Clinical Service Networks Re-Engineering Your Pharmacy Practice Bootcamp August 13, 2016

Transcription

1 Clinical Service Networks Re-Engineering Your Pharmacy Practice Bootcamp August 13, 2016 Ashley Branham, PharmD, BCACP Joe Moose, PharmD

2 Disclosures Ashley Branham is receiving an honorarium for this program. The conflict of interest was resolved by peer review of the slide content. Joe Moose is receiving an honorarium for this program. Joe Moose is a board member of the NCPA Innovation Center. The conflict of interest was resolved by peer review of this slide content.

3 Objectives 1. Discuss common characteristics of pharmacies in a community pharmacy enhanced service network. 2. Discuss the role of community pharmacy in providing medication management resources to the highest risk populations. 3. 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.

4 $100 Total Healthcare Spend $10 Pharmacy Spend Non-pharmacy Health Care Spend $90

5 The Opportunity: A Fundamentally Different Approach to Payment & Delivery

6 How we got to where we are ( our community pharmacy experience) Dilemma: How to Scale Team-Based Medication Optimization Efforts? >32,000 Individuals received CCNC Transitional Care Support in 2015 (24 different steps, 3 of which are medication optimization oriented)

7 Breaking Out of the Bubble ( our Policy Experience trying to Sell Community Pharmacy ) Care Team-Based HIT focus extremely important Care Team HIT focus less important

8 What Is a CPESN?

9 Community Pharmacy Enhanced Services Network Enhanced Pharmacy Services - Services that transcend conventional requirements of an outpatient pharmacy program contract that are focused on improving clinical and global patient outcomes Examples include, but are not limited to: In-home delivery with patient status review medication synchronization with clinical review, Adherence packaging with patient coaching; and Care management services.

10 Opportunity Knocks CCNC Enrollees with total Enrollees on Enrollees on Enrollees on Medication CCNC Enrollees medical cost > $10,000 CCNC Priority list TC Priority list Management Priority list Total number of members 1,348, ,529 17, ,241 6,377 Total medical cost $ 4,078 $ 27,527 $ 23,813 $ 18,215 $ 25,345 # of Inpatient visits Inpatient costs $ 369 $ 3,464 $ 5,337 $ 2,924 $ 6,456 # of mental health inpatient vi ED visits ED cost $ 178 $ 745 $ 1,262 $ 816 $ 1,657 Outpatient visits Mental health outpatient visits PCP visits Pharmacy visits Pharmacy costs (Pre Rebate) $ 721 $ 5,177 $ 3,342 $ 4,298 $ 6,183

11 What Does CPESN NC look Like?

12 North Carolina Medical Home Landscape Neighborhood

13 Growth of the NC CPESN Community Pharmacy Enhanced Services Network CPESN workgroups, initial collaboration card, common informatics platform, and care team relationship building Payment for services standardized/required documentation, performance, measurement, quality assurance 50 0

14 NC CPESN Distribution Geographic Representation of CPESN Pharmacies as of December 1, 2015

15 NC CPESN Participation Criteria Current registration with the BOP in good standing Current NC Medicaid pharmacy provider A signed agreement with CCNC that defines scope of work and CPESN participation Use of CCNC s PHARMACeHOME application Agreement to provide a minimum set of enhanced services: 1. Proactive waste management program 2. Patient counseling and adherence coaching 3. Assistance with medication reconciliation

16 Types of Enhanced Services 24 Hour Emergency Services Adherence Packaging Collection of Vital Signs Compounding Comprehensive Medication Review Home Delivery Home Visits Long-Acting Injections Med Synchronization Program Multi-Lingual Capability Naloxone Dispensing Nutritional counseling Point of Care Testing Smoking Cessation Standardized Assessments (PHQ-9) Disease State Management Programs

17 Moose Midland Pharmacy (704) Moose Pharmacy Mount Pleasant (704) loxone Dispensing X X X X X X X (704) Moose Professional Pharmacy (704) Akers Pharmacy (910) TAS Drug (910) Realo Discount Drugs (704) Keever Pharmacy (704) CareFirst Specialty Pharmacy (704) Dilworth Drug (704) Rx Clinic Pharmacy (910) Seven Lakes The Collaboration Card The Pharmacy Locator Application Hour Emergency Service/On Call (Dispensing) X X X Hour Emergency Service/On Call (Non-Dispensing) X X X X X X X X herence Packaging X X X X X X X X X X X ozapine Dispensing and Monitoring X X X X X X X X X llection of Vital Signs X X X X X X X X X X mpounding (Non-Sterile) X X X X X X X X X X mpounding (Sterile) mprehensive Medication Review X X X X X X X X X X X E Billing (Medicare and Medicaid) X X X X X X X X me Delivery (Free) X X X X X X X X X X X me Delivery (Fee Applies) X me Visits X X X X X X X X X Depth Counseling/Couching X X X X X X X X X X ng-acting Injections X X X X ed Synchronization Program X X X X X X X X X X X ulti-lingual Capability X X X X X X

18 Importance of Targeting and Channeling Patients to High Performing Pharmacies

19 ONC National Meeting, January 24, 2014

20 Three Project Aims Test New Payment Models for Community Pharmacy Test New Relationship Models with Medical Homes Determine What IT Needs are Needed for Community Pharmacy

21 What Does CPESN Iowa Look Like?

22 CPESN Highlights: Iowa IPA has hosted a Building a Community Pharmacy Enhanced Services Network Webinar Series Live Meeting on February 12 - Establish Work Groups Participation at the CCNC Pharmacy Home Annual Meeting Regular Work Group Meetings and participation engagement Live Meeting Schedule for June 18 in Des Moines

23 Progress in Iowa Core vs. Optional Service Sets Roles & Responsibilities Participation Agreement

24 Iowa CPESN Participation Criteria A signed agreement that defines roles & responsibilities with CPESN participation Current registration with the BOP in good standing Respect patient s right to choose their own practitioners and pharmacies Use secure data platforms and applications, when applicable Agreement to provide a minimum set of enhanced services 1. Medication Reconciliation 2. Clinical Medication Synchronization 3. Adherence Packaging 4. Immunizations 5. Complete Medication Reviews with Chronic Care Management

25 Why CPESN Supports Product Reimbursement

26 The Objective

27 The Opportunity: In Economic Terms to Medical Benefit

28 The Opportunity: In Economic Terms to Pharmacy Typical Referred Patient 10 Rx/Pt/Month Profit per Rx ~$10 How it Breaks Down ~ pts/day/referred to NC CPESN $1200/pt/yr X 200 pts = $240,000 in annual net profit per day

29 we are worried about reductions in reimbursement rates to community pharmacies.we work with a few that are essential for our patients.with special needs and circumstances if they went out of business it would be really hard on the practice and the patients - Primary Care Physician (CCNC Practice)

30 A Day in the Life of a CPESN Pharmacy

31 CPESN Example Workflow Adherence Technician Administrative Assistant Clinical Pharmacist Consultation Room Inventory Cashier Pharmacist Fill Technician Input Technician Delivery

32 CPESN Example Workflow Input Technician Key Responsibilities - Determine if patient is on attribution list - Assess profile for adherence when processing prescriptions - Clean up medication lists (discontinue medications) - Document identified DTPs on DTP Short Form Input Technician

33 Technician Tool: DTP Short Form Form placed at technician work station Technician to complete form if potential DTP s are identified Technician to send form in basket to the pharmacist Pharmacist investigate the issue and takes necessary steps to resolve DTP DTP documented in platform

34 CPESN Example Workflow Filling Technician Key Responsibilities - Accurately prepare medications for dispensing - Answer phone - Identify potential DTPs - Document identified DTPs on DTP Short Form - Alert pharmacists if consultation is needed Filling Technician

35 CPESN Example Workflow Adherence Technician Adherence Technician Key Responsibilities - Call patients on monthly basis - Point of contact for medication changes during the month (Transition of Care) - Handle Referrals from Provider(s) - Determine medication lists to be sent to PASS machine

36 Monthly Follow-Up Calls Patients called prior to synch date each month to assess adherence and changes in medication regimen Standardized script to fully assess Problems with medications Changes to medication regimen Review of each specific medication Evaluation of need of PRN medication

37 Evaluation of Adherence Integrate additional technology in dispensing process to access a comprehensive database for patientspecific prescription fill history, provider, pharmacy and adherence measures to prescribed therapy

38 CPESN Example Workflow Dispensing Pharmacist Key Responsibilities - Final verification on all medications - Review medication history - Counsel patients - Maximize encounters with attributed patients - Alert Clinical Pharmacist when CIPA is needed - Identify DTPs - Resolve medication-related problems through care coordination Pharmacist

39 CPESN Example Workflow Clinical Pharmacist Clinical Pharmacist Key Responsibilities - Prioritize attribution list - Perform Comprehensive Initial Pharmacy Assessments (CIPA) - Identify Drug-Therapy Problems (DTPs) - Home Visits - Perform Transition of Care Assessments - Documentation and follow up with patients

40 CPESN Example Workflow Administrative Assistant Administrative Administrative Assistant Assistant Key Responsibilities - Prioritize attribution list - Perform Comprehensive Initial Pharmacy Assessments (CIPA) - Identify Drug-Therapy Problems (DTPs) - Home Visits - Perform Transition of Care Assessments - Documentation and follow up with patients

41 Comprehensive Initial Pharmacy Assessment (CIPA) Work Flow Process Attribution List received by pharmacy Complete Matrix in PH noting any non-clinical DTPs Review Matrix entered in PH, noting clinical DTPs Request PCP med list, specialist med list, etc. Complete CMR with patient/caregiver Complete CMR Summary Note and Publish all Materials Review PH to ensure patient not reviewed recently Call patients to schedule Face-to-Face CMR or complete CMR via telephone Work with healthcare team to resolve any DTPs Technician/ Support Staff Pharmacist

42 CPESN Example Workflow Cashier Key Responsibilities - Review system flags with patients - Notify pharmacist to counsel when DTP is identified - Identify when medications are not picked up and alert pharmacists (especially if patient is enrolled in the adherence program) Cashier Cashier

43 CPESN Example Workflow Delivery Key Responsibilities - Deliver medications to patient s home - Provide instructional video(s) through ipad - Notify pharmacists through Face Time for consultations - Report back signs of poor adherence to pharmacist(s) Cashier Delivery

44 Summary of Moose Pharmacy Learnings Frequently discuss initiative with entire team to create a culture of providing value-based care Frequent Team Meetings When you stop talking about it, staff resume old practices Encourage everyone to work at the top of their degree Be efficient at dispensing medications Complex patients require time away from the workflow Invest in resources when appropriate to assist with workflow Relationship building is key to successful intervention

45 Report on the Multi-State Pharmacy Collaborative (MSPC) Supporting the Development of Community Pharmacy Enhanced Services Networks (CPESN) Beyond North Carolina

46 Multi-State Pharmacy Collaborative (MSPC) Facilitate expansion of high-performing networks* Provide a venue to connect pharmacists and other pharmacy stakeholders who have interest in delivery of financially sustainable, patient-centered care beyond traditional dispensing services * High Performing Pharmacy Network to coalesce pharmacies based on the principle of providing value beyond selling drug product to effectuate health trajectory

47 Goals Provide Launch Support for CPESN Implementation Explore opportunities for collaboration between value purchasers and CPESNs Support development of Pharmacy Locator Application/Collaboration Site Develop communication strategy for Multi-State Pharmacy Collaborative (MSPC) engagement

48 The Big Picture Form a nationwide Network of Networks Increase, Develop and Sustain High Performing Networks of Pharmacies that provide enhanced services offerings Create Marketplace Presence of CPESN Networks Create Marketplace Dependency on CPESN Networks Facilitate local value propositions to other care team members to establish margin positive referral patterns Create care team dependency on clinical activities performed by community pharmacies to mitigate against risk narrow networking or reimbursement reductions on product distribution Establish Relationships and Reimbursement models with Medical Benefit side of payer infrastructure

49 Requested Webinars & On Site Visits Webinar On Site Visit

50 Where We Are: Emerging CPESNs October 2015 December 2015 Active CPESN Emerging CPESN June 2016 Contact established

51 Next State(s) to Launch CPESN CO PA NY OK AR MS TN G A CPESN Fall Launch Emerging CPESN Contact established

52 CPESN Highlights: Baptist Memorial Health Care Large health center covering 3 states (MS, AR, TN) Expressed interest in collaborative effort between BMHC and CPESN in coverage area

53 CPESN Highlights: Mississippi MIPA has hosted Webinar Participation at the CCNC Pharmacy Home Annual Meeting Live Meeting held on May 14 Live Meeting with pharmacists and Baptist May 24

54 CPESN Highlights: Kentucky Wellcare Pilot Program (6 months) KY CPESN to provide NPI s of participating pharmacies Wellcare to provide patient attribution list with highest cost.

55 Launching a CPESN Phase 1: Determining Interest Phase 2: Develop Network Framework Phase 3: Preparing to Launch

56 Step 1: Determining Interest Identification of potential participating pharmacies Webinar, Live Meeting, One-on-one discussion with targeted community pharmacists Potential luminaries Organize Voluntary Work Groups Collectively determine the posture of your CPESN Schedule live meeting for network decision making

57 CPESN Work Groups Service Sets Input on standard and optional services and how those are defined Input on the education and communication about services to providers/stakeholders (i.e. Pharmacy Locator App) Network Operations & Communications Establish, monitor and grow the CPESN Input regarding interactive processes and communications needed for collaboration with CPESN community pharmacies around the care of specific patients Identify funding & sustainability opportunities Quality Assurance & Performance Measurement Guidance about appropriate measures and measure definitions needed to monitor overall performance and quality of CPESN network

58 Step 2: Develop Network Framework Determine entity that will organize the CPESN Non-profit, For-profit entity, CCNC assistance Determine name of your CPESN Determine value proposition of your network Determine intent of pharmacy participation by Letter of Commitment or Participation Agreement

59 Step 3: Preparing to Launch Identify Network Administrator Survey participants to determine enhanced services offering(s) Finalize minimum participation criteria Outline required and optional service sets Inclusion criteria Engage Potential Partnerships (SOP(s), Vendors, etc.) Branding/Logo Development Establish deadline for Letter of Commitment/Participation Agreement

60 Work Group Kick Off Meeting Brainstorming session & reporting of work groups Define owners of work group Selection of 1 or more luminaries Determine strategy for next follow up

61 Which Level of Support Will Your CPESN Need? Light Medium Heavy - Mentorship/Advice on network framework development - Resources when requested - Assistance accessing Pharmacy Locator App/Collaboration Site -Mentorship/Advice on network framework development - Administrative support as needed Resources when requested -Assistance accessing Pharmacy Locator App/Collaboration Site -Mentorship/Advice on network framework development -Administrative Support (webinar scheduling, create meeting agendas, recording minutes, organize list of participants) - Assistance developing network tools, resources, materials, branding -Available to attend Work Group Meetings/Live Meetings

62 Overview of CPESN Training Modules CPESN Training Module Components Introduction & Learning Objectives Primary Video (10 minutes) Practical Application (10 minutes) Resource Link CE Assessment Priority Topics Community Pharmacy Care Management Roles Community Pharmacy Care Management Workflow Motivational Interviewing: Initial Patient Engagement Motivation Interviewing: Developing a Patient-Centered Care Plan Building Provider Relationships and Communication Patterns

63 CPESN Website Preview

64 Pharmacy Locator Application

65 Summary of Network Launch Learnings Technology Platform- Documentation Tool A technology platform is not required to organize around a CPESN. While technology is an enabler of services and quality assurance and improvement, it is peripheral to the goals of establishing a CPESN. Identifying The Luminary One of the first steps for CPESN development is organizing around selfdetermined high performing pharmacies. In order to do this, you need one or more luminaries to bring other high performing pharmacies to participate. A luminary must be able to tell the story, communicate to other pharmacists why participation is important to be successful in the value-driven model. Identifying payment for services before CPESN development Do not wait for a value purchaser to approach you before starting the process of organizing a community pharmacy network. If you do, you will likely, experience a missed opportunity to work with a payer.

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67 What s Driving This? It s all about pivoting toward payers & alternative primary care providers Desire to not be dependent on PBM s $1,000,000,000,000 CMS Quadruple AIM

68 Call to Action

69 Contact Information Ashley Branham, PharmD, BCACP Director of Clinical Services, Moose Pharmacy Joe Moose, PharmD VP, Moose Pharmacy Lead Community Pharmacy Coordinator, Community Care of North Carolina