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  • CognitivePharmaceuticalServicesinCommunity

    Pharmacy

    ProfCharlieBenrimojProfessorofPharmacyPractice&HeadofGraduateSchoolofHealth

    CHEREOctober2013

  • Overview

    NationalandInternationalContext AustralianEnvironment&Research

    PharmacyBarometer ImplementationandSustainabilityModel PilotingofModel

    InternationalImpactStudy(ECHO)inSpain Conclusion

  • InternationalTrends

    Traditional pharmacy role as medicine

    supplier challenged1

    1975 Early 90s Late 90s 2000 2008/13

    Philosophical shift

    Pharmaceutical Care2

    Cognitive pharmaceutical

    services3

    Remuneration for service provision4

    Service integration and

    business viability5

    1.Mickeal,R.L.etal,AmJHospPharm,1975.32:p.56774.4.Benrimoj,S.I.andA.S.Roberts,AnnPharmacother,2005.39:p.191172.Hepler,C.andL.M.Strand,AmJHospPharm,1990.47:p.53343.5.Feletto,E.etal,FIP2008CongressAbstract(#147)3.Cipolle,R.J.,etal,PharmaceuticalCarePractice.1998,NewYork:McGrawHill.

    1.BusinessmodelsMarketDifferentiation2.Pacticeroles IndividualPharmacistCareers

  • HierarchicalModelofCognitivePharmaceuticalServices

    1.MedicinesInformation8

    2.Compliance,Adherenceand/orConcordance9

    3.DiseaseScreening10

    4.DiseasePrevention11

    5.ClinicalInterventionorDrugRelatedProblems12

    6.MedicationUseReviews13

    7.MedicationManagement/MedicationTherapyManagement1416

    a. HomeMedicationReviewsa. ResidentialCareMedicationReviewsa. Medicationreviewswithcontinuancefollowup(SFT)

    8.DiseaseStateManagementforChronicConditions17

    9.ParticipationinTherapeuticDecisionswithMedicalPractitioners18,19

    a. InClinicalsettinga. Inthepharmacy

    10.Prescribing20

    a. Supplementarya. Dependent

  • Payers Government

    Costsavings Qualityorrationaluseofmedicines

    HealthInsurers Decreasehospitalisations Prevention

    Pharmaceuticalcompanies Adherence

    DirectPatient

    5

  • Fundingtype Definition

    CapitationfundingFixedprepayment,perpatient,toahealthcareprovidertodeliverhealthservicestoaparticulargroupofpatients,overaspecifiedperiodoftime.

    Feeforservice Asystemoffeesthatarerelatedtospecificservicesprovided(e.g.visits,treatments,procedures).Salaries Afixedpaymenttoaproviderperunitoftime.

    PayforperformancePerformancebasedOutcomespayment

    Paymentsarerelatedtodefinedmeasuresofhealthoutcomesandprocessesofcareratherthannumberofservicesprovided.Performanceisusuallymeasuredintermsofprocessandtypesofcarerecommendedinevidencebasedguidelinesratherthanactualhealthoutcomes.

    Blendedpayments Usuallyamixof13aboveandpossibly4asanaddon.Focusedonprovidingincentivesforqualityimprovement.

    GrantpaymentsApaymentproposedtosupportmultidisciplinaryclinicalservicesandcarecoordination.Thesizeofthegrantwouldbelinkedtothevolumeofpatientsenrolledwiththeprimaryhealthcareservice.

    Episodicorbundledpayments

    Thesepaymentsaredesignedtoeventuallyreplacefeeforservice.Theyinvolvebundlingtogetherthecostofpackagesofprimaryhealthcareforenrolledindividualsoveracourseofcareorperiodoftime.

    1. Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L (2000). Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database of Systematic Reviews 2000, Issue 3.

    2. Australian Government Department of Health and Ageing (2009). Element 10: Fiscally sustainable, efficient and cost effective. In: Primary Health Care Reform in Australia: Report to Support Australias First National Primary Health Care Strategy

    3. Smith P C (2008). Formula funding of health services: learning from experience in some developed countries. Discussion Paper 1; World Health Organisation, Geneva. Ref:A.Robertsetal2012

  • StagesofServices

    DebateandDefiningServicese.g.

    SouthAmerica

    Japan

    ResearchStagee.g.

    Germany Spain Denmark France

    Paymentsecurede.g.

    UK USA Australia Canada NZ etc.

    NationalImplementation

  • Australia:CommunityPharmacyAgreements

    SignedbetweenthePharmacyGuildandtheCommonwealthGovernment

    Increasingshifttowardscognitiveservices

    $4m

    2nd Agreement19952000

    $302M

    3rd Agreement20002005

    $500M

    4th Agreement20052010

    $660M:

    6th Agreement201152020

    5th Agreement20102015

    ?

  • Fundingelements 5th AgreementElement $m

    Pharmacyremuneration(includesdispensingfee,pharmacyandwholesalermarkup, extemporaneouslypreparedanddangerousdrugfees,premiumfeedispensingincentive,andelectronicprescriptionfee)

    13,771.6

    Programs andServices 386.4

    Additional Programstosupportpatientservices

    277.0

    CommunityServiceObligation 949.5

    Total 15,384.5

  • 2nd Agreement19952000

    3rd Agreement20002005

    4th Agreement20052010

    5th Agreement20102015

    FundedProfessionalPrograms

    ResidentialMedicationReviews

    ResidentialMedicationManagement

    HomeMedicineReviews

    ProvisionofCMIs

    IndigenousPrograms

    RuralPrograms R&D

    ResidentialMedicationManagement

    HomeMedicineReviews

    ProvisionofCMIs

    IndigenousPrograms

    RuralPrograms R&D

    ResidentialMedicationManagementReviews

    HomeMedicineReviews

    Medscheck Diabetes

    IndigenousPrograms RuralPrograms R&D

    PracticePaymentIncentives

    (PPI)

    QualityCarePharmacyProgram

    QualityCarePharmacyProgram

    QualityCarePharmacyProgram

    QualityCarePharmacyProgram

    PPIsfor: DAAs DailyDispensing

    ClinicalInterventions

    AvailableFunds$5m $416m $568m $738m

  • PharmacyPracticeProjects/Programs

    ThreeGeneralTypes

    Projects:Defineandtheoreticallydesigntheservice,Classifyandtest&optimise

    feasibility

    Projects:Evaluatetheimpact(ECHO)

    Program:Implementation&

    Sustainability

  • ChronologyofHMR

    Chen,TF,BenrimojSetal. Medicationregimenreviews acollaborationbetweencommunitypharmacistsandgeneralmedicalpractitioners. [Report]

    95

    Chen,TFBenrimojSetal. Medicationregimenreviews acollaborativeprojectbetweencommunitypharmacistsandgeneralmedicalpractitioners.Development,implementationandevaluationofintervention.[Report]

    97

    Krass,IandSmith,C. "Impactofmedicationregimenreviewsperformedbycommunitypharmacistsforambulatorypatientsthroughliaisonwithgeneralmedicalpractitioners." IntJPharmPract 8(2):111120.

    00

    Chen,TF,BenrimojSetal. AcomparativestudyoftwocollaborativemodelsfortheprovisionofDMMR. [Report]

    Roberts,MSandWoodward,M.Thedomiciliarymedicationreviewproject.[Report]

    Gilbert,AandBeilby,J.Qualityuseofmedicinesinthecommunityimplementationtrial.[Report]

    00

    Seealso:http://beta.guild.org.au/research/

  • BarriersandFacilitators

    Barriers Pharmacistrelated

    Attitudee.g.fearofchange,lackofselfconfidence

    Practiceskillse.g.limitedcommunicationskills

    Resourcerelated E.g.lackofmanagementand

    incentives,lackofprotocolsandguidelines

    Systemrelated E.g.limitedacceptancebyother

    healthprofessionals Academicandeducation

    related Knowledgeandtraining

    Other Lackofmentorsandmodels,lack

    ofvision

    Facilitators Experiential

    Remuneration Pharmacistcompetence Useofprotocols Interactionwithpatientgroups Profilewithinlocalcommunity Atmosphereofpharmacy Motivation

    Potential Advertising Provenbenefitsofservice Workingasateam Documentationsystem Communicationskills Professionalreward Autonomy

    Roberts A.S., Benrimoj S.I., Chen T.F., Williams K.A., Aslani P. Implementing cognitive services in community pharmacy: a review of facilitators of practice change. I J P P (2006) 14: 163-170.

  • Quantificationoffacilitatorsofpracticechangeincommunitypharmacy

    RobertsA,BenrimojSI,ChenT,WilliamsK,AslaniP

    Investigatorinitiatedgrantthrough3rd AgreementR&Dprogram

    Policyuptake:incorporatedintoallprofessionalprogramsandservicesinthe4th Community

    PharmacyAgreement

    20052010

    SOURCE17.http://beta.guild.org.au/research/funded_projects.asp

    Buildingorganisationalflexibilitytopromotetheimplementationofprimarycareservicesincommunitypharmacy

    BenrimojSI&FelettoE

    Investigatorinitiatedgrantthrough4rd AgreementR&Dprogram

    Businessandprofessionalfacilitatorsofchangeincommunitypharmacy

    RobertsA,BenrimojSI,ChenT,WilliamsK,AslaniP

    Investigatorinitiatedgrantthrough3rd AgreementR&Dprogram

    ChangemanagementandcommunitypharmacyDunphyD,PalmerI,BenrimojSI,andRobertsA

    Commissionedstudythrough3rd AgreementR&Dprogram

    AUSTRALIA

  • OrganisationalFlexibility

    LOW HIGH

    LOW

    HIGH

    SPEEDatwhichthecapabilitiescanbeactivated

    VARIETY

    of

    managerialcapabilitie

    s

    STRUCTURAL

    STEADYSTATE

    STRATEGIC

    OPERATIONAL

    Source:VolberdaHWBuildingtheFlexibleFirm:HowtoRemainCompetitive.Oxford:OxfordUniversityPress;1998

    Currentstateofpharmacyinmanycountries:regulatedsystem,pharmaciesdoingwhattheyalwaysdo

    Emergingtrendinpharmacy:increasingthecapabilitiesofpharmacistsinspecificarease.g.diseasestatemanagement

    Notgenerallyseenasthetrendinpharmacy goalsetting&cognitiveabilitiesusedtochangestrategically

    :discountingmodel&servicemodel.

    Existingbusinessmodelinpharmacy:conveniencemodel larger,takinga

    supermarketapproach

  • ClassicPharmacy

    RetailDestinationPharmacy

    HealthSolutionPharmacy

    NetworkedPharmacy

    Dispensing

    Retail Offering

    Service Provision

    Combination

    VIA

    BIL

    ITY

    EmergingBusinessModels

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