ASHP InterSections ASHP InterSections

February 18, 2020

Active Pharmacists Use Exercise to Boost Health and Well-Being

Abhay Patel, Pharm.D., M.S., R.Ph.

AFTER FOUR MONTHS OF TRAINING for a half marathon, Abhay Patel, Pharm.D., M.S., R.Ph., Pharmacy Manager for Ambulatory Services at Children’s Hospital of Philadelphia, was amazed by not only improvements in his endurance and strength, but also by how his attitude about his work had changed. “Things that used to be a source of stress did not seem as stressful anymore,” he said.

Benefits of Exercise

As Dr. Patel and other pharmacists are finding out, staying fit can yield a multitude of rewards, from bolstering mental resilience to reducing symptoms of depression and anxiety. Staying fit through regular exercise is also one way individuals can address the problem of burnout, which over 50% of pharmacists in acute and ambulatory care settings experience.

The benefits of a fitness regimen became clear to Dr. Patel after he finished a short jog in the park near his home in the summer of 2015, during his PGY-2 residency. “At the end of that day, I looked back and realized I had accomplished even more than I normally did on a day without any deliberate physical activity,” recalled Dr. Patel, an ASHP member since 2011.

Fitness Journey

That realization left him wanting to exercise more. After completing residency and starting his job, he began to integrate short bike rides after work, weightlifting at his local fitness center, and taking advantage of his workplace’s wellness services. “I started by squeezing whatever I could into my day, and that laid the groundwork for establishing a more targeted, consistent routine,” he said.

As it turned out, squeezing in those bits of exercise yielded additional benefits. “My demeanor began to change positively, I had more energy, I was more focused on the tasks I was doing, and I felt better about myself and about the care I was providing, as well as my role as a team leader,” said Dr. Patel.

Exercising is not a panacea, he admitted, and his days include “all of the same highs and lows that I had before,” but his ability to manage these fluctuations has improved. There have been important changes in his perspective on work and life, Dr. Patel added. “It’s clearer to me that professionally and personally, it is not just about the pursuit of the finish line, but about pursuing progress instead,” he said. “It truly is a marathon, not a sprint, and about appreciating the journey.”

Yoga Unites Mind and Body

Jogs and gym visits are two ways to stay fit, but exercise can take other forms, as Christina Martin, Pharm.D., M.S., CAE, ASHP’s Director, New Practitioners Forum, has shown.

Christina Martin, Pharm.D., M.S., CAE

Dr. Martin started practicing yoga roughly seven years ago, an interest she developed when she began her first post-residency pharmacy supervisor position and fell into the trap of working too much. “Things went out of balance,” she said. “Yoga was something that I could commit to beyond work.” Over the years, Dr. Martin has learned to enjoy not only the physical aspects of yoga but also its inward, meditative focus.

“The Sanskrit word for yoga is ‘yuj,’ which means to control or to unite, and that is what my yoga practice has transformed into – controlling the noise from the outside world and uniting my mind, body, and soul,” said Dr. Martin. “One of my teachers regularly reminds us that coming to the yoga mat is an escape to our own private island.”

Yoga has also added another layer of meaning to her life, she said, as she recently completed a hot yoga teacher training program so that she can share her passion for the practice with others. The 200-hour training program included learning about human anatomy, how to address common ailments that yoga practitioners face, as well as studies in yogic breathing, nutrition, and chakra theory. A chakra is a center of spiritual power in Hindu thought.

“Being part of any community – including the yoga community – can be an antidote to the pervasive isolation and loneliness that we see in today’s society,” Dr. Martin said.

CrossFit Champ

A strong sense of community built around the goals of fitness is one reason Robert Weber, Pharm.D., M.S., FASHP, Chief Pharmacy Officer at the Ohio State University Wexner Medical Center in Columbus, Ohio, has fallen in love with CrossFit, a high-intensity form of exercise.

Robert Weber, Pharm.D., M.S., FASHP

As Dr. Weber recalls, his journey toward developing a rigorous CrossFit regimen began after years of struggling with weight gain as well as complications from a colon cancer diagnosis in 2008 and chemotherapy and surgery that eradicated his cancer, but left him with neuropathic pain in his hands and feet.

“I was told that I should not and could not [do any vigorous exercise] because of the neuropathy and that walking with some light yoga was sufficient,” said Dr. Weber, an ASHP Fellow and member since 1980. He assumed his physicians were right, because at the time, “I wasn’t able to balance myself, jump, and do all the things that are part of exercising.”

With the neuropathic pain limiting his ability to exercise, Dr. Weber tried to stay healthy through a proper diet, but eight years of a sedentary lifestyle left him overweight, and in need of cardiovascular medications, he said.

“The turning point for me came when my brother died of cancer in 2017,” Dr. Weber recalled. “I was standing over his grave, and I said to myself, ‘I need to make a change and start exercising again and move the dial in terms of my overall health and wellness.’”

His daughter urged Dr. Weber, who is now 63, to take CrossFit classes. While the exercise leaves him feeling “tired and winded, once I’m done, I feel like a million bucks,” he said. Dr. Weber noted that he overcame the neuropathic pain in his feet by increasing the frequency and intensity of the exercises in “baby steps, and not pushing too hard at first.”

Today, as a result of regular exercise and proper nutrition, Dr. Weber is 42 pounds lighter and has been able to discontinue most of his cardiovascular and neuropathic pain drugs. “I’m now more stable on my feet, more confident, and I make better decisions at work,” he added.

For those in his age group interested in starting an exercise regimen, Dr. Weber cautioned first to get a physician’s approval and also to start at a low intensity. He noted that a personal trainer or coach has the expertise to design a safe exercise program customized to your needs. This is important because performing too many repetitions too early can cause cardiac stress, he said, and lifting too much weight initially can lead to several days of discomfort and possibly serious injury.

“Particularly at my age, it can be frustrating if you start an exercise program and get stiff and sore for a few days,” said Dr. Weber. “I’ve seen many people my age quit after a brief time because they can’t tolerate the soreness that follows exercising.”

With those caveats in mind, Dr. Weber believes that almost anyone of any age can build an exercise regimen that works for them and reap the benefits. “You can do anything you set your mind to do,” he said.

 

By David Wild

 

# # #

November 28, 2018

Clinical Privileging Paves the Way for Expanded Pharmacy Services

This opinion column was authored by ASHP member and InterSections guest columnist Ryan Mills, Pharm.D., M.B.A, M.H.A., BCPS. Dr. Mills is the Pharmacy Manager at Novant Health Kernersville Medical Center and Novant Health Clemmons Medical Center in North Carolina. He is a passionate pharmacy leader who believes that bringing pharmacists to the forefront of patient care will have a significant impact on chronic disease management and population health issues.

 

Ryan Mills, Pharm.D., M.B.A, M.H.A., BCPS

HEALTH SYSTEMS TODAY STRUGGLE WITH RISING COSTS and lower reimbursement coupled with expectations for greater safety and quality of care. Failing to adapt to these changes and position your pharmacy enterprise for the future will result in fates similar to those of  Blockbuster and Kodak. As hospitals and health systems shift toward a value-based reimbursement model, we must promote a progressive pharmacy practice model with pharmacists working together with providers in collaborative practice agreements.

 

Leveraging Pharmacists’ Expertise

My colleague, Matthew Gibson, Pharm.D., M.S., BCPS, is the Clinical Pharmacy Manager for Ambulatory Services at Novant Health. He has many years of experience with implementing collaborative practice agreements, pharmacist credentialing, and expanding pharmacy services. His pharmacy team delivers the highest-quality clinical care to our patients throughout the continuum of care.

It takes more than interprofessional collaboration throughout the patient’s hospital stay to improve patient care. Pharmacists need to be officially recognized for their expertise. North Carolina state medical and pharmacy boards have recognized pharmacists as practitioners since 1998, under the designation of clinical pharmacist practitioners (CPPs). Like other midlevel providers, CPPs enter into collaborative practice agreements with physicians, whereby the physician grants authority to the pharmacist to provide specific patient care services. The North Carolina Board of Pharmacy requires a protocol agreement between the supervising physician and CPP. This agreement details the CPP’s scope regarding disease state, medication therapy, and monitoring privileges.

 

Know Your Medical Staff Bylaws

At Novant Health, Dr. Gibson has partnered with physician leadership to successfully add CPPs to the medical staff bylaws. This means CPPs are now considered advanced practice clinicians, which is the same designation as nurse practitioners and physicians assistants. At a high level, medical staff bylaws describe how the medical staff governs itself. The bylaws explain the rights of the medical staff, the qualifications for medical staff members and advanced practice clinicians, and the necessary steps in the appointment, reappointment, and clinical privileging processes.

Every health system has its own credentialing and privileging process. Our credentialing and privileging process occurs through our central verification and medical staff offices, which determined that our CPPs would complete the same rigor of credentialing, privileging, and oversight process as our medical providers.

North Carolina laws have established a quality assessment schedule for CPPs to meet with their supervising physician on a regular basis to review clinical performance. Since the training of pharmacists has rapidly progressed over the past 10 years resulting in a spectrum of clinical skill sets among pharmacists, we decided to adopt more stringent eligibility requirements than the state, such as Board of Pharmacy Specialties certification and two years’ clinical pharmacy experience.

 

Successful Use of CPPs

Novant Health first used CPPs in the acute care setting to support optimal medication management in the neurology service line and is in the process of expanding into other venues of care, such as medication reconciliation at admission and discharge, emergency department culture review, and high-risk chronic disease state management.

The role of the pharmacist has drastically changed over the years from dispensing and verifying orders to direct patient care in partnership with all other disciplines. Our pharmacists play a crucial role in ensuring that our patients receive the highest-quality care and safest experience possible every time.

One of the most cost-effective investments any health system can make is leveraging its pharmacists in collaborative practice agreements throughout every venue of care to deliver a remarkable experience.

By Ryan Mills, Pharm.D., M.B.A., M.H.A., BCPS

 

September 25, 2013

HENs Offer Opportunities for Pharmacists to Improve Patient Care

 

Hospital Engagement Networks are bringing together pharmacists, physicians, and nurses to improve patient outcomes in areas such as preventable infections, adverse drug events, and preventable readmissions.

A COLLABORATION BETWEEN ASHP and the American Hospital Association is yielding exciting opportunities for pharmacists to improve patient care across the country.

The two organizations are working together to increase pharmacist participation in Hospital Engagement Networks (HENs), part of the Centers for Medicare & Medicaid Services’ (CMS’s) Partnership for Patients program.

Approximately 3,700 hospitals participate in HENs, choosing among 10 areas in which to improve quality measures, including surgical site infections, adverse drug events, central line-associated bloodstream infections, venous thromboembolism, catheter-associated urinary tract infections, ventilator-associated pneumonia, and preventable readmissions.

The hospitals then share their successes with partnering organizations to help others replicate what they have achieved.

Pharmacists are a Natural Fit

Because so many of the primary goals for HENs involve medication therapy, pharmacists are in a perfect position to help as medication experts on the health care team. And when the American Hospital Association’s Health Research and Educational Trust (HRET) received a CMS grant to create a HEN, approaching ASHP seemed like a no-brainer.

The HRET HEN is focused on identifying solutions that are already reducing health care-acquired conditions and disseminating them to other hospitals and health care providers, according to David G. Schulke, HRET’s vice president of research programs in Washington, D.C.

“It was natural to reach out to ASHP because many readmissions are attributable to breakdowns in drug therapy, and pharmacists are well-trained and have tremendous knowledge in that area,” Schulke said. “I’ve worked with pharmacists and ASHP for many years, and HRET wanted to see if we could use that existing relationship to knit pharmacists into the HEN’s implementation teams.”

Beverly L. Black, MHSA, CAE

Beverly L. Black, MHSA, CAE

ASHP then turned to its strong network of state affiliates to reach members who might be interested in participating.

“Depending on what a state affiliate is focusing on, they may be able to recruit pharmacists to get involved,” said Beverly L. Black, MHSA, CAE, ASHP’s director of affiliate relations. She added that pharmacists attend workshops as presenters or participants, work within their health systems to design and implement quality improvement programs as part of the HEN, and forge strong partnerships among state health-system pharmacy groups and state hospital associations.

“These relationships are important because we are common stakeholders in ensuring that patients receive optimal therapy.”

Narrowing the Focus

Developing initiatives relevant to a hospital’s or health system’s needs, measuring outcomes, and sharing information with other providers in the network are major facets of the HRET HEN.

At Purdue University’s Center for Medication Safety Advancement in Indiana, pharmacists collaborated with the Indiana Hospital Association to create the Indiana Medication Safety Alliance. Last November, the Alliance hosted a conference about medication safety, ADEs and readmissions. Now the group has its own website, provides ongoing coaching, and hosts conference calls every other month or so.

The group initially focused on two measures, successful anticoagulation with warfarin and avoidance of hypoglycemia among insulin users, but has since whittled its efforts down to improving anticoagulation.

John B. Hertig, Pharm.D., M.S.

John B. Hertig, Pharm.D., M.S.

Narrowing the focus was essential because the HEN’s guidance offers so many possible areas for improvement, said John B. Hertig, Pharm.D., M.S., the Center’s associate director.

“The HRET HEN’s Encyclopedia of Measures contains more than 100 distinct measures. So, zeroing in on warfarin was a strategic decision because the HEN was looking at patient harm with regard to ADEs and the hospitals in Indiana were reporting [issues with anticoagulation] more than anything else,” Hertig said.

At the University of Arkansas for Medical Sciences in Little Rock, the focus is on reducing readmissions for heart failure patients.

“When Medicaid announced penalties for pneumonia, acute myocardial infarction, and heart failure, we decided to take a look at how that would affect us,” said Niki Carver, Pharm.D., assistant director of pharmacy.

“After working on medication reconciliation for years, I wondered if there was a way the pharmacy could be notified when heart failure patients were admitted so the pharmacy could obtain medication histories for those patients.”

Carver knew such an effort would have an impact on the pharmacy’s workload, so she created an elective rotation for fourth-year pharmacy students that tasks them with obtaining medication histories and assisting in quality improvement efforts. Thus far, reductions in monthly readmission rates for patients with congestive heart failure have ranged from 1.67 to 4.43 percent.

Pharmacists at The Johns Hopkins Hospital are working to improve HCAHPS scores related to educating patients about their medicines. Above, a pharmacist talks to a patient about how to properly use an insulin pen.

Above left, Leigh Efird, Pharm.D., BCPS, clinical pharmacy specialist, The Johns Hopkins Hospital, teaches a patient how to properly use an insulin pen.

Working Smarter, Not Harder

The Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) served as a catalyst for involving pharmacists in the HRET HEN at The Johns Hopkins Hospital in Baltimore, where their goal is to improve HCAHPS scores for medication-related questions.

“When we partnered with the Maryland Hospital Association, they knew we were working on issues related to HCAHPS,” said Meghan Davlin Swarthout, Pharm.D., MBA, BCPS, division director, ambulatory and care transitions.

“We were able to take actionable steps toward our goals and share information with other hospitals about our successes.”

Swarthout said that the hospital has increased its “Always” HCAHPS score from the 48th percentile in the second quarter of FY2013 to the 84th percentile in the fourth quarter for the survey question, “When I left the hospital, I clearly understood the purpose for taking each of my medications.”

Swarthout also stressed the value of sharing information within the network. “Sometimes the goals for quality and safety can be overwhelming. HENs bring in the expertise of your peers, and they can help you target your biggest problems,” she said.

Carver noted that HENs eliminate redundancy. “You hear what other hospitals have done, take what you need for your institution, make changes that fit your setting and implement them, instead of starting something from scratch.”

Pharmacist involvement in the HRET HEN is still fairly sporadic. For example, in a statewide workshop of roughly 250 attendees that Swarthout attended, only about 10 participants were pharmacists. Yet despite the relatively small number of pharmacists there, they made an impact: Once the other participants heard what the pharmacists had to say about safe medication use, many indicated they would promote better use of pharmacists’ skill within their own institutions.

ASHP is hopeful that by encouraging affiliate members to participate in the state-level HENS, other health systems will likewise more fully understand the valuable role that pharmacists play in ensuring patient safety and optimal health outcomes.

“We believe that if more pharmacists knew the benefits of participating in the HENs network, they would be more interested in participating,” Swarthout said. “We all have days when it feels like we’re not making any improvements, and that can be discouraging. But when you hear other people in the HEN talk about the same things, you realize you are not alone. You come away with ideas and external motivation.”

Showcasing Pharmacists’ Skills

HENs are also an excellent way to advance the profession, according to Hertig.

“It’s an opportunity for pharmacists to showcase their skills and abilities as members of interdisciplinary teams,” he said. “But it’s also in line with ASHP’s Pharmacy Practice Model Initiative in that it helps pharmacists work at the top of their licenses. What better avenue to show the impact we can have than a federal program where we work with nurses, physicians, and other professionals?”

Shekhar Mehta, Pharm.D., M.S.

Shekhar Mehta, Pharm.D., M.S.

Shekhar Mehta, Pharm.D., M.S., ASHP’s director of clinical guidelines and quality improvement, agreed.

“ASHP is primarily concerned with patient care, medication-use safety, and ensuring that pharmacists are part of a collaborative care team. So, this initiative supports all those goals,” he said.

“Pharmacists are also the most knowledgeable members of the team when it comes to medication use, and that’s a big issue in health care reform in improving the quality of care and lowering readmissions.”

Ultimately, patients are the ones who benefit most, said Carver.

“Skeptics will say that it’s more work for pharmacists, and it is. But if you’re in hospital pharmacy, you’re in it to improve patient care. And the outcomes you will see with this program are astounding.”

—Terri D’Arrigo

Editor’s Note: Interested in getting involved with an HRET HEN program? Send an email to affiliates@ashp.org, and we’ll put you in touch with the right resources within your state.

 

July 17, 2013

Novel Missouri MTM Program Benefits Patients, Pharmacists

DC Pro is a feature of the MO HealthNet Medicaid program.

DC Pro is a feature of the MO HealthNet Medicaid program.

A NEW FEATURE OF MISSOURI’S MEDICAID PROGRAM is drawing admiration from health care experts around the country for its ability to bring pharmacists and patients together.

The program in question—Direct Care Pro (DCPro)—provides pharmacists with a database of patients in their area who are eligible for medication therapy management (MTM) and other cognitive therapies.

Gloria Sachdev, Pharm.D., a clinical assistant professor, primary care, at Purdue University, West Lafayette, Ind., and director-at-large of ASHP’s Executive Committee for the Section of Ambulatory Care Practitioners, is one of the program’s admirers.

​“I would love Indiana to one day have the IT infrastructure in place to provide MTM like Missouri does,” she said, calling DCPro “an amazing example of how to operationalize MTM services in a streamlined manner.”

Gloria Sachdev, Pharm.D.

Gloria Sachdev, Pharm.D.

Pharmacists under the Missouri program receive direct reimbursement as health care providers, and a variety of conditions are covered, including asthma, chronic obstructive pulmonary disease, diabetes, gastroesophageal reflux disease, heart failure, hypertension, and hyperlipidemia.

“The number of covered conditions is constantly expanding,” according to Sandra Bollinger, Pharm.D., provider outreach coordinator with Xerox, which manages MO HealthNet. She added that only a handful of states allow pharmacists to bill directly to their Medicaid programs as health care providers.

Helping Patients During Care Transitions

The program is an excellent example of how pharmacists can help patients during transitions of care, according to Justine Coffey, JD, LLM, director of ASHP’s Section of Ambulatory Care Practitioners.

“It’s a great model because it ensures that patients receive the care they need once they leave the hospital and are back in the community setting,” Coffey said, noting that patients receive better care when pharmacists are involved in medication management decisions.

“This program provides both an opportunity for better patient care and new opportunities to advance ambulatory pharmacy practice.”

Opportunities for Intervention

Pharmacists who are registered with MO HealthNet can log into the DCPro system and view a list of all patients who are eligible for cognitive services. The information is based on gaps in Medicaid claims that would have been filed had the patient been keeping up with their care for a particular disease state.

Next, pharmacists select which patients they want to assist and then “reserve” an intervention (many patients are eligible for multiple interventions). They then contact patients and arrange face-to-face consultations. Interventions can take place in outpatient clinics, patients’ homes, or in areas of community pharmacies that are designated for patient care. Once reserved, an intervention must be completed within 30 days or the patient is released back into the database.

For example, consider an MO HealthNet patient who has diabetes, but has not had an A1C blood test for more than 90 days. The MO HealthNet system will detect that a claim for the test has not been filed.

Based on that care gap, the system automatically adds that patient’s name and flags the intervention for which the patient is overdue. A pharmacist seeing the information can provide the test as well as additional counseling.

During an intervention, DCPro guides the pharmacist through questions that must be answered before it allows users to move to the next topic. It also fills in progress notes and submits the billing automatically once an intervention is complete.

Reimbursement (which is based on the amount of time spent with the patient rather than the nature of the intervention) is calculated in 15-minute increments. Payment ranges from $10-$20 per 15-minute period with a one-hour maximum per intervention. There is no limit on the number of intervention hours a pharmacist can bill annually.

“Pharmacists who use the system don’t have to keep their own records regarding which patients are eligible. They can just log in to see a complete list of all eligible patients in their area,” said Dr. Bollinger. The system also handles all recordkeeping and billing.

Justin May, Pharm.D.

Justin May, Pharm.D.

Utilizing Program Results to Increase Pharmacist Reimbursement

Pharmacists at Red Cross Pharmacy’s 15 locations regularly check DCPro for any pending MTM and cognitive therapy claims, said Justin May, Pharm.D., director of pharmacy with the chain, based in Marshall, MO.

“Ideally, we use the system as part of our adherence program,” he explained. “A pharmacist takes a look at a patient’s medications five to seven days before the prescriptions are filled and identifies patients who require cognitive services. Then, they set up intervention times. When patients come in to pick up their prescriptions, we sit down with them to conduct the interventions for whatever health issues are indicated.”

Chuck Termini, B.S. Pharm., RPh, a hospital staff pharmacist and independent clinical pharmacist in Kansas City, MO, connects with many of his MO HealthNet patients through referrals from nursing homes and community pharmacies, who contract with him to provide cognitive services. But he also mines the database for additional interventions.

“I almost always find patients who need help,” Termini said, estimating that he interacts with about 60 MO HealthNet patients each month.

Although pharmacist enrollment in the system has been slow to catch on, Dr. Bollinger is optimistic that the numbers will grow as pharmacists learn of these new opportunities for patient intervention and care.

“My goal is to get every pharmacist in the state enrolled,” she said, adding that growing enrollment will help her make a case to state legislators to increase reimbursement rates. “It may take a little time, but I’m confident they will increase eventually.”

Dr. Bollinger also said that MO HealthNet has been able to demonstrate cost savings resulting from decreased emergency room visits and hospitalizations among patients who participated in the program.

“This is a huge opportunity for health-system pharmacists who can get past the idea that the business comes to them, because it doesn’t,” said Termini. “You have to be proactive in assisting patients.”

–By Steve Frandzel

           

June 4, 2013

Courage

Gerald E. Meyer, Pharm.D., MBA, FASHP

Editor’s Note: The following inaugural address was given by new ASHP President Gerald E. Meyer, Pharm.D., MBA, FASHP, at the Opening Session of ASHP’s Summer Meeting in Minneapolis, Minn.,  June 4, 2013. Dr. Meyer is director of experiential education, Jefferson School of Pharmacy, Philadelphia. His full address will appear in the August 15 issue of the American Journal of Health-System Pharmacy. To watch the speech in its entirety, click here.

GOOD MORNING, AND THANK YOU for that warm welcome!

I would like to begin by acknowledging you—our members. I want to personally thank all of the members who have participated in ASHP’s state societies.

ASHP could not fulfill its mission without the support and inspired leadership of our affiliates. Yes, being president of ASHP involves a lot of time and travel. But, it also comes with a large support staff.

Local volunteer leaders, on the other hand, do it all. You are the membership committee, the program committee, the finance committee, and the professional advocacy committee. So, to all of you, a great big thanks!

A Rich Pharmacy History

Many of you may know that I am from Philadelphia. And I am proud of it.

Philadelphia has a very rich pharmacy history. We have the first hospital in the United States—Pennsylvania Hospital, founded by Benjamin Franklin in 1751. We have the first college of pharmacy in the United States—the Philadelphia College of Pharmacy, which opened in 1821. And we had the first hospital pharmacist in the United States—no, not me. His name was Jonathan Roberts.

We also lay claim to the first Hospital Pharmacy Residency Program to be surveyed for ASHP accreditation and the first accredited Pharmacy Technician Training Program–both at Thomas Jefferson University Hospital.

We have four past-presidents of ASHP currently working in Philadelphia and a fifth in retirement nearby. I won’t tell you who they are—that’s a quiz.

I have been truly fortunate to have had access to so many health-system pharmacy leaders. They, together with many other professional colleagues, have been invaluable as I charted a course through my career. And, of course, I have the most wonderful personal support from my wife, Cheryl, and my family.

I want to extend my personal thanks to all of them for their encouragement and support.

Top Priorities

In writing this speech, I definitely had a lot of people to call upon. Yet, as much as I value their wisdom, I did not ask a single one of them for guidance on what I should talk about today.

Rather, I asked you, the members. ASHP is a membership organization. It is owned by you, its members. So I felt it was appropriate to focus our discussion today on those issues that are of greatest importance to you.

We sent out a survey to a random sample of ASHP members and asked: “What question would you like to ask Gerry Meyer?” Well, you did not disappoint. We received 130 questions, many of which spoke to the concept of courage. So, settle back and relax. This may take awhile. (OK, for the sake of time, we did narrow it down a bit.)

For our first question, Fred Bender, Pharm.D., FASHP, director of pharmacy services at Greenville Health System in Greenville, S.C., asked, “What will be your top priorities as incoming president of ASHP?”

Fred, I have a list of priorities to share with you. But my priorities are of little value unless they become our priorities. My top priority, therefore, is to be the best leader I can possibly be. And you can’t lead without a vision. So, let’s start there.

What makes a good leader?

  • The ability to articulate a vision,
  • The ability to motivate others toward that vision, and
  • The ability to remove obstacles to promote achievement of the vision.

Now, who among you can recite ASHP’s vision? ASHP’s vision is that medication use will be optimal, safe and effective for all people, all of the time. There’s no mention of “hospitals” or “health systems.” There’s not even mention of “patients.” It says “all people, all of the time.”

So, Fred, here is my list of priorities for the year. I would suggest that we view most of the individual items on this list as obstacles confronting us in our efforts to accomplish ASHP’s vision:

  • Build coalitions,
  • Implement the recommendations of the Pharmacy Practice Model Initiative,
  • Pursue provider status,
  • Promote interprofessional education and practice,
  • Expand training and certification for pharmacists and pharmacy technicians,
  • Position ASHP to be as nimble as possible in a rapidly changing environment, and…
  • World peace!

I’m somewhat serious about that last item on the list. Creating an environment in which medication use will be optimal, safe and effective for all people, all of the time is a bold and expansive vision. And just because it is hard to conceptualize, we cannot be deterred from putting our energies towards its achievement. (So, in that respect, our vision is a bit like world peace.)

Becoming Strong Advocates for Patients, Profession

Kevin Aloysius, who just graduated with his Pharm.D. last month from Texas Tech University Health Sciences Center, in Lubbock, (congratulations to all new graduates, by the way!), asked the next question: “How do we prevent doctors’ comments such as, ‘Well, if you wanted to give me recommendations on how to treat a patient, why didn’t you go to medical school?’ “

Kevin, there is a serious answer to your question, but if I wanted to be flippant, I’d say to the physician in question: “If you wanted to be a medication-use expert, why didn’t you go to pharmacy school?” That is an accurate, patient-centric response, isn’t it? A pharmacist’s unique education focuses on the optimal, safe and effective use of medication for all people, all of the time.

Having said that, let’s remember that physicians build their reputations on high-quality outcomes. Why, then, don’t physicians seek the counsel of pharmacists in all matters of medication use? After all, the rate of medication misadventures in the current system is well-documented and not acceptable.

I believe their hesitancy relates to the element of trust. Physicians trust pharmacists to prepare and dispense medications accurately. They trust pharmacists to offer advice on proper administration. They expect pharmacists to offer suggestions on medication compatibility and dosage adjustments.

But, some may not trust pharmacists to create optimal, safe and effective medication-use plans for all people, all of the time. How, then, do we build this trust?

We must aggressively pursue all avenues to modify the perceptions of physicians. And not just physicians, but also health care policy makers, decision makers, and providers, as well as  the general public about the unique education and training possessed by pharmacists. We must have the courage to be strong advocates for our patients and for our profession. Historically, we have been far too passive in promoting our value.

Antagonism vs. Synergism

Our next question comes from Jamie Ridley Klucken, Pharm.D., MBA, BCPS, an assistant professor of pharmacy practice at Shenandoah University, Ashburn, Va., who asked, “We see a push to work collaboratively with other health care providers but seem to have a difficult time putting this into practice. Are there ways to accelerate this interprofessional practice? Perhaps through pharmacy education and post-graduate residency programs?”

Jamie, by definition, interprofessional activities cannot be accomplished by one profession. Each profession must be willing to participate.

The good news is that in May 2011, a group called the Interprofessional Education Collaborative—consisting of educators representing pharmacy, medicine, nursing, dentistry, and public health—released a report that summarized the core competencies needed for interprofessional collaborative practice. Those core competencies fell within four domains:

  • Values and ethics,
  • Roles and responsibilities,
  • Interprofessional communication, and
  • Teams and teamwork.

What this report says is that to build an efficient and effective health care system, health care providers need to:

  • Have a common understanding of health care ethics and values,
  • Understand one another’s roles and responsibilities,
  • Learn how to communicate with one another, and
  • Learn how to be part of effective teams and how to play well together in the sandbox.

For two years, we have had this guidance document that delineates the curricular components that should be taught to health care students, interprofessionally. Jamie, I agree with you. Our profession needs to take a leadership position in incorporating interprofessional competencies into our formal education and training standards. These changes cannot occur fast enough.

Furthermore, to develop this set of skills and knowledge within practicing pharmacists, ASHP must incorporate this critical content within our continuing professional development offerings.

It’s important to consider what this report does not say. Nowhere does it say that interprofessional education should encompass getting health care students into the same classroom to teach them pathophysiology, pharmacology, diagnosis, or treatment. So, if those are not our commonalities, then those must be our differences. Exactly.

Let’s look at this in pharmacologic terms. Sometimes, we administer two very effective drugs that may compete for the same receptor, and the result is that they become less effective. We call that phenomenon “antagonism.” On the other hand, sometimes we prescribe two drugs and the positive effect is greater than the anticipated sum of their individual effects. We call that “synergism.”

Let’s move past interprofessional antagonism. Let’s have the courage to promote an efficient and effective health care system comprised of interdependent, synergistic health care providers.

Practicing at the Top of Our Education, Training

The next question comes from Cassie Heffern, Pharm.D., a PGY2 ambulatory care resident with CoxHealth, in Springfield, Mo., who asked: “In some more rural hospitals, change is almost feared. Despite [the fact] that no one will lose a position by  including more PPMI, the subject is still feared. How would you suggest to keep moving forward with PPMI?”

As you may know, ASHP’s Pharmacy Practice Model Initiative—or PPMI—envisions a future in which pharmacists practice at the top of their education and training. The model identifies the roles that pharmacists must assume and then describes the need to maximize the incorporation of enablers—notably, technicians and technology—to help achieve those roles.

Earlier, I stated that leadership encompasses stating a vision, engaging others to embrace the vision, and removing obstacles toward accomplishing the vision.

For 71 years, ASHP has been a leadership organization. This professional leadership continues. Through the PPMI, ASHP members created a bold vision, and ASHP is committing significant resources to help our members achieve their vision.

Cassie, your question alluded to challenges faced by rural health care providers. We recognize that many of our members are not able to leave their workplace to attend live educational offerings. We have begun, and will continue to accelerate, the delivery of educational programming in formats that offer accessibility to all of our members.

The PPMI envisions advancing pharmacy practice beyond pharmacists offering recommendations for others to implement. It envisions pharmacists as interdependent prescribers who accept accountability for the patient-care plans that they personally initiate.

The willingness to expand our scope of accountability to improve our patients’ health is the essence of our envisioned pharmacy practice model. Are we prepared to expand our scope of practice? Are we prepared to accept accountability for prescribing decisions?

Doing so requires courage. It requires the courage to challenge the status quo. It requires the courage to practice at the top of our education and training, not just at the top of our licenses. It requires the courage to practice beyond the borders of established practice.

The Future of Residency Training

Among the questions I received, more related to residencies than to any other topic. Two members, Kent Montierth, Pharm.D., director of pharmacy for Banner Estrella Medical Center, in Phoenix, Ariz., and Erica Maceira, Pharm.D., BCPS, CACP, clinical pharmacy specialist and student and resident coordinator at Albany Medical Center Hospital in Albany, N.Y., asked: “How does ASHP plan to help grow the number of residency programs and the number of available positions? And, how can the accreditation process be simplified?”

Although it sometimes may feel like we are making little progress in this area, the numbers tell a different story. From 1995 to 2006 (a 12-year period), the number of available accredited residency programs and the number of available positions in those programs doubled. From 2006 to 2012 (a subsequent six-year period), the number of accredited residency programs and number of positions doubled again.

Part of the reason for this rapid growth is that the value proposition for residencies is easily developed for residents,  employers, patients, and the profession. The ASHP website contains a number of documents that can assist practitioners in justifying, designing, and conducting residency training programs.

However, one of the greatest barriers to increasing the number of residency training programs cannot be overcome with guidance documents  alone. A good training program requires a solid infrastructure.

Pharmacy services must meet contemporary standards of practice. Preceptors must have the ability to impart knowledge and develop critical reasoning skills. Residency program directors must be able to mentor and  inspire those entering the profession. And an organization’s culture must be supportive of the training mission.

We cannot, and we should not, compromise on these foundational pillars.

There are now more than 1,000 residency programs in the United States that have a solid infrastructure. I call on those programs to consider expanding. For those institutions without a sufficient infrastructure currently in place, consider collaborating with an existing residency program.

In the 1970s, and then again in the 1990s, my institution offered joint residency positions with neighboring institutions. Those joint programs continued until our partners had developed sufficient infrastructure to conduct their residencies independently.

Kent and Erica, you also asked about simplifying the accreditation process. I agree that we must critically evaluate the current standards to ensure that each requirement contributes to the quality of the training process.

Both the PGY1 and PGY2 standards for accreditation are currently under revision, which presents us with just such an opportunity. As drafts of proposed revisions to those standards are circulated, I encourage all residency program directors to provide your feedback.

Many of the questions I received about residency training referred to ASHP’s member-developed policy that, by 2020, all pharmacists involved in direct patient care must complete a residency.

Let me be clear. Residency training is a critical element in enhancing patient care by expanding pharmacists’ responsibilities. Residencies instill the confidence in young practitioners to have the courage to drive the profession past its current borders.

Please remember that ASHP’s residency policy is aspirational in nature. The decision about whether to pursue a residency is  a career decision. You do not need a residency to obtain a pharmacist license. But you do need a residency to pursue and advance along certain career paths, and the number of those career paths continues to grow every year.

There are four stages to the education and continued training of a pharmacist: pre-pharmacy undergraduate education, professional doctorate education, formalized training, and continuing professional development.

Coordinating the outcomes of each of these four stages is a professional imperative. While the requirements for the pre-pharmacy and pharmacy curricula will evolve, we must recognize that there is only so much that we can accomplish in the classroom because (1) contact time is limited, and (2) students do not have pharmacist licenses.

At some point in time, the profession will need to address the question: Should residency training be required for pharmacists to meet their obligation to  their patients? At some point, that answer will be “yes.” Whether this happens by 2020 or not, it is far better for the profession to prepare for that future than to be unprepared when that future arrives.

Gaining Provider Status

Zina Gugkaeva, Pharm.D., a PGY1 resident at the University of Iowa Hospitals and Clinics, in Iowa City, asked our sixth and final question: “When are pharmacists finally going to be recognized as providers, and what will it change?”

Many of you may have attended the Provider Status Town Hall at this Summer Meeting where this very issue was discussed. Much of what we heard, we already knew:

  • The health care environment is changing.
  • Emerging practice models are focused on integrated health care delivery systems.
  • Policymakers are seeking ways to make health care more affordable for more people.
  • Payment will be focused on quality, not quantity, of care.
  • Consumers will demand transparency in the cost of their care.

So, what will happen when pharmacists are recognized as health care providers?

  • Pharmacists’ patient care services will improve access.
  • Pharmacists’ patient care services will improve quality.
  • Pharmacists’ patient care services will help control costs.

Access—quality—cost. There is substantial documentation to support the positive impact of pharmacists on access, quality and cost of care. We know it. Now we have to sell it. We must have the courage of our convictions.

The first step is to ensure that the profession moves forward with this common message by solidifying these basic principles within the existing coalition of pharmacy organizations. Then, we need to expand the coalition to include other critical stakeholders, including health care provider groups, payers, and patient advocates. We need to draft legislation and seek support by educating legislators, both on a state and national level.

ASHP will serve as your collective voice in formulating the message. ASHP will develop the materials needed to deliver that message. ASHP will tailor those materials for different audiences. And ASHP will train you.

But, we need you to deliver the message to your legislators, to your C-suite, to your health-system’s lobbyists, to your health care colleagues, to your complacent pharmacist colleagues, to your local media, and to your patients.

Access—quality—cost. The message is clear. The message is focused. The message meets society’s needs.

Gaining provider status will ensure that pharmacy is at the table when regulators and other policymakers invite health care providers to help construct new delivery models. And that is why ASHP, the American Pharmacists Association (APhA), the American College of Clinical Pharmacy (ACCP), and other health care organizations have committed significant resources to achieving provider status for pharmacists.

Zina, while no one can predict when we will finally succeed, I am confident that we will succeed if we have the courage to stand strong and united on this issue and if our members get personally involved.

I call upon all pharmacists who believe they are health care providers, on all student pharmacists who believe they are training to become health care providers, on all people who want their medication use to be optimal, safe and effective all of the time. I call on everyone to send the message: “Pharmacists are medication-use experts. Pharmacists improve access, improve quality, and control the cost of health care. Pharmacists are health care providers.”

In closing, I want to thank everyone who took the time to submit questions. I invite you to continue to send me your comments and suggestions over the next year. Finally, I want to thank you for the courage you show every day toward advancing ASHP’s vision: that medication use will be optimal, safe and effective for all people, all of the time.

Thank you.

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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