4/3/2014. Objectives. Who Is in the Audience? Pharmacists in the Patient Centered Medical Home. Amber K. Fisher PharmD, BCPS, BCACP Boise VA, 2014

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1 Pharmacists in the Patient Centered Medical Home Amber K. Fisher PharmD, BCPS, BCACP Boise VA, 2014 Objectives Define the concept of Patient Centered Medical Homes (PCMH) Discuss the pharmacist s role in and barriers to interprofessional education, collaboration and practice Explore ways for pharmacists in the community to foster interprofessional education and practice Discuss the pharmacist s role in PCMH 1 Who Is in the Audience? 2 1

2 The Patient Centered Medical Home An approach to the delivery of primary care that is: Patient-centered:A partnership among practitioners, patients, and their families ensures that decisions respect patients wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care. Comprehensive:A team of care providers is wholly accountable for a patient s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports. Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations. Committed to quality and safety:clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health. 3 The Patient Centered Medical Home A strategy that many organizations are using/working toward. Advocates bringing together a broad range of skills and perspectives Balance of skills is critical for physical, emotional, and social needs of patients. The team may include: primary care physicians nurse practitioners and physician assistants nurses pharmacists social workers health coaches mental health professionals The composition should depend entirely on each patient's needs. 4 Case: A new patient at the Family Practice Residency Clinic Dale is a 36 year old male patient. He is recently divorced, lives alone, and wants to have a stronger relationship with his 2 children. Chief Complaint: New patient in clinic today. He needs medication refills. Past Medical History: Hypertension lisinopril 10mg daily Anxiety takes something, doesn t know what it is Hyperlipidemia simvastatin - unknown dose Pre-Diabetic recent fasting bgs = , no HgA1c History: Today, one hour appointment with the intern. He has a job interview later today. The LPN does vitals and new patient checklist including a positive screen for alcohol abuse. The visit ends up taking 2 hours mostly waiting for the intern to report to supervisor HOW DOES THE TEAM HELP THIS PATIENT TODAY? 5 2

3 The Patient Centered Medical Home How do we learn the roles of our interprofessionalteam members? 6 The Patient Centered Medical Home What if health professionals entered the workforce trained to optimally function in a team care model? 7 Patient-Aligned Care Teams (PACT) 8 3

4 The REACHE Center Regional Enhancement of Ambulatory Collaboration and Health Education Boise VA Center of Excellence in Primary Care Education Funded Programs Co-Directors: C. Scott Smith, MD and Melanie Nash, MSN, ANP Academic Partners: Gonzaga University School of Nursing University of Washington School of Medicine Idaho State University School of Pharmacy Co-Directors: Mimi Singh, MD, MS and Sharon Watts, DNP, RN-C, CDE Academic Partners: Case Western Reserve University School of Nursing Cleveland Clinic Foundation Co-Directors: Rebecca Brienza, MD, MPH and Susan Zapatka, MSN, NP Academic Partners: Fairfield University School of Nursing Yale University School of Medicine Co-Directors: Joyce Wipf, MD and Laura Angelo, MSN, ANP Academic Partner: University of Washington Schools of Medicine and Nursing Co-Directors: Rebecca Shunk, MD and Susan Janson, DNSc, ANP Academic Partner: University of California at San Francisco Schools of Medicine and Nursing 10 Trainees in Boise VA Center of Excellence Nurse Practitioner Pharmacy Physician Psychology 11 4

5 Interprofessional Education 12 World Health Organization Model 13 It All Starts in the Classroom 14 5

6 What Is Interprofessional Education? World Health Organization 2010 Interprofessional education occurs when two or more professions learnabout, from and with each other to enable effective collaboration and improve health outcomes. World Health Organization Interprofessional Education in Pharmacy Schools 16 Interpr0fessional Education in Pharmacy Schools Often, pharmacy schools are in close proximity to other health professions colleges What is the benefit of learning alongside other professional students? Medicine Behavioral Health Nursing/Advanced Practice Nurses Physician Assistants Behavioral health Dental Physical Therapy Social Work 17 6

7 Video Clip University of New Mexico 18 Interprofessional Education Activities Emphasize Patient-centered care Define essential members of the team Simulation exercises reflect real-world experience Allow input from all existing disciplines expertise & knowledge Use existing models successfully implemented elsewhere Discussion/reflection on discipline-specific stereotypes, cultures, education, values and training ACCP White Paper. InterprofessionalEducation: Principles and Application. A Framework for Clinical Pharmacy. Pharmacotherapy 2009;29(3):145e-164e. 19 Why is Interprofessional Education important? Train health professionals to be workforce-ready Scarce resources & poor access to primary care worldwide has prompted boundary stretching for many health professionals. Expanding Roles resulting from MD shortages in Primary Care Opportunities for NP and PA to provide Primary Care Expanding roles for Pharmacists 20 7

8 March 18, 2014 Legislation Recognizes Pharmacists As Medicare Providers, Allows Payment A bill introduced in the House of Representatives on March 11 would allow the Medicare program to directly reimburse pharmacists for their services in medically underserved communities. The bill, which ASHPstrongly supports, would amend the Social Security Act to recognize pharmacists as providersunder Medicare Part B. Representatives Brett Guthrie (R-Kentucky), G.K. Butterfield (D-North Carolina), and Todd Young (R- Indiana) jointly called their legislation a "common-sense bill." Read more 21 Interprofessional Practice or THE PATIENT CENTERED MEDICAL HOME OOINTERPROFESSIONAL PRACTICE R 22 The Patient-Centered Medical Home 23 8

9 Interprofessional Practice Important Components PatientOutcomes drive team function Leadership willing to support and sustain the team Electronic Medical Record RN Care Manager Each member works at top of their scope Each member understands other members roles and articulates their own Patientsare engaged and involved Effective collaboration Shared responsibility and decision making Interprofessionalcompetencies are practiced and valued by all members Team reflection Team activities Celebration of success Data gathering/analysis PatientOutcomes are measured and improved (quality improvement) 24 Interprofessional Practice NO! Proactive Care YES! Concept courtesy of C.Scott Smith, MD 25 Interprofessional Practice Multidisciplinary Team A team of professionals who care for patients independently. Care is subdivided and handled by each professional separately. Interdisciplinary Team A team of professionals who coordinate care of patients. The team shares responsibility for patient goals and outcomes. Transdisciplinary Team A team of professionals who understand each others knowledge/skills and approach to enable seamless collaborative decisions on all the patient s problems. ACCP Position Statement: InterprofessionalEducation and Practice.Pharmacotherapy 2009;29(7): ACCP White Paper. InterprofessionalEducation: Principles and Application. A Framework for Clinical Pharmacy. Pharmacotherapy 2009;29(3):145e-164e. 26 9

10 How do I develop more Collaborative Practice skills? Core Competencies for Interprofessional Collaborative Practice Report of an Expert Panel May 2011 Sponsored by the Interprofessional Education Collaborative Core Interprofessional Competencies 1. Values/Ethics for Interprofessional Practice Place the interests of patients and populations at the center of interprofessional health care delivery. 2. Roles and Responsibilities Communicate one s roles and responsibilities clearly to patients, families, and other professionals. Understand others roles and responsibilities and act accordingly to improve patient care 3. Interprofessional Communication Listen actively, and encourage ideas and opinions of other team members. 4. Teams and Teamwork 5. Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care

11 Overlap of Professional Roles in Primary Care NP/PA + MD + Pharmacist Shared Areas: Chronic Disease Management Medication Management Pharmacist MD + NP/PA Shared Areas: Diagnosis Prescribing NP/PA Psychologist ALL Professions Shared Areas : Motivational Interviewing Patient Assessment Shared decision making Education/ counseling Physician 30 Example Project Analysis of Differences between Boise Training Disciplines Mechanistic Find It Fix It Relational Engage Empathize Educate Enlist MD PharmD NP PsyD 31 Interprofessional Collaboration for Trainees Exposure starts early in professional training (university) Interprofessionaldidactic sessions Simulations Pre-professionals begin to understand what roles their colleagues will have Practice-based experience occurs later in training Simulations Modeling by preceptors/mentors Experiential rotations in interprofessionalsettings (inpatient rounds, specialty disease management, etc.) Residency programs Solidifies the personal role on the team Solidifies others role on the team 32 11

12 How to Incorporate Interprofessional Collaboration into your practice site Model collaborative attitudes and practices Patients Technicians Other health care providers Make you and your practice site available To your patients To trainees Other professionals Network with other professionals in your area Prescribers, nurses, other pharmacists, etc. Start a new service/program that encourages you, staff, and trainees to collaborate with other professionals Find a need in the community/institution (the prescribers might be able to tell you what is needed!) and provide that service. Example: Partner for Promotion at Ohio State University 33 Guiding Metaphor Reflective Learning Formal Instruction Learners & Faculty Practice Environment 34 Barriers to Interprofessional Practice Hierarchical team structure Professional culture and silos (theirs and ours) Lack of knowledge another professional s role, education, competency Lack of dedicated time to develop team Lack of willingness to participate Lack of understanding of benefits to patients Inability to work at top of scope of practice (trumped by other duties) Poor staffing levels Lack of leadership support 35 12

13 Case Patient at The Local Community Pharmacy Sue is a 67 y/o female who comes to your pharmacy for the first time. She presents 4 prescriptions Topamax (topiramate) 50 mg pobid Benicar (olmesartan) 20mg po QD Amlodipine 5mg po QD Citalopram 40mg po QD After asking her about medication history and demographic info, she reports allergies to lisinopril(cough), has high blood pressure and migraines, and that the only new medication today is Topamax and she doesn t remember what it is for. She has been receiving samples of Benicar for one month. She has a high copay insurance plan. YOUR PHARMACY STUDENT IS ASSIGNED TO HELP THIS PATIENT. WHAT SHOULD THE STUDENT DO TO BEST ASSIST THIS PATIENT? 36 What Can a Pharmacist do as a member of PCMH? Accountable Care Organizations/Hospitals/Health Systems Care Transitions/Coordination Medication Adherence Medication Safety Population Health Academic Detailing (safe & effective alternatives, cost-savings) Community Pharmacies Medication Therapy Management Immunizations Assessment of Adherence Primary Care Practices Chronic Disease Management Performance Metrics Patient Education Medication Reconciliation 2014 LEAVITT PARTNERS 37 Throughout this decade, the Institute of Medicine s Quality Chasm report series has consistently articulated the role of pharmacists in promoting and assuring the quality and safety of medication use. It its 2000 report, the IOM states that because of the immense variety and complexity of medications now available the pharmacist has become an essential resource and thus access to his or her expertise must be possible at all times

14 Patient Centered Primary Care Collaborative 39 Re-Visit our Family Practice Case: Dale Dale is a 36 year old male patient. He is recently divorced, lives alone, and wants to have a stronger relationship with his 2 children. Chief Complaint: New patient COMING TO CLINIC IN 2 WEEKS. He will need medication refills. Past Medical History: records from previous provider show: Hypertension: metoprolol Depression Hyperlipidemia simvastatin 10mg Pre-Diabetic Blood Chem Panel -> glucose = 131 Problem list indicates Alcohol Dependence HOW DOES THE TEAM PLAN TO PROACTIVELY PLAN FOR THIS VISIT? 40 Test Questions Test Questions: 1. List the important components of a Patient Centered Medical Home: 2. InterprofessionalEducation is an important step in preparing health professionals to be workforce-ready and a.isrequired per ACPE (Pharmacy School Accreditation Standards) b. Only includes MD, RN, and pharmacy students c. May involve simulation activities d. Mostly happens at large universities e. Should be incorporated into Pharmacy Practice Experiences (IPPE and APPE) f. a, c, and e are correct 3. Important components of a successful InterprofessionalPractice include: a. All members understand the roles of the other members b. Each member works at the top of their scope of practice c. Each member takes full responsibility for their aspect of patient care d. Proactive patient care is prioritized e. Patient needs are central to all aspects of practice f. All of the above 4. The pharmacist s role in PCMH is evolving. Areas for expansion or innovation include: 41 14

15 QUESTIONS? 42 15