drug or commercially packaged prescription drug or device; (iii) properly and safely storing a drug or device; or (iv) maintaining proper records for a drug or device; (F) Performing for a patient a specific act of drug therapy management delegated to a pharmacist by a written protocol from a physician licensed in this state in compliance with Subtitle B; or (G) Administering an immunization or vaccination under a physician 's written protocol
WHAT DO PHARMACISTS DO? 4
•Administer immunizations •Health promotion & disease prevention counseling/consults •Respond to disaster needs and medical emergencies •Perform point-of-care testing •Care coordination between various healthcare delivery models and healthcare team members Manage drug shortages and IT infrastructure
•National Association of Boards of Pharmacy (NABP) administers NAPLEX examination for licensure
•Annual or Biannual licensure renewal •Maintenance of certification (MOC) ~ 15 CE credits/year
•Pharmacy technician
•Assist pharmacists in preparing prescription medications, providing customer service, performing administrative duties •Receive prescription requests, count tablets, label bottles, maintain patient profiles, prepare insurance claim forms, operate cash registers •37 states have formal training requirements •Pharmacy Technician Certification Board Examination or Institute for the Certification of Pharmacy Technicians •Clinical Pharmacy Technicians to call patients post-discharge, schedule appointments with pharmacist, prior authorization requests
SPECIALTY COMMUNITY PHARMACIST
•Blend between hospital, ambulatory care, and community pharmacy •Fastest growing segment of pharmacy > 10%/year •Interfaces with hospital and insurance companies •> $600/month, rare/chronic conditions, special handling or safety monitoring •Operated by chains (Walgreens, CVS) or University health systems or others •Completes "prior authorization" insurance paperwork, fills/dispenses Rx, reviews medical charts High Cost CMS - $600+ Month Copays up to 25 percent of the drug Long term conditions Special handling or administration Limited distribution Monitoring/REMS
INTERPROFESSIONAL TEAMS IMPROVE PATIENT OUTCOMES
•Collaboration in health care has been shown to improve patient outcomes such as reducing preventable adverse drug reactions, decreasing morbidity and mortality rates and optimizing medication dosages. •Teamwork has also been shown to provide benefits to health care providers, including reducing extra work and increasing job satisfaction. Advances in health care have made it virtually impossible for a clinician practicing alone to maintain the knowledge and skills necessary to provide optimal care. This fact, coupled with the increased prevalence of many chronic diseases, which require coordination of treatment involving multiple health care professionals and clinical settings, has led to an appreciation of the need for an interdisciplinary approach to provide appropriate patient-centered care.
Most Pharmacists With Direct Patient Care Collaborate with other Professions
•Community Pharmacists •Ambulatory Care Pharmacists •"Decentralized" hospital pharmacists stationed on hospital floors •Transition of care pharmacists • •Partial/practice setting-dependent •Home health care pharmacists •Consultant pharmacists •Specialty pharmacy pharmacists
Pharmacists With Direct Patient Care
•Community Pharmacists •Ambulatory Care Pharmacists •"Decentralized" hospital pharmacists stationed on hospital floors •Transition of care pharmacists • •Partial/practice setting-dependent •Home health care pharmacists •Consultant pharmacists •Specialty pharmacy pharmacists
Pharmacists With Direct Roles for Dispensing Medications
•Community Pharmacists •Sterile compounding pharmacists •"Centralized" hospital pharmacists •Closed door long-term care pharmacists •Nuclear pharmacists • •Partial roles for dispensing medications •"satellite pharmacy" pharmacists in hospitals •Oncology, pediatrics, operating room, hospice centers
WHAT IS "CMM"?
•Comprehensive medication management (CMM) •Term to describe the comprehensive pharmacist where we want to evolve as a profession •Not yet reimbursed by insurance companies •Pharmacist managing a patient and ALL of of their disease states and medications •Not just 1 thing like "anticoagulation" in an anticoagulation clinic •More advanced than MTM •Working within an interprofessional team under collaborative practice •Research is being conducted to determine clinical outcomes as a result of pharmacist intervention MTM ensures covered Part D drugs are used to optimize therapeutic outcomes through improved medication use, - Reduces the risk of adverse events - Is developed in cooperation with licensed and practicing pharmacists and physician (interprofessional team based care)
Pharmacists With No Direct Patient Care
•Corporate pharmacists •Review medication error reports from pharmacies •Develop practice standards for community pharmacists •Hospital pharmacy administrators •Medication quality and safety officers •Sterile compounding manager •Controlled substances manager •Pharmaceutical industry pharmacists •Medical writer /drug consultant pharmacists •Mail order / remote order entry pharmacists
CREDENTIALLING & PRIVILEGING
•Credentialing process definition •Process by which an organization documents and demonstrate that a healthcare professional has obtained qualifications to perform scope of practice expected for patient care in a given setting •Verification of transcripts, degree awarded, valid active pharmacy license, residency certificates, & training certificates (CDE, BCLS, ACLS), board certification
WHAT DO PHARMACISTS DO?
•Dispensing • •Drug Use Control / Policies / Procedures • •Medication safety • •Professional Services implementing Pharmacist's Patient Care Process (PPCP) within interprofessional team-based care Five essential elements serve as the cornerstones of the clinical pharmacist's patient care process: collect, assess the patient and his or her medication therapy, develop a plan of care, implement the plan, and evaluate the outcomes of the plan.
PRINCIPLES FOR INTERPROFESSIONAL COLLABORATION
•Healthcare accreditation standards set by Interprofessional Education Collaborative (IPEC) •Most health profession accreditation standards incorporate 2016 IPEC Core Competencies 1. Values/ethics of interprofessional practice •Honesty, integrity, confidentiality, dignity with patients & families 2. Roles/responsibilities for collaborative practice •Communicate own role & that of other healthcare professionals 3. Interprofessional communication •Choose effective communication tools including technologies to enhance team function 4. Interprofessional teamwork & team-based care •Engage other professions in problem solving & quality improvement Values/ethics: act with honesty & integrity in relationships with patients, families & other team members Respect the dignity and privacy of patients while maintaining confidentiality in the delivery of team-based care Roles/responsibilities: communicate one's role and responsibilities clearly to the patient, families, and other team members; explain the roles/responsibilities of other care providers and how the team works together to provide care Interprofessional communication: choose effective communication tools & techniques including information systems and communication technologies, for facilitating discsusions and interactions that enhance team function. Give timely, sensitive, instructive feedback to others about their performance on the team and respond respectfully as a team member to feedback from others Interprofessional teamwork: engage other health professions approriate to the specific situation in shared patient centered problem solving. Reflect on both individual and team performance improvement
QUALITY INFORMATION IN HEALTHCARE
•Healthcare quality measures are used to benchmark performance of health systems, clinics, physicians, pharmacists/pharmacies, etc •Utilized for accreditation of healthcare organizations •Accreditation status is a quality indicator •The Joint Commission accredits hospitals, long term care facilities, and healthcare organizations •Report cards are quality indicators of compliance with care documentation and providing evidence-based care when indicated •Patient ratings are captured by patient surveys of the care experience provided & level of patient satisfaction with care •Used by 3rd party payers & other patients to select healthcare providers & facilities Certifies competency in providing safe, effective care that improves patient outcomes and meets patients needs regarding care experiences
•Certificate programs
•Hyperlipidemia, Diabetes (CDE), Asthma
COLLABORATION WITH OTHER HEALTHCARE PROVIDERS "TEAM-BASED CARE"
•Inclusion of pharmacists on healthcare teams •Best practices well documented in cardiology & critical care; reimbursement in transplant •Reduces medication-related errors •Reduces costs of care •Reduces adverse reactions •Improves accuracy of medication history and reconciliation •improves continuity of care •Improves compliance with accreditation & quality metrics
MAIL ORDER; REMOTE ORDER VERIFICATION REGULATORY PHARMACISTS
•Information technology, med safety manager, drug shortages manager
CONSULTANT PHARMACISTS
•Long term care facilities, closed door pharmacies
PHARMACISTS CLINICAL SERVICES IN COMMUNITY & AMBULATORY CARE
•MTM terminology embraced by 2003 Medicare Prescription Drug, Improvement, and Modernization Act •Mandated payment for MTM services (~ $30-60/hr) •Includes pharmacists in the list of healthcare providers reimbursed for this process •Traditionally, pharmacists are not recognized "providers" of healthcare services eligible for reimbursement under Medicare Part B in the Social Security Act •Less about "provider status" and more about "reimbursement for pharmacists clinical services provided to patients" Medicare Part B "Providers" include physicians, Physicians assistants, certified nurse midwives, certified nurse practitioners, qualified psychologists, clinical social workers, certified nurse anesthetists, and registered dieticians. Exclusion of pharmacists from SSA language is a commonly cited reason by insurance plans as the reason why pharmacists cannot be reimbursed for services provided. Pharmacists are the ONLY member of the primary interprofessional team excluded from the social security act language presently. Certain laws have carved out exclusion such that pharmacists could get reimbursed under various parts of medicare, such as medicare part D (prescription drug act) to provide clinical services & get reimbursed, but even though pharmacists get reimbursed under medicare part D, they still presently do not get reimbursed or even recognized as healthcare providers under medicare part B (or medicare part A). Unfortunately, since insurance companies almost uniformly follow what the federal government offers for Medicare plans, pharmacists are excluded from having billing & reimbursement privileges for most commercial healhtcare plans.
"Front End" Sales
•Many pharmacies profit mostly from products sold in front of the prescription counter, or in other parts of the store •Items sold include greeting cards, candy, nonprescription medications and supplies, groceries, and other convenience items (Picture 1) •Other pharmacies rely on pharmacist education for profit (Picture 2)
WHAT IS "MTM"?
•Medication Therapy Management (MTM) •Billing term coined when Medicare Part D program was made into law •Affords senior citizens (age > 65) with prescription drug coverage plans •Pharmacists are reimbursed for providing clinical services •Drug regimen review •"polypharmacy" review -- •Patient counseling on drug therapy •Wellness visits to the pharmacy MTM ensures covered Part D drugs are used to optimize therapeutic outcomes through improved medication use, - Reduces the risk of adverse events - Is developed in cooperation with licensed and practicing pharmacists and physician (interprofessional team based care) The people who can benefit the most from MTM are those with chronic conditions and prescribed multiple medications. More than 77% of seniors between the ages of 65 and 79 suffer from one or more chronic diseases. The number rises to 85% for those over age 80. Medication-related problems are estimated to be one of the top five causes of death in that age group, and a major cause of confusion, depression, falls, disability, and loss of independence.
CONTINUITY OF CARE
•Patients may see multiple providers •Primary care, specialists, nurse practitioners •Transition between inpatient & outpatient care •The Joint Commission mandated medication reconciliation for hospital accreditation •Requirement for: •Informational continuity between providers including disease care plans and patient preferences for care •Management continuity established care plan & appointment scheduling that avoids patients becoming lost to follow-up •Relational continuity between patient and 1 or more providers Patient-physician sacred relationship of old has been replaced as healthcare system evolves Evolving role of the pharmacist-pharmacist handoff from amb care pharmacist to community pharmacist to handle
•Board Certification - Board of Pharmaceutical Specialties (BPS)
•Pharmacotherapy & growing number of specialties •Recertification every 7 years highest level of certification available for pharmacists. It is only available to those who have practiced for at least 3 years or who have undergone residency training
•Privileging process definition
•Process by which an organization authorizes healthcare professionals to perform a specific scope of practice after reviewing credentials, experience, & competencies •Pharmacists enter into legal collaborative practice agreement with physician to perform a certain scope of duties for a certain scope of medications
PHARMACEUTICAL INDUSTRY
•Research and development •Medical science liaisons •Drug information / Marketing
WHAT DO PHARMACISTS DO? 3
•Review and develop policies/procedures related to pharmacy operations and drug dispensing, storage, inventory, pharmacist functions •Evaluate safety and contribute to quality management within pharmacy & health systems •Provide adequate documentation to comply with regulations & accreditation standards •Manage employees, sales, marketing, inventory management, and budgets in health systems or insurance plans
What Do Pharmacists Do?
•Reviews, evaluates, and interprets prescriptions issued by physician, or other authorized prescriber, to ensure accuracy, safety, proper dosing, no drug-related problems •Labels, dispenses medications according to written orders/prescriptions issued by an authorized prescriber and laws/regulations •Answers questions and provides patient counseling on drug interactions, side effects, dosage, instructions for use, & storage of meds •Ensures all dispensed drugs are recorded and delivered in accordance with local, state and federal laws or regulations •Works within the interprofessional healthcare team to provide consultation on and recommendations for patients' medication plans •Utilize the pharmacist's patient care process to ensure optimal drug therapy regimens •Evaluate and recommend or educate others on cost-effective medications for populations