Innovative Pharmacy Practices: Thinking Outside the Pharmacy Box Colorado Pharmacist Society 2016 Annual Meeting & Exposition

Speakers Amy L Stump, PharmD, BCPS, FASHP Quality Improvement Clinical Pharmacist Associates in Family Medicine, PC Robert Willis, PharmD, BCACP Corporate Pharmacy Trainer/Residency Program Director Albertsons Safeway – Denver Division

Conflict of Interest Disclosure We have no conflicts of interest to disclose.

Objectives Define key steps to take when initiating a new clinical pharmacy service Compare and contrast clinical pharmacist reimbursement models Discuss the use of non-pharmacist staff to help run a clinical pharmacy service List several ways to determine service quality and productivity

True/False When initiating a new pharmacy clinical service it is important to plan, research, identify key stakeholders, create policies, procedures and workflow, determine outcomes, and continuously perform quality improvement initiatives.

When could you use incident-to physician billing for a clinical service? Providing anticoagulation consultations as the local community pharmacy Providing care to an established patient referred to your service by a provider within the practice Providing services for a new patient to the physicians practice Providing a service that is commonly rendered as an inpatient service

True/False Non-pharmacist staff are instrumental in the execution of a new clinical pharmacy service.

Private, physician-owned family medicine practice 70,000-80,000 active patient charts ~56 providers (MD, DO, PA, NP) 9 clinical sites, 3 of which are part of CPCI 1 site co-located with our Urgent Care Care coordinator in each office (RN or SW) 1 Clinical Pharmacist 1 Acupuncturist

Safeway Denver Division 122 pharmacies, 5 states Community Pharmacy focused Patient-Centered Care Immunizations Travel Health Services Biometric Screenings Disease State Management Smoking Cessation Specialty Drug Administration (IM, VG) Oncology – Adverse Drug Reaction Program

Audience Poll In what type of setting do you currently work? Hospital/inpatient Hospital/ambulatory care Community pharmacy Clinic, not associated with a hospital Other

What is your knowledge of starting a new clinical pharmacy service? Audience Poll What is your knowledge of starting a new clinical pharmacy service? I know a little I have working knowledge This is an area of expertise

Audience Poll What is your knowledge of implementing quality improvement initiatives for any type of patient care service? I know a little I have a working knowledge This is an area of expertise

Audience Poll Are you currently billing for clinical pharmacist services at your practice site? Yes No

Audience Poll Do you utilize technicians or other types of support staff to help deliver patient care services? Yes No

Question and Answer Session

What steps are needed to start a new clinical pharmacist service?

Steps to Starting a New Clinical Pharmacist Service Plan and research the new clinical service Assess the need for the new service Identify key stakeholders Organization leadership, providers, compliance Create policies, procedures, workflow process Determine outcomes measures, billing method, and staffing Implement Assess and make changes Expand as needed Perform continuous quality improvement

There are various types of reimbursement models for pharmacy services There are various types of reimbursement models for pharmacy services. How are you reimbursed for your services?

Quality Improvement Clinical Pharmacist Reimbursement Model Incident-to physician referral Patient must be an established patient, referred from a provider in the practice Direct supervision rules apply Service is a type that is commonly rendered in an a outpatient setting Person providing the service is an expense to the practice in some way Grant money Comprehensive Primary Care Initiative (CPCI)

Safeway Patient Care Services Reimbursement Models Specialty Drug Administration Product fulfillment Third Party reimbursement for administration fee Oncology ADR Program Manufacturer compensation for service

Additional Reimbursement Models Fee-for-service Facility fees Medication Therapy Management (MTM) codes Chronic Care Management (CCM) codes Contractual arrangements Employer sponsored wellness programs Medicare Advantage plans Grants Comprehensive Primary Care Initiative (CPCI) Colorado State Innovation Model (SIM)

Describe the workflow process for your service.

Quality Improvement Clinical Pharmacist Workflow Referral Scheduling Patient Appointment Documentation Communication Plan Implementation Follow up Outcomes monitoring CDTM agreement, policies and procedures reviewed annually with Medical Director

Specialty Drug Administration Workflow Patient appointment Product fulfillment Pharmacist administration Pharmacist completes required paperwork Specialty Care Support Center communicates with provider and reports to the manufacture as required

Oncology ADR Program Workflow Product fulfillment Product is sent to the patient Specialty Care Support Center contacts Program Pharmacist Pharmacist calls patient on day 3 or 4 Pharmacist documents ADR consultation Pharmacist sends document to Specialty Care Support Center Specialty Care Support Center communicates with provider and reports the ADR consultation to the manufacturer

How do you document the patient care that you provide?

Quality Improvement Clinical Pharmacist Patient Care Documentation Provider template in Epic for office visits Triage note template for telephonic care Patient portal template for “email” care Other templates as appropriate

Safeway Patient Care Services Documentation Specialty Drug Administration Specialty Drug Administration Tracking Tool Documented in our pharmacy computer system Oncology ADR Program ADR consultations are reported to the manufacturer

How do you communicate with other healthcare professionals regarding your patient care services?

Provider Communication Quality Improvement Clinical Pharmacist Notes in Epic Face-to-face Telephonically Rarely, faxes Specialty Drug Administration & Oncology ADR Program Specialty Care Support Center Electronic Reporting Faxes

Do you use non-pharmacist staff to help run your service Do you use non-pharmacist staff to help run your service? If so, who and how?

Quality Improvement Clinical Pharmacist Front desk staff Scheduling, rescheduling Practice call center Taking patient calls when I am not available Care coordinators Follow up telephone calls to check on how a patient is doing Population health team Data, administrative tasks Clinical staff Help in clinic with various tasks Help with data and pt calls with Medicare Advantage plans Office manager Watch my in-basket when I am out to be sure pt messages are addressed

Safeway Denver Division Patient Care Services Support Specialty Care Support Center (1 pharmacist, 14 technicians) Technicians – facilitate product procurement, third party investigation, coordinate care, direct patients to local ABS/SWY pharmacies, correspond with pharmacy teams, and follow up with provider and manufacturer Pharmacy Support Staff Specialty Drug Administration Technicians – Collate and prepare paperwork, help patients complete paperwork, prepare room/product for appointment, and follow up with Specialty Care Support Center Oncology ADR Program Service provided at the Division Office, telephonically

How long has your pharmacy service been up and running?

History of each Pharmacy Service Quality Improvement Clinical Pharmacist It will be 3 years at the end of July 2016 Specialty Drug Administration Established 2012 Oncology ADR Program Established 2015

What outcomes are you currently tracking, how do you track them, and why were these outcomes chosen?

Quality Improvement Clinical Pharmacist Anticoagulation Clinic % INR in range Costs/revenue generation, Return on Investment PharmD diabetes clinic A1c reduction Geriatrics HEDIS measures, data provided by various payers: A1c, high risk medications, etc. General Cost/benefit to the practice

Safeway Patient Care Services Specialty Drug Administration Adherence Injection site reactions Product complaints Patient satisfaction Oncology ADR Program Number of ADRs Number of pharmacist interventions

What quality improvement processes are in place to ensure the best patient care?

Quality Improvement Assessment Quality Improvement Clinical Pharmacists Annual review of Drug Therapy Management agreements Monthly meetings with AFM leadership Continuous quality improvement through AFM work groups, patient and provider feedback, and data analysis Safeway Patient Care Services Annual review of each Patient Care Service Outline Guideline updates, etc. Annual refresher of each Patient Care Service Patient feedback

How would Provider Status effect your service?

Provider Status Quality Improvement Clinical Pharmacist Clarify/improved revenue generation streams Confer ability to have charges billed out in my name, not under the physician’s May allow for a percentage of notes to require co-signature, not all of them Easier tracking of my productivity in clinic Safeway Patient Care Services Specialty Drug Administration Increase access to patients on MCO Oncology ADR Program Provide similar programs for various products

Helpful Resources Building a Successful Ambulatory Care Practice: A Complete Guide for Pharmacists Editors: Mary Ann Kliethermes and Tim R. Brown ACCP Ambulatory Care Pharmacist’s Survival Guide, 3rd Edition ASHP Ambulatory Care Resource Center http://www.ashp.org/menu/PracticePolicy/ResourceCenters/Ambulatory-Care Networking online ACCP Ambulatory Care PRN ASHP Connect

True/False When initiating a new pharmacy clinical service it is important to plan, research, identify key stakeholders, create policies, procedures and workflow, determine outcomes, and continuously perform quality improvement initiatives. True

When could you use incident-to physician billing for a clinical service? Providing anticoagulation consultations as the local community pharmacy Providing care to an established patient referred to your service by a provider within the practice Providing services for a new patient to the physicians practice Providing a service that is commonly rendered as an inpatient service

True/False Non-pharmacist staff are instrumental in the execution of a new clinical pharmacy service. True