Patient Centric Model (PCM)

Patient Centric Model (PCM) Operations Manual A product of your state pharmacy association For more information, contact: PCM Project Manager 804-285-4431 PCM@naspa.us

Background The typical pharmacy model has not changed for many years. The pharmacy is dependent on the patient bringing in their new prescription or calling when and if they remember to get their prescriptions refilled. The pharmacy staff answers inbound phone calls, contacts physicians, waits for call-backs and then fills prescription orders. The expectation is that the patient arrives at the pharmacy to pick up their medicines. This system is both endemic and inefficient. Customers with multiple prescriptions often call multiple times during the month, which results in inefficiencies for store operations. This method of operation is full of unknowns, and diminishes the ability of the pharmacy staff to build efficiencies that would free up valuable time. There is an increased pharmacy workload and an inherently inefficient operation. The lack of an ability to track customers and their chronic prescriptions leads to dismal adherence and persistence rates, which in turn results in less than optimal patient outcomes and increased healthcare costs. The Model The Patient Centric Model (PCM) changes the way the pharmacist operates his or her practice. This system is a patient care model designed to improve your patients medical outcomes and build efficiencies. With the PCM, the pharmacist takes control of their business, ending the tail wagging the dog scenario. This model is not new: it was successfully developed in 1996 by a pharmacist in California. Whereas over 50% of his patients are enrolled in his pharmacy, the pilot pharmacies are asked to initially enroll 10-20 patients with an ultimate goal of 15% to 20% of their patients who are taking multiple, on-going prescriptions for chronic conditions, especially if you notice they are experiencing gaps in their refill pattern.

The engine that drives the PCM is prescription synchronization. By having all of a patient s prescriptions synchronized to be refilled on the same day of the month, waiting for call-ins has been eliminated. The patient is assigned a day of the month that is convenient for them to pick up all prescriptions. Prior to this appointment day, the patient is contacted with a single call to determine the fill order for that patient. By simply eliminating multiple calls from the patient to the pharmacy, pharmacy efficiency has been improved. This has also paved the way for greater inventory control, improved patient-pharmacist relationships and increased medication persistence, as will be explained later in this manual. Pharmacy Benefits At its core, the PCM is primarily a new patient care model, designed to improve your patients medical outcomes and your pharmacy s operational efficiencies. The potential benefits to the pharmacist and pharmacy include: 1. Improved pharmacy/physician/patient relationships. 2. More pharmacist time to engage in other patient care activities. 3. Improved patient medication persistence. 4. Ability to identify recent hospitalizations, doctor visits, and changes to a patient s medication therapy. 5. Increased first fill (first time prescription filled at the pharmacy) rates since those new prescriptions will be identified during the consultation with patient. 6. Eased transition into patient service programs because the model frees pharmacist time and patients are seen on an appointment basis. 7. Increased work-flow efficiency; significant reductions in phone volume. 8. Management of pharmacy workflow to the store hours of operation. 9. Decreased inventory and increased inventory turnover (dependent upon number of patients enrolled). 10. Potential increase in pharmacy staff job satisfaction.

Requirements While the PCM can be adapted to any existing pharmacy environment, there are basic requirements needed to implement the system and participate in the 12- month pilot: 1. Staff/Space You will need dedicated staff member time to run the system. The staff member will be pulling verification sheets on patients at the appropriate time, calling those patients to discuss their medications for their next appointment, adjusting the medication list and making any appropriate notes for the pharmacist. 2. Supplies The following supplies are suggested: a. Master Accordion style file box labeled 1 to 31. b. Order Verification Sheet to list a patient s current drug list (supplied as an Excel spreadsheet). c. Master ID sheet to keep track of assigned patient ID numbers (supplied as an Excel spreadsheet). d. Clear plastic sleeves to keep all patient materials together. e. Call Back File box. Since not all patients are likely to be reached on the first call, this file box keeps track of those patients that need call-backs. f. File box for the pharmacist to organize the daily PCM refill requests. 3. Data Collection You will need to provide de-identified patient medication data baseline (two years history), 6-month and 12-month. See Appendix A on last page.

Getting Started 1. Identify your patients This is an Opt-In program, so you will have to identify patients to enroll. Ideal patients are those with multiple, on-going monthly prescriptions for chronic disease conditions, especially if you notice they are experiencing gaps in their refill patterns. We are suggesting that to minimize impact on your business, you enroll about 10-20 of your patients in the system to get started. As you get comfortable with the model, we encourage you to increase the number of patients participating. Identified patients will have to agree to participate in the system (opt-in). (See Patient Agreement Illustration #1.) They should also be given a Patient Enrollment Card (more about these later); a supply of cards is provided in your PCM starter kit. Program brochures are also provided to help you promote the advantages for patients: 2. Patient Advantages: a. Convenience fewer trips to the pharmacy. b. Builds a relationship between pharmacist and patient. c. Peace of mind being able to get medicines on time and in one order. d. Increased understanding of their medication therapy. e. Personal contact with pharmacist improves lines of communication. f. Improved medication persistence which will potentially lead to improved health outcomes. g. Patient no longer has to (remember to) call in chronic prescription refills. h. Patient can have their drug therapy reviewed for cost-effectiveness. i. Changes to therapy due to doctor visits and/or hospitalizations are noted and reinforced with the patient.

Illustration #1 Agreement to Participate in the Synchronized Prescription Refill Service Thank you for your interest in the Synchronized Prescription Refill Service. Advantages of participating in the program include: Increased convenience a single monthly trip to the pharmacy Peace of mind from being able to get medications on time and in one order More personal contact with your pharmacist to ask questions and discuss medications Increased understanding of your medication, its purpose, potential side effects and costs Your prescription records can be more easily updated to reflect changes to therapy made by doctors or upon hospital discharge I understand the program advantages and the following conditions of participation to achieve the maximum benefits from the service. I hereby agree: To accept a phone call each month from the pharmacy to discuss my prescription refills. To pick up medications on my assigned refill date. If necessary, to pay an extra co-pay one time for each medication in order to make all refills due on the same day. To keep an open dialogue with my pharmacist regarding doctor s appointments, hospital/urgent care visits, and changes in my health status. To allow my pharmacist to send de-identified prescription history information to the Alliance for Patient Medication Safety (APMS) for refill persistence calculations. This permission expires only upon my written cancellation of this agreement. I have read this document, understand it, and have had all questions answered satisfactorily. Patient Name (Please print) Patient Signature Date Pharmacist Signature Date

2. Dedicated Work Area / Dedicated Staff Member: This is the space that the pharmacy sets aside for the daily operation of the system. It can be located anywhere in the pharmacy, but ideally, it should be separate from the dispensing area and should be isolated from customers to provide a quiet, private space for calling patients. The dedicated work area is extremely important to the system, and success or failure will probably be due to consideration of these necessary components. It is also important to remember that the person who tracks refills, makes the calls, and records information for the pharmacist is CRITICAL to the success of the program. Please choose wisely. 3. Synchronization: While synchronization of refills is the heart of the PCM system, it can also be the most challenging for the pharmacist and the patient. This is the process where all of the patient s refills are synchronized to come due on the same day of the month. This is a one time process, and it is important that the patient understands what you are doing and why it is necessary. Patient consent to this one time process is critical if they are to be incorporated into the PCM system. The process will require some pre-planning by the pharmacist. The following points will help you execute the process: a. Determine and list the chronic, monthly prescriptions the patient will be taking and add them to the Verification Request form. b. The prescription with the highest co-pay should be the anchor prescription to which all other prescriptions will be synchronized. c. Determine the quantity needed for the rest of the prescriptions to synchronize them with the anchor prescription.

d. Call the patient s physician(s), briefly explain the PCM system, and request A ONE TIME prescription for the quantity required for synchronization, plus a second prescription for the normal monthly quantity. This is critical for accountability for any third-party audits. e. Fill the prescription in an appropriate quantity to synchronize it. f. Repeat this process for the other medications. 4. Setting Up the System: The following are the steps you need to take for each patient who opts into the PCM system: a. Set up a Verification Request form i. Verification form is an Excel spreadsheet. See Illustration #2. Requires form to be filled out monthly ii. An alternate verification form is shown in Illustration #3. Allows tracking of patients on one form for an entire year. b. Determine the appointment day of the month to assign the patient. The preferred method is to review the list of medicines and look for the prescription with the highest dollar co-pay. Use the date this prescription comes due as the anchor date to which all other drugs will be synchronized. Confirm with the patient that this day is convenient. c. Assign the PCM Number: The PCM number consists of two parts: the first 2 digits indicate the appointment date of the month (determined in step b above) and the second two digits the sequence of that patient assigned that date. For instance, 2603 indicates that the patient s appointment date is on the 26 th day of the month and they are the third person assigned to

that date. It is preferable to assign family members to the same date of the month, with different sequence numbers. For instance, the husband could be 2601, the wife 2602, and the daughter 2603. d. Entering Information into Verification Request Form i. Secure a list of the meds the patient takes on a monthly basis and enter the drug name and strength on the Verification Request form. ii. Slip the Verification Request form into a clear plastic sleeve and drop into the appropriate place in the Master Accordion File. The file will be numbered one (1) to thirty-one (31) and the first two digits of the patient s identification number will determine which slot the Verification Request form is inserted into. In the case of patients 2601-2603 (the examples in c above), the three patient verification forms would all go into slot 26 of the file folder. e. Tracking Form Make sure that the PCM numbers are entered into the PCM Tracking form (Excel spreadsheet) so you will know the name of the patient that each PCM number is assigned to. See Illustration #4. 5. Contact the Physician: This is a new concept for the prescriber so you need to introduce the concept and advantages to them: a. Fewer calls to the pharmacy/patients b. Ability to review the entire patient profile on one call c. Ability to identify patient adherence issues Patient Centric Model (PCM) Patient Centric Model For questions (PCM) - please For information, call: 804-285-4431 please ext call: 328 804-285-4431

Illustration #2 100 Main Street Anytown, State, Zip Phone Number Pharmacy USA Pharmacy Identifier Verification Request Form Patient Information Name: Jane Doe Address: 222 State St City, State: Flint, MI Phone: 555-1234 Ship Via: Request Date: Health Plan: BCBS PCM - 2602 Comments: Date of Birth Current Drugs / Strengths Humulin 70/30 Metformin 1000mg Lisinopril/HCTZ 20/12.5 mg Omeprazole 20 mg One Touch Ultra Test Strips One Touch Ultra Lancets Physician Notes Diagnosis Historic Drugs / Strengths Lisinopril 10 mg Notes Replaced with Lisinopril/HCTZ Nov 2007

100 Main Street Anytown, State, Zip Phone Number Patient Information Name: Address: City, State: Phone: Comments: Illustration #3 Pharmacy USA Verification Request Form Jane Doe 222 State St Ship Via: Flint, MI Request Date: 555-1234 Health Plan: Date of Birth Physician(s) Pharmacy Identifier Diagnosis PCM - 2602 Current Drugs / Strengths Humulin 70/30 x x Metformin 1000mg x x Lisinopril/HCTZ 20/12.5 mg x x Omeprazole 20 mg x x One Touch Ultra Test Strips x x One Touch Ultra Lancets x x JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC NOTES Historic Drugs / Strengths Lisinopril 10 mg Replaced with Lisinopril/HCTZ Nov 2007

Illustration #4 [Your] Pharmacy ID# PCM 0101 PCM 0102 PCM 0103 PCM 0201 PCM 0202 PCM 0301 PCM 0302 PCM 0401 PCM 0402 PCM 0501 PCM Master Record List Patient Name (Last, First)

PCM Daily Operation Procedure The following section will describe in detail how the system operates on a day-to-day basis. Make sure the following steps have been completed before you proceed: 1. Dedicated staff member is assigned to operate the system. 2. Dedicated work area is identified and has the required systems in place. 3. Patients have been identified and have agreed to participate. 4. Each patient has their Verification Request form filled in with their monthly prescriptions. 5. The PCM I.D. numbers have been added to the PCM Master Record List for each patient on the system. 6. All prescriptions have been synchronized. Beginning of Each Month 1. At the beginning of each month, a roster of all PCM patients should be printed out and posted in the pharmacy. 2. Any new prescriptions received will be cross-checked against this roster. 3. Any new PCM prescriptions will be synchronized to the patient s monthly fill date according to procedures previously described. 7 Days Prior to the Appointment Date 1. Pull all of the Verification Request forms from the Master Accordion file seven days ahead of the refill due date (the PCM date). For instance, if it is the currently the 10 th of the month, pull all files from the slot in the file folder marked 17 (17 represents the 17 th day of the month, 7 days after the 10 th ).

If the pharmacy is closed on that day, the prescriptions will actually be filled on the day before the PCM date (more on this later). 2. Call the patient to discuss each prescription on the list and verify that the patient will need that prescription filled. TWO ADDITIONAL QUESTIONS NEED TO BE ASKED OF EACH PATIENT: (1) Have you been to the doctor in the last month and (2) Have you been in the hospital in the last month? Both of these situations often result in new prescriptions, and these questions will enable you to determine if there needs follow up with the doctor. Highlight each prescription to be filled. If the patient does NOT need one of the prescriptions filled, determine if the order has been discontinued, changed or if a new prescription has been issued, and document this on the Verification Request form in the Notes section. 3. When medications are discontinued or replaced, the historical medication should be moved to the historical section of the Verification Request form and a note recorded in the Notes section. The following script can be used when calling the patient: Hi, this is Jane from Anytown Pharmacy, and I would like review your prescriptions for your next visit on the (date). Is this a good time? First, have you been to the doctor in the last month? Have you been in the hospital in the last month? (Make notes, if appropriate.) I see that you are due for the following refills. (Go over each one and verify that the patient wants each one refilled.) Do you have any questions about any of your medications? 4. Any patients not contacted on a call need to be called back. Have your Call Back File box available to help organize the call backs to keep track of who still needs to be called again.

5. Once you have determined which prescriptions need to be filled on the appointment date, you can generate labels for those prescriptions that can be refilled (if you have the ability to do so in the dedicated work area). 6. Any prescriptions with zero refills should be faxed to the physician for approval. Make a note on the Verification form that you are awaiting approval. You may wish to hold onto the Verification form until the approval has come back from the physician s office. The faxed authorization for refills should be put into the plastic sleeve along with the Verification Form. If the doctor denies the refill, make a note on the Verification Form and contact the patient. 7. The Verification Request form, notes, and any generated prescription labels should go back into the plastic sleeve for that patient. 8. The Verification Request form in the computer for that patient should now be modified to reflect any additions, deletions or changes to the list of prescriptions. Any notes (such as the prescription was not filled for XXX reason) should also be added to the computer spreadsheet. 9. The sleeve containing the Verification Request form should now be delivered to the pharmacist. He will put the form into a similar, but smaller, accordion file in the appropriate date slot. IF the patient s appointment date occurs on a day that the pharmacy is closed, the pharmacist should instead place the form into the next earlier slot when the pharmacy is open. For instance, if the PCM date is the 17 th and that is a Sunday, the pharmacist should place the form into the Friday slot, and the patient notified.

1-2 Days Before Patient s Appointment Date The pharmacist or technician pulls the Verification Forms for the following day and makes sure: All prescriptions to be filled have refills, or the refill authorization is in the plastic sleeve. The pharmacy has adequate inventory on hand; if not, order appropriately. Any note(s) on the form are addressed. The Appointment Date 1. Each morning the pharmacist / technician fills the prescriptions scheduled for that day. Once the prescriptions are filled, the Verification sheet is returned to the PCM manager. 2. The PCM manager makes any changes necessary on the Verification Form in the computer for the patient and prints out the new Verification form for the next month. This is put into a plastic sleeve and filed in the Master Accordion File accordingly, and the process is repeated the following month. The Patient Enrollment Card Each patient should receive a card to be placed with important documents such as an insurance card. Advise the patient to present the card to his/ her physician(s) to help explain the program. This will allow the physician to collaborate with the pharmacist in the program. See Illustration #5.

Illustration #5 Patient Enrollment Card

ACKNOWLEDGEMENTS This model was developed by John Sykora, RPh, MBA, who resides in Long Beach, California. He has been an independent pharmacy owner for over 30 years. John graduated in 1966, from the Philadelphia College of Pharmacy and received a MBA in 1970, from the University of California Long Beach. He worked for 7 years at Arcadia Methodist Hospital, as the pharmacist on the surgical floor, before purchasing Abrams & Clark Pharmacy in 1976. John has been active in pharmacy associations, served on the board of a PBM for 10 years, and currently serves on the board for the Long Beach Health Department and a Pharmacy and Therapeutics committee for a senior HMO. In 1996, John started working on ways to change his business that would put him more in control, allowing him to better compete in a marketplace where price was decided by others. A Personal Service Program was initiated that would manage patients prescriptions, with the added benefit of managing work flow, inventory, billing, hours of operation, reduce stress for the patient and business and allow the pharmacist to work more on MTM and disease state management. Patient Centric Model (PCM) Patient Centric Model (PCM) - For questions please call: 804-285-4431 For questions please call: 804-285-4431 ext 328

APPENDIX A Data Collection Persistence 1. In order to collect persistence data, we ask that you compile a de-identified baseline medication list for each patient enrolled with the following minimum data set. -Drug Name/Strength -Date Dispensed -Quantity Dispensed -Days Supply or Sig to calculate days supply This could be an end-of-year tax report using dates two years prior to enrolling in the program. 2. Remove all patient-specific data. 3. Add the patient s PCM #, Pharmacy Identifier and primary diagnosis, if available. 4. Write the start date for the patient on the form. 5. Six months after initiation, re-send patient history report for the first six months they were enrolled in the program 6. Repeat after 1 year. A reminder email will be sent to you for these follow-up reports. 7. Please send to: NASPA PCM PROGRAM c/o PCM Project Manager 2530 Professional Rd, Suite 202 Richmond, VA 23235 Fax: 804-612-6555 PCM@naspa.us

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without the written permission of NASPA. Copyright 2009 by the National Alliance of State Pharmacy Associations, 2530 Professional Road, Suite 202, Richmond, VA 23235