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October 9, 2009

The Battle Over Quality Health Care

Henri R. Manasse, Jr., Ph.D., Sc.D.

Henri R. Manasse, Jr., Ph.D., Sc.D.

AS CONGRESS CONTINUES TO WRESTLE over the details of health care reform, ASHP is keeping its focus on what matters most to hospital and health-system pharmacists and our patients. And members have been behind us all the way. During White House forums last spring and in visits with members of Congress and their staffs during Legislative Day in September, ASHP members highlighted the many ways in which pharmacists improve patient care.

ASHP’s health care reform principles have been very helpful in our ongoing dialogue with legislators and regulators. These principles are essentially three-pronged:

• We want to ensure that patients have coverage for safe and effective medication use,

• We want sustainable financing for health care coverage to help manage costs, and

• We want incentives that align with and encourage quality health care.

These principles help to promote the pharmacist’s value by demonstrating the role of a pharmacist in safe medication use. They support best practices by allowing innovative practices to be recognized, disseminated, and provided to patients. And they focus on quality, which provides opportunities to promote prevention and develop the pharmacy work force.

Specifically, we would like to add annual medication therapy review and assessment by a pharmacist to all Medicare Part D plans and include pharmacists as nonphysician providers under Medicare Part B.

Direct advocacy is not the only way that we are trying to influence the debate in this country over improved patient care. ASHP’s 2015 Initiative continues to be a shining light for improved quality and medication safety and efficacy. We are excited to hear from the increasing number of hospitals and state affiliates that are using the Initiative’s six goals and 31 objectives to drive their own strategic planning.

There is even growing international interest in the project. The Spanish Society of Hospital Pharmacists has modeled its own 2020 Initiative after ASHP’s work. Recently, I presented to the society via video about the 2015 Initiative. You may find this basic overview of the program to be helpful.

Stay tuned as ASHP works to secure a place for hospital and health-system pharmacists in coming changes to our nation’s health care.

Henri R. Manasse, Jr., Ph.D., Sc.D.

Pharmacist Team Brings “Med Rec” to New Level

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Jennifer Rief, Pharm.D, center, teaches two pharmacy residents about the “Safe Med” program.

A TEAM OF PHARMACISTS with Novant Health is on a mission to improve continuity of care by counseling patients with complex medical conditions within a week of hospital discharge. Novant serves more than five million residents in North Carolina and South Carolina across nine hospitals as well as nursing homes, physician practices, outpatient surgery centers, and rehabilitation and  community health outreach programs.

Only two years old, the Safe Med team of six pharmacists is already making substantial progress with the thousands of patients whom team members have counseled. Over that time period, the team cut patient hospital admissions related to adverse drug events (ADEs) from 18 percent to 4 percent.

Safe Med received the ASHP Research and Education Foundation’s Award for Excellence in Medication-Use Safety in 2008. The $50,000 award, supported by Cardinal Health, recognizes pharmacist-led, multidisciplinary teams for significant, institution-wide system improvement in medication use.

“Novant’s program dramatically improves the care of these high-risk patients through the work of these dedicated pharmacists,” said Stephen J. Allen, M.S., FASHP, executive vice president and chief executive officer of the Foundation. “It truly is a proven model that should inspire other health systems to consider implementing.”

Assessment and Education

The teammates view the foundation’s recognition as further evidence that they are making a difference in the lives of patients.

“We’re improving the care of patients by showing that pharmacists are medication experts who can decrease ADEs through a partnership with physicians and nurses,” said team leader Terri Cardwell, Pharm.D.

Terri Cardwell, Pharm.D., team leader of Novant Health’s “SafeMed” program.

Team members focus on patients who are 65 years or older and on medications that are most likely to cause ADEs, such as digoxin, hypoglycemics, and warfarin. They work with both hospital staff and ambulatory care providers to ensure consistent,effective medication use across the continuum of care.

Team members obtain hospital records and assess each patient’s medication regimen. They then speak with the patient and caregivers to educate them on how the medications should be used and provide a medication list that the patient can bring to his or her providers. The team members also provide a reconciled list of the patient’s medications to providers with recommendations for appropriate therapy.

Cardwell said that the team has uncovered many instances of potential harm during their reconciliation process. For example, one patient was prescribed digoxin in the hospital and told to continue taking medications he had at home. However, one of the drugs the man had at home was a version of digoxin with a different name. Luckily, a team member caught the problem in time. “It makes us all feel good that we’re helping the patients and their families understand their medication regimens,” Cardwell said.

Creating an Effective Pharmacy Residents Seminar Series

MANY OF US STRUGGLE with the fact that there often are not enough hours in the day to do all that’s expected of us. And if you participate in residency and fellowship programs, you probably feel the pinch even more. In the Washington, D.C., area, which is home to 15 fellowship and ASHP-accredited pharmacy residency programs, we developed and currently manage a long-standing seminar program for residents, preceptors, residency directors, and fellows that offers high-quality presentations on therapeutic and professional-development topics.

The Importance of Teamwork

As the seminar program has grown in size and complexity, we have relied on teamwork to make it more efficient and effective. Held six times a year, each four-hour seminar in the program series augments the training that residents receive in their health care settings. Residency directors can also network with faculty members from other accredited programs, and preceptors can expand their own knowledge and get professional speaking experience.

From left, Shannon H. Goldwater, Pharm.D., BCPS, FASHP; Pamela S. Smith, Pharm.D.; and Mary C. Binghay, Pharm.D.

Living and working in a metropolitan area has given us access to a variety of professional pharmacy organizations and agencies such as the National Institutes of Health and the Food and Drug Administration for programming ideas and faculty volunteers.

To help reduce costs, we recently moved the seminar series from an area hotel to local residency-site meeting rooms. This change allows residency directors to host the meetings and encourages more preceptors to give presentations. We have also been working to ensure that our communication about upcoming events is efficient. All seminar-series participants are asked to enroll in Yahoo! Groups, a free Internet forum through which we send meeting notices and post relevant information.

Ongoing Quality Improvement
An annual survey of the seminars’ participants has been a great source of information for program improvements. For example, based on feedback, we increased the number of meetings from four to six per year and changed presentation content from a therapeutic overview to a clinical pearls format.

Our meetings have focused on poster development, abstract preparation, presentation skills, pharmacy career development, and preparing for the Board of Pharmaceutical Specialties pharmacotherapy exam. Additionally, meetings have highlighted interviewing techniques, tips on working with other health care disciplines and hospital and health-system administrators work-life balance, and how to write for publication.

To date, feedback has been very positive. Participants, who are placed in groups for each seminar to promote teamwork, idea exchange, and networking, said they especially value working with residents, fellows, and faculty from other programs.

%%SIDEBAR%%Throughout the process of developing innovative programming for the seminar series, faculty members have modeled teamwork, the very behavior we hope to develop in our residents and fellows. Based on ongoing feedback we receive, it is clear that the seminar series has filled a real need locally for professional development and therapeutic knowledge.

Mary C. Binghay, Pharm.D., a pediatric clinical specialist and residency program director at Shady Grove Adventist Hospital in Rockville, Maryland, also contributed to this article.

Riding out the Economic Storm

Scott Knoer, M.S., Pharm.D., pharmacy director of the University of Minnesota Medical Center, Fairview, Minn.

ASHP MEMBERS are using creative tactics to soften the blow from an economic recession that has reduced revenue and forced

layoffs and loss of staff hours in hospital and health-system pharmacies nationwide.

Pharmacy managers have been struggling to make do with lower budgets and Medicaid reimbursements at the same time that the number of uninsured patients under their care is rising.

According to a recent ASHP survey:

• 37 percent of members have had their staffing budgets reduced,

• 10 percent have laid off personnel, and

• 66 percent have been required to reduce their drug budgets.

Creative Approaches

“It’s like the perfect storm,” said Scott Knoer, M.S., Pharm.D., pharmacy director at the University of Minnesota Medical Center at Fairview, referring to the local and national economic conditions that led to layoffs of pharmacists and pharmacy technicians in his department.

Knoer and his staff have found creative ways to keep costs down, especially in the hospital’s overall drug budget. He believes it is important to communicate those savings to the hospital’s administration.

“My drug budget is a lot bigger than my salary budget, so I’m constantly working to find ways to achieve savings for the hospital through better use of drugs, prescribing, and working with physicians,” Knoer said. “Finding all drug cost savings that your pharmacists produce and articulating those savings to your senior administration is very important. You need to communicate that reducing labor is being penny wise and pound foolish, because pharmacists save more in drug costs than in salaries.”

For example, the pharmacy discourages the use of intravenous (I.V.) medications with short expiration dates, which would have to be thrown out if not used in time. And Knoer makes sure workloads are evenly distributed among pharmacists to increase efficiency. More than ever, pharmacists stress to physicians the important cost savings in prescribing formulary medications.

To avoid laying off any more pharmacists, Knoer reduced the hours of five new pharmacists. “Now, they all work four days instead of five,” he said. “That way, they can keep working and maintain their health insurance coverage.”

Knoer sees a silver lining in the recession in that staff members are staying put in their positions. “We’re not having the turnover we might have had in a good economy,” he said.

Therapeutic Equivalents

Even though Beaumont Hospital in Royal Oak, Michigan, hasn’t lost pharmacy staff to layoffs, it’s still feeling the fallout from the diminishing fortunes of the auto industry.

Kathy Pawlicki, M.S., FASHP, director of Beaumont’s pharmaceutical services, also turned to the drug budget to help reduce expenses. “We look for alternative drugs, therapeutically equivalent, at a better cost,” she said. “We have found some significant savings in wound care products.”

Pawlicki said her staff also uncovered savings by making different operating room product choices. “For example, instead of providing medication with a combination product, we are providing individual components at a lower cost,” she said. “We also consider whether patients can take medication orally rather than through I.V.”

Pawlicki advises pharmacy leaders to engage their staff members in uncovering potential savings. “Your staff sometimes knows where waste is occurring. We discovered unused syringes were being discarded in the operating room,” she said. “You need to get more and more people involved. They look under rocks and behind corners, and they have a lot of great ideas.”

Staying Ahead of the Curve

The pharmacy department at Silver Cross Hospital in Joliet, Illinois, has likewise implemented cost-cutting measures to avoid staffing layoffs.

Kathy Pawlicki, M.S., FASHP, director of pharmaceutical services at Beaumont Hospital in Royal Oak, Mich.

Because the hospital’s daily patient population declined 8 percent over the past year, officials decided not to fill an open technician position. Pharmacy director Frank Butler, Pharm.D., BCPS, acknowledges that other pharmacies are facing more hardships than his has. Yet he continues to look for small ways to shave costs and keep larger financial troubles at bay.

“One thing we’re doing is encouraging staff to use paid time off. It takes expenses out of the books,” Butler said. “If it’s a slow night at the pharmacy, the pharmacists can decide to let other staff members leave early. And we’ve been working real hard to get folks out of here on time so that there is no incremental overtime.”

Butler advises other pharmacies to always keep an eye out for ways to cut costs.

“Make sure you watch for savings opportunities, even if there is no crisis in your hospital,” he said. “You definitely want to stay ahead of the curve.”

The Experiential Education Crunch

A GROWING NEED for experiential pharmacy education sites is running into the reality of a limited amount of available
rotations, according to residency preceptors around the country.
“Experiential education these days is challenging all the way around with more and more schools opening up,” said Kim I. Leadon, M.Ed., director of the professional experience program and clinical assistant professor at the University of North Carolina at Chapel Hill Eshelman School of Pharmacy. “The capacity issues are real. There are only so many sites, and it’s very competitive out there.”

A Numbers Game
A demand for the clinical services of pharmacists is fueling growth in new schools and swelling enrollments at existing schools. That means more students are in need of experiential education. The number of students enrolled in pharmacy professional degree programs jumped from 43,047 in 2003 to 50,691 in 2007, according to the American Association of Colleges of Pharmacy (AACP).

Additionally, a new Accreditation Council for Pharmacy Education (ACPE) requirement instituted in 2007 mandates that pharmacy school curricula include 300 contact hours of introductory pharmacy practice experience. Introductory experiences are defined as those that occur during the first three professional years of the pharmacy school curriculum. They must permit students, under appropriate supervision and as permitted by state practice regulations, to assume direct patient-care responsibilities.

A joint ASHP/AACP survey conducted in 2007 focused on determining future capacity for experiential education in the U.S. Although the survey found that hospitals have the capacity to meet demand for advanced experiential rotations and expand introductory experiences through 2012, hospitals will have to create new programs to keep pace with subsequent needs.

The Good News

Although questions of capacity and a growing number of students are challenging hospitals and health systems to keep pace, the tangible benefits that come with experiential education continue to motivate institutions to offer it.

Preceptors across the country attest to the very real benefits for hospitals and health systems that offer these types of rotations. And they are motivated by a number of factors, including the opportunity to mentor new practitioners and give back to the pharmacy profession.

Pharmacy students Michael Sprengler and Kati Ovik, talk with preceptor Debbie Sisson, M.S., Pharm.D.

Experiential education is a two-way street for learning, wherein preceptors and students share knowledge and insights. Rotations also serve as a prescreening and recruitment tool for future residents and staff pharmacists. Students who have a positive experience are often motivated to continue to pursue a career in the field, according to preceptors.

“I see experiential education having more of an impact on students early in their careers, and it may also help down the road for recruitment purposes,” said Craig Cox, Pharm.D., BCPS, associate professor of the pharmacy practice department and vice chair for experiential programs at Texas Tech University Health Sciences Center at Lubbock. “If you’re able to touch students in their first year, second year, third year, and then fourth year, they may be more interested in pursuing a health-system career in the future.”

Ninety percent of the respondents to the AJHP survey agreed or strongly agreed that being placed in preceptor roles stimulated staff members to maintain their professional knowledge. Eighty-two percent found value in assigning students to activities beneficial to both the students and the sites (e.g., medication reconciliation, service improvement projects, or assisting with literature searches).

A Win-Win for Students and Institutions

Some hospitals, such as North Mississippi Medical Center in Tupelo, offer both introductory and advanced experiential education. The center plans to expand its offerings in 2011, when it will begin training an additional 50 students from Union University School of Pharmacy in Jackson, Tennessee.

The experiential education rotations at North Mississippi are designed to ensure that students are integrated into the practice and work to improve patient care.

“Students help us teach patients and interview patients about their medications. They also present patient cases in clinical rotation,” said Kristie Gholson, Pharm.D., FASHP, North Mississippi Medical Center’s assistant director of pharmacy, pointing to the importance of handson experience.

The hospital offers long-term care, women’s health, neonatal, and informatics rotations, among others, ensuring that students can come back again and again and have a different experience each time.

In 2007, the medical center and the University of Mississippi School of Pharmacy in Oxford won an AACP Crystal APPLE (Academic-Practice Partnerships for Learning Excellence) Award, which honors exemplary pharmacy practice sites. Most of the students in the hospital’s program attend the university.

Gholson believes the strong partnership between the hospital and the school helped them win the award. “We’re both committed to teaching, we have good communication, and we’re driven by ACPE standards,” she said.

The Importance of Partnerships

Debbie Sisson, M.S., Pharm.D., in her previous role as associate director of experiential education and assistant professor at the University of Minnesota College of Pharmacy at Duluth, arranged for rotations throughout the state. Sisson believes that rural rotation sites benefit from college resources, such as free access to the university’s biomedical library.

Sisson is absolutely convinced of the value of experiential education, for students and for the hospitals in which they work.

“I’ve driven all over the state. I’ve done site visits to meet people. I’ve conducted educational programs at the sites,” she said.

Sisson and other pharmacists point to ASHP as an important resource for schools, hospitals, and health systems that want to launch new experiential education sites.

ASHP’s Web site offers a wealth of information on the important role of preceptor as well as resources to help start a new student rotation.

Speaking the Language of Health Literacy

SPEAK SLOWLY AND REPEAT information. Avoid complicated medical terms. Use pictures instead of written descriptions.

These are just some of the methods Pamela L. Stamm, Pharm.D., BCPS, CDE, uses to communicate effectively with patients who have low health literacy.

Stamm, a clinical pharmacy specialist who treats patients with diabetes and dyslipidemia at the Central Alabama Veterans Health Care System in Columbus, Georgia, also uses the “teach-back” method, in which patients repeat instructions.

“If patients can put it in their own words, there’s a greater chance they’ll be able to do what I’m asking them to do. My whole goal is to ensure that patients take their medications,” said Stamm.

Stamm’s effort to foster health literacy is just one example of how ASHP members are working to ensure that patients understand what medications they are taking, when and how they should take their medications, and what the medications treat.

“It’s important to remember that not every patient is going to read a pamphlet from the pharmacy, or a graph or table,” said Gina Ryan, Pharm.D., BCPS, CDE, clinical pharmacist at Grady Health System Diabetes Clinic in Atlanta. “If you’re going to give someone a table for blood-sugar values as a reference for adjusting insulin, you can’t just assume the patient understands it.”

A Growing Problem

A reduced capacity to understand medical instructions is a significant, and growing, problem in the U.S., experts say. According to the Institute of Medicine, 90 million people, including elderly patients, minority and immigrant populations, low-income patients, and people with chronic mental or physical health conditions, have difficulty understanding and using health information.

Gina Ryan, Pharm.D., BCPS, CDE , left, clinical pharmacist at Grady Health System Diabetes Clinic counsels a patient, right, at the clinic, as pharmacy student Rhondolyn Jones, takes notes.

The American Medical Association reports that this inability to understand instructions on prescriptiondrug bottles, appointment slips, medical education brochures, a doctor’s directions, and consent forms is “a stronger predictor of a person’s health than age, income, employment status, education level, and race.”1

ASHP and the ASHP Research and Education Foundation are trying to step into the gap, providing tools like “My Medicine List™” on both ASHP’s consumer Web site SafeMedication. com and the Foundation’s Web site.

This free, downloadable tool, which helps patients track the prescription medications, vitamins, ?and other dietary supplements they take daily, was created utilizing health literacy guidelines.

“‘My Medicine List’ is a really great tool to help facilitate that all-important conversation between pharmacists

and their patients,” said ASHP president Lynnae Mahaney, M.B.A., FASHP. “We know from national efforts like Healthy People 20102 that health literacy is a large and growing area of concern, and pharmacists can play a critical role in ensuring patients understand what medications they are taking and how to take them correctly.”

ASHP’s House of Delegates approved a policy in 2002 encouraging health literacy efforts among pharmacists. And it conducts educational programming to help members improve their medication counseling skills related to literacy. At the 2008 Summer Meeting, for example, ASHP offered a session called “Prescription for Confusion: Health Literacy and the Rx Label.” Attendees identified problems related to patients’ misunderstanding of common dosage instructions and learned the keys to drug-label design that ensure patient understanding.

Assessing for Literacy

Steven Chen, Pharm.D., FASHP, a clinical pharmacist at the JWCH Medical Clinic, Los Angeles, checks the blood pressure of a patient.

Pharmacists utilize a variety of tools to assess and respond to low health literacy. For example, a patient who says he can’t see the medication directions because he left his reading glasses at home may be hiding the fact that he can’t read. In this instance, a test such as the Rapid Estimate of Adult Literacy in Medicine (REALM) may be helpful. Pharmacists are also turning to the Ask Me 3 program, which empowers patients to ask and understand the following questions:

1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Ryan recommends that patients complete the REALM test during their initial visit. This assessment ensures that patients don’t feel they are being profiled for their reading abilities while giving health care providers insights into the health literacy challenges that may be present.

REALM test results help determine next steps, including using the teach-back method, arranging for relatives to help read instructions once the patient goes home, or informing physicians of the challenges that may be present through medical chart notes.

“I have encountered a significant number of patients who can’t read. It really is a big challenge,” Ryan said. “I’m always trying to figure out how to be effective and efficient. If I’m handing out pamphlets, I don’t want to just check a box to say I gave a person a piece of paper. I want it to work for them.”

Fotonovelas tell stories through the use of photos and word bubbles.

%%SIDEBAR%%But no matter how simple written instructions are, there is nothing better or more effective than face-to-face counseling with pharmacists, said Michael J. Miller, DrPH, who has researched health literacy as an associate professor at the University of Oklahoma College of Pharmacy in Tulsa.

“We have a tendency to communicate in the written word. We want to use that as a substitute for personal communication. But there’s no substitute for one-on-one questions,” Dr. Miller said.

ASHP members also use the unique medium of “fotonovelas” to educate patients on health issues such as diabetes. Similar to graphic novels or comic books, fotonovelas tell stories via photos and word bubbles and use limited text.

As a clinical pharmacy specialist at the JWCH Institute Center for Community Health, Los Angeles, Steven Chen, Pharm.D., FASHP, is very familiar with the appeal and effectiveness of fotonovelas among Hispanic patients.

Chen, who is also an assistant professor in the Department of Clinical Pharmacy and Pharmaceutical Economics and Policy, University of Southern California School of Pharmacy in Los Angeles, worked with colleague Mel Baron, Pharm.D., M.P.A., to create a fotonovela about the dangers of untreated diabetes.

Entitled Sweet Temptations, the fotonovela has effectively broken down a number of health literacy barriers among patients, according to Chen. The booklet was funded by a combination of university, industry, nonprofit, and local community pharmacy grants.

“We have to understand that different cultures have different methods that work better,” Chen said. “When you start talking about relatives with the disease, who are struggling with dialysis or facing the prospect of losing a leg, we speak to their values. Personalizing the problem and making it simple is the most important thing we can do for patients.

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