ASHP InterSections ASHP InterSections

February 18, 2016

ASHP Assumes Leadership Role in Campaign for Sustainable Rx Pricing

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

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

I AM PLEASED TO REPORT that ASHP has joined the Steering Committee of the Campaign for Sustainable Rx Pricing (CSRxP). The campaign’s goal is to foster a national dialogue on escalating drug prices and to find market-based solutions to address them. A project of the National Coalition on Health Care, the campaign includes the American Hospital Association, the Federation of American Hospitals, America’s Health Insurance Plans, Kaiser Permanente, AARP, and many other prominent organizations concerned about the impact on patients of rapidly escalating drug prices.

The spectrum of drugs experiencing large price increases is wide, and ranges from long available generics used to treat common chronic conditions to cancer and critical care medications. New specialty drugs with the potential to cure or mitigate once untreatable diseases are also often priced out of the reach of many patients.

The problems associated with escalating drug prices are highly complex and lack easy solutions, which is exactly why ASHP has taken on this issue as a top priority on behalf of our members and their patients. We believe that CSRxP has the best chance of sparking a national debate about the issue, with the capacity to bring together key stakeholders to identify market-based solutions that preserve the free enterprise system while ensuring that patients have access to affordable pharmaceuticals.

ASHP has a long history of leading efforts on drug shortages and various other clinical pharmacy, supply chain, access, and public health issues. ASHP led early efforts on the design of formulary and P&T systems, which resulted in the creation of evidence-based methods to improve medication therapy outcomes and patient safety — and to do so in a cost-conscious manner. It is for these reasons that we believe ASHP and its members can effect change in this area through the work of the campaign.

By joining CSRxP, ASHP will be able to provide the perspective of our members who are on the front lines of this problem, and we will work collaboratively with our partners to ensure that medications are accessible to those who need them. Ensuring sustainable drug pricing and access are long-term efforts, and ASHP is in it for the long run. We look forward to hearing your thoughts on this important issue and working with you to maintain the affordability of these lifesaving medications.

Thank you for all that you do on behalf of your patients and for being members of ASHP.

Paul

 

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February 9, 2016

Pharmacist-managed Diabetes Clinic Improves Care for Native Americans

The Winslow Indian Health Care Clinic serves patients with elevated A1c levels who haven’t been able to meet treatment goals through primary care visits.

Pharmacists at the Winslow Indian Health Care Center care for patients with elevated A1c levels who haven’t been able to meet treatment goals with primary care visits.

THE NAVAJO NATION stretches across more than 27,000 square miles of Arizona, Utah, and New Mexico. Many of its 300,000 residents have no physical address, no electricity, or no running water.

Some tribe members must drive for hours across dirt tracks and road-less open range to buy groceries, use a pay phone, or see a doctor. The difficulties residents face are compounded by the fact that more than 22 percent age 20 and older have diabetes–four times the rate of the same age group in the general U.S. population.

To help patients manage this often-devastating disease, pharmacists at the Winslow Indian Health Care Center (WIHCC) in Arizona are stepping into the gap. A pharmacist-managed insulin-titration clinic now serves patients with elevated A1c levels who haven’t been able to meet treatment goals through visits with their primary care providers.

“Some of our diabetic patients travel as far as 90 miles to get to our facility,” said LCDR Kelly Pak, Pharm.D., NCPS, CDE, clinical pharmacist/medication safety officer at the Winslow Indian Health Care Center. “And because the volume of patients is so high, it’s difficult for providers to find the time to consult with them regularly about insulin titration. Many patients only see their providers occasionally—perhaps every one to three months. That’s far from ideal.”

At that rate, it would take years to correctly titrate insulin dosing, and there’s no way to know how well patients are following their prescribed therapy regimen, added CDR Peter Laluk, Pharm.D., BCACP, NCPS, a clinical pharmacist and the WIHCC’s director of quality management.

Pharmacists at Winslow educate and monitor patients, mostly by telephone. Their common goal? To bring their patients’ A1c levels in line with the American Diabetes Association recommendation of less than 7 percent (based on age, A1c goal might be higher) and reduce the number of emergency room visits and hospitalizations caused by hypoglycemic episodes.

Helping Patients Become Self-Sufficient

Since its founding in 2013, the clinic’s impact has been nothing short of dramatic: Among 80 clinic patients, A1c levels have decreased by a mean of 3.0 percent, compared with a 1.1 percent decrease among control group members who were followed by their primary care providers but received no pharmacist intervention. In satisfaction surveys, clinic patients report that they feel more in control of their diabetes and feel more comfortable with home diabetes management.

From left, CDR Peter Laluk, Pharm.D., and LCDR Kelly Pak, Pharm.D.

CDR Peter Laluk, Pharm.D., (left) and LCDR Kelly Pak, Pharm.D.

The clinic, noted Dr. Pak, embodies key elements of ASHP’s Practice Advancement Initiative (PAI) recommendations (formerly known as the Pharmacy Practice Model Initiative, or PPMI), which call for every pharmacy department to “identify drug-therapy management services that should be provided consistently by its pharmacists.”

Clinic treatment begins with an initial educational session (conducted in person if possible). This is followed by weekly pharmacist follow-up phone calls to review progress, discuss hypoglycemic episodes, and adjust insulin dosages. Periodic visits to the clinic are encouraged but not mandatory.

“We want patients to reach the point where they can mostly take care of themselves,” said LT Kenya Destin, Pharm.D., a clinical pharmacist and Dr. Pak’s clinic partner.

Unique Challenges for a Special Patient Population

Although a reliance on working by phone allowed clinicians to reach more patients more frequently, it also has limitations. In such a large rural area, phone service can be spotty, and some patients can’t afford cellphone plans. In fact, some patients only have access to pay phones that are miles from home.

Another unique challenge with this patient population is that a significant number of elderly residents speak only Navajo and practice traditional medicine.

Since its founding in 2013, the clinic’s success has been nothing short of dramatic.

“Some patients told me their medicine man said to stop taking insulin for a couple of weeks before an important ceremony, and they ended up having hyperglycemia episodes,” said Dr. Pak. “Obviously, I can’t force my patients to always do what I’ve guided them to do. It’s important to be sensitive to cultural standards.”

The clinic, which began as a pilot program, has become a fixture at the WIHCC, in large part because the study results quantified its success and suggested even greater potential. “Dr. Pak’s presentation of the data to medical staff showed how well the program really works, and their support is what caused it to really take off,” said Dr. Laluk.

Equally important to the clinic’s acceptance and growth has been the rapport among pharmacists and physicians, which was carefully cultivated well before the clinic opened.

“That took some time to build,” recalled Dr. Laluk. “We were able to effectively show how we can provide a greater service beyond just filling prescriptions and counseling. Building that level of trust with our fellow healthcare professionals really helped to make the clinic happen.”

–By Steve Frandzel

February 5, 2016

Primary Care Centers Leverage Pharmacists to Expand Patient Care

Meghan Bolinger demonstrates inhaler use for a patient.

Conemaugh Memorial Medical Center PCRC transition-of-care pharmacist Meghan L. Bolinger, PA-C, Pharm.D., BCACP, demonstrates proper inhaler use for a patient.

THE GROWTH OF MULTIDISCIPLINARY AMBULATORY CARE CENTERS that prominently feature pharmacists is helping to transform patient care across the U.S. At six hospitals and health systems in Pennsylvania, Primary Care Resource Centers (PCRCs) are bridging the gap from hospital to home.

Each PCRC is a hospital-based hub staffed by three nurse care managers, a pharmacist, and administrative support. The ultimate aim is to reduce avoidable hospital readmissions for three health conditions that drive the majority of readmissions in western Pennsylvania: chronic obstructive pulmonary disease (COPD), heart failure (HF), and acute myocardial infarction (AMI).

“What sets PCRCs apart from other transitional care teams is that this model puts a pharmacist at the center,” said Keith T. Kanel, M.D., MHCM, FACP, project director and PHRI’s chief medical officer.

PRHI Chief Medical Officer Keith T. Kanel, M.D., MHCM, FACP

“In most other models, nurses and advanced practice nurses make up the core,” he noted. “Nurses are critical, of course, but so are pharmacists, because medication management plays a major role in the treatment of this patient population.”

A nonprofit collaborative, the Pittsburgh Regional Health Initiative (PRHI) developed the PCRC model using a three-year, $10.4 million grant from the Center for Medicare and Medicaid Innovation.

In each PCRC, pharmacists counsel patients about their illnesses and drug therapies, conduct a thorough medication review and reconciliation, and construct a home action plan with physician input.

After discharge, caregivers follow up by phone (or with a home visit if necessary) to resolve any medication issues. They also ensure that patients can get in touch with their medical care team.

PCRC Success Leads to Innovation

At Conemaugh Memorial Medical Center, a 555-bed community hospital in Johnstown, the need for pharmacist care was dramatic. Soon after the Conemaugh PCRC opened, monthly admissions of patients eligible for care at the center jumped 18 percent. But the lone pharmacist on the team struggled to keep up with the added patient load, and the number of pharmacist-patient encounters remained flat.

From left, Conemaugh pharmacy technician Amber Fink, CPhT, reviews a patient's medication regimen with Dr. Bolinger

From left, Conemaugh pharmacy technician Amber Fink, CPhT, reviews a patient’s medication records and regimen with Dr. Bolinger.

“It was quickly evident that I needed assistance to accomplish our goals in face-to-face patient interactions,” said Meghan L. Bolinger, PA-C, Pharm.D., BCACP, a PCRC transition-of-care pharmacist.

“My time was stretched thin taking care of nonclinical tasks, such as manually entering patient medications into the outpatient provider database. I often felt rushed because I was doing so much recordkeeping,” she added.

Although funding limitations meant that hiring a second pharmacist was not possible, the Conemaugh PCRC could support a full-time technician. In May 2014, eight months after the PCRC opened, certified pharmacy technician Amber Fink, CPhT, joined the center and was trained to handle a range of responsibilities. These include documenting patients’ medication records, locating pertinent laboratory and diagnostic tests, maintaining the active patient roster and pending discharges, assembling patient medication education cards, and noting discrepancies among incompatible medication record systems.

Ms. Fink even made some home visits to organize patients’ pill boxes and conduct medication reviews. On the administrative side, she managed patient submissions of medication assistance forms, coordinated hospital-to-home program vouchers, transmitted the pharmacist’s care notes to primary care physicians, and monitored the impact of her own activities on the pharmacist’s workload and efficiency.

What sets PCRCs apart from other transitional care teams is that this model puts a pharmacist at the center.

The impact of an added technician was dramatic: After only a few months, the number of patients who received a comprehensive medication review increased nearly 20 percent, and the average chart review time decreased 41 percent – from about half an hour to under 20 minutes.

“Amber reviewed and cleaned up the charts in advance, so I was able to get through the information quickly and efficiently,” said Dr. Bolinger. “I was definitely able to do far more than I ever would have imagined if I had been here by myself.”

Conemaugh has committed to keeping its pharmacy technician on the staff, and the other hospitals are considering adding technicians to their PCRCs.

Adding a pharmacy technician to the PCRC team turned out to be “a great way to expand Dr. Bolinger’s reach and help her to practice at the top of her license,” said Toni Fera, Pharm.D., PCRC consulting pharmacist  at the PRHI. “I think that says it all.”

Immediate and Lasting Success

The PCRC model ensures that the nurses and pharmacists are well-prepared for the patient care roles in which they serve. More than 8,000 hours of personnel training on quality improvement, motivational interviewing, and project management set the stage for success, according to Dr. Kanel. And the numbers bear out the PCRCs’ effectiveness. Between July 2013 and October 2015, the six PCRCs:

 

  • Managed more than 14,000 hospital discharges of patients with COPD, HF, or AMI.
  • Enrolled nearly 9,000 unique patients into longitudinal care plans.
  • Logged 40,541 face-to-face contacts with hospitalized patients for care management, education, medication reconciliation, self-management skill building, and advance directive planning.
  • Made more than 28,000 telephone calls to (or on behalf of) patients.
  • Conducted more than 2,300 outpatient visits to patients’ homes or post-acute care facilities.

As a result of this intense set of interventions, PRHI’s 30-day all-cause readmission rate for the three target conditions fell from 20.4 percent to 15.3 percent, for a net readmission reduction of 25.0 percent.

The collaborative is now conducting a detailed analysis of return-on-investment, multi-payer benefit, patient subgroup analysis, and long-term financial savings as well.

Considering the Future

As the grant winds down, five of the six hospitals that established a PCRC, including Conemaugh, have announced that they will sustain their centers.

“In today’s world, most healthcare occurs out of the hospital. We wanted to find a way to fill the gaps that existed with our current systems, and I think we’ve been very successful,” said Dr. Kanel. “The PCRC is a worthy solution for community hospitals trying to manage complex patient populations. We would love to see this model adopted widely.”

–By Steve Frandzel

February 1, 2016

Pharm.D.-M.D. Team Successfully Enacts Opioid-Free ED Shift

ED Intake

A pharmacist-physician team at Maimonides ED successfully substituted non-opioid pain meds for its patients in a recent IRB-approved study.

OPIOIDS ARE OFTEN THE GO-TO ANALGESICS in the emergency department (ED). They’re fast, powerful, and easy to prescribe and administer. But opioids are also addictive and a favorite among drug-seekers.

At Maimonides Medical Center, a 705-bed academic medical facility in Brooklyn, N.Y., a team of pharmacists, physicians, and researchers designed and implemented an eight-hour opioid-free shift in the ED to determine whether non-opioid analgesics could provide sufficient pain relief to help avoid some of the challenges of opioid overuse, such as dependency.

The project arose from a discussion between Victor Cohen, Pharm.D., BCPS, CGP, then clinical pharmacy manager of emergency medicine, Department of Pharmacy, and Sergey Motov, M.D., FAAEM, assistant program director, Department of Emergency Medicine, about the growing national problem of opioid addiction.

Victor Cohen, Pharm.D., BCPS, CGP

Victor Cohen, Pharm.D., BCPS, CGP

“We were getting stories from psychiatry physicians about OxyContin and other opioids. There is a significant OxyContin epidemic,” said Dr. Cohen, who is now corporate clinical director of pharmacy services at the Health and Hospital Corporation of New York City. “I thought we really needed to try to achieve an opioid-free ED for a day.”

Because Dr. Motov had conducted prior research on the effectiveness of ketamine vs. morphine in the ED, he was on board with the idea from the start and went to the Maimonides ED administration and institutional review board with the concept.

“I let them know that I would take full responsibility for provider education and for writing the protocol,” he said. “We were very clear that we didn’t want anyone to suffer, and we promised to designate a time limit for patients. If they were still in pain after other alternatives were used, we would use an opioid such as morphine, fentanyl, or hydromorphone as a rescue therapy.”

We knew based on personal experience that we would get a reasonable response to the [non-opioid] medications.

From there, Dr. Motov assembled a team of staff from the departments of emergency medicine, pharmacy, and clinical informatics to design a pain management strategy based on channel/enzyme/ receptor-targeted analgesia.

The team then developed a corresponding order set for input into their computerized prescriber order entry system. Options for treatment depended on the type and severity of pain and included acetaminophen PO/IV, dexamethasone sodium phosphate, diazepam, ibuprofen, ketamine, ketorolac IV, lidocaine IV, and methocarbamol

Challenges and Results

One of the greatest challenges to implementing the opioid-free day was in getting other clinicians acclimated to using other medications, according to Dr. Motov. “There was a fair amount of discomfort [among the team] about using unfamiliar medications,” he noted. “The nursing team, in particular, was uncomfortable with off-label uses.”

Sergey Motov, M.D., FAAEM

Sergey Motov, M.D., FAAEM

Fortunately, Drs. Cohen and Motov had conducted comparative studies of the medications to be used that allowed them to assemble provider education that set the other clinicians at ease. “We had extremely high-level safety guidance in how to do these activities in the ED due to the studies we did,” said Dr. Cohen. “The protocols were all within accepted standards of care.”

The team’s combined clinical experience also came in handy, said Dr. Motov. “We knew based on personal experience that we would get a reasonable response to the [non-opioid] medications. But we actually had a higher rate of patient satisfaction than we anticipated.”

Of the 17 patients who were managed during the shift, 83 percent were satisfied with their pain relief after 30 minutes of treatment, and 86.7 percent were satisfied after 60 minutes. Two patients were admitted, and four received no prescriptions for pain medications. Of the remaining patients, only one received a prescription for an opioid. The rest received prescriptions for non-opioid analgesics. The details of the protocol and study appear in the December 1, 2015, issue of AJHP, co-authored in part by Drs. Cohen and Motov.

This represents a real opportunity to change patient care for the better.

As part of the initiative, the team also developed a pocket-sized card for acute pain management that includes the protocol. The cards have ensured that ED physicians continued the process after the opioid-free day, said Dr. Cohen.

“We found that attending physicians who weren’t part of the research team did not continue the process,” he noted. “Although some would do it intermittently, many of the seasoned practitioners didn’t change their typical prescribing behavior. The card has helped more physicians adapt to the new protocol.”

Pharmacists were integral to both the protocol development and the project’s implementation. According to Dr. Cohen, the team conducted the study as a public health exercise with the blessing of Fredrick Cassera, MBA, R.Ph., Maimonides vice president of outpatient pharmacy services and director of pharmacy.

An Opportunity to Reduce Opioid Addiction

Dr. Cohen feels there is a large and important role for pharmacists in the implementation of new non-opioid pain management protocols in both the ED and across the healthcare enterprise.

“Our roles lie in conception, adjudicating guidelines, preparing admixtures, developing order sets, assisting physicians in entering orders, and implementing the protocols,” he said. “This represents a real opportunity to change patient care for the better.”

For pharmacists in other hospitals and health systems who wish to do something similar, Dr. Motov had some helpful advice.

“Pharmacists know better than physicians what medications can do for patients,” he said, adding that pharmacists should actively collaborate with physicians when pursuing this new protocol. “You only need one doctor to agree to try something, and then that doctor will bring another one on board, who will bring another one. All it takes is that first physician, and it will all fall into place.”

Protocols for non-opioid pain management stand to have a great impact on emergency department care, according to Dr. Cohen. “We can’t get rid of opioids altogether, but we can certainly streamline their use and help to cut down on abuse and dependency in this country.”

–By Terri D’Arrigo

 

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