Assessing pharmacist-led annual wellness visits: Interventions made and patient and physician satisfaction

Transcription

1 EXPERIENCE Assessing pharmacist-led annual wellness visits: Interventions made and patient and physician satisfaction Courtenay Gilmore Wilson, Irene Park, Susan E. Sutherland, and Lisa Ray Abstract Objectives: To quantify the nature and frequency of interventions made by pharmacists during a Medicare annual wellness visit (AWV), to determine the association between the number of medications taken and the interventions made, and to assess patient and physician satisfaction with pharmacist-led AWVs. Setting: Large, teaching, multidisciplinary family medicine practice in North Carolina. Practice description: Mountain Area Health Education Center (MAHEC) is a large academic practice that serves rural, western North Carolina. There is a heavy emphasis on team-based care. Practice innovation: Pharmacist-led AWV. Evaluation: Between April 2012 and January 2013, the following were evaluated for 69 patients: the nature and frequency of interventions made, the association between the number of medications taken and the interventions made, and patient and physician satisfaction scores. Results: A total of 247 medication-related interventions and 342 nonmedication interventions were made during the pharmacist-led AWVs. The majority of medication interventions (69.6%) involved correcting medication list discrepancies. The number of medications taken was positively associated with the total number of medication interventions (r = 0.37, P <0.01). On a 5-point Likert scale, patients strongly agreed that the AWV is important for their overall health (mean 4.8, median 5) and that they would like to see the same provider next year (mean 4.8, median 5). Physicians strongly disagreed that they would prefer to do the visit themselves (mean 1.5, median 1) and strongly agreed that their patients benefited from a pharmacist-led AWV (mean 5, median 4.9). Conclusion: Pharmacists addressed both medication and nonmedication interventions during AWVs. Patients taking a greater number of medications required more medication interventions than patients taking fewer medications. Patients and physicians reported satisfaction with the pharmacist-led AWV. J Am Pharm Assoc. 2015;55: doi: /JAPhA Courtenay Gilmore Wilson, PharmD, CDE, BCPS, BCACP, CPP, Assistant Professor of Clinical Education, Eshelman School of Pharmacy, and Clinical Instructor, School of Medicine, University of North Carolina, Chapel Hill, NC; and Associate Director of Pharmacotherapy, Mountain Area Health Education Center, Asheville, NC Irene Park, PharmD, CPP, Assistant Professor of Clinical Education, Eshelman School of Pharmacy, Chapel Hill, NC; and Clinical Pharmacist, Mountain Area Health Education Center, Asheville, NC Susan E. Sutherland, PhD, Director, Mission Hospital Research Institute, Asheville, NC Lisa Ray, MD, Clinical Assistant Professor, School of Medicine, University of North Carolina, Chapel Hill, NC; and Assistant Residency Director, Family Medicine Residency Program, Mountain Area Health Education Center, Asheville, NC Correspondence: Courtenay Gilmore Wilson, PharmD, CDE, BCPS, BCACP, CPP, Mountain Area Health Education Center, 123 Hendersonville Road, Asheville, NC 28803; courtenay.wilson@ mahec.net Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Mountain Area Health Education Center was the recipient of a grant to support the expansion of the Annual Wellness Visit service subsequent to this study. Acknowledgments: Suzanne Landis, MD, MPH Previous presentation: American Society of Health-System Pharmacists Midyear Clinical Meeting, Anaheim, CA, December 10, 2014 Received October 10, Accepted for publication December 23, Journal of the American Pharmacists Association japha.org JUL/AUG :4 JAPhA 449

2 EXPERIENCE MEDICATION DISPENSING AFTER ELECTRONIC DISCONTINUATION The Patient Protection and Affordable Care Act created several provisions focused on preventive care, including the Medicare annual wellness visit (AWV). 1 AWVs are designed to ensure that preventive screenings are up-to-date, to assess health risks, and to update medical history, including medication use. 2 Primary care physicians have struggled to fulfill all required elements of AWVs while addressing the acute needs of their patients during their allotted visit times. 3 Research has begun to explore the feasibility of alternative care models in which the AWV is led by nonphysician health professionals, including pharmacists. 4 7 Preliminary work has described the pharmacistled AWV and demonstrated the financial implications of the AWV for pharmacists in primary care settings. 5 7 Park et al. showed that AWVs provide a way for pharmacists to support their salary in a physician s office. One study briefly detailed the interventions made by a pharmacist during an AWV. 5 Perceived barriers to the pharmacist-led AWV include lack of patient acceptance and physician support; however, there is no current information published assessing patient or physician satisfaction with the pharmacist-led AWV. Objective To build on these previous findings, the current article seeks to (1) quantify the nature and frequency of interventions made by a pharmacist providing AWVs; (2) determine the relationship between the number of medications taken and the interventions made during a Key Points Background: The pharmacist-led Medicare annual wellness visit (AWV) has been proposed as a way to further integrate clinical pharmacy services into primary care settings given the revenuegenerating potential of these visits. Little is known about the impact pharmacists can have on medication management during these visits and how receptive patients and physicians may be to the pharmacist-led AWV. Findings: During the AWV in a family medicine practice, pharmacists made 3.6 medication interventions per patient. The number of medications per patient was positively associated with the total number of medication interventions made. Physicians and patients reported satisfaction with the pharmacist-led AWV. pharmacist-led AWV; and (3) assess patient and physician satisfaction with pharmacist-led AWV. Setting The Mountain Area Health Education Center (MA- HEC) in Asheville, NC, houses a large family medicine residency with an emphasis on multidisciplinary care. A team of physicians, clinical pharmacists, behavioral medicine providers, interpreters, and nurses care for more than 15,000 patients. MAHEC was recognized as a Level 3 Patient-Centered Medical Home in Practice description At MAHEC, five fully integrated pharmacists provide collaborative drug therapy management to patients via North Carolina s clinical pharmacist practitioner (CPP) licensure. The CPP license allows pharmacists to independently initiate, adjust, and discontinue medications as well as order and interpret medication-related tests. 8 Pharmacists meet face-to-face with patients in pharmacotherapy clinics for comprehensive medication management and patient education. Practice innovation The implementation of pharmacist-led AWVs at MA- HEC was described previously. 7 Briefly, one pharmacist piloted the AWV clinic in April 2012 for three faculty physicians. The success of this pilot led to the expansion of services to include all patients in November As outlined by Medicare, patients are eligible for an AWV if they have had Part B coverage for 1 year and if they have not had a Welcome to Medicare Visit or a previous AWV within the past 12 months. A list of required components of the AWV can be found at the Centers for Medicare and Medicaid Services website. 9 Table 1 summarizes the standing orders developed based on the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommendations. 10,11 Updating the patient s medication list is one of the required components of the AWV; however, in the pharmacist-led AWV at MAHEC, services were expanded to include comprehensive medication management as described by the Patient-Centered Primary Care Collaborative. 12 The pharmacist used interventions permitted under the CPP license to resolve any medication-related problems identified during the AWV. Evaluation We completed a retrospective chart review of all patients who completed a pharmacist-led AWV between April 1, 2012, and January 31, 2013, to determine the nature and frequency of interventions made by the pharmacist. Two separate surveys were then administered to assess patient and physician satisfaction with the pharmacistled AWV. 450 JAPhA 55:4 JUL/AUG 2015 japha.org Journal of the American Pharmacists Association

3 MEDICATION DISPENSING AFTER ELECTRONIC DISCONTINUATION EXPERIENCE Table 1. Screening recommendations and actions taken by pharmacists during AWV Screening recommendations a Actions taken by pharmacists Abdominal aortic aneurism: men aged years who have ever smoked Complete standing order to imaging Breast cancer: women aged 40 years and older, every 1 2 years Complete standing order to radiology Cholesterol: men older than 35 years and women older than 45 years if they are at increased risk for coronary heart disease Order lipid panel Colorectal cancer: aged years Complete standing order to gastroenterology Depression: universal Alert PCP if PHQ9 > 5 Diabetes: all men and women with sustained blood pressure treated or untreated >135/80 mm Hg Order fasting blood glucose Falls prevention Refer to Falls Clinic if >1 fall or 1 fall with injury in past year Hearing Refer to PCP if patient reports difficulty Influenza vaccine: annually Order vaccine if visit is during influenza season Osteoporosis screening: women aged 65 years and older and younger women whose fracture risk is that of a 65-year-old white woman who has no additional risk factors Order DXA Pneumonia: aged 65 years or older, 1-time dose and patients meeting criteria for immunization <65 years Order vaccine Shingles: aged 60 or older, 1-time dose Give prescription for vaccine Td/Tdap: 1-time dose of Tdap for Td booster, then boost with Td every 10 years Order vaccine Source: Adapted from references 10 and 11. Abbreviations used: FOBT, fecal occult blood testing; PCP, primary care physician; PHQ, patient health questionnaire; DXA, dual-energy X-ray absorptiometry; Td, tetanus diphtheria; Tdap, tetanus diphtheria pertussis. a Based on recommendations of the United States Preventive Services Task Force and the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices. Mission Hospitals Institutional Review Board approved this project. Nature and frequency of interventions Interventions were divided into two main categories: medication and nonmedication interventions. We defined our medication interventions using the Patient- Centered Primary Care Collaborative framework for identifying medication-related problems, by assessing a medication for appropriateness, effectiveness, safety, and adherence. 12 Specific medication interventions were defined as new therapy recommended, dose/frequency/duration adjustment, interaction identified, duplicate/unnecessary medication discontinued, adverse effect addressed, and electronic health record medication list discrepancy resolved. A discrepancy in the patient s electronic health record medication list could include the following: a patient appropriately taking an unlisted medication, patient inappropriately taking an unlisted medication, and patient inappropriately or not taking a listed medication. We classified nonmedication interventions as one of the following: vaccination required, preventive screening referral placed, laboratory tests ordered, impairment identified, primary care provider (PCP) appointment made, and other. Vaccines were considered nonmedication interventions because pharmacists do not administer vaccines at this site. The clinic s workflow is designed for the medical assistants to administer vaccines ordered by the providers. Interventions classified as other included referral to a MAHEC clinic such as pharmacotherapy, falls, or osteoporosis clinic to further address a problem identified during the AWV; smoking cessation counseling provided; diet or exercise counseling provided; and additional routine screenings completed (i.e., thyroid stimulating hormone). Interventions were marked as complete if appropriate documentation was found in the note from the visit. Patient satisfaction A patient satisfaction survey was distributed to patients seen for pharmacist-led AWVs between April 1, 2012, and October 31, 2012, as an internal quality assurance measure. Patients were asked to use a 1 5 Likert scale to indicate their level of agreement or satisfaction with specific statements regarding their pharmacist-led visit. At the conclusion of the visit, the pharmacist gave the survey to the patient to complete and return to check out upon leaving. Physician satisfaction A physician satisfaction survey was developed to assess physician perceptions of the pharmacist-led AWV. The physician survey consisted of five statements assessed on a 1 5 Likert scale. The surveys were distributed and collected by the pharmacist at a faculty meeting on July 24, Analyses Two correlations were computed to ascertain the strength of the relationship between the number of med- Journal of the American Pharmacists Association japha.org JUL/AUG :4 JAPhA 451

4 EXPERIENCE MEDICATION DISPENSING AFTER ELECTRONIC DISCONTINUATION ications a patient was taking and the number of (1) medication interventions and (2) total interventions. Survey responses were compiled and the mean and median of each question was calculated. Results Data were collected on 69 patients. Baseline demographics are summarized in Table 2. Patients were taking a mean of 12.2 medications (SD = 5.1). The pharmacist made 589 interventions, the majority of which were related to medications. This resulted in an average of 3.6 medication interventions per patient. The most common medication intervention was identifying and correcting a discrepancy in the medication list. A summary of medication-related interventions is found in Table 3. Nonmedication interventions are summarized in Table 4. The pharmacist addressed 342 nonmedication interventions, averaging 4.9 per patient. The most common nonmedication intervention was vaccine-related interventions with each patient requiring a mean of 1.4 vaccines (SD = 1.2). Of these, 17% were referred back to the PCP for complete advanced care planning. Other reasons patients were referred back to the PCP included addressing chronic diseases and determining the need for preventive screening in situations where the patient fell outside of or did not agree with U.S. Preventive Services Task Force recommendations. The number of medications taken was positively associated with the number of medication interventions made (r = 0.37, P <0.01). The number of medications taken was not associated with the total number of interventions (medication and nonmedication) made (r = 0.13, P = 0.14). Patient and physician satisfaction survey responses are summarized in Table 5. Of the 51 patients seen during the time period in which satisfaction surveys were distributed, 32 surveys were collected (response rate 62.7%). Patients strongly agreed that the AWV was important for their overall health (mean 4.8, median 5) and disagreed that they were expecting a physical examination (mean 2.1, median 1). Patients were neutral about their preference of seeing their PCP for the AWV (mean 2.8, median 3). Patients strongly agreed that they will repeat the AWV next year (mean 4.9, median 5) and that Table 2. Baseline patient demographics (n = 69) Characteristics Result Age, years (mean ± SD) 74.0 ± 8.3 Female, n (%) 48 (69.6) Race, n (%) White 49 (71.0) Black 5 (7.3) Refused/unknown 13 (18.8) Other 2 (2.9) No. medications (mean ± SD) 12.2 ± 5.1 they would like to see the same provider (mean 4.8, median 5). Of the 17 faculty physicians, 10 were present for survey administration and all 10 surveys were collected (response rate 100%). Physicians agreed that patients are willing to see the pharmacist for their AWVs (mean 4.2, median 4) and strongly agreed that patients have benefited from the AWVs with the pharmacist (mean 4.9, median 5). Physicians strongly disagreed that they would prefer to conduct the AWVs themselves (mean 1.5, median 1). Discussion To date, three articles have described pharmacist-led AWVs. 5 7 This article builds on those by further detailing interventions made during the visit, determining if there is a relationship between the number of medications and interventions made, and presenting patient and physician satisfaction surveys. Pharmacists were able to address both medication and nonmedication interventions. Standing orders and a collaborative practice agreement allowed pharmacists to take direct action during the visit. This system allows for a more efficient and coordinated approach to care. Further studies are needed to assess whether interventions that require subsequent action by the patient (i.e., colonoscopy) are actually completed and, ultimately, if clinical outcomes are improved. The positive association between the number of medications taken and medication interventions suggests that comprehensive medication management by a pharmacist during the AWV is particularly useful in patients with a higher medication burden. In areas where pharmacists are limited, a useful strategy may be to have pharmacists conduct the AWV for patients with more extensive medication lists. The lack of association between medications taken and the total number of interventions demonstrates the benefit that the pharmacist may have on nonmedication interventions for all patients, regardless of the number of medications taken. This may reflect the effective use of standing orders to address the preventive care needs of the patient. Before implementation, we believed that barriers to the pharmacist-led AWV would include patient unwill- Table 3. Medication interventions made by pharmacists during AWV (n = 247) Total Interventions n (%) Medication list discrepancies identified/corrected 172 (69.6) New therapy recommended/initiated 27 (10.9) Dose/frequency/duration adjusted 14 (5.7) Discontinue duplicate/unnecessary medication 11 (4.5) Adverse effects addressed 11 (4.5) Rescheduled medication 6 (2.4) Interaction identified 6 (2.4) 452 JAPhA 55:4 JUL/AUG 2015 japha.org Journal of the American Pharmacists Association

5 MEDICATION DISPENSING AFTER ELECTRONIC DISCONTINUATION EXPERIENCE ingness to see the pharmacist, patient misconceptions of what the AWV entails, and physician reluctance to embrace the pharmacist-led AWV. The survey results suggested that many of these perceived barriers did not exist. Both patients and physicians were satisfied with pharmacist-led AWVs. Patients did not express concern over not seeing their physician during the visit. This was likely due to MAHEC s efforts to set clear expectations regarding visit components when scheduling patients. Results of the physician survey were also positive. We saw that physicians embraced the pharmacist-led AWV and believed their patients benefited from them. As team-based care evolves, the support of the physician is imperative to effectively implement clinical pharmacy Table 4. Nonmedication interventions made by pharmacists during AWV (n = 342) Total Interventions n (%) Vaccine required/administered 97 (28.4) Refer to PCP 59 (17.3) Positive impairment/functional status screening identified 54 (15.8) Laboratory tests ordered 50 (14.6) Preventive screening referral placed 47 (13.7) Other 35 (10.2) Abbreviations used: PCP, primary care physician. services. As the team leader, a physician champion can advocate for pharmacists to other stakeholders including patients, practice managers, and billing and/or compliance officers in order to gain the support required for successful integration. These results suggest that at this practice physicians welcomed pharmacist-led AWVs. This project demonstrates the positive impact of the pharmacist-led AWV in one academic, family medicine practice. As team-based, quality-driven care evolves, there will be increasing demand for pharmacy services in the ambulatory care setting. However, until provider status is achieved, the inability to adequately bill for services will continue to be a main barrier for fully integrating the clinical pharmacist. These positive results, combined with the revenue generating potential of the AWV, provide a compelling argument for using the pharmacist-led AWV as a vehicle to implement and augment clinical pharmacy services in the primary care setting. It is important to replicate this service at multiple different practice sites, including private practice, hospital-based clinics, and internal medicine practices, to assess the generalizability of this success to other settings. Limitations Assessing the nature and frequency of interventions by chart review was limited by how well the pharmacist documented the visit at the time of the encounter. Table 5. Patient and physician satisfaction survey results Participants Mean Median Patients (n = 32) On a scale from 1 to 5 where 1 is strongly disagree and 5 is strongly agree: During the visit I learned about things that I can do to improve my health I was expecting a physical exam during the visit I am comfortable discussing my health information with a clinical pharmacist. 5 5 I am just as comfortable discussing my health information for this visit with a clinical pharmacist as with my PCP I would rather see my PCP for this visit I will repeat this visit each year I would like to see the same provider next year for a Medicare wellness visit Teams of providers from multiple health care disciplines have the potential to improve the care I receive at the MAHEC Family Health Center This visit was important for my overall health This visit led me to make changes in my behavior to improve my health. 4 4 On a scale from 1 to 5 where 1 is very dissatisfied and 5 is very satisfied: How would you rate your satisfaction with the visit? How would you rate the care you received from the provider? Physicians (n = 10) On a scale from 1 to 5 where is 1 is strongly disagree and 5 is strongly agree: I have referred patients to Pharmacy AWV clinic My patients are willing to see the clinical pharmacist for their AWV My patients have benefited from seeing the clinical pharmacist for their AWV Knowing my patient had an AWV with the pharmacist frees me from needing to address health maintenance issues for that year I would prefer to conduct AWVs myself Abbreviations used: PCP, primary care physician; MAHEC, Mountain Area Health Education Center; AWV, annual wellness visit. Journal of the American Pharmacists Association japha.org JUL/AUG :4 JAPhA 453

6 EXPERIENCE MEDICATION DISPENSING AFTER ELECTRONIC DISCONTINUATION Some of the interventions required referrals to outside providers, but we did not assess whether patients acted on these interventions. To date, no data is available assessing the long-term impact of the AWV on patient outcomes. North Carolina s CPP license is very broad; pharmacists in other states may not have the same scope of practice to implement medication-related interventions. However, the majority of states have some type of collaborative practice agreements. In addition, all nonmedication interventions can be completed by the pharmacist through creating standing orders within the practice. Satisfaction surveys were used for internal quality assurance purposes and thus were not validated before use. Selection bias may exist for the physician survey since it was administered only to those in attendance at one faculty meeting. Further, this innovation occurred within an academic practice where patients and physicians are accustomed to working with pharmacists and thus may already have a more favorable opinion of their role on the team. Conclusion Pharmacists conducting AWVs were able to address both medication and nonmedication interventions for patients during an AWV. Patients and physicians were satisfied with the pharmacist-led AWV at one family medicine practice. This study showed that the pharmacist-led AWV provides the opportunity to expand pharmacist-provided direct patient care services in the primary care setting. References 1. The patient protection and affordable care act. Pub. L. No , 124 Stat 119 (March 23, 2010). pkg/plaw-111publ148/pdf/plaw-111publ148.pdf. Accessed July 16, Your Medicare coverage: preventive visit and yearly wellness exams. Accessed July 16, Cuenca AE. Making Medicare wellness visits work in practice. Fam Pract Manag. 2012;19(5): Tetuan TM, Ohm R, Herynk MH, et al. The affordable health care act annual wellness visits: the effectiveness of a nurse-run clinic in promoting adherence to mammogram and colonoscopy recommendations. J Nurs Adm. 2014;44(5): Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. Am J Health Syst Pharm. 2014;71(1): Thomas MH, Goode JV. Development and implementation of a pharmacist-delivered Medicare annual wellness visit at a family practice office. J Am Pharm Assoc. 2014;54(4): Park I, Sutherland SE, Ray L, Wilson CG. Financial implications of pharmacist led Medicare annual wellness visits. J Am Pharm Assoc. 2014;54: Clinical Pharmacist Practitioner. 21 NCAC 32T %20occupational%20licensing%20boards%20and%20commissions/chapter%2032%20 %20north%20carolina%20medical%20board/ subchapter%20t/subchapter%20t%20rules.html. Accessed July 16, Centers for Medicare & Medicaid Services. Quick reference information: the ABCs of providing the annual wellness visit (AWV). and Education/Medicare Learning Network MLN/MLNProducts/downloads/AWV_ chart_icn pdf. Accessed September 18, U.S. Preventive Services Task Force. USPSTF A and B recommendations: Page/Name/uspstf a and b recommendations./ Accessed September 18, Centers for Disease Control and Prevention. Immunization schedules. adult.html. Accessed September 18, McInnis T, Webb E, Strand L. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes. Patient-Centered Primary Care Collaborative, July media/medmanagement.pdf. Accessed October 5, JAPhA 55:4 JUL/AUG 2015 japha.org Journal of the American Pharmacists Association