Transcript Penobscot Community Health Care
Expanding Pharmacy Services in a Health-System Primary Care Clinic: Factors to Consider
Andrea Lee, PharmD PGY2 Health-System Pharmacy Administration Resident
Objectives
Identify methods to justify the expansion of sustainable primary care pharmacy services in a health-system clinic.
Health-Care Facility
Penobscot Community Health Care (PCHC) is a Patient Centered Medical Home serving over 60,000 patients annually at 16 practice sites – Totaling over 350,000 patient visits – 70% of patients are lower income Largest and most comprehensive Federally Qualified Health Center (FQHC) in Maine – Shared Savings Accountable Care Organization (ACO) – Previously in a Pioneer ACO- 2013 – Rural health care facility providing comprehensive health care services to the greater Bangor area and surrounding communities Image: www.visitmaine.org
Outpatient Pharmacy Background
Three Outpatient Pharmacies – Roughly 80,000 prescriptions annually – Hours of Operation vary among locations • One pharmacy open weekday evenings and weekends starting October 2012 3 Full-time Pharmacists – Focus of time spent in dispensing roles
Clinical Pharmacy Services Background
Two* Clinical Pharmacists- Husson University Faculty Four PGY1 Community Pharmacy Residents – 75% of time in clinics, 25% of time dispensing – Program developed in 2011 Clinical participation from pharmacists within the integrated team is limited to Husson Faculty presence and resident rotation within practice sites – Current services include clinical consults, chart reviews, joint patient visits with primary care provider (PCP) Administrators desire increased clinical pharmacy services within the organization
New Position Proposal
Pharmacy Business Model Innovation –
Service Design:
•
0.6 FTE – Pharmacy Staffing at Helen Hunt Health Center (HHHC) Pharmacy in Old Town, ME
•
0.4 FTE – Clinical Pharmacy Integration conducting reimbursable patient visits
– Allows for expansion of outpatient pharmacy hours in another location – Adds a desired imbedded clinical component
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Benefits of the Proposed Position
1.
6.
7.
Increased access to outpatient pharmacy services for Walk-in Care Patients Increased capture rate on new and refilled prescriptions Improved oversight and documentation of continuity of care Increased pharmacy presence within practice sites Increased patient satisfaction and efficiency of the care experience Increased touches on Medicare patients Improved student/resident education
Overview of the Landscape in Old Town, ME
Pharmacy Locations – 3 pharmacies within 5 mile radius of health center Walk-In-Care (WIC) Locations – HHHC is the only WIC open Weekends – EMMC Orono no longer provides WIC services (Sat Appts only) – UMaine Cutler Health Center- Mon-Fri only
Hours of Operation for Outpatient Pharmacy Extended Hours- HHHC
Current Hours
Monday- Friday 8:30am – 5:00 pm
Proposed Hours
Monday-Friday 8:30am – 8:00pm Saturday 9:00am – 4:00pm Staffing: 1 FTE (40hr) Staffing: 1.6 FTE (67hr)
Historical Perspective on Extended Hours
Brewer location began extended hours October 2012 – Staffing component for PGY1 residents Brewer Totals y = 0,4062x - 16301 800 700 600 500 400 300 200 100 0 TOTAL NEW REFILL Линейная (TOTAL)
Trends at Brewer Pharmacy – Extended Hours
Average Monthly Fill 2012 182.3
2013 2014 258.8
295.5
Average Montly Fill 2012 112.6667
2013 2014 111.25
136
Analysis of Brewer Pharmacy, cont.
Change in Patient Perception – Knowing that the pharmacy is open nights and weekends as a driver for growth – Objective Measure: Volume of refilled prescriptions filled during extended hours Average Capture Rates of WIC RX’s around 40% – Varies by day, provider in WIC
Extrapolation to HHHC Pharmacy
FINANCIAL IMPLICATIONS – Additional Cost/Year to Extend Hours
$177,242.00
Includes salary, fringe, direct expenses, administration fees Requires approximately 5550 additional prescriptions to break even 13% rate in growth needed Market Analysis- Questions to Consider – What is the WIC volume at HHHC in terms of Brewer?
– What is the pharmacy’s current capture rate of prescriptions coming out of clinic?
Trends in Pharmacy Totals
Background on Medicare Annual Wellness Visit (AWV)
Fully paid for by Medicare Part B for beneficiaries 65 and older – No cost to eligible beneficiaries Focused visit on “Health Risk Assessment (HRA)” – Health prevention – Disease detection – Coordination of screening Pharmacists across the country have performed AWVs Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/
Billing for Annual Wellness Visit
HCPCS Codes
G0402 G0438
Billing Code Descriptors Reimbursement (FFS Maximum Rate)
Initial preventative physical examination (IPPE); face to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment Provider Required Annual wellness visit (AWV); includes a personalized prevention plan of service (PPPS), initial visit $159.38
G0439 Annual wellness visit (AWV); includes a personalized prevention plan of service (PPPS), subsequent visit $106.35
AWV eligible for Medicare beneficiaries 66 years and older Subsequent visits billable every year Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/ Warshany K et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):44-9.
Benefits to the Organization
Utilization Drivers – Increase vaccinations (~1.25 vaccinations recommended per person, ~30% received vaccinations at time of visit) – Referrals for additional services; ie. lab, podiatry, dietitian, PT, audiology, mental health (~1 referral placed per patient) – Opportunities to improve quality metrics • • Patient’s accessing electronic portal Focus on a specific metric requiring improvement (eg. Mammogram, colonoscopy)
Feasibility of AWV Proposal
5510 Medicare Beneficiaries 66 years and older at PCHC practice sites Pharmacist to see 13 patients each week Estimated Net Revenue
$5,435
per year Factors to consider – No show rates ~33% within institution – Start-up costs – Marketing of services – Provider and patient buy-in
Post Question
What factors should be considered when justifying sustainable primary care pharmacy services?
a) Understand the unique characteristics of the surrounding community to support expanded pharmacy services b) c) d) e) Align proposed services with the clinical and financial priorities of the organization Ensure payments for pharmacy services are within the scope of the organization’s reimbursement structure Ensure a sustainable infrastructure of support is included in the proposal, including staffing levels, anticipated growth, shifts in payments, and future technology costs All of the above
References
Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/ Desselle SP, Zgarrick DP. Pharmacy management: essentials for all practice settings. 2nd ed. New York: McGraw Hill Medical, 2009.
Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. Am J Health Syst Pharm. 2014 Jan 1;71(1):44-9.
Questions?
Medicare Part B licensure
Evaluating its potential in a federally qualified health center (FQHC) outpatient pharmacy system Kari London, PharmD PGY-1 Community Pharmacy Practice Resident Penobscot Community Heath Care April 26 th , 2014
Objective
Understand the barriers and benefits of DME Supplier enrollment in the independent pharmacy setting – Focus: Diabetic testing supplies
Background
• From 1980 to 2004 the number of people age 65 years and older diagnosed with diabetes increased almost two fold, from 2.3 million to 5.8 million 1 • Prescription medications to treat diabetic complications, and antidiabetic agents plus testing supplies, are two of the largest drivers of expense at 18% and 12%, respectively 2 • Medicare Part B coverage is an important means of mitigating prescription costs of these products
Background cont.
• FQHC with 16 primary care practice sites • Pharmacy services • 3 outpatient pharmacies, residency program, faculty practice sites, pharmacy students • Exploring feasibility of piloting DME supplier enrollment at one pharmacy • Primary products on interest: diabetic testing supplies
Barriers
Program administrative costs
Medicare DMEPOS Enrollment Fee NABP DMEPOS Accreditation Fees Application and Survey Fees Annual Participation Fee Year 1 subtotal Estimated total for 3-year accreditation Surety Bond (annual fee) Estimated Total Fees Year 1 Year 1-3 Total Per Site (USD)
532 3250 125 3375 3625 1200 5107 7757
Barriers cont.
Program infrastructure – Software systems – Documentation requirements – Employee training – Inventory management
Barriers Cont.
Patient recruitment – Eligible patient population size
Total Patient Capture Diabetic Patient Capture 19.9%
Other pharmacies
18.7% 80.1%
PCHC pharmacies
81.3%
Low product reimbursement
50ct Test Strips 100ct Lancets Medicare reimbursement Average Revenue
$10.41
-$42.86
$2.52
-$5.10
BG Monitor
$72.34
$51.06
Prescription
----------- -$324.18
Benefits
Improved patient recruitment – The “Loss Leader” – i.e. gross ~$7,000/year of revenue on prescriptions for 1 patient Increased services Improved patient care – Patient Centered Medical Home – Coordination of care
The Numbers
Revenue per diabetic pt. / year Testing Supplies RXs Other RXs Total Revenue $(648) $1 464 $2 112
The Numbers cont.
Revenue projection
Year 1 Average / Year
$6 000 $4 000 $2 000 $ $(2 000) $(4 000) $(6 000) $(8 000) $2 050 $(5 107) $(3 057) $2 050 $(2 585) $(535)
Cumulative Years 1-3
$6 150 $(7 757) Administrative Costs Potential DM Pt. Revenue $(1 607) Net Revenue
Conclusions
Administrative costs of implementing Medicare Part B billing pose the most significant barrier to program feasibility Potential increase in capture of non-diabetic supply prescriptions may be sufficient to mitigate losses associated with filling diabetic testing supply prescriptions Being a participating DME supplier for diabetic testing supplies presents a negligible loss ($535/ pharmacy/year) – Utilized conservative patient capture increase numbers and high estimate of revenue loss of diabetic supplies – Did not account for potential revenue loss from lost patients
References
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Ashkenazy R, Abrahamson MJ. Medicare coverage for patients with diabetes. A national plan with individual consequences.
J Gen Intern Med
. 2006 Apr;21(4):386-92.
American Diabetes Association. Economic costs of diabetes in the U.S. in 2012.
Diabetes Care
. 2013; 36 (4): 1033-46.
DMEPOS. NABP National Association of Boards of Pharmacy. Website. http://www.nabp.net/programs/accreditation/dmepos . Accessed November 29th, 2013 NHIC, Corporation. The DME MAC Jurisdiction A Supplier Manual. Website. http://www.medicarenhic.com/dme/supmandownload.aspx
. Accessed December 6th, 2013.
Post question
Potential threats to the success of Medicare Part B DME program for this FQHC pharmacy system include: A. Low product reimbursements B. High administrative costs C. Documentation requirements D. Eligible patient population size E. All of the Above
Questions?
Zach Deabay, PharmD Penobscot Community Health Care PGY1 Pharmacy Practice Residents April 26 th , 2014
Objectives
Discuss the interdisciplinary team approach in the management of COPD Evaluate strategies utilized to improve disease state management and access to medications Analyze effect of the program on healthcare utilization and strategies moving forward Disclosure: Study funded by grant received from Cardinal Health. Did not influence implementation, execution, or analysis of study.
Background
• • • Prevalence of COPD in the US is estimated at 23.6 million adults 1 Medicare patient with COPD have higher rates of hospitalization, ER visits, and home healthcare use than non-COPD peers 2 • Total excess healthcare costs of ~$20,000/year higher • ~80% due to inpatient services Studies looking at efficacy of self-management interventions to improve COPD management have demonstrated mixed results 3,4
Overview
Components of Program – Education session with care manager and pharmacist – Rescue Pack • Providers choice of antibiotic +/- steroid for patients to keep at home • Patient must contact care manager or provider before use Goals – Educate patient to better self-manage disease state – Optimize therapeutic regimen – Provider easier/quicker medication access to reduce severity of COPD exacerbation
Workflow
Pre-visit – – Chart review by care manager Pharmacotherapy review by pharmacist • Recommendations made to provider Visit – Disease state assessment, education, and management techniques – Comprehensive medication assessment • Technique, compliance, barriers, perception Post-visit – – Care management follow-up Rescue pack
Program Materials
Target Population
Documented COPD exacerbation in prior 12 months prompting patient to seek acute medical attention (Emergency Department, Walk-In Care, Office Visit) Other Inclusion Criteria • Patient desire to participate • Patient attendance of educational visit Exclusion Criteria • History of non-compliance • Comorbidity affecting ability to self manage disease state COPD Diagnosis Inclusion Criteria Met Approval of PCP Pre-visit Protocol Education Visit
Enrollment
First patient enrolled 8/29/13 Enrollment ongoing 52 patients enrolled to date – Females – 32 (62%) – Males – 20 (38%) – Age • Range – 42-91 years • Average – 65 years – Current Smoker – 49% – Average # Medications – 10 – Average # Respiratory Medications – 3 – Oxygen Therapy – 20%
Result Analysis
Patients required to be in study a minimum of 3 months before analysis performed 26 patients meet this criteria – Additional 11 patients qualify in May Analysis will include: – Primary endpoints • Hospitalizations • Use of emergency department and walk-in services • Death – Secondary endpoints • Rescue pack use (appropriate/inappropriate) • Number of exacerbations
Preliminary Observations
Majority of patients enrolled in program are prescribed rescue pack (>80%) Of those prescribed rescue packs, most have not used them (<50%) Most commonly prescribed combination is azithromycin/prednisone Several patients have used the rescue packs inappropriately but majority of uses (>75%) have been appropriate Program appears to be reducing utilization of emergency room – Possible shift from decreased ER visits to increased office visits
Program Benefit
Patient Benefits Disease state education Medication education Pharmacotherapy review Relationship with care manager Easier access to medication Organization Benefits Patient care divided among team members Accurate medication list Assessment of medication compliance Pharmacotherapy review
Improved patient outcomes* Lower healthcare costs* *Being assessed in current study
Patient Case
56 yof with COPD, typically waits if she is sick After CM visit reports recognition of symptoms that warrant appt. Lack of maintenance medication identified at visit with follow-up recommended Patient initiated antibiotic and steroid, with PCP follow-up visit within several days. Instructed to call back for appointment if symptoms do not improve. Patient call: states "been having more shortness of breath and burning in chest, which is always the first sign of the bronchitis." Follow-up office visit: “patient reluctant in gen to take meds but with recent exacerbation she started the pack and did much better than usual, recovering more quickly from COPD exac.”
Key Points
Interdisciplinary approaches utilize the expertise of all healthcare team members Rescue packs provide quicker and easier access to medication and may be a useful tool, if used appropriately It is essential to do educational visit Before rescue pack medications are sent to pharmacy Difficult to predict which patients are most appropriate for rescue packs – All patients expected to benefit from educational component
Assessment Question
Benefits of enrollment in the COPD program include all of the following except: A.
B.
C.
D.
Medication and disease state education Patient ability to decide when their symptoms warrant antibiotic therapy Quicker access to medications if deemed appropriate by provider All of these are benefits of the program
References
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Mannino DM, Braman S. The epidemiology and economics of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2007; 4 (7): 502-6.
Make B, Dutro MP, Paulose-Ram R, Marton JP, Mapel DW. Undertreatment of COPD: a retrospective analysis of US managed care and Medicare patients. Int J Chron Obstruct Pulmon Dis. 2012; 7: 1-9.
Effing T, Monninkhof EEM, van der Valk PP, et al. Self-management education for patients with chronic obstructive pulmonary disease (Review). Cochrane Database Systm Rev. 2009 Bucknall CE, Miller G, Lloyd SM, et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomized controlled trial. BMJ 2012; 344: e1060 doi: 10.1136/bmj.e1060
London, Kari. Chronic obstructive pulmonary disease management in high risk patients: Evaluation of a multidisciplinary team approach to reduce readmission rates within a federally qualified health center population. MSHP Conference. Jan 26, 2014.
Questions?
Pharmacist Interventions on Prescribing Habits for Urinary Tract Infections (UTIs) in a Walk In Care Clinic
Nicholas LeBlanc, PharmD PGY1 Pharmacy Resident Penobscot Community Health Care
Objective
Identify trends in antibiotic resistance of urinary tract infections and formulate a plan to reduce inappropriate prescribing of antibiotics.
Introduction
Uncomplicated cystitis is a very common infection among young women and a major source of antimicrobial exposure.
Repeated antimicrobial exposure can select for resistant organisms.
Antimicrobial resistance has complicated treatment of urinary tract infections.
Community pharmacists can play a role in lowering resistance.
Guidelines
First-line agents are Nitrofurantoin, Trimethoprim Sulfamethoxazole (Bactrim), and Fosfomycin.
TMP-SMX should not be used empirically if local resistance is greater than 20%.
Second-line agents are fluoroquinolones and β lactams.
Fluoroquinolones should not be used empirically if local resistance is greater than 10%.
Local Resistances
Local Resistances
UTI Prescription Analysis
A 6 month time period was analyzed.
Reviewed antimicrobial prescriptions associated with ICD-9 code 599.0 (UTI).
Inappropriate medications were omitted: – Azithromycin – Doxycycline – Metronidazole
Initial Results
Tetracyclines 3%
Antimicrobial Agents
Nitrofurantoin 20% Penicillins 9% TMP-SMX 29% Fluoroquinolones 34% Cephalosporins 5%
Discussion
A total of 1315 prescriptions were analyzed.
Approximately half of the prescriptions analyzed were for non-first line agents.
Fluoroquinolones were the most highly prescribed antimicrobial class (33.38%).
Penicillins, cephalosporins, and tetracyclines were sparsely prescribed.
Limitations
ICD-9 codes do not describe the patient well.
The data does not distinguish whether the UTI was treated empirically or not.
Tetracycline use may not have been associated with UTIs.
Role of the Pharmacist
Community pharmacists can serve as a source of information for providers.
– – Up to date on guidelines Drug experts – Useful resources Giving feedback to providers on prescribing habits.
Provider education – CME presentations – Calling about errors in prescriptions – – Group meetings Handouts – – EMR alerts Get feedback from providers
Conclusion
Antimicrobial resistance is low, but prescribing habits leave much room for improvement.
Pharmacists can be a valuable resource of drug information and provide education to providers.
There are many different ways in which pharmacists may educate providers.
References
Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011; 52(5):e103–20.
Gupta K, Hooton TM, Stamm WE. Increasing Antimicrobial Resistance and the Management of Uncomplicated Community-Acquired Urinary Tract Infections. Ann Intern Med. 2001;135(1):41-50.
Hooton T, Gupta K. Acute Uncomplicated Cystitis and Pyelonephritis in Women. UpToDate. 2013.
Assessment Questions
Which of the following is an appropriate way to reduce resistance of urinary tract infection organisms by pharmacists?
A.
B.
C.
Ensure proper prescribing of first-line agents Antimicrobial stewardship programs Keeping providers up to date on current guidelines D.
E.
Be a resource of drug information for providers All of the above are true
Questions?
Implementation and outcomes of an interdisciplinary collaborative practice group on controlled substance use and prescribing within a patient-centered medical home
Rachel Bastien, PharmD PGY1 Resident, Penobscot Community Health Care Bangor, ME
Objective
Summarize the development, workflow, and pharmacist involvement of the Controlled Substances Initiative (CSI) committee and evaluate the impact on providers, patients, pharmacy dispensing, and prescribing habits.
Disclosure Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: Rachel Bastien: Nothing to disclose
Motivation
Increasing rates of prescription drug abuse The cost to the overall health of patients and the community Negative social impact Increased costs associated with abuse Provider frustrations
Development
Formed in March 2013 Initially, the committee members were appointed by the executive medical director – Executive medical director – Chief quality officer – Chief psychiatrist – Physicians – Nurse practitioners Soon after pharmacists were added for their drug expertise Weekly meetings where approximately 8-12 patients are reviewed
Workflow
1 • Referral to CSI 2 • Pharmacist conducts a comprehensive chart review 3 4 5 • Pharmacist presents patient case from chart review to committee • Collaborative interdisciplinary discussion generates targeted, evidence-based recommendations with action plans • Consensus recommendations communicated to provider 6 • Review and appeal process
The Role of the Pharmacist
Pharmacist conducts a comprehensive chart review, including – Maine Prescription Monitoring Program (PMP) report – Health Info Net – Office visit notes – Consults with specialists – Medication history – Imaging studies – Any additional pertinent information – Calculate Morphine Equivalent Dose (MED) Presents case to committee Communicates responses to providers
Population reviewed
Outcomes
Percentage of patients with MED changes post CSI review
5% 24% 32% Off of narcotics entirely (N = 21) Reduced dose (N = 34) No change (N = 28) 39%
Outcomes
Narcotic and Benzodiazepine prescriptions written organization wide
2200 2150 2100 2050 2000 1950 1900 1850 1800 1750 June July
Month
August 2012 2013
Outcomes
Number of prescriptions filled at largest-volume internal outpatient pharmacy 2012 (June-Aug) 2013 (June-Aug)
CII
Total
Opiates Stimulants
1514
673 841
1245 (-17.7%)
606 (-9.9%) 639 (-24%) CIII-V
Total
Benzodiazepine Codeine/Hydrocodone Products Buprenorphine Products Hypnotics Other (Lyrica, Soma, Testosterone, etc.)
1307
433 392 265 127 90
1080 (-17.3%)
350 (-19.1%) 296 (-24.4%) 281 (+6%) 93 (-26.7%) 60 (-33.3%)
Challenges and opportunities
Presenting alternative treatments to providers – Use of NSAIDs, SSRIs, therapy, etc where appropriate Challenges within PCHC prescribing trends – Increase prescribing of tramadol and ketorolac Engaging the entire healthcare team – Physical therapy – OMT – Addiction services
Discussion
An overall 63% reduction in MED occurred in patients reviewed by the committee A 12% reduction in the number of opioid prescriptions written occurred between January and September 2013 The largest of the 3 internal outpatient pharmacies saw a 17.7% decrease in the number of C-II prescriptions filled
Takeaway points
Provides provider support and education Defines clear expectations for both patients and prescribers Allows for objective and evidence-based use of controlled medications
Assessment question
As a result of instituting a controlled substances committee, which of the following was not directly enhanced?
1. Multidisciplinary collaboration 2. Patient acceptance of need for dose reduction 3. Chapter 21 compliance measures 4. Provider prescribing support