ASHP InterSections ASHP InterSections

March 25, 2013

With Students’ Help, Pharmacists Reach Every Patient at Cleveland Clinic Florida

Front row, Diana Pinto Perez, Pharm.D., pharmacist, is joined by (from left) Lori Milicevic, Pharm.D., BCPS, pharmacist, and Eniko Balasso, Pharm.D., graduate intern.

ON THE HEELS of ASHP’s Pharmacy Practice Model Initiative Summit in 2010, Cleveland Clinic Florida (CCF) set the goal of giving all patients at the 155-bed academic institution the opportunity to interact with pharmacists as part of their care.

It was a lofty goal, one that would stretch the pharmacy department’s staff and resources.

In addition to the responsibilities they already had for conducting profile reviews, reviewing medication dosing, attending patient care rounds, and providing drug information, pharmacists would also take on conducting medication histories, performing medication reconciliation, and offering disease-state or discharge medication counseling on all patients.

They were clearly going to need help, and that help would come from pharmacy students.

Layered Learning Models for Students

Six months after the Summit, Osmel Delgado, Pharm.D., BCPS, cPH, administrative director of clinical operations and director of pharmacy services, and William Kernan, Pharm.D., BCPS, assistant director and PGY1 residency program director, traveled to Cleveland Clinic’s main campus in Cleveland.

At the Cleveland Clinic Pharmacy Practice Model Summit, they met with pharmacy thought leaders from prominent health systems and learned how other systems were incorporating PPMI recommendations into their practice models.

Osmel Delgado, Pharm.D., BCPS, cPH

Delgado and Kernan were particularly impressed with the layered learning models involving students at the University of Michigan and the University of North Carolina–Chapel Hill.

“We took their examples as lessons learned, and began to engage the colleges of pharmacies that we had affiliations with to see how we could accept more students,” Delgado said. “It took a good six to 12 months to refine and retool the ways we could create a valuable learning experience for the students, but also have them apply what they know in practice.”

Building On a Solid Foundation

CCF already had a progressive pharmacy program in which four clinical pharmacists would take on at least one student per month for introductory and advanced pharmacy practice experiences.

Under the new model, each preceptor would offer at least four rotations per month, and students would work as pharmacist extenders. The process begins with an orientation that covers the health system’s electronic medical records system, documentation practices, medication history and reconciliation processes, and disease-state and discharge education.

From left, student pharmacists Yesenia Fike and Pamela Silva (Nova Southeastern University College of Pharmacy, Class of 2013) consult about a patient’s medications.

After orientation, students provide hands-on care in rotation blocks up to three months long. The preceptors act as coaches, and they review and sign off on the students’ activities and patient notes.

“When students come to orientation, we tell them that they are crucial to the process and that we expect them to do what the pharmacists do and ask questions if they need help,” said Kernan. He added that the block rotations offer consistency across areas of care such as internal medicine, infectious disease, critical care, and anticoagulation.

“In each area, the students have to do medication reconciliation, provide discharge counseling, and answer patient questions about medications.”

Accessing Patient Charts

Under the old system, pharmacy students lacked individual computer access to the health system’s electronic medical records (EMR) and documentation system, which limited their ability to participate fully in recording care and tracking patients. That has since changed, according to Antonia Zapantis, Pharm.D., M.S., BCPS, preceptor in the program and associate professor at Nova Southeastern University College of Pharmacy, Fort Lauderdale, Fla.

“We felt it was crucial that students have access to the records and use the same systems and forms as the pharmacists, so that they could learn how to use these resources as part of providing pharmacy services,” she said.

The pharmacy informatics team reworked several aspects of the EMR and documentations systems so that students could put progress notes into patient charts. Pharmacists cosign the student notes.

Happier Patients, Better Outcomes

Thanks to student involvement in the hands-on provision of care, the pharmacy department has met its goal of providing every patient at CCF with pharmacist interaction. As a result, patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) have risen steadily over the last four quarters.

“The feedback we get from patients is that they’re happy to know and learn about their medications,” said Martha Espinoza-Friedman, Pharm.D., BCPS, clinical pharmacist and preceptor in the program. “Those who were in other hospitals before coming to CCF were impressed. They haven’t seen this kind of care before.”

Jaime Riskin, Pharm.D., BCPS

The patients are safer, too, said preceptor Jaime Riskin, Pharm.D., BCPS, clinical assistant professor at Nova Southeastern University College of Pharmacy.

“The pharmacy caught errors and documented adverse drug events because of all the students out there identifying discrepancies. It shows just how helpful students can be if you give them the right tools,” she said.

Riskin added that having access to the EMR system allows students to follow up and see whether their interventions made a difference in a patient’s care.

According to Kernan, the program at CCF shows how there is nothing to fear by extending the student experience into patient care areas. “We found that when you add more students, it makes your job more efficient. If you train them and use them right, it works in your favor.”

Delgado is optimistic about the future—for the program, the students who participate, and the students’ future patients.

“We’re teaching students to inject themselves into the process at key times for the patient, such as discharge or any transition of care from acute to post-acute settings,” he said. “As pharmacists, they will ultimately understand the importance of their work across an enterprise-wide continuum of care.”


At Wishard Hospital, Better Diabetes Care through Teamwork

Zachary Weber, Pharm.D., BCPS, BCACP, CDE, (right) counsels a diabetes patient at Wishard Hospital in Indianapolis.

DIABETES MANAGEMENT can be tricky, especially for patients who have been diagnosed and prescribed oral agents or insulin to help them control their blood glucose. Those with type 2 diabetes often also grapple with hypertension and dislipidemia and must take additional medications.

The juggling act these patients face inspired Zachary A. Weber, Pharm.D., BCPS, BCACP, CDE, clinical assistant professor of pharmacy practice at Purdue University College of Pharmacy and clinical pharmacy specialist in primary care at Wishard Hospital in Indianapolis, to approach the hospital’s endocrinologists with a working model that focused on multidisciplinary teamwork.

The resulting collaborative practice agreement between Weber and physicians in the endocrinology clinic serves as a great example of how pharmacists can be granted enhanced patient-care privileges as part of integrated care teams, one of the recommendations of ASHP’s Pharmacy Practice Model Initiative.

New patient-care privileges can include starting new medications, adjusting medication doses, and ordering relevant laboratory monitoring.

A Basis for Teamwork

The collaborative practice agreement Weber has with the endocrinology department is modeled after agreements among other pharmacists and primary care physicians in clinics throughout the Wishard system. These agreements allow pharmacists to serve as physician extenders and work side-by-side with ambulatory care physicians to optimize patients’ medication regimens.

“The evidence from the initial collaborative practice site demonstrated improved patient care, and we felt it would be beneficial to extend it,” Weber said. “We changed the primary care agreement to fit the endocrine clinic, but the agreements are basically the same throughout the system. We have one for primary care and one for specialty care.”

Rattan Juneja, M.D., associate professor of clinical medicine, who reviewed Weber’s proposal, said the agreement came at an opportune time.

“We were swamped. Our waiting lists were six to eight months long. We spoke with Zach about how to deal with patients who [were having trouble managing their blood glucose], and he came up with the idea to work directly with patients in managing their medications.”

Dr. Weber (back, far right) consults with the diabetes team in Wishard’s endocrinology clinic.

Under the collaborative practice agreement, physicians such as Dr. Juneja and his colleague Dr. Kieren Mather, M.D., associate professor of medicine, draw up diabetes management plans and oversee patient care.

Select patients are then referred to Weber, a certified diabetes educator, for the nitty-gritty of explaining how medications work and demonstrating how to take insulin.

Weber also helps to make ongoing adjustments to the medications within the written scope of the collaborative practice agreement to help patients achieve their goals. This agreement allows him to make certain adjustments without needing to seek physician approval.

“People tend to think that you send a patient to an endocrinologist, and the endocrinologist fixes the diabetes,” said Dr. Juneja. “But it’s really the patient who treats the diabetes, and physicians can’t oversee the details of diabetes management to the extent patients need because of our patient volume.”

The results thus far have been positive: Over two years in clinic, patients who received care from Dr. Weber experienced a reduction in their average A1C levels around 1.5 – 2 percent. In addition, patients’ average LDL dropped around 20-25 mg/dl, with many more achieving American Diabetes Association (ADA) goals of less than 100 mg/dl.

Similarly, the average blood pressure for Dr. Weber’s patients fell within the recommended ADA treatment goal.

 Ironing out the Details

Although the collaborative practice agreement has been successful, initially, there were a few wrinkles. To further a continuity of process, the clinic staff had to get used to having a pharmacist around and scheduling appointments for Weber.

“We wanted patients to experience checking into the clinic, going to the exam room, leaving the clinic, and scheduling appointments as a simple process, and we didn’t want the support staff to have to learn something new,” said Weber.

“But the reality is that we were adding a whole new provider. It took some time for the clinic staff to understand who I am, what I do, and how my patients should be treated as they move through the clinic as compared to the physicians’ patients.”

The team also needed to strike a balance in terms of when patients saw whom, said Dr. Mather.

“The intent is not to refer patients to Zach as an alternate approach to long-term diabetes management. Instead, the intent is to help patients overcome hurdles to get their disease on track with better control, starting early in their care through our clinic.”

Ramping up took some time, as well. In the beginning there weren’t many referrals, Weber said. “There were only a few patients. You have to show what you can do in the clinic and how you can help patients before physicians send patients your way. You have to build that trust.”

ROI Can Take Time

The hospital administration had already seen successful collaborative practice agreements among pharmacists and physicians in primary care clinics, so there were no raised eyebrows when it took over a year for Weber to have a steady stream of patients. It also didn’t hurt that he was already salaried as a professor at Purdue.

“I didn’t face too much pressure because I have a faculty appointment, but pharmacists at other health systems or hospitals might want to stress to their administrations that it could be 12 to 24 months before there’s a return on investment,” he noted. “They might have to do some convincing at first.”

Finally, there was the issue of compensation. Because Weber is salaried, his work in the clinic does not cost Wishard any extra money. Other institutions might not have the same situation, said Mather.

“Because we are an academic institution, we’re able to have it that way, but other hospitals or physicians in private practice may face a few financial challenges with that, depending on how pharmacists are licensed in their states.”

Because Wishard physicians are not compensated per patient, neither Mather nor the other physicians in the clinic are paid for supervising and signing off on Weber’s care. “But that’s fine because the collaboration is such a help to us.”






March 13, 2013

CPPA’s Value to Pharmacy Practice

Filed under: From the CEO — Tags: , , , , , , , — jmilford @ 9:49 am


Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

AS YOU MAY BE AWARE, ASHP recently joined the Center for Pharmacy Practice Accreditation (CPPA) as a governing member. We believe that the CPPA brings considerable value to pharmacy. Its voluntary accreditation standards will help drive improvements in patient care in and between all sites of care, and, thus, will advance the profession of pharmacy.

Accreditation now exists for residency and technician training, schools of pharmacy, hospitals, clinics, and many other components of healthcare, education and delivery. Applying consistent standards in all of these areas has resulted in marked improvements in quality.

Recognizing that the breadth and complexity of the medication-use process calls for a more detailed level of focus to ensure consistent quality outcomes, we believe there is a need for a single integrated accreditation body, with strong medication-use knowledge and experience to identify and sustain these improvements. This is why ASHP joined the CPPA.

As a full partner in the CPPA, ASHP envisions a patient-centered, comprehensive approach to accrediting the medication-use process in various health care settings. The organization’s first goal is to start with community pharmacies that are not presently accredited and later expand its efforts to accredit other practice sites to ensure a continuum of care that focuses on the patient’s complete therapy from start to finish.

Thus, we hope to close the gaps present today between sites of care wherever medications are prescribed, dispensed or administered. Joining the CPPA will also help to significantly convey to patients and stakeholders our commitment to better patient care.

Further, we are happy to report that on March 1, 2013, the CPPA released its Community Pharmacy Practice Accreditation Standards with interpretive narrative. Within the standards, the Center identified three domains that reflect the overarching purpose of community pharmacy practice accreditation: practice management, patient care services and quality improvement. We also expect that these standards and the future work of the CPPA will greatly help to ensure better, more effective transitions of care.

Structurally, the CPPA is managed by a board of directors that consists of nine voting members, including chief  executive officers from APhA, NABP and ASHP, and six appointed directors (two from each partner organization). ASHP’s two board members are ASHP Past-Presidents Roger W. Anderson, Dr.P.H., R.Ph., FASHP, and Daniel M. Ashby, M.S., FASHP.

ASHP Past-President Lynnae Mahaney, B.S. Pharm, M.B.A., FASHP, is the CPPA’s new executive director. She is responsible for overseeing the Center’s business and organizational affairs.

The CPPA also has two standing committees: a Standards Oversight Committee, which coordinates the development of consensus-based standards, and an Accreditation Process Oversight Committee, which coordinates the development and implementation of the accreditation process. Both committees will have equal representation from ASHP, APhA and NABP.

To learn more about the CPPA and its efforts, we encourage you to visit its website, where you will also find answers to frequently asked questions.

Our hope is that the CPPA will contribute to the improvement of patient care through voluntary accreditation of all facets of the continuum of the medication-use process. Our goal is to ensure quality and safety for every patient who takes medications, throughout their lives.

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