Transcript Penobscot Community Health Care

Expanding Pharmacy Services in a
Health-System Primary Care Clinic:
Factors to Consider
Andrea Lee, PharmD
PGY2 Health-System Pharmacy
Administration Resident
Objectives
 Identify methods to justify the expansion of
sustainable primary care pharmacy services in a
health-system clinic.
Health-Care Facility
 Penobscot Community Health Care (PCHC) is a Patient Centered
Medical Home serving over 60,000 patients annually at 16 practice sites
– Totaling over 350,000 patient visits
– 70% of patients are lower income
 Largest and most comprehensive Federally
Qualified Health Center (FQHC) in Maine
– Shared Savings Accountable Care Organization (ACO)
– Previously in a Pioneer ACO- 2013
– Rural health care facility providing comprehensive health care services to
the greater Bangor area and surrounding communities
Image: www.visitmaine.org
Outpatient Pharmacy Background
 Three Outpatient Pharmacies
– Roughly 80,000 prescriptions annually
– Hours of Operation vary among locations
• One pharmacy open weekday evenings and
weekends starting October 2012
 3 Full-time Pharmacists
– Focus of time spent in dispensing roles
Clinical Pharmacy Services
Background
 Two* Clinical Pharmacists- Husson University Faculty
 Four PGY1 Community Pharmacy Residents
– 75% of time in clinics, 25% of time dispensing
– Program developed in 2011
 Clinical participation from pharmacists within the integrated team is
limited to Husson Faculty presence and resident rotation within practice
sites
– Current services include clinical consults, chart reviews, joint patient visits
with primary care provider (PCP)
 Administrators desire increased clinical pharmacy services within the
organization
New Position Proposal
 Pharmacy Business Model Innovation
– Service Design:
• 0.6 FTE – Pharmacy Staffing at Helen Hunt Health Center
(HHHC) Pharmacy in Old Town, ME
• 0.4 FTE – Clinical Pharmacy Integration conducting
reimbursable patient visits
– Allows for expansion of outpatient pharmacy hours in
another location
– Adds a desired imbedded clinical component
Benefits of the Proposed Position
1.
2.
3.
4.
5.
6.
7.
Increased access to outpatient pharmacy services for Walk-inCare Patients
Increased capture rate on new and refilled prescriptions
Improved oversight and documentation of continuity of care
Increased pharmacy presence within practice sites
Increased patient satisfaction and efficiency of the care
experience
Increased touches on Medicare patients
Improved student/resident education
Overview of the Landscape
in Old Town, ME
 Pharmacy Locations
– 3 pharmacies within 5 mile
radius of health center
 Walk-In-Care (WIC)
Locations
– HHHC is the only WIC open
Weekends
– EMMC Orono no longer
provides WIC services (Sat
Appts only)
– UMaine Cutler Health
Center- Mon-Fri only
Hours of Operation for Outpatient
Pharmacy Extended Hours- HHHC
Current Hours
 Monday- Friday
8:30am – 5:00 pm
Proposed Hours
 Monday-Friday
8:30am – 8:00pm
 Saturday
9:00am – 4:00pm
Staffing: 1 FTE (40hr)
Staffing: 1.6 FTE (67hr)
Historical Perspective on Extended
Hours
 Brewer location began extended hours October 2012
– Staffing component for PGY1 residents
Brewer Totals
y = 0.4062x - 16301
800
700
600
500
400
300
200
100
0
TOTAL
NEW
REFILL
Linear (TOTAL)
Trends at Brewer Pharmacy –
Extended Hours
Average Monthly Fill
2012
182.3
2013
258.8
2014
295.5
Average Montly Fill
2012 112.6667
2013
111.25
2014
136
Analysis of Brewer Pharmacy, cont.
 Change in Patient Perception
– Knowing that the pharmacy is
open nights and weekends as
a driver for growth
– Objective Measure: Volume of
refilled prescriptions filled
during extended hours
 Average Capture Rates of WIC
RX’s around 40%
– Varies by day, provider in WIC
Extrapolation to HHHC Pharmacy
FINANCIAL IMPLICATIONS
Additional Cost/Year to Extend Hours
$177,242.00
– Includes salary, fringe, direct expenses, administration fees
 Requires approximately 5550 additional prescriptions to break even
 13% rate in growth needed
 Market Analysis- Questions to Consider
– What is the WIC volume at HHHC in terms of Brewer?
– What is the pharmacy’s current capture rate of prescriptions coming out of clinic?
Trends in Pharmacy Totals
Background on Medicare Annual
Wellness Visit (AWV)
 Fully paid for by Medicare Part B for beneficiaries 65 and
older
– No cost to eligible beneficiaries
 Focused visit on “Health Risk Assessment (HRA)”
– Health prevention
– Disease detection
– Coordination of screening
 Pharmacists across the country have performed AWVs
Centers for Medicare and Medicaid Services. Providing the annual wellness visit
(AWV). www.cms.gov/
Billing for Annual Wellness Visit
HCPCS
Codes
Billing Code Descriptors
Reimbursement
(FFS Maximum
Rate)
G0402
Initial preventative physical examination (IPPE); face- Provider Required
to-face visit, services limited to new beneficiary during
the first 12 months of Medicare enrollment
G0438
Annual wellness visit (AWV); includes a personalized
prevention plan of service (PPPS), initial visit
$159.38
G0439
Annual wellness visit (AWV); includes a personalized
prevention plan of service (PPPS), subsequent visit
$106.35
 AWV eligible for Medicare beneficiaries 66 years and older
 Subsequent visits billable every year
Centers for Medicare and Medicaid Services. Providing the annual wellness visit
(AWV). www.cms.gov/
Warshany K et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):44-9.
Benefits to the Organization
 Utilization Drivers
– Increase vaccinations (~1.25 vaccinations recommended
per person, ~30% received vaccinations at time of visit)
– Referrals for additional services; ie. lab, podiatry,
dietitian, PT, audiology, mental health (~1 referral placed
per patient)
– Opportunities to improve quality metrics
• Patient’s accessing electronic portal
• Focus on a specific metric requiring improvement (eg.
Mammogram, colonoscopy)
Feasibility of AWV Proposal
 5510 Medicare Beneficiaries 66 years and older at
PCHC practice sites
 Pharmacist to see 13 patients each week
 Estimated Net Revenue $5,435 per year
 Factors to consider
–
–
–
–
No show rates ~33% within institution
Start-up costs
Marketing of services
Provider and patient buy-in
Post Question
 What factors should be considered when justifying sustainable primary
care pharmacy services?
a)
Understand the unique characteristics of the surrounding community to
support expanded pharmacy services
b)
Align proposed services with the clinical and financial priorities of the
organization
c)
Ensure payments for pharmacy services are within the scope of the
organization’s reimbursement structure
d)
Ensure a sustainable infrastructure of support is included in the
proposal, including staffing levels, anticipated growth, shifts in
payments, and future technology costs
e)
All of the above
References
 Centers for Medicare and Medicaid Services. Providing the
annual wellness visit (AWV). www.cms.gov/
 Desselle SP, Zgarrick DP. Pharmacy management:
essentials for all practice settings. 2nd ed. New York:
McGraw Hill Medical, 2009.
 Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare
annual wellness visits conducted by a pharmacist in an
internal medicine clinic. Am J Health Syst Pharm. 2014 Jan
1;71(1):44-9.
Questions?
Medicare Part B licensure
Evaluating its potential in a federally qualified health
center (FQHC) outpatient pharmacy system
Kari London, PharmD
PGY-1 Community Pharmacy Practice Resident
Penobscot Community Heath Care
April 26th, 2014
Objective
 Understand the barriers and benefits of DME
Supplier enrollment in the independent
pharmacy setting
– Focus: Diabetic testing supplies
Background
• From 1980 to 2004 the number of people age 65
years and older diagnosed with diabetes increased
almost two fold, from 2.3 million to 5.8 million1
• Prescription medications to treat diabetic
complications, and antidiabetic agents plus testing
supplies, are two of the largest drivers of expense
at 18% and 12%, respectively2
• Medicare Part B coverage is an important means
of mitigating prescription costs of these products
Background cont.
• FQHC with 16 primary care practice sites
• Pharmacy services
• 3 outpatient pharmacies, residency program, faculty
practice sites, pharmacy students
• Exploring feasibility of piloting DME supplier
enrollment at one pharmacy
• Primary products on interest: diabetic testing supplies
Barriers
 Program administrative costs
Per Site (USD)
Medicare DMEPOS Enrollment Fee
532
NABP DMEPOS Accreditation Fees
Application and Survey Fees
3250
Annual Participation Fee
125
Year 1 subtotal
3375
Estimated total for 3-year accreditation
3625
Surety Bond (annual fee)
1200
Estimated Total Fees
Year 1
5107
Year 1-3 Total
7757
Barriers cont.
 Program infrastructure
– Software systems
– Documentation requirements
– Employee training
– Inventory management
Barriers Cont.
 Patient recruitment
– Eligible patient population size
Total Patient Capture
Other pharmacies
PCHC pharmacies
Diabetic Patient Capture
19.9%
18.7%
80.1%
81.3%
 Low product reimbursement
50ct Test Strips
100ct Lancets
BG Monitor
Prescription
Medicare reimbursement
$10.41
$2.52
$72.34
------------
Average Revenue
-$42.86
-$5.10
$51.06
-$324.18
Benefits
 Improved patient recruitment
– The “Loss Leader”
– i.e. gross ~$7,000/year of revenue on prescriptions for 1
patient
 Increased services
 Improved patient care
– Patient Centered Medical Home
– Coordination of care
The Numbers
 Revenue per diabetic pt. / year
Testing Supplies RXs
Other RXs
Total Revenue
$(648)
$2,112
$1,464
The Numbers cont.
 Revenue projection
Year 1
Average / Year
Cumulative Years 1-3
$6,150
$6,000
$4,000
$2,000
$2,050
Administrative
Costs
$2,050
Potential DM
Pt. Revenue
$$(535)
$(2,000)
$(3,057)
$(4,000)
$(6,000)
$(8,000)
$(1,607)
$(2,585)
$(5,107)
$(7,757)
Net Revenue
Conclusions
 Administrative costs of implementing Medicare Part B billing pose
the most significant barrier to program feasibility
 Potential increase in capture of non-diabetic supply prescriptions
may be sufficient to mitigate losses associated with filling diabetic
testing supply prescriptions
 Being a participating DME supplier for diabetic testing supplies
presents a negligible loss ($535/ pharmacy/year)
– Utilized conservative patient capture increase numbers and high estimate
of revenue loss of diabetic supplies
– Did not account for potential revenue loss from lost patients
References
1. Ashkenazy R, Abrahamson MJ. Medicare coverage for patients with
diabetes. A national plan with individual consequences. J Gen Intern
Med. 2006 Apr;21(4):386-92.
2. American Diabetes Association. Economic costs of diabetes in the
U.S. in 2012. Diabetes Care. 2013; 36 (4): 1033-46.
3. DMEPOS. NABP National Association of Boards of Pharmacy.
Website. http://www.nabp.net/programs/accreditation/dmepos.
Accessed November 29th, 2013
4. NHIC, Corporation. The DME MAC Jurisdiction A Supplier Manual.
Website. http://www.medicarenhic.com/dme/supmandownload.aspx.
Accessed December 6th, 2013.
Post question
Potential threats to the success of Medicare Part B
DME program for this FQHC pharmacy system include:
A. Low product reimbursements
B. High administrative costs
C. Documentation requirements
D. Eligible patient population size
E. All of the Above
Questions?
Zach Deabay, PharmD
Penobscot Community Health Care
PGY1 Pharmacy Practice Residents
April 26th, 2014
Objectives

Discuss the interdisciplinary team approach in the
management of COPD

Evaluate strategies utilized to improve disease state
management and access to medications

Analyze effect of the program on healthcare utilization
and strategies moving forward
Disclosure: Study funded by grant received from Cardinal Health. Did not
influence implementation, execution, or analysis of study.
Background
• Prevalence of COPD in the US is estimated at 23.6 million
adults1
• Medicare patient with COPD have higher rates of
hospitalization, ER visits, and home healthcare use than
non-COPD peers2
• Total excess healthcare costs of ~$20,000/year higher
• ~80% due to inpatient services
• Studies looking at efficacy of self-management
interventions to improve COPD management have
demonstrated mixed results3,4
Overview
 Components of Program
– Education session with care manager and pharmacist
– Rescue Pack
• Providers choice of antibiotic +/- steroid for patients to keep at home
• Patient must contact care manager or provider before use
 Goals
– Educate patient to better self-manage disease state
– Optimize therapeutic regimen
– Provider easier/quicker medication access to reduce severity of COPD
exacerbation
Workflow
 Pre-visit
– Chart review by care manager
– Pharmacotherapy review by pharmacist
• Recommendations made to provider
 Visit
– Disease state assessment, education, and management
techniques
– Comprehensive medication assessment
• Technique, compliance, barriers, perception
 Post-visit
– Care management follow-up
– Rescue pack
Program Materials
Target Population
Documented COPD exacerbation in prior
12 months prompting patient to seek acute
medical attention
(Emergency Department, Walk-In Care, Office Visit)
Other Inclusion Criteria
•
Patient desire to participate
•
Patient attendance of educational visit
Exclusion Criteria
•
History of non-compliance
•
Comorbidity affecting ability to selfmanage disease state
COPD
Diagnosis
Inclusion
Criteria Met
Approval of
PCP
Pre-visit
Protocol
Education Visit
Enrollment
 First patient enrolled 8/29/13
 Enrollment ongoing
 52 patients enrolled to date
– Females – 32 (62%)
– Current Smoker – 49%
– Males – 20 (38%)
– Average # Medications – 10
– Age
– Average # Respiratory
Medications – 3
• Range – 42-91 years
• Average – 65 years
– Oxygen Therapy – 20%
Result Analysis
 Patients required to be
in study a minimum of 3
months before analysis
performed
 26 patients meet this
criteria
– Additional 11 patients
qualify in May
 Analysis will include:
– Primary endpoints
• Hospitalizations
• Use of emergency
department and walk-in
services
• Death
– Secondary endpoints
• Rescue pack use
(appropriate/inappropriate)
• Number of exacerbations
Preliminary Observations
 Majority of patients enrolled in program are prescribed rescue
pack (>80%)
 Of those prescribed rescue packs, most have not used them
(<50%)
 Most commonly prescribed combination is
azithromycin/prednisone
 Several patients have used the rescue packs inappropriately
but majority of uses (>75%) have been appropriate
 Program appears to be reducing utilization of emergency room
– Possible shift from decreased ER visits to increased office visits
Program Benefit

Patient Benefits






Disease state education
Medication education
Pharmacotherapy
review
Relationship with care
manager
Easier access to
medication
Organization Benefits






Patient care divided
among team members
Accurate medication list
Assessment of medication
compliance
Pharmacotherapy review
Improved patient
outcomes*
Lower healthcare costs*
*Being assessed in current study
Patient Case
After CM visit reports
recognition of
symptoms that
warrant appt. Lack of
maintenance
medication identified
at visit with follow-up
recommended
56 yof with COPD,
typically waits if she
is sick
Patient initiated
antibiotic and steroid,
with PCP follow-up
visit within several
days. Instructed to call
back for appointment
if symptoms do not
improve.
Patient call: states
"been having more
shortness of
breath and
burning in chest,
which is always the
first sign of the
bronchitis."
Follow-up office visit:
“patient reluctant in gen
to take meds but with
recent exacerbation she
started the pack and did
much better than usual,
recovering more quickly
from COPD exac.”
Key Points
 Interdisciplinary approaches utilize the expertise of all
healthcare team members
 Rescue packs provide quicker and easier access to
medication and may be a useful tool, if used appropriately
 It is essential to do educational visit Before rescue pack
medications are sent to pharmacy
 Difficult to predict which patients are most appropriate for
rescue packs
– All patients expected to benefit from educational component
Assessment Question
Benefits of enrollment in the COPD program
include all of the following except:
A. Medication and disease state education
B. Patient ability to decide when their symptoms warrant
antibiotic therapy
C. Quicker access to medications if deemed appropriate by
provider
D. All of these are benefits of the program
References
1. Mannino DM, Braman S. The epidemiology and economics of chronic
2.
3.
4.
5.
obstructive pulmonary disease. Proc Am Thorac Soc. 2007; 4 (7): 502-6.
Make B, Dutro MP, Paulose-Ram R, Marton JP, Mapel DW. Undertreatment
of COPD: a retrospective analysis of US managed care and Medicare
patients. Int J Chron Obstruct Pulmon Dis. 2012; 7: 1-9.
Effing T, Monninkhof EEM, van der Valk PP, et al. Self-management
education for patients with chronic obstructive pulmonary disease
(Review). Cochrane Database Systm Rev. 2009
Bucknall CE, Miller G, Lloyd SM, et al. Glasgow supported self-management
trial (GSuST) for patients with moderate to severe COPD: randomized
controlled trial. BMJ 2012; 344: e1060 doi: 10.1136/bmj.e1060
London, Kari. Chronic obstructive pulmonary disease management in high
risk patients: Evaluation of a multidisciplinary team approach to reduce
readmission rates within a federally qualified health center population.
MSHP Conference. Jan 26, 2014.
Questions?
Pharmacist Interventions on
Prescribing Habits for Urinary
Tract Infections (UTIs) in a WalkIn Care Clinic
Nicholas LeBlanc, PharmD
PGY1 Pharmacy Resident
Penobscot Community Health Care
Objective
 Identify trends in antibiotic resistance of urinary
tract infections and formulate a plan to reduce
inappropriate prescribing of antibiotics.
Introduction
 Uncomplicated cystitis is a very common infection
among young women and a major source of
antimicrobial exposure.
 Repeated antimicrobial exposure can select for
resistant organisms.
 Antimicrobial resistance has complicated treatment
of urinary tract infections.
 Community pharmacists can play a role in lowering
resistance.
Guidelines
 First-line agents are Nitrofurantoin, Trimethoprim-
Sulfamethoxazole (Bactrim), and Fosfomycin.
 TMP-SMX should not be used empirically if local
resistance is greater than 20%.
 Second-line agents are fluoroquinolones and β-
lactams.
 Fluoroquinolones should not be used empirically if
local resistance is greater than 10%.
Local Resistances
Local Resistances
UTI Prescription Analysis
 A 6 month time period was analyzed.
 Reviewed antimicrobial prescriptions associated
with ICD-9 code 599.0 (UTI).
 Inappropriate medications were omitted:
– Azithromycin
– Doxycycline
– Metronidazole
Initial Results
Antimicrobial Agents
Penicillins
9%
Nitrofurantoin
20%
Tetracyclines
3%
TMP-SMX
29%
Fluoroquinolones
34%
Cephalosporins
5%
Discussion
 A total of 1315 prescriptions were analyzed.
 Approximately half of the prescriptions analyzed
were for non-first line agents.
 Fluoroquinolones were the most highly
prescribed antimicrobial class (33.38%).
 Penicillins, cephalosporins, and tetracyclines
were sparsely prescribed.
Limitations
 ICD-9 codes do not describe the patient well.
 The data does not distinguish whether the UTI
was treated empirically or not.
 Tetracycline use may not have been associated
with UTIs.
Role of the Pharmacist
 Community pharmacists can serve as a source of information for providers.
– Up to date on guidelines
– Drug experts
– Useful resources
 Giving feedback to providers on prescribing habits.
 Provider education
– CME presentations
– Calling about errors in prescriptions
– Group meetings
– Handouts
– EMR alerts
– Get feedback from providers
Conclusion
 Antimicrobial resistance is low, but prescribing
habits leave much room for improvement.
 Pharmacists can be a valuable resource of drug
information and provide education to providers.
 There are many different ways in which
pharmacists may educate providers.
References
 Gupta K, Hooton TM, Naber KG, et al. International Clinical
Practice Guidelines for the Treatment of Acute Uncomplicated
Cystitis and Pyelonephritis in Women: A 2010 Update by the
Infectious Diseases Society of America and the European
Society for Microbiology and Infectious Diseases. Clin Infect
Dis. 2011; 52(5):e103–20.
 Gupta K, Hooton TM, Stamm WE. Increasing Antimicrobial
Resistance and the Management of Uncomplicated
Community-Acquired Urinary Tract Infections. Ann Intern Med.
2001;135(1):41-50.
 Hooton T, Gupta K. Acute Uncomplicated Cystitis and
Pyelonephritis in Women. UpToDate. 2013.
Assessment Questions
Which of the following is an appropriate way to reduce
resistance of urinary tract infection organisms by
pharmacists?
A. Ensure proper prescribing of first-line agents
B. Antimicrobial stewardship programs
C. Keeping providers up to date on current guidelines
D. Be a resource of drug information for providers
E. All of the above are true
Questions?
[email protected]
Implementation and outcomes of an
interdisciplinary collaborative practice group
on controlled substance use and prescribing
within a patient-centered medical home
Rachel Bastien, PharmD
PGY1 Resident, Penobscot Community Health Care
Bangor, ME
Objective
 Summarize the development, workflow, and
pharmacist involvement of the Controlled
Substances Initiative (CSI) committee and
evaluate the impact on providers, patients,
pharmacy dispensing, and prescribing habits.
Disclosure

Authors of this presentation have the following to disclose concerning possible financial or personal
relationships with commercial entities that may have a direct or indirect interest in the subject matter of
this presentation:
Rachel Bastien: Nothing to disclose
Motivation
 Increasing rates of prescription drug abuse
 The cost to the overall health of patients and the
community
 Negative social impact
 Increased costs associated with abuse
 Provider frustrations
Development
 Formed in March 2013
 Initially, the committee members were appointed by the executive
medical director
– Executive medical director
– Chief quality officer
– Chief psychiatrist
– Physicians
– Nurse practitioners
 Soon after pharmacists were added for their drug expertise
 Weekly meetings where approximately 8-12 patients are reviewed
Workflow
1
2
3
4
5
6
• Referral to CSI
• Pharmacist conducts a comprehensive chart review
• Pharmacist presents patient case from chart review to committee
• Collaborative interdisciplinary discussion generates targeted, evidence-based
recommendations with action plans
• Consensus recommendations communicated to provider
• Review and appeal process
The Role of the Pharmacist
 Pharmacist conducts a comprehensive chart review, including
– Maine Prescription Monitoring Program (PMP) report
– Health Info Net
– Office visit notes
– Consults with specialists
– Medication history
– Imaging studies
– Any additional pertinent information
– Calculate Morphine Equivalent Dose (MED)
 Presents case to committee
 Communicates responses to providers
Population reviewed
Outcomes
Percentage of patients with MED changes post CSI review
5%
24%
32%
Off of narcotics entirely (N =
21)
Reduced dose (N = 34)
No change (N = 28)
39%
Outcomes
Narcotic and Benzodiazepine prescriptions written organization wide
2200
Number of prescriptions
2150
2100
2050
2000
2012
1950
2013
1900
1850
1800
1750
June
July
Month
August
Outcomes
Number of prescriptions filled at largest-volume internal outpatient pharmacy
CII
Total
Opiates
Stimulants
CIII-V
Total
Benzodiazepine
Codeine/Hydrocodone Products
Buprenorphine Products
Hypnotics
Other (Lyrica, Soma, Testosterone,
etc.)
2012 (June-Aug)
2013 (June-Aug)
1514
673
841
1245 (-17.7%)
606 (-9.9%)
639 (-24%)
1307
433
392
265
127
90
1080 (-17.3%)
350 (-19.1%)
296 (-24.4%)
281 (+6%)
93 (-26.7%)
60 (-33.3%)
Challenges and opportunities
 Presenting alternative treatments to providers
– Use of NSAIDs, SSRIs, therapy, etc where appropriate
 Challenges within PCHC prescribing trends
– Increase prescribing of tramadol and ketorolac
 Engaging the entire healthcare team
– Physical therapy
– OMT
– Addiction services
Discussion
 An overall 63% reduction in MED occurred in patients reviewed by the
committee
 A 12% reduction in the number of opioid prescriptions written occurred
between January and September 2013
 The largest of the 3 internal outpatient pharmacies saw a 17.7%
decrease in the number of C-II prescriptions filled
Takeaway points
 Provides provider support and education
 Defines clear expectations for both patients and prescribers
 Allows for objective and evidence-based use of controlled medications
Assessment question
 As a result of instituting a controlled substances
committee, which of the following was not
directly enhanced?
1. Multidisciplinary collaboration
2. Patient acceptance of need for dose reduction
3. Chapter 21 compliance measures
4. Provider prescribing support
Questions?