collaborative practice successes in primary care- final
TRANSCRIPT
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COLLABORATIVE PRACTICE SUCCESSES
IN PRIMARY CARE
KPhA Annual MeetingSeptember 7, 2014
Tiffany R. Shin, PharmD, BCACPLyndsey N. Hogg, PharmD, BCACP
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Objectives
Describe basic concepts of collaborative practice
Review recent changes in the Kansas Pharmacy Act relating to collaborative practice
Discuss how collaborative practice impacts patient care
Provide examples of collaborative practice successes in primary care clinics
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Introduction to Collaborative Practice
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Audience Poll
What is your experience with collaborative practice agreements?
A. I have a collaborative practice agreement (CPA)B. I have heard of other pharmacists with CPAsC. I am interested in implementing a CPAD. None, I want to learn about CPAs
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Traditional Healthcare:Insufficient Collaboration
Limited communication between healthcare professionals, health-systems, and payers Fragmented care Lack of coordination – acting in “silos”
Consequences may include: Increased time to care Duplication of care Increased costs Decreased safety
Crabtree BF, et al. Ann Fam Med. 2010;8:S80-S90. Crossing the Quality Chasm, 2001 IOM.
Cooperation among clinicians is a priority
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Core Competencies for Interprofessional Practice
Domain 1 - Values/Ethics for Interprofessional Practice Domain 2 - Roles/Responsibilities Domain 3 - Interprofessional Communication Domain 4 - Teams and Teamwork
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
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Collaborative Practice
Key terms/phrases:Mutual respectUnderstanding other’s roles and abilitiesPlanned approach to patient careFrequent communicationTeamwork
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Collaborative Drug Therapy Management (CDTM)
A collaborative practice agreement between one or more providers and pharmacists in which qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility
Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
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Potential CDTM Delegated Functions
Perform patient assessments Conduct counseling Place referrals Order laboratory tests Administer drugs and immunizations Select, initiate, monitor, continue, and adjust
drug regimens
Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
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Collaborative Practice Agreements (CPAs)
A formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions
Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
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CPA Complexities and Levels of Responsibility
Broad to specific scope Medication or disease state limitations
Levels of management Provision of education or recommendations to
collaborative modification of therapy Specific requirements
Training, experience, certification, competencies
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Milestone in Kansas Pharmacy Law
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Audience Poll
As of 2012, how many states did not have laws explicitly authorizing pharmacist collaborative practice?A. None B. 4 statesC. 8 statesD. 16 states
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Laws on Collaborative Practice, 2012
Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
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Senate Sub. for HB 2146
Amended Kansas Pharmacy Act Effective July 1, 2014
Added definitions Collaborative drug therapy management (CDTM) Collaborative practice agreement (CPA) Practice of pharmacy (definition expanded)
Created ‘Collaborative Drug Therapy Management Advisory Committee’
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Collaborative Drug Therapy Management
“A practice of pharmacy where a pharmacist performs certain pharmaceutical-related patient care functions for a specific patient which have been delegated to the pharmacist by a physician through a collaborative practice agreement.”
-Senate Sub. for HB 2146
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Collaborative Practice Agreements
“A written agreement or protocol between one or more pharmacists and one or more physicians that provides for collaborative drug therapy management. Such collaborative practice agreement shall contain certain specified conditions or limitations pursuant to the collaborating physician’s order, standing order, delegation or protocol. A collaborative practice agreement shall be: (A) Consistent with the normal and customary
specialty, competence and lawful practice of the physician; and
(B) appropriate to the pharmacist’s training and experience.”
-Senate Sub. for HB 2146
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Practice of Pharmacy
“performance of collaborative drug therapy management pursuant to a written collaborative practice agreement with one or more physicians who have an established physician-patient relationship”
-Senate Sub. for HB 2146
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CDTM Advisory Committee
For the purpose of promoting consistent regulation and enhancing coordination between Board of Pharmacy & Board of Healing Arts
Chair (non-voting) Jim Garrelts, PharmD, FASHP Kansas Board of Pharmacy
3 Licensed Pharmacists
Rick Couldry, MS, RPh, FASHPLyndsey Hogg, PharmD, BCACPTiffany Shin, PharmD, BCACP
KU Medical CenterVia Christi HealthKU School of Pharmacy
3 Licensed Physicians
Determined by Kansas Board of Healing Arts
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Collaborative PracticeAcross the Country
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Mountain Area Health Education CenterAsheville, NC
Family medicine resident training program Level III Patient-Centered Medical Home (PCMH)
Interdisciplinary collaboration Physicians & residents Pharmacists (3 + 2) Nurses Nutritionists
Pharmacotherapy, anticoagulation & osteoporosisScott MA, et al. J Am Pharm Assoc. 2011; 51: 161-166.
Care managers Behavioral medicine
specialists Spanish translators
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Pharmacist CP Impact on Patient Care
Clinical outcomes Increased number of patients achieve treatment goals Improved adherence to medication regimens Fewer adverse drug events and medication errors
Humanistic outcomes Improved patient satisfaction, quality of life,
improvements in patient knowledge Economic outcomes
Decreased medication costs, medical costs, and visits to emergency room or hospital
Draugalis, et al. AACP Argus Commission Report. 2009-2010.Haines SL, et al. Am J Pharm Ed. 2010; 74(10): Article S5.
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The Minnesota Experience
Intervention Medication management provided by pharmacist
in collaboration with primary care providers
Patient selection BCBS health plan beneficiaries At least 1 of 12 medical conditions Intervention (n=285): patients seen/managed by
pharmacists Control (n=126): patients selected from clinics
without pharmacist collaborative services
Isletts BJ, et al. J Am Pharm Assoc. 2008; 48:203-211.
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Minnesota Experience: Clinical Outcomes
637 drug therapy problems resolved(285 intervention patients)
Improvements in percentage patients meeting HEDIS goals
Isletts BJ, et al. J Am Pharm Assoc. 2008; 48:203-211.
Intervention(n=128)
Control (n=126) P value National
Avg (2001)
Hypertension 71% 59% 0.03 51%
Cholesterol (LDL) 52% 30% 0.001 53%
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Minnesota Experience: Economic Outcomes
Intervention group, n = 186 31.5% reduction in total annual health
expenditure (p < 0.001)
Return on Investment (ROI) = 12:1
Isletts BJ, et al. J Am Pharm Assoc. 2008; 48:203-211.
Before Intervention$ per person-year,
mean + SD
After Intervention$ per person-year,
mean + SD
11,965.27 + 48,969.64 8,197.33 + 10,551.02
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Collaborative Practice Successes at Via Christi Clinic (VCC)Lyndsey N. Hogg, PharmD, BCACP
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Beginning of Ambulatory Care at VCC
October 2012 CPA signed by physicians & administrators 1 pharmacist began in clinics (3 half days/week)
3 clinics, 7 teams, 25 providers Began PCMH transformation process Aug 2012
Referral-based pharmacy services Providers, nursing staff, care coordinators Variety of disease states
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VCC Collaborative Practice Agreement
Broad scope
Collaboratively modify therapy
Currently no pharmacist training/experience requirements included*
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VCC Collaborative Practice Agreement
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VCC Collaborative Practice Agreement
4) Order appropriate laboratory tests to aid in monitoring medication therapy
5) Evaluate patients’ medication regimens based on efficacy, safety, tolerability, drug interactions, cost, patient preference and professionally recognized clinical guidelines
6) Initiate, discontinue, or adjust dosesof medications as clinically indicated based on professionally recognized clinical guidelines and patient-specific factors
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VCC Collaborative Practice Agreement
8) Provide patient education regarding disease states, self monitoring, and medication therapy
11) Maintain close communication with patient’s primary care physician, acting at all times as an additional expert member of the patient’s medical home team and an agent of the physician
10) Document patient encountersin the electronic medical record
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Pharmacotherapy Clinic Workflow
•From provider, care coordinator or nursing staff•Pharmacotherapy appointment scheduled by clinic staff
•Chart review (labs, provider encounters, etc.)•Comprehensive medication review•Prepare anticipated educational materials as necessary
•Medication reconciliation•Vitals & limited physical assessment•Patient interview•Assessment of barriers to care•Education (chronic diseases, medications, lifestyle)•Therapy modification as indicated
•Note to provider through EHR•Face-to-face consult with provider if indicated•Complete referrals (as needed)•Pharmacotherapy follow up appointments as needed
Referral
Prior to appointment
Appointment
After Appointment
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Overview of Patients
Nov 2012 – June 2014 (PCMH only)
Diabetes management Total patients = 56 Average A1C
Initial 3 mo. 6 mo. 9 mo. 12 mo. 15 mo. 18 mo.No. pts 56 40 29 22 15 5 3avg A1C 9.8% 8% 8.1% 7.8% 7.4% 6.9% 7.2%
Number unique patients 274Total patient visits 491Number drug therapy problems 843
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Improvements in DM Control
Months since initiating CDTM
Num
ber o
f pat
ient
s
0
2
4
6
8
10
12
14
16
Initial 3 6 9 12
A1C < 8% A1C 8-8.9% A1C > 9%
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A1C Changes in Select Patients
6
7
8
9
10
11
12
13
14
15
Initial 3 6 9 12 15
Avg all pts Patient 1 Patient 2 Patient 3
Months since initiating CDTM
Hem
oglo
bin
A1C
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Patient Case- RH
59 y/o Caucasian male PMH: T2DM, HTN, hx DVT, depression Uncontrolled T2DM and labile INR
Collaboration between PCP, PharmD, RN, care coordinator
Patient barriers identified Low health literacy Finances Lack of family support
Regular appointments with PharmD scheduled INR obtained same day Written instructions
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Patient Case- Outcomes
Improvement in A1C During CPINR Stabilization
Date INR7/29 2.2
10/30 1.31/21 1.21/31 9.82/7 2.7
Date A1C1/31/14 11%4/25/14 9.6%
Date INR3/6 3.8
3/13 2.93/20 3.13/28 2.34/3 2.5
4/10 2.14/23 35/8 2.6
5/30 2.1
Before CPFluctuating INR
CP = collaborative practice
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Keys to Success at VCC
Physician champion Leverage established resources and processes
Clinic rooms Scheduling process EHR and communication systems
Integration into clinic culture Utilization of clinic reports
Geriatric polypharmacy Uncontrolled diabetes
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Collaborative Practice Successes in a Residency ClinicTiffany R. Shin, PharmD, BCACP
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Via Christi Family Medicine Resident Clinic
Joined clinic and residency faculty in September 2013 No prior ambulatory care clinical pharmacist
presence 4 half-days per week 40% of clinical faculty responsibilities
Participation in clinic/residency meetings and committees
Collaborative practice agreement approved May 2014
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Pharmacy Referral Services
Any clinic patient may be referred Referred by PCP, other providers, or clinic staff
Scheduled individual visits with patients Phone call encounters Documentation in the EHR routed to PCP Verbal communication with PCP
Focus on patient co-management
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Pharmacy Referral Services
Pre-MD Visit MD Visit PharmDVisit
Follow-up
Physician/PCP X X XPharmacist X XStudent Pharmacist
X X
MD Resident or Attending Patient
Pharmacist
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Collaborative Care Planning (Pharmacy consults)
Pro-active Referred patients Chart reviews
Re-active Medical Resident
preceptingEvaluate resident’s plan
Questions from providers Answer drug information
questions Potential Outcomes:
Therapeutic recommendation or education Patient evaluation or education by pharmacy Referral for co-management
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Collaborative Care Planning
Pre-MDVisit
MD Visit MD Resident Precepting
Follow-up
Physician/PCP X X X XPharmacist X X X If referredStudent Pharmacist
X X X If referred
MD Resident
Patient
Pharmacist
+ MD Resident
Pharmacist
+
MD Attending
+
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Collaborative Care Planning Results
Data from 27 clinic half-days*: 218 patients precepted and/or charts reviewed 29 (13%) pediatrics 29 (13%) obstetrics 130 (58%) adult
112 total contributions or recommendations from pharmacist 56 pharmacist-initiated recommendations
*Does not include individual pharmacist visits or phone follow-up encounters
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Patient DM – Prior to Collaboration
48yAAM with uncontrolled Type 2 DM Other PMH: HTN, stroke, glaucoma,
adenocarcinoma of colon, hx of falls Barriers to care: Low health literacy Poor memory Poor dexterity Finances Lives alone
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Patient DM – Prior to Collaboration
13.2% 8.3% 12.9%
Legend
MD Visit
MD + PharmDVisit
PharmDPhone
PharmDVisit
Insulin dose increase
Jul Aug Sept Oct Nov Dec Jan Feb
Insulin startedpo med
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Patient DM - During Collaboration
March 2014 during PCP visit PCP asks clinic pharmacist to provide patient
education on meter use Identify difficulty of checking blood sugar at home
Referral to pharmacist for DM co-management
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Patient DM - During Collaboration
6.8%13.4%
March April May June July
Legend
MD Visit
MD + PharmDVisit
PharmDPhone
PharmDVisit
Insulin dose increase
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Keys to Success
Strong physician and clinic staff relationships Multiple options for communication High risk patient population Foster long-term patient relationships Academic teaching environment Being both proactive and reactive
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Conclusion
Collaborative practice is occurring in Kansas and across the US
Communication and building relationships is key to collaborative care
Successful implementation can improve patient outcomes
More guidance to come from the CDTM Advisory Committee
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COLLABORATIVE PRACTICE SUCCESSES
IN PRIMARY CARE
KPhA Annual MeetingSeptember 7, 2014
Tiffany R. Shin, PharmD, BCACPLyndsey N. Hogg, PharmD, BCACP