Pharmacy Access Office Hours May 16 2019 Focus Topic Clinical Pharmacy 101 This session is supported by the Health Resources and Services Administration HRSA of the US Department of Health and Human Services HHS as part of an award totaling 6375000 The contents are those of the aut ID: 760727
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Slide1
Pharmacy Access Office Hours
Pharmacy Access Office HoursMay 16, 2019Focus Topic: Clinical Pharmacy 101
This session is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,375,000. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
Slide2Webinar Logistics
We strongly recommend calling in on your telephonePhone: 866-469-3239Access Code: 632 274 023 #Your Attendee ID: Listed below the access code in the box under “Select Audio Connection”.
To ask/ answer a question, or share a comments, please use the Chat box on the right hand side of the screen
You can download
these slides
on Noddlepod
,
& from NACHC’s
NEW
340B/ Rx webpage:
http://www.nachc.org/focus-areas/policy-matters/340b
/
Or go to NACHC.org and search 340B
Slide3Operational UpdatesFocus Topic – Clinical Pharmacy 101Q&AAnd Comment Box discussions throughout…
Slide4OPERATIONAL UPDATES
Colleen Meiman
Senior Policy Advisor
National Association of Community Health Centers
cmeiman@nachc.org
Slide5Additional Support for Rx Operations
Tim Mallett from 340Basics is now under contract with NACHC to provide Training and Technical Assistance (T&TA) to health centers on pharmacy operations.Contract is funded through BPHC Cooperative Agreement, so:Thank you BPHC!Focus is operations, not advocacy.To access Tim’s expertise, you can either:email Colleen at Cmeiman@nachc.org oremail Tim directly at tmallett@340Basics.com and cc Colleen (This is probably the faster route….)
Slide6Discriminatory Contracting
Health Centers – and other 340B providers -- are continuing to receive contract addendums from third-party groups offering reimbursement/ fee structures that are inconsistent with Congressional intent. Because this topic relates to advocacy, we cannot discuss it in this forum.
Slide7An on-line platform, limited to members of the health center “family”, to discuss pharmacy and 340B-related issues.Free & open to all health centers -- but as it’s not sponsored by BPHC, won’t go into details now. Do NOT discuss confidential details of reimbursement, etc.Sign up to join by emailing cmeiman@nachc.org or cdevoe@nachc.org
Are You on “Noddlepod”?
It’s actually noDDlepod, not nOOdlepod
– but I still thought the image might help.
Slide8Outreach from “DecisionPoint Research?
DecisionPoint Research (DPR), an independent market research firm, has been hired by a major retail pharmacy chain to study FQHCs’ in-house pharmacies. If you or your colleagues are contacted by DPR, please contact Colleen Meiman at cmeiman@nachc.org before responding.
Slide9Info on Medicaid & 340B
For more info, contact Gavin
Magaha
at Apexus
-
gavin.magaha@apexus.com
Slide10Starting this month, 340B providers can verify that they are not being overcharged for 340B drugs.*Info is available in a new section of the Office of Pharmacy Affairs Info System (OPAIS.)
The Ceiling Price Database is LIVE!
* Remember that the 340B CEILING price is not always the same as the 340B PURCHASE price, since the PURCHASE price may contain “sub-ceiling” discounts & distributor fees.
Slide11Are You Overpaying for Vaccines or IUDs?
Neither vaccines nor IUDs are subject to mandatory discounts 340B.BUT… as a 340B provider, you are eligible for discounts on vaccines, and $50 IUDs (similar to Mirena.)
For info on discounted vaccines, contact Apexus at 888.340.BPVP or apexusanswers@340Bpvp.comFor info on $50 IUDs, contact mdiallo@medicines360.org or go www.medicines360.org
Slide12Miscellaneous
Recordings of most Rx Office Hours sessions are now available on the NEW NACHC Pharmacy website.A couple months are missing due to Colleen’s IT learning curve….GAO now conducting a study of methods to avoid duplicate discounts.Increased focus on contract pharmacy compliance.If you are contacted by Kalderos, we advise you to respond promptly.
Slide13Looking Ahead
Upcoming Office Hours TopicsMAY: Clinical Pharmacy 101 (Matt Bertsch)JUNE: TPAs? (Jim Donnelly) or Recent Trends in Audit Findings (Matt Atkins)JULY: Pharmacy Charges - Sliding Fee Scale & Other Considerations
Slide14More Learning Opportunities
For
people who work with 340B or their FQHC’s finances:340B Coalition ConferenceJuly 15-17 in Washington DCThree sessions focused specifically in FQHCsTwo will focus on “Three Strategies to Optimize the value of your 340B program.”
For people new to 340B
:
A “
340B 101” webinar
– in May (exact date TBD
)
340B
University for FQHCs
– Aug 17 in Chicago (right before NACHC CHI)
Slide15Email Tim Mallett at tmallett@340Basics.com for support with operational issues. (Please cc Cmeiman@nachc.org.)Sign up for Noddlepod by emailing cmeiman@nachc.org or Cdevoe@nachc.org.Contact Colleen if you are contacted by DecisionPoint Research.The Apexus website has info about Medicaid and 340B in each state. FQHCs can purchase discounted vaccines and $50 IUDs.There are several upcoming learning opportunities around 340B, geared both to “newbies” and “old hands.”
Summary of Operational Updates
Slide16Please do the 1-minute evaluation
Slide17Focus Topic: Clinical Pharmacy Programs in an FQHC
Speaker: Matthew Bertsch, PharmDUniversity of Arizona, College of Pharmacy GraduateClass of 2012Director of PharmacySun Life Family Health CenterResidency Program DirectorPGY1 Community-Based Pharmacy Residency Program340B Coalition Speaker/FacilitatorWC 2017, SC 2017, WC 2018, SC 2018, WC 2019
Slide18Today’s Agenda
An overview of Sun Life
Pharmacy Care Initiatives
Sun Life wellness initiatives that would be impossible without 340B savings
Pharmacy residency program and residency projects
Anticoagulation
Weight management
Opioid management
Diabetes management
Affordable medication program
Chronic care management services and Annual Wellness Visits
Collaborative practice agreements
Developing smart business models around clinical programs
Conclusion
Slide19An Overview of Sun Life
Sun Life Family Health Center is a not-for-profit organization providing health care to Apache Junction, Casa Grande, Chandler, Eloy, Coolidge, Florence, Maricopa, Oracle and San Manuel. Sun Life Family Health Center is Pinal county's largest provider of primary health care services. Governed by a Board of Directors representing the patients and communities served by the organization, Sun Life serves over 47,000 patients, 28% of whom are children. What makes us different is our unfailing concern for the well-being of our patients, and our willingness to provide the best possible experience for every person that walks through our doors.
19
Slide20An Overview of Sun Life
13 sites6 pharmaciesFrom San Manuel to Maricopa114 miles2 hoursCounty road travelOracle4,500ft elevationMaricopa1,175ft elevationEloy The only pharmacy in townFlorenceThe only pharmacy for 8 milesSan ManuelThe only pharmacy for 28 miles
A County Map
Center for Women – No In-House Pharmacy
Clinic Sites– No In-House Pharmacy
Center for Children– No In-House Pharmacy
Clinics with an In-House Pharmacy
Dentistry
Chandler Center for Women – Off the Map
Slide21Sun Life’s Pharmacy Program
6 In-House Pharmacies
7 FTE Pharmacists
A Community Based Pharmacy Residency Program
2 FTE Pharmacists and 2 Pharmacy Residents
Pharmacy Administration Team
Oversees Community, Clinical, In-House Pharmacy Needs, 340B Program Administration, Clinical Integration
Slide22Today’s Focus: Clinical Pharmacy Programs
What are “clinical pharmacists”?
Clinical pharmacists focus on providing direct patient care to optimize medication therapy and promote health and disease prevention.
Clinical pharmacists are often found in hospitals or ambulatory care settings, paired with more traditional providers.
How
can a clinical pharmacy program add value to our patients’ care?
Clinical pharmacy can
“advertise”
for community pharmacy
Continuity of care between provider and pharmacist
Clinical
pharmacy services can improve outcomes for patients
High risk measures/grant dollars
Clinical pharmacy can make
for a more positive provider
experience.
Can we offload providers with clinical pharmacists
?
Slide23The History of SLFHC Clinical Pharmacy Program
December of 2015Discussion between Director and PICDecember of 2015 through July of 2016Buildup – Physical spaceProvider buy-in and C-Suite justificationHR Preparation – New positionFirst Contracted SLFHC Pharmacists
July
5
th
,
2016
First two PGY1 Ambulatory Care residents started for SLFHC
New Orleans, LA; and Charlotte, NC
Retained one of the two
June
26
th
,
2017
Second batch of residents started for SLFHC
SC; AZ; NV; CA
Retained 2 of the
4
July 2
nd
, 2018
Third
batch of residents started for SLFHC
AZ; PA
April 25
th
, 2019
Received
ASHP
accreditation confirmation
PGY1 – Community Pharmacy
Slide24What do our clinical pharmacists do?
Primary services out of Casa Grande
location
Expanded to: Florence, AJ, CG-CFW
Can assist all providers through the EHR and telephonically
Focused on diabetes education, gestational diabetes, pain management, anti-coag, ambulatory
care
Medication Reconciliation Services
Serve as provider and staff resource
Assist in prior authorizations from nursing staff
Answer medication questions from patients
Meet one on one with patients
Monthly staff/provider lunch and learns
Patient education in rooms during provider visits
Place and interpret continuous glucose
monitors
All of these activities are funded with 340B savings.
Slide25Integrating pharmacy into diabetes education
Program is based on referrals from
providers
Diabetes program consisted of
FTE CDE – Traveling and Teaching
Per diem Program Coordinator – Meter trainings, assessments, etc.
Per diem program assistant – Meter trainings, assessments, etc.
Appointments
were backed up two months
Patients were not being seen in a timely fashion
Referral – First Visit (Assessment) – Group Classes - Graduation
Bottleneck was the assessment
Simply no manpower
Decided
to integrate pharmacy resident into the program
Slide26Integrating Clinical Pharmacy into Provider Workflow
Ambulatory Care portion of our
workflow
Providers are overloaded with patients…
Tasked with treating disease states, meeting health plan metrics, maintaining productivity, UDS measures, etc.
Provider visit can look like…
What is your chief complaint?
Sick visit…
Chronic condition review...
…diabetes, hypertension, hyperlipidemia…
Review and target the metrics...
Colonoscopy, influenza vaccine, Medicare – scheduled for your annual wellness visit, medication review, medication adherence to statin/ACE or ARB…deciding new prescription therapy, sending prescriptions…charting everything, using the proper CPTII code…
Trying to sell the pharmacy…
Generate revenue…
Slide27Integrating Clinical Pharmacy into Provider Workflow
Clinical pharmacists can assist with everything after the chief complaint…
PCP sees patient
PCP consults with clinical pharmacist
Clinical pharmacist can see the patient before or after the PCP
visit,
can schedule follow-ups with clinical pharmacist, etc.
Clinical pharmacist may be able to generate refills or prescriptions via standing order, and ensure proper therapy.
Clinical pharmacist makes recommendations to PCP
PCP closes out
visit
Slide28Pharmacy Care Initiatives
Clinical and Community Pharmacy Projects
Anticoagulation
Weight management
Opioid management
Affordable medication program
Chronic
Care Management services
Annual
Wellness
Visits
Collaborative
practice agreements
Developing
smart business models around clinical
programs
Slide29Anticoagulation
Over the past year, our clinical pharmacist-directed anticoagulation monitoring service achieved significantly better INR control when compared against the patients of one physician. This study showed a 10.1% improved control in patient’s INRs when seen at the SLFHC anticoagulation clinic. This difference is similar to other studies which show 8% - 17.7% better INR control by clinical pharmacist-run anticoagulation clinics versus usual physician care
.
Patients are referred to pharmacists for anticoagulation services for VKAs. These patients are controlled and monitored by the clinical pharmacy team.
Where
appropriate, patients are also identified for changes to DOACs (then filled at Sun Life Pharmacies where possible…)
Slide30Weight Management
Patients that were followed by a pharmacist lost weight. Patients that did not follow-up gained weight. More than 50% of the 12 patients lost at least 5% of their bodyweight, as predicted. This amount of weight loss has been correlated with positive cardiovascular outcomes
.
This program has evolved from the ketogenic diet (before “keto” was popular with the masses) to general nutrition and weight management services.
Slide31Opioid Management
With a team-based approach in a FQHC, a significant decrease in morphine equivalent dose was seen at 3 months. A 45% decrease in morphine equivalent dose was seen in 3 months, and a 0.23 in pain score. This showed that a team-based approach can manage pain with minimal opioids
.
With National and State Opioid regulations aplenty, clinical pharmacists have stepped in to assist with the opioid epidemic by helping providers find suitable alternatives, helping patients and providers decrease MMEDs for patients, and offloading providers by assisting with prior authorizations.
Slide32Diabetes Management
The mean hemoglobin A1C pre DSME classes was 8.66%, while the hemoglobin A1c post DSME class was 7.58%. The median hemoglobin A1c pre DSME was 8.1%, while the post DSME median was 7.1%. The p-value was statistically significant (<0.05).
Our CDE pool has grown from 1 headcount (an RN) to 2 (an RN and a clinical pharmacist). This team owns the all-important HBA1c >9 performance metric, and has nearly gotten it to goal.
Slide33Chronic Care Management
Promoted an LPN to and LPN Care Manager to assist our quality department
Chronic Care Management
Quality metrics with a focus on Medicare Annual Wellness Visits
Also works as an intermediary between the quality department, clinical pharmacy and the health plans
Slide34Annual Wellness Visits
Targeted 2 major
h
ealth plans for a Performance Improvement Project
445 Patients in one health plan
Outreach to those patients by Sun Life = 100%
275 of those completed (61.8%)
170 of those declined
28 Patients in one health plan
Outreach to those patients by Sun Life = 100%
15 of those completed (53.6%)
13 of those declined
Slide35Proving Clinical Pharmacy Profitability in the Future
Visits are typically not billed, not a DIRECTLY profitable model
currently
How can we bring direct revenue to the program?
Annual Wellness Visits
Requires a provider to assist in the process, but leads to reimbursement plus incentive payments
Chronic Care Management
Clinical Pharmacists can perform CCM services for patients in certain settings
Indirect
costs addressed
Provider satisfaction leading to decreased turnover, patient compliance with medications leading to increased incentive payments, compliance with UDS and payor metrics leading to increased incentive payments.
Slide36Using Pharmacy Technicians differently
Empowering pharmacy technicians to work to the top of their license
Also to work
differently
Pharmacy Operations (Resource)
Supervisor
Pharmacy Operations Technician (340B Auditor and Contractor
)
Certified Clinical Pharmacy Technician
Slide37Collaborative Practice Agreements
Sun Life Pharmacists have initiated collaborative practice agreements/standing orders to assist providers in practice
Slide38Developing Smart Business Plans
Get your CFOs on your side
…
No matter how much we THINK we change healthcare for the better, where is the money flowing?
Do
our changes contribute to direct revenue?
Are you paid for your services?
Can you attribute your interventions to increased prescription count?
Do
our changes contribute to indirect revenue?
Are we moving quality metrics and getting paid by health plans even though the visit is not reimbursed?
Slide39The In-House Pharmacy Discussion
Do we really need an in-house pharmacy if we capture all of our prescriptions via contract pharmacy?
Do
you REALLY capture all scripts?
Medicaid
?
Access
to care
?
Really, this is a WHOLE OTHER conversation for another time.
Slide40Fringe Benefits of a Strong Pharmacy Program(A message for CFOs and CEOs in the audience)
Clinical Pharmacists now lead most of our quality measures Performance Improvement
Teams
More departments are collaborating within the organization
Integrated Behavioral Health and Pharmacy share an Integrated Services Case Manager
Dental
and Pharmacy have an expedited prescription and OTC program
In-House
capture rates have increased 4.5% since tracking started (15 months)
Pharmacy
is leading organizational initiatives such as customer service, standard operating procedures, and general workflow initiatives (prior authorizations, organization-wide refill practices, six sigma initiatives, etc.)
Slide41This Man…
A personal philosophy, and one our department has embraced.“No Risk It, No Biscuit” If you don’t take the chances (personnel and clinical program creation), you will never reap the benefits.Find employees you can TRUST, and let them do their jobs to the top of their license and positionIf you cannot trust them to do so, you need to find other people.
Slide42Today’s Agenda
An overview of Sun Life
Pharmacy Care Initiatives
Sun Life wellness initiatives that would be impossible without 340B savings
Pharmacy residency program and residency projects
Anticoagulation
Weight management
Opioid management
Diabetes management
Affordable medication program
Chronic care management services and Annual Wellness Visits
Collaborative practice agreements
Developing smart business models around clinical programs
Conclusion
Slide43Additional Questions?
Matthew Bertsch, PharmD
Director of Pharmacy
Residency Program Director,
PGY1 Community Based Pharmacy Residency Program
Sun Life Family Health Center
865 N. Arizola Rd.
Casa Grande, AZ 85122
520-252-1308 (mobile number – call or text)
matthew.bertsch@slfhc.org
Slide44Please do the 1-minute evaluation
Slide45General Q&AReminder: Qs submitted in advance get priority.
Slide46Other Questions?
Slide47Please do the 1-minute evaluation
https://www.surveymonkey.com/r/ZVXFWVS