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Role of Clinical Pharmacists in Disease State Management Amy

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Role of Clinical Pharmacists in Disease State Management Amy M. Lugo, PharmD, BCPS, CDM Clinical Coordinator Clinical Specialist, Internal Medicine – PowerPoint PPT presentation

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Title: Role of Clinical Pharmacists in Disease State Management Amy


1
Role of Clinical Pharmacists in Disease State
Management
  • Amy M. Lugo, PharmD, BCPS, CDM
  • Clinical Coordinator
  • Clinical Specialist, Internal Medicine
  • Department of Pharmacy
  • National Naval Medical Center
  • Bethesda, Maryland

2
Objectives
  • Review the BUMED requirement for disease state
    management
  • Describe how pharmacists can assist in your
    disease management programs
  • Define the roles and responsibilities of a
    clinical pharmacist
  • Provide evidence supporting the use of
    pharmacists in disease management programs
  • Discuss the credentialing process for clinical
    pharmacists and provide a sample collaborative
    practice agreement

3
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4
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5
BUMED Requirement
  • Navy Medicine (NAVMED) Policy 06-011
  • Disease Management Programs
  • Asthma
  • Diabetes
  • Breast Health
  • Dental Health
  • MedIG Checklist

6
Disease State Management
  • A continuous, coordinated, evolutionary process
    that seeks to manage and improve the health
    status of a carefully defined patient population
    over the entire course of a disease
  • A successful DSM program achieves this goal by
    identifying and delivering the most effective and
    efficient combination of available resources
  • Encompasses the entire spectrum of health care
  • Includes prevention efforts as well as patient
    management after the disease has developed

Academy of Managed Care Pharmacy
7
Collaborative Drug Therapy Management (CDTM)
8
Collaborative Drug Therapy Management (CDTM)
  • A collaborative practice agreement between one
    or more physicians and pharmacists wherein
    qualified pharmacists working within the context
    of a defined protocol are permitted to assume
    professional responsibility for certain tasks

Pharmacotherapy 2003231210-1225.
9
Collaborative Drug Therapy Management (CDTM)
  • Tasks include
  • Performing patient assessments
  • Ordering and evaluating drug therapy-related
    tests
  • Selecting, initiating, monitoring, continuing and
    adjusting drug regimens
  • Assessing patient response to therapy
  • Counseling and educating a patient on medications
  • Administering medications

Pharmacotherapy 2003231210-1225.
10
Collaborative Practice
  • Collaborative Drug Therapy Management (CDTM)
  • 43 states have some form of CDTM or collaborative
    practice
  • Authority is generally incorporated in the state
    pharmacy practice act
  • Describes the authorized scope of practice

11
Pharmacists in the Navy
  • Licensed Independent Practitioners (LIP)
  • BUMEDINST 6320.66E
  • BUMEDINST 6320.66D
  • No requirement for collaborative practice
    agreement
  • No requirement for notes and orders to be
    co-signed by physicians
  • Scope of practice determined by individual
    commands

12
Components of a Collaborative Practice Agreement
  • A pharmacist agrees to work with prescriber(s)
    under a written, signed agreement
  • Agree to perform certain patient care functions
    under specified conditions
  • The pharmacist must possess the knowledge, skills
    and ability to perform the authorized functions
  • Determination of competence is usually left up to
    the individuals who are party to the agreement

13
Components of a Collaborative Practice Agreement
  • Authority to document activities in a medical
    record
  • Accountability for the same quality measures for
    all those involved in the collaborative agreement
  • Provisions to allow compensation for drug therapy
    management activities

14
Roles and Responsibilities of a Clinical
Pharmacist
  • Assuring safe, accurate, rational and
    cost-effective use of medications
  • Engage in collaborative practice with other
    healthcare practitioners for the purpose of
    improving care and conserving resources
  • Make patient-focused transitions into and out of
    acute care practice settings, ambulatory care or
    alternative site settings with the patients best
    interest in mind
  • Possess in-depth knowledge of medications that is
    integrated with a foundational understanding of
    the biomedical, pharmaceutical, sociobehavioral,
    and clinical sciences

American College of Clinical Pharmacy
15
Roles and Responsibilities of a Clinical
Pharmacist
  • To achieve desired therapeutic goals, the
    clinical pharmacist applies evidence-based
    therapeutic guidelines, evolving sciences,
    emerging technologies, and relevant legal,
    ethical, social, cultural, economic and
    professional principles
  • Assume responsibility and accountability for
    managing medication therapy in direct patient
    care settings, whether practicing independently
    or in consultation/collaboration with other
    health care professionals
  • Within the system of health care, clinical
    pharmacists are experts in the therapeutic use of
    medications
  • Routinely provide medication therapy evaluations
    and recommendations to patients and health care
    professionals

American College of Clinical Pharmacy
16
Other roles
  • Clinical pharmacist researchers generate,
    disseminate, and apply new knowledge that
    contributes to improved health and quality of life

American College of Clinical Pharmacy
17
The Process
  • Pharmacists find a physician
  • Physicians find a pharmacist
  • Discuss the role the pharmacist will play
  • Each commands credentialing committee determines
    pharmacists scope of practice
  • Not necessary, but strongly encouraged to have
    collaborative practice agreements with providers

18
Medication Management Services
  • Identify a need
  • Build support for services
  • Determine the focus of the service
  • Develop patient care protocols
  • Market the service
  • Receive additional training if needed
  • Provide care and document outcomes

Pharmacotherapy 2003231153-1166.
19
Identify a Need
  • Focus group discussions
  • Networking with opinion leaders
  • Surveys of physicians within a practice
  • Identify high risk patients
  • Identify costly disease states

Pharmacotherapy 2003231153-1166. Pharmacy Times
200151-63.
20
Build Support for Services
  • Identify practice champions
  • Build relationships with key people such as
    nurses, billing specialists, and lab personnel
  • Market what you can do for patients

Pharmacotherapy 2003231153-1166. Pharmacy Times
200151-63.
21
Determine the Focus of the Service
  • Use needs assessment data to decide what services
    will be offered
  • Determine how you can enhance what services are
    already being provided
  • Other Considerations
  • Your patient population
  • Pharmacy staff expertise
  • BUMED requirement and MedIG checklist

Pharmacotherapy 2003231153-1166. Pharmacy Times
200151-63.
22
Develop Patient Care Protocols
  • Develop practice-specific standards for care
  • Network with colleagues
  • Base protocols on national standards
  • Sample Protocol

Pharmacotherapy 2003231153-1166. Pharmacy Times
200151-63.
23
Market the Service
  • Market to physicians, clinic champions and
    patients
  • Share the benefits of the service 11 and at
    staff meetings
  • Marketing ideas include flyers, posters, and
    mailings

Pharmacotherapy 2003231153-1166. Pharmacy Times
200151-63.
24
Receive Additional Training
  • Council on Credentialing published definitions of
    credentialing in 2001
  • Opportunities include additional education
    through residencies, traineeships, certificate
    programs, and CE
  • Certification examinations include BPS, CGP,
    disease management, and various multidisciplinary
    examinations

Council on Credentialing. AJHP 20015869-76
25
Pharmacists CredentialsCertifications
  • Pharmacists need to demonstrate that they possess
    the knowledge to manage certain disease states
  • Board of Pharmaceutical Specialties
  • BCPS, BCOP, BCPP, BCNSP, BCNP
  • Diabetes
  • Certified Diabetes Educator (CDE)
  • Certified Disease Manager (CDM)
  • Asthma
  • Certified Asthma Educator (AE-C)

26
Pharmacists CredentialsCertificates
  • Certificate Programs
  • State associations
  • Colleges of pharmacy
  • Regional AHECs
  • National associations
  • National meetings (APhA)
  • Pharmacy-Based Immunization Delivery
  • Pharmaceutical Care for Patients with Diabetes
  • Pharmacy-Based Lipid Management
  • OTC Advisor Pharmacy-Based Self-Care Services
  • Delivery Medication Therapy Management Services
    in Your Community

27
Provide Care and Document Outcomes
  • Provide pharmaceutical care
  • Document the visit appropriately for the level of
    service provided
  • Evaluate humanistic, financial and therapeutic
    outcomes

Pharmacotherapy 2003231153-1166. Pharmacy Times
200151-63.
28
Supporting Evidence
  • American Pharmacists Association
  • Listed by disease state
  • Referenced primary literature

www.aphanet.org
29
Supporting Evidence
  • Precedents
  • Veterans Health Administration
  • VHA Directive 2003-004
  • Department of the Army
  • AR 40-68, Chapter 7, Subparagraph 8
  • North Carolina
  • 21 NCAC 46.3101 Clinical Pharmacist Practitioner
  • Maryland
  • 12-6A-01 12-6A-10 Drug Therapy Management

30
The Asheville Project
  • 1997 2007
  • 2 self-insured employers
  • Many spin-off projects
  • gt 900 patients
  • Diabetes
  • Asthma
  • Hyperlipidemia
  • Hypertension
  • Depression pilot study

J Am Pharm Assoc. 20034317384.
31
The Asheville Project
  • Patients have co-pays waived
  • Patients must see their pharmacist at least
    monthly
  • Pharmacists are paid for their time
  • Results
  • ? total health care costs per pt per yr
  • ? work productivity

J Am Pharm Assoc. 20034317384.
32
The Asheville ProjectDiabetes 5 Year Results
  • N 187
  • Mean A1c ? at all follow-ups, with more than 50
    of patients demonstrating improvements at each
    time
  • The number of patients with optimal A1c values
    (lt 7 ) also ? at each follow-up
  • gt 50 showed improvements in lipid levels at
    every measurement
  • Patients with higher baseline A1c values or
    higher baseline costs were most likely to improve
    or have lower costs, respectively

J Am Pharm Assoc. 20034317384.
33
The Asheville ProjectDiabetes 5 Year Results
  • Costs shifted from inpatient and outpatient
    physician services to Rxs, which ? significantly
    at every follow-up
  • Total mean direct medical costs ? by 1,200 to
    1,872 per patient per year compared with
    baseline
  • Days of sick time ? every year (19972001) for
    one employer group
  • Estimated increases in productivity estimated at
    18,000 annually

J Am Pharm Assoc. 20034317384.
34
The Asheville ProjectAsthma Data
  • Asthma program implemented in 1999
  • 2 self-insured employers
  • N 207
  • Outcome measures
  • FEV1
  • Asthma severity
  • Symptom frequency
  • Presence of an asthma action plan
  • Asthma-related emergency department/hospital
    events
  • Changes in asthma-related costs over time

J Am Pharm Assoc. 200646133147.
35
The Asheville ProjectAsthma Results
  • All measures of asthma control improved and were
    sustained for as long as 5 years
  • FEV1 and severity classification improved
    significantly
  • Asthma action plans ? from 63 to 99
  • ED visits ? from 9.9 to 1.3
  • Hospitalizations ? from 4.0 to 1.9
  • Spending on asthma medications increased

J Am Pharm Assoc. 200646133147.
36
The Asheville ProjectAsthma Results
  • Asthma-related medical claims ? and total
    asthma-related costs were significantly lower
    than the projections
  • Direct cost savings averaged 725/patient/year
  • Indirect cost savings were estimated to be
    1,230/patient/year
  • Missed/nonproductive workdays ? from 10.8
    days/year to 2.6 days/year
  • Patients were 6 times less likely to have an
    ED/hospitalization event after program
    interventions

J Am Pharm Assoc. 200646133147.
37
Keys to Success in Replicatingthe Asheville Model
  • Focus on the patient and desired outcomes
  • Include all stakeholders in planning and
    implementation
  • Maintain open communication, sharing information
    in a timely fashion
  • Ensure that the role of each team member is clear
  • Health care team members should be supporting
    each othernot duplicating efforts
  • Respect, integrity, trust, and excellence of each
    provider
  • Coordination of patient referrals
  • Education of patients and providers
  • Aligned incentives for seeking and providing care

Pharmacy Times June 2005.
38
Clinic Reengineering
  • Carved out or carved in
  • Pharmacotherapy clinic vs. diabetes clinic
  • Obtain AHLTA training and become familiar with
    clinic operations
  • Continuously educate physicians and support staff
    about pharmacy services
  • Actively seek referrals to fill clinic spots

39
Credentialing Process
  • Required Documents
  • BUMEDINST 6320.66E - Core privileges
  • BUMEDINST 6320.66D - Supplemental privileges
  • Optional Documents
  • Peer review evaluation form
  • Performance Assessment Review (PARs)
  • Protocol/Collaborative practice agreement
  • Clinical specialist position description
  • Supporting evidence

40
Additional Supporting Evidence
  • Clinical Pharmacy Services associated with
    decreased mortality rates
  • Pharmacist-provided drug use evaluation (4491
    reduced deaths p0.016)
  • Pharmacist-provided in-service education (10,660
    reduced deaths, p0.037)
  • Pharmacist-provided ADR management (14,518
    reduced deaths, p0.012)
  • Pharmacist-provided drug protocol management
    (18,401 reduced deaths, p0.017)

Pharmacotherapy 200727(4)481493.
41
Additional Supporting Evidence
  • Clinical Pharmacy Services associated with
    decreased mortality rates
  • Pharmacist participation on the CPR team
    (12,880 reduced deaths, p0.009)
  • Pharmacist participation on medical rounds
    (11,093 reduced deaths, p0.021)
  • Pharmacist-provided admission drug histories
    (3988 reduced deaths, p0.001)

Pharmacotherapy 200727(4)481493.
42
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43
Billing Incident To Physician Services
  • An option for pharmacists practicing in a
    physicians office
  • Not an option for pharmacists who provide
    services in a community pharmacy
  • Allows physicians to bill for services provided
    by non-physicians
  • Specific criteria for use

44
Billing Incident To Physician Services
  • Criteria for use
  • The service must be an integral, although
    incidental, part of the physicians professional
    service
  • commonly furnished in physicians office
  • Provided under direct supervision of a physician
  • Provider must be a contractural worker

www.cms.hhs.gov/manuals/pm_trans/R1764B3.pdf
45
Summary
  • Evidence has shown that pharmacists involvement
    in disease management improves outcomes
  • Pharmacists are uniquely positioned to play a
    role in disease state management
  • We can help commands meet BUMED requirements
  • Publishing and presenting our successes will
    support future endeavors
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