where do you fit? piecing together the puzzle of ... idt learner... · piecing together the puzzle...

8/15/2017

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Where do you fit? Piecing together the puzzle of interdisciplinary health care teams

Brandon Herk, PharmD, BCACPClinical Pharmacist Advocate Medical Group

Rebecca Young, PharmD, BCACP, Assistant Professor of Clinical Sciences Roosevelt University College of PharmacyPractice Site Clinical Pharmacist Advocate Medical Group

IPhA & MPA Joint Annual Meeting September 7-10, 2017

Disclosure and Conflict of Interest

– Dr. Herk declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings and honoraria.

– Dr. Young declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings and honoraria.

Pharmacist Learning Objectives

At the conclusion of this program, the pharmacist will be able to:

• Define the clinical aspects of an interdisciplinary team

• Identify how to incorporate students and education into interdisciplinary team

• Describe operational components of interdisciplinary teams

• Design an appropriate care plan for a complex patient within an interdisciplinary team

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Consider this…

Pertinent Labs:

BP: 132/74 mmHg Spirometry: None on file HDL: 86Pulse: 72 bpm CAT Test: 17/40 TG: 49Weight: 191 lbs HbA1C: 6.9% LDL: 88Height: 66 inches Microalbumin/Cr: 1530 mcg/mgBMI: 30.8 kg/m2 SrCr: 0.65 mg/dlINR 3.7 TC: 185

RZ is a 68 year old man with a history of COPD, DM, HTN, alcoholism, and previous DVT. He is here today for education on his COPD and inhalers. He presents today with fluticasone/salmeterol, budesonide/formoterol, umeclidinium, and fluticasone/vilanterol. Some inhalers from recent hospitalization and some inhalers are expired. He states he is confused as to which inhaler to use. He states his mucus feels sticky sometimes. RZ states that the fluctuating weather changes his level of activity. He states that as the day goes on his breathing gets worse. He states that he is supposed to wear his O2 but is not currently wearing. He states that his clonazepam helps with sleep. He also states that his diabetic drink gives him some energy. He reports compliance with his medications. He denies problems paying for his inhalers. He continues to drink up to six drinks a day and smokes up to 5 cigarettes a day.

Consider this…

Medication List: • fluticasone/salmeterol (samples)• budesonide/formoterol (samples)• fluticasone/vilanterol (samples)• Umeclidinium 62.5mcg/inh once

daily• ipratropium-albuterol 0.5-

2.5mg/3ml every 4 hours• albuterol HFA 108 mcg/act 2 puffs

every 4 hours as needed • accu chek supplies• glipizide ER 5mg once daily• acetaminophen 325mg 2 tablets

every 6 hours • folic acid 1mg once daily• MVI once daily

• lisinopril 5mg once daily

• metoprolol tartrate 50mg twice daily

• warfarin 2.5mg as directed

• pantoprazole 40mg once daily

• aspirin 81 mg once daily

• atorvastatin 40 mg once daily

• quetiapine 50 mg at bedtime

• vitamin D3 1000 units once daily

• clonazepam 0.5mg once daily

Consider this…

• In what ways can this patient benefit from interdisciplinary teams?

Pre-Test Questions

In regards to interdisciplinary teams, who is the driver of the patient’s overall healthcare goals?

A. Physician

B. Pharmacist

C. Caregiver

D. Patient

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Pre-Test Questions

Which health care professions require interprofessional education as part of their curriculum?

A. Medicine

B. Pharmacy

C. Physical Therapy

D. All of the above

Pre-Test Questions

What health care organization recently published a guideline for establishing collaborative practice agreements between pharmacists and physicians?

A. Center for Disease Control (CDC)

B. Agency for Healthcare Research and Quality (AHRQ)

C. Center for Medicare and Medicaid Services (CMS)

D. The Joint Commission

Pre-Test Questions

Interdisciplinary care can be provided in any pharmacy practice setting.

A. True

B. False

Health Care is Changing...

http://www.emrandehr.com/2017/03/17/the-sad-state-of-healthcare-fun-friday/

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Chronic Disease Management

• Common medical conditions (heart disease, diabetes, etc.) are costly and preventable

• 50% (~157 million people) had 1 or more chronic health condition

• 25% (~78 million people) had 2 or more chronic health conditions

• Disease that contribute to ambulatory health care burden include: – Uncontrolled blood pressure– Uncontrolled cholesterol– Smoking– Alcohol consumption– Lack of physical activity

https://www.census.gov/popest/about/terms.htmlWard BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis.2014;11:130389.

Annual Chronic Disease Management Cost

DeVol R, Bedroussian A. An unhealthy America: the economic burden of chronic disease. Milken Institute. October 2007

http://i.huffpost.com/gen/315049/DEBT-V.jpg

*Health Care Systems, not only ambulatory arena

https://www.pcpcc.org/sites/default/files/page-files/PCMH-PCPCC-Infographic.pdf

Medical Home Model Medical Home Model

https://www.pcpcc.org/sites/default/files/page-files/PCMH-PCPCC-Infographic.pdf

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https://pcmh.ahrq.gov/page/defining-pcmhhttp://www.aafp.org/dam/AAFP/documents/about_us/initiatives/AAFP-PCMHWhitePaper.pdf?cmpid=npp12_ad_com_na_van_1

https://www.ama-assn.org/delivering-care/physician-led-team-based-care

Agency on Healthcare Research & Quality (AHRQ):...accountable for meeting...health care needs, including prevention and wellness, acute care, and chronic care....team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators...

American Academy of Family Physicians (AAFP): …support an interdependent, team-based approach to care. It should address patient needs for high-quality, accessible health care and reflect the skills, training, and abilities of each health care team member to the full extent of his or her license.

American Medical Association (AMA):…most effective way to maximize the complementary skill sets of all health care professionals is to work as a team… a team-based approach can include various combinations of physicians, nurses, physician assistants, pharmacists, social workers, case managers and other health care professionals.

Definition of Interprofessional Care Interprofessional Care vs. Multi-disciplinary Care

Interprofessional

- Collaborative interactions to provide quality care

- Different by complementary skills

- Climate of mutual respect and values

- Communicate with patient, families, and communities that support team approach

Multi-disciplinary- “Silos” of multiple health

professionals

- Different but complementary skills

- Referral systems (Cardiology, Pulmonology, PT, etc.)

- Evidence of communication, sometimes lack of collaboration

Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.

Healthcare Professionals on Team Benefits of pharmacists on team

• Reduction in medication related problems– 708 errors identified (85% acceptance) over 18 months

• Cost avoidance– $2.11 in cost avoided for every $1 spent on pharmacist

• Improved patient satisfaction/adherence– 61.2% adherence→8 month study→96.9%

• Improved clinical outcomes– Blood pressure– Cholesterol– Diabetes– Smoking cessation

Kennedy AG, Chen H, Corriveau M, Maclean CD. Popul Health Manag. 2015;18(1):23-9.Simpson SH, Majumdar SR, Tsuyuki RT, Lewanczuk RZ, Spooner R, Johnson JA. Diabetes Care. 2011;34(1):20-6.Lee JK, Grace KA, Taylor AJ. JAMA. 2006;296(21):2563-71.Choe HM, Mitrovich S, Dubay D, Hayward RA, Krein SL, Vijan S. Am J Manag Care. 2005;11(4):253-60.Pape GA, Hunt JS, Butler KL, et al. Arch Intern Med. 2011;171(16):1480-6.

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Reid Blackwelder, MD, FAAFP

https://www.youtube.com/watch?v=5Qwfcs66Smw

Interprofessional Education Collaborative

• Established in 2009

• Purpose: create core competencies for interprofessional collaborative practice

• 6 national schools of health professions– Dentistry– Nursing– Medicine– Osteopathic medicine– Pharmacy– Public health





• Competency 1: Values/Ethics

• Competency 2: Roles/Responsibilities

• Competency 3: Interprofessional Communication

• Competency 4: Teams and Teamwork

Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.Hammer D, Anderson MB, Brunson WD, et al. J Allied Health. 2012;41(2):e49-53.

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Professionals Accelerating Clinical and Educational Redesign (PACER)

• Purpose: transform primary care to include medical home model with interprofessional practice and education

• Specialties involved– Family Medicine– Internal Medicine– Pediatrics– Nursing– Physician Assistants– Pharmacists– Behavioral Health– Other Health professionals

https://pcpacer.org/Functions and Structure of a Medical school. Liaison Committee on Medical education. March 2016.

Accreditation Standards and key Elements for the Professional Program in Pharmacy Leading. Council for Pharmacy Education. January 2015.Standards and required elements for accreditation of physical therapist education programs. CAPTE, March 2016.

Commission on Osteopathic College Accreditation. Accreditation of Colleges of Osteopathic Medicine: Come Accreditation Standards and Procedures. July 2016.

Pharmacy (07/01/2016)

• ACPE "2016 Standards“– Standard 11-Interprofessional Education (IPE)

Medical Doctors (07/01/2017)

• Liaison Committee of Medical Education (LCME)– Standard 7.9: Interprofessional Collaborative Skills

Osteopathic Medicine (07/01/2016)

• Commission on Osteopathic College Accreditation– Standard 6.4: Curriculum Interprofessional Collaborative Practice

Physical Therapy (07/01/2018)

• Commission on Accreditation in Physical Therapy Education (CAPTE)– Standard 6F: Didactic and Clinical Curriculum includes interprofessional

education

Interprofessional Education

Pitman SK, Farley M, Catney CM, Weetman DB. Integrating pharmacy students into medication reconciliation through a volunteer program. AM J Health System Pharm . 2013. (70) 1-2.https://accred.ashp.org/aps/pages/directory/residencyProgramSearch.aspx

IPE Student Involvement

Pharmacy Residency (Community=6-IL, 3-MO; Ambulatory= 5-IL, 4-MO)

Pharmacy Lectures

Round Tables

Discharge Medication Reconciliation

Chart Review

Patient Education (Group & Individual)

Changing the Norm?

EducationCollaboration

Outcomes

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Building the Puzzle

• Build relationships– Build trust

– Define roles

– Professional interactions• COMMUNICATION!

• Identify Partners– Use who you know

• Commonly seen prescriber

• Immunizations

• Involvement in Community organizations

– Similar goal

– Collaborate with Universities/Colleges

Advancing Team-Based Care Through Collaborative Practice Agreements. CDC. 1-44.Jacobson D. A medlist Clinic: perspectives pf a pharmacists and a studetn pharmacist. University of California School of Pharmacy.

https://pharmacy.ucsf.edu/news/2014/03/medlist-clinic-perspectives-pharmacist-student-pharmacist

Community Pharmacy

• Authorization of refills– Pending pharmacist assessment

• Therapeutic Interchange

• Disease state management– Initiate, modify, discontinue medication

• Labs– Order and interrupt

Advancing Team-Based Care Through Collaborative Practice Agreements. CDC. 1-44.

Osterhaus Pharmacy

• Independent Community Pharmacy in Iowa

• Offers Immunizations, medication substitution and MTM services

• Serves 6,500 patients annually– 60% have diabetes, HTN and/or hyperlipidemia

• Collaborates with Maquoketa Family Clinic and Medical Associates of Maquoketa

Synder ME, Earl Tr, Gilchrist S, et. Al. Collaborative Drug Therapy Management: Case studies of three Community-based Models of Care. Prev Chronic Dis 2015;12:140504. https://www.cdc.gov/pcd/issues/2015/14_0504.htm

Collaborative Practice Agreements and Pharmacists' Patient Care Services. National Center for Chronic Disease Prevention and Health Promotion. 2013. 1-7.

Kerr Drug and El Rio

Kerr Drug• Chain Pharmacy in North Carolina• Therapeutic recommendations• Residency program

El Rio Community Health Center• Provider of medical and dental services in Arizona• Services offered

– Patient assessment– Medication regimen review (formal and informal)– Medication adjustment– Perform examinations

• Health center offered lower costs, more screenings, and fewer ER visits

Synder ME, Earl Tr, Gilchrist S, et. Al. Collaborative Drug Therapy Management: Case studies of three Community-based Models of Care. Prev Chronic Dis 2015;12:140504. https://www.cdc.gov/pcd/issues/2015/14_0504.htm

Collaborative Practice Agreements and Pharmacists' Patient Care Services. National Center for Chronic Disease Prevention and Health Promotion. 2013. 1-7.

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Synder ME, Earl Tr, Gilchrist S, et. Al. Collaborative Drug Therapy Management: Case studies of three Community-based Models of Care. Prev Chronic Dis 2015;12:140504. https://www.cdc.gov/pcd/issues/2015/14_0504.html

American Society of Health system pharmacists. ASHP guidelines:minimum standard for ambulatory care pharmacy practice. AM J Health-Syst Pharm. 2015; 72:1221-316.Epplen KK, Dusing-Wiest M, Freedlund J, et al. Stepwise approach to implementing ambulatory clinical pharmacy services. Am J Health-Syst Pharm 2007;64:945-951.

• Establishing a practice– Identify laws and regulations

– Identify need (DM education, anticoagulation, etc.)

– Create business plan• Mission and Vision

• Workflow

• Resources

– Identify stakeholders (patients, physicians, health systems)

– Identify scope of practice/protocol development

– Establish documentation practices

Operational Components

Synder ME, Earl Tr, Gilchrist S, et. Al. Collaborative Drug Therapy Management: Case studies of three Community-based Models of Care. Prev Chronic Dis 2015;12:140504. https://www.cdc.gov/pcd/issues/2015/14_0504.html

American Society of Health system pharmacists. ASHP guidelines:minimum standard for ambulatory care pharmacy practice. AM J Health-Syst Pharm. 2015; 72:1221-316.Epplen KK, Dusing-Wiest M, Freedlund J, et al. Stepwise approach to implementing ambulatory clinical pharmacy services. Am J Health-Syst Pharm 2007;64:945-951.

• Factors to Consider– Collaborative practice

– Physician champion

– Challenges• Lack of compensation

• Hesitation to trust pharmacist

• Lack of time and resources

• Existing informal relationship

Operational Components

Collaborative Practice



State SiteRestrictions

Pharmacist Qualification

Multiple or single

pharmacist(s)?

Which prescribers

(MD, NP, PA)?

Multiple or single

prescriber (s)?

Multiple or single

patient(s)

?

Prescriber-Patient

Relationship

defined?

IL Silent Silent Multiple Physician Single Multiple Silent

MO Yes-A,B Yes-I Multiple Physician Multiple Single Yes-QQ

A-Allowed in most or all setting but with different rules for someB-Physician must be nearby the collaborating pharmacist-see law/regulations for more detailsI-Complicated Requirements-see state law/regulations for detailsQQ-Patient specific information must be included in the protocol/agreement-see law/regulations for details


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State Modify Existing

Therapy

Initiate New Therapy

Perform a Physical

Assessment

Order Laboratory

Tests

InterpretLaboratory

Tests

Perform Laboratory

Test

IL Yes-A Yes-A Yes-H Yes-I Yes-I Silent

MO Yes-E, W, CC Yes-E, W, CC Yes Yes Yes Yes

A-Drugs limited to those in protocol H-Ordering or performing routine drug therapy-related patient assessment proceduresI-As specified in the agreement/protocolE-State specific rules regarding initiation and modification of a prescription-refer to state law/regulations for detailsW-Disease States limited to those specified in protocol or agreement CC-Does not include any controlled substances



State Additional continuing

education

requirements?

Requirement for liability

insurance?

Documentation and/or

notification

requirements?

Patient involvement in

agreement-

signature or opt out?

Must agreements be sent to or

approve by state

agency?

Length of time

agreement

is valid defined?

IL Silent Silent Silent Silent Silent Silent

MO Yes-F Silent Yes-H Silent Yes-W Yes-YY

F-Biennial recertification required (6 hours of continuing education in medication therapy management)H-Complicated requirements-see law/regulations for detailsW-Copy of agreement must be submitted to the relevant board(s)YY-Agreement can only be valid for up to 1 year


Consider this…again.

Pertinent Labs:

BP: 132/74 mmHg Spirometry: None on file Pulse: 72 bpm CAT Test: 17/40 Weight: 191 lbs HbA1C: 6.9%Height: 66 inches Microalbumin/Cr: 1530 mcg/mgBMI: 30.8 kg/m2 SrCr: 0.65 mg/dlINR 3.7

RZ is a 68 year old man with a history of COPD, DM, HTN, alcoholism, and previous DVT. He is here today for education on his COPD and inhalers. He presents today with fluticasone/salmeterol, budesonide/formoterol, umeclidinium , and fluticasone/vilanterol. Some inhalers from recent hospitalization and some inhalers are expired. He states he is confused as to which inhaler to use. He states his mucus feels sticky sometimes. RZ states that the fluctuating weather changes his level of activity. He states that as the day goes on his breathing gets worse. He states that he is supposed to wear his O2 but is not currently wearing. He states that his clonazepam helps with sleep. He also states that his diabetic drink gives him some energy. He reports compliance with his medications. He denies problems paying for his inhalers. He continues to drink up to six drinks a day and smokes up to 5 cigarettes a day.

Consider this…again

Medication List: • fluticasone/salmeterol (samples)• budesonide/formoterol (samples)• fluticasone/vilanterol (samples)• umeclidinium Ellipta 62.5mcg/inh

once daily• ipratropium-albuterol 0.5-

2.5mg/3ml every 4 hours• albuterol HFA 108 mcg/act 2 puffs

every 4 hours as needed • accu Chek Supplies• glipizide ER 5mg once daily• acetaminophen 325mg 2 tablets

every 6 hours • folic acid 1mg once daily• MVI once daily

• lisinopril 5mg once daily

• metoprolol tartrate 50mg twice daily

• warfarin 2.5mg as directed

• pantoprazole 40mg once daily

• aspirin 81 mg once daily

• atorvastatin 40 mg once daily

• quetiapine 50 mg at bedtime

• vitamin D3 1000 units once daily

• clonazepam 0.5mg once daily

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Consider this…again

• In what ways can this patient benefit from interdisciplinary teams?

Post-Test Questions

In regards to interdisciplinary teams, who is the driver of the patient’s overall healthcare goals?

A. Physician

B. Pharmacist

C. Caregiver

D. Patient

Post-Test Questions

Which health care professions require interprofessional education as part of their curriculum?

A. Medicine

B. Pharmacy

C. Physical Therapy

D. All of the above

Post-Test Questions

Interdisciplinary care can be provided in any pharmacy practice setting.

A. True

B. False

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Take Home Points

• Healthcare is expensive, continually changing and health care professional need to find ways to optimize care for patients

• Interdisciplinary education is occurring across all curricula

• Pharmacists in EVERY practice setting play important roles on interdisciplinary teams

Resources

• NCQA (National Committee for Quality Assurance)– http://www.ncqa.org/programs/recognition/practices/pati

ent-centered-medical-home-pcmh

• CDC– https://www.cdc.gov/dhdsp/pubs/docs/CPA-Team-

Based-Care.pdf

• ASHP– American Society of Health system pharmacists. ASHP

guidelines: minimum standard for ambulatory care pharmacy practice. AM J Health-Syst Pharm. 2015; 72:1221-316.

• IPEC – Interprofessional Education Collaborative

References

• http://www.emrandehr.com/2017/03/17/the-sad-state-of-healthcare-fun-friday/• https://www.census.gov/popest/about/terms.html• Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic

Dis.2014;11:130389.• https://pcmh.ahrq.gov/page/defining-pcmh• http://www.aafp.org/dam/AAFP/documents/about_us/initiatives/AAFP-PCMHWhitePaper.pdf?cmpid=npp12_ad_com_na_van_1• https://www.ama-assn.org/delivering-care/physician-led-team-based-care• https://www.pcpcc.org/sites/default/files/page-files/PCMH-PCPCC-Infographic.pdf• https://pcpacer.org/• Functions and Structure of a Medical school, Standards for accreditation of medical education of medical education programs

leading the the MD degree. Liaison Committee on Medical education. March 2016.• Accreditation Standards and key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree.

Accrediation Council for Pharmacy Education. January 2015.• Standards and required elements for accreditation of physical therapist education programs. CAPTE, March 2016.• Commission on Osteopathic College Accreditation. Accreditation of Colleges of Osteopathic Medicine: Come Accreditation

Standards and Procedures. July 2016.• Pitman Sk, farley M, Catney CM, Weetman DB. Integrating pharmacy students into medication reconciliation through a volunteer

program. AM J Health System Pharm . 2013. (70) 1-2.• https://accred.ashp.org/aps/pages/directory/residencyProgramSearch.aspx• Advancing Team-Based Care Through Collaborative Practice Agreements. CDC. 1-44.• Jacobson D. A medlist Clinic: perspectives pf a pharmacists and a studetn pharmacist. University of California School of Pharmacy.

https://pharmacy.ucsf.edu/news/2014/03/medlist-clinic-perspectives-pharmacist-student-pharmacist• Synder ME, Earl Tr, Gilchrist S, et. Al. Collaborative Drug Therapy Management: Case studies of three Community-based Models of

Care. Prev Chronic Dis 2015;12:140504. https://www.cdc.gov/pcd/issues/2015/14_0504.htm• Collaborative Practice Agreements and Pharmacists' Patient Care Services. National Center for Chronic Disease Prevention and

Health Promotion. 2013. 1-7. • American Society of Health system pharmacists. ASHP guidelines: minimum standard for ambulatory care pharmacy practice. AM J

Health-Syst Pharm. 2015; 72:1221-316.• Epplen KK, Dusing-Wiest M, Freedlund J, et al. Stepwise approach to implementing ambulatory clinical pharmacy services. Am J

Health-Syst Pharm 2007;64:945-951.

Speaker Contact Information

Brandon Herk, PharmD, BCACP

Advocate Medical Group

[email protected]

Rebecca Young, PharmD, BCACP

Roosevelt University College of Pharmacy

[email protected]

where do you fit? piecing together the puzzle of ... idt learner... · piecing together the puzzle...

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