1. The Pharmacist’s Role In a Residency-based Patient Centered Medical Home Eric Schneider, PharmD, BCPS Jonell Hudson, PharmD, BCPS Lois Coulter, PharmD, BCPS UAMS AHEC Northwest Family Medicine Residency Fayetteville, Arkansas

2. Objectives 1. Determine the role for clinical pharmacy services in each of the areas of the patient centered medical home. 2. Evaluate their family practice program for areas that would be improved by clinical pharmacy services. 3. Develop a model of the patient centered medical home that includes clinical pharmacy services.

3. The Pharmacist and the Patient Centered Medical Home

4. Definition of the PCMH “The Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it……” National Committee for Quality Assurance http://www.ncqa.org/tabid/631/Default.aspx

5. Components of the PCMH http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html

6. Core Features of the Medical Home Personal Physician Physician Directed Medical Practice Whole Person Orientation Care is Coordinated and/or Integrated Quality and Safety Enhanced Access Payment Reform Center for Policy Studies in Family Medicine and Primary Care. The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change

7. Pharmacist Role in PCMH Adding people with varied skills to the team increases the number of possible solutions that will be generated. Specialists, pharmacists, mental health providers and others can provide focused recommendations… Center for Policy Studies in Family Medicine and Primary Care. The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change

8. University of Arkansas for Medical Sciences AHEC Northwest

9. UAMS AHEC Northwest Family Medicine Residency Program 27 Residents 9 Faculty Physicians 3 Faculty Pharmacists 2 Clinics / inpatient services in 2 hospitals EHR

10. UAMS AHEC Northwest Pharmacy Services Inpatient teaching and clinical service in both hospitals Outpatient patient care services (direct and consultative) Residency Teaching Quality Assurance

11. Information Technology

12. EMR Utilization UAMS NW representation on the AHEC-wide EMR committee responsible for improving the functionality and optimal use of the EMR includes a pharmacist member. Development of policy regarding EMR use Development of standardized minimal data sets for chronic disease management Implementation of population-based chronic disease management

13. EMR Safety Monitoring “Free text” entry of medications and medication allergies prevents medications from being included in interaction screening. A standard query of the active database was designed to identify un-coded medication and allergy entries. Pharmacists review all un-coded medications and allergies entered in the EMR and make corrections on a regular basis.

14. EMR Refill Management Service A pharmacist coordinated refill management service is being developed to ensure appropriate drug therapy, follow-up and monitoring. Refill requests for routine, non-controlled medications will be routed to pharmacists for review and processing. Feedback to prescribers will be provided regarding appropriateness of use and monitoring needed.

15. Registry Functions Patient Information entered into Registry Point of care data for patient visits Status reports provide clinician feedback Identify patients needing follow-up care

16. Why Use a Registry? 1. Ensure regular follow-up 2. Ensure use of evidence-based guidelines 3. Provide reminders for clinicians (and patients) 4. Facilitate planned care visits 5. Monitor performance of practice team 6. Enable population management 7. Enable task delegation to other members of the healthcare team

17. Anticoagulation Clinic Pharmacist-run anticoagulation clinic Chronic monitoring and education of anticoagulated patients Disease registry is being developed to assist in tracking patients requiring anticoagulation therapy.

18. Quality Measures

19. Practice Guidelines Use of practice guidelines Education of residents Chart reviews Management of Patients Pharmacy managed clinic services Examples: American Diabetes Association Standards of Medical Care American College of Chest Physicians Evidence-based Clinical Practice Guidelines for Anticoagulation NHLBI Expert Panel Report of the Treatment of Asthma National Cholesterol Education Panel

20. Chart Reviews “Just in time” chart reviews Focus on individual family medicine resident Individualized review for the patient Using EMR to streamline access to patient data and facilitate communication with resident physicians Process: Review medical record for upcoming patient encounters Allows medical resident to review prior to appointment

21. Chart Reviews Provide recommendations: Pharmacotherapy (evidence based guidelines) Goals of therapy (BP, lipids, A1c) Monitoring of medications (LFTs, renal function, drug levels) Interpretation of drug levels Adherence (reviewing refills provided/requested) Preventative therapies (vaccines) Drug interactions/allergy concerns Drug induced diseases/problems

22. Chart Reviews Recommendations are phrased to provide teaching opportunity Referencing guidelines or studies Explaining rationale for recommendations Recommendations are “flags” in the electronic medical record Prior to EMR – written recommendation sheet was utilized

23. Example Chart Review

24. Chart Reviews Evaluation of “just in time” chart reviews already presented All charts were reviewed with ½ of the recommendations sent to the resident. residents who were advised of these items before the encounter acted on them 51% of the time when not given the items prospectively, residents were able to identify issues and take action on their own 17% of the time

25. Collaborative Practice Agreement Arkansas Code Annotated 17-92-101 and 17-92-205 Specific acts of disease state management (DSM) delegated to a pharmacist for an individual patient by an authorized practitioner through a written protocol Other states have similar laws/codes/regulations

26. Collaborative Practice Agreement In draft form Protocol specifics: Identifies practitioner Identifies pharmacist Statement of activities provided through DSM interaction National guidelines are utilized and referenced to develop protocol

27. Patient Experience

28. Pharmacist Managed Clinic Services “PharmD clinic” Process: Referral from faculty or resident physician Individual appointment with faculty PharmD Appointment times vary in length Physician and pharmacist work collaboratively to help patient reach their health care goal Clinic notes forwarded to physician Patient is “discharged” from PharmD clinic when goal is met

29. Pharmacist Managed Clinic Services Examples: Diabetes Asthma Anticoagulation Lipid Management Hypertension Smoking Cessation Weight Management

30. Other Patient Care Experiences Diabetes US Diabetes Conversation Map Group diabetes education facilitated by pharmacist “Brown bag” review for geriatric patients Home bound patients Education and monitoring of anticoagulation

31. Example Encounter Example: Type 2 Diabetes Encounter Discuss general management: Development of Type 2 DM Review goals of therapy Glucometer education Discuss patient specific topics Medications and adjustments if needed Nutrition Exercise Goal setting – patient specific

32. Example Encounter Example: Asthma Encounter Discuss general management: Asthma pathophysiology and general triggers Rescue versus controller Preventative measures Discuss patient specific topics Specific triggers Use of medication devices – adjust if needed Development of asthma action plan Goal setting – patient specific

33. Practice Organization

34. Pharmacists’ Educational Role in Family Medicine Residency Program Clinic chart reviews Hospital teaching rounds Noon conference curriculum Journal Club e-Drug Bulletin 4 week PGY2 Pharmacotherapy rotation 4 week PGY3 Scholarly Activity and Evidence-Based Medicine rotation Quarterly Productivity Report Card

35. Hospital Teaching Rounds Medication Reconciliation Evidence-based pharmacotherapy Cost-effectiveness Pharmacokinetic Dosing Drug interactions Drug therapy Monitoring IV to PO Conversion Patient education

36. Pharmacists’ Noon Conference Curriculum Anticoagulation Asthma Contraception Diabetes Drugs in Pregnancy and Lactation Drug Interactions Drug Therapy in the Elderly Good Prescribing Habits Heart Failure Hormonal Therapy Hyperlipidemia Hypertension New Drug Update Pharmacojeopardy Psychiatric Pharmacotherapy

37. Journal Club Understand Evidence-Based Medicine approach Literature evaluation skills Classify the different types of studies Strengths, weaknesses, applicability Statistical tests Know and apply the hierarchy of evidence Will these findings change the way I manage patients in my practice? Will these findings change the way I manage patients in my practice?

38. e-Drug Bulletin

39. PGY2 Pharmacotherapy Rotation Initiated as elective rotation Evolved into required 4 week rotation Rotation’s Goal To learn the principles of rational medication evaluation, prescribing and monitoring Series of didactic discussions for common medical problems in primary care Evidence-based discussions Case-scenarios Medical calculations OTC Field Trip

40. PGY2 Pharmacotherapy Rotation Objectives 1. Evaluate patient’s medications with respect to indications, efficacy, adverse effects, toxicity, compliance, drug-drug/drug-disease interactions and cost-effectiveness. 2. Select and utilize cost-effective medications prescribed for common primary care disease states. 3. Monitor a patient’s medications appropriately for efficacy and toxicity. 4. Understand pharmacokinetic principles for appropriate prescribing in pediatric, elderly, pregnant, renally- or hepatically-impaired patient populations.

41. PGY2 Pharmacotherapy Rotation Objectives 5. Understand importance of medication reconciliation across the continuum of care. 6. Select and use appropriate drug information resources and clinical guidelines, including electronic and online references. 7. Identify, prevent, and educate patients about common adverse effects of medications. 8. Understand the principles of basic biostatistics and literature evaluation.

42. PGY2 Pharmacotherapy Rotation Objectives 9. Critically review the literature. 10. Select most appropriate patient-specific medications for common disorders in primary care. 11. Effectively educate a patient about their medications. 12. Correctly evaluate and adjust a patient’s warfarin therapy based on their INR.

43. Pharmacotherapy Rotation Pre-/Post Assessment “Test” to assess pharmacotherapy knowledge base given on first and last days of rotation Mean improvement = 44.6% Median improvement = 41.3% Combination of multiple choice, matching, short answer, and calculation questions covering primary care pharmacotherapeutics

44. Pharmacotherapy Rotation Pre-/Post Assessment Sample question Circle all of the following drug classes which have proven mortality benefits in the treatment of patients with heart failure. a. ACE inhibitors b. Beta blockers c. Loop diuretics d. Digoxin e. Aldosterone antagonists

45. PGY3 Scholarly Activity and Evidence Based Medicine Rotation Required 4 week rotation Learning opportunity to further develop medical literature evaluation skills and understanding of evidence based medicine. Family Practice Inquiries Network (FPIN) Education modules within FPIN and Med-Challenger Publication of HelpDesk Answer

46. Quarterly Productivity Report Card for Individual Practitioners Provides practice management information Compares resident and faculty information to each other and the national benchmark Reviewed quarterly during noon conference Demonstrated improved E&M coding

47. Quarterly Productivity Reports

48. Concluding Remarks

49. Pharmacist’s Role in Residency-based Patient Centered Medical Home Clinical pharmacists can play an integral role in each component of the Patient Centered Medical Home and work collaboratively to support attainment of optimal, patient centered outcomes.