10/22/2019

1

THE ROLE OF THE AMBULATORY CARE PHARMACIST IN THE

MANAGEMENT OF COPDRachael Hiday, PharmD, MBA, BCPS, BCACPrhiday@iuhealth.org

DISCLOSURE

I have no relevant financial relationships to disclose.

10/22/2019

2

EDUCATIONAL NEED ANDPRACTICE GAP

• COPD is the 3rd leading cause of death in the US

• $50 billion was spent in 2010 - 70% attributed to exacerbations

• Each COPD admission/readmission costs approximately $8400-$11,100

EDUCATIONAL NEED

• Lack of education on disease state and inhaler technique

• Time constraints during provider visits post-hospitalization

• Pharmacists have key role in prevention of exacerbations/admissions

PRACTICE GAP

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD – 2016. GOLD website. goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/. Published 2016. Accessed December 27, 2016

LEARNING OBJECTIVES

Describe the components of effective collaborative drug therapy management (CDTM) for COPD

Demonstrate how to perform a pharmacist-led COPD visit

Explain different programs available to enhance access to medications for COPD

10/22/2019

3

EXPECTED OUTCOMES

After this presentation, the pharmacist will be able to: Develop a pharmacist-led practice model to

successfully manage patients with COPD

Demonstrate how to perform an initial and follow up pharmacist-led COPD visit

Identify available patient-specific resources to decrease or eliminate affordability barriers in managing COPD

Indiana University Health

AMBULATORY CARE PHARMACY

10/22/2019

4

INDIANA UNIVERSITY HEALTH

Academic Health Center comprised of three major hospitals in downtown Indianapolis 16 PGY1 pharmacy residents

11 PGY2 pharmacy residency programs

Indiana University Health Physicians (IUHP) 50 primary care practices surrounding Indianapolis

metro area

23 ambulatory care pharmacists embedded in primary care practices

AMBULATORY CLINICAL PHARMACY SERVICES

OutcomesQuality metrics, readmissions, medication interventions

16 unique CDTM protocolsPatients referred by providers or through population health

19,203 patient visits in 2018Patients managed by a pharmacist in a primary care setting

10/22/2019

5

COPD MANAGEMENT

REQUIREMENTS FOR REFERRAL

Recent exacerbation requiring a hospital admission or emergency department visit Automatic referral to the clinical pharmacist

Providers can refer patients to pharmacy services for any of the following: COPD disease-state education

Medication management

Affordability concerns regardless of exacerbation history

10/22/2019

6

OFFICE-BASED SPIROMETRY

All patients with diagnosis of COPD must have documentation of pulmonary function testing (PFT)

If no record or history of PFTs in medical record perform office-based spirometry

OFFICE-BASED SPIROMETRY

Pharmacists are trained and certified to perform office-based spirometry American Association for Respiratory Care (AARC)

Pharmaceutical manufacturers will coordinate set up and pay for course (Boehringer Ingelheim)

10/22/2019

7

INITIAL VISIT - ASSESSMENT

MEDICATION HISTORY

• All current and prior medication trials

• Assess adherence

• Assess inhaler technique

SPIROMETRY

• Ensure appropriate diagnosis

• Document severity and classification

• May be repeated annually or if significant change in symptoms

IMMUNIZATION STATUS

• PPSV23

• PCV13

• Influenza vaccine

SYMPTOM ASSESSMENT

• CAT (assess symptoms)

• mMRC (assess breathlessness)

TOBACCO USE

• Current and prior use

• Previous quit attempts

• Previous quit methods

• Emphasize smoking cessation

INITIAL VISIT - PLAN

DISEASE STATE EDUCATION

• Understanding the disease process

• Symptoms

• Risk factors

GOALS OF TREATMENT

• Set realistic expectations

• COPD action plan

THERAPY SELECTION

• Appropriate drug

• Appropriate device

• Appropriate technique

• Formulary status

10/22/2019

8

INHALER TECHNIQUE

COPD ACTION PLAN

GREEN ZONE ACTIONS

• Usual activity and exercise level• Usual amounts of cough and phlegm• Sleep well at night• Appetite is good

• Take daily medications• Use O2 as prescribed• Continue regular exercise/diet plan• Avoid cigarette smoke and inhaled irritants

YELLOW ZONE ACTIONS

• More breathless than usual• Less energy for daily activities• Increased cough and/or thicker phlegm• Using rescue inhaler/nebs more frequently• Poor sleep• Poor appetite

• Continue daily medications• Use rescue inhaler ever 4 hours• Start oral corticosteroids• Use O2 as prescribed• Use pursed lip breathing• Call provider immediately if symptoms do not

improve

RED ZONE ACTIONS

• Severe shortness of breath at rest• Unable to perform any activity or sleep due to

shortness of breath• Fever, shaking, or chills• Confusion• Coughing up blood

• Call 911 immediately

10/22/2019

9

FOLLOW UP VISITS

Patients are seen every 2-12 months based on severity of symptoms

Updated medication history obtained

Assess inhaler technique, compliance, adverse effects, and effectiveness

History of COPD exacerbations, hospitalizations, or ED visits since previous visit

Assess frequency/severity of symptoms of COPD Review or perform spirometry, at least annually, if there is substantial increase in

symptoms or suspected complications

Assess classification of COPD CAT and/or mMRC

FOLLOW UP VISITS

Initiate, discontinue and/or adjust COPD medications based on protocol

Educate on inhaler technique/compliance if new medication started

Update COPD action plan

Order/administer immunizations based on CDC recommendations

Provide any necessary patient education materials

10/22/2019

10

SMOKING CESSATION

ASSESS HISTORY

DISCUSS BARRIERS AND TRIGGERS

SELECT TREATMENT AGENTS

SET QUIT DATE

PROVIDE SUPPORT AND FOLLOW UP

SMOKING CESSATION

Maintain close follow up Patient encouraged to come for appointment even if

initial quit date did not result in cessation!

Subsequent follow up monthly for 4-6 months (coordinate with COPD visits)

Keep the visit positive Much higher success rates if focus is not about the

negative effects of smoking but rather the positive effects that will occur once patient quits

10/22/2019

11

SMOKING CESSATION

12 MONTH SUCCESS RATE

NATIONAL AVERAGE

4.7%

IUH AVERAGE

42%

MEDICATION ACCESS

COPAY CARDS

PATIENT ASSISTANCE PROGRAMS

LOW-INCOME SUBSIDY

GOOD RX (WALGREENS)

10/22/2019

12

COPAY CARDS

Available on manufacturer website

Eligibility Requirements: Must have non-government funded prescription

insurance

Must not be eligible for Medicare

Monthly limit for savings Not good for patients with high-deductible plans

PATIENT ASSISTANCE PROGRAMS

COMPANY DRUGS ELIGIBILITYREQUIREMENTS

OTHER REQUIREMENTS

GLAXOSMITHKLINE (GSK)

Advair Diskus/HFA®

Anoro Ellipta®

Arnuity Ellipta®

Breo Ellipta®

Flovent Diskus®

/Flovent HFA®

Incruse Ellipta®

Trelegy Ellipta®

Ventolin HFA®

< 250% FPL US address

Uninsured

Medicare Part D must have spent $600 in prescriptions during

calendar year

10/22/2019

13

PATIENT ASSISTANCE PROGRAMS

COMPANY DRUGS ELIGIBILITYREQUIREMENTS

OTHER REQUIREMENTS

ASTRA ZENECA (AZ)

Bevespi®

PulmicortFlexhaler®

Symbicort®

< 250% FPL US citizen

Uninsured

Medicare Part D must have spent 3% of

annual income on prescriptions during

calendar year AND not eligible for LIS

PATIENT ASSISTANCE PROGRAMS

COMPANY DRUGS ELIGIBILITYREQUIREMENTS

OTHER REQUIREMENTS

BOEHRINGERINGELHEIM

CombiventRespimat®

Spiriva Respimat®

Stiolto Respimat®

Uninsured< 300% FPL

Medicare Part D< 250% FPL

US address

Uninsured

Medicare Part D must not be eligible for

LIS

10/22/2019

14

LOW INCOME SUBSIDY

• Higher income level than Medicaid• Annual income for couple = $24,690• Annual income for individual = $18,210

LIMITED INCOME

• No Medicare Part D premium, deductible, or coverage gap

• Brand copay = $8.50• Generic copay = $3.40

REDUCED DRUG COSTS

• Social Security website – apply online• Apply in person at Social Security office• Call Social Security to apply over the

phone

APPLICATION

GOOD RX

Free discount prescription program Accessible via smartphone app or via website

Walgreen Pharmacy Fluticasone/salmeterol HFA (generic Airduo) - $51.14

Albuterol HFA (generic Proair) - $22.54

10/22/2019

15

OUTCOMES TRACKING

QUALITYMETRICS

NUMBER OF VISITS

DRUG INTERVENTIONS

COST SAVINGSSUBSEQUENT

EXACERBATIONSSMOKING

CESSATION

THE ROLE OF THE AMBULATORY CARE PHARMACIST IN THE

MANAGEMENT OF COPDRachael Hiday, PharmD, MBA, BCPS, BCACPrhiday@iuhealth.org