ASHP UPDATE. The Path to Provider Status. Disclosure. Learning Objectives. Learning Objectives 2/18/2018. The Intersection of Healthcare & Policy

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1 Disclosure ASHP UPDATE The presenter for this continuing education activity reports no relevant financial relationships No off-label uses of medications will be described in this presentation Thomas J. Johnson, PharmD, MBA, BCPS, BCCCP, FASHP, FCCM Treasurer and Member Board of Directors - ASHP Learning Objectives Provider Status (pharmacist) Describe the pharmacy profession s efforts in pursuing provider status at the national level and what impact this has at the state level and what can be done to prepare. Drug Shortages (pharmacist and technician) Describe the impact of drug shortages on patient care Discuss ASHP s efforts in dealing with drug shortages Opioid Crisis (pharmacist and technician) Describe the current opioid crisis in the U.S. Discuss the pharmacists role in patient care and ASHP s efforts in dealing with this national crisis. Learning Objectives PAI Discuss ways the pharmacy profession can progress and adapt to advance its patient care contributions. Describe Practice Advancement (PAI) implementation, activities, and resources. Discuss the use of the PAI Hospital and Ambulatory Care Self Assessments as strategic planning tools to advance pharmacy practice particularly in regards to pharmacy technicians. Clinician Well-Being and Resilience Provide background on burnout as a patient care and healthcare workforce problem Introduce the National Academy of Medicine Action Collaborative Share strategies and next steps The Intersection of Healthcare & Policy The Path to Provider Status States grant authority to practice Licensure Scope of practice Federal government determines reimbursement Medicare Private, state payers typically follow Medicare 1

2 Provider Status is About Patients Social Security Act & Provider Status Achieving provider status is about giving patients access to care that improves patient safety, healthcare quality, and outcomes, and decreases costs for the healthcare system. Medicare resides under the Social Security Act Social Security Act determines eligibility for current and new payment models Pharmacists are not recognized under the Social Security Act as health care providers Who Has Provider Status? Provider Status: Physicians Nurse practitioners Physician assistants Certified nurse midwives Psychologists Clinical social workers Certified nurse anesthetists Speech-language pathologists Audiologists Registered dietitians Physical therapists 7 bills introduced between No clear consensus among pharmacy about path to provider status None of the bills were signed into law Patient Access to Pharmacists Care Coalition (PAPCC) The Pharmacy and Medically Underserved Areas Enhancement Act Coalition pushing for passage of legislation Most pharmacy groups are active members Patient advocacy groups 2

3 Focus on Underserved Populations Help meet unmet healthcare needs Increase patients access to care Improve quality Decrease costs Strategy follows similar successful paths taken by other healthcare professionals to gain provider status The Pharmacy and Medically Underserved Areas Enhancement Act Increases access to healthcare for patients in medically underserved areas. Promotes cost-effective healthcare by increasing opportunities for early interventions. Allows pharmacists to provide services authorized by state scope of practice. The Pharmacy and Medically Underserved Areas Enhancement Act Services Managing chronic diseases Medication management Efficient care transitions Health and wellness testing Overall impact: Improved health outcomes Reduced hospital readmissions Reduced emergency department visits Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 592 and S. 109) Early reintroduction signals commitment of lead sponsors Grassley, Guthrie Strong, bipartisan support H.R. 592: 242 co-sponsors S. 109: 50 co-sponsors Keys to Success Pharmacy must maintain unified stance Grassroots efforts must be robust Focusing on the unmet need, new Medicare enrollees Drug Shortages Threaten Patient Care 3

4 Map of Drug and Device Manufacturing: Puerto Rico 300 National Drug Shortages Annual New Shortages by Year January 2001 to December 31, University of Utah Drug Information Service Contact for more information 30% National Drug Shortages Reasons for Shortages * % 3% 2% 4% 53% Unknown 53% Manufacturing 30% Supply/demand 8% Natural Disaster 3% Raw Material 2% Discontinuation 4% ASHP Has Lead Legislative and Regulatory Efforts on Shortages for over a Decade Long-standing Drug Shortages Resource Center Collaborative relationship with UUDIS and FDA 2010: First drug shortages summit 2011: FDASIA includes Title X drug shortage reporting requirements 2014: Second drug shortages summit 2017: Drug shortages meeting between clinician groups, the FDA, and HHS 2018: Congressional activity on drug shortages *Based on information provided by manufacturers to the University of Utah Drug Information Service University of Utah Drug Information Service Contact for more information What is Your Message on Shortages How is this impacting your practice and your ability to properly care for patients? What Congress can do: Strengthen the reporting requirements of FDASIA to include more detail on why production is interrupted and when it will resume ASHP Opioid Efforts Require manufacturers to have back up plans 4

5 Educational Activities Webinars: Establishing a Controlled Substances Diversion Prevention Program: From Leadership to Frontlines Controlled Substances Diversion Prevention: Data Management and Surveillance Program Development Safe Opioid Prescribing: Dashboards and Clinical Care Opioid Stewardship: What, Why, and How Foundation: Empowering Pharmacists as Active Members of the Care Team for Patients with Chronic Non-cancer Pain Meetings: SM ABC's of opioid stewardship program, in the "P" track MCM sessions tentative (22-23 hours) related to pain, naloxone, etc. Veterans Health Administration pain and opioid session on Sunday, June 4 th, 2017 Policies and Guidelines Policies 2 new policies Council on Public Policy: Partial fills, needs approved by the House yet Council on Pharmacy Practice: Reduction of Unused Prescription Drug Products, now approved Guidelines ASHP Guidelines on Preventing Diversion of Controlled Substances Working with TJC Submitted comments, new guidelines coming in Summer Concept of opioid stewardship State and Federal Involvement State: Webinar for State Affiliates April 2017 Continued need for naloxone education Federal ASHP has been invited to 3 town hall meetings under the Obama administration and participated in Dr. Botticelli's taskforce Trump administration: ONDCP will stay intact, 2 interim directors, waiting on appointment of official director There will be another taskforce, Governor Chris Christie to lead with 4 agency involvement (CDC will most likely lead efforts) Viewed as an epidemic (more wide-spread and diverse effects than AIDS) ASHP continues to work with HHS, CDC, NABP, TJC, USP and other organizations/associations to help fight the epidemic Journal - AJHP Since 2014 AJHP has published 53 items with an opioid related topic (40 of the 53 have been since 2015) 4 ASHP reports 4 case studies 2 clinical reviews/consultations 2 editorials 2 frontline pharmacist reports 5 letters 21 news write-ups 3 notes 2 practice reports 2 resident reports (in the resident s edition of AHJP) 3 special reports 1 therapy update The Role of the Pharmacist Partnering with the provider Identifying true opioid needs Identifying patients at risk for substance use disorder Use of guidelines Use of alternative agents Develop and update patient specific plan: Acute - starting, tapering, and discontinuation Chronic optimal regimen that works for that patient Provide follow-up care for acute pain patients and continued care for chronic patients (assessing needs at periodic intervals) Leverage and use electronic solutions including the PDMP and EHR Determine patients at risk and have needs for naloxone Practice Advancement Initiative (PAI) 5

6 PAI: The Journey to Improve Patient Care Imperative for Change Distribution of Outpatient vs. Inpatient Revenues MACRA Merit-based Incentive Payment System (MIPS) Alternate Payment Model (APM) incentive system Movement away from volume toward value-based payment Risk-based, care coordination MIPS + APM = Quality Payment Program Aging population and declining Medicare beneficiary ratio amplifies unsustainable trajectory of healthcare spending 40 percent of older Americans take at least five prescription medications, and the number is growing Self-care, cost-effective innovations, and infrastructure to support aging in place (e.g., CMS Independence at Home demonstration project) Hospital Outpatient Care Hospital Inpatient Care Managed Care. 2015; 24: Am J Health-Syst Pharm. 2016; 73: accessed 23 February Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2014, for community hospitals. Data for Chart 4.3 Essential Strategies to Expand the Pharmacy Enterprise Change perspective Understand and participate in the C-suite s ambulatory care strategic plan Assess revenue cycles Invest in outpatient pharmacy, specialty pharmacy, and home infusion Population health management Transitions of care focused planning Develop a layered learner model expanding student and resident training within primary care and ambulatory care Actively engage technologies to reach ambulatory care patients Market pharmacists value Advocate for the profession Polling Questions How many of you have done an ASHP Hospital Self- Assessment? What are the two ways one can take the Ambulatory Care Self-Assessment? Where can you find a PAI case study or spotlight on the PAI website? How many have used the State Affiliate Toolkit? Am J Health-Syst Pharm. 2016; 73:

7 Hospital Self-Assessment Complete Hospital Self-Assessment Prepare Action Plan identify priorities based on feasibility and impact Consists of 106 questions designed to assess an individual hospital s alignment with the recommendations Covers a wide range of topics: Advancing the application of IT in the medication-use process Advancing the use of Pharmacy Technicians Care team integration HSA Action Plan Opportunities Top Three Action List Priorities Residency-trained pharmacists Assigning initiation of medication reconciliation to appropriately trained pharmacy technicians to: Capture admission and discharge medication histories for a reconciled personal medication list Care coordinate patient assistance services for postdischarge medication use (e.g., ensuring patient access to affordable medications) Provision of discharge counseling by pharmacists to include standardized process for hand-offs to next level of care (e.g., skilled nursing facility, home health) Data from 6/24/ assessments and 664 Action plans Why do the Ambulatory Care Self- Assessment? Assess how your practice aligns with the ASHP Ambulatory Care recommendations Reflect on where you are and showcase what is going well Identify areas of need Two versions of the self-assessment (system and practitioner) Create an action plan to improve practice Put data to use (e.g., strategic planning priorities, business plan development) Determine steps to move from current state to a desired future state Benchmark against other facilities and measure progress over time Prioritizing Action List 7

8 2/18/ assessments completed (229 practitioner, 205 system) NOTE: no data for DC, DE, GA, HI, NM, and PR Ambulatory Care Action Plan Opportunities Top Three Action List Priorities (System Assessment) Ambulatory care pharmacists actively engaged in transitions of care activities Decrease care fragmentation across the continuum Establishing and engaging in a comprehensive ambulatory care strategy (e.g., community pharmacy, specialty pharmacy, ambulatory care pharmacist in a primary care setting) Use of billing codes when providing ambulatory pharmacist patient-care services Use of standardized framework for clinical documentation (i.e., SNOMED CT) Clinical pharmacist engaged in team-based, patient centered care (e.g., Patient Centered Medical Homes, ACOs, bundled payment-arrangements, aging in place demonstration pilots) Creating financially sustainable services Progress Measures Measures with greatest progress (hospital) Distribution tasks assigned to technicians PTCB certified technicians Barcode medication dispensing and administration IT strategic plan to improve safety and quality Measures with greatest progress (ambulatory care) Systems utilizing collaborative practice agreements Systems with pharmacists practicing in ambulatory clinics Systems with ambulatory oncology clinics that include pharmacists Active participation by ambulatory care pharmacists in organization-wide committees Case Studies, Spotlights, and Toolkits PAI RESOURCES 8

9 What You Can Do Now Complete the self-assessments and share with your pharmacy team to develop actionable plans Evaluate the medication management system for quality, safety, and reimbursement/revenue gaps Engage in discharge counseling after monitoring inpatient Delegate distributive functions to pharmacy technicians Medication reconciliation at admission and discharge Get involved with ambulatory care (e.g., community, specialty, population health, leverage provider status) Educate others on PAI and be a catalyst for change Some Priority Focus Areas for PAI Progress measure review and update to reflect PAI integration Structure to help advance student pharmacist exposure to direct patient care activities Provider status readiness resources to help prepare pharmacists to practice at the level we envision Clinical documentation standardization for pharmacy services (e.g., SNOMED-CT, quality/value, interoperability) Tools to help individual practitioners overcome PAI barriers Increased utilization of pharmacy technicians Action Collaborative on Clinician Well-Being and Resilience Burnout is a Patient Care Problem Bodenheimer T, Sinsky C. From triple aim to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6): Quality and Safety Medical Error ~8000 surgeons Medical Malpractice Litigation ~7000 surgeons Health-care associated infections Mean burnout hospital nurses independent predictor Patient mortality ratios Teamwork scores Mean EE physicians & nurses ICU Shanafelt Ann Surg 2009; Balch J Am Coll Surg 213; West JAMA 2006, 2009; Jones J Appl Psychol 1988; Cimiotti Am J Infect Control 2012; Welp Front Psychol 2015; Welp Crit Care 2016 Burnout Medical Error Bi-directional relationship Higher levels of burnout associated with increased odds of reporting a medical error in subsequent 3 months Self-perceived medical error associated with worsening burnout & depressive symptoms 9

10 Health Care Costs Medical Errors Malpractice claims Turnover x salary ($82-$88,000 per RN in 2007) $500,000 to >$1 million Absenteeism Job productivity Referrals Ordering What is Burnout? Syndrome of: depersonalization emotional exhaustion low personal accomplishment Jones J Nurs Am 2008; Fibuch Physician Leadersh J 2015; Buchbinder Am J Manag Care 1999; Kushnir, Fam Pract 2014; Bachman Soc Sci Med 1999; Parker J Behav Med 1995, Toppinen-Tanner Behav Med 2005, Hilton J Occup Environ Med 2009 High Prevalence of Burnout Medicine 2014, 6880 physicians, all specialties, all practice types 2012, 5521 medical students & residents Nursing 1999, >10,000 inpatient RN 2007, 68,000 nurses Aiken JAMA 2002;288; McHugh Health Aff 2011;30; Dyrbye Acad Med 89(3): ; Shanafelt MCP 2015:90:1600 Drivers of Burnout in Healthcare Professionals Excessive workload Inefficient work environment Problems with work-life integration Loss of autonomy, flexibility and control Organizational culture and values Reduction of meaning in work Lack of social support at work Leadership behaviors Nurses: Moral distress Trainees: Learning environment, Educational debt Shanafelt. MCP 2016(7):836; Dyrbye et al. Arch Surg 2011; 146(2):211; Dyrbye et al. Arch Surg 147(10): ; Shanafelt Arch Intern Med 2009; Dyrbye Med Educ 2016;50: ; Shanafelt MCP 2016; Williams Health Care Manag Rev 2007; Aiken JAMA 2002; Hamric Crit Care Med 2007 National Academy of Sciences Founded in March, 1863 Private, nonprofit organization of the country s leading researchers National Academy of Medicine Formed in 1970 to advise the nation on medical & health issues Dr. Victor Dzau is President 10

11 Action Collaborative Goals NAM Improve baseline understanding across organizations of challenges to clinician well-being Raise visibility of clinician stress and burnout Advance evidence-based, multidisciplinary solutions to reverse these trends, leading to improvements in patient care by caring for the caregiver ASHP Improve patient outcomes through optimal medication use Identify mechanisms to improve and sustain pharmacy workforce well-being and resilience Deploy pharmacy workforce to support multidisciplinary solutions for improving healthcare workforce well-being and resilience Collaborative Composition & Commitments 36 sponsoring organizations, 100 network organizations: Professional organizations Government Technology and EHR vendors Large health care centers Payors 130 commitment statements To provide an opportunity for organizations across the country discuss and share plans of action to reverse clinician burnout and promote clinician well-being. Working Groups *Charged with creating products and activities to effect the factors driving clinician well-being and burnout, and develop organizing principles for the work of the collaborative* 1. Research, Data and Metrics 2. Messaging and Communications 3. Conceptual Model (ASHP participation) 4. External Factors and Workflow 5. Perspectives Paper & Art Show **DRAFT** 11

12 ASHP Vision & Strategic Plan STRATEGIES ASHP s vision is that medication use will be optimal, safe, and effective for all people all of the time Strategic Priorities and Goals Our Patients and Their Care Goal 4: Improve Patient Care by Enhancing the Well- Being and Resilience of Pharmacists, Student Pharmacists, and Pharmacy Technicians Our Members and Partners Our People and Performance Our Patients and Their Care: Goal 4 Key Objectives Engage in major national initiatives on clinician well-being and resilience Facilitate the development of education aimed at helping pharmacists, student pharmacists, and pharmacy technicians address and effectively cope with the stress and burnout associated with demanding patient care environments Seek opportunities to improve the well-being and resilience of pharmacists participating in postgraduate residency training. Foster research that addresses well-being and resilience issues of pharmacists, student pharmacists, and pharmacy technicians Follow the conversation: nam.edu/clinicianwellbeing #ClinicianWellBeing Join the conversation: Pharmacy Technician Post-test True or False One of the things Congress could do related to drug shortages is to require that manufacturers have a backup plan for disasters and other manufacturing delays. True or False One of the key initiatives of the ASHP Practice Advancement Initiative is to advance the role of technicians, and as part of this initiative, ASHP has recently launched the ASHP Technician Forum. True or False Burnout is described as Syndrome of: depersonalization, emotional exhaustion, and low personal accomplishment. 12

13 Pharmacist Post-test True or False Obtaining provider status through Medicare will alter scope of practice in the states. True or False One of the things Congress could do related to drug shortages is to require that manufacturers have a back-up plan for disasters and other manufacturing delays. THANK YOU True or False Pharmacists and pharmacy departments in healthsystems / hospitals should complete the PAI self-assessment to help develop an action plan / strategic plan. True or False ASHP is a member of the National Academy of Medicine Action Collaborative on Clinician Well-being and Resilience. 13