Expanding Pharmacy Services in a Health-System Primary Care Clinic: Factors to Consider

Andrea Lee, PharmDPGY2 Health-System Pharmacy

Administration Resident

Objectives Identify methods to justify the expansion of

sustainable primary care pharmacy services in a health-system clinic.

Penobscot Community Health Care (PCHC) is a Patient Centered Medical Home serving over 60,000 patients annually at 16 practice sites– Totaling over 350,000 patient visits– 70% of patients are lower income

Largest and most comprehensive Federally Qualified Health Center (FQHC) in Maine– Shared Savings Accountable Care Organization (ACO)– Previously in a Pioneer ACO- 2013– Rural health care facility providing comprehensive health care services to the

greater Bangor area and surrounding communities

Health-Care Facility

Image: www.visitmaine.org

Outpatient Pharmacy Background Three Outpatient Pharmacies– Roughly 80,000 prescriptions annually– Hours of Operation vary among

locations• One pharmacy open weekday evenings and

weekends starting October 2012

3 Full-time Pharmacists– Focus of time spent in dispensing roles

Clinical Pharmacy Services Background

Two* Clinical Pharmacists- Husson University Faculty Four PGY1 Community Pharmacy Residents

– 75% of time in clinics, 25% of time dispensing– Program developed in 2011

Clinical participation from pharmacists within the integrated team is limited to Husson Faculty presence and resident rotation within practice sites– Current services include clinical consults, chart reviews, joint patient visits with

primary care provider (PCP) Administrators desire increased clinical pharmacy services within the

organization

New Position Proposal Pharmacy Business Model Innovation– Service Design:

• 0.6 FTE – Pharmacy Staffing at Helen Hunt Health Center (HHHC) Pharmacy in Old Town, ME

• 0.4 FTE – Clinical Pharmacy Integration conducting reimbursable patient visits

– Allows for expansion of outpatient pharmacy hours in another location

– Adds a desired imbedded clinical component

Benefits of the Proposed Position1. Increased access to outpatient pharmacy services for Walk-in-Care

Patients2. Increased capture rate on new and refilled prescriptions 3. Improved oversight and documentation of continuity of care 4. Increased pharmacy presence within practice sites5. Increased patient satisfaction and efficiency of the care experience6. Increased touches on Medicare patients7. Improved student/resident education

Overview of the Landscape in Old Town, ME

Pharmacy Locations– 3 pharmacies within 5 mile

radius of health center Walk-In-Care (WIC) Locations

– HHHC is the only WIC open Weekends

– EMMC Orono no longer provides WIC services (Sat Appts only)

– UMaine Cutler Health Center- Mon-Fri only

Hours of Operation for Outpatient Pharmacy Extended Hours- HHHC

Current Hours Monday- Friday

8:30am – 5:00 pm

Staffing: 1 FTE (40hr)

Proposed Hours Monday-Friday

8:30am – 8:00pm Saturday

9:00am – 4:00pm

Staffing: 1.6 FTE (67hr)

Historical Perspective on Extended Hours Brewer location began extended hours October 2012

– Staffing component for PGY1 residents

1/7/2

012

1/26/2012

2/14/2

012

3/4/2

012

3/23/2

012

4/11/2

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4/30/2

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5/19/2

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6/7/2

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6/26/2

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8/3/2

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8/22/2012

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9/29/2012

10/18/2

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11/6/2

012

11/25/2

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1/21/2

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2/9/2

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2/28/2

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3/19/2

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4/7/2

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4/26/2

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5/15/2

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6/22/2

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7/11/2

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7/30/2

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8/18/2013

9/6/2

013

9/25/2

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10/14/2

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11/2/2

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11/21/2

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12/10/2

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12/29/2

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014

3/15/2

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4/3/2

0140

100

200

300

400

500

600

700

800

f(x) = 0.406247576718317 x − 16300.6305704516

Brewer Totals

TOTAL Linear (TOTAL) NEW REFILL

Trends at Brewer Pharmacy – Extended Hours

Average Monthly Fill2012 182.32013 258.82014 295.5

Average Montly Fill2012 112.66672013 111.252014 136

Analysis of Brewer Pharmacy, cont. Change in Patient Perception

– Knowing that the pharmacy is open nights and weekends as a driver for growth

– Objective Measure: Volume of refilled prescriptions filled during extended hours

Average Capture Rates of WIC RX’s around 40%– Varies by day, provider in

WIC

Extrapolation to HHHC PharmacyFINANCIAL IMPLICATIONS

Additional Cost/Year to Extend Hours $177,242.00

– Includes salary, fringe, direct expenses, administration fees

Requires approximately 5550 additional prescriptions to break even 13% rate in growth needed

Market Analysis- Questions to Consider– What is the WIC volume at HHHC in terms of Brewer?– What is the pharmacy’s current capture rate of prescriptions coming out of clinic?

Trends in Pharmacy Totals

Background on Medicare Annual Wellness Visit (AWV)

Fully paid for by Medicare Part B for beneficiaries 65 and older– No cost to eligible beneficiaries

Focused visit on “Health Risk Assessment (HRA)” – Health prevention– Disease detection– Coordination of screening

Pharmacists across the country have performed AWVs Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/

Billing for Annual Wellness VisitHCPCS Codes

Billing Code Descriptors Reimbursement (FFS Maximum Rate)

G0402 Initial preventative physical examination (IPPE); face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment

Provider Required

G0438 Annual wellness visit (AWV); includes a personalized prevention plan of service (PPPS), initial visit

$159.38

G0439 Annual wellness visit (AWV); includes a personalized prevention plan of service (PPPS), subsequent visit

$106.35

AWV eligible for Medicare beneficiaries 66 years and older Subsequent visits billable every year

Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/Warshany K et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):44-9.

Benefits to the Organization Utilization Drivers– Increase vaccinations (~1.25 vaccinations recommended

per person, ~30% received vaccinations at time of visit)– Referrals for additional services; ie. lab, podiatry, dietitian,

PT, audiology, mental health (~1 referral placed per patient)– Opportunities to improve quality metrics

• Patient’s accessing electronic portal

• Focus on a specific metric requiring improvement (eg. Mammogram, colonoscopy)

Feasibility of AWV Proposal 5510 Medicare Beneficiaries 66 years and older at PCHC

practice sites Pharmacist to see 13 patients each week Estimated Net Revenue $5,435 per year Factors to consider

– No show rates ~33% within institution– Start-up costs– Marketing of services– Provider and patient buy-in

Post Question What factors should be considered when justifying sustainable primary

care pharmacy services?a) Understand the unique characteristics of the surrounding community to

support expanded pharmacy services

b) Align proposed services with the clinical and financial priorities of the organization

c) Ensure payments for pharmacy services are within the scope of the organization’s reimbursement structure

d) Ensure a sustainable infrastructure of support is included in the proposal, including staffing levels, anticipated growth, shifts in payments, and future technology costs

e) All of the above

References Centers for Medicare and Medicaid Services. Providing the

annual wellness visit (AWV). www.cms.gov/ Desselle SP, Zgarrick DP. Pharmacy management: essentials for

all practice settings. 2nd ed. New York: McGraw Hill Medical, 2009.

Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. Am J Health Syst Pharm. 2014 Jan 1;71(1):44-9.

Questions?

Medicare Part B licensureEvaluating its potential in a federally qualified health

center (FQHC) outpatient pharmacy system

Kari London, PharmD PGY-1 Community Pharmacy Practice ResidentPenobscot Community Heath CareApril 26th, 2014

Objective Understand the barriers and benefits of DME

Supplier enrollment in the independent pharmacy setting– Focus: Diabetic testing supplies

Background• From 1980 to 2004 the number of people age 65

years and older diagnosed with diabetes increased almost two fold, from 2.3 million to 5.8 million1

• Prescription medications to treat diabetic complications, and antidiabetic agents plus testing supplies, are two of the largest drivers of expense at 18% and 12%, respectively2

• Medicare Part B coverage is an important means of mitigating prescription costs of these products

Background cont.• FQHC with 16 primary care practice sites • Pharmacy services• 3 outpatient pharmacies, residency program,

faculty practice sites, pharmacy students• Exploring feasibility of piloting DME

supplier enrollment at one pharmacy• Primary products on interest: diabetic testing

supplies

Barriers Program administrative costs

Per Site (USD) Medicare DMEPOS Enrollment Fee 532 NABP DMEPOS Accreditation Fees

Application and Survey Fees 3250 Annual Participation Fee 125 Year 1 subtotal 3375 Estimated total for 3-year accreditation 3625

Surety Bond (annual fee) 1200 Estimated Total Fees

Year 1 5107

Year 1-3 Total 7757

Barriers cont. Program infrastructure– Software systems– Documentation requirements– Employee training– Inventory management

Barriers Cont. Patient recruitment– Eligible patient population size

Low product reimbursement

80.1%

19.9%Other pharmacies

PCHC pharmacies 81.3%

18.7%

Total Patient Capture Diabetic Patient Capture

50ct Test Strips 100ct Lancets BG Monitor Prescription

Medicare reimbursement $10.41 $2.52 $72.34 ------------

Average Revenue -$42.86 -$5.10 $51.06 -$324.18

Benefits Improved patient recruitment– The “Loss Leader”– i.e. gross ~$7,000/year of revenue on prescriptions for 1

patient Increased services Improved patient care– Patient Centered Medical Home– Coordination of care

The Numbers Revenue per diabetic pt. / year

Series1

$1,464

$2,112

$(648)

Testing Supplies RXs Other RXs Total Revenue

The Numbers cont. Revenue projection

Year 1 Average / Year Cumulative Years 1-3

$(8,000)

$(6,000)

$(4,000)

$(2,000)

$-

$2,000

$4,000

$6,000

$(5,107)

$(2,585)

$(7,757)

$2,050 $2,050

$6,150

$(3,057)

$(535)

$(1,607)

Administrative Costs

Potential DM Pt. Revenue

Net Revenue

Conclusions Administrative costs of implementing Medicare Part B billing pose

the most significant barrier to program feasibility

Potential increase in capture of non-diabetic supply prescriptions may be sufficient to mitigate losses associated with filling diabetic testing supply prescriptions

Being a participating DME supplier for diabetic testing supplies presents a negligible loss ($535/ pharmacy/year)

– Utilized conservative patient capture increase numbers and high estimate of revenue loss of diabetic supplies

– Did not account for potential revenue loss from lost patients

References1. Ashkenazy R, Abrahamson MJ. Medicare coverage for

patients with diabetes. A national plan with individual consequences. J Gen Intern Med. 2006 Apr;21(4):386-92.

2. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013; 36 (4): 1033-46.

3. DMEPOS. NABP National Association of Boards of Pharmacy. Website. http://www.nabp.net/programs/accreditation/dmepos. Accessed November 29th, 2013

4. NHIC, Corporation. The DME MAC Jurisdiction A Supplier Manual. Website. http://www.medicarenhic.com/dme/supmandownload.aspx. Accessed December 6th, 2013.

Post questionPotential threats to the success of Medicare Part B DME program for this FQHC pharmacy system include:

A. Low product reimbursementsB. High administrative costsC. Documentation requirementsD. Eligible patient population sizeE. All of the Above

Questions?

Impact of a interdisciplinary team approach in the treatment of high risk patients with chronic obstructive pulmonary disease (COPD):

A pilot program in the primary care settingZach Deabay, PharmD

Penobscot Community Health Care

PGY1 Pharmacy Practice Residents

April 26th, 2014

Objectives Discuss the interdisciplinary team approach in the

management of COPD Evaluate strategies utilized to improve disease state

management and access to medications Analyze effect of the program on healthcare utilization

and strategies moving forward

Disclosure: Study funded by grant received from Cardinal Health. Did not influence implementation, execution, or analysis of study.

Background• Prevalence of COPD in the US is estimated at 23.6 million adults1

• Medicare patient with COPD have higher rates of hospitalization, ER visits, and home healthcare use than non-COPD peers2

• Total excess healthcare costs of ~$20,000/year higher

• ~80% due to inpatient services• Studies looking at efficacy of self-management interventions to

improve COPD management have demonstrated mixed results3,4

Overview Components of Program

– Education session with care manager and pharmacist

– Rescue Pack

• Providers choice of antibiotic +/- steroid for patients to keep at home

• Patient must contact care manager or provider before use

Goals– Educate patient to better self-manage disease state

– Optimize therapeutic regimen

– Provider easier/quicker medication access to reduce severity of COPD exacerbation

Workflow Pre-visit

– Chart review by care manager

– Pharmacotherapy review by pharmacist

• Recommendations made to provider

Visit– Disease state assessment, education, and management techniques

– Comprehensive medication assessment

• Technique, compliance, barriers, perception

Post-visit– Care management follow-up

– Rescue pack

Program Materials

Target PopulationDocumented COPD exacerbation in prior

12 months prompting patient to seek acute

medical attention(Emergency Department, Walk-In Care, Office Visit)

COPD Diagnosis

Other Inclusion Criteria• Patient desire to participate• Patient attendance of educational visit

Exclusion Criteria• History of non-compliance• Comorbidity affecting ability to self-

manage disease state

Inclusion Criteria Met

Approval of PCP

Education Visit

Pre-visit Protocol

Enrollment First patient enrolled 8/29/13 Enrollment ongoing 52 patients enrolled to date

– Current Smoker – 49%

– Average # Medications – 10

– Average # Respiratory Medications – 3

– Oxygen Therapy – 20%

– Females – 32 (62%)

– Males – 20 (38%)

– Age

• Range – 42-91 years

• Average – 65 years

Result Analysis Patients required to be

in study a minimum of 3 months before analysis performed

26 patients meet this criteria – Additional 11 patients

qualify in May

Analysis will include:– Primary endpoints

• Hospitalizations

• Use of emergency department and walk-in services

• Death

– Secondary endpoints• Rescue pack use

(appropriate/inappropriate)

• Number of exacerbations

Preliminary Observations Majority of patients enrolled in program are prescribed rescue

pack (>80%) Of those prescribed rescue packs, most have not used them

(<50%) Most commonly prescribed combination is

azithromycin/prednisone Several patients have used the rescue packs inappropriately

but majority of uses (>75%) have been appropriate Program appears to be reducing utilization of emergency room

– Possible shift from decreased ER visits to increased office visits

Program Benefit Organization Benefits

Patient care divided among team members

Accurate medication list Assessment of medication

compliance Pharmacotherapy review Improved patient

outcomes* Lower healthcare costs*

Patient Benefits Disease state education Medication education Pharmacotherapy

review Relationship with care

manager Easier access to

medication

*Being assessed in current study

Patient Case

After CM visit reports recognition of symptoms that warrant appt. Lack of maintenance medication identified at visit with follow-up recommended

Patient call: states "been having more shortness of breath and burning in chest, which is always the first sign of the bronchitis."

Patient initiated antibiotic and steroid, with PCP follow-up visit within several days. Instructed to call back for appointment if symptoms do not improve.

Follow-up office visit: “patient reluctant in gen to take meds but with recent exacerbation she started the pack and did much better than usual, recovering more quickly from COPD exac.”

56 yof with COPD, typically waits if she is sick

Key Points Interdisciplinary approaches utilize the expertise of all

healthcare team members Rescue packs provide quicker and easier access to

medication and may be a useful tool, if used appropriately It is essential to do educational visit Before rescue pack

medications are sent to pharmacy Difficult to predict which patients are most appropriate for

rescue packs– All patients expected to benefit from educational component

Assessment QuestionBenefits of enrollment in the COPD program include all of the following except:

A. Medication and disease state education

B. Patient ability to decide when their symptoms warrant antibiotic therapy

C. Quicker access to medications if deemed appropriate by provider

D. All of these are benefits of the program

References1. Mannino DM, Braman S. The epidemiology and economics of chronic obstructive

pulmonary disease. Proc Am Thorac Soc. 2007; 4 (7): 502-6.2. Make B, Dutro MP, Paulose-Ram R, Marton JP, Mapel DW. Undertreatment of COPD: a

retrospective analysis of US managed care and Medicare patients. Int J Chron Obstruct Pulmon Dis. 2012; 7: 1-9.

3. Effing T, Monninkhof EEM, van der Valk PP, et al. Self-management education for patients with chronic obstructive pulmonary disease (Review). Cochrane Database Systm Rev. 2009

4. Bucknall CE, Miller G, Lloyd SM, et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomized controlled trial. BMJ 2012; 344: e1060 doi: 10.1136/bmj.e1060

5. London, Kari. Chronic obstructive pulmonary disease management in high risk patients: Evaluation of a multidisciplinary team approach to reduce readmission rates within a federally qualified health center population. MSHP Conference. Jan 26, 2014.

Questions?

Pharmacist Interventions on Prescribing Habits for Urinary Tract Infections (UTIs) in a Walk-In Care ClinicNicholas LeBlanc, PharmDPGY1 Pharmacy ResidentPenobscot Community Health Care

Objective Identify trends in antibiotic resistance of urinary

tract infections and formulate a plan to reduce inappropriate prescribing of antibiotics.

Introduction Uncomplicated cystitis is a very common infection among

young women and a major source of antimicrobial exposure.

Repeated antimicrobial exposure can select for resistant organisms.

Antimicrobial resistance has complicated treatment of urinary tract infections.

Community pharmacists can play a role in lowering resistance.

Guidelines First-line agents are Nitrofurantoin, Trimethoprim-

Sulfamethoxazole (Bactrim), and Fosfomycin. TMP-SMX should not be used empirically if local

resistance is greater than 20%. Second-line agents are fluoroquinolones and β-lactams.

Fluoroquinolones should not be used empirically if local resistance is greater than 10%.

Local Resistances

Local Resistances

UTI Prescription Analysis A 6 month time period was analyzed. Reviewed antimicrobial prescriptions associated

with ICD-9 code 599.0 (UTI). Inappropriate medications were omitted:– Azithromycin– Doxycycline– Metronidazole

Initial Results Penicillins9%

TMP-SMX29%

Cephalosporins5%

Fluoro-quinolones

33%

Tetracyclines3%

Nitrofurantoin20%

Antimicrobial Agents

Discussion A total of 1315 prescriptions were analyzed. Approximately half of the prescriptions analyzed

were for non-first line agents. Fluoroquinolones were the most highly

prescribed antimicrobial class (33.38%). Penicillins, cephalosporins, and tetracyclines

were sparsely prescribed.

Limitations ICD-9 codes do not describe the patient well. The data does not distinguish whether the UTI

was treated empirically or not. Tetracycline use may not have been associated

with UTIs.

Role of the Pharmacist Community pharmacists can serve as a source of information for providers.

– Up to date on guidelines– Drug experts– Useful resources

Giving feedback to providers on prescribing habits. Provider education

– CME presentations– Calling about errors in prescriptions– Group meetings– Handouts– EMR alerts– Get feedback from providers

Conclusion Antimicrobial resistance is low, but prescribing

habits leave much room for improvement. Pharmacists can be a valuable resource of drug

information and provide education to providers. There are many different ways in which

pharmacists may educate providers.

References Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice

Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011; 52(5):e103–20.

Gupta K, Hooton TM, Stamm WE. Increasing Antimicrobial Resistance and the Management of Uncomplicated Community-Acquired Urinary Tract Infections. Ann Intern Med. 2001;135(1):41-50.

Hooton T, Gupta K. Acute Uncomplicated Cystitis and Pyelonephritis in Women. UpToDate. 2013.

Assessment QuestionsWhich of the following is an appropriate way to reduce

resistance of urinary tract infection organisms by pharmacists?

A. Ensure proper prescribing of first-line agentsB. Antimicrobial stewardship programsC. Keeping providers up to date on current guidelinesD. Be a resource of drug information for providersE. All of the above are true

Questions?

nleblanc@pchc.com

Implementation and outcomes of an interdisciplinary collaborative practice group on controlled substance use and prescribing

within a patient-centered medical home Rachel Bastien, PharmD

PGY1 Resident, Penobscot Community Health CareBangor, ME

Objective Summarize the development, workflow, and

pharmacist involvement of the Controlled Substances Initiative (CSI) committee and evaluate the impact on providers, patients, pharmacy dispensing, and prescribing habits.Disclosure Authors of this presentation have the following to disclose concerning possible financial or personal

relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation:

Rachel Bastien: Nothing to disclose

Motivation Increasing rates of prescription drug abuse The cost to the overall health of patients and the

community Negative social impact Increased costs associated with abuse Provider frustrations

Development Formed in March 2013 Initially, the committee members were appointed by the executive

medical director– Executive medical director– Chief quality officer– Chief psychiatrist– Physicians– Nurse practitioners

Soon after pharmacists were added for their drug expertise Weekly meetings where approximately 8-12 patients are reviewed

Workflow

1 •Referral to CSI

2 •Pharmacist conducts a comprehensive chart review

3 •Pharmacist presents patient case from chart review to committee

4 •Collaborative interdisciplinary discussion generates targeted, evidence-based recommendations with action plans

5 •Consensus recommendations communicated to provider

6 •Review and appeal process

The Role of the Pharmacist Pharmacist conducts a comprehensive chart review, including

– Maine Prescription Monitoring Program (PMP) report– Health Info Net– Office visit notes – Consults with specialists – Medication history – Imaging studies – Any additional pertinent information – Calculate Morphine Equivalent Dose (MED)

Presents case to committee Communicates responses to providers

Population reviewed

Outcomes

24%

39%

32%

5%

Percentage of patients with MED changes post CSI review

Off of narcotics entirely (N = 21)

Reduced dose (N = 34)

No change (N = 28)

Dose increase (N = 4)

Outcomes

June July August 1750

1800

1850

1900

1950

2000

2050

2100

2150

2200

Narcotic and Benzodiazepine prescriptions written organization wide

20122013

Month

Num

ber o

f pre

scrip

tions

Outcomes Number of prescriptions filled at largest-volume internal outpatient pharmacy

2012 (June-Aug) 2013 (June-Aug) CIITotal 1514 1245 (-17.7%) Opiates 673 606 (-9.9%) Stimulants 841 639 (-24%)

CIII-VTotal 1307 1080 (-17.3%) Benzodiazepine 433 350 (-19.1%) Codeine/Hydrocodone Products 392 296 (-24.4%) Buprenorphine Products 265 281 (+6%) Hypnotics 127 93 (-26.7%) Other (Lyrica, Soma, Testosterone, etc.)

90 60 (-33.3%)

Challenges and opportunities Presenting alternative treatments to providers – Use of NSAIDs, SSRIs, therapy, etc where appropriate

Challenges within PCHC prescribing trends – Increase prescribing of tramadol and ketorolac

Engaging the entire healthcare team – Physical therapy – OMT– Addiction services

Discussion An overall 63% reduction in MED occurred in patients reviewed by the

committee A 12% reduction in the number of opioid prescriptions written occurred

between January and September 2013 The largest of the 3 internal outpatient pharmacies saw a 17.7%

decrease in the number of C-II prescriptions filled

Takeaway points Provides provider support and education Defines clear expectations for both patients and prescribers Allows for objective and evidence-based use of controlled medications

Assessment question As a result of instituting a controlled substances

committee, which of the following was not directly enhanced?1. Multidisciplinary collaboration

2. Patient acceptance of need for dose reduction

3. Chapter 21 compliance measures

4. Provider prescribing support

Questions?