Innovations in Interprofessional Practice 2013

Gary R. Matzke, Pharm.D, FCP. FCCP, FASN, FNAPSchool of Pharmacy

Virginia Commonwealth University

Learning Objectives

• Identify key events that have shaped interprofessional education and practice transformation.

• Describe the interprofessional care models in which academic pharmacists have practiced in Virginia.

• Characterize the "Improving Health of At risk Rural Patients" interprofessional care model

Activities at the State Level

• Gov. McDonnell establish a Healthcare Reform Advisory Council• What issues are important to Virginians?• It has been a very active process

• Advisory Committee made up of 30 people, 6 subcommittees• Medicaid, Workforce, Insurance costs,

Telemedicine• Report: Dec 2010 -- 28 recommendations on how

Virginia should move forward

• www.HHR.virginia.gov

Pharmacy Practice Transformation at the State Level

• The Virginia Pharmacy Congress reviewed the December 2010 report of the Virginia Health Reform Initiative Advisory Council

• Collectively the Congress supported the statement from that report suggesting “changing scope of practice laws to permit more health professionals to practice up to the evidence-based limit of their training”.

• The Congress crafted a policy position document that

addressed the value that pharmacists can bring to direct

patient care and identified the barriers to integration of

pharmacists in interprofessional practices and thus the

broad provision of these clinical services in Virginia.

Pharmacy Practice Transformation

Following an initial diagnosis, pharmacists can deliver a

number of patient care services in a variety of practice

settings through collaborative practice agreements with

other healthcare providers

• Perform or obtain necessary assessment of the health and functional status of each patient;

• Initiate, modify or discontinue treatment to manage disease according to therapeutic goals agreed upon by the primary provider and the patient;

• Order, interpret and monitor laboratory tests;• Formulate clinical assessments and develop therapeutic plans;• Document and communicate essential information about the care delivered to other

appropriate health care providers;• Provide education and training to the patient or caregiver designed to enhance

understanding and appropriate use of medications and adherence with treatment regimens;

• Provide care coordination and services for wellness and disease prevention.2011 U.S. Surgeon General’s Recommendations

Pharmacists Interprofessional Care in the Community

• Models: Service, Education, Scholarship• Goals: Enhance Medication Access, Safety,

and Outcomes• Roles: Patient, Provider, Learner Education• Coordinated Care within “system”• Engaged with Community Partners• Interprofessional

IHARP ProjectImproving Health of At-Risk Rural Patients

Key PrincipalsMichael J. Czar RPh, PhD – Project CoordinatorWilliam T. Lee RPh, MS – Principal Investigator

Anthony R. Stavola MD– Co-Principal InvestigatorGary R. Matzke Pharm.D. – Co-Principal Investigator

Leticia R. Moczygemba Pharm.D., PhD – Co-Investigator

Charles Tarasidis RPh – Director, Carilion Retail Pharmacy OperationsChad Alvarez RPh – Director, Pharmacy TSG/Epic Initiative

Karen J. Williams Pharm.D. – Lead Primary Care Clinical PharmacistHeidi Wengerd Pharm.D.- Primary Care Clinical Pharmacist

Health Care Needs of Community

Planning District

Reasons for Hospitalizations

Heart Disease CerebrovascularDisease COPD Diabetes Asthma

State of Virginia 98.1 26.9 17.8 15.1 11.8Alleghany 108.9 31.9 21.5 17.4 10.2

Central Shenandoah 104.9 25.4 18.2 25.8 9.0

Central Virginia 101.9 31.9 25.4 22.1 15.1

Cumberland Plateau 114.4 20.8 78.8 18.7 21.5

Mount Rogers 69.7 17.8 21.8 14.8 6.9New River 138.2 29.2 30.0 17.1 10.3

Roanoke City 125.1 31.2 30.8 33.5 18.7West Piedmont 102.7 26.9 29.3 26.7 12.2

The number of hospitalizations is the age-adjusted rate per 10,000 people.statistically significant differenceSource: Chronic Disease Indicators by Health District 2010.

Improving Health of At Risk Rural Patients

• Create a sustainable patient centered continuity of care process within a rural health system comprised of multiple hospitals, primary care practices, and community pharmacies;

• Achieve better health outcomes for patients by establishing a coordinated “community-based,” individualized prevention and wellness strategy

• Reduce costs by optimizing medication-related health outcomes of hospitalized and ambulatory patients;

• Implement two new models of pharmacist workforce development and training; and

• Evaluate the clinical, humanistic and economic outcomes associated with this new health care delivery model

Carilion Clinic Characteristics

Service Area• Headquartered in Roanoke, Va.,

Carilion Clinic serves the residents of 18 counties and six cities in western Virginia and southern West Virginia.• Primary Service Area (PSA):

653,717• Secondary Service Area: 334,379

Community Benefit• Uncompensated Care: $106.7 million• Education: $20.4 million• Research: $ .7 million• Total: $131.1 million

Resources, etc. (FY 2011)• Employed physicians: 575

representing more than 60 specialties

• Practice sites: 160• Primary care visits: 767,283• Employees: 10,975• Licensed beds: 1,187 (does not

include 60 Neonatal ICU beds available)

• Admissions: 49,074• Emergency Department visits:

179,664• Total revenues: $1.28 billion (net)

The Role Of Pharmacists in the “Medical Home”

• Pharmacists should play key roles as team members in medical homes,

• Their potential to serve effectively in this role should be evaluated as part of medical home demonstration projects.• 71 percent of physician office visits had at least one

prescription listed in the patient record. • 32 percent of adverse events leading to hospital

admission were attributed to medications• 33–50 percent of patients with chronic conditions

adhere completely to prescribed medication therapies

Interprofessional Practice is Crucial to our Future

• Team members work closely together, • They collaborate and communicate frequently,

establish team goals, and support each other’s contributions, while each shares his or her own knowledge and skill set,

• Team members are involved in problem solving beyond the confines of their own disciplines; they are partners in designing a plan of care; they have joint responsibility for action,

• The team capitalizes on its diversity and executes its work in a flexible and synergistic manner.

A Team must have a Common Game Plan or Strategy

• True teamwork depends on the mutual exchange of sufficient patient information and a sharing of decision-making, so that the team can function as an efficient, coordinated unit to the benefit of the patient.

• Teams succeed when each member is willing to look past their needs and contribute to the common good of in this case THE PATIENT

• Pharmacists in community settings have long been hampered in their goal of providing direct patient care because they have had insufficient patient medical information

Key Elements for Successful Practice

• Can’t be a provider of care if you don’t know where the patient is clinically! It starts there, not with the medications• Must know the clinical status of the patient related to

each and every condition that is being prevented or treated by drug therapy (or should be treated by drug therapy)

• Can’t assess the adequacy of the meds if you don’t know the stage of the disease

• The days of pen and paper records are over- robust IT and clinical pathways required

• Must be capable of recognizing and making evidenced-based recommendations to resolve drug therapy problems to obtain clinical goals of therapy

PHARMACY CONSULT NOTES/Interventions

PHARMACY ADMISSION NOTE

Pharmacy Discharge Note / Summary of Medication Issues

Recommendations for MD, Patient, PCCP, & CP

Non Carilion Practices Carilion

PCMH

Primary CarePharmacist

Patient

Institutional Component

Primary Care ComponentCommunity Component

Medication Management Care Plan

Provide ongoing care as part of health care

team.

Community Pharmacists

Patient follow up post DC & ongoing

PATIENT

Carilion PHYSICIANS

CarilionPROVIDERS

Community Pharmacies & Providers

Public Health of Southwest Virginia

Up-to-Date Medication List

Drug Information for Physicians and

Providers

Disease State Education and Management Monitor and Clarify

Incomplete Prescribed Drug Orders

Coordination of Care

CMMMedication Reconciliation

Medication AdherenceADE Monitoring

Monitoring Drug Therapy Outcomes

IHARP Impact Map

• We utilized a three tiered approach to enhance the practice skills of our pharmacists

• The ADAPT process developed by the Canadian Pharmacists Association was the foundational initiative for our hospital and primary care pharmacists

• The VCU MTM training program was the mechanism through which we integrated community pharmacists

• Finally the Carilion IT staff developed an EPIC training program for community pharmacists

It’s about team work, and partnership building will get you there.

Collaboration

CGCH FM-Narrows

St.Alban’s /

CNRV

FM & OB-Christiansburg

FM-Blacksburg

FM-Floyd

FM- Radford

FM-Pearisburg

IM-Christiansburg

FM-North Main

FM-Shawsville

IHARP RX

IHARP RX

IHARP RX

IHARP RX

IHARP RX

Tazewell

Phase One Rollout 2013

IHARP RX

IHARP RX

Health Outcomes Evaluation

• Clinical, economic, and humanistic outcomes will be evaluated quarterly.

• Disease specific clinical measure outcomes will be assessed from baseline to last visit.

• Patient satisfaction and physician, nursing staff, and pharmacist perceptions of IHARP will be evaluated quarterly

• The economic analysis will ascertain the impact of this intervention strategy on participants overall healthcare costs by: • comparing their health care utilization in the year prior to participation

with the utilization during the final year of the project. • Comparing the costs of a matched comparison group selected

retrospectively from those monitored in the same time frame.

Implementation Challenges

• Establishing a community expectation for pharmacist’s delivered clinical services

• Development of consistent practice deliverables

• Improving Health Information Technology • Future innovations in funding• Student and practitioner education and training

Future Directions

• Engage other communities within Virginia in health care system reform to increase access, improve quality, and reduce the cost of health care.

• Disseminate the results of the project broadly in peer –reviewed journals and via non-traditional means such as community presentations to business and corporate leaders, government agency officials, and health care consumer organizations.

• Partner with others across the country to assess the value of implementing similar care models in other populations.

DISCUSSION

Interprofessional Practice isOUR FUTURE