Transcript Strategic Thinking Clinical Pharmacy Services

James G. Stevenson, PharmD, FASHP
Professor and Associate Dean for Clinical Sciences
Chair, Department of Clinical, Social and Administrative Sciences
University of Michigan College of Pharmacy
Chief Pharmacy Officer
University of Michigan Health System
Creating the Future of Pharmacy and
Healthcare
 Clinical sciences and practice
 10-15 year time horizon
 Rapidly changing healthcare environment and
financing
 Recognition of significant problems in the quality and
safety of medication use
 Rapidly evolving clinical and translational science
 Disclaimer
Genetic Individualization of Drug Therapy
 Pharmacogenomics
 Goal to optimize efficacy and safety through
understanding human genetic variability and its
influence on drug response
 Single gene and polygenic models
 http://www.fda.gov/Drugs/ScienceResearch/ResearchAreas/P
harmacogenetics/ucm083378.htm
 Over 110 drugs with labeled genomic markers
 Significant opportunities
 Clinician education
 Clinical translational research
 Application of results in clinical setting
 Creation of pharmacogenomic testing and drug use policy
New Models of Care
 Improved coordination across hospitals, health
systems, community providers (including community
pharmacies)
 Projections for physician shortages to intensify over
the next 15 years while aging population with health
insurance will increase
 Increase in team-based care
 Increase in scope of practice of nurses, PAs, pharmacists
(collaborative practice agreements and interdependent
practice)
 Increased transparency of results and costs
Transforming Healthcare Delivery
 Significant financial pressures for long term sustainability
of health care and global competitiveness
 Emergence of bundled payment systems
 Expanded health coverage of the population
 Focus on payment for better results/quality
 Value-based Purchasing


Clinical Process Indicators – largely medication-related
HCAHPS- Hospital Consumer Assessment of Healthcare Providers
and System
 Patient-Centered Medical Home Models
 Accountable Care Organizations
VBP Opportunities for the Pharmacist
 Process of Care/HCAHPS
Medication Related Process of Care Measures
Medication Related HCAHPS Measures
FFY 2013
(11 of 12)
(2 of 8)*
FFY 2014
(11 of 13)
(2 of 8)*
FFY 2015
(9 of 11)
(2 of 8)*
 Readmissions and 30-Day Mortality

Impact of evidence-based medication use (AMI, HF, PNE)
 Hospital Acquired Conditions



Falls and Trauma (inappropriate medication use)
Manifestations of Poor Glycemic Control (hyperglycemia management)
CAUTI, CLABSI (antimicrobial stewardship)
 Future measures proposed for potential VBP inclusion





Immunization (Pneumococcal and Influenza)
Healthcare Provider (HCP) Influenza Immunization Rates
Venous Thromboembolism (VTE) Measures (medication use)
Stroke Measures (STK) (medication use)
Clostridium difficile rates (antimicrobial stewardship)
*Pain Management, Communication about Medications
Patient-Centered Medical Home (PCMH)
AHRQ Definition
 Patient-centered The primary care medical home provides primary




health care that is relationship-based with an orientation toward the
whole person.
Comprehensive care Providing comprehensive care requires a team of
care providers. This team might include physicians, advanced practice
nurses, physician assistants, nurses, pharmacists, nutritionists, social
workers, educators, and care coordinators. ..linking themselves and
their patients to providers and services in their communities.
Coordinated care The primary care medical home coordinates care
across all elements of the broader health care system. Such
coordination is particularly critical during transitions
Superb access to care
A systems-based approach to quality and safety
AHRQ recognizes the central role of health IT in successfully
operationalizing and implementing the key features of the medical home
Accountable Care Organizations (ACO)
ACO
Patient Centered
Medical Home
(Primary Care)
Specialty Areas
Inpatient Care and
Transitions of Care
Apply principles from PCMH and extend to specialty
care/areas; integrate with inpatient care and
transitions
Accountable Care Organizations (ACO)
Shared Savings Program
 Providers agree to be accountable for quality and cost
of care for beneficiaries
 ACO shares in the savings it achieves if it meets
specified quality measures and cost controls targets
 Demonstration projects have shown that with
integrated approaches and coordination, significant
reductions in cost of care can be realized
Key Strategies Considered by ACOs
 Treat patients in best location
 Utilize best practice guidelines
 Utilize the expertise of team-based care
 Avoid unnecessary admissions
 Enhance data integration between providers/hospitals
in all sites of care
 Focus on chronic care of populations
 Focus on preventative care, screenings, and wellness
 Improve transitions of care
Importance of Medications
 At least 2/3 of physician visits result in prescription




medication
Chronic diseases managed primarily by drug therapy
Medicare beneficiaries have high utilization of
medications and multiple chronic conditions
Medications major problem at transitions
Suboptimal use of medications can lead to excess costs
in care, hospital admissions, ED visits
Key Medication-Related Measures in
CMS Demonstration Project (Pioneer)
 Diabetes




hemoglobin A1c
LDL
BP
Aspirin use
 Controlling high blood pressure
 Ischemic vascular disease
 LDL
 Aspirin use
 Heart failure
 Beta-blocker therapy for left ventricular systolic dysfunction
 Coronary artery disease
 Drug therapy for lowering LDL
 ACE inhibitor or ARB for CAD and diabetes and/or LVSD
 Influenza and pneumococcal vaccination
The Role of Pharmacists in ACOs
 Critical role in assuring optimal outcomes related to
medications:
 Ensuring appropriate medication use
 Reducing adverse drug events
 Improving transitions of care
 Preventing hospital readmissions
 More optimal management of chronic conditions with
lower total costs
 Poorly developed in most ACOs currently
Pharmacist Integration into PCMH/ACO
at UM
 Developed a systematic and standardized pharmacy
practice model to provide comprehensive
patient care
 Established collaborative practice agreements
with physicians




Performing patient assessments
Ordering drug therapy-related lab tests
Administering drugs
Selecting, initiating, monitoring, continuing,
discontinuing, and adjusting drug regimens
 Developed new billing structure and process for
service reimbursement
UM Pharmacist Practice Model
 Embedded pharmacists in primary care clinics
 Patient recruitment
• Physician referral
• Site-specific disease registries
• Targeted interventions without referral
 Collaborative practice agreements with delegated
prescriptive authority
• Diabetes, hypertension, hyperlipidemia
 Scheduled patient visits/consults
• Clinic visits (30 minutes)
• Phone consults (15 – 30 minutes)
Therapeutic Interventions by
Pharmacists (PCMH)
211
245
357
Year 3: 2,674 interventions
1338
523
increased dose
added medication
decreased dose
deleted medication
optimized regimen
Example of Impact on Clinical Measures
 Diabetes Management by pharmacists
 Results during Year 1 (ramp up)


Patients with baseline A1c > 7% (n=270) had a mean decrease
of 0.8% (95% CI 0.6 to 1.0, p<0.001)
Patients with baseline A1c > 9% (n=118) had a mean decrease
in A1c of 1.4% (95% CI 1.1 to 1.8, p<0.001)
Large Number of Medications in High Cost
Patient Population
18
17
16
Average number of medications
16
14
12
13
11
10
8
6
4
2
0
$20,000-50,000 (n=147)
$50,000-80,000 (n=76)
$80,000-110,000 (n=55)
Annual Health Care Cost
$110,000-140,000 (n=34)
Opportunity to Develop Significant
Pharmacist Roles
 Pharmacists should be actively engaged within their
health-system’s ACO initiatives
 Pharmacists should be an integral part of providing teambased care (right person doing the right jobs)
 Selection of most appropriate regimen
 Modifying regimens as needed to achieve goals
 Patient education/patient empowerment
 Enhancing medication adherence
 Targeted interventions for high risk populations
 Create linkages between community pharmacy and health-
systems and physician organizations
Opportunity to Develop Significant
Pharmacist Roles
 Create new services or expand existing programs
 Chronic disease management
 Polypharmacy
 Adherence
 Transitions of care


Educational needs of patients
Medication access issues
 Case management of high risk populations
 Impact clinical process of care measures, readmissions
 Need for robust measurement of impact and dissemination
of results (CSAS faculty)
New Payment Models
 Bundling of physician, hospital payments; bundling of
payments around acute events
 Incenting improved quality and efficiency (pay for
performance)
 Improving population health
 Paying for cost-effective treatments and services
 Are we preparing our future practitioners with skills in
quality improvement, population management,
pharmacoeconomics and outcomes research?
Focus on Specialty Pharmacy Programs
 Expensive, typically biologically derived, complex, and





often injectable
Fastest growing segment of prescription drug spend
(24% by dollar volume in 2011)
Restricted distribution results in fragmentation of care
(not consistent with ACO principles)
Reimbursement and patient out-of-pocket challenges
Entry of biosimilars into the US market
Pharmacists in team-based care to improve clinical
management, promote best outcomes, as well as
generate margin for health system
Health Informatics and Automation
 Improved HIT to improve care (“big data”)
 Safety goals will not allow reliance on pharmacist
“judgment” and human performance to the degree accepted
today
 Drug information provider role minimized – interpretation,
application, and policy development role enhanced
 Clinical decision support tools need to be
enhanced/customized to realize benefits of significant
national investments in HIT
 Increased use of robotics, automation, end-product testing
to improve safety
 Are we preparing our future pharmacists adequately to utilize
informatics and automation?
 Where is the science behind the decisions being made with HIT
related to medication use?
Significant Changes in Community
Pharmacy Practice
 Major changes in drug distribution models
 Central fill
 Expanded use of technicians/technology
 3rd class of drugs (e.g. ACOG recommendation on oral contraceptives)
 Understanding of problems at transitions of care
 ACO and PCMH models need to create effective hand-off’s and
capacity to manage large numbers of patients
 Explosion in point of care testing
 Recognition of community pharmacist as a resource in improving
population health
 Need collaborative practice agreements, EHR access,
documentation standards, new payment models that encourage
coordination of care plans and goals
Renewed Interest in Sterile Products
Compounding Practices
 Morbidity and mortality from inadequate sterile
compounding practices (e.g. NECC)
 Increased focus on patient safety
 Increased awareness of risks of hazardous drugs
and biological therapies to healthcare workers
 Commercialization of human gene therapies likely
to be managed by pharmacy
Aligned Missions of Academic Medical
Centers and Colleges of Pharmacy
UMHS Mission
 Excellence and Leadership in:
 Patient Care/Service
 Research
 Education
UM COP Mission
 To prepare students to become
pharmacists …who are leaders in any
setting. The College achieves its mission
by striving for excellence in education,
service and research, all directed
toward enhancing the health and quality
of life of the people of the State of
Michigan, the nation and the
international community.
Best Practices for School of Pharmacy in
Academic Health System
 Integrate leadership with mutual goal setting -tripartite





mission in mind; interdependence
Utilize faculty to develop new programs and to evaluate
impact; disseminate best practices
Utilize health system resources to expand and hard-wire
new programs
Integrate students and residents into pharmacy practice
models
Work collaboratively to create models of team-based care
(ACO, PCMH, etc.)
Utilize expertise to manage drug use policy issues for
university employees and retirees; assure success of health
system in new healthcare environment
Summary of Opportunities
 Pharmacogenomics – clinical and translational science
 Developing pharmacist role and demonstrating value in
new healthcare models
 Individual and population health
 New community pharmacy roles
 Expertise in pharmacoeconomics and health outcomes





Specialty pharmacy services
Health informatics and automation
Quality improvement and patient safety
Sterile products preparation
Academic medical center/college integration to support
tripartite mission
References
 Futurescan 2012: Healthcare Trends and Implications 2012-2017. The Society for
Healthcare Strategy and Market Development. Health Administration Press.
http://www.ache.org/pubs/redesign/product-catalog.cfm?pc=WWW1-2206
 Strategic Issues Forecast 2015, American Hospital Association. November 2010.
www.aha.org/research/cor/content/2015CORSIF.pdf
 100 Top Hospitals CEO insights: Keys to Success and Future Challenges. August
2011. Thomson Reuters.
http://100tophospitals.com/assets/CEOInsightsResearchPaper.pdf
 Zellmer WA, ed. Pharmacy Forecast 2013-2017: Strategic Planning Advice for
Pharmacy Departments in Hospitals and Health Systems. December 2012.
Bethesda, MD: Center for Health-System Pharmacy Leadership, ASHP Research
and Education Foundation. www.ashpfoundation.org/pharmacyforecast
 Joint Commission of Pharmacy Practitioners. An Action Plan for the
Implementation of the JCPP Future Vision of Pharmacy Practice. January 31, 2008