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July 15, 2013

West Penn Clinic Successfully Treating Underserved Patients

Pharmacists at West Penn are a key part of the transition-of-care team as indigent patients move from inpatient care to care at the Health and Wellness Clinic.

PITTSBURGH KNOWS A THING OR TWO about comebacks. The Rust Belt capital suffered big losses when the steel industry collapsed in the 1980s, but returned to prosperity with a diversified economy. The West Penn Hospital also faced its own budgetary crisis a few years ago, after peaking in patient volume in 2008.

In 2010, we were forced to significantly downsize and reduce patient care services due to the financial difficulties of our parent organization. After an acquisition and two years of rebuilding and revitalization, we have turned things around with the reopening of a transformed emergency department, an increase in patient beds, technology upgrades, and the biggest transformation yet: the opening of a “new concept” health and wellness clinic in downtown Pittsburgh.

The West Penn Hospital Health and Wellness Clinic, which opened in February 2013, helped us to re-establish our reputation as a cornerstone of medical care in Pittsburgh and the surrounding Bloomfield-Garfield community. Funded 100 percent by proceeds from the hospital’s 340B drug discount program, the clinic provides critical medical services to underinsured and otherwise underserved patients.

Jennifer Davis, Pharm.D.

Jennifer Davis, Pharm.D.

Since its inception, the pharmacy services department has been a driving force behind West Penn’s 340B program.  As the system director for outpatient pharmacy services, I’ve taken the lead in the overall operations of the new clinic. We run the clinic as efficiently as possible, saving time and resources by using existing space and personnel, including on-staff physicians. The funds generated by our 340B program pay for medications that patients might not otherwise be able to afford and for the cost of staffing the clinic.

As a 340B-covered entity, West Penn Hospital contracts with local pharmacies to fill prescriptions using inventory purchased by the hospital at the 340B price. Through this contract pharmacy network, we provide discounted medications to uninsured patients and generate much-needed supplemental revenue from prescriptions covered by insurance.  The revenue, in turn, is used to cover the cost of the downtown Health and Wellness Clinic as well as costs associated with other uncompensated care.

Clinic Grows, Hospital Readmission Shrinks

Physicians at the clinic see uninsured and underserved patients weekly, and we expect to see more patients as word spreads. With funding generated by the 340B program, we help patients offset the costs of their medications. They literally benefit twice from the same 340B savings—patients now have increased access to care and their prescription costs are lower.

As with most hospitals today, readmission is a hot topic at West Penn. Pharmacists at the clinic help keep patients from using the hospital’s emergency department by providing disease management, medicine adjustments, and lab monitoring services. In addition, we receive prescription compliance data from our 340B program administrator to help clinicians monitor the patients who use the program. In February alone, the clinic saw 52 patients. We were also able to hire a full-time receptionist. By year’s end, the clinic hopes to see 800 patients.

Transitioning to Better Care

At the clinic, we are strong advocates for the “transition of care” program, which helps patients use the wellness clinic and Allegheny General Hospital (AGH) Apothecary (one of the hospital’s 340B contract pharmacies) and other local contract pharmacies. This program helps to ensure the coordination and continuity of care as patients transfer between different locations or different levels of care within the same location.

Another service we offer at the clinic is bedside medication counseling at discharge and seeing these patients at the clinic for medication management. AGH Apothecary fills prescriptions as needed. Pharmacists also provide post- hospitalization follow-up for patients who are unable to see their regular doctor.

Key Partners in Setting up the Clinic

With the health and wellness clinic, we have made the best possible use of the hospital’s 340B savings. Starting the clinic, however, took planning, resourcefulness, hard work, and a partnership with a contact pharmacy administrator, Wellpartner, to manage the program.

Wellpartner has expertise in creating custom 340B retail pharmacy networks that include both chains and independents.  Our network is well balanced with the right geographical coverage, which helps increase 340B program utilization.

The hospital first implemented its 340B contract pharmacy program in 2011, after a local pharmacist noted that uninsured and underinsured patients from the hospital’s Joslin Diabetes Center could no longer pay for their medications. Currently, West Penn’s 340B program uses 29 contract pharmacies, filling more than 8,800 prescriptions in 2012.

I also credit the hospital’s C-suite for helping to get the clinic started. They were huge champions for us, and I believe that with strong C-suite support any hospital can implement such a program.

The economy has caused plenty of setbacks for us and for people in need throughout our service area.  But the West Penn Hospital Health and Wellness Clinic proves that with hard work and ingenuity, positive results are possible, even in the worst of times.

–By Jennifer Davis, Pharm.D., Director of Outpatient Pharmacy Services, West Penn Health System, Pittsburgh

 

 

 

July 1, 2013

Moving Closer to Achieving Our Vision

Abramowitz-PREFERRED-Featured

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

In the last 20 years, the ASHP House of Delegates has debated and passed important proposals like support for the entry-level Pharm.D., universal health insurance, mandatory reporting of medication errors and “just culture,” collaborative practice, and the implementation of health information technology.

In recent years, the ASHP House of Delegates has approved policies that set future goals for residency training for all practitioners in direct patient care roles; defined the role of pharmacist prescribing in interprofessional patient care; called on federal officials to take action on compounding, drug shortages, REMS, and meaningful use standards; and pushed for standardized education, certification, registration, and licensure requirements for pharmacy technicians.

These policies touch every facet of pharmacy practice and have a profound impact on medication use in this country. ASHP’s professional policies offer a vision for the future of the profession in which pharmacists are essential members of every health care team and where medication use is optimal, safe and effective for all people, all of the time.

Last month, the ASHP House of Delegates approved more than 20 new professional policies during its session at the 2013 Summer Meeting in Minneapolis. Along with passing measures that support training in team-based patient care for student pharmacists and residents and the reclassification of hydrocodone combination products under the Controlled Substances Act, delegates also took strong positions on compounding safely and achieving provider status for pharmacists.

These actions are emblematic of the leadership that ASHP has taken on key medication-use issues throughout its history. ASHP’s professional policies provide a solid foundation for the Society to pursue transformative solutions to the issues that affect our ability to care for our patients.

In particular, the newly approved policies on compounding by health care professionals and pharmacist recognition as health care providers highlight this principle.

Compounding

ASHP is actively engaged in federal efforts to close gaps in the regulatory oversight of pharmaceutical compounding activities. We’ve worked closely with members of Congress and congressional staff on legislation that we expect the Senate to vote on this month; namely, the Pharmaceutical Quality, Security, and Accountability Act. While this legislation addresses federal authority, our new policy focuses on the laws and regulations that govern traditional compounding that occurs in hospitals, clinics, and other areas within health systems. It advocates for the adoption of applicable standards of the United States Pharmacopeia by state legislatures and boards of pharmacy.

The laws and regulations governing compounding vary from state to state. It is essential for the safety of all patients that all pharmacies that compound medications, regardless of the setting, adhere to the very highest standards. A uniform standard will help to ensure that the medications our patients receive are safe and that they are not harmed by agents that are intended to help them.

Pharmacist Recognition as a Health Care Provider

Pharmacists are health care providers. You demonstrate that each day. But we have some work to do to fix antiquated federal and state laws that place unnecessary limits on patients having access to the care we provide.

Our new policy on pharmacist recognition as a health care provider makes a strong case for changing the status quo. It points to the pharmacist’s role as a medication expert who provides safe, accessible, high-quality, cost-effective care. The policy also highlights that, as health care providers, pharmacists improve access to patient care and bridge existing gaps in care.

Achieving recognition as providers for pharmacists is ASHP’s top advocacy priority. We are devoting substantial time and energy with our partner pharmacy organizations to push for changes in the Social Security Act that will recognize the valuable role we play in the health care system.

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

Pharmacist Recognition as a Health Care Provider

To advocate for changes in federal (e.g., Social Security Act), state, and third-party payment programs to define pharmacists as health care providers; further, to affirm that pharmacists, as medication-use experts, provide safe, accessible, high-quality care that is cost effective, resulting in improved patient outcomes; further, to recognize that pharmacists, as health care providers, improve access to patient care and bridge existing gaps in health care; further, to collaborate with key stakeholders to describe the covered direct patient-care services provided by pharmacists; further, to pursue a standard mechanism for compensating pharmacists who provide these services.

Compounding by Health Professionals

To advocate that state laws and regulations that govern compounding by health professionals adopt the applicable standards of the United States Pharmacopeia.

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I also encourage you to spend some time thinking about what you envision for the future of practice and what is needed to bring us closer to that goal. Share your thoughts with me in the comments section of this column or by sending an email to ceo@ashp.org. Members serve as the catalyst for our policy initiatives. Your input can help bring us even closer to achieving the vision we have for patient care.

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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April 30, 2013

New Strategic Plan Points the Way Forward

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

March 25, 2013

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

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

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

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

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

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

Layered Learning Models for Students

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

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

Osmel Delgado, Pharm.D., BCPS, cPH

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

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

Building On a Solid Foundation

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

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

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

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

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

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

Accessing Patient Charts

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

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

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

Happier Patients, Better Outcomes

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

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

Jaime Riskin, Pharm.D., BCPS

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

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

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

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

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

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

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