Improving Health Outcome Measures and Medication Safety through Integration of Clinical Pharmacy Services

Improving Health Outcome Measures and Medication Safety through Integration of Clinical Pharmacy Services Steven Chen, Pharm.D., FASHP Associate Professor Director, PGY1 Residency Program in Primary Care Faculty Fellow, Center for Excellence in Teaching Co-Chair, HRSA Patient Safety & Clinical Pharmacy Collaborative 2.0

Key Questions What are benefits of integrating clinical pharmacy services (CPS) into the medical home? How can interdisciplinary education be delivered in a manner that promotes respect and self-learning?

Clinicas Del Camino Real SCHFC Arroyo Vista Family Health Center CHOC Breathmobile Patient Safety & Clinical Pharmacy Services Collaborative (PSPC) Interdisciplinary Education

USC School of Pharmacy Affiliated Safety Net Clinics (11 sites and growing) Clinicas Del Camino Real Arroyo Vista M.G. SCHFC

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education $$ drug The Need for Integrated CPS Disorganized medication delivery processes Struggling with chronic disease control MTM Limited healthcare professional student & resident exposure to care for the underserved (health literacy, cultural competency)

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education What is Medication Therapy Management (MTM)? A partnership of the pharmacist, the patient or their caregiver, and other health professionals that promotes the safe and effective use of medications and helps patients achieve the targeted outcomes from medication therapy. American Pharmacists Association

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Pharmacist Medication Therapy Management NOT a new concept / practice Kaiser Permanente: since early 1980 s Veterans Affairs: since 1960 s Private medical groups Pharmacy Benefit Management companies July 2010: Resource Guide from Patient- Centered Primary Care Collaborative

Clinical Pharmacy Services: Medication Therapy Management Process Physician / PA / NP appointment Drug-related problem(s) 1 and/or poor chronic disease control? Yes Schedule CPS appointment Pharmacist evaluation 1, screen for drug-related problems Yes PHYSICIAN / NP / PA CLINICAL PHARMACIST Drug-related problem(s) 1 identified? No Modify drug therapy per approved protocols, follow-up 2 No END continue usual care Drug-related problem(s) resolved? No Yes

Pharmacist Disease-State / Medication Therapy Management Programs: Responsibilities Interview patient, apply assessment skills PRN Provide f/u care to ensure successful outcome Identify potential Rxrelated prob s Diabetes Dyslipidemia Hypertension Heart failure Asthma Promote patient self-management, Document activities Consult w/ primary provider PRN Order labs, Rx s, consults PRN per protocol

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Examples of Patient Self-Management Tools

Teaching / Service Opportunities for Students SHARE Patient Education Classes Counseling Data Collection Translation Health Fairs Immunizations

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Teaching / Service Opportunities for Students Impact of Volunteer Service on Career Choices Changed Perception of Profession of Pharmacy (82%) Impacted Plans after Graduation (62%) Interest in Job in Safety Net Clinic (63%)

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Return on Investment Medication cost savings (1 FTE pharmacist serving 3 clinics) > $700,000 in annual medication costs saved access to critical medications thought to be unattainable Extension of pharmacy services with the help of students Student assistance in dispensary + 10-20 hours of disease state management time Increased access to medical care CPS funded by grants self-funded by clinics

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Blood Pressure Management (n=242) Majority of patients with DM (BP goal < 130/80) 160 152 Baseline Post-enrollment Blood Pressure (mmhg) 140 120 100 80 126-26 mmhg SBP 83 71-12 mmhg DBP 60 SBP DBP

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education A1C (n=225) 12 11.3 11 A1c (%) 10 9 8 7.6-3.7 % 7 6 Baseline Post-enrollment

Variables Overall Impact of Pharmacist Intervention on Individuals with Diabetes (N=484) Change in A1C Adj.R 2 = 0.4093 Estimated Effect (% A1C) p-value Intercept 7.760 <0.0001 Likelihood of Achieving A1C < 7 Estimate Effect (Odds Ratio) p-value Likelihood of Achieving A1C < 8 Estimate Effect (Odds Ratio) p-value Intervention group -1.38 <0.0001 4.037 <0.0001 5.129 <0.0001 Gender (male) 0.292 0.0770 0.586 0.1167 0.819 0.3931 Age (in years) -0.025 0.0018 0.986 0.3655 1.021 0.0687 Insured (1=MediCal + other) 0.358 0.2719 - - - - Hispanic (1 = Black + other ) 0.403 0.0717 0.819 0.6486 0.978 0.9437 Smoker (1=yes) 0.080 0.8783 1.622 0.2348 0.832 0.5584 Baseline A1C level -0.721 <0.0001 0.874 0.2069 0.824 0.0123 Days between first /last A1C test -0.0002 0.5708 1.000 0.9004 1.001 0.0724

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Interventions Provided by Pharmacists (N=222) Interventions (#) Change Dose/ Drug Interval Add Medication S ubs titute Medication D is continue Medication Educate Patient P rovide Adherence Aid Order lab/ Diagnostic test Refer to Other Service Other 29 22 10 5 1 45 104 132 154 0 50 100 150 200

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Problems Identified by Pharmacists (N = 222) Quality of Care 67% Medication Safety 28% $ Legal /dispensing <1%

2009 2007 APHA 2008

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education HRSA Patient Safety & Clinical Pharmacy Collaborative http://www.hrsa.gov/patientsafety/

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education Aim of HRSA s Patient Safety & Clinical Pharmacy Collaborative To save and enhance thousands of lives a year by achieving optimal health outcomes and eliminating adverse drug events through integration of clinical pharmacy services into the medical home.

Vision for Results Generated by PSPC Teams Integrated CPS Health Status Adverse Drug Events

~ 70 Safety Net Clinics in Year 1 ~120 Clinics in Year 2 The process

HRSA PSPC Teaching Institute for Healthcare Improvement Breakthrough Learning Approach Leadership Commitment Patient Centered Care Safe Medication Use System Measurable Improvement Integrated Care Delivery 24

pade rates fell 60%, from 0.75/patient to 0.3/patient ADE rates fell 50%, from 0.12/patient to 0.06/patient PSPC 2.0, from 44 teams

I. Integrated Clinical Pharmacy Services, Local II. Integrated Clinical Pharmacy Services, Nat l III. Interdisciplinary Education + Evaluation of assisted living residents Joint case conferences

Summary 1. Integrated clinical pharmacy services improve medication safety, health outcomes, and demonstrate a return on investment 2. Applied interdisciplinary learning demonstrates the value of collaboration to healthcare professional students as opposed to sharing classrooms