Reducing the Expenditures and Workload Associated with Partial Fill Prescription Processing in a Veterans Affairs Health Care System Sara E. Carlisle, Pharm.D. PGY1 Pharmacy Resident Fayetteville North Carolina Veterans Affairs Medical Center (FNCVAMC) Fayetteville, NC April 2017

Disclosure Statement These individuals have nothing to disclose concerning possible financial or personal relationships with commercial entities (or their competitors) that may be referenced in this presentation. Primary Investigator: Sara E. Carlisle, Pharm.D. Project Mentor and Co-investigators: Lauren T. Howard, Pharm.D. William J. Elliott, Pharm.D., BCPS Jennifer C. Nazarchyk, Pharm.D., BCACP, CDE This material is the result of work supported with resources and the use of facilities at the Fayetteville Veterans Affairs Healthcare Center in Fayetteville, North Carolina. The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Fayetteville North Carolina Veterans Affairs Medical Center Background Fayetteville North Carolina Veterans Affairs Medical Center (FNCVAMC) 2 Health Care Centers (HCC) 6 Community Based Outpatient Clinics (CBOC) 21 counties served in the Carolinas 3 pharmacies serving 53, 916 Veterans 232,890 prescriptions during fiscal year 2016

Consolidated Mail Outpatient Pharmacy (CMOP) Background Charleston, South Carolina Consolidated Mail Outpatient Pharmacy (CMOP) FNCVAMC filled 1,177,314 prescriptions through CMOP Fiscal Year (FY) 2016

Material Expenditures Background FY 2016 Partial Fills Raw Drug Cost: $232,504 Material Expenditures Workload Expenditure Why Partial Fill?

Purpose The purpose of this quality improvement project was to evaluate the effect of providing refill and partial fill process education to a VA Healthcare System staff and Veterans on partial fill expenditures and workload fiscal impact.

Objectives Primary Objective Secondary Objective To compare the effect of refill and partial fill process education on partial fill expenditures after intervention as compared to baseline expenditure Secondary Objective To compare the effect on the total average workload expenditure associated with partial fill prescription processing after intervention as compared to baseline expenditure

Methodology Preliminary data (August – October) Updated partial fill guidance Implementation (November) Pharmacy in-services and electronic training module

Methodology Non-pharmacy staff in-services Digital signage and updated patient materials New patient orientation Post-intervention data (December – February)

Partial Fill Guidance Criteria for partialing medications Treatment of acute illness Prevention of hospitalization Criteria for partialing medications Refill education Provide updated handout Emphasizes correct refill process Maximum 7 days Partial days supply Indicate why medication partialed Utilization of partial fill justification codes

Partial Fill Expenditures Definitions Partial Fill Expenditures Material Cost Vial + cap + labeling $0.26/partial fill Raw Drug Cost Via ProClarity Reporting Summed material cost + raw drug cost Workload Expenditure Averaged hourly technician and pharmacist rates Multiplied by average time for 10 test partial fills Summed technician + pharmacist partial fill rates $4.85/partial fill

Results: Primary Objective

Results: Primary Objective $1,454.96 $50,596.48   $664.28 $43,398.73

Results: Secondary Objective

Top Partial Fill Classes by Count Preliminary (N= 5596) Post-Intervention (N = 2555) Class Cost Count Antidepressants $4,572.94 600 Beta Blockers $268.64 295 ACE Inhibitors $169.27 287 Anticonvulsants $723.39 284 CCBs $824.33 274 Oral Hypolgycemics $404.71 273 Antilipemics $772.47 264 Class Cost Count Antidepressants $1,226.28 292 CCBs $456.66 206 ACE Inhibitors $72.63 177 Beta Blockers $148.23 172 Oral Hypolgycemics $128.55 153 Anticonvulsants $433.72 110 Thiazides $14.39 105 N = Total Partial Fills CCB = Calcium Channel Blocker

Preliminary Partial Fill Reasons

Post-Intervention Partial Fill Reasons Extra Bridge to CMOP and Released but not received by pt Bridge to CMOP – specified that tracking not shown delivered but was in transit Processed and released could also encompass patients that are saying the patient did NOT receive in mail but showed delivered. Miscellaneous unspecified, no reason stated

Limitations Brief implementation phase Staff non-adherence to guidance Natural disaster during preliminary period Cost variance in type of partial fills

Future Directions Potential stem project 57 reports of taking medication incorrectly Possible review of tablet splitting practice Continued integration in New Patient Orientation Further emphasis on refill education and adherence to partial fill guidance

Summary Total partial fill expenditure cost avoidance $7,988.43 Extrapolated into a year: $7,988.43 x 4 = $31,953.72 Total workload fiscal impact cost avoidance $14,748.85 Extrapolated into a year: $14,748.85 x 4 = $58,995.40 Total projected cost avoidance for continued implementation Nearly $91,000/year

Self Assessment Question How could refill and partial fill process education potentially impact a VA Healthcare System? Reduction in pharmacist and technician workload Reduction in partial fill expenditures Reduction in material waste All of the above

Acknowledgements Lauren T. Howard, Pharm.D. Project Mentor William J. Elliott, Pharm.D., BCPS Residency Preceptor Jennifer C. Nazarchyk, Pharm.D., BCACP, CDE

References Department of Veterans Affairs. Health Benefits. VA/DoD webpage. Available at https://www.va.gov/healthbenefits/access/prescriptions.asp. Accessed on March 20, 2017. Department of Veterans Affairs. VHA Chief Business Office. VA/DoD webpage. Available at https://www.va.gov/healthbenefits/access/prescriptions.asp. Accessed on March 20, 2017. U.S. Office of Personnel Management. Pay and Leave. OPM webpage. Available at https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/. Accessed on March 20, 2017. Department of Veterans Affairs. Fayetteville VA Medical Center. Fayetteville VAMC webpage. Available at http://www.fayettevillenc.va.gov/about/index.asp. Accessed on March 20, 2017.

Reducing the Expenditures and Workload Associated with Partial Fill Prescription Processing in a Veterans Affairs Health Care System Sara E. Carlisle, Pharm.D. sara.carlisle@va.gov PGY1 Pharmacy Resident Fayetteville North Carolina Veterans Affairs Medical Center (FNCVAMC) Fayetteville, NC April 2017