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August 20, 2018

Get Ready to Join the New ASHP Section of Specialty Pharmacy Practitioners

Filed under: From the CEO — Tags: , , , , , — Amy Erickson @ 7:33 pm

AS MANY OF YOU KNOW, the ASHP Board of Directors approved the creation of a new Section of Specialty Pharmacy Practitioners during its June meeting. The creation of this important new section is an example of how ASHP is providing leadership to shape the evolving healthcare landscape. The new section is the membership home for all pharmacy practitioners who are interested or engaged in specialty pharmacy.

All current and new members who practice in broad and diverse specialty pharmacy areas are invited to join the new section. We encourage those who provide direct patient care services and help manage and support the interface between specialty pharmacies, their organizations, and the patients they serve to also join the new section. ASHP members can add the section to their already existing benefits, providing an enhanced value to their membership at no additional charge.

Section of Specialty Pharmacy Practitioner members will provide ASHP with overall direction for a broad range of education, tools, resources, strategic initiatives, professional policies, and more. This member-driven approach ensures that the resources ASHP provides reflect the current and f

uture state of pharmacy practice, and it does so in a way that helps pharmacists provide optimal care to their patients. We’re eager for the members of the new Section of Specialty Pharmacy Practitioners to contribute in meaningful ways and guide ASHP on the path forward for specialty pharmacy practice.

The new section will meet the needs, address the challenges, and identify opportunities of this unique and growing industry and patient populations. The role of specialty pharmacy practitioners is vital to improving health outcomes, identifying accessible and affordable medications for rare and chronic conditions, and ensuring the highest quality of care for these complex and highly specialized patients. ASHP envisions many new professional growth opportunities for our members in this exciting and evolving pharmacy practice area.

We plan to have the new Section of Specialty Pharmacy Practitioners fully up and running this fall. The inaugural ASHP Section Executive Committee will be appointed at the end of August and will begin its important work on behalf of the new section during its first meeting in October. ASHP will be seeking additional volunteers to serve in advisory group capacities. We will be reaching out to you soon to encourage you to join the ASHP Section of Specialty Pharmacy Practitioners and spread the word about this new endeavor.

The energy and excitement for the new ASHP Section of Specialty Pharmacy Practitioners is very high, and we look forward to engaging many current and new ASHP members in its important activities.

Thank you for being a member of the fastest-growing and most forward-looking organization in pharmacy, and for everything you do for your patients and our profession.

Sincerely,

Paul

May 9, 2013

Pharmacist Involvement Integral to Medical Home at Advocate Health

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

AS HEALTH CARE 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 Health Care 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, M.D.

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

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March 25, 2013

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.”

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February 25, 2013

Expansion into Prescribing at the VA

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.”

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September 6, 2012

The Power of Policy: Pathways to the Future

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

SOMETIMES, WHEN PEOPLE THINK of the word “policy,” they think of “red tape,” bureaucracy, or an arduous process. However, when I think about the word policy, a different connotation comes to mind. I think about how much has changed in our profession since I first became an ASHP member 35 years ago, and I reflect upon the policies that helped to get us here.

Clinical pharmacy practice, the entry-level doctor of pharmacy degree, specialization, pharmacists providing direct patient care in clinics and other ambulatory settings, collaborative practice agreements, barcode medication administration, electronic clinical information systems, and so many more advancements in our profession started with just one thought: How can we do things better? And, that thought, driven by policy turned into action, ultimately led to change.

At the root of all professional advancements and change are the policies that guide us there.

Change in pharmacy practice does not just happen. It is carefully crafted, nurtured and re-evaluated over and over – even after success.

Today, ASHP stands strong as an organization adaptable and responsive to the changing needs of our patients as well as the changing demands within health care as whole. And, it is all because of you, our members. You make this happen. Through ASHP’s professional policy process, our members do not just play a significant role in bringing new and innovative ideas to the forefront of pharmacy practice; they are the catalysts for our efforts.

In June, there were several groundbreaking policies that came before the ASHP House of Delegates for debate that will make similar strides for pharmacy practice, including policies related to pharmacist prescribing, board certification, and licensing and training of pharmacy technicians. All of these were inspired by the recommendations of ASHP’s Pharmacy Practice Model Initiative (PPMI). I’d like to share some thoughts about them with you.

While these policies concern different aspects of practice, they have one thing in common: a shared vision for the future of the profession in which pharmacists are essential members of every health care team, helping our patients with our deep and extensive knowledge about all aspects of medication therapy.

The policies regarding pharmacist prescribing puts this activity in context of the pharmacist’s role on the interprofessional team and clearly states that prescribing is a complex function that requires pharmacists to have specific skills and competencies. The policy regarding board certification addresses the growing demand for board-certified pharmacists and sets a new expectation that pharmacists should become certified by the Board of Pharmacy Specialties (BPS) if they practice in a specialty in which BPS offers certification.

And the policies regarding pharmacy technicians take a strong stand on requiring licensure, as well as specialized training for advanced roles. These technician positions are an outgrowth of ASHP’s Pharmacy Technician Initiative and should serve to strengthen ASHP’s advocacy for standards for training, certification, and licensure.

These are just a few examples of the forward-thinking policies that ASHP members have conceptualized and that were brought before the House of Delegates. Although some of these concepts might seem far-reaching to some of us today, it is easy to imagine that these ideas will one day be part of routine practice, and that a new set of future-oriented policies to advance the profession for the betterment of patients will be brought before future ASHP Houses of Delegates. We look forward to working with our members and our state affiliates in creating a future in which these policies are the standard operating procedure.

Please take a look at these summaries, and review the professional policies that were recently finalized by the ASHP House of Delegates:

Prescribing:

A) Pharmacist Prescribing in Interprofessional Patient Care

Defines pharmacist prescribing as patient assessment and the selection, initiation, monitoring, adjustment, and discontinuation of medication therapy pursuant to diagnosis of a medical disease or condition; further, The policy also advocates that health care organizations establish credentialing and privileging processes to ensure competency.

B) Qualifications and Competencies Required to Prescribe Medications

Affirms that prescribing is a collaborative process that, if performed collaboratively, requires that competent, interdependent professionals complement each others’ strengths at each step. The policy also suggests the creation of prescribing standards that would apply to all prescribers, and encourages research on the effectiveness of educational processes currently available.

Board Certification:

Board Certification for Pharmacists

This policy, recommended by the ASHP Section of Clinical Specialists and Scientists, supports the principle that pharmacists practicing in formally recognized specialty areas should become BPS certified in that specialty. Among other things, the policy also calls for BPS to prioritize recognition of new specialties in areas that have a sufficient number of PGY2 residencies and existing training programs.

Pharmacy Technicians: 

A) Licensure of Pharmacy Technicians 

Advocates for licensure of pharmacy technicians by state boards of pharmacy, as well as the development of uniform state laws and regulations and mandatory completion of an ASHP-accredited training program as a prerequisite to licensure.

B) Qualifications of Pharmacy Technicians in Advanced Roles 

Advocates that beyond completing an ASHP-accredited training program, certification and licensure, pharmacy technicians working in advanced roles should have additional training and should be required to demonstrate competencies specific to these tasks.

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Once these new policies take root and grow to become the norm across health care and the nation, imagine their impact on the practice of pharmacy and how they will give us new tools to enhance patient care. Further, imagine all the future creative enhancements in the care delivery process that they will set in motion. Think back to some of the policies approved by our House of Delegates in the past and what they have led us to achieve.

Then, begin using these new policies to create the future.

Innovations in Reimbursement

Betsy Bryant Shilliday, Pharm.D., CDE, CPP, right, speaks with a patient during the patient’s Annual Wellness Visit (AWV).

LAST APRIL, THE PHARMACY DIRECTOR of a large, multi-hospital health system in the Midwest phoned Gloria Sachdev, Pharm.D., clinical assistant professor of primary care at the Purdue University School of Pharmacy, West Lafayette, Ind.

Several administrators had bombarded the director with requests for additional clinical pharmacists. Faced with juggling the competing demands while securing adequate resources to support the costs—and with his organization in the midst of becoming an accountable care organization (ACO)—he turned to Dr. Sachdev, an authority on establishing sustainable clinical pharmacy models.

“No one had a firm idea of what services they needed, yet they all felt pressure to meet shifting quality-of-care measures,” said Dr. Sachdev. These included reducing 30-day readmission rates or boosting subpar performance measures which would be tied to how much money they could share from savings created by its ACO. And all of the petitioners knew that medication-related measures were intertwined with many of the health outcomes they wanted to influence.

“The question was wide open: Can pharmacists make an impact on some of these measures? The answer is yes,” said Dr. Sachdev.

Creating a Financially Sustainable Plan

After multiple meetings with the administrators and the pharmacy director, Dr. Sachdev helped the group identify what services each had in mind, which diseases and conditions needed the most attention, and the role pharmacists could play within the organization’s nascent accountable care model. Then, they hammered out a financially sustainable plan to expand pharmacist services.

Ultimately, two ambulatory care pharmacist positions were approved to focus on chronic disease management, transitions of care, and quality improvement. Both positions were designed to be billed “incident to” a physician’s care.

Gloria Sachdev, Pharm.D.

“Reimbursement for the pharmacists will cover a bit more than the cost of their services,” said to Dr. Sachdev. “It’s essentially a cost-neutral proposition.”  Getting the billing department involved and educating employees regarding billing opportunities for pharmacists early on was key to the group’s success.

When direct billing for pharmacist services isn’t available—which is usually the case in today’s health care environment—Dr. Sachdev noted that “in a pay-for-quality environment, if pharmacists can show that they can help a health system achieve quality measures of high priority, when the organization gets a large payment for attaining these measures, some of that money can be designated to pay the pharmacists’ salaries.”

“Pay-for-quality programs, such as ACOs, Patient-Centered Medical Homes (PCMHs), Medicare Part C (Medicare Advantage), etc., offer pharmacists new payment opportunities by implementing this indirect model of reimbursement,” she added.

Helping Patients Manage Their Medications

Elsewhere, pharmacists have put their own distinct imprint on direct patient care. The P3 (Patients, Pharmacists, Partnerships) program at the University of Maryland School of Pharmacy began as a diabetes management initiative, then broadened its scope considerably.

The P3 Program is a dynamic partnership that begins with the University of Maryland School of Pharmacy, and includes the Maryland Pharmacists Association, the American Pharmacists Association Foundation, the Maryland General Assembly, and the Maryland Department of Health and Mental Hygiene, Office of Chronic Disease Prevention.

The program contracts with six companies, including ASHP, to conduct medication management and preventive care for employees with chronic diseases such as diabetes, high blood pressure, and high cholesterol. Any employee covered under the employer’s health plan is eligible, and more than 400 are currently enrolled.

P3 pharmacists consult patients four to seven times annually. They assess each patient’s understanding of his or her illness and medication regime, emphasize the importance of medication adherence, and provide education about adverse effects and drug interactions. Pharmacists may also help patients set personal goals, coordinate referrals for lab tests and specialist visits, and administer pneumococcal and influenza vaccinations.

Consults occur at wellness clinics, at community pharmacies, or at an employer’s premises. All P3 pharmacists receive training in medication therapy management, chronic disease management, and self-management coaching and must have completed an Accredited Council for Pharmacy Education-level Diabetes Certficate program, be a certified diabetes educator, or be a Board-certified Pharmacotherapy Specialist.

“We bill the employer every month based on the number of visits and pay the pharmacists who saw the patient,” said Dawn Shojai, Pharm.D., assistant director of P3.

The results are telling: Since January 2009, P3 participants have experienced statistically significant improvements in outcomes for all clinical endpoints, including hemoglobin A1c levels, blood pressure, and LDL cholesterol levels.

The numbers also compare favorably to national and statewide indicators, according to Dr. Shojai. For example, 83 percent of P3 participants had HbA1c levels under 8 percent, compared with 62.3 percent and 64 percent of patients enrolled in national and Maryland commercial plans, respectively, according to data from the 2011 HEDIS (Healthcare Effectiveness Data and Information Set). On average, employers saved about $1,500 per employee annually.

Dr. Shojai continues to push hard for recognition of P3 by Maryland’s Medicaid program, which she expects to occur eventually. “Most of the battles have been to convince people that paying for pharmacists, while expensive, will save money and lives,” she said.

Annual Wellness Visits: A New Kind of Patient Care

Farther south, pharmacists in North Carolina are mining a section of the Affordable Care Act (ACA) and hauling out a steady new revenue source. The ACA established Medicare coverage for annual wellness visits (AWV), but Medicare doesn’t stipulate who must conduct the visit except to say that the clinician must be a licensed health professional.

“This is a completely new avenue for pharmacists to generate revenue by seeing Medicare patients and earning direct reimbursement at a higher service level,” said Betsy Bryant Shilliday, Pharm.D., CDE, CPP, associate clinical professor at the University of North Carolina at Chapel Hill School of Medicine and Eshelman School of Pharmacy.

“Across the board, this is a different type of visit than pharmacists are used to providing. It’s a big deal,” she said. Patients seem to think so, too. Appointment slots fill up weeks in advance. “It’s a service patients want, and that means I am generating income, too,” Dr. Shilliday added.

Reimbursement varies by region, but rates are uniformly higher than for nurse visits, and the service isn’t subject to the usual 20 percent copayment, said Dr. Shilliday, who details the visit requirements on the Section of Ambulatory Care Practitioners portion of the ASHP website.

The practice of pharmacists conducting AWVs is not yet widespread, but Dr. Shilliday predicts steady growth as health systems realize that this represents a practical and profitable way to mitigate the shortage of primary care providers. Ultimately, it is up to pharmacists to identify these kinds of opportunities, according to Dr. Shilliday. “We need to step outside our comfort zone of practice to embrace innovative opportunities, expand our scope of practice, and assume new responsibilities” she said.

Bearing the Burden of Proof 

Mary Ann Kliethermes, Pharm.D., vice chair of ambulatory and associate professor at the Chicago College of Pharmacy, Midwestern University, in Downers Grove, Ill., agrees that in the current health care landscape, pharmacists bear the burden to prove their worth. Her own experience is a case in point. Dr. Kliethermes works part-time in an internal medicine office of a large, multi-site physician group in the Chicago suburbs. Until recently, her main responsibility had been counseling patients who were on anticoagulation therapy. She and the one other pharmacist in the office, however, envisioned much more.

Mary Ann Kliethermes, Pharm.D.

Over six months, they assembled a detailed business plan to broaden medication management services and projected the potential clinical and financial gains. They supported their case with data that showed, among other things, how pharmacist-directed medication management greatly reduced drug-related hospital readmission rates. By fortunate coincidence, the physician group had decided to adopt a patient-centered medical home model, necessitating a closer look at clinical outcomes. The result: Two pharmacists were added to their staff and a third is under consideration.

Their approach embraced the reality of the newer models to which health organizations must hew, and which tie reimbursement to quality and cost reduction, said Dr. Kliethermes, who co-edited, Building a Successful Ambulatory Care Practice, recently published by ASHP.

“We offered a total business package, justified our skills, and showed how we could help the practice meet its goals,” she said. “It is up to the health organization to decide how to allocate its resources, but it is up to pharmacists to show how they can improve outcomes.”

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