COLLABORATIVE PRACTICE SUCCESSES IN PRIMARY CARE KPhA Annual Meeting September 7, 2014 Tiffany R. Shin, PharmD, BCACP Lyndsey N. Hogg, PharmD, BCACP
Objectives Describe basic concepts of collaborative practice Review recent changes in the Kansas Pharmacy Act relating to collaborative practice Discuss how collaborative practice impacts patient care Provide examples of collaborative practice successes in primary care clinics
Introduction to Collaborative Practice
Audience Poll What is your experience with collaborative practice agreements? A. I have a collaborative practice agreement (CPA) B. I have heard of other pharmacists with CPAs C. I am interested in implementing a CPA D. None, I want to learn about CPAs
Traditional Healthcare: Insufficient Collaboration Limited communication between healthcare professionals, health-systems, and payers Fragmented care Lack of coordination acting in silos Consequences may include: Increased time to care Duplication of care Increased costs Decreased safety Cooperation among clinicians is a priority Crabtree BF, et al. Ann Fam Med. 2010;8:S80-S90. Crossing the Quality Chasm, 2001 IOM.
Core Competencies for Interprofessional Practice Domain 1 - Values/Ethics for Interprofessional Practice Domain 2 - Roles/Responsibilities Domain 3 - Interprofessional Communication Domain 4 - Teams and Teamwork Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
Collaborative Practice Key terms/phrases: Mutual respect Understanding other s roles and abilities Planned approach to patient care Frequent communication Teamwork
Collaborative Drug Therapy Management (CDTM) A collaborative practice agreement between one or more providers and pharmacists in which qualified pharmacists working within the context of a defined protocol are permitted to assume professional responsibility Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
Potential CDTM Delegated Functions Perform patient assessments Conduct counseling Place referrals Order laboratory tests Administer drugs and immunizations Select, initiate, monitor, continue, and adjust drug regimens Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
Collaborative Practice Agreements (CPAs) A formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
CPA Complexities and Levels of Responsibility Broad to specific scope Medication or disease state limitations Levels of management Provision of education or recommendations to collaborative modification of therapy Specific requirements Training, experience, certification, competencies
Milestone in Kansas Pharmacy Law
Audience Poll As of 2012, how many states did not have laws explicitly authorizing pharmacist collaborative practice? A. None B. 4 states C. 8 states D. 16 states
Laws on Collaborative Practice, 2012 Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists Patient Care Services: A Resource for Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
Senate Sub. for HB 2146 Amended Kansas Pharmacy Act Effective July 1, 2014 Added definitions Collaborative drug therapy management (CDTM) Collaborative practice agreement (CPA) Practice of pharmacy (definition expanded) Created Collaborative Drug Therapy Management Advisory Committee
Collaborative Drug Therapy Management A practice of pharmacy where a pharmacist performs certain pharmaceutical-related patient care functions for a specific patient which have been delegated to the pharmacist by a physician through a collaborative practice agreement. -Senate Sub. for HB 2146
Collaborative Practice Agreements A written agreement or protocol between one or more pharmacists and one or more physicians that provides for collaborative drug therapy management. Such collaborative practice agreement shall contain certain specified conditions or limitations pursuant to the collaborating physician s order, standing order, delegation or protocol. A collaborative practice agreement shall be: (A) Consistent with the normal and customary specialty, competence and lawful practice of the physician; and (B) appropriate to the pharmacist s training and experience. -Senate Sub. for HB 2146
Practice of Pharmacy performance of collaborative drug therapy management pursuant to a written collaborative practice agreement with one or more physicians who have an established physician-patient relationship -Senate Sub. for HB 2146
CDTM Advisory Committee For the purpose of promoting consistent regulation and enhancing coordination between Board of Pharmacy & Board of Healing Arts Chair (non-voting) 3 Licensed Pharmacists 3 Licensed Physicians Jim Garrelts, PharmD, FASHP Rick Couldry, MS, RPh, FASHP Lyndsey Hogg, PharmD, BCACP Tiffany Shin, PharmD, BCACP Determined by Kansas Board of Healing Arts Kansas Board of Pharmacy KU Medical Center Via Christi Health KU School of Pharmacy
Collaborative Practice Across the Country
Mountain Area Health Education Center Asheville, NC Family medicine resident training program Level III Patient-Centered Medical Home (PCMH) Interdisciplinary collaboration Physicians & residents Pharmacists (3 + 2) Nurses Nutritionists Care managers Behavioral medicine specialists Spanish translators Pharmacotherapy, anticoagulation & osteoporosis Scott MA, et al. J Am Pharm Assoc. 2011; 51: 161-166.
Pharmacist CP Impact on Patient Care Clinical outcomes Increased number of patients achieve treatment goals Improved adherence to medication regimens Fewer adverse drug events and medication errors Humanistic outcomes Improved patient satisfaction, quality of life, improvements in patient knowledge Economic outcomes Decreased medication costs, medical costs, and visits to emergency room or hospital Draugalis, et al. AACP Argus Commission Report. 2009-2010. Haines SL, et al. Am J Pharm Ed. 2010; 74(10): Article S5.
The Minnesota Experience Intervention Medication management provided by pharmacist in collaboration with primary care providers Patient selection BCBS health plan beneficiaries At least 1 of 12 medical conditions Intervention (n=285): patients seen/managed by pharmacists Control (n=126): patients selected from clinics without pharmacist collaborative services Isletts BJ, et al. J Am Pharm Assoc. 2008; 48:203-211.
Minnesota Experience: Clinical Outcomes 637 drug therapy problems resolved (285 intervention patients) Improvements in percentage patients meeting HEDIS goals Intervention (n=128) Control (n=126) P value National Avg (2001) Hypertension 71% 59% 0.03 51% Cholesterol (LDL) 52% 30% 0.001 53% Isletts BJ, et al. J Am Pharm Assoc. 2008; 48:203-211.
Minnesota Experience: Economic Outcomes Intervention group, n = 186 31.5% reduction in total annual health expenditure (p < 0.001) Before Intervention $ per person-year, mean + SD After Intervention $ per person-year, mean + SD 11,965.27 + 48,969.64 8,197.33 + 10,551.02 Return on Investment (ROI) = 12:1 Isletts BJ, et al. J Am Pharm Assoc. 2008; 48:203-211.
Collaborative Practice Successes at Via Christi Clinic (VCC) Lyndsey N. Hogg, PharmD, BCACP
Beginning of Ambulatory Care at VCC October 2012 CPA signed by physicians & administrators 1 pharmacist began in clinics (3 half days/week) 3 clinics, 7 teams, 25 providers Began PCMH transformation process Aug 2012 Referral-based pharmacy services Providers, nursing staff, care coordinators Variety of disease states
VCC Collaborative Practice Agreement Broad scope Collaboratively modify therapy Currently no pharmacist training/experience requirements included*
VCC Collaborative Practice Agreement
VCC Collaborative Practice Agreement 4) Order appropriate laboratory tests to aid in monitoring medication therapy 5) Evaluate patients medication regimens based on efficacy, safety, tolerability, drug interactions, cost, patient preference and professionally recognized clinical guidelines 6) Initiate, discontinue, or adjust doses of medications as clinically indicated based on professionally recognized clinical guidelines and patient-specific factors
VCC Collaborative Practice Agreement 8) Provide patient education regarding disease states, self monitoring, and medication therapy 10) Document patient encounters in the electronic medical record 11) Maintain close communication with patient s primary care physician, acting at all times as an additional expert member of the patient s medical home team and an agent of the physician
Pharmacotherapy Clinic Workflow Referral Prior to appointment Appointment After Appointment From provider, care coordinator or nursing staff Pharmacotherapy appointment scheduled by clinic staff Chart review (labs, provider encounters, etc.) Comprehensive medication review Prepare anticipated educational materials as necessary Medication reconciliation Vitals & limited physical assessment Patient interview Assessment of barriers to care Education (chronic diseases, medications, lifestyle) Therapy modification as indicated Note to provider through EHR Face-to-face consult with provider if indicated Complete referrals (as needed) Pharmacotherapy follow up appointments as needed
Overview of Patients Nov 2012 June 2014 (PCMH only) Number unique patients 274 Total patient visits 491 Number drug therapy problems 843 Diabetes management Total patients = 56 Average A1C Initial 3 mo. 6 mo. 9 mo. 12 mo. 15 mo. 18 mo. No. pts 56 40 29 22 15 5 3 avg A1C 9.8% 8% 8.1% 7.8% 7.4% 6.9% 7.2%
Improvements in DM Control 16 14 12 Number of patients 10 8 6 4 A1C < 8% A1C 8-8.9% A1C > 9% 2 0 Initial 3 6 9 12 Months since initiating CDTM
A1C Changes in Select Patients 15 Hemoglobin A1C 14 13 12 11 10 9 8 7 6 Avg all pts Patient 1 Patient 2 Patient 3 Initial 3 6 9 12 15 Months since initiating CDTM
Patient Case- RH 59 y/o Caucasian male PMH: T2DM, HTN, hx DVT, depression Uncontrolled T2DM and labile INR Collaboration between PCP, PharmD, RN, care coordinator Patient barriers identified Low health literacy Finances Lack of family support Regular appointments with PharmD scheduled INR obtained same day Written instructions
Patient Case- Outcomes Improvement in A1C Date A1C 1/31/14 11% 4/25/14 9.6% Before CP Fluctuating INR Date INR 7/29 2.2 10/30 1.3 1/21 1.2 1/31 9.8 2/7 2.7 CP = collaborative practice During CP INR Stabilization Date INR 3/6 3.8 3/13 2.9 3/20 3.1 3/28 2.3 4/3 2.5 4/10 2.1 4/23 3 5/8 2.6 5/30 2.1
Keys to Success at VCC Physician champion Leverage established resources and processes Clinic rooms Scheduling process EHR and communication systems Integration into clinic culture Utilization of clinic reports Geriatric polypharmacy Uncontrolled diabetes
Collaborative Practice Successes in a Residency Clinic Tiffany R. Shin, PharmD, BCACP
Via Christi Family Medicine Resident Clinic Joined clinic and residency faculty in September 2013 No prior ambulatory care clinical pharmacist presence 4 half-days per week 40% of clinical faculty responsibilities Participation in clinic/residency meetings and committees Collaborative practice agreement approved May 2014
Pharmacy Referral Services Any clinic patient may be referred Referred by PCP, other providers, or clinic staff Scheduled individual visits with patients Phone call encounters Documentation in the EHR routed to PCP Verbal communication with PCP Focus on patient co-management
Pharmacy Referral Services Pre-MD Visit MD Visit PharmD Visit Follow-up Physician/PCP X X X Pharmacist X X Student Pharmacist X X MD Resident or Attending Patient Pharmacist
Collaborative Care Planning (Pharmacy consults) Pro-active Referred patients Chart reviews Re-active Medical Resident precepting Evaluate resident s plan Questions from providers Answer drug information questions Potential Outcomes: Therapeutic recommendation or education Patient evaluation or education by pharmacy Referral for co-management
Collaborative Care Planning Pre-MD Visit MD Visit MD Resident Precepting Follow-up Physician/PCP X X X X Pharmacist X X X If referred Student Pharmacist MD Resident Pharmacist X X X If referred Patient MD Attending + MD Resident + + Pharmacist
Collaborative Care Planning Results Data from 27 clinic half-days*: 218 patients precepted and/or charts reviewed 29 (13%) pediatrics 29 (13%) obstetrics 130 (58%) adult 112 total contributions or recommendations from pharmacist 56 pharmacist-initiated recommendations *Does not include individual pharmacist visits or phone follow-up encounters
Patient DM Prior to Collaboration 48yAAM with uncontrolled Type 2 DM Other PMH: HTN, stroke, glaucoma, adenocarcinoma of colon, hx of falls Barriers to care: Low health literacy Poor memory Poor dexterity Finances Lives alone
Patient DM Prior to Collaboration Jul Aug Sept Oct Nov Dec Jan Feb 13.2% 8.3% 12.9% po med Insulin started Legend MD Visit MD + PharmD Visit PharmD Phone PharmD Visit Insulin dose increase
Patient DM - During Collaboration March 2014 during PCP visit PCP asks clinic pharmacist to provide patient education on meter use Identify difficulty of checking blood sugar at home Referral to pharmacist for DM co-management
Patient DM - During Collaboration March April May June July 13.4% 6.8% Legend MD Visit MD + PharmD Visit PharmD Phone PharmD Visit Insulin dose increase
Keys to Success Strong physician and clinic staff relationships Multiple options for communication High risk patient population Foster long-term patient relationships Academic teaching environment Being both proactive and reactive
Conclusion Collaborative practice is occurring in Kansas and across the US Communication and building relationships is key to collaborative care Successful implementation can improve patient outcomes More guidance to come from the CDTM Advisory Committee
COLLABORATIVE PRACTICE SUCCESSES IN PRIMARY CARE KPhA Annual Meeting September 7, 2014 Tiffany R. Shin, PharmD, BCACP Lyndsey N. Hogg, PharmD, BCACP