Implementation Practices: Motivating and Training Your Staff. Enhanced Services Boot Camp

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2 Implementation Practices: Motivating and Training Your Staff Enhanced Services Boot Camp

3 Objectives Develop mechanisms for getting buy in on your pharmacy culture. Apply best practices for engaging and training the pharmacy team to streamline operations. Develop mechanisms for giving feedback and managing resistance to change.

4 Panel Discussion Panelists: Tripp Logan, Pharm.D., L and S Pharmacy Joe Moose, Pharm.D., CPESN USA and Moose Pharmacy Denise Pratt, Pharm.D., First Pharmacy Services Moderator: Bri Morris, Pharm.D., NCPA Innovation Center

5 Workflow Best Practices Enhanced Services Boot Camp Ashley Branham, Pharm.D. & Joe Moose, Pharm.D. CPESN USA and Moose Pharmacy

6 Objectives Discuss how a med sync program can positively affect pharmacy operations. Outline staffing/workflow considerations needed for enhanced service delivery.

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8 Everyone Must Work at the Top of Their License We need to re-engineer our practices to align with new payment models Technology should support us all moving to work at the top of our abilities

9 Different Approach to Payment and Delivery Fee for Service Population Health Management

10 Case Study When considering a patient population of 50,000

11 Technology to Help Me Fill Scripts Fast, Accurately, & Cheap Finding from NC State School of Industrial Engineering: If you are not efficient at the filling prescription process you will never get the enhanced services and clinical support process optimized. We don t address problems/opportunities at the time we find them. We wait until the end of the filling process.

12 What is the ABM? Appointment-Based Model (ABM): Coordinating all of a patient s prescription medications to be picked up on the same date each month, coupled with communications from the pharmacy.

13 Best Thing Since Sliced Bread Patient Improved: Communication Patient adherence Quality of care Health outcomes Workflow/efficiencies Inventory management Coordinated refill program Completes triad of care Business differentiator Win-win-win model Improved patient outcomes Prescriber satisfaction Increased business efficiencies and margins Pharmacist Business margins Physician

14 ABM Impact on Workflow Reactive proactive Optimizes dispensing process the way we do business here Scripts patients Are we optimizing therapy? How s the patient s adherence? Facilitates the patient appointment Opportunity for revenue each month Additional time for meaningful patient interaction

15 Hello, Goodbye What you can expect: Streamlined workflow Predictable workload Decreased delivery runs Better inventory control Healthier bottom line More time for enhanced services What you won t miss: Manic Mondays Frequent flyers Waiting for patients to remember to call in a refill Last-minute call-ins on Friday afternoons or before holidays Taking care of patients who run out of pills

16 Synchronization: How It Works Action 1. Determine and list the chronic monthly prescriptions the patient will be taking. Example Lisinopril 20mg daily (due 4 th ) Synthroid 137mcg daily (due 16 th ) Metformin 500mg BID (due 22 nd ) 2. The medication with the highest copay should become the anchor prescription. Synthroid 137mcg (due 16 th ) 3. Calculate the quantity needed for each medication to synchronize it with the anchor prescription. Lisinopril 20mg (12 tablets) Metformin 500mg (50 tablets)

17 Synchronization: How It Works 4. Contact the patient s prescriber, explain your ABM program, and request two prescriptions for each synchronized medication: One for the quantity required for synchronization A second for the normal monthly quantity 5. Short/long fill the appropriate prescription(s) to synchronize with the anchor prescription. Document on the hard copy the one-time short fill was for the adherence program.

18 7-10 Days Prior to the Appointment Call patient to review medications Assess adherence Have you been to the doctor in the last month? Have you been in the hospital in the last month? Are you taking any new prescription or over-the-counter medications? Are there any other changes we need to be aware of at this time?

19 3-7 Days Prior to the Appointment Initiate refill requests, PAs; contact prescribers as needed Update the patient profile in the pharmacy management system Pharmacist reviews orders and resolves any drug therapy problems identified by the program manager

20 1-2 Days Prior to the Appointment Review inventory/order products Dispense product(s) Call and remind patient to pick up prescriptions

21 Appointment Date Patient picks up medications Pharmacist addresses any clinical issues Are we optimizing patient therapy? How s the patient s adherence? What services can we add on?

22 ABM is more than syncing medications. Leveraging the patient appointment for enhanced service delivery is key.

23 Tips from the Experts Designate a technician to run the daily operations Best use of staff time Something for them to own Vested interest in success Leverage your technology Identify non-adherent patients Group patients by sync date Reports to help with patient calls Robust sync programs

24 Med Sync Pearls Submission clarification codes for Medicare D Patients allow for prorated copays for <30 supply 47 use on first attempt (short fill) 48 use on subsequent usual fill (if you get a RTS reject for being <30 days) Figure out your anchor Highest copay med Delivery area Disease state drive to enhanced services Pay schedule

25 Free Tools/Resources Simplify My Meds Operations manual, patient forms Marketing kit Free to NCPA members ( Implementing Med Sync video series <25 minutes Step by step training Great for pharmacy staff

26 Failing Forward: Our Guide to Prepare Community Pharmacy for Delivering Value Rethink Workflow Operations Population Management Strategies Shifting the Patient s Expectation of the Pharmacy Experience

27 Rethink Workflow Operations Involvement of Pharmacy Staff This CPESN model will remain a disruption until all staff are educated to participate. Pharmacists need to engage and train pharmacy technicians, delivery drivers, and cashiers for roles supporting CPESN. You go into this project thinking you can be a super pharmacist, but you quickly realize that it needs to be a team effort.

28 Community Pharmacy Care Management Community Pharmacy Care Management Services provided locally by a community pharmacy in close coordination with other care team members, including other care managers that focus on optimal drug use. The objective of Community Pharmacy Care Management is to procure, update and re-enforce a team-based, patientcentered pharmacy care plan over time. This service line is longitudinal and coordinated with the rest of the care team. Confidential Do not reproduce or reuse without consent.

29 Intensity Intensity Intensity Transformational Change in Frequency & Nature of Clinical Patient Interactions Part D CMR Steady State Community Pharmacy Care Management Model Time (6+ months) Initial NC CPESN attempts at Community Pharmacy Care Management Time (6+ months) Time (6+ months) Confidential Do not reproduce or reuse without consent.

30 Meet Karrie We take a proactive approach for our patients. We start the process by calling them each month and finding out what medications they need, what has changed and what concerns they may have Adherence Technician They feel like they know me and they feel like they have a connection with our pharmacy. They know when they call Moose Pharmacy, they are more than a refill number.

31 Glimpse into Operations Input & Counting Typical Day 8:30AM-6:00PM Run queue for the day. Drug therapy problems (DTPs) identified in adherence and medication list discrepancy. 11:00AM-6:00PM- DTP follow up queue in dispensing system. Call patients, prescriber offices, insurance companies and comment on progress in dispensing system.

32 Getting in the Habit of Documentation Technician Tool: DTP Short Form 1. Form placed at technician work station 2. Technician to complete form if potential DTP s are identified 3. Technician to send form in basket to the pharmacist 4. Pharmacist investigate the issue and takes necessary steps to resolve DTP 5. DTP documented in platform

33 Glimpse into Operations Adherence Technician Typical Day 8:30-9:30AM: Identify patients for daily phone calls on call list. 9:30-1:30PM: Call patients- DTPs identified while reviewing adherence and medication list discrepancies. DTPs input added to dispensing system DTP queue via MTM Actions. Advise pharmacists on complex medication list and therapeutic considerations 1:30PM-5:00PM: Process patient medications-primary DTPs during this part of the day will be system failure (insurance reject, PA required) DTPs added to dispensing system DTP queue via MTM Actions. Help with DTP queue as allowed

34 Scripts Pfor Technician Touch Points

35 Vaccine Screening Form Instructions: By checking a box below, I am indicating that I have screened this patient and he/she is eligible to receive the marked vaccine. Section 1: Zoster (Shingles) Zostavax The patient is 60 years old AND has not received Zostavax at any point in the past. Section 2: Influenza (Flu) Fluzone (Trivalent), Fluvirin (Trivalent), Flulaval (Quadrivalent), Fluzone HD (High Dose) The patient has not had the influenza vaccine AND is 14 YO Section 3: Pneumococcal Conjugate Prevnar13 (PCV13) The patient has never received Prevnar13 (PCV13) AND any one of the following: 65 years old years old AND has one of the following conditions: congenital/acquired immunodeficiency (including B-,T-lymphocyte, or complement deficiencies, phagocytic disorders). leukemia, lymphoma, Hodgkin s disease, generalized cancer, multiple myeloma. HIV infection. chronic renal failure, nephrotic syndrome, or solid organ transplant. iatrogenic immunosuppression (including long-term corticosteroids and radiation therapy). anatomical or functional asplenia. cerebrospinal fluid leak. cochlear implant. Section 4: Pneumococcal Polysaccharide Pneumovax23 (PPSV23) The patient is: 65 years old AND one of the following: has never received Pneumovax23 (PPSV23) AND has received Prevnar13 (PCV13) 1 year ago. received Pneumovax23 (PPSV23) when they were < 65 YO AND it has been 5 years since the previous PPSV23 dose years old AND has a high risk medical condition: chronic heart condition (chronic heart failure or cardiomyopathies, excluding hypertension). diabetes. chronic lung disease (COPD, emphysema, asthma). alcoholism. chronic liver disease (cirrhosis). immunocompromising conditions (HIV, long-term steroids, chronic renal failure). smokes cigarettes. anatomical or functional asplenia. Section 5: Tetanus Boostrix (Tdap) or Tenivac (Td) The patient is 18 years old AND any one of the following: pregnant. has not received the Tdap vaccine. received Tdap 10 years ago. it is unknown if they have received Tdap. Section 6: Hepatitis B (Engerix-B) The patient is 18 years old AND any one of the following: has not received the hepatitis B series or did not receive the full hepatitis B series. is at high risk for acquiring the infection (i.e. diabetes, healthcare professional, household contacts with HBV, end -stage renal disease, kidney dialysis, HIV, chronic liver disease, seeking/receiving STD treatment). Section 7: Meningococcal Menactra The patient is years old AND any one of the following: has no previous meningococcal vaccination. has not received a dose of meningococcal vaccine after their 16 th birthday and requires catch up vaccination. is a first year college student who lives in a dorm or plans to live in a dorm. 18 YO AND plans to travel to an area of the world where meningococcal disease is common. Vaccine Screening Form Created by Laura A. Rhodes, PharmD, Moose Pharmacy of Concord Rhodes, L. A., Branham, A. R., Dalton, E. E., Moose, J. S., & Marciniak, M. W. (2017). Implementation of a vaccine screening program at an independent community pharmacy. Journal of the American Pharmacists Association, 57(2), Revised: 02/10/2016

36 Glimpse into Operations Dispensing Pharmacist 8:30AM-9:30AM Work on DTP follow up queue 9:30AM-6:00PM- Identify DTPs while dispensing. Risk score of 75 warrants checking to see if a CMR has been completed within a year. If no CMR, notify cashier or delivery drive and attempt to complete if time permits or schedule. Notify cashier if RPh needs to speak w/ patient to address DTP when in the store Delivery driver to call RPh when he arrives at patient home to address DTP Scheduled CMR should be added to dispensing system queue. If dispensing pharmacist is unable to complete CMR with patient, then clinical pharmacist will assist

37 Glimpse into Operations Cashier 8:30-9:30AM: Tag bags for potential face to face CMRs from report given by pharmacist or technician. 8:30AM-6:00PM: Schedule CMR for pharmacist at point of sale if no time to do CMR. Pull return to stock medications if remaining in will call bin for 10 days or more (call patient to determine if still need medication or reason for denial). Notify staff if patient chooses not to get a medication or if returned by delivery driver.

38 Glimpse into Operations Delivery Drivers Call pharmacist or technician after arrival at patient home per pharmacist/technician request. Share any compelling social/health status changes with pharmacist. Notify technicians of new phone numbers of any points of contact for patient (extended family, neighbor) for difficult to reach patients. Notify cashier of address change so it can be changed in dispensing system.

39 Different Expectations of Our Pharmacy Team If we are going to be different in the marketplace We need to deliver services differently

40 Identifying Drug Therapy Problems- It s a Team Approach Prescription ON HOLD for Simvastatin 40mg and Aspirin 325mg Prescriber office (different from the PCP) was contacted. Told that the patient was recently discharged from the rehabilitation center. Patient s PCP was also notified to discuss discrepancies in medication regimen. PCP unaware of patient s most recent discharge from rehabilitation center. Patient was notified and fill was initiated Medication was delivered to the patient s home

41 Identifying Drug Therapy Problems- It s a Team Approach Prescription ON HOLD for Simvastatin 40mg and Aspirin 325mg Student Pharmacist Discovery through Data Mining Project

42 Identifying Drug Therapy Problems- It s a Team Approach Prescription ON HOLD for Simvastatin 40mg and Aspirin 325mg Prescriber office (different from the PCP) was contacted. Told that the patient was recently discharged from the nursing home Consulted with Pharmacist and Adherence Technician Notified Prescriber

43 Identifying Drug Therapy Problems- It s a Team Approach Prescription ON HOLD for Simvastatin 40mg and Aspirin 325mg Prescriber office (different from the PCP) was contacted. Told that the patient was recently discharged from the nursing home Patient s PCP was also notified to discuss discrepancies in medication regimen. PCP unaware of patient s most recent discharge from nursing home. Consulted with Pharmacist again and Adherence Technician Notified PCP

44 Identifying Drug Therapy Problems- It s a Team Approach Patient was notified and fill was initiated Medication was delivered to the patient s home Pharmacist discussed with patient and alerted Technician to fill the medications Delivery Driver

45 Targeting Patients and Populations

46 Importance of Targeting and Channeling Patients to High Performing Pharmacies

47 Panel Management & Risk Stratification Managing a panel of patients is new to community pharmacy Adequate training is needed to acclimate to this model Patients at different levels of risk need different types of intensities of services from enhanced service pharmacies Assists with targeting intensive activities toward highest risk, most complex patients

48 Well Informed Protocols. Risk Scores Algorithms Protocols Risk of Admission (30 Days) 6 or More Medications If X, then Schedule Appt. Risk of Admission (12 Months) High Risk Medications If X, then Med Sync Risk of Low Adherence Preferred Payer If X, then phone f/u Risk of Therapeutic Consideration Preferred Clinician/Provider If X, ask if they would like Risk of Discrepancy Discharged & >3 Chronic Meds If CMR Due, Task. Composite Medication Chaos Risk Low PDC for >2 Classes If High Risk for Hosp., Offer Potential Savings From CPCM 6 Or More Opioids in 90 days If Overdose Risk Offer Naloxone

49 Using Risk Scores in Your Community Pharmacy Obtain report with spreadsheet of risk scores organized from highest to lowest Proactively engage patients at high risk (alert staff, conduct medication reviews, reach out by phone for check-in) For those not reached, flag in the system to alert staff at next point of contact

50 No Population Management Tool? Do you have patients that fit any of the following criteria? Trends of poor adherence to chronic medications Recurrent visits to ED or hospital Transportation challenges Literacy challenges Complex medication regimens Looking to reduce number of visits to the pharmacy

51 Changing Patient Expectations The patient experience in this model may be different than how the patient previously worked with his or her pharmacy. - Intensive monitoring - Initial attempts to engage patients in this way should be acknowledged to help set new expectations

52 Strategies for Patient Engagement Leverage information about their recent health care utilization or concern with their medications Leveraging a referral from their care manager or provider Using a connection point such as an immunization or assistance with Medicare Part D plan selection to build trust

53 Referral from Provider to Provider

54 Ashley Branham, PharmD CPESN USA Joe Moose, PharmD CPESN USA

55 Financial Planning: Building the Business Case for Expanded Services Enhanced Services Boot Camp Tripp Logan, Pharm.D. L and S Pharmacy

56 My Background: COMMUNITY PHARMACIST / PHARMACY OWNER 2 nd generation multi-pharmacy owner in Southeast Missouri Strong focus on appropriate medication use Quality focused pharmacy practices Residency program, care coordination, disease state management, diabetes support group, medication use monitoring, MTM, compliance packaging, TOC, etc. PHARMACY QUALITY CONSULTANT / PARTNER MedHere Today is a healthcare quality and performance consulting firm created to help healthcare stakeholders expand and grow their quality and value based initiatives by leveraging community pharmacy. SERVICE ORGANIZATIONS Pharmacy Quality Alliance (PQA) Board Liaison NCPA Innovation Center Board Member CPESN USA National Luminary CPESN Missouri Lead Luminary Local Department of Health Board of Directors

57 Disclosures Tripp Logan, PharmD NCPA Innovation Center Board Member CPESN USA National Luminary Partner, MedHere Today Consulting Vice President, Logan & Seiler Inc. (L&S Pharmacy / Medical Arts Pharmacy)

58 Disclosures Tripp Logan, PharmD does not have (nor does any immediate family member have) actual or potential conflict of interest, within the last twelve months, a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias this presentation.

59 Personal Disclaimer The content of this presentation reflects my personal experiences in our pharmacies, our consulting firm, and my service within pharmacy advocacy groups. Each pharmacist & pharmacy is unique, with a unique payer mix, unique set of offered services, unique opportunities, and most of all unique patient populations. The purpose of this presentation is to walk you through our ROI exploration process in our businesses. The purpose of this presentation IS NOT for it to be used as specific guidance on how you should operate your pharmacy practice, how you work within your current or future pharmacy contracts, or how you care for your unique set of patients. --Tripp Logan, PharmD

60 Most Taboo Words in Health Care: Provider Profitability

61 Pharmacy Staff Orientation Speech: As a community pharmacy, our primary responsibility is to the patients that walk through our doors. If we make poor business decisions, we close our doors, and FAIL EVERY PATIENT WE SERVE.

62 The Community Pharmacy Conundrum: Pharmacies must: 1. Think PATIENT FIRST PAYER SECOND, 2. While we ensure that our patients have access to the medication they need, 3. And maintain pharmacy profitability at the same time.

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64 Pharmacy Service Litmus Test How Do You Identify a Return On Investment?

65 Good Investments are Typically: Good for Prescribers Good for Employers Good for Third Parties Good for Pharmacy Staff Good for Pharmacy Good for Patients

66 Standard Question: How Can I Afford This? Pharmacist time is limited Pharmacist time is expensive Enhanced pharmacy service reimbursement is not always available My dispensing reimbursement is shrinking and my DIR fees are rising

67 Begin With a Business Plan How much time will this service take to implement? Can I start small and scale? What is my target market? What will this cost in labor? What will this cost to implement? Will this service also provide advertising? What is the short term & long term program budget?

68 Begin With a Business Plan There is a How much time will this service take to implement? Can I start small and scale? What is my target market? What will this cost in labor? What will this cost to implement? Will this service also provide advertising? What is the short term & long term program budget? difference between REIMBURSABLE and PROFITABLE

69 Consider Services That Are Profitable and/or Marketable Profitable Marketable Adherence monitoring program with packaging Transition of care with hospital Care coordination with mental health provider Immunizations Medication Therapy Management Clinical services (blood pressure, blood glucose testing, Etc.)

70 Ask yourself: Is This? Good for my patients? Revenue producing & profitable? Good for my pharmacy s image? Something my staff will buy in to? Is this sustainable? If the answer is NO, that s OK. Don t force it.

71 What s Out There? To seize opportunities, you MUST look beyond the counter at things like: Your current business model and processes Your unique patient mix Your exposure to national markets Your exposure to LOCAL markets

72 Key Universal Targets: Patients Rx Volume / New Patients / Foot Traffic Pharmacy Operations Workflow / Efficiency / Labor / Wages Providers Health Systems / Clinics / Prescribers Payers Health Plans / PBMs / Employers

73 Adherence Monitoring: ROI Increase in ADDITIONAL program-driven Rx volume Number of patients enrolled in program Additional Rxs per patient annually * 2900 *Armstrong T., Impact of the MedHere Today Program on Persistence and Adherence, A Descriptive Report; Pfizer, May 2011.

74 Adherence Monitoring: ROI Cash flow savings for pro-active medication management of 20 patients $ $10000 Pharmacy cost of Each Prescription Number of patients filling one $500 Rx/mo

75 Adherence Monitoring: ROI Cash flow savings for pro-active medication management of 20 patients $10,000/mo = $120,000/year $ That s a Pharmacist Salary!!!! $10000 Pharmacy cost of Each Prescription Number of patients filling one $500 Rx/mo

76 All Rxs ARE NOT Created Equal

77 All Rxs ARE NOT Created Equal

78 All Rxs ARE NOT Created Equal

79 Targeting Exercise 1. Who is my most profitable third party payer? 2. Which prescriber accounts for the most prescriptions from that payer? 3. What is my average margin per patient per month from this third party payer and prescriber 4. How many patients do I have from that prescriber and how could I get more?

80 Targeting Exercise 1. Who is my most profitable third party payer? 2. Which prescriber accounts for the most prescriptions from that payer? 3. What is my average margin per patient per month from this third party payer and prescriber 4. How many patients do I have from that prescriber and how could I get more? 1. State Medicaid Local Results 2. Multi-Site Mental and Behavioral Health Clinic 3. Average 4 Rx/patient but most see multiple prescribers ($63 avg margin/mo) 4. We see 88 patients/month

81 Targeting Exercise 1. Who is my most profitable third party payer? 2. Which prescriber accounts for the most prescriptions from that payer? 3. What is my average margin per patient per month from this third party payer and prescriber 4. How many patients do I have from that prescriber and how could I get more? 1. State Medicaid Local Results 2. Multi-Site Mental and Behavioral Health Clinic 3. Average 4 Rx/patient but most see multiple prescribers ($63 avg margin/mo) 4. We see 88 patients/month

82 Targeting Exercise 1. Who is my most profitable third party payer? 2. Which prescriber accounts for the most prescriptions from that payer? 3. What is my average margin per patient per month from this third party payer and prescriber 4. How many patients do I have from that prescriber and how could I get more? 1. State Medicaid Local Results 2. Multi-Site Mental and Behavioral Health Clinic 3. Average 4 Rx/patient but most see multiple prescribers ($63 avg margin/mo) 4. We see 88 patients/month

83 Targeting Exercise 1. Who is my most profitable third party payer? 2. Which prescriber accounts for the most prescriptions from that payer? 3. What is my average margin per patient per month from this third party payer and prescriber 4. How many patients do I have from that prescriber and how could I get more? 1. State Medicaid Local Results Don t Forget to Factor in average DIR Fees 2. Multi-Site Mental and Behavioral Health Clinic 3. Average 4 Rx/patient but most see multiple prescribers ($63 avg margin/mo) 4. We see 88 patients/month

84 Internal DIR Fee Assessment Plan A $0.00 / Rx Plan E $2.76 / Rx Plan B $0.00/ Rx Plan F $5.00 / Rx Plan C $0.00 / Rx Plan G $7.00 / Rx Plan D $2.17 / Rx Plan H $20.16 / Rx

85 Targeting Exercise 1. Who is my most profitable third party payer? 2. Which prescriber accounts for the most prescriptions from that payer? 3. What is my average margin per patient per month from this third party payer and prescriber 4. How many patients do I have from that prescriber and how could I get more? 1. State Medicaid Local Results 2. Multi-Site Mental and Behavioral Health Clinic 3. Average 4 Rx/patient but most see multiple prescribers ($63 avg margin/mo) 4. We see 88 patients/month

86 Targeting Exercise 1. Started with Research in Mental Health, Medicaid, the Clinic 2. Became familiar with some pharmacy best practices in mental and behavioral health 3. Learned who was on the board and who was in administration 4. Explored common barriers and pharmacy solutions that could positively impact mental and behavioral health

87 Targeting Exercise: Gaps Primary non-adherence Never get first fill Routine non-adherence Doesn t continue medication Formulary issues patients unable to acquire medication Lack of Care Coordination Patients unable to navigate the health care maze Transportation Patients struggle with acquisition of meds Lack of communication among providers Patients receive sub optimal care due to health care silos Limited continuity of care Treatment often stops once the patient walks out of the clinic

88 Targeting Exercise: Use What You Have Our care coordination and adherence monitoring leads to improvements in medication adherence across multiple chronic conditions *Armstrong T., Impact of the MedHere Today Program on Persistence and Adherence, A Descriptive Report; Pfizer, May 2011.

89 Targeting Exercise: Solutions? Adherence Packaging

90 Targeting Exercise: Adherence Packaging Business Planning How much does a vial cost? How much does a cap cost? How much does a label cost? How much does a package / card cost? How many vials equal the cost of one package / card? How many cards will each new clinic patient purchase?

91 Targeting Exercise: Adherence Packaging Results Found packaging solution that allowed us to start with minimal investment and automation upgrade opportunities Estimated that patients with 10 or more prescriptions would cost us around $20/year to covert to packaging Estimated that each new clinic Medicaid patient is worth the cost of around 870 packages/cards

92 Targeting Exercise: Questions for Clinic What can we do to help you? Adherence packaging? 28 vs 30 day supply packages? Increasing communication with the pharmacy? Reporting back on dispensing, refill status, adherence, clinical markers, etc? Would extra patient monitoring post-visit help? PHQs, waist circumference, weight, blood glucose, 7,14,28 day package pickup/delivery to increase touch points, etc? Patient bring in package to office visit? Suggestions?

93 Targeting Exercise: Secondary Solutions Medication Reconciliation 28 vs 30 day dispensing Consolidation of medication + home visit Coordinate & communicate with clinic & PCPs Patient Health Questionnaire PHQ2 used on previous project to target depression in DM and could be used here PHQ9 could be used if preferred Metabolic monitoring Waist circumference Weight BG checks Medicaid MTM Interventions Standardized reporting back to Clinic after assessment and medication is delivered Referrals to Clinic for at risk patients not currently receiving mental health care

94 Targeting Exercise: ROI Held meetings with administrator for clinic needs assessment and pharmacy service detailing Hosted in service for case managers to detail pharmacy services Immediately began receiving referrals from case managers for packaging, care coordination, and other pharmacy services Prescription volume & referrals from target clinic and target payer increased Ongoing communication with clinic exploring new collaboration opportunities, despite clinic opening an on site pharmacy

95 Payer Programs: ROI? Is the program Pay for Performance or Pay to Play? Is it the program an Incentive Program or a Penalty Program? Are the metrics movable? Is the workflow process achievable and sustainable? Is the program in the best interest of your target patients? Will the program bring you patients? Revenue? Volume? Marketing? Is the Rx volume worth the investment with this payer? Is the program worth investing time, money, and valuable resources?

96 ROI: The Payers Themselves Began by looking at the payers themselves BEFORE we looked at their programs. Specifically looked at: Average margin per Rx Average DIR per Rx Our pharmacy s cost to dispense Average annual Rx volume per Rx Determined which plans had patients we wanted more of, and which plans we were losing money on. Created a list of positive ROI partners and poor ROI partners

97 ROI: Payer Programs Examples: 90 day supply conversion FFS Traditional Medicare Part D FFS Medication Therapy Management Medicare Part D adherence interventions through MTM vendors Medicare Part D performance program using health plan quality metrics Per member per month disease state management programs Enhanced MTM opportunities, Chronic Care Management, Etc. Patient attribution for enhanced pharmacy services Drug Manufacturers (PHARMA) are becoming payers Currently LOTS of innovation and experimentation in this space!!!!

98 Payer Strategies There is more value in hitting the measure's star rebate level, than a focus on the medical cost reduction -Medicare Part D Plan Executive, August 2017

99 Pharmacy Strategies Claims Based Fill reminders Med sync Fill gaps in care Medication safety CMR Packaging Days supply DIR reduction Patient Based Copay assistance Medication access Transition of care Health literacy/social Care coordination Transportation Education Empathy

100 Positive ROI: Current & Future Examples: Outcomes based programs, contracts, and collaboration opportunities A1C, BP, Lipids, Asthma, Admissions, Readmissions, CHF, etc Drug manufacturer programs Surveys, trainings, education, etc. Medicare Part D programs BEYOND claims based metrics Admissions per 1000, ER visits/1000, Complaints to Medicare, $PMPM (medical & drug), etc. Community Pharmacy Enhanced Service Network expansion The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Risk sharing with Health Systems & Hospitals No one knows what the future holds is it Amazon?

101 Good Investments Are Typically: Good for Prescriber Good for Employers Good for Third Parties Good for Pharmacy Staff Good for Pharmacy Good for Patients

102 Tripp Logan, Pharm.D. L & S Pharmacy tlogan@semorx.com

103 Making Connections, Developing Your Brand Enhanced Services Boot Camp Jay Williams CPESN USA

104 Objectives Articulate your pharmacy elevator speech. Create a plan to build relationships with other health care professionals in your area that can lead to opportunities for your pharmacy.

105 Importance of a Marketing Strategy Why should you invest the time? Articulate your brand clearly and consistently Assess your uniqueness Manage a clear set of marketing deliverables

106 Elements of a Successful Strategy 1. Identify your target groups 2. Create your brand position 3. Take action

107 1. Identify Your Target Groups 1. Group targets by characteristics not job titles Example: Physicians in Dublin, Ohio verses Plain City, Ohio 2. Understand targets based on their needs/desires Example: Care Managers typically have homebound patients, so pharmacies that deliver are needed 3. Create a Message Map

108 Attract Your Ideal Patient Identify your ideal patient Lure the ideal patient into your store Create a retention strategy to keep ideal patients

109 Target Groups The aim of marketing is to know and understand the customer so well that the product or service fits and sells itself. Peter Drucker

110 2. Create Your Brand Position

111 2. Create Your Brand Position 1. Consider the needs of all target groups 2. Create your key messages 3. Evaluate your Brand Strength How well does it resonate with your target groups? How different is it from your competition s position?

112 SWOT Analysis Strengths Weaknesses Opportunities Threats

113 Create Your Key Messages

114 Gallup Poll 2016

115 J.D. Power 2016 Independents were #1 overall Independents were #1 in 4 out of 5 categories

116 Boehringer Ingleheim 2013 Independents were rated #1 overall #1 in Pharmacist Engagement, Pharmacy Staff

117 Consumer Reports 2016 Independents* were rated #1 overall * Non-Medicine Shoppe Independents #1 in Personalized Service among others

118 Physician Messaging Be responsive to immediate needs Help foster medication adherence Make it easier to manage complicated patients Keep it simple

119 Messages that Resonate

120 Payer Messaging One size does not fit all Listen to (and understand) the payer s pain points Emphasize your situational adaptability & readiness Be prepared with an ask

121 Messages that Resonate

122 Messaging "People don't buy what you do. They buy why you do it. Simon Sinek

123 3. Take Action 1. Build your brand 2. Create a Strategy on a Page 1. Simple, easy-to-draft, easy-to-implement document 2. Establish clear deliverables for your teams 3. Test effectiveness, evaluate, then try new approaches 3. Try and try again

124 Build Your Brand 1. Focus on everything you do 2. Train and retrain team members 3. Be consistent!

125 Brand A brand for a company is like a reputation for a person. You earn a reputation by trying to do hard things well. Jeff Bezos

126 Strategy-on-a-Page

127 Taking Action/Risks There are risks and costs to action. But they are far less than the long range risks of comfortable inaction. John F. Kennedy

128 Taking Action/Risks The biggest risk is not taking any risk... In a world that changing really quickly, the only strategy that is guaranteed to fail is not taking risks. Mark Zuckerberg

129 Summary 1. Identify your target audiences 2. Create your brand position 3. Take action!

130 Jay Williams CPESN USA

131 How to Make It Work: Billing for Services in Tennessee Enhanced Services Boot Camp Micah Cost, Pharm.D., Tennessee Pharmacists Association Jacqueline Woeppel, TennCare

132 Objectives Describe the pharmacist payment structure within the TennCare program. Outline a plan for incorporating this new opportunity into the community pharmacy setting.

133 Micah Cost, Pharm.D. Tennessee Pharmacists Association

134 Update on Chronic Care Management: Opportunities and Challenges Enhanced Services Boot Camp Aaron Garst, Pharm.D. Seamless Healthcare PLLC

135 Objectives Discuss chronic care management and transitional care management opportunities for revenue in delivering clinical pharmacy services. Demonstrate how businesses are able to implement these programs while remaining profitable.

136 Chronic Care Management (CCM) Non-face-to-face, time-based services Billing Code Payment Clinical Staff Time Billing Practitioner Work $43 20 minutes Ongoing oversight, direction and management $94 60 minutes +moderate-high complexity $ minutes +moderate-high complexity G0506 $64 N/A Personally performs extensive assessment and CCM care planning beyond the usual effort described by the separately billable CCM initiating visit Initiating Visit $ Face-to-face work required by the initiating visit code

137 Evaluation of a Collaborative Pharmacy Practice Model for Community Pharmacist- Provided Chronic Care Management (CCM) Services

138 Med Review Physician Visit Care Plan Unnecessary Referrals CCM Call

139 Results Pharmacist-Provided Medication Reconciliation and CCM Services Insurance Patients Seen Enrolled Declined Enrollment % Reimbursed Medicare Only % 5 Medicare w/ Supplement % 15 Dual Eligible % 3 Total % 23

140 Final Thoughts Community pharmacists should consider a Hybrid Collaborative Pharmacy Practice (HCPP) model Must ensure the ability to provide billable services at the physician s office Focus on providing CCM services with primary care practices instead of specialists Insist on receiving at least the amount paid by Medicare (i.e. 80% of the billable code) and let the practice manage copay collection

141 Community Pharmacy Foundation (CPF) Synopsis and Toolkit on CPF website What s Next? Implementation of a Hybrid Collaborative Pharmacy Practice (HCPP) Model with Community Pharmacies Utilizing Technician Product Verification (TPV) Workflow Selection of at least two, but not more than seven, CPhT pilot project sites to receive additional support in establishing a HCPP model of care

142 Aaron Garst, PharmD Owner, Seamless Healthcare PLLC

143 Aaron Garst, Pharm.D. Tennessee Pharmacists Association

144 Community Pharmacy Enhanced Services Networks Enhanced Services Boot Camp Ashley Branham, Pharm.D. & Joe Moose, Pharm.D. CPESN USA and Moose Pharmacy

145 Objectives Discuss common characteristics of pharmacies in a community pharmacy enhanced service network Discuss the role of community pharmacy in providing medication management resources to the highest risk populations. Describe how pharmacies are positioning themselves to integrate with care teams to lower health care costs and participate in new models of care and reimbursement.

146 Healthcare Spend in in America Medication/Pharmacy Spend Medication/Pharmacy Spend 10% 10% Medical/Non-Pharmacy Spend Medical/Non-Pharmacy Spend 90%

147 Threats to Community Pharmacy

148 Patient Access

149 Strategic Considerations for Community- Based Pharmacy Networks History of NC CPESN Model Overview of States with CPESN Development Underway

150 How did Community Pharmacy Enhanced Services Networks Begin? Goal: Create a network of community pharmacies who are willing to provide enhanced services and coordinate care with the broader care team Started in January 2014 with official network launch in April 2014 Open network which includes ~ 280 North Carolina community-based pharmacies Confidential Do not reproduce or reuse without consent.

151 Types of Enhanced Services Medication Synchronization Adherence Packaging Home Delivery Home Visits Point-of-Care Testing Collection of Vital Signs Nutritional Counseling Smoking Cessation Compounding Long-Acting Injections 24-Hour Emergency Services Multi-Lingual Capabilities

152 CPESN Network Structure

153 Clinically Integrated Network Pharmacy Benefit Payer

154 Building a Network of Networks

155 Minimum CPESN Network Service Set Comprehensive Medication Reviews A systemic assessment of medications, including prescription, over-the-counter, herbal medications and dietary supplements to identify medication-related problems, prioritize a list of medication therapy problems and create a patient-specific plan to resolve medication therapy problems working with the extended healthcare team. Medication Synchronization Program Aligning a patient s routine medications to be filled at the same time each month. The pharmacists will provide clinical medication management and monitoring for progression toward desired therapeutic goals during the patient appointment at time of medication pick-up or delivery.

156 Minimum CPESN Network Service Set Immunizations- Act of screening patients for ACIP recommended immunizations, educate patients about needed immunizations and administer immunizations when appropriate. Medication Reconciliation- The process of comparing a patient s medication orders to all of the medications that the patient has been taking (active, chronic, as needed and OTC including herbal) to avoid medication errors. This service is especially important during transitions of care when patients are most vulnerable to medication errors or mishaps. Personal Medication Record- Ability to create a comprehensive list of current patient medications manually or from dispensing software

157 CPESN Tennessee Minimum Requirements Adherence Packaging & Counseling Collection of Vital Signs Comprehensive Medication Review (10 step process) Home Delivery Immunizations In-Depth Counseling/Coaching Medication Synchronization Program Personal Medication Record Medication Reconciliation

158 The Big Picture Form a nationwide Network of Networks Increase, develop and sustain Networks of high performing pharmacies that provide enhanced services Create a marketplace presence of & dependency on CPESN networks Facilitate local value propositions to other care team members to establish positive referral patterns Establish relationships and reimbursement models with the Medical Benefit side of payer infrastructure

159 CPESN USA A Network of Networks CPESN USA will focus on providing services and solutions to the local network where scale and aggregation make the most sense 3 Main Areas of Support: Subject Matter Expertise & Network Consultation Value Expression & Marketing Support Quality Assurance & Best Practice Identification

160 Deployment of the CPESN Model Care Team Integration Pharmacy ecare Plan

161 The Health Care System with Convenience Care vs. Chronic Care / CPESN Pharmacies Confidential Do not reproduce or reuse without consent.

162 Care Team Collaboration Joint home visits may be a way to establish a coordinated care plan for complex patients Pharmacies can assist care managers with patient engagement and longitudinal management Care managers and CPESN pharmacies can work together to address: Barriers preventing optional medication adherence Health literacy challenges, cognitive deficits, or lack of caregiver support that require pill box fills, special packaging, or special labeling Other specialized medication-related needs that could be fulfilled by a CPESN pharmacy Patient understanding of special instructions for administration or storage

163 Opportunity for Pharmacies Today Typical Referred Patient: 10 Rx/Pt/Month Estimated Profit per Rx: ~$10 How it Breaks Down: patients/day referred to NC CPESN ~$1200/patient/year X 200 patients =

164 Opportunity for Pharmacies Today Typical Referred Patient: 10 Rx/Patient/Month Estimated Profit per Rx: ~$10 How it Breaks Down: patients/day referred to NC CPESN ~$1200/patient/year X 200 patients = $240,000 in annual net profit per day

165 Pharmacist ecare Plan Goal of the Project: Create a new standard for electronic pharmacist care plans called Pharmacist Care Plan which is a further constraint on a standard in the Interoperability Standards Advisory. Integrate the pharmacist care plan into coordination efforts for patient care across the health continuum.

166 Group III Group II Group I Pharmacist ecare Plans Pharmacist ecare Plans are essential to quality assurance, quality improvement and Clinically Integrated Networks status. Vendors that are now certifying:

167 What Makes the CPESN Model Different? Community-based pharmacies that focus on high risk patients in a chronic care model Patient targeting Panel management Patients instead of prescriptions Accountability on global outcomes and quality Shared metrics with the rest of the care team Local care team integration and care coordination Change packages and network support to enable practice transformation Workflow changes related to panel management, care team integration, and weaving together clinical components with enhanced services Approach to HIT Pharmacist ecare Plans Confidential Do not reproduce or reuse without consent.

168 Lessons Learned Network Size: A SMALL, HIGHLY ENGAGED AND HIGH-PERFORMING NETWORK is better than a larger network with variable quality. Workflow: Enhanced services and Community Pharmacy Care Management MUST BE INTEGRATED INTO WORKFLOW FOR EFFECTIVE, EFFICIENT DEPLOYMENT; this includes HIT and efforts to coordinate with the care team Staff Engagement: CPESN concepts, including Community Pharmacy Care Management, are TRANSFORMATIONAL CHANGES in the way the pharmacy operates THAT REQUIRE A CULTURE SHIFT. To be successful, ALL STAFF SHOULD BE TRAINED AND ENGAGED.

169 ings Newsroom Innovation Center LTC s Pharmacy Assessment Survey Tool Join/Renew 018 Pharmacy Self-Assessment

170 Ashley Branham, PharmD CPESN USA Joe Moose, PharmD CPESN USA

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