Pamela L. Stamm, PharmD, BCACP, BCPS, CDE, FASHP Associate Professor of Pharmacy Practice August 4, 2016
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1 Pamela L. Stamm, PharmD, BCACP, BCPS, CDE, FASHP Associate Professor of Pharmacy Practice August 4, 2016
2 Google 2016
3 Imagine What should Ambulatory Care Pharmacy Practice look like? Think of 3 tasks or services an Ambulatory Care Pharmacist might perform. Briefly share your description with your neighbor Raise your hand if the tasks were EXACTLY the same
4
5 Objectives Define Ambulatory Care Pharmacy Practice Describe the evolution of ambulatory care pharmacy practice in the US Understand key forces supporting the changing practice roles
6 Ambulatory Care Pharmacy Practice The provision of integrated, accessible healthcare services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community. Ambulatory Care Summit Proceedings. AJHP. 2014: 71; Board of Pharmacy Specialties. Specialties ambulatory care.
7 Ambulatory Care This is accomplished through direct patient care and medication management for ambulatory patients, long-term relationships, coordination of care, patient advocacy, wellness and health promotion, triage and referral, and patient education and self-management. Ambulatory Care Summit Proceedings. AJHP. 2014: 71; Board of Pharmacy Specialties. Specialties ambulatory care.
8 Ambulatory Care The ambulatory care pharmacists may work in both an institutional and community-based clinic involved in direct care of a diverse population. AJHP. 2014: 71;
9 Primary Care Care to OUTPATIENTS Where patient ENTERS the health care system and receives CONTINUOUS care over time The focal point of care Nonphysician Primary Care Providers provide a SPECIALIZED portion of primary care and work in COLLABORATION with the primary care team American Academy of Family Physicians Feelgraffix.com Jake Vargo (photographer)
10 The Low of Pharmacy Practice 1938: Federal Food Drug and Cosmetic Act stopped pharmacist prescribing 1951: Durham Humphrey Act made it illegal for a pharmacist to refill a medication without the authorization of a physician Am Pharmaceutical Association Code of Ethics prevented discussion of therapeutic effects or composition Pamela Stamm (photographer)
11 1960 and 70s Indian Health Service jpg Accessed July 25, 3016
12 Health Manpower Project sets stage for future collaborative practice in California (Amcare in 1994) Indian Health Service receives grant to develop Pharmacist Practitioner Program Health, Education, and Welfare Department enact a drug regimen review regulation for nursing homes Carmichael J. Am J Health-Syst Pharm. 2015: 72: Kock K
13 Oregon became third state to recognize collaborative practice. AmCare included. Very broad. 7 States recognized pharmacists collaborative care abilities Veterans Health Administration allows pharmacists with advanced training to participate in CDTM, with a scope of practice Carmichael J. AJHP. 2015: 72:
14 Collaborative Drug Therapy Management (CDTM) A collaborative practice agreement between one or more providers and pharmacists wherein qualified pharmacists working within the context of a defined protocol are responsible for patient assessments, counseling, and referrals; ordering laboratory tests; administering drugs; and selecting, initiating, monitoring, continuing, and adjusting drug regimens. Hammond R, et al. Pharmacotherapy. 2003;23:
15 Comprehensive Medication Management (CMM) Standard of care that ensures each patient s medications are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended...
16 Comprehensive Medication Management includes an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes..
17 Comprehensive Medication Management Patient understands, agrees with, and actively participates in the treatment regimen, thus optimizing each patient s medication experience and clinical outcomes.
18 CDTM 2012
19 Collaborative Drug Therapy (CDTM) RED: No CDTM YELLOW: Authorized but not for chronic diseases or limited by practice setting 100% 80% 60% GREEN: Authorized to collaborate or provide services by protocol for all health conditions 40% 20% 0% (n=51) 2016 (n=51)
20 OBRA1990
21 1990s Rhoda Baer (Photographer)
22 Components of Immunization Protocol Written loosely to follow the current standard of care (CDC and ACIP recommendations and manufacturer s prescribing information) Defines credentialing standards Provides a standing order defining Who is a candidate for vaccination Conditions when vaccination may / may not be administered Vaccinations permitted Vaccination technique Emergency procedures Describes standards of storage and preparation if needed Includes documentation standards
23 Pre-Vaccination Paperwork Patient name and identifier Date of birth Contact information Insurance info (for billing) Brief PMH as it relates to vaccinations Vaccine history (including previous reactions to vaccines) Includes a copy of the current VIS Patient signature and date provides consent to vaccinate Area to document vaccine name, lot number, expiration date, administration site
24 Marketing Service
25 % Flu Vaccinations Provided by Community Pharmacies (2012 National Flu Survey, 2012 National Immunization Survey) 19.7 % Adults (6 mths 17yrs)
26 States Allowing Influenza Vaccination & Pharmacists Trained to Administer Vaccines
27 Authority to Administer Any Vaccine Any vaccine (5 plus Puerto Rico and DC) Certain vaccinati ons only (4) CA OR WA NV ID AZ UT MT WY CO NM ND SD NE KS TX OK MN IA MO AR WI IL MS MI IN KY TN AL NY PA OH WV VA NC SC GA VT ME NH MA RI CT NJ DE MD DC AK LA FL HI PR Based upon APhA/NASPA Survey of State IZ Laws/ Rules Updated July 1,2015
28 Improve Persistence and Compliance with Therapy (IMPACT) Lipids Outcomes at 24 months ,5 90,1 93,6 0 At LDL Goal Adherence Persistence APHAFoundation.org 1998
29 Avg A1C = 8 to 6.8% Asheville Project 50% decrease in sick days (recovered 6 working days per year) Average savings of $ (5mil-10.4 mil pesos) per person per year Saved ~$4 (12,000 pesos) for every $1 (3095 pesos) spent Cranor CW, et al. J Am Pharm Assoc. 2003; 43:
30 Expansion of AmCare in US 2003 Medicare Modernization Act mandated MTM services be offered by drug plans for patients at high risk of ADEs
31 MTM Core Service Elements 1. Medication Therapy Reviews 2. Patient Medication Record 3. Medication Action Plan 4. Intervention and/or Referral 5. Documentation and Follow-up MTM in Pharmacy Practice tm_practice.pdf
32 Medication Action Plan (MAP) Action Steps -> What I need to do Aspirin: Discuss stopping this with my heart doctor at appointment next week (July 10 th ) since I am also warfarin for my a-fib Lisinopril: Tell heart doctor my Lisinopril dose was increased to 40mg and give him copy of progress note from visit also. (July 10 th ) Notes -> What I did and when I stopped aspirin July 11, 2016 per heart doctor. Done Bring copy of progress note from heart doctor to next visit. practice.pdf
33 Expansion of AmCare in US 2003 Medicare Modernization Act mandated MTM services be offered by drug plans for patients at high risk of ADEs Requires Annual Comprehensive Medication Review 677 MTM programs in the US (2015 data) 100% of programs utilize pharmacists at some level as required by law Coverage/PrescriptionDrugCovContra/Downloads/CY2015-MTM-Fact-Sheet.pdf
34 Comparing Models MTM Drug Therapy Focused Review may be targeted or comprehensive Often coincides with dispensing or by insurer program CDTM Outcomes focused Patient Centered Patient agrees with plan Patient is active & willing participant Collaborative
35 Drivers of AmCare Expansion Institute of Medicine Report 1.5 million preventable medication related Adverse Events occur annually in the United States Estimated cost of $4 billion annually Estimated Primary Care Physician shortage 2010 = = -20,400 to -44,000 Institute of Medicine of the National Academies, Preventing Medication Errors, National Academies Press, ojectingprimarycare.pdf
36 Drivers of AmCare Expansion
37 Principles of AmCare Practice Ambulatory Care Practice is continuing to evolve Models of Care depend on practice site, state, and collaborators Community models MTM, Immunizations, Screenings, Monitoring, and Education, Referrals Clinic models Collaborative, Extenders of Care
38 Pamela L. Stamm, PharmD, BCACP, BCPS, CDE, FASHP Associate Professor of Pharmacy Practice August 4, 2016
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