community pharmacy foundation project community pharmacy

FinalDraft

CommunityPharmacyFoundationProject

CommunityPharmacyChangePackage

IntegratingComprehensiveMedicationManagementServices

IntoCommunityPharmacyPractice

KrogerPharmacyJ-909CareProHealthServices

MeyerPharmacyTowncrestPharmacyAppleDiscountDrugsGoodrichPharmacyHealthPartners

SUPERVALUPharmaciesWalgreens

CareSouthCarolina

CohortLearningCoach:JoshFeldmann,PharmD

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IntentTransformation:Thisdocumentisaworkingdesignofhowcommunitypharmacyorganizationscanstepbeyondthemedicationdispensingroletobecomeprovidersofeffectiveclinicalpharmacyservices.Thecommunitypharmacistwouldbecomepartofanintegrateddeliverysystem.Theywouldprovideintegratedmedicationmanagementserviceswithinateamaccountableforthepatienthealthstatusbeingatgoal.Leadershiprole:Thecommunitypharmacistisplayingaleadershiprolebyenvisioningthisnewdeliverysystem,bycallingitintoexistence,andbysecuringcommitmentsandagreementsfromothernecessaryplayers.Thisdocumentwillcapturetheevolutionaryprocessbydistinguishingthreetypesofprogress.

• Creatingconditionsthatneedtobeinplaceforthenewservicedeliverysystemtoemergeandthrive(context)• Bestpracticesthataredefiningpartsofaneffectiveandsustainableintegrateddeliverysystem(blueprint)• Opportunitiestofurtherdevelopandadvancethedeliverysystemmodel(challengestoaddress)

Opportunity:Communitypharmacistsrepresentaspecialassetinthecommunity’shealthcaresystem.Theyhaveauniqueandpersonalrelationshipwiththepatient.Theyhavefrequentencounterswiththepatient.Theyhavetheprofessionaltrainingtooptimizemedicationtherapy.Theyarepositionedtoplayaproviderrolethatcandramaticallyimprovequalityandlowercosts.Objective:Prepareanddisseminateanexperiencedbasedguide-ChangePackage-forcommunitypharmacists.Itshowsthemhowtobecomepartofadeliverysystemthatassureshighriskpatientshavetheirhealthstatusatgoal.Framework:TheworkisorganizedaroundfivestrategiesthattheAIMMexperienceshowsarenecessaryandsufficienttorealizethegoal.

1. LeadershipCommitment:Developorganizationalcultureandrelationshipsthatpromotesafemedicationusesystemsandoptimalhealthoutcomes.

2. DemonstrateMeasurableImprovement-Achievechangeusingthevalueandpowerofdata-drivenimprovements.Communitypharmacist’sacknowledgeroleandinachievinghealthoutcomes.

3. IntegratedCareDelivery-Buildanintegratedhealthcaresystemacrossprovidersandsettingsthatproducesafetyandoptimalhealthoutcomes.Create“systempartnerships”withcommunityprovidersthatpromotedevelopmentofacommunityintegratedcaredelivery.

4. SafeMedicationUseSystems:Developandoperatebysafemedication-usepractice5. ComprehensivePatientCenteredCare:Buildapatient-centeredmedication-usesystem(integratedcomprehensivemedication

managementsystem).

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Design:Thisdocumentisorganizedasthreetables:

• Table1istheBlueprintforaServiceDeliverySystem–thistableincludespracticestrategiesemployedbycommunitypharmaciesthatdefinethenatureoftheintegrateddeliverysystemtheyenvision.Eachstrategyissupportedbyabestpracticeandexamplesfromvarioussiteperspectives.

• Table2istheContextwithinwhichtheServiceDeliverySystemmustoperate–thistableincludestheconditionsnecessaryandconceptsonhowtocreatethemtopromotesuccessoftheservicedeliverysystem.Eachconditionissupportedbyexamplesfromthecohortparticipants.

• Table3istheSummaryofChallengesthatcanbeaddressedthroughaQualityImprovementProcess–thistable

highlightsmajoropportunitiesthatcanimprovethemodeldeliverysystem.Itdescribespotentialsolutionsandthoughtsandinsightsfromthecohortparticipants.

Theauthorshopethatcommunitypharmacistsfindtheinformationcontainedbelowhelpfulinbringinghigh-riskpatientsintheirpracticetogoalineachoftheirhealthconditions.

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Table1.BlueprintforServiceDeliverySystemBestPracticethatdefineahighperformingintegrateddeliverysystemwithcommunitypharmacistsdeliveringmedicationtherapymanagementservices.

PracticeStrategiesThatDefineTheNatureoftheIntegratedDeliverySystemEnvisionedbyCommunityPharmacy

BestPractice:(Definingelementsandperformanceprinciples) LeadingSitesDemonstratingtheBestPractice

1. LeveragethepersonalrelationshipsdevelopedbetweentheCommunityPharmacists&Patients/Family

MovePharmacistsfromdispensingroletoprovidingeducationinteractionwithcustomer/patient.Encouragepharmacist’sengagementofeachpatientandprovidetoolstofurtherdevelopmotivationalinterviewingskills.(Meyer)

Wehavegoodrelationshipswithourpatientsandusepatient“CommunicationSlips”tocommunicatedosechanges,questions,clarifications,andspecificconsultnotes.Wealsodocumentday-to-dayinterventionselectronicallyinourdispensingsystem,althoughdonothaveagoodwaytoquantifytheinterventionsyet.(MeyerPharmacy)Wehavepharmacistsremovedfromworkflowdedicatedtocompletingeducationalsessionswithpatients.Beyondourpersonalpatientcarestandardsweutilizeourdispensingteamtorecruitforourappointmentbasesservices.(SUPERVALU)EncourageDSMEclassattendeestoinvitefamilymembersandclosefriendswhoarepartoftheirsupportsystemtotheclasses.(AppleDiscountDrugs)

2. FreeupPharmaciststimetobestutilizeskillsandeducation

FocusPharmacistsworkon:1)achievingtherapeuticoutcomes;2)safetherapy&3)effectivetherapy.Furthertrainandintegratetheuseoftechnicianssothatpharmacist’swillhavemoretimetofocusonclinicalinterventionandreview.(Meyer)

Useroboticsinthepharmacytohelpstreamlineworkflowandtraintechnicianstafftopracticeatthetopoftheirlicense.(SUPERVALU)

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3. Createmechanismfornaturaldocumentationofinterventionsaccessiblebyhealthcareteam

Documentinterventionsinsharedelectronicmedicalrecords Pharmacycommunicateswiththerestofthe

healthcareteamthroughtheelectronicmedicalrecord.Inadditiontousingthismeanstoclarifyprescriptionsandmakerecommendations,pharmacistsdocumentassessmentsofpatients’diabetesmanagement.(HealthPartners)WehaveanintegratedsystemtodocumentDTPsandfacilitatecommunicationwithlocalproviders.Further,weprovideproviderswithasummarytheirpatientsappointment-basedservices.(SUPERVALU-)

4. Reviewonthetherapeuticendpointssothatallpharmacistscanfeelupdatedwithnewguidelines

ReviewJNC8andADAendpointssoastoensurepharmacistsfeelconfidentaboutthetherapymanagementandinterventionsneeded

WepurchasedtheACCPTherapeuticsReviewCEforeachofourpharmaciststostayupdatedonnewguidelinesandrecommendations.(MeyerPharmacy)

5.Createrelationshipswithproviderstodemonstratevalue

Providesoundrecommendationsthatmattertopatientandprovideroutcomesandvalues

Communicatewithlocalproviders.Conductprovideroutreach.Utilizestudentdeveloped,residenteditednewslettertoprovideclinicalupdatestotheproviders.(SUPERVALU)Bi-annualnewslettersenttoprovidershighlightingoutcomes,servicesprovided,andrecentresearchofinterestonpharmacybeinganactivememberofthepatientcarecontinuum.(AppleDiscountDrugs)

6.Developingrelationshipswithprovidersinthecommunity

Reachouttolocalclinicgroupsexplainingwhatpharmacycandotohelpthemoutandhowthey

Wehavemetwithsomeoftheprimarypracticesinourcommunitytosharemoreaboutthe

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arealreadyhelpingimprovethehealthoftheirpatients.

servicesthatwecurrentlyoffertoimproveourpatient’scareandtheclinicalprogramwehopetogrowmovingforward.(MeyerPharmacy)Pharmacists-in-Chargeattendclinicprovidermeetingstostayupdatedonclinicinitiativeandexplaintoproviderswhatpharmacycanoffer.(HealthPartners)Communicatewithlocalproviders.Conductprovideroutreach.Utilizestudentdeveloped,residenteditednewslettertoprovideclinicalupdatestotheproviders.(SUPERVALU)

7.Definedservicewithdefinedgoals-geteveryoneinthepharmacyonboardwiththeplan

Ensurethateveryonethattalkstopatientsinthepharmacyknowswhatservicesthepharmacycanofferandwhomightbenefitfromtheseservices.

8.Createanenvironmentwithinthecommunitypharmacythatemphasizesqualityserviceandpromotesclinicalinterventiontoimprovepatientoutcomes.

Providecontinuingeducation,training,andreviewworkshopstobuildastrongfoundationforstafftofurtherengagepatientsandprovidequalityclinicalservice.Activelyinvolvepharmacystaffandshareorganizationalgoalstoreinforcethevitalrolethatcommunitypharmacistsandtechnicianscanplayinimprovingclinicaloutcomes.

WepurchasedtheACCPTherapeuticsReviewCEforeachofourpharmaciststostayupdatedonnewguidelinesandrecommendations.(MeyerPharmacy)

9.Creatinganewparadigmwithinthecommunitypharmacy

1.Changingjobdescriptions2.Changingresponsibilities

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practicewithstaffengagementtomovetoanewmodelofpatientcare

3.Redesigningthepharmacytosupportpatientcare

10.Deliveringadifferentmodelofpatientcarewithinthecommunitypharmacy

1.Changingworkflow2.Techniciandrivendispensingprocess3.Pharmacistsprovidingcontinuousmedicationmonitoring(prospectiveDUR)services

4.Pharmacistdocumentingtheircare.

Wearecurrentlydecidinghowtorestructureourworkflowprocesstofreeupforpharmacisttimeforclinicalreviewandinterventionsbuthavenotimplementedanythingyet.(MeyerPharmacy)Currentlydocumentsignificantinterventionsinrealtimeaspartofthepatientprofileinaspecific“MTM”fieldthatwillflagifnotcompletedorfollowupisneeded.Alsoabletodocumentlabvaluesthathavebeenreportedandcanbefollowedtoidentifytrends.(MeyerPharmacy)NowincludingdepressionandsleepapneascreeningsintoDSMEtofacilitateidentificationofhighriskpatientstoachievebetteroutcomesandtotalpatienthealth.(AppleDiscountDrugs)

11.Marketingthe“newtype”ofpracticetopatientsandkeystakeholders

1.Patientdiscussions/counselingsessions.2.Sendingfaxestophysicianswithclinicalinterventions/recommendations

3.Meetingwithphysicians/prescriberstodiscussthechangesoccurringinthepharmacy

Developedastandardformtocommunicateinterventionsanddrugtherapyproblemstoprovidersbyfax.Developedastandardizedformtorequestspecificlabvaluesbyfax.(MeyerPharmacy)

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4.Meetingwithotherkeystakeholders(e.g.healthsystems,ACOs,long-termcareorganizations,visitingnurses,etc.)todiscussthechangesoccurringinthepharmacy

Havemetwithlocalproviderstomakeawareofourgoaltoimproveourpatient’soutcomesbytakingamoreactiveroleintheircareanddiscusssomeoftheinitiativesofourclinicalfocusedprogram.(MeyerPharmacy)Useourmedsynchronizationprogramasasellingpointtopatientsandthenpromoteanddiscussthemoreindepthmonitoringandclinicalserviceweareabletoofferthemaspartofthat.ThesyncprocesscreatesvalueforthepatientbecauseittakessomeoftherefillresponsibilityfromthemandgivesusanopportunitytocompleteaCMRandmedreviewtogetstarted.(MeyerPharmacy)

Utilizingourpharmacystafftopromoteserviceslocallyandutilizingourclinicalleadershipteamtomarketservicesanddevelop/expandclinicalserviceswithothercommunityleaders.(SUPERVALU)

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Table2.ContextCreatingconditionsthatneedtobeinplaceforthenewservicedeliverysystemtoemergeandthrive

Conditionsthatmustbeinplaceforthenewservicedeliverysystemtoform

Howthoseconditionsarecreated Sitedemonstratingthestrategytocreatetherequiredconditions

1. Partnershipswithothercommunityorganizations

Identifycommongoalsandaimsandassertivelysolicitotherorganizationstojoininachievingthem.Createvaluebyfocusingontheuniquepositionthatcommunitypharmacyholdstoengagepatientsandevaluateadherencedata,akeypiecetosuccessfuloutcomes.

Wehaveusedourdispensingsoftware’sabilitytocreatean“AdherenceReportCard”thatevaluatesrefilldataandMedicationPossessionRatioasatalkingpointinourmeetingswithpotentialpartners.(MeyerPharmacy)

Communityoutreachutilizingpharmacyteamstocollaborateanddevelopopportunitiestoeducatecommunitiesandincreasecompetenciestopreventmedicationerrorsandpromotingproactivehealthcare.Findcommonground,commit,andexecute.(SUPERVALU)Workwiththelocalschoolofpharmacyaswellasmultiplelocalcharitablehealthcareorganizationswithinthecommunity.(AppleDiscountDrugs)

2. Supportandengagementfrompharmacyteam

Encourageinputfromallstaffonthedesignandworkflowofservices

Staffprovidedinputontheprocessofflaggingourpatientswithasthmaduringworkflow.Pharmacistswereshowedhowtoextractinformationoutofthemedicalrecord(ACTscores&asthmamanagementplans)touseasacounselingtoolatthewindow.(HealthPartners)Trainandsolicitfeedbackfromallstaffmembers.(SUPERVALU)

3. Technologicalsupportataninter-storelevel

CreatingastandardexcelsheetorotherprogramwhichcanbeaccessedatthestoreanddoesnotneedWi-Fi(Internetservice)toaccess.

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4. Buildprojectintostandardofcareincorporatinggoalsandobjectivesoftheprojectasoutlinedabove

Staffshouldhaveobjectivesinstandardofcaregiventoallpatientstoensureitiscompletedinaconsistentfashion.

5. Leveragetechnologyandinnovationtofreepharmacisttime

Automateddispensing,tech-check-tech Weusecentralfillandmedicationsynchronizationtoattempttostreamlineourprocessinthepharmacy.(HealthPartners)BlockingoffclinicalpharmacisttimeformeetingwithpatientsinthecontextofMTM,DSME,etc.(AppleDiscountDrugs)

6. Supportfrompharmacymanagement

Discussimportanceofservicewithmanagement.Securepaymentforservicesthatshowsthevalue.

Lobbyideasandnewopportunitiestotheleadershipteam.Ifit’sagoodidea,they’llsupportitandguideustotheappropriateresources.(SUPERVALU)

7. Creatingadefinedprocesssothateachpharmacist/studentperformingtheserviceisprovidingthesamecomprehensivepatientcare

Definingprotocolsforservices,developingdocumentationtemplates,implementingaqualityimprovementprocesstoensurethateveryoneisfunctioningatthesamehighlevel.

Createserviceoutlinesandtrainstaffaccordingly.(SUPERVALU)Allclinicalservicesaredefinedbywrittenpoliciesandprocedurescompiledonthecompanyweb.(AppleDiscountDrugs)

8. Effectivemeansofcommunicatingbetweenhealthcaresettings.

Developeffectiveandefficientwaysofcommunicatingbetweenhealthsettingsandtransitionsofcare.

Havedevelopedstandardizedfaxformstocommunicatetoprovidersaboutclinicalinterventions.Automaticallyreceivefaxdischargeordersfromthelocalhospital’spharmacydepartmentwhenapatientisreleased.(MeyerPharmacy)

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PharmacycommunicateswiththerestofthehealthcareteamthroughtheelectronicmedicalrecordusingproviderIn-Basketmessages.(HealthPartners)Utilizeservicecustomizedformstofollowupandcommunicatewithothermembersofthepatient’shealthcareteam.(SUPERVALU)

9. Workplaceenvironmentsuitabletomeetingwithpatientsforappointmentsandindepthcounseling.

Createaworkspaceawayfromtheprimarydispensingfunctionswherepharmacistscanreviewprofilesandmeetwithpatientswithoutbeinginterruptedbydailyretailpharmacyactions.Provideasecureandwelcomingenvironmentconducivetocounselingandclinicalreview.(Thischangecanhelpalterthe“patient’sperspective”ofhowretailpharmacyisviewed)

Currentremodelofourpharmacyhascreatedaprivateconsultationroomthatisidealforascheduledmeetingwithpatients.Alsowillallowapatienttofeelmorecomfortablebecausetheyaren’tinthemiddleofthebusypharmacy.(MeyerPharmacy)Manypharmacieshaveprivateconsultationroomstomeetwithpatientsawayfromthepharmacywindow.(HealthPartners)Buildclinicalareasinremodelsandmakedowithwhatyouhavebeforetheremodels.Mostofourpharmaciesutilizeprivacyscreensinlowtrafficareas.(SUPERVALU)

10. Utilizationofsupportstaffwiththegoaltofreeupthepharmacist

1. 1.Techniciandrivendispensing2. Dependingonstatelaw:Tech-check-Tech

dispensingmodels3. Pharmacistsarefreeduptoprovide

prospectiveDURservicesalsocalledcontinuousmedicationmonitoring(CMM)

4. Staffacceptance

Trainanddevelopstafftopracticeatthetopoftheirlicense.Leveragetherelationshiptheteamshavewiththecommunitytoachieveprogramsuccess.(SUPERVALU)

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11. UtilizationofTechnologywiththegoaltofreeupthepharmacist

1. Useofrobotstoprovideautomateddispensingfunctions

2. Staffacceptance

UtilizeaScriptProrobotfordispensing.(MeyerPharmacy)Schedulingtools,schedulingservices,etc.(SUPERVALU)

12. Utilizingdispensingstrategiestocreateefficienciesinthepharmacywiththegoaltofreeupthepharmacist

1. Providingmedicationsynchronizationservices

2. Identifyingandrecruitingpatientswhoaregoodcandidatesformedsync.

3. Staffacceptance

Syncprogramactiveforabout1year.Needtousetechniciansduringthisprocessalittlemore.AlsoofferaMedPackagingservicethatisprettypopular.(MeyerPharmacy)Weusecentralfillandmedicationsynchronizationtoattempttostreamlineourprocessinthepharmacy.(HealthPartners)Automationandcentralfill(SUPERVALU)

13. Efficientdocumentationsystemsthatcommunicatewithdispensingsystems

1. Workingwithvendorsofdispensingsystemstofindbettersolutionsfordocumentingclinicalactivities

2. Attheveryleast,createapaperbasedsystemtodocumentpatientcareactivities

HavecontactedoursoftwarevendortosuggestaSOAPnotebaseddocumentationupdate,butdonothaveanythinglikethatyet.(MeyerPharmacy)

14. Strengthencommunicationbetweeninterdisciplinaryworkerswithinthepharmacy.(I.e.surgical,respiratory,pharmacy,infusion).Interdisciplinaryprofessionalsseepatientswithinthepharmacyforavarietyofhealthneeds.Besurethateffectivecommunicationskillsare

1. Hostinterdisciplinarycontinuingeducationonsite.

2. Communicateappropriateclinicaldatabetweendepartments.

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presenttoensurethatpatientcareiscontinuousbetweendepartments.

Table3.ChallengestoaddressthroughPDSAprocess.Opportunitiestofurtherdevelopandadvancethedeliverysystemmodel

Majoropportunitiesthatwillimprovethemodeldeliverysystem Possiblesolutionstotest. Sitescurrentlypursuingtheopportunityina

systematicwaywithmethodanddiscipline1. Createread/writecapability

withlocalproviderElectronicHealthRecords

Localhospitals,insurancecompanies,primarycarephysicians

Oursystemcanautofaxnotes,butwearenottrulyintegrated.(SUPERVALU-)

2. Expandfocustomorecomprehensivecarefromdisease-specificfocus

Testaddressingcurrentlytargetedpatientsmorecomprehensively.

RatherthanaspecificPoFweareapproachingpatientsthatappeartobehighriskorinneedofadditionalserviceingeneralandmorecomprehensively.Thisallowsustoreachmoreofourpatientpopulationandwetrytodoamorecompletereviewduringourdailyfunctions.Becauseofoursmallercommunityweknowmanyofourpatientsandareabletoidentifywhichonesmaybenefitfromadditionalmonitoring.(MeyerPharmacy)Completecomprehensivereviewsbillablethroughavarietyofplatforms.(SUPERVALU-)

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systematicwaywithmethodanddiscipline3. Abilitytogetpatientsto

adherewithscheduledtimeforservice

Schedulingfunctionalitynotavailable,butwouldbehelpful.Incentivestoensurepatientswouldattendscheduledsessions/appts.(i.e.acontrolgroupwithincentive)

Utilizesupportstaffandautomationtomakepersonalizedremindercalls.We’vestudiedthisanddeterminedthepharmacyteamtobemosteffectiveatreducingtheno-showrate.(SUPERVALU)

4. Timeandadaptationbyotherpharmacists

Createanddevelopamodelwheretheobjectivesareincorporatedindailyfunctionsofstaff,butnomoreworkisrequired.

5. HowtointerestprovidersinbeginningCPSifnotalreadyinplace

• Tailorthe“ask”toproviders’timeandinterestlevel

• Beginprovidingservicestothepatientsofaspecificproviderthenapproachwithactualdata/interventionsofvalue

• Leverageavailableresources(i.e.:QIN-QIO)toseeinwhatarea(s)aproviderneedshelpthenapproachwithinterventionsspecifictotheirneeds

Wehavebeendocumentingourinterventionsthatweoftenmakeonadailybasiswithahopetousethemasanexamplewhenwemeetwithprovidersagain.Initiallywetriedtosetupasystemdirectlywiththephysicianfromthebeginningbuttherewasn’tmuchinterestsowesimplystarteddocumentingandsuggestinginterventionsandwillusethisinformationtofurtherdevelopourprogrammovingforward.

6. Reliablepaymentforservices Providerstatus,contractingwithphysiciangroups,insurancecompanies,etc.

Goodrichsaiditall.Providerstatusisnotrequiredtobillforourservices(SUPERVALU)RecognizedbyCareFirstasapreferredprimaryproviderfordiabeteseducationontheEasternShoreandtheyareactivelyreferringintoourprogram.(AppleDiscountDrugs)

7. Effectivepatientrecruitment Differenttypesofoutreach,differentphrasingwhenspeakingtopatients

Utilizepharmacystafftoleveragerelationships.UtilizereferralsfromPBMsandotherhealthcareentities.(SUPERVALU)Usingourmarketingdirectortoremindprovidersaboutourclinicalservicesthatcan

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systematicwaywithmethodanddisciplineaugmentthePCPservices.(AppleDiscountDrugs).

8. Exploredifferentwaytogeneraterevenuefromaclinicalpharmacyservice.

9. Testpaymentstrategieswithpayersthatemphasizepatientcare/outcomes

1. Payforperformance2. Prospectivepaymentsforcareand

retrospectivesharedcostsavings3. Developmentofhigh-performingpharmacy

networks

Metwithacommercialpayertonegotiateprospectivepaymentforservice/improvingpatientoutcomesinapayforperformancemodel(perpatient/permonth)nextyearaspartofahigh-performingpharmacynetwork.(MeyerPharmacy)Reviewcontractscloselytofindopportunitiestobereimbursedforpatientcare.(SUPERVALU)

10. CreatenewpartnershipswithhealthsystemsandACOs

1. Sharingpatientinformation2. Communitypharmacistsintegratedinto

patientcaredeliverysystems.3. Pharmacistsprovidingclinicalinterventions4. Measuringpatientoutcomes

Recentlyworkedwiththehospitalpharmacistdirectlyandhomehealthtocompleteamedreconaveryhighriskpatientthatwehavebeentryingtohelpforseveralmonths.Activelycounseledandplantofollowupregularlynow.Goingtopursueworkingdirectlywiththehospitalpharmacywhenpatientsaredischargedforfuturecomplexcasestohelpdecreasetherisksofreadmission.(havenotmetwithhealthcentertodiscussfuturecollaborationyet).(MeyerPharmacy)Reachouttootherhealthcareentitiesandfindcommongroundtodeveloprelationshipsandnewinitiatives.(SUPERVALU)

community pharmacy foundation project community pharmacy

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