From left, a patient reviews his test results with Golbarg Moaddab, M.D., and Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE.

AS HEALTHCARE REFORM EVOLVES and providers are held to higher standards of quality and improved patient outcomes, more physicians and health systems are turning to the patient-centered medical home (PCMH) to offer comprehensive, cost-effective care.

At Advocate Medical Group, a subsidiary of the Advocate Health System in Chicago, administrators recognized the value pharmacists can bring to the medical home. When they needed a pharmacist who had experience working with heart failure patients, they contacted the Midwestern University College of Pharmacy for a candidate.

Enter Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE, assistant professor of pharmacy practice at Midwestern University Chicago College of Pharmacy, whose work with Advocate meets ASHP’s Pharmacy Practice Model Initiative recommendations for pharmacist involvement in the medical home. She is part of a PCMH that includes six primary care physicians, a cardiologist, a nurse practitioner, a physician assistant, a nurse educator, and a dietician.

Schumacher has a broad and well-integrated role in the PCMH. Through collaborative practice agreements, she initiates, discontinues, and titrates medications and provides medication reconciliation and education to improve patient adherence. She also orders and interprets laboratory values, arranges medical referrals, and provides disease-state and lifestyle education. Schumacher is also available for medication recommendations and physician consults.

A Key Member of the Healthcare Team

Schumacher works closely with the team’s nurse practitioner, Monique Colbert, APN. The primary care physicians and cardiologist refer heart failure patients to Schumacher and Colbert through a “task” message in the patients’ electronic medical records.

Although physicians can select the team member whom they would like a patient to see, Schumacher and Colbert often review the medical history and make the determination themselves.

Patients who need more help with their medications see Schumacher, whereas those who need lifestyle management counseling see Colbert. Yet the two share the goals of improving patient outcomes and lessening the physicians’ load.

“We are extra help for the doctors. When patients need follow-up, the cardiologist and primary care physicians just can’t see them every two weeks. That’s where we step in and provide that in-depth care,” said Schumacher. Initial visits last about an hour, and follow-up visits last about 30 minutes.

Although Schumacher was initially tapped for her experience in treating heart failure, it soon became clear that patients needed assistance in managing coexisting conditions.

Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE

“We were seeing high A1Cs in people with diabetes, up around 10 or 11 percent, so we started making recommendations to the physicians about how to treat them. Then we did the same for patients with hypertension and dislipidemia,” said Schumacher. “The physicians asked us if we could handle treating this condition, and we went from there.”

Schumacher now uses pharmacist-created protocols and current guidelines to help her manage patients with diabetes, hypertension, dislipidemia, chronic obstructive pulmonary disease, and asthma. Plans are in the works to add chronic kidney disease to the mix.

Colbert said she has learned from Schumacher. “My background is heart failure, and Christie helped me come on board with diabetes. At first, I would see the patients with A1Cs of eight or lower, and Christie would see patients with more complex cases, but as I became more educated and more skilled, I began to take on complex patients as well.”

Proving the Case

The PCMH took six months to implement and, initially, there weren’t many patients to see: The primary care physicians and nurses were a bit wary of Schumacher conducting physical assessments. But support from the cardiologist, with whom she had worked before, helped, as did Schumacher’s own drive to show the value of pharmacist-provided care.

“I took the time to learn physical assessments. Many pharmacists aren’t comfortable with that, but it makes a difference. You need to show the physicians that you know what you are talking about,” she said. “At first, the physicians wanted us to run everything by them, but after two weeks of seeing what we could do, they told us to just go ahead [with our care].”

Although physicians still sign off on the care notes, both Schumacher and Colbert can now write prescriptions.

Golbarg Moaddab, MD, Advocate Health Care

Goldbarg Moaddab, M.D., an internist on the team, finds the collaboration indispensible. “I can’t imagine practicing without the medical home anymore. The other professionals can be so much more thorough regarding patient history and medications, and they have more time to spend with patients than physicians do,” she said.

Advocate Medical Group is currently looking at outcome measures such as hospitalizations, readmissions, emergency room visits, blood pressure, LDL cholesterol, and A1Cs.

Regardless of how those measures come out, Moaddab said she has noticed a change among her patients.

“Before Christie was part of the medical home, it took much longer to get patients to their goals for A1Cs, blood pressure, and lipid control. Now that they are seen more frequently by other health care professionals on the team, they get there faster,” she said.

The patients appreciate the care, as well, said Schumacher, noting that for many patients, the in-depth follow-up is a new phenomenon.

“We have patients in their 60s who tell us that no one has ever sat down with them and discussed their medications,” she said. “We have a high turnout, and they like to come to their appointments. That’s going to go a long way toward increasing adherence and helping them to get better.”

–By Terri D’Arrigo

Paul W. Abramowitz, Pharm.D., FASHP

A GOOD STRATEGIC PLAN allows us to map our future with a clear course to success. In January of this year, the ASHP Board of Directors approved a new comprehensive Strategic Plan.

This plan is a significant departure from the Leadership Agenda that it replaces because it includes and integrates all ASHP activities and operations. While the previous document focused only on professional priorities, our new Strategic Plan includes three main pillars: Our Patients and Their Care, Our Members and Partners, and Our People and Performance.

This new plan embodies our passion, our energy, and our unwavering commitment to you–our members–and the patients whom you serve.

We began the process of creating this comprehensive Strategic Plan by starting with a new vision statement for ASHP. Working with a great team of Board members, Section and Forum Executive Committee leaders, and ASHP staff at an April 2012 retreat, we strove to develop a new vision that would be bold, far-reaching and important to our members and patients.

In particular, we wanted to create a vision that is universal in focus and covers all patients in all settings across the continuum of care. I am pleased to say that our new vision statement achieves this important goal:

ASHP’s vision is that medication use will be optimal, safe and effective for all people, all of the time.

Working from our new vision statement, we turned to revising our mission. Again, we focused on pharmacists’ role in the full spectrum of individual and public health. We wanted to craft a mission statement that moved beyond medications to emphasize that, in addition to treating disease, pharmacists have an important role in improving and maintaining health. Our new mission statement, below, also sets the stage for our member pharmacists as providers caring for and following patients through their entire healthcare experience, regardless of the site of care:

The mission of pharmacists is to help people achieve optimal health outcomes. ASHP helps its members achieve this mission by advocating and supporting the professional practice of pharmacists in hospitals, health systems, ambulatory clinics, and other settings spanning the full spectrum of medication use. ASHP serves its members as their collective voice on issues related to medication use and public health.

Drawing from the vision and mission, we created ambitious strategies, goals and objectives. As I mentioned above, the Strategic Plan includes three pillars, which are short and simple, yet all-encompassing, high-level strategies:

1. Our Patients and Their Care
2. Our Members and Partners
3. Our People and Performance

The first pillar focuses on the central purpose of pharmacists: improving the health of our patients throughout the entire continuum of care, including both ambulatory and acute care. The goals and objectives within this strategy provide a roadmap for how ASHP helps its members care for their patients now and in the future. They include:

• Improving patient outcomes from medications;
• Wellness and preventative care;
• Advancing pharmacy practice;
• Helping the pharmacy workforce meet patient needs;
• Providing professional development;
• Advocating for laws, regulations, and standards; and
• Placing an increasing emphasis on expanding our members’ practices in clinics and other ambulatory care settings.

Examples of activities in this realm include efforts related to improving care transitions, using information technology and pharmacy technicians more effectively, advancing efforts related to the Pharmacy Practice Model Initiative, ensuring an adequate supply of well-trained pharmacists, providing contemporary education and professional development, and advocating for changes in laws and regulations that give patients greater and more effective access to pharmacists.

The second pillar of our new Strategic Plan focuses on the central purpose of ASHP: our members. Members are the focus of our work and are the core of ASHP’s inspiration and reason for being. The goals and objectives of this pillar relate to how we serve our members and work with other stakeholders, including:

• Maintaining a high level of member satisfaction,
• Growing membership,
• Supporting our state affiliates,
• Engaging members through Sections and Forums,
• Working in collaboration with our various partners in pharmacy and the broader healthcare community, and
• Publishing timely and innovative resources.

Some examples of activities in this area include enhancing opportunities for members to participate and take leadership roles in ASHP; partnering with ASHP state affiliates on advocacy and other efforts to improve patient care; increasing the number of tools and resources to help our members best care for their patients; and fostering and growing relationships with pharmacy, medicine, nursing, consumer organizations, and others.

The third pillar focuses on a vital element to our success: our staff and organizational performance. ASHP can be proud of its strong staff team. Our staff is a critical success factor and an invaluable asset to the organization as we strive to meet and exceed our ambitious goals. This pillar’s goals include:

• Fostering staff excellence, teamwork and innovation;
• Ensuring a financially strong organization;
• Maintaining effective and energized governance;
• Effectively managing our organizational infrastructure; and
• Fostering high-performance staff leadership.

The essence of this pillar and its related goals and objectives is that having the best staff in the business and a financially strong organization is central to the Society’s ability to continue to maintain and enhance the services that we provide to our members.

We are all very excited about the future this plan will help guide us to. We will use the Strategic Plan to direct all ASHP activites, focusing our work on the most important issues and services required by you and the patients you serve.

I encourage you to review the new ASHP Strategic Plan, share it with your colleagues, and use this plan as you engage in your own strategic planning efforts within your practice setting.

Ambulances line Columbus Avenue after two explosions went off near the finish line of the Boston Marathon on April 15, 2013. (Photo by David L. Ryan/The Boston Globe via Getty Images)

THE PEOPLE WHO ARRIVED in the emergency department on April 15, 2013, had injuries unlike any Nancy Balch had seen in her 12 years as an emergency department pharmacist at Massachusetts General Hospital in Boston. Their injuries were severe. At least one person had had a limb blown off.

“I’ve seen a lot, unfortunately,” she said of her decade-plus in emergency care at the level 1 trauma center, “but nothing like this.”

High Volume, Extensive Injuries

By the end of Balch’s regularly scheduled shift on Monday, the hospital had treated 29 people injured by the bombs that exploded near the finish line of the Boston Marathon.

People came to the emergency department the next day, too, Balch said. Some sought care because their hearing had not returned to normal. Others did not realize until Tuesday that they had a piece of metal stuck in them.

Shannon Manzi, at Boston Children’s Hospital, has spent almost as much time in an emergency department as Balch has.

“I have not seen these types of injuries since I was in Haiti,” said Manzi, who went there in 2010 immediately after the 7.0-magnitude earthquake.

But in Haiti, the patients had crush injuries, she said. On Monday, the patients at Boston Children’s had blast injuries. Both types of injuries can sever limbs.

The children hit by the blasts, however, had injuries more extensive than what Manzi had seen after the earthquake.

On Monday, Boston Children’s, a level 1 pediatric trauma center, received 10 patients from the blasts, the hospital has reported. Manzi said she had just torn down the medical tent at mile 15 in the marathon when her pager alerted her to a “mass casualty” at the hospital. The first two patients were in the emergency department when she arrived.

Good Decisions, Well-Made Plans

The bombs exploded about the same time as the overlap in day and evening shifts for emergency department pharmacists and pharmacy technicians, Manzi said.

On arrival, she assumed the role of managing pharmacist. Pharmacists with emergency department training who had been working upstairs in the hospital came downstairs to bring the total to six.

Shannon Manzi

Manzi said emergency care personnel organized into four teams, each with two physicians, two nurses, one clinical assistant, one respiratory therapist, and one pharmacist. She remained available to manage resources, ensure everyone had what they needed, communicate with the main pharmacy, and step in when a pharmacist needed relief. The sixth pharmacist worked with the patients who were in the emergency department for reasons other than the bomb explosions.

Brigham and Women’s Hospital, a level 1 trauma center next to Boston Children’s, received 31 patients from the explosions, an emergency department physician told CNN on Monday night. Nine of those patients underwent major surgery that day, he said.

Pharmacy services executive director William Churchill said his department’s immediate goal was to ensure that the physicians and nurses in the emergency department would not have to leave a bedside to obtain a medication. The pharmacy accomplished that goal by shifting resources to have six pharmacists in the emergency department in the initial hours after the explosions, he said.

One pharmacist was already in the emergency department for the evening shift. The day-shift emergency department pharmacist, Churchill said, stayed on, as did nearly all the staff.

And, “as luck would have it,” he said, several members of the “emergency department pharmacy team” were already on duty in other areas of the hospital. The pharmacy deployed two to each of the main areas of the emergency department. In each twosome, one spoke with the nurses and physicians to determine what they needed and answer questions and the other pharmacist expedited medication delivery.

“We drill a lot with preparing for disasters and mass casualties,” Churchill said.

In those types of emergencies, patients may need a medication before they have a medical record number or their name is known. Lacking that information, he said, personnel other than the pharmacists can have trouble obtaining a medication from an automated dispensing machine. So the pharmacy on Monday deployed pharmacists who could obtain medications quickly from automated technology, he said. Those pharmacists also facilitated the preparation and delivery of preoperative i.v. drug doses for the patients heading for surgery.

“One of the pharmacists said to me that it was her perception that . . . the nurses seemed to be relieved that the pharmacists were there as part of the team helping them,” Churchill said. All of this transpired while he was offsite.

John Fanikos, one of the pharmacy’s senior directors, assumed the role of the pharmacy unit leader and went to the hospital’s command center, Churchill said. “We’ve actually drilled and practiced that with all of my senior directors.” 

With Fanikos in the hospital’s command center, Churchill said, two of the mid-level managers took roles in operating the pharmacy command center.

Contingencies

Erasmo “Ray” Mitrano

At Massachusetts General, interim chief pharmacy officer Erasmo “Ray” Mitrano made sure Balch had support in the emergency department—another pharmacist who could lend a hand and provide care to pediatric patients if any arrived.

Mitrano sent Lois Parker to the emergency department from the pediatric intensive care unit. He also had pharmacists elsewhere in the hospital remotely handle the workload that would have been Balch’s on a normal day. This, he said, freed up Balch and Parker to focus on the patients injured by the bombs.

Parker said she stayed in the pediatric emergency department to be out of the way until her assistance was needed. But no pediatric patients had arrived by 5:30 p.m., she said, when the hospital’s incident command center sent a broadcast e-mail stating that staff coverage was adequate enough for the day shift to leave. She checked with Balch, who concurred that Parker could leave.

Parker said she felt “pretty prepared” for the situation in the emergency department. The hospital has conducted disaster drills on a regular basis, and she participated in a tabletop disaster drill that was specifically geared toward pediatrics.

Emotional Support

The day after the bombs exploded, Manzi said, Boston Children’s held a debriefing for emergency department personnel. She said the hospital commonly holds a debriefing after a bad outcome. But the recent debriefing was held for another reason. The injuries on Monday were not the type seen every day, she said.

“When it’s in your background and it’s terrorism,” Manzi said, “it’s a different thing than when it was a very, very sad case of a motor vehicle accident or a shaken baby.”

Churchill estimated that 50-some pharmacists were at “The Brigham” when the bombs exploded. “People rolled up their sleeves and volunteered to stay and did whatever was necessary to get it done,” he said. “I couldn’t be more proud of that situation or my department.”

When interviewed two days after the bombing, Churchill said he continues to check on how his staff members are doing. “Hopefully, everybody’s going to do real well,” he said.

Parker, who said she was not directly involved in caring for any of the injured, said the bombing hit particularly “close to home” because coworkers could have been among the injured. “The Mass General has a fairly sizable team of people who run in the marathon, and they raise money for various programs at the hospital, including the pediatric oncology clinic,” she said.

Word of the bombing reached Parker soon after she and others had determined through the marathon organizer’s athlete tracking system that some of their colleagues were near the finish line. Balch said she sees “awful accidents” all the time, yet what she saw April 15 was different.

“The thing that most struck me,” she said, “is it was something that somebody did to people. . . . That’s what makes it most horrific for me.”

Three hours after the bombing, the Boston Police Department reported that three people had died. Local hospitals had received 176 people by 7 a.m. Tuesday, the department later stated.

–By Cheryl Thompson; reprinted with permission from ASHP News.

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.”

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.”

Paul W. Abramowitz, Pharm.D., 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.

Seizing the opportunity to demonstrate leadership, the pharmacy staff devised a plan, and with the hospital administration’s approval, the High-Risk Medication Team (HRMT) was born. Their endeavor successfully implements ASHP’s Pharmacy Practice Model Initiative recommendation for pharmacist involvement in establishing processes to ensure medication-related continuity of care.

Getting Off to a Good Start

Seeking to expand pharmacist duties often requires making a case to management, but at Scott and White, the administration had full faith in pharmacy staff from the start.

From left, Kurt Bradley Anderson, Pharm.D., staff pharmacist, consults with patient care pharmacists Lori Jackson-Khalil, Pharm.D., and Qing Xu, Pharm.D.

“We were fortunate that our leadership was in tune to this vulnerable period for patients,” said Tricia A. Meyer, M.S., Pharm.D., FASHP, of the HRMT. “They saw this as an opportunity for pharmacists based on our understanding of patient medication profiles and discharge medications.”

Tasked with providing options to the administration, the pharmacy staff set about devising several plans from which to choose. They met with the hospitalist, nursing staff, and leaders from different units to get their input and learn about their discharge processes.

Team members also called other institutions where they knew pharmacists had responsibilities similar to those they were seeking to obtain.

“We decided it would be a great opportunity for a new group of pharmacists to focus strictly on discharge,” said Meyer. “We already have pharmacists who focus on patient care, but they don’t have the time to dedicate to discharge.”

The team came up with three potential plans: One would cover medication review for every discharge; one would focus on high-risk patients and medications; and one would focus solely on anticoagulation. Administration opted for the second program, which focuses on high-risk.

From there, Meyer searched for a pharmacist who had expertise in patient interaction and counseling, and two additional team members who were ambulatory care specialists comfortable with counseling patients and reviewing medication profiles.

Working Past the Challenges

Although the pharmacy team did not have to worry about administrative buy-in, implementing the HRMT program was not without its challenges.

Patient care pharmacist Qing Xu, Pharm.D., consults with a physician about a patient’s medications.

“One of the initial barriers we had was easily knowing when patients were to be discharged,” Meyer said. “Sometimes even the attending physician doesn’t know when the patient will be discharged. Test results or a change in the patient’s condition can extend or shorten a stay, and the physician might not know until rounds.”

The team tapped into several resources around the hospital, consulted with inpatient pharmacists, and accessed data from outpatient clinics, according to Lori Jackson-Khalil, Pharm.D., patient care specialist. “For example, the anticoagulation clinic has a list of patients, and we review that list each day. The cath lab would send us a list of patients on their schedule every day, as well.”

At first, software presented a challenge, said Jackson-Khalil. “We started with a spreadsheet in Excel, and we would manually input patient data. The trick was to set up the spreadsheet to give us the information we needed.”

The team decided to err on the side of caution and create detailed records.

“We kept data on everything—every visit to a patient’s room, every call to a physician, all categorized by drug and service. The team spent a lot of time documenting,” said Meyer. “But it was worth it. In the first six months or year of a new program, you are vulnerable. You have to show that you are accomplishing the goals the administration has given you. You can never keep too much data when trying to justify a program and its growth.”

Laborious data entry may soon be a thing of the past, however. The hospital is currently switching over to a new system that the staff believes will make it easier to identify which patients are about to be discharged.

Expanding Responsibilities

Once patients on high-risk medications are identified as transitioning to discharge, their orders are scanned to the pharmacy. Initially, the HRMT would review the orders and consult with prescribers as necessary regarding additions, possible errors in omissions, and unsafe prescribing conditions.

But as of November 2012, pharmacists are able to add medications or modify discharge orders. Their new responsibilities came about in part because they were able to demonstrate their impact on patient care through the data in their spreadsheets. For example, between January and June 2011, the team identified and successfully intervened in 42 unintentional omissions of high-risk medications such as phenytoin, warfarin, clopidogrel, and prasugrel.

“Now the administration sees us as a very effective team, and physicians call us and request that we add drugs to our oversight list,” said Meyer.

Pharmacy leadership in medication-related continuity of care is currently expanding. The team has begun counseling and oversight for patients with congestive heart failure in the hope that pharmacist-provided medication management at discharge will decrease readmissions.

Lauren Rass, Pharm.D., a PGY1 pharmacy resident, (center left) and Lynsey Neighbors, Pharm.D., BPCS, RPD, counsel a patient.

A KEY ELEMENT of advancing pharmacy practice—and a recommendation of ASHP’s Pharmacy Practice Model Initiative—is the expansion of pharmacists’ duties to include writing medication orders.

At the Central Alabama Veterans Health Care System (CAVHCS), which serves more than 134,000 veterans in a 43-county area of Georgia and Alabama, the clinical pharmacy team has achieved this goal through a 10-year evolution.

What began with protocol-driven care in anticoagulation management has expanded into broad scopes of practice across a range of diseases and conditions. Pharmacy practice at CAVHCS now includes not only medication management, but prescribing privileges, in person and on the telephone.

Finding a Physician Champion

Expanding pharmacy practice in a health system requires strategy. When a system-wide evaluation revealed that CAVHCS wasn’t meeting its goals for lipid management, pharmacists saw an opportunity to showcase both their training and their clinical competency.

“We thought lipid management would be fairly easy to sell to management because it’s less risky than other practice areas,” said Addison Ragan, Pharm.D., BCPS, GCP, clinical pharmacy program manager. In 2002, the system opened a lipid management clinic where pharmacists had prescribing privileges under a protocol, and it wasn’t long before physicians throughout the system took notice.

“The primary care providers loved it, and they referred patients to us across the hospital setting,” said Ragan.

The following year, pharmacists moved into managing dyslipidemia in diabetes, again, under protocols. After the VA’s national clinical pharmacy leadership released guidance on dyslipidemia and diabetes and field guidance advocating broad scopes of practice, CAVHCS pharmacists worked closely with endocrinologist Neil E. Schaffner, M.D., meeting with him weekly for a roundtable discussion. The rapport that the team developed with Schaffner would later prompt him to become a physician champion for pharmacist-provided care.

Lynsey J. Neighbors, Pharm.D., BCPS, trained with Dr. Schaffner.

“He was somewhat skeptical of pharmacists stepping into this role at first, but after working with other pharmacists and later myself, he realized what pharmacists could do,” she said.

Accountability Counts

Ragan knew that if CAVHCS pharmacists wanted to work under broad scopes of practice, they would have to demonstrate their competency in quantifiable ways. The team developed competency checklists and professional practice evaluations to determine pharmacists’ knowledge and ability. She also implemented a mentoring process to improve performance as necessary. Under this system, pharmacists evaluate their peers every quarter.

“Having an accountability system in place shows leadership that you are monitoring the clinical competency of your staff,” said Ragan. “Even if there are cases where there need to be improvements, leadership can see that you are doing your due diligence.”

Such accountability helps pharmacists be their own best advocates, she added. “We become more conscientious in our documentation because we know it will be reviewed.”

When the time came to ask for expanded scopes of practice for several pharmacists, Ragan presented the evaluations to the administration, and Schaffner wrote a letter attesting to the pharmacists’ clinical competency.

With such evidence before them, the administration saw fit to grant Ragan’s request. Now, pharmacists have expanded scopes of care that allow them to prescribe and manage medications for anticoagulation, diabetes, dyslipidemia, hypertension, pain, hypothyroidism, osteoporosis, and gout, with more opportunities on the way as Neighbors dives into the world of hepatitis C management.

Saving Time and Money

Expanded scopes of care and increased pharmacist involvement in direct patient care have been time-savers for physicians and patients alike.

“Pharmacists now titrate insulin, do follow-up, work with insulin pump patients, and handle the day-to-day management of diabetes that doesn’t always fit into a physician’s schedule,” Neighbors said. She is currently training other pharmacists to take on these new roles in diabetes care.

Other pharmacists are currently handling aftercare for heart failure patients. The pharmacists meet the patients in shared appointments with cardiologists. From there, the pharmacists follow up via telephone to discuss medications, blood pressure, and post-discharge care.

Pharmacists with this expanded scope of practice have prescribing privileges that allow them to adjust medications based on the cardiologists’ goals for treatment, particularly with respect to diuretics.

“We’re hoping that, by having pharmacists engaged in diuretic management, we will be able to prevent readmissions,” Ragan said.

Pharmacist follow-up via telephone has been a boon to patients, many of whom live in rural areas and must travel as far as 80 miles to come to one of the system’s facilities. Patients aren’t charged for the pharmacists’ telephone calls, so the saved time translates into saved money, as well—enough so that the team is now testing a video telehealth program.

But beyond that, it’s just plain easier on the patients, said Ragan. “Often they’re not feeling well,  so it’s taxing for them to travel long distances for simple changes in their medications.”

Pharmacy practice continues to expand at CAVHCS, Ragan added.

“Current scopes of practice are written to be very general and broad, and we can jump into managing disease states that we wouldn’t have been able to before without completely rewriting their scopes.”

Paul W. Abramowitz, Pharm.D., FASHP

Today, I am pleased to make a very special announcement to the members of ASHP.

At its January meeting, the Board of Directors voted unanimously to name the ASHP headquarters building, here at 7272 Wisconsin Avenue in Bethesda, Maryland, after the man who led our organization for 37 years: Dr. Joseph A. Oddis.

As of now, the headquarters of ASHP will be known as the Joseph A. Oddis Building. The building will be dedicated at a ceremony to be held this spring.

There could not be a more fitting person to receive this honor. Dr. Oddis’ leadership over nearly four decades helped make ASHP the strong, vibrant, growing, and influential organization it is today. Joe’s vision for what ASHP could be and the important role we could play in shaping pharmacy practice, improving patient care, and influencing public policy to improve public health set this organization on the path it still follows today.

Here are just a few significant achievements from Dr. Oddis’ career and his legacy to ASHP:

• Joined ASHP in 1960 as Executive Secretary, later to be renamed Chief Executive Officer.
• Leading ASHP’s growth from 3300 members and a staff of 1 (himself!) to 31,000 members and a staff of 180.
• Developing a staff culture that focuses on serving our members in a respectful, team-based approach, with a commitment to excellence.
• Growing ASHP’s education services, launching the national meetings that would become the ASHP Summer Meeting and the ASHP Midyear Clinical Meeting, now the largest meeting of pharmacists in the world.
• Building upon ASHP’s early support of international efforts to improve pharmacy practice, including serving as president of FIP from 1986 – 1990.
• Improving pharmacy practice and raising the visibility and status of ASHP by recognizing the importance of practice standards. Under Dr. Oddis’ stewardship, ASHP worked with practitioners to develop and publish nearly 100 practice standards, guidelines, technical assistance bulletins, and position papers.
• Helping promote the concept of formularies and the acceptance of pharmacy and therapeutics (P&T) committees in the early 1960s by building consensus among key stakeholders, including the American Hospital Association, the American Medical Association, the American Pharmacists Association, and ASHP.  In 1965, Medicare based its standards on ASHP’s statements and standards and The Joint Commission deemed an active P&T committee essential for hospital accreditation.
• Establishing ASHP’s pharmacy residency accreditation program, now celebrating its 50^th anniversary. Today, ASHP has 1,582 pharmacy residency programs and 246 pharmacy technician training programs in the accreditation process. In 2012, there were more than 2,500 residents in a PGY1 or PGY2 residency program.
• Creating the ASHP Research and Education Foundation, which today offers extensive research grant, educational, and awards programs that assist and recognize pharmacists providing care to patients in our nation’s hospitals and health systems, leading to optimal medication outcomes.
•  Expanding ASHP’s publishing efforts:
  • Introducing the American Hospital Formulary Service (AHFS), which has gained national recognition as the most comprehensive resource of unbiased drug information, and recognized by the U.S. Congress as an official compendium.
  • Introducing International Pharmaceutical Abstracts (IPA), which was published by ASHP from 1964 to 2004.
  • 1964 publication of Mirror to Hospital Pharmacy, which has developed into the ASHP National Survey of Hospital and Health-System Practice.
• Building ASHP’s leadership and influence by collaborating with other pharmacy and health care organizations and government regulatory agencies on the important issues of the time, including the American Hospital Association, the American Nurses Association, the American Society of Internal Medicine, The Joint Commission, the Food and Drug Administration, and the agency that administered Medicare, among others.

Please join me in thanking Dr. Oddis for his dedication to ASHP and the profession of pharmacy.

Kathryn Schultz, Pharm.D., FASHP

AS WE BEGIN A NEW YEAR, I always like to look back at the year that was and focus on moments of success. In my inaugural address, I urged all ASHP members to become Most Valuable Pharmacists (MVPs) within their institutions. And I’ve been privileged to hear from many ASHP members over the last six months about the exciting things they are doing to improve the care of their patients.

In particular, I want to draw your attention to the many MVPs and pharmacy heroes who stepped up before, during, and after the recent devastation of Hurricane Sandy in the Northeast. As you’ll see in our feature story, “Pharmacists Take on Superstorm Sandy,” pharmacy MVPs were everywhere during this unprecedented event.

Even as their own homes and families were being affected, ASHP members in New Jersey, New York, and Connecticut courageously and selflessly took on new duties, helping to evacuate patients, setting up pharmacies in temporary quarters, and managing the medication therapy regimens of patients—often without access to patient records or traditional medication supply chains.

At New York University’s Langone Medical Center, N.Y., for example, Arash Dabestani, Pharm.D., MHA, FASHP, senior director of pharmacy, had to dive into emergency prep in a new environment (he had just been at the hospital a week when the storm hit).

Dabestani managed to arrange hotel rooms for pharmacy staff to ensure full coverage, but on the night of Oct. 29, water flooded the hospital’s basement and Langone lost power. Even the back-up generators failed, forcing staff to evacuate more than 300 patients to nearby hospitals. Without power, pharmacy team members had to climb up to 15 flights of stairs just to deliver medications.

It’s been a tough few months for pharmacists and hospital staff throughout the New York-New Jersey region. Extensive overtime has been common as the hospitals and clinics try to clean up and get back to a more-normal operating mode. Pharmacists everywhere have had to put on their game faces and exhibit real flexibility and courage in the wake of this terrible storm.

As you read their stories, I’m sure you’ll be amazed, as I was, at the innovation and dedication of our pharmacy colleagues. They’ve come so far since that fateful late October storm. These heroes continue to prove just how critical pharmacists are to the health of our patients and to the entire health-system enterprise. They are true MVPs.