Medication Use Crisis

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Strategies to Meet Patient Unmet Clinical Need

Through Pharmacy Systems Redesign Approach

Anthony P. Morreale, Pharm.D., MBA, BCPS, FASHP

Medication Use Crisis

VA Medication Reconciliation Initiative

In conjunction with

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Strategies to Meet Patient Unmet

Clinical Need Through Pharmacy

Systems Redesign Approach

• Anthony P. Morreale, Pharm.D., MBA, BCPS, FASHP

•

Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare Delivery Services Research

Pharmacy Benefits Management Services (119) Department of Veterans Affairs

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LEARNING OBJECTIVES:

• Understand that there are a number medication related of unmet clinical needs in both the primary care and specialty care arena.

• Understand the unique and critical role that a well trained

clinical pharmacist can play in helping improve care and lower overall costs.

• Describe the Challenges that currently exist in a resource constrained environment that force us to look for ways to redesign practices to free up scare clinical Pharmacy Staff • Describe specific systems redesign steps that Pharmacy

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VETERANS ADMINISTRATION PATIENT CARE SERVICES

Unmet Needs: Disease Management

• There are a number of common disease states that are medication intensive and are undertreated in the VA. Some of these include:

– Hyperlipidemia – Diabetes – Hypertension – Pain Management – Hepatitis C – Smoking Cessation – Obesity – COPD

– Mental health including PTSD, Depression, Schizophrenia and substance abuse.

– Heart Failure

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Unmet Needs: Drug Induced Problems

• There are a number of disease states that are medication intensive and are undertreated in the VA. Some of these

include:

– Osteoporosis – thousands of veterans are on chronic steroids,

anticonvulsants and other agents that ultimately lead to osteoporosis. Many of these patients have not been assessed for risk nor treated – Adherence – Non-compliance Issues

– Overtreatment of diseases

• Diabetes

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High Risk Populations

• Geriatrics

• Renal disease

• Immunosuppressed

• Dementia

• Women’s Health

• Transplant

• Oncology

• Intensive Care Unit

• Emergency Room

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Patient Complexity, Health Status, Needs

Medical Home Team Specialty Care

Clinical Nurse Leader, Case Managers, Clinical Pharmacist Specialist Coordination of Care Management of Care Disease/Cohort Management

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Clinical Pharmacist Specialist: Who Are They

And What Training Do They Have?

 Doctor of Pharmacy Degree or equivalency with 4

solid years of pharmacology training and clinical

application

 Many have Post Graduate Residency training in

Clinical Pharmacy practice

 Many are also Board Certified in Pharmacotherapy

and/or specialty care

 In VHA are considered mid-level providers who work

under approved Scope of Practice Directive

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CPS Scope of Practice

Scope of Practice allows CPS to:

• Work in concert with an attending physician

• Evaluate medication therapy through direct patient care • Prescribe medications, devices and supplies to include:

initiation, continuation, discontinuation, monitoring and altering therapy without co-signature

• Perform physical measurements necessary to ensure appropriate patient clinical responses to drug therapy • Order consults, as appropriate, to maximize positive drug

therapy outcomes and disease state management

• By working with a Scope of Practice and not a protocol, CPS can adopt practice changes quickly to reflect changes in literature, medication formulary, safety changes as well as new practice guidelines

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Pharmacists with a Scope of Practice (2250 of 7500)

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Pharmacist SOP by Disease State

1403 1014 969 ₉₅₃ 578 368 ₃₅₄ 307 ₂₉₅ ₂₇₆ 250 245 ₂₂₄ 115 ₉₄ ₇₉ ₈₁ 48 41 36 39

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Pharmacist SOP by Disease State

32 26 40 24 18 ₁₇ 14 14 ₁₃ 14 12 ₁₁ 10 16 11 10 10 11 ₉ 8 8

# of Pharmacists with SOP

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Challenges that currently exist in a resource

constrained environment

• Additional funding and resources coming to the field are limited as the Federal Government struggles with its staggering debt

• New funds that come to the field are often earmarked for specific

programs and often do not align with the needs at the VISN or facility level • Competition for limited funds across many disciplines and needs are

intense often resulting in limited distribution to any one service

• Unmet patient needs remain high so leaders are challenged with making changes that can improve efficiency, care for more patients and do it at the same overhead costs.

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PBM Recommended Systems Redesign:

Redeploying Pharmacist to add more PACT &

Specialty Care Clinical Pharmacists

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Making the Most Out of…

• Technicians

• Outpatient Staff

• Clinical Staff

• Experts

• Contractors

• Workload Assessment

• Innovation

• Technology

• “Buy vs. Make”

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Some Basic Principles of System Redesign

• Eliminate or reduce unnecessary tasks:

– What value is added by the process? – Is it required by law, regulation or – does it improve patient care / safety

• If the task cant be eliminated

– Is the person performing the task working at the top of their license? – Can another service or section do the task more efficiently?

– Can the task be centralized or streamlined from multiple steps to single steps? – Can automation take the place of current processes more efficiently

• Bring in outside consulting or ideas that will have different ideas on how to perform the task can often be liberating for those inside the process

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Manipulations with Pharmacy Tech workforce

Use Pharmacy techs to

do all the tasks that don’t require

Pharmacist

Allow sites to exchange 1 pharmacist vacancy

for 3 techs where needed (same cost)

Enhance technician training to support

new tasks and competencies

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Fully Utilizing Pharmacy TECHNICIANS IV Preparation Screening NFs/PAs Acquisitions Ward Inspections Checking Unit Doses Quality Assurance & MUE Patient Medication History Controlled Substances Filling and managing all automation 17

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IV Preparation

• Technicians can prepare all IV’s - Set up training & competency

checklists

• IV to PO conversions reduce total IV

• Use premade/frozen solutions and batch stable medications

whenever possible

• Quicker dispensing

• Drug budget easier to attain than staff FTEE

• Investigate expiration date extensions

– Evidence-based studies to extend dating

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Acquisitions – Inventory Management

• Having a Pharmacy technicians in charge of all purchasing at your facility should be the goal

• Technicians to can handle recalls, shortages, and drug accountability (credits, high cost, etc)

• Technicians can manage all return processes

• Use of centralized inventory management techniques can reduce un-necessary ordering, stocking and outdates

• Screen order requests

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Checking Unit Doses

• VA PBM Inpatient Pharmacy Handbook allows for

technician unit dose dispensing without a pharmacist checking.

• Need to assure adequate training, competency and quality assurance measures are in place

• Multiple studies have been published in the literature that technicians can perform this task safely and effectively • In VA additional margins of safety can be achieved

through the use of automation and BCMA.

• Can be applied to code trays, pre-filled med trays, carts • “Tech Check Tech”

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Ward Inspections

• At many CBOCs, these are completed by nurses since no pharmacy personnel may be on station

• Need to assure adequate training for technicians and nurses to assure competency.

• Competency checklists can be found on the Clinical Pharmacy SharePoint site

• Quality assurance policies can assure compliance

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Quality Assurance

• In many sites, pharmacists’ are in charge of managing the quality assurance programs including DUE.

• Pharmacy Technicians can be trained to perform many of these tasks at a much lower cost and free up the

pharmacist to do more direct clinical patient care. • Technicians can collect MUE data for pharmacist

review and interpretation. They can also be useful in pulling data from the computers

• Technicians performing audits (narcotics • “Tech Check Tech”

• REMS monitoring

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Controlled Substances

• VHA policies allow for Pharmacy technicians to manage the CS system from cradle to grave.

• In outpatient techs should be filling all CS prescriptions with a pharmacist check

• VHA policy allows for 90 day fills on controlled

substances and at many sites this is severely under-utilized

• Reductions in total number of prescriptions can have dramatic impact on pharmacist availability for clinical work

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Screening Medication Requests

• Have technicians perform initial screening for Non-formulary/Prior

Authorization Agents. This is a standard of practice outside the VA but is not used well internal to the VA.

• Cancel/deny requests that do not meet documented criteria or require more information before forwarding to pharmacist can be done by

trained and competent technicians

• Use of order sets and note templates for screening, adjudication and documentation

• Set up appropriate training & competencies to assure thorough review

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Patient Medication History

• Nearly any healthcare professionals can be trained on how to take a good medication history.

• Training nurses, physicians, technicians and others can free up pharmacist time.

• Strong training and competency programs are essential • Standardized note templates prompt the history taker to

ask about all potential issues assure thorough reviews • Trained technicians can screen & filter patient questions

(med counseling vs refill system)

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Other Ways Pharmacy Service Can Support PACT & Specialty CPS Business Rules Non-Formulary Patient Counseling Medication Recalls Refill Extensions Drug Shortages Quality Assurance & MUE Medication Reconciliation New Patient Enrollment

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Centralizing Processes CMOP Meds by Mail Centralized formulary management Centralized call centers Centralized disease management centers Centralized tele-pharmacy Centralized Intake Pharmacist 27

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Deploy Use of Automation

Automation Inpatient Outpatient ED Clinic settings Supply packaging

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Contracts

With local retail pharmacies to fill urgent medication needs at CBOCs and close those pharmacies.

Tremendous savings of FTEE and inventory

With Home IV companies

All non-sterile compounding should be contracted out

Sterile product preparation

Clinical Services in Nursing Homes and other settings

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Use of Pre-made Products

Premade Prepackaged and unit of issue outpatient medications Pre-packaged unit dose Formulary conversions to products that can be purchased vs. compounded Pre-made TPN Frozen or premade IV products 30

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Policy changes

Reduce outpatient window hours to enhance efficiency of operations Eliminate the need for pharmacist to check outpatient prescriptions

for supply, dietary and testing items (national policy change) Eliminate non-urgent refills at outpatient pharmacy windows

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Support for CPS who is in provider role

• Assure teamlet support from all other disciplines the same as any other provider (MD, NP, PA) for vitals, lab follow-up etc so that they can improve access.

• Assure Outpatient Pharmacy manages all non-CPS activities

• Analysis of CPS setting patient needs to assure CPS is trained to manage the majority of patient medication management needs

• Increase time residents and students spend in PACT and Specialty Clinics to improve throughput

• Assure no clinic slot for CPS is greater than ½ hour

• Assure Panel Management Criteria for CPS is enforced. Referral and discharge

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Other CPS efficiencies

• Consider expanding use of Dabigatran instead of warfarin and move those clinical pharmacists into other clinical roles in PACT and Specialty care

• Assure CPS care delivered on teams is completed through non-face to face methods when feasible to increase throughput

• Assure CPS do not continue to follow patients that are already at goal for the problem they were referred for

• Assure that CPS is not taking patients who can easily be managed by the PCP for connivance. They should be more difficult cases that maximize the value of the CPS

• Shift non-CPS Pharmacy work to outpatient pharmacy staff – this includes things like medication reconciliation, counseling, refills, etc.

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Outpatient Staffing & Workload Management

• Deploy trainees into clinical and distributive staffing support roles • Consolidate to single medical center pharmacy

– Establish contracts with retail pharmacies for CBOCs – Pushes more patients to mail

• Improve CMOP Utilization

• Reduce Pharmacy Hours of Operation to concentrate workload. • Enforce policies that reduce window fills

– Maximize 90 day fills including controlled substances where appropriate – Reevaluate Do Not Mail patients on a regular basis

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Bring in the Experts

• Don't think you know how to redesign your workflow the best

• Employ expert’s consultants or other leaders. Fresh eyes can always see better.

• Use outside pharmacy teams to come review to help move things around.

• They can also pressure leadership to add staffing in some cases

• Principle - 10% improvement in efficacy is a huge staff increase.

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Be Prepare to Strike

• Learn how to put together good evidence based staffing requests

– Business plans to support new positions

– Annual strategic or global business plan should be done at every facility.

• Anticipate opportunities – Strategic Planning

– Crisis Management

– Know what is happening locally, nationally and regionally

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Contracting Out When Needed

• Faculty and WOC arrangements similar to what

MD’s do to manage workload

• Contract out services to free up existing staff. EG:

telephone care, Home IV

• Reduce operational hours and consolidate

pharmacies and use local contract pharmacies for

urgent fills which is generally more cost

effective

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Workload Assessment

• Detailed staffing review of all areas. Stop what is not required by law or regulation and that doesn't improve care.

• Engage staff in efficiency drive with a promise that captured time goes to clinical

• Assure that existing techs are performing efficiently to free up tech time to do more Pharmacist support. Some techs are less than productive.

• Examine workload/volume in different areas for daily/hourly patterns. Cross-trained staff could be shifted throughout the day based on workload location

• Ensure all workload/encounters are being captured appropriately to justify current and future clinical staff

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Technology

• Examine technology that can improve efficiency and improve safety:

– Omnicell, ScriptPro etc

• Use of Phone vs. face to face (f2f) visits can significantly improve throughput. Many Pharmacist believe F2F visits are better for

patient care but many patients would prefer not to. Evidence to date does not support the premise.

• Employ computer reports and programs to improve efficiency

– Examples:

• exception reports, • dashboards,

• Inpatient high risk reports, • drug class duplication reports

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Innovation

• VISN Virtual Clinical Pharmacists

– NF Reviews – Anticoagulation

• Establish pilot programs out of existing staff or trainees (residents are great) and demonstrate performance then ask for staff

– Lipid Telehealth

• Departmental liaison’s for other services (PC, Spec. Care, Nursing, MH, CLC)

– open and continuous communication can facilitate efficiency and buy-in for the goal of expanding clinical services and improving operational efficiency

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“

Buy vs. Make”

• A critical skill that needs to be part of

every supervisory or management

structure

• Much easier to get drug budget money

than FTEE dollars.

• Employ pre-made and pre-packs even

though higher drug cost and redeploy

staffing.

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Formulary Opportunities

• Changes in formulary can sometimes result in large gains in staff time

• Examples are highly restricted medications going to unrestricted

• New drugs, like Dabigatran, can be used to quickly redeploy staff to new areas

• Non drug technology, like implants and surgeries can also so lead to gains in staffing by reducing high use medications.

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Service Line Budgets

• Consider staffing swaps 3 techs per

Pharmacists to then redeploy rest of Pharmacist

into Clinical roles – budget neutral but improved

efficiency

• Request a pharmacy staffing global budget to

use positions where needed for service goals

• Special project budgets can get temporary

staffing. Example medications in CMOP at high

cost but a lot cheaper if filled at local site

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Other ways to get Clinical Staff

• New Program estimates

• Solve problems for other Services

example: SPD

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Conclusions

• Utilizing proven strategies can help facilities examine their processes to assure that they have addressed all the issues that prevent them from expanding clinical pharmacy services.

• Applying these principles and learning from others is the key to success.

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Questions

For further information or support for Clinical Pharmacy Services contact

Anthony P. Morreale, Pharm.D., MBA, BCPS Assistant Chief Consultant for Clinical Pharmacy Services and Healthcare

Services Research Pharmacy Benefits Management [email protected]

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