Monday, October 24, :30 p.m. to 3:30 p.m. Regency Ballroom 3

Transcription

1 Current Research and Practice: Patient-Centered Team-Based Care Activity Number: L04-P, 1.75 hours of CPE credit; Activity Type: A Knowledge-Based Activity Monday, October 24, :30 p.m. to 3:30 p.m. Regency Ballroom 3 Moderator: Grace Kuo, Pharm. D., Ph.D., MPH Professor of Clinical Pharmacy, Associate Dean for Strategic Planning and Program Development, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego Agenda 1:30 p.m. Clinical Effectiveness of the Improving Health of at Risk Rural Patients (IHARP) Pharmacist-Physician Collaborative Care Model Gary R. Matzke, Pharm. D., FCCP. FASN Founding Director of ACCP/ASHP/VCU Congressional Health Policy Fellow Program; Professor of Pharmacotherapy and Outcome Sciences, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia 2:00 p.m. Integration of Clinical Pharmacy in a Chronic Care Management Team within an Accountable Care Organization (ACO): a report from the ACO Research Network, Services and Education (ACORN SEED) Tina Joseph, Pharm. D., BCACP Assistant Professor, Nova Southeastern University, Fort Lauderdale, Florida 2:30 p.m. A Population Health Intervention by PGY-2 Pharmacy Residents to Optimize Medication Management in Patients with Atherosclerotic Cardiovascular Disease (ASCVD) Joseph P. Vande Griend, Pharm. D., FCCP, BCPS Associate Professor, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, Colorado 3:00 p.m. Establishing a Common Language for Comprehensive Medication Management: Applying Implementation Science Methodologies to the Patient Care Process Carrie Martin Blanchard, Pharm. D. Postdoctoral Research Fellow, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina Conflict of Interest Disclosures Tina Joseph: no conflicts to disclose Grace Kuo: no conflicts to disclose Carrie Martin Blanchard: no conflicts to disclose Gary R. Matzke: no conflicts to disclose Joseph P. Vande Griend: no conflicts to disclose American College of Clinical Pharmacy 1

2 Learning Objectives 1. List benefits of patient-centered team-based care. 2. Compare and contrast delivery models of patient-centered team-based care. 3. Explain the value of a consistent model of patient-centered team-based care. 4. Define comprehensive medication management (CMM) and other terminology related to practice transformation. Self-Assessment Questions Self-assessment questions are available online at American College of Clinical Pharmacy 2

3 Practice Transformation Research Informing the Future Delivery of Healthcare: Insights from IHARP Gary R. Matzke, BS Pharm, PharmD, FCP, FCCP Professor VCU School of Pharmacy On behalf of the IHARP INVESTIGATOR TEAM Current Research and Practice: Patient-Centered Team-Based Care October 24, 2016

4 Essentials of the IHARP Care Model Ambulatory Care Patients identified by primary care provider (PCP) Provider Referral Initial enrollment interview Medication care plan and discharge medication list provided Hospital Encounter PCCP/PCP collaboration 72 hour discharge phone follow up In person comprehensive medication review Ongoing medication management Updated medication list sent to pharmacy when changes are made Read only Epic access to monitor patient s Community Pharmacy

5 Pharmacist s Intervention Identify medication related problems and propose interventions to resolve them Provide CMM and CDSM to optimize medication use and clinical outcomes Patients have scheduled visits with their primary care pharmacist Each primary care pharmacist staffs up to 4 clinics Coordination of care with hospital and community pharmacists Matzke GR, Czar MJ, Lee WT, Moczygemba LR, Harlow LD. Am J Health Syst Pharm 2016;73:e583 91

6 Patient Population Enrollment Criteria Inclusion criteria 18 years of age at enrollment Primary use of English for oral and written communication 2 chronic diseases (one of which must be asthma, CHF, DM, COPD, HTN, hyperlipidemia, or depression) 4 chronic prescription medications Have a telephone line available Exclusion criteria Terminal condition with life expectancy 6months

7 Primary Outcome Measures Clinical outcomes were assessed longitudinally from baseline to last visit and at defined time intervals. Patient, physician, and clinic staff satisfaction with IHARP were evaluated routinely. Health care services utilization of all patients for at least one year prior to and during their participation. Cost of ED and hospitalizations incurred by the Medicare patients at least one year prior to and during their participation.

8 Patient Enrollment Enrollment Total: 2,678 2,480 enrolled for at least one year Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March April May June July August Sept Oct Nov Dec Number Enrolled Primary Care Enrolled Hospital Enrolled

9 Patient Population Demographics IHARP PATIENTS Age 65.3 (13.0) Gender 57.4 % Female Race 87.3 % White 11.7 % Black 0.3 % Hispanic # Chronic Diseases 3.3 (1.3) Health Insurer 63.5 % Medicare 6.8 % Medicaid 17.1 % Commercial COMPARITOR PATIENTS Age 65.5 (14.2) Gender 57.9 % Female Race 87.9 % White 11.1 % Black 0.4 % Hispanic # Chronic Diseases 3.2 (1.2) Health Insurer 63.9 % Medicare 7.6 % Medicaid 16.8 % Commercial

10 Clinical Outcomes

11 Clinical Outcomes in Diabetic Patients IHARP versus Comparator IHARP PATIENTS COMPARATOR PATIENTS Clinical Measure N Baseline Value Follow up Value Mean Difference Intra group p value N Baseline Value Follow up Value Mean Difference Intra group p value Between Group p value A1c ± ± < ± ± SBP ± ± < ± ± DBP ± ± < ± ± LDL ± ± Total Cholesterol ± ± ± ± ± ±

12 Clinical Outcomes in Non Diabetic Patients IHARP versus Comparator IHARP PATIENTS COMPARATOR PATIENTS Clinical Measure N Baseline Value Follow up Value Mean Difference Intra group p value N Baseline Value Follow up Value Mean Difference Intra group p value Between Group p value SBP ± < ± ± DBP ± ± ± ± LDL ± ± Total Cholesterol ± ± ± ± ± ±

13 IHARP Diabetics and Non Diabetics with baseline values above goal Baseline versus Follow Up Outcome Measure Values All p values < SBP DBP LDL A1c x 10 Diabetic baseline Diabetic final Non Diabetic baseline Non Diabetic final

14 Comparator Diabetics and Non Diabetics with baseline values above goal Baseline versus Follow Up Outcome Measure Values All p values < SBP DBP LDL A1c x 10 Diabetic baseline Diabetic final Non Diabetic baseline Non Diabetic final

15 Difference between IHARP and Comparator Patients with baseline values above goal Mean Difference of Patients Outcome Measure Values p = p = p = P = p = p = SBP DBP LDL IHARP Diabetic Comprator Diabetic IHARP Non Diabetic Comparator Non Diabetic

16 Time Course of Changes in Clinical Values IHARP Diabetic Patients with baseline values above goal A1C X 10 OR BLOOD PRESSURE (MMHG) OR LDL (MG/DL) Baseline Baseline to 6 months 6 12 months months SBP DM DBP DM LDL DM A1c x

17 Patient Satisfaction with IHARP Program I would return to my IHARP pharmacist. N=775 I would encourage family members to consult with an IHARP pharmacist. N=775 My IHARP pharmacists helped me avoid having problems with my medications I would request that Carilion Clinic continue the IHARP program. N= Disagree Neutral Agree

18 Physician Satisfaction with IHARP Program I would like to work with pharmacists in the same way in the future I am satisfied with the collaboration with the IHARP pharmacists The IHARP program has enhanced positive outcomes for my patients The pharmacists have reduced the time I spend on medication reconcilliation

19 Lessons Learned Data collection and archiving were challenging but essential Continual monitoring of data (CQI) allowed for adjustment of procedures to facilitate achievement of desired outcomes Access to EMR data greatly facilitated continuity of care The role for a pharmacist on a primary care team is not apparent to everyone Building relationships with staff is as important as building relationships with patients Adherence is sometimes all about money

20 Lessons Learned Collaboration with community pharmacies and Carilion owned retail pharmacies a challenge Medication reconciliation process system and community wide coordination is needed Increased MAP needs recognized required changes in staffing and communication

21 Conclusions The addition of comprehensive medication and disease state management into team based PCMH resulted in significant improvements in clinical outcomes. PCMH staff, physicians, and patients expressed a high degree of satisfaction with the pharmacists contribution to the patient care team. Health services utilization was reduced and suggests a strong return on investment. The question is to whom.

22 IHARP PROJECT TEAM Leadership William Lee, DPh, MPA, FASCP Michael J. Czar, RPh, PhD Anthony R. Stavola, MD Gary R. Matzke, PharmD FCP, FCCP Leticia R. Moczygemba, PharmD, PhD Carilion Partners Michael Jeremiah, MD Charles Tarasidis, PharmD Chad Alvarez, PharmD Clinical Pharmacists Karen J. Williams, PharmD, BCPS Heidi D. Wengerd, PharmD Kelley D. Hall, PharmD Courtney P. Dickerson, PharmD Tanvi Patil, PharmD Nikisa Blevins, PharmD Ann Lucktong, PharmD, BCACP Randi Earls, PharmD IHARP Staff Kristy Cornell Christine Riddell Andrea Pierce, PharmD Della Varghese, PharmD, PhD Bhavini Kaneria, MS Samantha Marks, PharmD Alicia Johns

23 Questions PHARMACY

24 Integration of Clinical Pharmacy in a Chronic Care Management Team within an Accountable Care Organization: A report from the ACO Research Network, Services, and Education Tina Joseph, PharmD, BCACP Nova Southeastern University College of Pharmacy Fort Lauderdale, Florida October 24, 2016

25 Question 1 Which of the following is true regarding ACOs? A. Reimbursement is based on 33 quality measures B. Minimum of 5,000 Medicare beneficiaries must be assigned to the ACO C. Must have processes in place that promote patient centered care and evidence based medicine D. All of the above

26 Question 2 Which of the following condition(s) must be met to bill for CCM? A. 20 minutes of face to face contact per calendar month B. Patient must have 1+ chronic conditions expected to last at least 12 months or until the death of the patient C. Allow 24/7 access to that electronic health record (EHR) for staff to respond to urgent care needs D. All of the above

27 Question 3 Which of the following is true concerning pharmacist involvement in the multidisciplinary team? A. Pharmacists are more likely to recommend costlier drugs B. Having a pharmacist on the multidisciplinary team negates the need to select and follow guidelines C. Pharmacist involvement has been shown to reduce ER visits and hospital readmissions D. Patient and physician satisfaction tend to decrease

28 What is an ACO? Network of healthcare providers that receives reimbursement based on metrics of Quality Care, Patient Satisfaction, and Reductions in Cost of Care Centers for Medicare and Medicaid Services. Accountable Care Organizations. Jan Available at Fee for Service Payment/ACO/index.html?redirect=/ACO/. Accessed on October 6, 2016

29 ACO Shared Savings Requirements Become accountable for the care delivered Commit to a 3 year agreement Formal legal structure Establish and maintain a shared governance structure Sufficient number of primary care providers to ensure that at least 5,000 Medicare beneficiaries will be assigned to the ACO Have processes in place that promote patient centered care, evidence based medicine, care coordination, and quality and cost measures Centers for Medicare & Medicaid Services. Summary of Final Rule Provisions for Accountable Care Organizations under the Medicare Shared Savings Program April 2015 Available at fee for service payment/sharedsavingsprogram/downloads/aco_summary_factsheet_icn pdf. Accessed on October 6, 2016.

30 ACO Quality Measures ACO Quality Measures Patient/Caregiver Experience #1 7 Care Coordination/Patient Safety #8 13 Preventive Health #14 21 At risk Population #22 33 Centers for Medicare and Medicaid Services. ACO Shared Savings Program Quality Measures: Table 33 ACO Quality Measures. Available from: Fee for Service Payment/sharedsavingsprogram/Downloads/ACO Shared Savings Program Quality Measures.pdf. Accessed on October 6, 2016

31 Chronic Conditions Account for Most Spending TOTAL MEDICARE MEDICAL SPENDING MEDICARE SPENDING ON 65+ POPULATION 65+ WITH 2 OR MORE CHRONIC CONDITIONS 65+ WITH 6 OR MORE CHRONIC CONDITIONS $324 billion $261 billion $246 billion $135 billion 34 million 25 million 19 million 4 million Hoyer, Meghan. Nation s Sickest Seniors Reshape Healthcare. USA Today. Available from: costs seniors sick chronic conditions/ /. Accessed on October 6, 2016.

32 What is Chronic Care Management? 2+ chronic conditions* 20 mins nonface to face contact $42.91/ patient per month *Alzheimer s disease, arthritis, asthma, atrial fibrillation, cancer, COPD, depression, diabetes, heart failure, hypertension, ischemic heart disease, or osteoporosis American College of Physicians. Chronic care management tool kit: what practices need to do to implement and bill CCM codes 2015 Available from: Accessed on October 6, 2016.

33 Steps for Implementing CCM 1. Identify patients with 2+ chronic conditions 2. Enroll patients and sign consent forms 3. Engage patients 4. Follow up with patients 5. Practice bills Medicare

34 Accountable Care Options, LLC Network of 36 primary care physician offices located in South Florida Expansion of CCM/TOC team in medical assistant 2 paramedics 1 mental health coach 1 nurse practitioner

35 Nova Southeastern University College of Pharmacy Private, not for profit university Offers entry level Doctor of Pharmacy Program in 3 sites Fort Lauderdale, Palm Beach Gardens, and San Juan ACO Research Network, Services, and Education (ACORNSEED) Established in 2014 and composed of 5 pharmacy practice faculty, 1 clinical pharmacist, and 1 ACO fellow Purpose: Prepare students for innovative healthcare models and provide benefit to value based healthcare systems

36 CCM Team Vision: Provide optimal care of patients and work to improve ACO quality benchmark measures Daily, weekly or monthly follow up of patients Educational classes for patients that focus on chronic disease state management CCM Grand Rounds: Meeting of a multidisciplinary team on Friday morning to discuss high risk, complicated patients Goals: Promote professional development and optimal patient care practices

37 Primary Care Physician Medical Assistants Paramedics Administrative Team Patient Mental Health Counselor Pharmacists Palliative Care (DO/NP) Nurse Practitioner

38 Results: Total Cost Group (N=45) Total Costs 2015 (First 6 months) Total Costs 2016 (First 6 months) Percent Change ACO beneficiaries $775, $420, %

39 Results: Emergency Room Visits 100% 111%

40 Results: Inpatient Visits 55% 66%

41 Lessons Learned Start small and continue to build Teams do not replace the physician patient relationship, but rather enhance Communication among team members needs to be efficient Mechanisms for billing are still being evaluated Multidisciplinary training is necessary for future healthcare professionals

42 Acknowledgements Nova Southeastern University/ ACORNSEED Renee Jones, PharmD, CPh Matthew Seamon, PharmD, Esq. Genevieve Hale, PharmD, BCPS Stephanie Gernant, PharmD, MS Matthew Schneller, PharmD Cynthia Moreau, PharmD Yesenia Prados, PharmD Accountable Care Options, LLC Richard Lucibella, MHS, MBA Haidy Rodriguez Janice Del Pilar, MSEd, LMHC Melissa Sedli Joe Walsh, MAG, NRP Elizabeth Lucas, MA Leonard Hock, DO, MACOI, CMD, HMDC, FAAHPM Margaret Pizarro, ARNP

43 Question 1 Which of the following is true regarding ACOs? A. Reimbursement is based on 33 quality measures B. Minimum of 5,000 Medicare beneficiaries must be assigned to the ACO C. Must have processes in place that promote patient centered care and evidence based medicine D. All of the above

44 Question 1 Which of the following is true regarding ACOs? A. Reimbursement is based on 33 quality measures B. Minimum of 5,000 Medicare beneficiaries must be assigned to the ACO C. Must have processes in place that promote patient centered care and evidence based medicine D. All of the above

45 Question 2 Which of the following condition(s) must be met to bill for CCM? A. 20 minutes of face to face contact per calendar month B. Patient must have 1+ chronic conditions expected to last at least 12 months or until the death of the patient C. Allow 24/7 access to that electronic health record (EHR) for staff to respond to urgent care needs D. All of the above

46 Question 2 Which of the following condition(s) must be met to bill for CCM? A. 20 minutes of face to face contact per calendar month B. Patient must have 1+ chronic conditions expected to last at least 12 months or until the death of the patient C. Allow 24/7 access to that electronic health record (EHR) for staff to respond to urgent care needs D. All of the above

47 Question 3 Which of the following is true concerning pharmacist involvement in the multidisciplinary team? A. Pharmacists are more likely to recommend costlier drugs B. Having a pharmacist on the multidisciplinary team negates the need to select and follow guidelines C. Pharmacist involvement has been shown to reduce ER visits and hospital readmissions D. Patient and physician satisfaction tend to decrease

48 Question 3 Which of the following is true concerning pharmacist involvement in the multidisciplinary team? A. Pharmacists are more likely to recommend costlier drugs B. Having a pharmacist on the multidisciplinary team negates the need to select and follow guidelines C. Pharmacist involvement has been shown to reduce ER visits and hospital readmissions D. Patient and physician satisfaction tend to decrease

49 Integration of Clinical Pharmacy in a Chronic Care Management Team within an Accountable Care Organization: A report from the ACO Research Network, Services, and Education Tina Joseph, PharmD, BCACP Nova Southeastern University College of Pharmacy Fort Lauderdale, Florida October 24, 2016

50 A Population Health Intervention by PGY2 Pharmacy Residents to Optimize Medication Management in Patients with Atherosclerotic Vascular Disease (ASCVD) Joseph Vande Griend, PharmD, FCCP, BCPS, CGP Associate Professor and Assistant Director of Clinical Affairs University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Co Authors: Michael S. Kelly, PharmD, Jessica L. Norman, PharmD Alvin B. Oung, PharmD, Sara A. Wettergreen, PharmD Joseph J. Saseen PharmD

51 Clinical Pharmacy and Family Medicine Collaboration at University of Colorado 3 pharmacist faculty, pharmacy residents 1998: A.F. Williams Family Medicine Center (Medical Residency Training Clinic) 2000: University of Colorado Hospital (Inpatient Family Medicine Service) 2011: Park Meadows Clinic 2013: Boulder Clinic 2014: Westminster Clinic* Distant from main University campus *PGY-2 Pharmacy Resident support started in 2014

52 Outlying Family Medicine Clinical Pharmacy Service Population Health approach Definition of population health Clinical pharmacist and PGY2 resident onsite ½ day weekly at each clinic with offsite support through the EHR Development of collaborative working relationship Prospective clinical pharmacy comprehensive medication management (CMM) Utilizing the CP2 Score, PGY2 residents targeted patients with ASCVD from July 2015 through December 2015 Statin therapy, diabetes, HTN, antiplatelets, vaccines Team based comprehensive medication management When medication related problems were identified, Clinical Pharmacy Consultation note was placed in EHR prior to patient appointment Provider consultation in person when available

53 Clinical Pharmacy Priority (CP2) Score CP2 Score development Programmed within the EPIC EHR using ICD 9/10 codes and patient specific data Cross section report of the upcoming week s appointments, with prioritized scores, generated each Friday Previously shown to identify patients who are most likely to have medication related problems Ongoing prospective clinical pharmacy review to prioritize patients for CMM

54 CP2 Score (range: 0-21 points) Criteria Diagnosis - Diabetes, HTN, Vascular disease - COPD, Heart failure, Depression Score 2 points each 1 point each Age (years) < 65, 65 to 75, > 75 0, 1, 2 points egfr < 45 ml/min A1c > 7.9%, > 8.9% BP > 140/90 (including average of last 3) BP > 160/100 (including average of last 3) Items on medication list < 3 3 to 5 6 to 9 > 9 1 point 1, 2 points 1 point 2 points 0 points 1 points 2 points 4 points Vande Griend JP, Saseen JS, Bislip D, et al. Prioritization of patients for comprehensive medication review by a clinical pharmacist in family medicine. J Am Board Fam Med 2015;28:

55 Justification 223 patients reviewed; 176 medication recommendations Overall Patient Demographics (n=223) Mean age 69.5 years Diabetes diagnosis 36.8% Hypertension diagnosis 75.8% Depression diagnosis 21.5% Elevated blood pressure* 6.7% Elevated A1c# 6.7% Mean number of items on medication list 12.7 items Mean CP2 Score 9 *Last BP > 140/90 and average of last 3 BP > 140/90 #Last A1c > 7.9%

56 Patient characteristics in those with and without identified medication related problems (MRPs) Characteristic Patients with MRPs Mean age (years) Diabetes diagnosis (%) HTN diagnosis (%) Depression diagnosis (%) Elevated blood pressure (%)* Elevated A1c (%)# Mean number of items on med list Mean CP2 Score *Last BP > 140/90 and average of last 3 BP > 140/90 #Last A1c > 7.9% Patients without MRPs

57 Justification Most common medication related Common recommendations problems identified Needs additional therapy (107) Vaccine (85), Statin (8), Antiplatelet (7) Blood pressure lowering (1), Antidiabetic (1) Unnecessary drug therapy (11) ER niacin not indicated (4), gemfibrozil not indicated (2), ezetimibe not indicated (2) Wrong dose (23) High potency statin needed (16), diabetes medication dose too low (4), blood pressure dose too low (3)

58 Justification Percentage of patients reviewed with at least one MRP 61% 39% At least one MRP No MRPs Percentage of recommendations implemented by provider 50% 50% Implemented Not Implemented

59 Recommendations with the highest implementation rate

60 Adaptability CMM by PGY2 Ambulatory Care residents identified MRPs in approximately 40% of patients with ASCVD The acceptance rate of recommendations was similar to those seen in previously published clinical pharmacy studies 1 9 Less than 50% acceptance: Offsite MTM service or community pharmacy utilizing fax 55% to 90% acceptance: hospital, long term care, primary care This intervention could be used by other family medicine clinics, but may be improved by using collaborative practice agreements to optimize resolution of identified MRPs 1. Fam Med. 2014; 46(5): J Am Board Fam Med. 2015; 28: J Am Pharm Assoc. 2010; 50(3): J Clin Pharm. 2012; 34(2): J Manag Care Pharm. Jun 2011;17(5): Consult Pharm. Jan 2011;26(1): Am J Geriatr Pharmacother. Mar 2007;5(1):40-47J 8. Am Pharm Assoc (2003). Nov-Dec 2008;48(6): J Am Pharm Assoc (2003). Sep-Oct 2012;52(5):

61 Significance This population health intervention improved quality of care for patients with ASCVD at three family medicine clinics Using PGY2 Ambulatory Care residents to deliver clinical pharmacy services in family medicine clinics can improve medication management for patients with ASCVD

62 Population health strategies for medication management All strategies should efficiently and effectively target the population of patients needing the benefit 8 key elements for effective collaboration 1 1) Pharmacist with clinical experience 2) Pharmacist patient relationship 3) Access to EHR 4) Patient interview by the pharmacist 5) Patient referral from PCP 6) Face to face meeting with pharmacist and PCP to discuss 7) Action plan to implement recommendations 8) Follow up 1. Drugs and Aging 2013;30:

63 Optimizing the Collaborative Working Relationship (CWR) Physician, nurses, medical assistants Trust Professional relationship Communication Access to EHR Two-way Communication CWR Patient Trust Professional relationship Communication Pharmacist

64 Ongoing initiatives Ongoing prospective medication review targeting ASCVD and other clinical metrics Hypertension metrics important within UCHealth system Last blood pressure for patients aged years Average of last 3 blood pressures Pilot program utilizing clinical pharmacist at outlying clinics Retrospective chart review to identify reasons for uncontrolled BP HTN considered a Critically Important Condition so patients with HTN have regular visits Prospective clinical pharmacist review Collaborative practice agreement and Chronic Care Management

65 Establishing a Common Language for Comprehensive Medication Management: Applying Implementation Science Methodologies to the Patient Care Process Carrie Blanchard, PharmD Post-doctoral Fellow in Implementation Science UNC Eshelman School of Pharmacy Chapel Hill, NC October 24, 2016

66 Medication Therapy Management Interventions in Outpatient Settings: A Systematic Review and Meta-analysis Evidence is insufficient for most outcomes because of inconsistency and imprecisions that stem from underlying heterogeneity in populations and interventions. MTM may reduce DTPS, nonadherence, and lower utilization and costs, but evidence inconsistent. JAMA Intern Medicine 2015.

67 Barriers to Widespread Implementation Limited understanding of the medication management intervention itself (i.e., unclear to many what it is and how one would deliver it) Limited targeting of patients most in need Wide variability and inconsistency in implementation across care settings Wide variability in outcomes Fidelity lacking in most studies (is there really no impact or is the lack of impact failure to effectively implement) Limited reimbursement to support such services in primary care

68 Research to Practice SCIENCE IMPLEMENTATION PRACTICE

69 Formula for Success Effective Innovations Effective Implementation Enabling Contexts Significant Outcomes

70 Active Implementation Frameworks (AIF) EFFECTIVE & USABLE INNOVATIONS What exactly are people saying and doing that makes things better for our intended beneficiaries? STAGES What steps lead to successful implementation? DRIVERS What critical supports are needed to make this change? What is the infrastructure? TEAMS Who takes responsibility for and helps guide the change process? IMPROVEMENT CYCLES How can we create more hospitable environments, efficiently solve problems and get better? Usable Innovations Stages Drivers Teams Cycles

71 Why Establish a Usable Innovation?

72 Is it a Usable Innovation? Fidelity Assessment Operational Definitions CMM Patient Care Process Clear Description Essential Functions

73 Developing a Common Language Stages. Common Language

74 Methods Document Review Scoping Literature Review Semistructured Interviews Vetting & Consensus Usability Testing Reviewed CMM guidelines, pharmacy curriculum material, and CMM documentation resources Comprehensive review of published work related to medication management Conducted interviews with key stakeholders Document vetted by Grant Steering Committee and practice sites Rapid cycle Plan-Do-Study-Act cycles testing of the CMM Common Language in real-world practice May-July 2016 May-August 2016 August-October 2016 September- October 2016 Forthcoming field work

75 Guiding Principles Efforts to optimize medication use through CMM take a whole-person approach and target patients who will gain the most benefit. Building a patient-centered relationship is essential to the patient care process. The pharmacist assumes responsibility for ensuring the safe, effective, appropriate, and convenient use of medications by patients. Providing continuity of care, follow-up, and clinical monitoring are key to sustaining desired outcomes. Consistent care processes enable rapid uptake and spread of CMM as it maximizes efficiencies, both for pharmacists and for integration into the larger health care team.

76 Essential Functions Collect Relevant Information Monitor and Evaluate through Follow-up Assess the Information Implement the Care Plan Develop the Care Plan

77 Operational Definitions Essential Function: Implement the Care Plan Review the care plan with the patient and assure understanding and agreement. Implement recommendations (the pharmacist), where appropriate. Communicate the care plan to the rest of the care team, indicating where implementation of the plan is required by a member of the team. Communicate instructions for follow up with the patient. Document all drug therapy problems. Document the encounter and plan. Coordinate with other providers to ensure that patient follow-up and future encounters are aligned with the patient s medical and medication-related needs. Arrange follow-up in a time frame that is clinically appropriate for the specific patient, the medical conditions being monitored, and the drug therapy being taken. This will vary with each patient.

78 Operational Definitions Revisit the medical record to obtain updates on the patient s clinical status and achievement of clinical goals. Essential Function: Monitor and Evaluate through patient follow-up Conduct ongoing assessments (whether face-to-face or via phone) and refine care plan to optimize medication therapy and ensure that individual goals are achieved. Reassess the patient to determine if any new drug therapy problems have developed. Document the identification of new drug therapy problems and the resolution of previously identified drug therapy problems. Repeat the essential functions of CMM to ensure consistency in process and continuity of care.

79 Next Steps Incorporate feedback from clinical pharmacists at sites Complete 1:1 interviews with select clinical pharmacists Finalize the Common Language document and distribute to all sites Develop fidelity assessment tool Conduct usability testing (Plan-Do-Study-Act cycles) Refine Common Language document over time, as needed

80 A special thank you to ACCP and the ACCP Research Institute!