1. Clinical Webinar: Integrated Pharmacy
Benjamin Gross, Pharm D, MBA, BCPS, BCACP, CDE, BC-ADM, ASH-CHC
Associate Professor
Director of Residency Programs
Lipscomb University College of Pharmacy

2. Objectives
Understand services provided by a pharmacist in a primary care office
Recognize quality metrics related to pharmacy services
Develop a plan on how to incorporate pharmacy services into a primary care office with emphasis on Federally Qualified Health Centers (FHQC)

3. CLINICAL PHARMACY SERVICES
COLLABORATIVE PRACTICE
MANAGE
DIABETES
HYPERLIPIDEMIA
HYPERTENSION
CONGESTIVE HEART FAILURE
ASTHMA AND COPD
NICOTINE DEPENDENCE
MEDICATION THERAPY REVIEW
IMMUNIZATIONS
EDUCATE
MEDICATIONS
CHRONIC DISEASE STATES
MEDICATION RECONCILATION
QUALITY ASSURANCE
MEDICAL HOME

4. Comprehensive Medication Management: What is It?
Ensures each patient’s medications (Rx, OTC, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to:
determine that each medication is appropriate for the patient
effective for the medical condition
safe given the comorbidities & other meds taken
able to be taken by the patient as intended

5. Comprehensive Medication Management: What is It?
Is Comprehensive Medication Management equal to Medication Therapy Management?
MTM Centers for Medicare & Medicaid Services (CMS) adopted it in January legislation to refer to the new, additional service required for certain patients receiving Medicare Part D benefits
Comprehensive Medication Management Includes:
An individualized care plan that achieves intended goals
Appropriate follow-up
Patient agreement
Focus on achieving an optimal regimen optimizing the patients medication experience

6. Comprehensive Medication Management: Specific Procedures
An assessment of the patient’s medication related needs
-Uncovering the patient’s medication experience
-Medication History
-Patient’s current medication record
Identification of patient’s medication related problems
-Appropriateness of the medication
-Effectiveness of the medication
-Safety of the medication
-Adherence of the medication

7. Comprehensive Medication Management: Specific Procedures
3. Development of a care plan with individualized goals of personalized interventions -Intervene to solve problems -Establish individualized goals for EACH condition -Design personalized regimens and education -Establish measurable outcomes -Determine appropriate follow-up 4. Follow-up evaluation to determine actual patient outcomes

8. Comprehensive Medication Management: Which Patients Benefit
Those who have not reached goals for care of chronic disease states
Those experiencing adverse effects from medications
Those in need for preventative therapy
Those who are frequently readmitted for care to the hospital or emergency room

9. Pharmacy Services in FHQC
Clinical pharmacists focus on managing complex chronic conditions under collaborative drug therapy management agreements (CDTMs) as well as targeting quality and outcomes metrics for the organization.
Current CDTMs include:
Diabetes
Hypertension
Cardiovascular risk reduction
Asthma
COPD
Smoking cessation
Depression
Anxiety
Psychiatric medication monitoring

10. Pharmacy Services in FHQC
Transitions of care from a local hospital
Post-discharge medication reconciliation
Comprehensive medication reviews for high utilizers of the health care system
Addressing gaps in care for elderly patients
Pharmacists also support primary care teams through drug information presentations and individualized patient consults.

11. What does a typical day look like?
One-on-one appointments minutes
Scheduled ahead of time with help from staff
Assure space in clinic to see patients
Available for curbside consults
Balance time seeing patients with time available for curbside consults

12. WHAT IS A PATIENT-CENTERED MEDICAL HOME?
PUTS THE PATIENT AT THE CENTER OF THE HEALTH CARE SYSTEM
PROVIDES A SYSTEMATIC APPROACH TO PROVIDING COORDINATED CARE TO PATIENTS

13. PCMH Standards Performance Measurement and Quality Improvement (QI)
Care Coordination and Care Transitions (CC)
Care Management and Support (CM)
Patient-Centered Access and Continuity (AC)
Knowing and Managing Your Patients (KM)
Team-Based Care and Practice Organizations (TC)

15. How do you achieve NCQA PCMH recognition?
Must meet all core criteria and earn at least 25 elective credits across five different concept areas

16. Patient Center Medical Home (PCMH)
Integration of pharmacy services within PCMH model in FHQC
Co-Visits
Collaborative Practice Agreements

17. Co-Visits vs. Pharmacist-Only Visit

18. Annual Medicare Wellness Visits
Review of medical and family history
Review of list of current medical providers
Measurement of height, weight, BMI, and BP, along with other appropriate routine measurements
Detection of cognitive impairment
Review of risk factors and establishment of list of risk factors
Review of functional ability
Establishment of a written screening schedule for next 5 to10 years
Provision of advice and referrals to health education and preventive counseling services

19. Annual Medicare Wellness Visits
Medicare mandates that AWVs must be furnished by a health professional, meaning a physician; physician assistant, nurse practitioner, or clinical nurse specialist; or a medical professional (including pharmacists) or a team of medical professionals working under the direct supervision of a physician

20. Annual Medicare Wellness Visits
From a coverage perspective, Medicare provides annual coverage of an AWV for beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not received an AWV within the past 12 months. However, patients may receive subsequent AWVs annually. Currently, initial AWVs are paid at $165 per visit, and subsequent visits at $110 per patient per year. -

21. Annual Medicare Wellness Visits
Based on the fee schedule for AMVs, about 1000 visits per year are needed to sustain a pharmacist full-time equivalent (FTE) position and associated ancillary personnel resources

22. DEVELOPING (Services)
“Define the Services Provided”
Pt enrollment or referral
Pt encounter
Documentation
Collaborative agreements:
Compliance with practice standards
Scope of practice agreement
Collaborative drug therapy management agreement
Legal & liability issues, risk management
Other regulations (OSHA, CLIA, etc)
Certification & Credentialing

23. COLLABORATIVE PRACTICE AGREEMENT
AGREEMENT BETWEEN ONE OR MORE PROVIDERS AND PHARMACISTS
QUALIFIED PHARMACTIS WORKING WITHIN THE CONTEXT OF A DEFINED PROTOCOL
PERMITED TO ASSUME PROFESSIONAL RESPONSIBILITY FOR
PERFORMING PATIENT ASSESSMENTS
ORDERING DRUG THERAPY-RELATED LABORATORY TESTS
ADMINISTERING DRUGS
SELECTING, INITIATING, MONITORING, CONTINUING, AND ADJUSTING DRUG REGIMENS

24. PROTOCOL A DRUG THERAPY MANAGEMENT PROTOCOL IS A WRITTEN PLAN
DELEGATES LEGAL PRESCRIPTIVE AUTHORITY TO PHARMACISTS UNDER DESIGNATED CIRCUMSTANCES
SERVES TO GUIDE THEIR CONDUCT
DIRECT THE COURSE OF ACTION
DELINEATE THE FUNCTIONS, PROCEDURES, AND DECISION CRITERIA TO BE FOLLOWED

26. American College of Clinical Pharmacy (ACCP) Clinical Competencies

27. SUSTAINING (outcomes)
“Evaluate Service Outcomes”
Clinical Outcomes
Humanistic Outcomes
Economic Outcomes
Should be agreed upon before service begins
Should know “where the bar is” before you jump
DOCUMENTATION VERY IMPORTANT!!!

28. Value of Clinical Pharmacy Services
Improved Patient Outcomes
Paynesville Area Health Care System
92% of diabetic patients seen by pharmacist test blood blood glucose compared to 10% who are not seen by a pharmacist
89% of anticoagulation patients are within therapy goal
El Rio Community Health Center
Controlled A1c increased from 6 % to 41%

29. Value of Clinical Pharmacy Services
Cost Savings
Harris Count Hospital
1.5 million in cost savings
Asheville Project
Decrease in total mean direct medical cost by $1200 per patient year
Increased productivity estimated at $18,000 annually

30. SUSTAINING (revenue) * * TOC ICT CCM - Incident-to - Employer-based
- Facility Fee
- G codes
- CLIA waved tests
- Procedures (CGMS, ABPM, insulin pump) *

31. Billing Options
CPT Billing Codes
Practice Setting
Medicare Reimbursement
Diabetes Self-Management Training (DSMT)
G0108 (individual visit)
G0109 (group visit)
All
G0108: $53.70
G0109: $14.30
Incident to physician: office visit
99211
Physician- and hospital-based outpatient clinic
99211: $20.02
Incident to physician: Transitional Care Management (TCM)
99496
99495
99496: $
99495: $
Medication Therapy Management
99605 (first 15 minutes for a new patient)
99606 (first 15 minutes for an established patient)
99607 (additional 15 minute increments)
Pharmacy and self-insured employers, contract health plan
Variable
CMS Annual Wellness Visit
G0438 (first visit)
G0439 (subsequent annual visits)
Physician-and hospital-based outpatient clinic
G0438: $173.41
G0439: $117.28
Chronic Care Management
99490

32. 340 B Discount Drug Pricing Program
Average savings of 19-22% of clinic purchases
Increase the number of patients served
Offset losses from providing pharmacy services for less than full compensation
Reduce prescription prices for patients
Increase services offered at clinics

35. QUESTIONS???