- Email: [email protected]
Implementation of a medication therapy management collaborative within a pediatric health system
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2018) 1e6
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Implementation of a medication therapy management collaborative within a pediatric health system Gregory Sneed*, Karl Kappeler, Travis Gilmore, Catherine Kuhn a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 September 2017 Accepted 10 April 2018
Objectives: To describe the implementation of a medication therapy management (MTM) collaborative within a pediatric health system to ensure the safe use of medication. Setting: Outpatient pharmacies and clinics within a pediatric health system in Central Ohio. Practice description: The outpatient pharmacies conducted the daily operations of a community pharmacy following a standard, 4-point workflow. The ambulatory clinical pharmacists served on interdisciplinary teams within outpatient clinics to ensure the appropriate use of medication. Practice innovation: A collaborative model was developed to offer MTM services to patients within outpatient pharmacies and clinics throughout the health system. The pharmacist responsibilities varied, with outpatient pharmacists focused on targeted medication reviews (TMRs) and ambulatory clinical pharmacists focused on comprehensive medication reviews (CMRs) and TMRs. Evaluation: The use of multiple plan-do-study-act cycles allowed for program improvements throughout implementation. Data collection included a pharmacy staff perception survey, mapping of MTM opportunities, and a quantitative report on the number, type, and intervention rate of all MTM activities. Results: Four hundred nine MTM interventions, 349 TMRs (70 clinic based and 279 pharmacy based) and 60 CMRs, were completed throughout the first 6 months. Two hundred thirty-eight of the TMRs were pharmacist-initiated interventions that allowed pharmacists to provide medication counseling and follow-up with patients beginning new therapy. Ambulatory clinical pharmacists identified and resolved drug-related problems in greater than half of the CMRs completed. The intervention rates were 39% for CMRs and 44% for TMRs. Conclusion: The implementation of a collaborative MTM model provided an opportunity to address drug-related problems to ensure the appropriate use of medication. The model consisted of pharmacy staff members within 2 different patient care environments working together to complete MTM services for patients throughout the health system. The key elements of the program included the use of training sessions tailored to the pharmacy staff member’s role in MTM, incorporation of technician champions, and creation of pharmacistinitiated interventions. © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Previous presentations: The results of this study have been presented as a poster presentation at the 2017 American Pharmacists Association Annual Meeting and Exhibition, San Francisco, CA (March 24-27, 2017), and as a podium presentation at the 32nd Great Lakes Pharmacy Residency Conference, Lafayette, IN (April 26-28, 2017). * Correspondence: Gregory Sneed, PharmD, Postdoctoral Academic Fellow, University of Cincinnati James L. Winkle College of Pharmacy, 3225 Eden Avenue, Kowalewski Hall 361, Cincinnati, OH 45267. E-mail address: [email protected] (G. Sneed).
Medication therapy management (MTM) services are often offered within community pharmacies across the country because of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2013.1 The MMA secured the pathway for pharmacists to play a vital role as the medication expert by providing MTM services to optimize medication use. The majority of community pharmacies provide MTM programs that yield positive clinical and economic outcomes.2,3 However, barriers to implementing such services include lack of interprofessional relationships with providers, poor access to patient-specific medical information, and an inability
https://doi.org/10.1016/j.japh.2018.04.021 1544-3191/© 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE G. Sneed et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
Key Points
because it may inform other institutions of a pharmacy service that positively affects patient care through community and ambulatory clinical pharmacist collaboration.
Background: Methods Medication therapy management (MTM) services have been shown to yield positive clinical and economic outcomes. Despite the growth of MTM over time, barriers to implementation remain for community and ambulatory clinical pharmacists. The use of a community and ambulatory clinical pharmacist MTM collaborative allows both groups of pharmacists to overcome barriers to completing MTM activities. Findings: The implementation of an MTM collaborative requires ongoing support and innovation from pharmacy staff members, especially in a unique patient population. The MTM collaborative allowed pharmacists to engage with patients throughout the health system to ensure optimal medication use. to influence prescribing practices.3 Community pharmacists largely rely on telephone and facsimile communication with providers, as direct communication between pharmacists and prescribing physicians is extremely limited.4 Ambulatory clinical pharmacists value working alongside these key stakeholders while completing MTM activities. This growing group of pharmacists, the second largest certification group within the Board of Pharmacy Specialties, can communicate directly with providers to ensure appropriate medication use. However, these pharmacists have a different set of barriers to overcome, including their inability to communicate directly with outpatient pharmacies, a lack of real-time insurance plan adjudication to verify medication coverage, and compensation and sustainability challenges.5,6 A collaborative approach between community and ambulatory clinical pharmacists within a health system offers a unique opportunity to provide MTM services in direct collaboration with other health professionals. All pharmacists can identify and resolve a drug-related problem (DRP), defined as an instance involving drug therapy that actually or potentially interferes with desired health outcomes, within multiple settings throughout the health system. There is limited research describing collaborative MTM services targeting a pediatric patient population, as most programs are largely focused on Medicare beneficiaries because of limited pediatric-focused outcome measures. Our study illustrated the implementation of such services in a pediatric patient population using a collaborative department-wide approach.
Objectives The aim of this work was to describe the implementation of a collaborative MTM model within the outpatient pharmacies and clinics of a pediatric health system. This work is significant 2
Practice setting The study site was Nationwide Children’s Hospital, a large, academic, free-standing children’s health system in Columbus, Ohio. The health system serves as the home of The Ohio State University College of Medicine Department of Pediatrics, with inpatient and outpatient pediatric care provided by interdisciplinary teams. Practice description The ambulatory pharmacy services department consisted of pharmacy staff members within 2 outpatient pharmacies and 6 onsite outpatient clinics. The pharmacy staff members within the outpatient pharmacies conducted the daily operations of a community pharmacy with the addition of nonsterile compounding because of a large pediatric patient population. The ambulatory clinical pharmacists within the outpatient clinics served as essential members within their care teams. They worked collaboratively with attending physicians and medical residents to initiate and adjust medication therapy, to schedule and interpret pertinent lab tests, and to discontinue unnecessary medications. In each setting, the pharmacist provided direct patient-centered pharmaceutical care through establishing close pharmacistepatient relationships. Practice innovation The ambulatory pharmacy services department, along with pharmacists within our affiliated accountable care organization (ACO), recognized the importance of establishing viable MTM services to support the ACO’s value-based care model. Before establishing the MTM collaborative, the project team revisited the outpatient pharmacy’s brief history with MTM. For a short time, the outpatient pharmacists provided MTM services by completing comprehensive medication reviews (CMRs). Unfortunately, they found this program unsustainable because of an inability to engage patients in completing a CMR at a specific scheduled time or at the time of dispensing. The knowledge of this barrier informed our revised MTM practice model through establishing a collaborative approach. The project team reviewed potential MTM opportunities for our pediatric patient population, including targeted medication reviews (TMRs) and CMRs, and identified diverse opportunities for individuals seen within the outpatient pharmacies and clinics. The team then developed an MTM model (Figure 1) that allowed the pharmacy staff members to offer these services to patients throughout the health systemdfrom a postdischarge medication pickup at one of the outpatient pharmacies to a routine follow-up visit within an outpatient specialty clinic. The pharmacists’ MTM opportunities and responsibilities varied within each setting, and the collaborative MTM model focused on using the strengths of having pharmacists in both settings to minimize barriers such as time and incorporation of MTM into the workflow. The outpatient pharmacists focused on completing TMRs, while ambulatory clinical pharmacists focused on completing a combination of CMRs and TMRs, submitting claims through a
SCIENCE AND PRACTICE Medication therapy management collaborative
Figure 1. Collaborative MTM model.
shared online platform to ensure intervention visibility among all pharmacists. Training The collaborative MTM model consisted of 2 separate, yet integrated, workflows. It required all pharmacists to identify and resolve DRPs using the Pharmacists’ Patient Care Process.7 The collaborative, integrated workflows allowed pharmacists to make interventions in the time afforded to them based on their practice environment. The pharmacy resident provided all pharmacy personnel with role-specific training on their care environment’s MTM workflow. The outpatient pharmacists were trained in multiple 1-hour small group sessions, ambulatory clinical pharmacists were trained in two 1-hour sessions, and pharmacy technicians and student pharmacists received on-the-job training to minimize disruptions in normal workflow.
Outpatient pharmacy workflow The outpatient pharmacies use a standard 4-point workflow including data entry, clinical review, production, and final verification (Figure 2). The pharmacy staff members have access to each patient’s comprehensive electronic medical record, providing a unique opportunity compared to most community pharmacies. The MTM program within the outpatient pharmacy targeted completion of TMRs. The data entry technician searched the online MTM platform to identify TMR-eligible patients. The technician printed all opportunities and placed them in a patient-specific bin to continue throughout the workflow. The technician placed a comment within the patient’s real-time workflow request of the pharmacy management system, which allowed all staff members to see the TMRs to be addressed at the patient’s pharmacy visit. The clinical review pharmacist ensured that all TMRs were clinically appropriate for the patient (e.g., hydrofluoroalkane
Figure 2. Outpatient pharmacy workflow.
3
SCIENCE AND PRACTICE G. Sneed et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
Table 1 Medication therapy management interventions by type Type TMR New medication education and monitoring Medication adherence check-in Patient education Cost-effective alternative Needs drug therapy Suboptimal drug therapy Unnecessary drug therapy CMR Total
Quantity 349 238 82 13 10 4 1 1 60 409
Abbreviations used: TMR, targeted medication review; CMR, comprehensive medication review.
inhaler preferred clinically for pediatric patients, regardless of insurance preference). If appropriate, the TMRs continued through the production station and to the pharmacist for final verification. The final verification pharmacist placed the TMR printout in a bag with all verified medications to review with the patient upon dispensing. When the patient arrived, a pharmacist or student pharmacist completed the tasks associated with the TMR. He or she completed each TMR with the patient (i.e., patient consultation) if it related to adherence, immunization opportunities, or annual health reminders, or the patient’s prescriber if a medication change (i.e., prescriber consultation) is needed for insurance formulary preferences. Upon completion, the individual who completed the TMR was responsible for its documentation within the online MTM platform. Outpatient clinic workflow Each outpatient clinic had its own unique workflow, while all followed a general pattern for CMR completion. CMR and TMR opportunities were identified for the 6 clinics 1 week in advance based on the clinic’s upcoming patient appointment schedule. This workflow afforded the pharmacist an opportunity to identify DRPs and to update medication lists for these patients before their appointment. The pharmacist met with the patients in the clinic to complete the CMR, addressing TMRs, reviewing medication-related concerns, finalizing medication lists, and developing a plan to address any identified DRPs. The clinical pharmacist documented this
information in the online MTM platform and printed the updated personal medication list and medication action plan to deliver or mail to the patient. Evaluation Project management and feedback The project management team, which consisted of the ambulatory pharmacy services director, ambulatory pharmacy services outpatient pharmacy supervisor, the ACO clinical pharmacist, and the PGY1 community-based pharmacy resident, met weekly to review programmatic progress. The group implemented multiple plan-do-study-act cycles to make program improvements throughout implementation. The group ensured that pharmacy staff members were informed of program progress by providing updates at monthly outpatient pharmacy staff meetings and ambulatory clinical pharmacist meetings. Continual feedback was solicited from outpatient pharmacy staff members on their perceived barriers for the service, which were identified as time, forgetfulness, and education or training. Outpatient pharmacy workflow improvements The project management team enhanced several areas within the outpatient pharmacy workflow based on staff feedback. Stickers were placed on all monitors to remind staff to login to the online MTM platform. This was especially important as the platform existed outside of the normal pharmacy management system, and TMR identification was the rate-limiting step for the entire process. An accordion-type alphabetic file folder was placed near the fill station for placement of TMRs as the patient-specific bin process led to confusion because of the large amount of bins within the workflow. Signs were posted at each station throughout the outpatient pharmacies to remind pharmacy staff of their MTM roles and responsibilities. Pharmacist-initiated interventions A unique opportunity exists within the outpatient pharmacies from the tremendous amount of counseling the pharmacy staff members provide to patients within the dispensing process. The pharmacists and student pharmacists automatically counsel every patient on each medication. They
Figure 3. Total MTM interventions.
4
SCIENCE AND PRACTICE Medication therapy management collaborative
Figure 4. CMR and TMR intervention rates.
counsel patients on compounded medication handling and storage requirements (i.e., shake well, refrigeration, expiration), medication administration techniques (i.e., intranasal midazolam, intramuscular epinephrine), dose measurement techniques using oral syringes, and traditional prescription information (i.e., indications, adverse effect profile, refills). The provision of these counseling services, along with a follow-up telephone call, was reimbursable as pharmacist-initiated interventions. The project team introduced pharmacist-initiated TMRs at the end of month 3, which provided an opportunity for pharmacy staff members to identify and resolve a DRP, or to counsel on any new prescription or over-the-counter medication and follow up with the patient by telephone, for reimbursement. Pharmacy technician champions The project team identified 2 pharmacy technician champions to assist with duties related to program improvements and sustainability. They were responsible for identifying clinical pharmacists' CMR and TMR opportunities across all 6 clinics and conducting follow-up telephone calls for all pharmacist-initiated TMRs. To identify MTM opportunities, they used a weekly calendar template that included patient name, date of birth, appointment time, medical record number, CMR opportunity (yes or no), and number of available TMRs. They reviewed each clinic schedule the week preceding clinic visits to identify opportunities, allowing the pharmacists to review the list in advance via secure e-mail. The clinic pharmacists used this calendar to prioritize patients with CMR/TMR opportunities. If the patients were unable to be seen, the pharmacist would follow up with them at their next clinic visit. The pharmacy technician champions used previously existing daily project time within the workflow to complete follow-up telephone calls under the supervision of outpatient pharmacists. When conducting these calls, they contacted the patient to review satisfaction with therapy, adherence to therapy, symptom resolution with therapy, and related adverse events. Any discussion requiring professional judgment and counseling was referred to their supervising pharmacist. The technician champions were then responsible for completing and submitting the final documentation within the online MTM platform. The introduction of this technician champion program was instrumental in program success,
allowing for buy-in from pharmacy staff because of their increased role in providing a new service to our unique patient population. Practice implications Data were collected to quantify the number and type of interventions completed by pharmacy staff members in both the outpatient pharmacies and clinics (Table 1). In total, 409 interventions were completed, including 349 TMRs (70 clinic based and 279 pharmacy based) and 60 CMRs throughout the first 6 months of offering the service (Figure 3). Of the total TMRs, 238 were pharmacist-initiated interventions, and 111 were prepopulated TMRs from the online MTM platform based on prescription claims data. Of note, greater than half of the CMRs completed allowed for the identification and resolution of DRPs. In addition, we calculated the intervention rate for all TMRs and CMRs, based on the total number of interventions made over the total number of prepopulated TMR and CMR opportunities available for patients within the online MTM platform. Our intervention rates for CMRs and TMRs were 39% and 44%, respectively, throughout the first 6 months (Figure 4). Of note, the most significant increases in TMR intervention rate occurred with the introduction of pharmacist-initiated interventions and the pharmacy technician champion program. Discussion The collaborative MTM model facilitated a partnership between pharmacists in outpatient pharmacies and clinic settings allowing for a comprehensive approach. It allowed the outpatient pharmacy staff members to focus on real-time interventions to improve patient medication use with minimal disruption to regular pharmacy workflow. It allowed ambulatory clinical pharmacists the opportunity to work with pharmacy technician champions to identify patients with drug-related problems and to resolve such problems while meeting with the patients in their respective clinics. The approach allowed for completion of MTM activities without additional staffing and provided opportunities to strengthen departmental communication within an ambulatory pharmacy services department and document overall impact on patient care. 5
SCIENCE AND PRACTICE G. Sneed et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
The implementation of MTM services within outpatient community pharmacies presents many challenges, with studies showing inability to collaborate directly with prescribers as the most challenging barrier.2,3 This barrier is often one that is difficult to overcome with most prescribers practicing outside the immediate pharmacy environment. The use of an approach that incorporated collaboration between outpatient pharmacy staff and ambulatory clinical pharmacists in multiple care environments of a health system increased access to prescribers. The program allowed the pharmacy department to offer MTM services regardless of the patient’s location within the health system. Establishing the program within the small cohort of pharmacies and clinics resulted in 409 interventions. The number of interventions was highest following pharmacist-initiated interventions and the technician champion program. There were weeks of low MTM activity completion, which was largely attributed to technician champion staffing changes and the beginning stages of opening a new outpatient pharmacy toward the end of the study period. The main challenge for the program is the relatively small number of MTM-eligible pediatric patients at the pharmacy because of a lack of established pediatric MTM eligibility criteria, which previous literature has attempted to address.8 The team was able to overcome this barrier through the introduction of the pharmacist-initiated interventions, which largely involved medications used in the treatment of asthma, infections, and pain. This new aspect to the MTM model was well received by patients, stating their gratitude for telephone follow-up measures to ensure proper medication use. The success of a collaborative MTM model requires buy-in from the entire pharmacy team. It is especially important to develop pharmacy staff communication and relationships that allow for continual feedback on MTM practices and workflow improvement. Pharmacy technician champions reinforced the ties between the outpatient pharmacies and ambulatory clinical pharmacists. They worked together to develop a template that illustrates the information needed when identifying MTM-eligible patients within the clinic setting. In addition, the technician champion program fostered buy-in from pharmacy staff members and allowed the technicians to gain a higher level of responsibility within the daily pharmacy operations. This aspect was important for moving forward to ensure that the program remained successful after the departure of the community care pharmacy practice resident. Future investigation is warranted to determine whether using a collaborative MTM approach within the health system setting leads to overall cost savings for an affiliated ACO and revenue sufficient to justify the program in the long term. In addition, it will be important to define pediatric-specific criteria for MTM services that our study suggests may relate
6
to asthma, infection, and pain management. It is the intent to expand the program to an additional new outpatient pharmacy and several off-site ambulatory clinics within the health system with the expansion of the ambulatory pharmacy services department. Conclusion Implementation of a collaborative MTM model within a pediatric hospital setting provided an opportunity to address drug-related problems to ensure appropriate medication use. The model consisted of pharmacy staff within 2 different patient care environments working together to complete MTM services for patients throughout the health system. The key elements of the program that were identified and implemented through multiple plan-do-study-act processes included the use of training sessions tailored to the pharmacy staff member’s role in MTM, incorporation of technician champions, and creation of pharmacist-initiated interventions. References 1. Pellegrino AN, Martin MT, Tilton JJ, Touchette DR. Medication therapy management services: definitions and outcomes. Drugs. 2009;69(4): 393e406. 2. Cranor CW, Christensen DB. The Asheville Project: short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (2003). 2012;52(6):838e850. 3. Lounsbery JL, Green CG, Bennett MS, Pedersen CA. Evaluation of pharmacists’ barriers to the implementation of medication therapy management services. J Am Pharm Assoc. 2009;49(1):51e58. 4. Smith M, Sprecher B. Pharmacy communications with physician offices to clarify prescriptions. J Am Pharm Assoc (2003). 2017;57(2):178e182. 5. Riche DM, Wilson L, Jackson RT, Wofford MR, Adams C. Effect on institutional revenue of clinical pharmacy services in an ambulatory care clinic. Am J Health Syst Pharm. 2013;70(6):482e484. 6. Weber ZA, Skelley J, Sachdev G, et al. Integration of pharmacists into teambased ambulatory care practice models. Am J Health Syst Pharm. 2015;72(9):745e751. 7. Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. JCPP; 2014. Available at: https://jcpp.net/wp-content/ uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf. Accessed June 30, 2017. 8. Benavides S, Madzhidova S, Hernandez A, Le T, Palma SM, Stephen S. Establishment of pediatric medication therapy management: a proposed model. Pharmacy (Basel). 2016;4(1). Gregory Sneed, PharmD, Postdoctoral Academic Fellow, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH; at the time of the study, PGY1 Community-Based Pharmacy Resident, Nationwide Children’s Hospital, Columbus, OH Karl Kappeler, MS, RPh, FASHP, Director, Clinical Information, Silvergate Pharmaceuticals, Dublin, OH; at the time of the study, Director, Ambulatory Pharmacy Services, Nationwide Children’s Hospital, Columbus, OH Travis Gilmore, PharmD, Supervisor, Ambulatory Pharmacy Services, Nationwide Children’s Hospital, Columbus, OH Catherine Kuhn, PharmD, BCACP, FAPhA, Pharmacy Coordinator, Population Health, Nationwide Children’s Hospital/Partners for Kids, Columbus, OH
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Implementation of a medication therapy management collaborative within a pediatric health system Gregory Sneed*, Karl Kappeler, Travis Gilmore, Catherine Kuhn a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 September 2017 Accepted 10 April 2018
Objectives: To describe the implementation of a medication therapy management (MTM) collaborative within a pediatric health system to ensure the safe use of medication. Setting: Outpatient pharmacies and clinics within a pediatric health system in Central Ohio. Practice description: The outpatient pharmacies conducted the daily operations of a community pharmacy following a standard, 4-point workflow. The ambulatory clinical pharmacists served on interdisciplinary teams within outpatient clinics to ensure the appropriate use of medication. Practice innovation: A collaborative model was developed to offer MTM services to patients within outpatient pharmacies and clinics throughout the health system. The pharmacist responsibilities varied, with outpatient pharmacists focused on targeted medication reviews (TMRs) and ambulatory clinical pharmacists focused on comprehensive medication reviews (CMRs) and TMRs. Evaluation: The use of multiple plan-do-study-act cycles allowed for program improvements throughout implementation. Data collection included a pharmacy staff perception survey, mapping of MTM opportunities, and a quantitative report on the number, type, and intervention rate of all MTM activities. Results: Four hundred nine MTM interventions, 349 TMRs (70 clinic based and 279 pharmacy based) and 60 CMRs, were completed throughout the first 6 months. Two hundred thirty-eight of the TMRs were pharmacist-initiated interventions that allowed pharmacists to provide medication counseling and follow-up with patients beginning new therapy. Ambulatory clinical pharmacists identified and resolved drug-related problems in greater than half of the CMRs completed. The intervention rates were 39% for CMRs and 44% for TMRs. Conclusion: The implementation of a collaborative MTM model provided an opportunity to address drug-related problems to ensure the appropriate use of medication. The model consisted of pharmacy staff members within 2 different patient care environments working together to complete MTM services for patients throughout the health system. The key elements of the program included the use of training sessions tailored to the pharmacy staff member’s role in MTM, incorporation of technician champions, and creation of pharmacistinitiated interventions. © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Previous presentations: The results of this study have been presented as a poster presentation at the 2017 American Pharmacists Association Annual Meeting and Exhibition, San Francisco, CA (March 24-27, 2017), and as a podium presentation at the 32nd Great Lakes Pharmacy Residency Conference, Lafayette, IN (April 26-28, 2017). * Correspondence: Gregory Sneed, PharmD, Postdoctoral Academic Fellow, University of Cincinnati James L. Winkle College of Pharmacy, 3225 Eden Avenue, Kowalewski Hall 361, Cincinnati, OH 45267. E-mail address: [email protected] (G. Sneed).
Medication therapy management (MTM) services are often offered within community pharmacies across the country because of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2013.1 The MMA secured the pathway for pharmacists to play a vital role as the medication expert by providing MTM services to optimize medication use. The majority of community pharmacies provide MTM programs that yield positive clinical and economic outcomes.2,3 However, barriers to implementing such services include lack of interprofessional relationships with providers, poor access to patient-specific medical information, and an inability
https://doi.org/10.1016/j.japh.2018.04.021 1544-3191/© 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE G. Sneed et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
Key Points
because it may inform other institutions of a pharmacy service that positively affects patient care through community and ambulatory clinical pharmacist collaboration.
Background: Methods Medication therapy management (MTM) services have been shown to yield positive clinical and economic outcomes. Despite the growth of MTM over time, barriers to implementation remain for community and ambulatory clinical pharmacists. The use of a community and ambulatory clinical pharmacist MTM collaborative allows both groups of pharmacists to overcome barriers to completing MTM activities. Findings: The implementation of an MTM collaborative requires ongoing support and innovation from pharmacy staff members, especially in a unique patient population. The MTM collaborative allowed pharmacists to engage with patients throughout the health system to ensure optimal medication use. to influence prescribing practices.3 Community pharmacists largely rely on telephone and facsimile communication with providers, as direct communication between pharmacists and prescribing physicians is extremely limited.4 Ambulatory clinical pharmacists value working alongside these key stakeholders while completing MTM activities. This growing group of pharmacists, the second largest certification group within the Board of Pharmacy Specialties, can communicate directly with providers to ensure appropriate medication use. However, these pharmacists have a different set of barriers to overcome, including their inability to communicate directly with outpatient pharmacies, a lack of real-time insurance plan adjudication to verify medication coverage, and compensation and sustainability challenges.5,6 A collaborative approach between community and ambulatory clinical pharmacists within a health system offers a unique opportunity to provide MTM services in direct collaboration with other health professionals. All pharmacists can identify and resolve a drug-related problem (DRP), defined as an instance involving drug therapy that actually or potentially interferes with desired health outcomes, within multiple settings throughout the health system. There is limited research describing collaborative MTM services targeting a pediatric patient population, as most programs are largely focused on Medicare beneficiaries because of limited pediatric-focused outcome measures. Our study illustrated the implementation of such services in a pediatric patient population using a collaborative department-wide approach.
Objectives The aim of this work was to describe the implementation of a collaborative MTM model within the outpatient pharmacies and clinics of a pediatric health system. This work is significant 2
Practice setting The study site was Nationwide Children’s Hospital, a large, academic, free-standing children’s health system in Columbus, Ohio. The health system serves as the home of The Ohio State University College of Medicine Department of Pediatrics, with inpatient and outpatient pediatric care provided by interdisciplinary teams. Practice description The ambulatory pharmacy services department consisted of pharmacy staff members within 2 outpatient pharmacies and 6 onsite outpatient clinics. The pharmacy staff members within the outpatient pharmacies conducted the daily operations of a community pharmacy with the addition of nonsterile compounding because of a large pediatric patient population. The ambulatory clinical pharmacists within the outpatient clinics served as essential members within their care teams. They worked collaboratively with attending physicians and medical residents to initiate and adjust medication therapy, to schedule and interpret pertinent lab tests, and to discontinue unnecessary medications. In each setting, the pharmacist provided direct patient-centered pharmaceutical care through establishing close pharmacistepatient relationships. Practice innovation The ambulatory pharmacy services department, along with pharmacists within our affiliated accountable care organization (ACO), recognized the importance of establishing viable MTM services to support the ACO’s value-based care model. Before establishing the MTM collaborative, the project team revisited the outpatient pharmacy’s brief history with MTM. For a short time, the outpatient pharmacists provided MTM services by completing comprehensive medication reviews (CMRs). Unfortunately, they found this program unsustainable because of an inability to engage patients in completing a CMR at a specific scheduled time or at the time of dispensing. The knowledge of this barrier informed our revised MTM practice model through establishing a collaborative approach. The project team reviewed potential MTM opportunities for our pediatric patient population, including targeted medication reviews (TMRs) and CMRs, and identified diverse opportunities for individuals seen within the outpatient pharmacies and clinics. The team then developed an MTM model (Figure 1) that allowed the pharmacy staff members to offer these services to patients throughout the health systemdfrom a postdischarge medication pickup at one of the outpatient pharmacies to a routine follow-up visit within an outpatient specialty clinic. The pharmacists’ MTM opportunities and responsibilities varied within each setting, and the collaborative MTM model focused on using the strengths of having pharmacists in both settings to minimize barriers such as time and incorporation of MTM into the workflow. The outpatient pharmacists focused on completing TMRs, while ambulatory clinical pharmacists focused on completing a combination of CMRs and TMRs, submitting claims through a
SCIENCE AND PRACTICE Medication therapy management collaborative
Figure 1. Collaborative MTM model.
shared online platform to ensure intervention visibility among all pharmacists. Training The collaborative MTM model consisted of 2 separate, yet integrated, workflows. It required all pharmacists to identify and resolve DRPs using the Pharmacists’ Patient Care Process.7 The collaborative, integrated workflows allowed pharmacists to make interventions in the time afforded to them based on their practice environment. The pharmacy resident provided all pharmacy personnel with role-specific training on their care environment’s MTM workflow. The outpatient pharmacists were trained in multiple 1-hour small group sessions, ambulatory clinical pharmacists were trained in two 1-hour sessions, and pharmacy technicians and student pharmacists received on-the-job training to minimize disruptions in normal workflow.
Outpatient pharmacy workflow The outpatient pharmacies use a standard 4-point workflow including data entry, clinical review, production, and final verification (Figure 2). The pharmacy staff members have access to each patient’s comprehensive electronic medical record, providing a unique opportunity compared to most community pharmacies. The MTM program within the outpatient pharmacy targeted completion of TMRs. The data entry technician searched the online MTM platform to identify TMR-eligible patients. The technician printed all opportunities and placed them in a patient-specific bin to continue throughout the workflow. The technician placed a comment within the patient’s real-time workflow request of the pharmacy management system, which allowed all staff members to see the TMRs to be addressed at the patient’s pharmacy visit. The clinical review pharmacist ensured that all TMRs were clinically appropriate for the patient (e.g., hydrofluoroalkane
Figure 2. Outpatient pharmacy workflow.
3
SCIENCE AND PRACTICE G. Sneed et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
Table 1 Medication therapy management interventions by type Type TMR New medication education and monitoring Medication adherence check-in Patient education Cost-effective alternative Needs drug therapy Suboptimal drug therapy Unnecessary drug therapy CMR Total
Quantity 349 238 82 13 10 4 1 1 60 409
Abbreviations used: TMR, targeted medication review; CMR, comprehensive medication review.
inhaler preferred clinically for pediatric patients, regardless of insurance preference). If appropriate, the TMRs continued through the production station and to the pharmacist for final verification. The final verification pharmacist placed the TMR printout in a bag with all verified medications to review with the patient upon dispensing. When the patient arrived, a pharmacist or student pharmacist completed the tasks associated with the TMR. He or she completed each TMR with the patient (i.e., patient consultation) if it related to adherence, immunization opportunities, or annual health reminders, or the patient’s prescriber if a medication change (i.e., prescriber consultation) is needed for insurance formulary preferences. Upon completion, the individual who completed the TMR was responsible for its documentation within the online MTM platform. Outpatient clinic workflow Each outpatient clinic had its own unique workflow, while all followed a general pattern for CMR completion. CMR and TMR opportunities were identified for the 6 clinics 1 week in advance based on the clinic’s upcoming patient appointment schedule. This workflow afforded the pharmacist an opportunity to identify DRPs and to update medication lists for these patients before their appointment. The pharmacist met with the patients in the clinic to complete the CMR, addressing TMRs, reviewing medication-related concerns, finalizing medication lists, and developing a plan to address any identified DRPs. The clinical pharmacist documented this
information in the online MTM platform and printed the updated personal medication list and medication action plan to deliver or mail to the patient. Evaluation Project management and feedback The project management team, which consisted of the ambulatory pharmacy services director, ambulatory pharmacy services outpatient pharmacy supervisor, the ACO clinical pharmacist, and the PGY1 community-based pharmacy resident, met weekly to review programmatic progress. The group implemented multiple plan-do-study-act cycles to make program improvements throughout implementation. The group ensured that pharmacy staff members were informed of program progress by providing updates at monthly outpatient pharmacy staff meetings and ambulatory clinical pharmacist meetings. Continual feedback was solicited from outpatient pharmacy staff members on their perceived barriers for the service, which were identified as time, forgetfulness, and education or training. Outpatient pharmacy workflow improvements The project management team enhanced several areas within the outpatient pharmacy workflow based on staff feedback. Stickers were placed on all monitors to remind staff to login to the online MTM platform. This was especially important as the platform existed outside of the normal pharmacy management system, and TMR identification was the rate-limiting step for the entire process. An accordion-type alphabetic file folder was placed near the fill station for placement of TMRs as the patient-specific bin process led to confusion because of the large amount of bins within the workflow. Signs were posted at each station throughout the outpatient pharmacies to remind pharmacy staff of their MTM roles and responsibilities. Pharmacist-initiated interventions A unique opportunity exists within the outpatient pharmacies from the tremendous amount of counseling the pharmacy staff members provide to patients within the dispensing process. The pharmacists and student pharmacists automatically counsel every patient on each medication. They
Figure 3. Total MTM interventions.
4
SCIENCE AND PRACTICE Medication therapy management collaborative
Figure 4. CMR and TMR intervention rates.
counsel patients on compounded medication handling and storage requirements (i.e., shake well, refrigeration, expiration), medication administration techniques (i.e., intranasal midazolam, intramuscular epinephrine), dose measurement techniques using oral syringes, and traditional prescription information (i.e., indications, adverse effect profile, refills). The provision of these counseling services, along with a follow-up telephone call, was reimbursable as pharmacist-initiated interventions. The project team introduced pharmacist-initiated TMRs at the end of month 3, which provided an opportunity for pharmacy staff members to identify and resolve a DRP, or to counsel on any new prescription or over-the-counter medication and follow up with the patient by telephone, for reimbursement. Pharmacy technician champions The project team identified 2 pharmacy technician champions to assist with duties related to program improvements and sustainability. They were responsible for identifying clinical pharmacists' CMR and TMR opportunities across all 6 clinics and conducting follow-up telephone calls for all pharmacist-initiated TMRs. To identify MTM opportunities, they used a weekly calendar template that included patient name, date of birth, appointment time, medical record number, CMR opportunity (yes or no), and number of available TMRs. They reviewed each clinic schedule the week preceding clinic visits to identify opportunities, allowing the pharmacists to review the list in advance via secure e-mail. The clinic pharmacists used this calendar to prioritize patients with CMR/TMR opportunities. If the patients were unable to be seen, the pharmacist would follow up with them at their next clinic visit. The pharmacy technician champions used previously existing daily project time within the workflow to complete follow-up telephone calls under the supervision of outpatient pharmacists. When conducting these calls, they contacted the patient to review satisfaction with therapy, adherence to therapy, symptom resolution with therapy, and related adverse events. Any discussion requiring professional judgment and counseling was referred to their supervising pharmacist. The technician champions were then responsible for completing and submitting the final documentation within the online MTM platform. The introduction of this technician champion program was instrumental in program success,
allowing for buy-in from pharmacy staff because of their increased role in providing a new service to our unique patient population. Practice implications Data were collected to quantify the number and type of interventions completed by pharmacy staff members in both the outpatient pharmacies and clinics (Table 1). In total, 409 interventions were completed, including 349 TMRs (70 clinic based and 279 pharmacy based) and 60 CMRs throughout the first 6 months of offering the service (Figure 3). Of the total TMRs, 238 were pharmacist-initiated interventions, and 111 were prepopulated TMRs from the online MTM platform based on prescription claims data. Of note, greater than half of the CMRs completed allowed for the identification and resolution of DRPs. In addition, we calculated the intervention rate for all TMRs and CMRs, based on the total number of interventions made over the total number of prepopulated TMR and CMR opportunities available for patients within the online MTM platform. Our intervention rates for CMRs and TMRs were 39% and 44%, respectively, throughout the first 6 months (Figure 4). Of note, the most significant increases in TMR intervention rate occurred with the introduction of pharmacist-initiated interventions and the pharmacy technician champion program. Discussion The collaborative MTM model facilitated a partnership between pharmacists in outpatient pharmacies and clinic settings allowing for a comprehensive approach. It allowed the outpatient pharmacy staff members to focus on real-time interventions to improve patient medication use with minimal disruption to regular pharmacy workflow. It allowed ambulatory clinical pharmacists the opportunity to work with pharmacy technician champions to identify patients with drug-related problems and to resolve such problems while meeting with the patients in their respective clinics. The approach allowed for completion of MTM activities without additional staffing and provided opportunities to strengthen departmental communication within an ambulatory pharmacy services department and document overall impact on patient care. 5
SCIENCE AND PRACTICE G. Sneed et al. / Journal of the American Pharmacists Association xxx (2018) 1e6
The implementation of MTM services within outpatient community pharmacies presents many challenges, with studies showing inability to collaborate directly with prescribers as the most challenging barrier.2,3 This barrier is often one that is difficult to overcome with most prescribers practicing outside the immediate pharmacy environment. The use of an approach that incorporated collaboration between outpatient pharmacy staff and ambulatory clinical pharmacists in multiple care environments of a health system increased access to prescribers. The program allowed the pharmacy department to offer MTM services regardless of the patient’s location within the health system. Establishing the program within the small cohort of pharmacies and clinics resulted in 409 interventions. The number of interventions was highest following pharmacist-initiated interventions and the technician champion program. There were weeks of low MTM activity completion, which was largely attributed to technician champion staffing changes and the beginning stages of opening a new outpatient pharmacy toward the end of the study period. The main challenge for the program is the relatively small number of MTM-eligible pediatric patients at the pharmacy because of a lack of established pediatric MTM eligibility criteria, which previous literature has attempted to address.8 The team was able to overcome this barrier through the introduction of the pharmacist-initiated interventions, which largely involved medications used in the treatment of asthma, infections, and pain. This new aspect to the MTM model was well received by patients, stating their gratitude for telephone follow-up measures to ensure proper medication use. The success of a collaborative MTM model requires buy-in from the entire pharmacy team. It is especially important to develop pharmacy staff communication and relationships that allow for continual feedback on MTM practices and workflow improvement. Pharmacy technician champions reinforced the ties between the outpatient pharmacies and ambulatory clinical pharmacists. They worked together to develop a template that illustrates the information needed when identifying MTM-eligible patients within the clinic setting. In addition, the technician champion program fostered buy-in from pharmacy staff members and allowed the technicians to gain a higher level of responsibility within the daily pharmacy operations. This aspect was important for moving forward to ensure that the program remained successful after the departure of the community care pharmacy practice resident. Future investigation is warranted to determine whether using a collaborative MTM approach within the health system setting leads to overall cost savings for an affiliated ACO and revenue sufficient to justify the program in the long term. In addition, it will be important to define pediatric-specific criteria for MTM services that our study suggests may relate
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to asthma, infection, and pain management. It is the intent to expand the program to an additional new outpatient pharmacy and several off-site ambulatory clinics within the health system with the expansion of the ambulatory pharmacy services department. Conclusion Implementation of a collaborative MTM model within a pediatric hospital setting provided an opportunity to address drug-related problems to ensure appropriate medication use. The model consisted of pharmacy staff within 2 different patient care environments working together to complete MTM services for patients throughout the health system. The key elements of the program that were identified and implemented through multiple plan-do-study-act processes included the use of training sessions tailored to the pharmacy staff member’s role in MTM, incorporation of technician champions, and creation of pharmacist-initiated interventions. References 1. Pellegrino AN, Martin MT, Tilton JJ, Touchette DR. Medication therapy management services: definitions and outcomes. Drugs. 2009;69(4): 393e406. 2. Cranor CW, Christensen DB. The Asheville Project: short-term outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc (2003). 2012;52(6):838e850. 3. Lounsbery JL, Green CG, Bennett MS, Pedersen CA. Evaluation of pharmacists’ barriers to the implementation of medication therapy management services. J Am Pharm Assoc. 2009;49(1):51e58. 4. Smith M, Sprecher B. Pharmacy communications with physician offices to clarify prescriptions. J Am Pharm Assoc (2003). 2017;57(2):178e182. 5. Riche DM, Wilson L, Jackson RT, Wofford MR, Adams C. Effect on institutional revenue of clinical pharmacy services in an ambulatory care clinic. Am J Health Syst Pharm. 2013;70(6):482e484. 6. Weber ZA, Skelley J, Sachdev G, et al. Integration of pharmacists into teambased ambulatory care practice models. Am J Health Syst Pharm. 2015;72(9):745e751. 7. Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. JCPP; 2014. Available at: https://jcpp.net/wp-content/ uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf. Accessed June 30, 2017. 8. Benavides S, Madzhidova S, Hernandez A, Le T, Palma SM, Stephen S. Establishment of pediatric medication therapy management: a proposed model. Pharmacy (Basel). 2016;4(1). Gregory Sneed, PharmD, Postdoctoral Academic Fellow, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH; at the time of the study, PGY1 Community-Based Pharmacy Resident, Nationwide Children’s Hospital, Columbus, OH Karl Kappeler, MS, RPh, FASHP, Director, Clinical Information, Silvergate Pharmaceuticals, Dublin, OH; at the time of the study, Director, Ambulatory Pharmacy Services, Nationwide Children’s Hospital, Columbus, OH Travis Gilmore, PharmD, Supervisor, Ambulatory Pharmacy Services, Nationwide Children’s Hospital, Columbus, OH Catherine Kuhn, PharmD, BCACP, FAPhA, Pharmacy Coordinator, Population Health, Nationwide Children’s Hospital/Partners for Kids, Columbus, OH