The Journal July/August 2019 by Pharmacy Society of Wisconsin

Volume 22 THE JOURNAL OF THE PHARMACY SOCIETY OF WISCONSIN

RETURN S ERV ICE RE QUES TE D

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Issue 4 www.pswi.org

July/August 2019

JULY/AUGUST 2019 • VOLUME 22 • ISSUE 4

Practice Advancement

WHERE EXPERIENCE

MEETS THE FUTURE

SAVE THE DATE PHARMACY DAYS 2019 CAREER FAIR

OCTOBER 11 SIGN UP TODAY!

cuw.edu/pharmacy

Employers are encouraged to provide students with information about rotations, internships, residencies, and employment opportunities. The event is free for everyone. Interview space will be available for interested employers.

2019

July/August Continuing Education

CE for Pharmacists & Technicians: Improving Patient Care by Ensuring Well-Being and Resilience in HealthSystem Pharmacy

Features

UpFront: It's Finally Summer!

PSW News/Initiatives

I am a Pharmacy Professional and an... Innovator

Expanding Access to Medication-Assisted Treatment: Emergency Department-Initiated Buprenorphine/Naloxone

Meeting Recap

A Reflection on Practice Advancement

WPQC Update: Community Pharmacy Practice Advancement Alphabet Soup: CPESN and WPQC

ID Corner: Ambulatory Point of Care Testing: Implications for Ambulatory Antimicrobial Stewardship

Advancing Ambulatory Care Pharmacy Practice Across Michigan Through Collaboration with a Payer

Ambulatory Care Practice Development: Highlighting Best Practices

Ambulatory Care Pharmacy Practice Advancement: Diffusing Strong Practices

Precepting Series: Meeting Precepting Challenges with Layered Learning

Medical Staff Credentialing and Privileging of Hospital Pharmacists

Investing in Pharmacy Technician Resources

A Reflection on UW Health Practice Advancement

Review Articles

The Evolution of Sterile Compounding Practices

Federally Qualified Health Centers: A Practice Advancement Opportunity for Pharmacists

Behind the Scenes Look at Quality Measurement

Original Work

The State of Pharmacist Credentialing and Privileging in Wisconsin

Implementation of a Pharmacist-Optimized Education and Transition (POET) Service Advances Pharmacy Practice at a Community Teaching Hospital

2019 PSW Educational Conference

Pharmacy Reflections

The Journal of the Pharmacy Society of Wisconsin is a professional publication for original research, review, experience, and opinion articles that link science with contemporary pharmacy practice to improve patient care. Together we can inspire each other to advance our profession with the single purpose of enhancing the lives of our patients. Guest Editor LYNNAE MAHANEY, MBA , BS PharmD Pharmacist Editor AMANDA MARGOLIS, PharmD, MS, BCACP Managing Editor & Creative Content Director MEGAN GRANT, mgrant@pswi.org CE Coordinator PATRICIA CARLSON, PharmD Peer Review Coordinators ANGELA COLELLA, PharmD, BCPS MICHAEL NAGY, PharmD SARAH PEPPARD, PharmD ID Corner Series Coordinator LYNNE FEHRENBACHER, PHARMD, BCPS-AQ ID Precepting Series Coordinator MELISSA THEESFELD, PharmD Open Access Coordinator NICK J FRIEDLANDER, 2020 PharmD Candidate

Editorial Advisory Board PATRICIA CARLSON, PharmD DCV Clinical Health Outcomes Director, Sanofi, St. Paul, MN

NATHAN MENNINGA, PharmD Clinical Phamacist, William S. Middleton Memorial Veterans Hospital, Madison

LOREN CARRELL, PharmD Clinical Pharmacist/Pharmacist in Charge, Gundersen Health System, La Crosse

SUSIE MORONEY, PharmD, MS Regional Scientific Director in Immunology, Novartis, Fitchburg

ANGELA COLELLA, PharmD, BCPS Drug Formulary Specialist, Drug Use Policy Aurora Healthcare, Milwaukee

MICHAEL NAGY, PharmD Assistant Professor, Department of Clinical Sciences, Medical College of Wisconsin School of Pharmacy, Milwaukee

SHABNAM DABIRSHAHSAHEBI, PharmD, MS Drug Information Pharmacist Dean Clinic-Landmark Office, Madison

MIKE OCHOWSKI, RPh, BBA Formulary Pharmacist, Group Health Cooperative of South Central Wisconsin, Madison

MELISSA HEIM, PharmD, BCCCP Clinical Pharmacist William S. Middleton Memorial Veterans Hospital, Madison

TRISHA SEYS RANOLA, PharmD, CGP, CDE Clinical Phamacist, William S. Middleton Memorial Veterans Hospital, Madison

LYNNE FEHRENBACHER, PharmD, BCPS-AQ ID Associate Professor of Pharmacy Practice Concordia University School of Pharmacy, Mequon CATHERINE (KATIE) KUECKER, PharmD PGY2 Ambulatory Care Pharmacy Resident William S. Middleton Memorial Veterans Hospital, Madison LYNNAE MAHANEY, MBA, BS PharmD Director, Pharmacy Accreditation American Society of Health-System Pharmacists

SARA SMITH-SHULL, PharmD, MBA, BCPS Drug Policy Program, UW Health, Madison DIMMY SOKHAL, PharmD Clinical Pharmacist, Hayat Pharmacy, Milwaukee JULIE THIEL, BS Pharm, PharmD Clinical Pharmacist Winnebago Mental Health Institute, Winnebago MATTHEW WOLF, PharmD, MS Pharmacy Manager Froedtert Hospital, Wauwatosa

Visit the JPSW Website

www.jpswi.org 2 The The Journal Journal November/December July/August 2019 2015 2

PSW Executive Board NICK OLSON, PharmD, BCACP, AAHIVP Chairman of the Board

ALLAN LOEB, MS, RPh Treasurer

MATTHEW MABIE, RPh President

CHRISTOPHER DECKER, RPh Executive Vice President & CEO

MICHAEL GILLARD, PharmD, BCPS President-Elect

PSW Board GRETCHEN KUNZE, PharmD, BCPS Region B Director 2018-20

SARAH SCHMIDT, PharmD Director-at-Large 2018-20

XIN RUPPEL, MBA, PharmD, BCPS, BCACP Region C Director 2017-19

ELLINA SECKEL, PharmD, BCACP Region A Director 2017-19

JOYLYN MOORE, PharmD Region D Director 2018-20

KEN WALKER, RPh Director-at-Large 2017-19

ANGELA DE IANNI, RPh Region E Director 2017-19

DEAN ARNESON, PharmD, PhD Dean Concordia University Wisconsin SOP

JUSTIN KONKOL, PharmD, BCPS Region F Director 2018-20

STEVE SWANSON, PhD Dean UW School of Pharmacy

ARLENE IGLAR, MS, RPh, FASHP Director-at-Large 2017-19

GEORGE MACKINNON, PhD, MS, RPh Dean Medical College of Wisconsin SOP

SCOTT LARSON, PharmD Director-at-Large 2018-20

NICOLE SCHREINER, PharmD Senior & LTC Section Chair 2018-2019

RYAN MILLER, PharmD, BCPS Director-at-Large 2017-19

JANE BARTON, MS, CPhT Technician Section President 2018-2019

KATE SCHAAFSMA, MBA, MS, PharmD, BCPS Director-at-Large 2018-20

PSW Staff ELLEN BRUMMEL CHRISTOPHER DECKER, RPh MEGAN GRANT AMANDA MARGOLIS, PharmD, MS, BCACP ERICA MARTIN HELENE MCDOWELL, MS

CHAD NECHVATAL, CPA RYAN PSYCK KAY SCHELL SARAH SORUM, PharmD KARI TRAPSKIN, PharmD DANIELLE WOMACK, MPH

Send correspondence to: Megan Grant, Pharmacy Society of Wisconsin 701 Heartland Trail, Madison, WI 53717, phone: 608-827-9200, fax: 608-827-9292, thejournal@pswi.org Authors are encouraged to submit manuscripts to be considered for publication in The Journal. For Author Guidelines, see http://www.pswi.org/Get-Involved/Publish-articles-in-The-Journal Advertising inquiries: Megan Grant, Pharmacy Society of Wisconsin, 701 Heartland Trail, Madison, WI 53717, phone: 608-827-9200, fax: 608-827-9292, mgrant@pswi.org

The Journal of the Pharmacy Society of Wisconsin (ISSN 1098-1853) is the official publication of the Pharmacy Society of Wisconsin. Subscription included in membership dues. Non-member subscription $90 per year. Outside North America, add $60. Single copies $25 ($50 if outside North America). Periodical postage paid at Madison, WI and additional offices. Published bimonthly by the Pharmacy Society of Wisconsin, 701 Heartland Trail, Madison, WI 53717. Postmaster: Send address changes to PSW, 701 Heartland Trail, Madison, WI 53717. Opinions expressed by contributors do not necessarily reflect those of PSW.

www.pswi.org

Features

Up Front: It’s Finally Summer! by Matt Mabie, RPh

inally, summer is upon us here in WI. The

It’s one thing to brainstorm and dream about where we want our

budget process at the state Capitol is heating

profession to go, It’s a totally different ball-game to execute those

up as fast as the temps rise outside my window. The momentum surrounding several propharmacy bills that have been introduced is

gaining support in Madison across party lines and we have open dialogue with a number of representatives and the governor's office on a number of new issues that face our profession. I honestly

dreams and our staff is one of the best around at putting a plan into place to execute our dreams. A great big Thank You from me to all the PSW staff members! For someone who is not naturally a comfortable public speaker, this past year has been an amazing yet scary experience for me. Put me in a room with a dozen people and I have trouble letting anyone else speak, but put me in front of 500 of my closest friends, peers, and colleagues, and I start shaking like a leaf. Thankfully,

can’t believe how fast this past 10 months have flown by since our

you start your presidential year off giving a 45 minute speech in

last PSW Annual Meeting at the Kalahari last August. As a quick

front of your closest friends and things get better throughout the

reminder, if you haven’t reserved a room for the upcoming annual meeting in Green Bay in September, do so quickly! It happens to

year. As President, I have had the opportunity to participate in ceremonies and new traditions established at the pharmacy schools that didn’t exist when I was in school. Speaking in front of the

be a home Green Bay Packer game that weekend and rooms are

incoming pharmacy class at the white coat ceremony, with close

scarce. If you wait too much longer, you may not find a hotel

friends and relatives looking on at the Memorial Union Theater

room closer than Rosendale.. When I was first asked to run for PSW president by Chris Decker a couple years ago, it was hard to estimate and fully understand the magnitude, responsibility, and paperwork associated with this position. On the surface, being the face of the country’s leading professional pharmacy association sounds great. Who could resist meeting and networking with lots of new people, getting drinks served to you by the president-elect, helping to shape policy and the direction of our organization for years to come all sounds great, but there are definitely some long volunteer hours put in after the store closes. On top of all those hours spent by our board members, executive committee members, advisory boards, networking groups, sections and any other group within

was another tug at your heartstrings moment. Several weeks later, I was asked to lead the graduating class from UW Madison Pharmacy School in the reciting of the Oath of the Pharmacist. Thankfully this is all I had to say that day, as the room full of parents, grandparents, siblings, and closest relatives had me as nervous as my first dance at my wedding! As the PSW calendar continues to roll toward the annual meeting, we have elections finishing up and an amazing slate of programming to schedule to make this annual meeting one of the best. I sure hope you are able to join me and many of our closest PSW “Pharmily” in Green Bay in September. On Wisconsin! Matt Mabie is the President of the Pharmacy Society of Wisconsin in Madison, WI.

PSW; we have the most amazing team at 701 Heartland Trail. www.pswi.org

July/August 2019

The Journal 3

Hotel Information

NEW Way to Claim CE!

Hyatt Regency & KI Convention Center 333 Main St Green Bay, WI 54301

PSW has partnered with LecturePanda to facilitate your ability to claim CE. To claim CE for this conference, scan the QR code on your program booklet at the conference or visit the PSW app and click “Claim CE” in the 2019 Annual Meeting portion of the app. A link to claim CE credit will also be provided in the post-conference email.

The PSW room block at the Hyatt Regency is open through August 21st. Room rates start at $135/night + tax. To make your hotel reservation, please call the hotel at 920-432-1234 or book online through the Hyatt's online reservation system. A link to our booking is on the Annual Meeting page of the PSW website. Please note the Green Bay Packers have a home game on Sept. 15th and hotel rooms will be in high demand. We recommend making your hotel reservation as soon as possible.

4 The Journal

July/August 2019

You will need to know your NABP e-Profile ID in order to claim your credit. If you do not know your NABP number you can look it up on the NABP website or ask a PSW staff member at registration to look it up for you. Once you have claimed your CE, your credits will appear in CPE Monitor within 24 hours. We strongly recommend you review your CPE Monitor portal quarterly. If you have questions, please visit the PSW registration desk at the conference for assistance. We are happy to assist!

www.pswi.org

Registration PSW Annual Meeting • September 12-14, 2019

Please select which functions you plan on attending ...

Name (as you would like to see it on your name tag)

Please help PSW in its planning by indicating below which functions you will be attending. The following events are INCLUDED in the full and daily registration fees. However, you must purchase additional tickets for guests who are NOT registered. Name(s) of Guests: ____________________________________________

Worksite Preferred Mailing Address

Mark which functions you plan on attending. ❒ Welcome Reception (Thursday) Additional Tickets #_______$20 each ❒ Friday Night Party - KI Convention Center (Friday) Additional Tickets for Adults #_______ $50 each (ages 6 to 17) #_______ $20 each (ages 5 & under) #_______ FREE ❒ Presidents Reception & Awards Banquet (Saturday) Students (not included in registration fee) #_______ $30 Additional Tickets for Adults #_______ $50 each (ages 6 to 17) #_______ $20 each (ages 5 & under) #_______ FREE ❒ I will not be attending any of these functions

City State Zip Is this a ❒ home or ❒ worksite address? Work Phone Fax E-mail Address NOTE: Please pre-register. You can pre-register by filling out this form or by going to www.pswi.org On-site registrants will be charged an additional $25.

REGISTRATION FEES FULL CONFERENCE

Before Aug 23

❒ PSW Member $375 ❒ Nonmember $515 ❒ PSW Tech Member $195 ❒ Tech Nonmember (incl PSW membership) $260 ❒ Pharmacy Student $150 ❒ Residents/Grad Students $260

After Aug 23

Amount $______

$615

$______

$225

$______

❒ Registration Fee $100 ❒ Spouse/Guest Fee $100 each

$290

$______

(Name)____________________________________________

$185

$______

Name of golfers you wish to tee off with (optional): Email kays@pswi.org

$290

$______

Luncheon (Saturday)

DAILY

❒ FRIDAY ❒ SATURDAY Before Aug 23 After Aug 23 Amount ❒ PSW Member $240 $270 $______ ❒ Nonmember $365 $395 $______ ❒ PSW Tech Member $115 $145 $______ ❒ Tech Nonmember (incl PSW membership) $180 $210 $______ ❒ Pharmacy Student $110 $140 $______ ❒ Residents/Grad Students $160 $190 $______ Total Enclosed $__________________

Send this form with check (payable to: Pharmacy Society of Wisconsin) or credit card order to: PSW, 701 Heartland Trail, Madison, WI 53717 Charge: ❒ VISA

Fee includes 18 holes of golf at Thornberry Creek at Oneida, golf cart, prizes, lunch

$435

Full registration includes admission to the Exhibits, Reception, all sessions both days, and continental breakfast and lunch on both days.

PAYMENT

PSW Golf Outing (Thursday)

❒ Master Card ❒ Discover ❒ American Express

and drinks. Tournament pairings and directions will be mailed to all golfers one week in advance of the outing. $__________ $___________

Free to students from the respective schools. All Annual Meeting registrants & their guests are invited to attend. ❒ Concordia University Luncheon $35 $_______ ❒ Medical College Wisconsin Luncheon$_______ ❒ Rosalind Franklin Luncheon $35 $_______ ❒ UW PAA Luncheon $35 $_______ I have Special Dietary needs: __________________________________

STUDENT SPONSORSHIP

All sponsors will be recognized at the conference.

❒ Sponsor Fee #______ @ $25 $__________ The pharmacy student registration rate is only $140. All pharmacists are encouraged to support PSW’s ability to provide this reduced rate to pharmacy students through a $25 donation to the student attendance fund. All student sponsors will be recognized at the Annual Meeting.

PSW_FullLogo_3c PMS 7729

Card #___________________________ Exp Date________ 3-4 digit security code_______ Name on Card_______________________________________________________________

❒ YES, preferred address above is the billing address Billing Address______________________________________________________________ __________________________________________________________________________ Signature___________________________________________________________________ Refunds for cancellations less a $75 handling charge if written request is received by August 23, 2019.

Four ways to register Mail: PSW, 701 Heartland Trail Madison, WI 53717 Call: 608.827.9200 Fax: 608.827.9292 Web: www.pswi.org

Continuing Education PHARMACIST & TECHNICIAN CE:

Improving Patient Care by Ensuring Well-Being and Resilience in Health-System Pharmacy by Christina Y. Martin, PharmD, MS

he US healthcare workforce is reporting alarming rates of depression, posttraumatic stress disorder, and poor work-life balance contributing to clinician burnout. At the individual clinician level, it presents as emotional exhaustion (e.g. compassion fatigue), depersonalization (e.g. cynicism), and a low sense of accomplishment. At the healthcare system level, it is associated with medical errors and loss of productivity.1-7

Burnout Explained

The focus on clinician burnout as a public health problem is gaining significant momentum.1-3 Burnout impacts patient care and disrupts the healthcare workforce. Studies have demonstrated associations between clinician burnout and lower patient satisfaction, increased health care-associated infections, and increased malpractice claims.4-7 As a consequence, it is believed that there is a bi-directional relationship between burnout and medical errors with studies showing correlation between poor well-being in healthcare professionals and worsening patient safety and, inversely, involvement with a medical error and worsening burnout and depressive symptoms.8 Burnout has also been associated with a loss of productivity in the health care workforce ranging from work absenteeism to professional attrition. In medicine, professional attrition extrapolated at the national level in the United States is equivalent to the annual elimination of seven graduating classes of medical schools from the medical profession.9 When talking about burnout, it is important to differentiate between stress and burnout. The two terms are often interchanged in conversation; however, 6 The Journal

July/August 2019

CE FOR PHARMACISTS & TECHNICIANS

COMPLETE ARTICLE AND CE EXAM AVAILABLE ONLINE: WWW.PSWI.ORG

Learning Objectives • Define burnout and its relation to the pharmacy profession. • Describe why clinician burnout is a patient care and healthcare workforce problem. • Identify strategies to impact well-being and resilience in pharmacists, residents, student pharmacists and pharmacy technicians.

there are key differences to highlight. Stress is a physical, mental, or emotional factor that causes bodily or mental tension. A lack of stress may result in boredom and display as disinterest, while too much stress may result in burnout and display as anxiety or exhaustion.10 In between no stress and distress is a termed coined by 20th century Hungarian-Canadian endocrinologist Hans Seley – eustress. Whereas distress (“negative stress”) is extreme anxiety, sorrow, or pain that feels unpleasant, decreases performance, and may result in mental & physical problems, eustress is a moderate or normal psychological stress (“positive stress”) that motivates, focuses energy, and leaves one feeling excited often resulting in improved performance. Left unregulated, frequent and repeated distressful events may result in burnout. While it may seem that the term burnout only emerged in the 21st century, it was actually defined decades ago by American psychologist Herbert Freudenberger. Freudenberger connected the term with those who work in helping professions that experience prolonged high levels of stress and mental exhaustion. While the problem is not new, some research demonstrates that the rate of burnout amongst healthcare professionals has been increasing in recent years.11 A growing body of evidence demonstrates workforce burnout amongst

physicians, nurses, and social workers. While it is no doubt experienced by pharmacists, residents, student pharmacists and pharmacy technicians, robust evidence highlighting the issue in the pharmacy profession is still in its infancy. In the pharmacy profession, burnout has been evaluated in dispensing roles12, pharmacy faculty and students13-14, and limited specialty areas15. Most recently a publication revealed that 53.2% of healthsystem pharmacists reported at least one burnout domain.16 Therefore, based on formal and anecdotal evidence, burnout is believed to be a profession-wide dilemma and one that needs addressing. The drivers of burnout are multifactorial.2,17 When contextualizing the causes, experts consider both individual and external factors as risk factors that compromise well-being and resilience and may contribute to burnout. For example, lack of social support at home or poor work-life integration are considered individual factors, whereas regulatory burden and lack of autonomy in the workplace are considered external factors.18 Focusing on the individual suggests that burnout arises when individuals are unable to adapt to the learning and practice environment; focusing on the organization suggests that it is the environment that should adapt to promote quality of care and clinician well-being. A full listing of www.pswi.org

FIGURE 1. Factors Affecting Clinician Well-Being and Resilience

Reprinted with permission

these factors can be found in Figure 1. Factors Affecting Clinician Well-Being and Resilience. The current conceptual model is broad enough to define the issue across all healthcare professions and satisfactorily encompasses multiple environments (education and practice), multiple stages of development of the health professional (student, resident/fellow, early-midlate career), and multiple healthcare professionals (e.g. medicine, nursing, pharmacy, etc.) while attempting to define the problem without stigmatizing a particular segment. The colors are intentional to show that the combination of individual factors (blue) and external factors (yellow) lead to clinician wellbeing – a positive clinician-patient relationship and patient well-being (green). www.pswi.org

Research indicates that external factors contribute to burnout to a greater extent than individual factors3,19, though what is felt by individual practitioners could be caused by a combination of factors, and this combination may evolve over one’s professional journey. For example, student pharmacist well-being may be influenced by financial stressors of paying for college (personal factors), retaining knowledge of new clinical information (skills & abilities), and integrating into pharmacy practice (learning/practice environment) where a more seasoned professional well-being may be influenced by attainment and maintenance of licensure and certification (rules & regulations), expanding pharmacist scope of practice (organizational factors), and work-life integration (personal factors). Research is needed to understand

what factors are influenced at various career stages of the pharmacy workforce. In applying the conceptual model to practice, the tool should be used to understand well-being, rather than as a diagnostic or assessment. As more information emerges on causes of burnout and implementation of evidence-based solutions, the model will be revised and its use may be expanded.

To Care is Human

The National Academy of Medicine (NAM) established an Action Collaborative on Clinician Well-Being and Resilience (i.e., the “Action Collaborative”) in January 2017 after several physician groups presented their concerns and it was identified to move the issue forward as an awareness campaign and incorporated it to their national research agenda. The July/August 2019

The Journal 7

goals of the Action Collaborative are to 1) raise the visibility of clinician anxiety, burnout, depression, stress, and suicide; 2) improve baseline understanding of challenges to clinician well-being; and 3) advance evidence-based, multidisciplinary solutions to improve patient care by caring for the caregiver. In contrast to centering the collaborative on clinician burnout, the emphasis was deliberately selected to support and improve clinician well-being and resilience. The American Society of Health-System Pharmacists (ASHP) is an inaugural sponsor of the Action Collaborative. The first public meeting on Establishing Clinician Well-Being as a National Priority occurred on July 14, 2017 and, since then, a total of three public meetings have been conducted on the topic. The anticipated impact of the Action Collaborative has been likened to that of the 1999 To Err is Human: Building a Safer Health System Institute of Medicine (now NAM) report19, which highlighted medical errors and their consequences, and the solution-based follow up report released in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century.20 In-progress is a consensus study to examine components of the clinical training and work environment that can contribute to burnout, as well as potential systems interventions to mitigate those outcomes. To quote current NAM President, Dr. Victor Dzau, “we look forward to learning 8 The Journal

July/August 2019

more when the study concludes at the end of 2019. Through collective action and targeted investment, we can not only reduce burnout and promote well-being, but also help clinicians carry out the sacred mission that drew them to the healing professions — providing the very best care to patients.”1

Towards Well-being and Resilience Burnout is a complex problem with interconnected and interdependent risk factors. There is no single solution to this problem. Our colleagues within the Action Collaborative have expressed that ‘we can’t resilience our way out of this.’ Commitment to addressing and preventing burnout needs to be adopted by everyone from the top level executive to the front line clinician. The immediate response after learning about burnout and its risk factors is how can it be prevented and more importantly, how can a resilient pharmacy workforce be cultivated and sustained? The answer to this question is still evolving; however, just as the issue itself is complex, so too will be the solutions required to address it. An important realization is that burnout is a local issue that requires local solutions and a genuine commitment from leadership to address it. Next, it requires shared accountability between individuals and organizations to identify meaningful and

effective actions. Resources are available that outline an approach and a framework for executive leadership to apply within organizations when seeking to understand and improve well-being and resilience.21-22 An important first step is to acknowledge and assess the presence of burnout. Forming a committee – or community – around the topic will help identify impediments and opportunities to test system-level changes. Testing should be conducted through small, rapid-cycle tests of change to learn what may or may not work for system-level changes that align with the organizations’ values and, ultimately, help strengthen the culture. Change management can be an energy-consuming process for both leaders and teams, so do not forget to use rewards and incentives wisely throughout the process. Identify rewards to recognize achievements; these rewards may vary between financial, institution, social types and helpful to identify the motivations behind the individuals on the team. The American Medical Association has created guidance through their STEPS Forward work on creating a wellness culture, specifically at the Resident/Fellow program level.23 When looking to create a wellness culture, there are five steps to consider: creating a framework; developing a program; fostering well-being at the individual level; empowering faculty and trainees to confront burnout; and creating a sustainable culture of wellness, well-being, www.pswi.org

and resilience. Where does one start with assessing burnout and well-being? There are several validated instruments which one can use to identify and quantify burnout both individually and in teams.24 The most commonly used survey instrument to measure burnout in healthcare practitioners is the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which looks at the three domains of emotional exhaustion, depersonalization, and low sense of personal accomplishment. A recent NAM discussion paper details the considerations to help an individual or institution select the appropriate instrument for measuring burnout.24 There are also validated instruments available to measure wellbeing, if choosing to follow the NAM intentionality of focusing on measuring well-being and resilience in individuals and on teams.24 Self-assessment and conversations with peers and supervisors may also be another early signal for identifying burnout in oneself. ASHP offers an online resource center and networking community to assist its members with not only recognizing burnout in themselves and their teams, but in also identifying solutions to care for the pharmacy workforce. Additional resources have been developed to address external factors that impact well-being and resilience, such as burdensome clinical documentation requirements and optimization of the care team.25-26 There is some early evidence of associations between high performing teams and improved clinician well-being. More research is needed to fully understand this relationship; however, it is not too early to consider the key features of a high performing team include: 1. Mutual trust and psychological safety 2. Effective communication 3. Clear roles 4. Shared, measurable goals Other system and organization-based interventions are being researched to support well-being and resilience and will be added to the body of evidence over the next few years. NAM anticipates collecting and sharing case studies to help leaders and clinicians by providing them with a better understanding and ideas for tangible and www.pswi.org

actionable solutions to support workforce well-being in their local settings. These case studies will represent a diverse cohort of outpatient clinics, academic and nonacademic medical centers, community hospitals and feature diversity in practice area and stage of career development. At the individual level, various approaches can be applied to monitor stress levels and bolster resilience and coping skills. Individual resilience is a skill that can be refined and improved with intentional self-care techniques, frequent self-reflection and burnout mitigating strategies. One evidence-based exercise that builds resilience and improves well-being is recording three positive events each day to reframe a negative outlook and increase positive emotions.27 Continuing this habit for at least 21 consecutive days until it becomes a habit has been shown to re-wire the neural connections as humans are naturally wired to remember – and focus on – the negative. Some practitioners suggest recording these three positive events in a journal or through a mobile app, while others use a wipe board that is visible to others. There is evidence that sharing good news with others not only increases selfpositive emotions, but that to share good news enhances the positive emotions in not only the sharer, but also in the listener.28 Anecdotally, resident classes and pharmacy teams have reported incorporating this technique into daily huddles or team gatherings as an opportunity to reflect on positive experiences and to hear the positive experiences of others. Other individual approaches like meditation and mindfulness have shown improvements; however, these approaches are not a onesize-fits-all in benefit.29

Looking Ahead

ASHP has prioritized well-being and resilience as a patient care priority in their strategic plan30, and to date, has committed resources to engaging in major national initiatives, developing formal policy, conducting research, and providing education and resources. More formal programming from ASHP, the NAM, and other organizations is anticipated to be developed in the near future. In the meantime, pharmacists, residents, student pharmacists and pharmacy technicians

are encouraged to educate themselves, join the conversation, and access the resources currently available. For starting the conversation, ASHP offers a Workforce Well-Being and Resilience Resource Center devoted to the topic, including several webinars on a variety of topics ranging from mindfulness and meditation to leadership strategies.31 A “to-do” checklist has been developed as a template to identify where your team or your professional organization is in their journey to promoting a resilient and thriving pharmacy workforce.32 Finally, ASHP is grateful to its members and partners that have shared their stories of resilience and suggested strategies to promote well-being. Until the Action Collaborative and related organizations identify more system-level solutions to address those external factors that contribute so significantly to burnout, evidence shows that starting the discussion at the local level is a critical first step. Burnout is mostly a local problem and requires local and authentic leadership. Start a genuine conversation on burnout in the workplace and then take meaningful steps to address it. There are tools available to do this in a thoughtful and constructive manner with frameworks that outline steps starting with initiating the discussion and finishing with plans for evaluating and measuring progress. For those pharmacists, residents, student pharmacists, and pharmacy technicians experiencing overt burnout with severe impairment, we urge them to seek support immediately through employee/student assistance programs or professional care.

Future Considerations

In summary, burnout among healthcare providers not only impacts themselves, but also impacts patients and the workforce. Solutions that build resilience and promote well-being are key to patient health and a thriving workforce. ASHP seeks to support members in functioning at their highest capacity by developing and promoting

ASHP Workforce Well-Being and Resilience Resource Center: http://wellbeing.ashp.org

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efforts to improve well-being and resiliency in the pharmacy workforce and looks forward to evolving conversations on this topic. Christina Martin is the Director of Membership Forums at the American Society of HealthSystem Pharmacists (ASHP).

This article has been peer-reviewed. The contribution in reviewing is greatly appreciated!

Acknowledgments: The author would like to acknowledge Dr. Anna Legreid Dopp for her contributions to the article. Dr. Dopp is Director of Clinical Guidelines & Quality Improvement at ASHP. Disclosure: The author declares no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts and honoraria.

References

1. Dzau VJ, Kirch DG, Nasca TJ. To care is human – collectively confronting the clinicianburnout crisis. N Engl J Med. 2018;378(4):312-314. 2. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. 3. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals. A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/burnout-among-health-careprofessionals-a-call-to-explore-and-address-thisun¬derrecognized-threat-to-safe-high-quality-care. 4. Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med. 1998;47(10):1611-1617. 5. Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associate with patient satisfaction? J Gen Intern Med. 2000;15(2):122-128. 6. Cimiotii JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection. Am J Infect Control. 2012;40(6):486-490. 7. Jones JW, Barge BN, Steffy BD, Fay LM, Kunz LK, Wuebker LJ. Stress and medical malpractice: organizational risk assessment and intervention. J Appl Psychol. 1988;73(4):727-735. 8. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. 9. Shanafelt TD, Dyrbye LN, West CP, Sinsky C. Potential impact of burnout on the US physician workforce. Mayo Clin Proc. 2016;91(11):1667-1668. 10. Yerks RM, Dodson JD. Journal of Comparative Neurology and Psychology. 1908;18:459-482.

10 The Journal

July/August 2019

11. Shanafelt TD, Boone S, Litjen T. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385. 12. Chui MA, Look KA, Mott DA. The association of subjective workload dimensions on quality of care and pharmacist quality of life. Res Social Adm Pharm. 2014;10(2):328-340. 13. El-Ibiary SY, Yam L, Lee KC. Assessment of burnout and associated risk factors among pharmacy practice faculty in the United States. Am J Pharm Educ. 2017;81(4):75. 14. Ried DL, Motcycka C, Mobley C, Meldrem M. Comparing self-reported burnout of pharmacy students on the founding campus with those at distance campuses. Am J Pharm Educ. 2006;70(5):114. 15. Holden RJ, Patel NR, Scanlon MC, et al. Effects of mental demands during dispensing on perceived medication safety and employee well being: a study of workload in pediatric hospital pharmacies. Res Social Adm Pharm. 2010;6(4):293-306. 16. Durham ME, Bush PW, Ball AM. Evidence of burnout in health-system pharmacists. Am J Health Syst Pharm. 2018;75(suppl 4):e801-808. 17. Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health Syst Pharm. 2018;75(3):147-152. 18. Brigham T, Barden C, Legreid Dopp A, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/journeyconstruct-encompassing-conceptual-modelfactors-affecting-clinician-well-resilience/ 19. Institute of Medicine. 2000. To err is human: building a safer health system. Washington, DC: National Academies Press. 20. Institute of Medicine. 2001. Crossing the quality chasm: a new health system for the 21st Century. Washington, DC: National Academies Press. 21. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. 22. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI framework for improving joy in work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. 23. Henry TA. These tools, resources address physician burnout at systems level. News article. American Medical Association. 2018. 24. Dyrbye LN, Meyers D, Ripp J, et al. 2018 A pragmatic approach for organizations to measure health care professional well-being. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201810b 25. Ommaya AK, Cipriano PF, Hoyt DB, et al. 2018. Care-Centered Clinical Documentation in the Digital Environment: Solutions to Alleviate Burnout. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. doi: 10.31478/201801c 26. Smith, CD, Balatbat C, Corbridge S, et al. 2018. Implementing optimal team-based care to reduce clinician burnout. NAM Perspectives.

Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/ implementing-optimal-team-based-care-to-reduceclinician-burnout. doi: 10.31478/201809c 27. Adair KC, Sexton JB. Positively reflecting backwards and forwards is associated with improvements in well being. J Posit Psychol. Accepted for publication. 28. Reis HT, Smith SM, Carmichael CL, et al. Are you happy for me? How sharing positive events with others provides personal and interpersonal benefits. J Pers Soc Psychol. 2010;99(2):311-29. 29. Loria K. Avoiding Pharmacist Burnout. News article. Drug Topics. February 22, 2019. 30. ASHP Strategic Plan, ASHP, Bethesda, MD. Accessed April 3, 2019. 31. ASHP Workforce Well-Being and Resilience Resource Center. https://www.ashp.org/ pharmacy-practice/resource-centers/clinician-wellbeing-and-resilience Accessed 3 April 2019. 32. American Society of Health-System Pharmacists. State affiliate toolkit well-being and resilience. https://www.ashp.org/State-Affiliates/ Affiliate-Resources/State-Affiliate-Toolkit-Wellbeing-and-Resilience. Accessed April 3, 2019.

Assessment Questions 1.

At the individual clinical level, burnout presents as all of the following EXCEPT: a. Emotional exhaustion b. Physical pain c. Depersonalization d. Low sense of accomplishment

Burnout does NOT lead to medical errors: a. True b. False

3. What percentage of health-system pharmacists reported at least one burnout domain? a. 53.2% b. 12.7% c. 67.8% d. 29.9% 4.

Lack of social support at home or poor work-life integration are considered individual factors that contribute to burnout: a. True b. False The goals of the National Academy of Medicine established an Action Collaborative on Clinician Well-Being and Resilience with all of the following goals EXCEPT: a. Raise the visibility of clinician anxiety, burnout, depression, stress, and suicide b. Improve baseline understanding of challenges to clinician well-being c. Advance evidence-based, multidisciplinary solutions to

www.pswi.org

d. 6.

7. 8.

improve patient care by caring for the caregiver Only address the external risk factors that lead to burnout

One evidence-based exercise that builds resilience and improves well-being is recording three positive events each day to reframe a negative outlook and increase positive emotions a. True b. False Some key features of a high performing team include all of the following EXCEPT: a. Mutual trust and psychological safety b. Effective communication c. Shared, measurable goals d. Vague roles Which of the following can burnout cause? a. Loss of productivity in the health care workforce b. Increased patient satisfaction

c. Decreased health-care associated infections d. Decreased malpractice claims Did the activity meet the stated learning objectives? (if you answer no, please email sarahs@pswi.org to explain) a. Yes b. No

10. On a scale of 1 – 10 (1-no impact; 10-strong impact), please rate how this program will impact the medication therapy management outcomes or safety of your patients. 11. On a scale of 1 – 10 (1-did not enhance; 10-greatly enhanced), please rate how this program enhanced your competence in the clinical areas covered. 12. On a scale of 1 – 10 (1-did not help; 10-great help), please rate how this program helped to build your management and leadership skills.

CE FOR PHARMACISTS & TECHNICIANS

13.

How useful was the educational material? a. Very useful b. Somewhat useful c. Not useful

14. How effective were the learning methods used for this activity? a. Very effective b. Somewhat effective c. Not effective 15. Learning assessment questions were appropriate. a. Yes b. No 16. Were the authors free from bias? a. Yes b. No 17. If you answered “no” to question 16, please comment (email info@pswi.org). 18. Please indicate the amount of time it took you to read the article and complete the assessment questions.

Submit Your CE Online

Continuing Education Credit Information The Pharmacy Society of Wisconsin is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Continuing education credit can be earned by completing the self assessment questions. Questions may be completed online at www.pswi.org or by mailing completed answer form to PSW, 701 Heartland Trail, Madison, WI 53717. Participants receiving a score of 70% or better will be granted 0.5 hours (0.05 CEU) credit through CPE Monitor within 60 day of quiz completion. Accurate birth date (MMDDYY) and CPE Monitor ID must be provided in order to receive this credit as required by ACPE. This CE offering is offered free-of-charge t o a l l P S W m e m b e r s . No n m e m b e r s a r e charged $20 for each exam submitted to cover administrative costs.

Quiz Answer Form circle one answer per question 1) a b c d 2) a

3) a b c d 4) a b 5) a b c d 6) a b 7) a b c d 8) a b c d 9) a b

10)_______________ 11)_______________ 12)_______________ 13) a

14) a

15) a

16) a

17)_________________ 18)_________________

July/August 2019 Improving Patient Care by Ensuring Well-Being and Resilience in Health-System Pharmacy

Name______________________________Designation (RPh, PharmD, etc.)__________

ACPE Universal Activity Number: 0175-0000-19-112-H04-P, T

CPE Monitor #___________________________________ DOB (MMDDYY)__________

Target Audience: Pharmacists & Technicians Activity Type: Knowledge-based Release Date: July 1, 2019

Preferred Mailing Address________________________________________________

(No longer valid for CE credit after July 1, 2022)

www.pswi.org

City__________________________________State________ Zip_______________ Is this your home □ or work □ address?

July/August 2019

The Journal 11

Features

A Reflection on Practice Advancement by Lynnae M Mahaney, BSPharm, MBA, FASHP

12 The Journal

July/August 2019

hen I learned we would have a JPSW issue on practice advancement, I jumped at the opportunity to coordinate the articles. Easy right? Wisconsin pharmacy has always been at the forefront of innovative improvements and advancements to the pharmacy care provided to patients. Just look at the early adoption of many pharmacy practice advances over the years: unit dose and IV compounding, development and growth of pharmacy residency programs, introduction of pharmacy clinical services in hospitals and then community and ambulatory settings, advancement of technician roles, utilization of bar code medication administration and electronic health records, and most recently, specialty pharmacy services. Many Wisconsin pharmacy teams have contributed articles about their pharmacy practice advancements to this issue and we have contributors from our colleagues across the country as well. This issue also includes the national pharmacy efforts in use of quality measures, compounding safety, the American Society of Health-System Pharmacists (ASHP) Practice Advancement Initiative, and pharmacy staff well-being. We have long talked about the importance and efforts of advancing our pharmacy practices. As a profession, we really highlighted the term ‘practice advancement’ with the launch of the ASHP Pharmacy Practice Model Initiative (PPMI) in 2010. PPMI was ‘rebranded as the Practice Advancement Initiative (PAI) in 2015 to better align with the profession’s emphasis on clinical activities, including expanded roles in acute and ambulatory care settings and transitional care services. PAI reflects the evolving healthcare environment that includes pharmacists as key members of interprofessional teams caring for patients across all practice settings and is focused on transforming the practice of pharmacy to enhance the role of the pharmacist in providing direct patient care services.1 Over the last 9 years, PAI selfassessment tools have been developed and implemented at a national and state level for all pharmacy practice settings and many of these tools were developed with www.pswi.org

the assistance of Wisconsin pharmacy and PSW. These tools have helped pharmacy across the country to assess, plan, develop and implement impactful changes in how we deliver care and positively affect our patients’ outcomes. Some of the most frequently used tools include: • Assignment of initiation of medication histories to appropriately trained pharmacy technicians • Provision of discharge education by pharmacists to include standardized process for hand-offs to next level of care • Pharmacists part of organizational credentialing and privileging process • Organizational employment of residency-trained pharmacists • Billing for provision of ambulatory care pharmacist patient care services • Ambulatory care pharmacists actively engaged in transitions of care activities • Creating financially sustainable models for provision of ambulatory care services (e.g., medication management services) by pharmacists It is these demonstrated accomplishments in our practices, many of which are published in this and past issues of JPSW, which provide the evidence of how greatly we have advanced as patient care providers. Here a just a few of measures we use to gauge our significant progress: • Pharmacists are providing direct patient care to a majority of patients in 61% of hospitals (up from 38% in 2012)2 • Pharmacists lead Antimicrobial Stewardship Programs in 80% of hospitals with programs (up from 48% in 2010)2 • Pharmacist involvement in ambulatory care clinics continues to grow • Nearly all states allow pharmacist collaborative practice agreements3,4

• Transitions of care with inclusion of pharmacy is receiving a great deal of focus • Residency training and certification continue to grow – 75 residency programs in Wisconsin to date5 • Pharmacy technicians certification continues to grow • Use of automation and technology in medication use is commonplace Our practices advancement efforts must continue into the future to position the pharmacist front and center as a respected and valued clinician as part of the interprofessional care team centered on patient care needs and outcomes. As part of this evolution, pharmacy practice is becoming more reliant on leveraging pharmacy extenders (i.e. technicians, student pharmacists, and pharmacy residents) for the provision of essential patient care services. Furthermore, we need to ensure that pharmacy technicians receive education and training to allow them to perform at the top of their scope so pharmacists can also function at the top of theirs. This journal of PSW is about celebrating our practice advancements through various examples from our colleagues across the state and the nation. I hope these articles will continue to motivate you to transform your practices and pharmacy teams enabling the pharmacists to provide direct patient care services and position them as clinical members of the teams caring for patients across all practice settings.

References

1. Kate Traynor. Practice Advancement Initiative Looks to Next Decade. https://www.ashp.org/ news/2019/03/27/practice-advancement-initiativelooks-to-next-decade. Published March 27, 2019. 2. Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration-2017. Am J Health Syst Pharm. 2018;75(16):1203-1226. 3. Most states now allow collaborative practice. Drug Topics. https://www.drugtopics.com/legislative/ most-states-now-allow-collaborative-practice. Published July 24, 2006. Accessed June 17, 2019. 4. Map of states in the United States, colored by legality of collaborative practice agreements. https://en.wikipedia.org/wiki/Collaborative_ practice_agreement#/media/File:CPAs_2017.png. Updated February 2016. Accessed June 17, 2019. 5. ASHP Accreditation Services Division June 2019.

Lynnae M Mahaney is the Director of Pharmacy Accreditation at ASHP. Acknowledgments: The assistance and contribution of Eric Maroyka, PharmD, BCPS, Director, Center on Pharmacy Practice Advancement at ASHP, is greatly appreciated.

Editors Note: Lynnae Mahaney served as the Guest Contributing Editor for this issue of JPSW. This reflection summarizes core themes throughout this issue and other issues of JPSW regarding the direction of pharmacy practice.

www.pswi.org

July/August 2019

The Journal 13

Features WPQC UPDATE:

Community Pharmacy Practice Advancement Alphabet Soup: CPESN and WPQC by Kari Trapskin, PharmD, Michelle Farrell, PharmD, BCACP, Brekk Feeley, PharmD

he Wisconsin Pharmacy Quality Collaborative (WPQC) was designed in 2006 by PSW and collaborators as a practice advancement initiative. Thirteen years later, it continues with the same principles of promoting the quality of care and value that community and embedded ambulatory care pharmacists offer patients and payers as part of the health care team. Currently, the WPQC program has two PSW staff members working specifically to support and manage facets of the program, along with support from other PSW staff members to manage administrative and support functions of the program. This April, the WPQC network reached a goal of providing over 10,000 comprehensive medication reviews (CMRs) to Wisconsin Medicaid (ForwardHealth) members. As you may already be aware, PSW has been in close communication with the Community Pharmacy Enhanced Services Network (CPESN), which grew out of the Community Care of North Carolina’s (CCNC) work under a 2014 round two Center for Medicare and Medicaid Services (CMS) Healthcare Innovation Award. CPESN-USA aims to create a nationwide network of community-based pharmacies contracted with payers and health systems to provide value-based services for patients. Currently, Wisconsin has a local CPESN network, led by Michelle Farrell, PharmD, BCACP, owner of Boscobel Pharmacy. Michelle has been an active pharmacist in the WPQC program since the program’s start, many times being the highest utilizer of the program. Michelle is joined by other WPQC pharmacists as her co-CPESN leaders including Abbi Linde, Matt Mabie, Marv Moore, Jake Olson, Rani Raju, Thad Schumacher, Dimmy Sokhal, and Kristen Weiler-Nytes. Reading this you may think, “I’m

14 The Journal

July/August 2019

TABLE 1. CPESN Network Requirements

Core CPESN Network Requirements

• WPQC-accreditation • Face-to-Face Access: Providing each patient receiving a dispensed medication from the participating pharmacy ready access to unscheduled face-to-face meeting(s) with a pharmacist employed by the participating CPESN pharmacy during operational hours • Medication Reconciliation: Comparing a patient’s medication orders to all of the medications the patient has been taking to avoid medication errors during care transitions when they are vulnerable to medication errors • Clinical Medication Synchronization: Aligning a patient’s routine refills to be filled at the same time each month and in conjunction pharmacist’s clinical disease state management and monitoring, to progress toward desired therapeutic goals • Immunizations: Screening patients for ACIP recommended immunizations, educating patients about needed immunizations, and providing immunizations or referring to other health care providers • Comprehensive Medication Reviews: Providing a systemic assessment of medications to identify medication-related problems, prioritize those problems, and create a patient-specific plan to resolve them working with the extended healthcare team • Personal Medication Record: Creating a comprehensive list of current patient medications manually or from dispensing software

Additionally, all member pharmacies:

• Offer a private and confidential setting to talk with the patient about medications and related healthcare issues as well as counseling regarding how to use and take medications safely • Provide an in-depth review of medication regimens to identify ways to optimize therapy • Share information about the benefits and potential side effects of medications • Help the patient understand the importance of taking medications as prescribed

Additional Enhanced Pharmacy Services Offered by select CPESN Network Pharmacies:

• • • • • • • • • •

24-hour Emergency Services Collection of Vital Signs Home Delivery/Home Visits Tobacco Cessation Program Durable Medical Equipment Point of Care Testing Long-Acting Injections Naloxone Dispensing Nutritional Counseling Specialty Medication Compounding

WPQC: Wisconsin Pharmacy Quality Collaborative; CPESN: Community Pharmacy Enhanced Services Network; ACIP: Advisory Commitee on Immunization Pracites

already practicing at a WPQC-accredited pharmacy and am a WPQC-certified pharmacist. CPESN sounds a lot like WPQC but costs more, and there is no guarantee that a national payer will be

willing to pay me to optimize medications for populations of patients. I’ll join CPESN when I see the value proposition.” PSW/ WPQC has been, and continues to be, hard at work discussing with the leaders www.pswi.org

of CPESN Wisconsin how we can work together to meet the needs of both WPQC and CPESN. How do WPQC and CPESN differ? Figure 1 (found on page 16) depicts where the commonalities and differences lie. The main difference is that CPESN-USA is considered a Clinically-Integrated Network (CIN), meaning that CPESN has the legal ability to contract with a payer on behalf of a network such as a local or state-based CPESN network. WPQC has never strived to have that ability, though WPQC has successfully connected payers to contract with individual pharmacies in the WPQC network. What sets WPQC/PSW apart is knowledge of the statewide landscape and having established relationships with many local and statewide groups. Further, there is benefit in state-based support and training that already exists. The existing training has been complemented by the frequent webinars and enrichment materials that CPESN offers to their members. CPESN focuses on incorporating a value-based payment model into the community pharmacy mindset, which complements the evolution occurring in health systems. This will take time, may be challenging, but likely will be worth it. The calculated pharmacy density for network adequacy is 114; without that number of pharmacies involved, CPESNWI is unlikely to attract a national payer. In the meantime; however, let’s not forget about the robust programs already existing. Payers don’t want to pay for status quo, they want to pay for enhanced services from high performing clinicians. The first task of the CPESN group has been to develop the starter set of network requirements for Wisconsin CPESN pharmacies. Initial CPESN-WI pharmacies were already WPQC-accredited and saw the value in continuing to require that CPESN-WI pharmacies be WPQCaccredited. WPQC pharmacy accreditation includes pharmacist certification as well as consistent implementation of seven qualitybased best practices that focus on providing safe and streamlined care to all patients of the pharmacy.1 Therefore, the leadership of the two groups decided to include WPQC accreditation as a requirement for CPESN. Additional core CPESN network www.pswi.org

requirements are referenced in Table 1. WPQC and CPESN-WI have also discussed the unique opportunities that exist through WPQC including the Wisconsin ForwardHealth Medicaid Medication Therapy Management (MTM) Program, which requires WPQC accreditation to obtain compensation for providing CMRs. The ForwardHealth (Medicaid) MTM program provides the opportunity to receive face to face CMR services for over 1 million members statewide. Additionally, the United Way of Dane County provides local opportunities to pharmacists in Dane County to provide CMRs to patients at risk of falls and adverse drug events. In both of these cases, pharmacies are compensated for CMR services provided. PSW has also recently facilitated targeted CMR compensation opportunities for WPQC pharmacies in specific regions of the state with WEA Trust/Neugen patients. These opportunities are focused on improving heart health by offering WEA Trust members with comorbidities (pre-diabetes, diabetes, hypertension and/or hyperlipidemia) the opportunity to participate in a series of CMR visits with their pharmacist. This heart health work is in collaboration with the Division of Public Health Chronic Disease Prevention Program. The leadership teams of both groups discussed how CPESN will be an opportunity for national payer growth once the network is built to adequacy. However, while building the network, pharmacies must begin and continue to utilize programs that are currently available. Though WPQC has met the goal of providing 10,000 CMRs since the program’s start with Medicaid in 2012, the program continues to be underutilized. CPESN-WI pharmacies have agreed to focus on providing additional CMRs for Medicaid members on a fast track. If you have questions about how to become involved in WPQC and CPESNWI, please contact Kari Trapskin (karit@ pswi.org) or Michelle Farrell (mfarrell@ boscobelpharmacy.com).

Boscobel Pharmacy Boscobel Pharmacy has been active in patient care delivery as opportunities have expanded and contracted. The combination of a talented technical staff, a growing number of prescriptions filled through medication synchronization, and the final product verification (“tech check tech”) pilot, has allowed our pharmacist staff time to function at the top of their licenses and grow delivery of immunizations, CMRs, and other clinical services. Participation in WPQC, CPESNWI, and CPESN-USA are where the community pharmacies of tomorrow will thrive. CPESNUSA contracts will not be offered to networks who do not have adequate patient coverage (network adequacy). In Wisconsin, network adequacy for CPESN-WI is 114 pharmacies; our network is currently just over 40 pharmacies. If you want to get involved with our network, please feel free to reach out to Michelle Farrell at: mfarrell@boscobelpharmacy.com.

WI. At the time of this article, Brekk Feeley was a Community Pharmacy Resident at Boscobel Pharmacy in Boscobel, WI.

References

1. Frey M, Trapskin K, Margolis A, Sutter S, Cory P, Decker C. Pharmacist-reported practice change as a result of a statewide community pharmacy accreditation program. 2019; J Am Pharm Assoc. 59(3):403-409.

Kari Trapskin is the Vice President of Health Care Quality Initiatives at the Pharmacy Society of Wisconsin in Madison,WI. Michelle Farrell is the Owner of Boscobel Pharmacy in Boscobel, July/August 2019

The Journal 15

WPQC + CPESN = More Opportunities for Wisconsin Community Pharmacies. Better Care for Patients. WPQC and CPESN have similar missions – promoting the quality of care and overall value community pharmacies offer patients and payers as part of the health care team. While the missions are similar, the attributes that WPQC and CPESN bring are complementary – WPQC provides essential local Wisconsin knowledge, experience, credibility and familiarity. CPESN provides Clinical Integrated Network (CIN) expertise and compliance. CPESN also offers pharmacies the ability to directly approach payers to seek reimbursement for the enhanced services provided to patients. Express your value in a new way. Consider joining CPESN+WPQC!

Benefits and Services Provided Local Education, Support and CE • Pharmacist Certification Homestudy • Pharmacy Accreditation • Chronic Disease Clinical Toolkits • Billing and Implementation Training Webinars • CMR Coaching Workgroups • Educational Conferences Local Payer and Partner Relationships • Knowledge of providers, payers, resources Established Service Billing Opportunities • Wisconsin Medicaid > 1,000,000 members • United Way of Dane County • WEA Trust (NeuGen) Care Goals Delivered Locally • WI Pharmacies commit to provide these enhanced service sets – Medication Reconciliation, Medication Synchronization, Medication Reviews, Immunization education, screening, referral or administration, Face to Face interaction, and the ability to create a Personal Medication Record at the patient’s request. Local Governance and Control • Strong leaders and luminaries • Decisions for the network made at the local level • Established partnership with the Pharmacy Society of Wisconsin CPESN USA Supports Local Networks • CIN structure compliant with antitrust laws o Monthly fee pays for expertise that local networks utilize (e.g., legal, training, compliance, payer engagement, marketing, work groups, webinars, and access to Subject Matter Experts o Collaboration Site and Pharmacy Finder Presence CIN Tools Adapt to Local Conditions • CIN structure allows local network to negotiate with payers and enter into contracts that recognize benefits of a single contracting entity. National and Regional Payer Relationships • Assist local networks with engagement • Give local networks opportunity to participate in regional/national payer pharmacy networks. Quality Data Reporting • Support of clinical documentation using the eCare Plan • Ability to prove value via eCare plan Quality Reports.

WPQC

($100/yr*)

CPESNWI

CPESN-USA ($85/mo**)

WPQC+ CPESN

✔

*2019 Pharmacy/Pharmacist Certification Costs dependent on PSW membership

✔

**Costs as of January 2019

Contact Michelle Farrell mfarrell@boscobelpharmacy.com (608)375-4466 or Kari Trapskin karit@pswi.org (608) 827-9200 4837-1190-1318.3

16 The Journal

July/August 2019

www.pswi.org

PSW News

I am a Pharmacy Professional and a...

Innovator

Sept/Oct 2019 Theme:

I am a Pharmacy Professional and a...Traveler

Email your response to mgrant@pswi.org by August 1.

Nov/Dec 2019 Theme:

I am a Pharmacy Professional and an...Pet Owner

Email your response to mgrant@pswi.org by October 1. Responses should be <100 words and include a photo.

Edward Portillo Assistant Professor (CHS) University of Wisconsin-Madison School of Pharmacy, Madison

I am an innovator because my students are innovators! I have the privilege of teaching students at the University of Wisconsin-Madison School of Pharmacy as part of a Practice Innovations year-long course. In this class, innovative students complete a pharmacy practice advancement project to improve healthcare delivery in rural communities across Wisconsin. We have partnered with pharmacists serving patients in rural communities to develop novel pharmacy services and evaluate the impact of their work. Over the last year, we have had the privilege of partnering with the Department of Veterans Affairs to further improve healthcare delivery for our Veterans living in rural communities. Our team of students, preceptors, and faculty look forward to expanding partnerships and continuing to be pharmacy practice innovators!

Katie Kuecker & Andy Cannon PGY-2 Ambulatory Care Residents William S. Middleton Memorial Veterans Hospital, Madison

From our very first weeks as pharmacy students at UW-Madison, we knew pharmacy played a special role within MEDiC, an organization within the School of Medicine and Public Health that organizes studentrun free clinics. At MEDiC, pharmacy students are members of interdisciplinary teams that provide care to patients. However, pharmacy leadership roles were lacking. Once every month, a pharmacist would be available in clinic to help with prescription questions that usually ranged from how to write prescriptions to finding affordable options. As current pharmacists, we knew we could enhance those roles and improve care. We recruited pharmacists from around the state to staff these clinics on a weekly basis and challenged them to become a more integrated part of the team. Currently there are two pharmacists per week who are embedded within the interdisciplinary teams and can help students, providers and patients alike.

www.pswi.org

July/August 2019

The Journal 17

Features

ID CORNER

Ambulatory Point of Care Testing: Implications for Ambulatory Antimicrobial Stewardship by Brian Buss, PharmD, Jennifer Fever, PharmD, Ben Heikkinen, PharmD, Lucas T Schulz, PharmD

he World Health Organization identified antimicrobial resistance as one of the 10 threats to global health in 2019.1 Antimicrobial misuse, including overuse and inappropriate use, is the principle driver of resistance emergence.2 Combined with a lack of new antimicrobial availability, healthcare faces a post-antibiotic era.3 The United States responded to this emerging crisis through a multifaceted response outlined in the National Action Plan for Combating Antibiotic-Resistant Bacteria.4 This action plan lays the framework for how the “effort to combat resistant bacteria will become an international priority for global health security.” Antimicrobial stewardship programs (ASP) are identified in the action plan as one solution to reduce antimicrobial misuse and improve antimicrobial prescribing. Historically, ASPs targeted

18 The Journal

July/August 2019

actions toward inpatient prescribing due to the breadth and independence associated with ambulatory practice. Inpatient stewardship programs are making a positive impact on antimicrobial prescribing; unfortunately, most antimicrobial use occurs in the ambulatory setting.7 In 2015, 269 million antibiotic prescriptions were dispensed from outpatient pharmacies.5,6 This results in a rate of 835 prescriptions per 1000 people with variability across regions. Wisconsin’s prescribing rate was 733 prescriptions per 1000 people.7 Compounding the resistance emergence issue, many prescriptions represent antibiotic misuse. Fleming-Dutra, et al found that greater than 30% of antibiotic prescriptions were either unnecessary or inappropriately prescribed.5 A separate study of outpatient antibiotic prescriptions in privately insured patients (ages 0-64 years) identified over 11.3 million (59%) prescriptions were inappropriate or potentially inappropriate.8 Inappropriate

prescriptions occurred in office-based appointments, urgent care visits, and emergency departments (71%, 6%, 5% of prescription volume, respectively). High rates of ambulatory antibiotic misuse, increasing rates of antibiotic resistance, and a sluggish antibiotic pipeline identified antimicrobial stewardship (AMS) as a potential solution again. Ambulatory stewardship programs are a proposed Joint Commission Standard for the accreditation of clinics and surgical centers beginning in 2021.9 Similar to the inpatient stewardship requirements, ambulatory ASPs will require leadership, tracking/ reporting, drug expertise, and need to demonstrate actions towards improving antibiotic utilization.10 The immense quantity of ambulatory prescriptions makes preauthorization/restriction or prospective audit and feedback impractical. Therefore, many ambulatory ASPs will utilize clinical guidelines, clinical decision support systems, and rapid diagnostics to improve www.pswi.org

antimicrobial use. Rapid diagnostic testing, combined with guideline-based clinical decision support systems, expedite the identification of the target pathogen and quickly narrow the differential diagnosis.11 Rapid diagnostic tests reduce result turnaround time and get vital information to clinicians. Point-of-care (POC) rapid diagnostics further reduce turnaround time and eliminate process steps associated with specimen transport and processing.12 Ultimately, POC testing done in the clinic setting can quickly identify a pathogen or rule out a pathogen which results in clinicians choosing to not use antibiotics or choosing a narrower spectrum antibiotic.13 These POC and rapid diagnostic tests include a variety of infectious diseases, from common viruses, streptococcal pharyngitis, and methicillin-resistant Staphylococcus aureus (MRSA) detection.12 In this manuscript, we briefly review rapid diagnostic tests, including POC tests that impact antimicrobial prescribing and can improve antimicrobial selection. These tests can be used as part of a comprehensive program to achieve ambulatory antimicrobial stewardship.

Influenza

The burden of influenza disease in the United States is vast and contributes to significant morbidity and mortality. The Centers for Disease Control estimates that influenza lead to 9.3 million - 49.0 million illnesses, 140,000 - 960,000 hospitalizations, and 12,000-79,000 deaths yearly since 2010.14 Acute respiratory infections, even though they are mostly caused by viruses, are the syndrome for which antibiotics are most commonly prescribed.5,15 Increasing access to diagnostic data can reduce unnecessary utilization and increase appropriate anti-viral prescriptions.16 Havers et al. found that among a 15,000-patient cohort, 3306 patients (22%) had laboratory confirmed influenza. Nine-hundred and forty-five (29%) of the influenza-positive patients still received an antibiotic prescription. The most common reason for antibiotic prescribing for a viral process was lack of access to data during the visit. Time constraints and clinic volume metrics drive quick treatment decision-making and providers err on www.pswi.org

the side of providing more prescriptions than necessary through watchful waiting or â&#x20AC;&#x153;just-in-caseâ&#x20AC;? prescribing, a strategy of providing antimicrobial prescriptions and encouraging patients only to fill after a certain amount of time with no improvement. While this method is used to help avoid antibiotic prescribing, these prescriptions are often filled and are contributing to antibiotic resistance emergence.17 Several types of rapid influenza tests exist including: rapid influenza diagnostic tests (RIDTs), rapid influenza molecular assay, immunofluorescence, RT-PCR, rapid cell culture, or viral cell cultures.14 The 2018 Infectious Disease Society of America (IDSA) influenza guidelines recommend for the use of rapid molecular assays (i.e. nucleic acid amplification tests) over RIDTs to improve detection.18 This recommendation is due to moderately high - high sensitivity and high specificity associated with rapid molecular assays compared to lower sensitivity for RIDT.18 In a recent meta-analysis, POC influenza testing had no impact on morbidity and mortality, hospital admissions, time spent in the emergency department.19 POC testing did decrease antibiotic prescribing (RR 0.64; 95% CI, 0.48-0.86 I2 81%) and increased antiviral prescribing (RR 2.65; 95% CI, 1.95-3.6 I2 0%) when looking at randomized trials. Lastly, POC testing demonstrated a reduction in blood tests by 20% (RR 0.8; 95% CI 0.69-0.92 I2 0%) blood cultures by 18% (RR 0.82; 95% CI 0.68-0.99; I2 0%) and chest radiography by 19% (RR 0.81; 95% CI 0.68-0.96; I2 32%) in RCTs. Influenza rapid diagnostics, including POC testing improves antibiotic prescribing. It reduces the unnecessary use of antibiotics, increases the use of appropriate antivirals, and reduces unnecessary diagnostic testing. An often under-recognized testing benefit results from decreased horizontal transmission when influenza-positive patients are promptly isolated and infection control procedures implemented.

Methicillin-resistant Staphylococcus aureus

The presence or absence of MRSA drives many antibiotic treatment decisions.

Since the emergence of communityacquired MRSA in the early 1990s, MRSA has emerged as a common cause of purulent skin and soft tissue (SSTI) infections. Per the IDSA SSTI guidelines, incision and drainage (I/D) alone is usually sufficient for treatment of mild ambulatory MRSA SSTI infections, whereas a combination of I/D plus antibiotic therapy is recommended for moderate to severe infections.20 When antibiotic therapy is prescribed, coverage of MRSA is usually the goal and is provided nearly universally. Similar studies and anecdotes show similar experiences in pneumonia and diabetic foot infections, although not quite to the same extent. MRSA detection via Polymerase Chain Reaction (PCR) in the nares has demonstrated impressively high negative predictive value (NPV) rates between 89%-99% depending on suspected site of infection and PCR platform selected.21-24 The sensitivity of this test coupled with typically low MRSA colonization rates around 30%, allows ASPs to use these clinical tools to more appropriately target empiric therapy for patients with suspected cellulitis,25,26 pneumonia,22,23 diabetic foot infection,27 or surgical prophylaxis.21,28 Recent studies evaluating MRSA PCR POC testing versus centralized laboratory testing via other PCR based platforms or culture based techniques, have shown shorter time to MRSA colonization status and similar sensitivity values when POC testing is utilized.24,29-31 These newer, faster testing modalities have opened the door to evaluating and testing MRSA colonization status at the bedside or in clinic to help establish appropriate empiric antimicrobial therapy when appropriate. To better elucidate the applicability of a MRSA PCR POC test, a study by Parcell and Phillips evaluated the use of a nasal MRSA PCR POC test compared to microbiological culture as a reference standard in a pre-admission orthopedic clinic and patients newly admitted to a vascular surgery ward.32 In the orthopedic clinic, 752 swabs were processed via MRSA PCR POC testing which demonstrated a 75.0% sensitivity, 97.8% specificity, and a positive predictive value (PPV) of 28.6% and a NPV of 99.7%. The results for patients in the vascular ward were similar with a NPV of 99.8%. A similar study July/August 2019

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from Wu and colleagues evaluated MRSA PCR POC testing versus conventional microbiological screening for patients admitted to a tertiary care hospital.30 The MRSA PCR POC test reduced median reporting time of MRSA colonization by 36.7 hours (3.7 hours versus 40.4 hours, p<0.001). When used for patients immediately prior to admission or a surgical procedure for which antibiotics are indicated and Staphylococcus aureus is a potential pathogen of interest, MRSA PCR POC testing in the ambulatory setting has the potential to influence initial antibiotic prescribing instead of its more established utility as clinical tool for de-escalation.28,33,34

Procalcitonin and Combined MxA and CRP POC A common antibiotic misuse scenario occurs when both viral and bacterial diagnoses are under consideration. Influenza and MRSA assays test for the presence of specific pathogens. Procalcitonin (PCT) as well as combined myxovirus resistance protein (MxA) and C-reactive protein (CRP) POC tests offer two tests that can differentiate bacterial from viral illness (without specifically identifying a pathogen). These biomarkers can inform prescribing clinicians and change antibiotic prescribing practices. Procalcitonin is an amino acid precursor to calcitonin that is released during the inflammatory cascade in response to bacterial infections.35 Within six hours of the inflammatory cascade onset, PCT levels rise to detectable levels. Levels peak at 48 hours and fall rapidly during clinical recovery (usually associated with antibiotic therapy initiation).35,36 Procalcitonin levels are not usually elevated in viral infections, most inflammatory conditions, or following corticosteroid use. However, PCT may be mildly elevated in pancreatitis, burn and trauma injuries, renal failure, and post-surgical patients.35 Testing should be discouraged and result interpretation in these scenarios should be done with caution. Procalcitonin monitoring reduces unnecessary antimicrobial exposure and is available as a POC testing device. A controlled trial of 172 randomized patients explored the impact of PCT testing on 20 The Journal

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antibiotic use in outpatient community acquired pneumonia (CAP) therapy. Antibiotic initiation was discouraged for patients with a PCT ≤ 0.25 µg/L. Antibiotic therapy was encouraged for patients with PCT > 0.25 µg/L. The rate of antibiotic exposure was significantly reduced in patients treated according to the PCT guidance (RR 0.55, 95% CI: 0.51-0.60).37 A second study in 15 German primary care practices studied 550 patients with mild respiratory tract infections. The same PCT interpretation guidelines were used to guide antibiotic therapy initiation. one hundred and eighteen (21.5%) patients with low PCT values initiated antibiotics compared to 36.7% of non-PCT guided antibiotic initiation (p<0.05).38 A new desktop POC assay was developed in 2016 and is available for use in the emergency department and outpatient settings.39 The approval studies found similar results to laboratory-based testing with reduced antibiotic exposure in adult patients with acute chronic obstructive pulmonary diseases exacerbations40 and improved diagnostic accuracy in identifying invasive bacterial infections in young infants.41 A second host-response POC testing combines two biomarkers, CRP and MxA, to create a sensitive and specific test for identifying a pathogen-associated systemic host response while differentiating viral or bacterial etiology. The 10-minute POC test device is available in Canada, Europe and Australia and is expected to enter United States clinical trials in 2019 and the market in 2021 (clinical trials.gov ID: NCT 02018198). C-reactive protein is an acute-phase protein which rises within 4-6 hours in response to bacterial infection and peaks at 36 hours after antibiotic initiation. Serum CRP is not usually elevated above 10 mg/L in viral infections; however, influenza and invasive adenovirus can raise CRP to 10-80 mg/L.42 Myxovirus resistance protein A is produced by interferon cells and elevates during viral infections within 1-2 hours and remains elevated throughout the interferon cell response.43,44 Combined, CRP and MxA provide a sensitive and specific means to assess viral versus bacterial causes of respiratory illness. In two prospective trials, the positive predictive value (PPV) and negative predictive value (NPV) of the

combined CRP/MxA test were 45-79% and 97-99% for bacterial diagnoses and 63-75% and 890%-98% for viral diagnoses respectively.45,46 During one prospective, interventional study, 21 were tested and the multiplexed (CRP + MxA) results altered treatment and reduced antibiotic prescription without causing harm, though no statistical analysis was performed on this small sample size.46 Management interventions included antibiotic therapy avoidance and antiviral therapy initiation when bacterial diagnosis was excluded and decision to omit antiviral therapy when viral diagnosis was excluded.

Conclusion

Ambulatory antimicrobial stewardship is addressing the growing antimicrobial resistance problem in a multipronged approach, including rapid diagnostics. Rapid diagnostics and POC testing can reduce diagnostic uncertainly which partially drives inappropriate prescribing. The fast-paced clinic environment ideally places available testing devices in the office and results provided in near real-time, so accurate decisions can be made. Influenza, MRSA, PCT, and combined CRP/MxA tests identify causative pathogens or exclude potential pathogens with high sensitivity and specificity. Accurate and reliable tests reduce unnecessary antibiotic exposure, adverse drug events, antibiotic resistance emergence, and drug costs all while providing peace of mind to clinicians and patients alike. Brian Buss is a Clinical Pharmacist – Infectious Diseases, Jennifer Fever is a PGY2 Ambulatory Care Pharmacy Resident, Ben Heikkinen is a PGY2 Infectious Diseases Resident, and Lucas Schulz is the Clinical Coordinator - Infectious Diseases at UW Health in Madison, WI.

This article has been peer-reviewed. The contribution in reviewing is greatly appreciated!

Disclosures: The authors declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.

www.pswi.org

References

1. World Health Organization. Ten threats to global health in 2019. https://www.who.int/ emergencies/ten-threats-to-global-health-in-2019. 2. Ventola CL. The antibiotic resistance crisis: part 1: causes and threats. P T. 2015;40(4):277-283. 3. Aminov RI. A brief history of the antibiotic era: lessons learned and challenges for the future. Front Microbiol. 2010;1:134. 4. Centers for Diseases Control and Prevention. U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria (National Action Plan). https://www.cdc.gov/drugresistance/ us-activities/national-action-plan.html. 5. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among us ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873. 6. Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Matusiak LM, Schumock GT. Antibiotic expenditures by medication, class, and healthcare setting in the United States, 20102015. Clin Infect Dis. 2018;66(2):185-190. 7. Centers for Diseases Control and Prevention. Outpatient antibiotic prescriptions — United States, 2016. https://www.cdc. gov/antibiotic-use/community/programsmeasurement/state-local-activities/outpatientantibiotic-prescriptions-US-2016.html. 8. Chua KP, Fischer MA, Linder JA. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ. 2019;364:k5092. 9. The Joint Commission. Proposed new requirement at MM.09.01.03 – Antimicrobial Stewardship – Ambulatory Health Care. https://www.jointcommission.org/ antimicrobial_stewardship_%E2%80%93_ ambulatory_health_care_ahc/. 10. Centers for Diseases Control and Prevention. Core elements of outpatient antibiotic stewardship. https://www.cdc.gov/antibioticuse/community/improving-prescribing/coreelements/core-outpatient-stewardship.html. 11. Messacar K, Parker SK, Todd JK, Dominguez SR. Implementation of rapid molecular infectious disease diagnostics: the role of diagnostic and antimicrobial stewardship. J Clin Microbiol. 2017;55(3):715-723. 12. Kozel TR, Burnham-Marusich AR. Point-ofcare testing for infectious diseases: past, present, and future. J Clin Microbiol. 2017;55(8):2313-2320. 13. Andrews D, Chetty Y, Cooper BS, et al. Multiplex PCR point of care testing versus routine, laboratory-based testing in the treatment of adults with respiratory tract infections: a quasi-randomised study assessing impact on length of stay and antimicrobial use. BMC Infect Dis. 2017;17(1):671. 14. Centers for Diseases Control and Prevention. Burden of influenza. https://www. cdc.gov/flu/about/burden/index.html. 15. Centers for Diseases Control and Prevention. Office-related antibiotic prescribing for persons aged ≤ 14 years--United States, 1993-1994 to 2007-2008. MMWR Morb Mortal Wkly Rep. 2011;60(34):1153-1156. 16. Havers FP, Hicks LA, Chung JR, et al.

Outpatient antibiotic prescribing for acute respiratory infections during influenza seasons. JAMA Netw Open. 2018;1(2):e180243. 17. McGow CJ. Prescribing antibiotics "just in case" must be tackled to slow rise in antibiotic resistance. BMJ. 2019;364:l553. 18. Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical practice guidelines by the Infectious Diseases Society of America: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenzaa. Clin Infect Dis. 2019;68(6):895-902. 19. Lee JJ, Verbakel JY, Goyder CR, et al. The clinical utility of point-of-care tests for influenza in ambulatory care: a systematic review and meta-analysis [Published online October 4, 2018] Clin Infect Dis. doi: 10.1093/cid/ciy837. 20. Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med. 1985;14(1):15-19. 21. Robicsek A, Suseno M, Beaumont JL, Thomson RB, Peterson LR. Prediction of methicillinresistant Staphylococcus aureus involvement in disease sites by concomitant nasal sampling. J Clin Microbiol. 2008;46(2):588-592. 22. Parente DM, Cunha CB, Mylonakis E, Timbrook TT. The clinical utility of methicillinresistant Staphylococcus aureus (MRSA) nasal screening to rule out MRSA pneumonia: a diagnostic meta-analysis with antimicrobial stewardship implications. Clin Infect Dis. 2018;67(1):1-7. 23. Dangerfield B, Chung A, Webb B, Seville MT. Predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab PCR assay for MRSA pneumonia. Antimicrob Agents Chemother. 2014;58(2):859-864. 24. Wolk DM, Picton E, Johnson D, et al. Multicenter evaluation of the Cepheid Xpert methicillin-resistant Staphylococcus aureus (MRSA) test as a rapid screening method for detection of MRSA in nares. J Clin Microbiol. Mar 2009;47(3):758-764. 25. Schleyer AM, Jarman KM, Chan JD, Dellit TH. Role of nasal methicillin-resistant Staphylococcus aureus screening in the management of skin and soft tissue infections. Am J Infect Control. 2010;38(8):657-659. 26. Reber A, Moldovan A, Dunkel N, et al. Should the methicillin-resistant Staphylococcus aureus carriage status be used as a guide to treatment for skin and soft tissue infections? J Infect. 2012;64(5):513-519. 27. Lavery LA, Fontaine JL, Bhavan K, Kim PJ, Williams JR, Hunt NA. Risk factors for methicillin-resistant Staphylococcus aureus in diabetic foot infections. Diabet Foot Ankle. 2014;5. 28. Iqbal HJ, Ponniah N, Long S, Rath N, Kent M. Review of MRSA screening and antibiotics prophylaxis in orthopaedic trauma patients; the risk of surgical site infection with inadequate antibiotic prophylaxis in patients colonized with MRSA. Injury. 2017;48(7):1382-1387. 29. Tong SY, Davis JS, Eichenberger E, Holland TL, Fowler VG. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev. 2015;28(3):603-661. 30. Wu PJ, Jeyaratnam D, Tosas O, Cooper BS, French GL. Point-of-care universal screening for meticillin-resistant Staphylococcus

aureus: a cluster-randomized cross-over trial. J Hosp Infect. 2017;95(3):245-252. 31. Brenwald NP, Baker N, Oppenheim B. Feasibility study of a real-time PCR test for meticillin-resistant Staphylococcus aureus in a point of care setting. J Hosp Infect. 2010;74(3):245-249. 32. Parcell BJ, Phillips G. Use of Xpert® MRSA PCR point-of-care testing beyond the laboratory. J Hosp Infect. 2014;87(2):119-121. 33. Rao N, Cannella B, Crossett LS, Yates AJ, McGough R. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008;466(6):1343-1348. 34. Smith MN, Brotherton AL, Lusardi K, Tan CA, Hammond DA. Systematic review of the clinical utility of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening for MRSA pneumonia. Ann Pharmacother. 2019;53(6):627-638. 35. Fazili T, Endy T, Javaid W, Maskey M. Role of procalcitonin in guiding antibiotic therapy. Am J Health Syst Pharm. 2012;69(23):2057-2061. 36. Schuetz P, Chiappa V, Briel M, Greenwald JL. Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms. Arch Intern Med. 2011;171(15):1322-1331. 37. Long W, Deng X, Zhang Y, Lu G, Xie J, Tang J. Procalcitonin guidance for reduction of antibiotic use in low-risk outpatients with community-acquired pneumonia. Respirology. 2011;16(5):819-824. 38. Burkhardt O, Ewig S, Haagen U, et al. Procalcitonin guidance and reduction of antibiotic use in acute respiratory tract infection. Eur Respir J. 2010;36(3):601-607. 39. Scientific T. B·R·A·H·M·S PCT direct at Point of Care (POC). https://www.procalcitonin. com/clinical-utilities/point-of-care-poc.html. 40. Corti C, Fally M, Fabricius-Bjerre A, et al. Point-of-care procalcitonin test to reduce antibiotic exposure in patients hospitalized with acute exacerbation of COPD. Int J Chron Obstruct Pulmon Dis. 2016;11:1381-1389. 41. Waterfield T, Maney JA, Hanna M, Fairley D, Shields MD. Point-of-care testing for procalcitonin in identifying bacterial infections in young infants: a diagnostic accuracy study. BMC Pediatr. 2018;18(1):387. 42. Nakabayashi M, Adachi Y, Itazawa T, et al. MxAbased recognition of viral illness in febrile children by a whole blood assay. Pediatr Res. 2006;60(6):770-774. 43. Horisberger MA. Interferon-induced human protein MxA is a GTPase which binds transiently to cellular proteins. J Virol. 1992;66(8):4705-4709. 44. Ronni T, Melén K, Malygin A, Julkunen I. Control of IFN-inducible MxA gene expression in human cells. J Immunol. 1993;150(5):1715-1726. 45. Self WH, Rosen J, Sharp SC, et al. Diagnostic accuracy of FebriDx: a rapid test to detect immune responses to viral and bacterial upper respiratory infections. J Clin Med. 2017;6(10). 46. Shapiro NI, Self WH, Rosen J, et al. A prospective, multi-centre US clinical trial to determine accuracy of FebriDx point-of-care testing for acute upper respiratory infections with and without a confirmed fever. Ann Med. 2018;50(5):420-429.

Features

Ambulatory Care Practice Development: Highlighting Best Practices by Andy Cannon, PharmD, Josh Nachreiner, PharmD, Beth Buckley, PharmD, CDE, Katie Higgins, PharmD, Michelle Maynard, PharmD, BCPS, Amy Mahlum, PharmD, Elyse Weitzman, PharmD, Ashley Lorenzen, PharmD, and Kate Hartkopf, PharmD

n 2018, PSW’s Ambulatory Care Advisory Board (ACAB) sent out two surveys to pharmacists practicing in ambulatory care settings across Wisconsin. These surveys were designed to better understand what patient-specific factors and processes drive ambulatory care practice in Wisconsin. Responses were received from a representative sample of practice settings, including health-systems, the VA medical centers, progressive community pharmacy settings, and specialty pharmacy practices. ACAB members would like to thank all pharmacists who responded to one or both surveys. The responses provided valuable information for the ACAB to better understand the current state of ambulatory care practice in Wisconsin and help other pharmacists learn from existing programs and services to achieve the common goal of improved patient care while utilizing a multi-disciplinary, patient-centered approach. Some interesting findings were identified from the first survey that focused on patient-specific factors (n = 42). There were eight practice sites (19%) that utilized biomarkers and guidelines to enroll patients. These included hemoglobin A1c greater than 9%, blood pressure greater than 140/90 mmHg, patients with diabetes not taking a statin, and a condition requiring anticoagulation. A small number of practices are identifying patients for their service based on a minimum number of disease states or medications (17% and 24%, respectively), a recent qualifying event such as a hospitalization (26%), or specific therapeutic classes of medications (38%). In the second survey that focused on practice site processes (n=35), we found that most practice sites are enrolling patients in their service by both provider referral and pharmacist identification

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(57%). Ambulatory care practices are tracking interventions made at 74% of sites, patient outcomes at 60% of sites, and time spent on patient care at 74% of sites. Nearly 50% of respondents track at least two of these metrics at their practice, and an impressive 97% of sites report using the electronic medical record as a tool to track the service. Taking lessons learned from other ambulatory care services is an ideal way to make implementation of a new or expanded service at your practice site easier. At a national level, there have been resources shared on how to implement pharmacist ambulatory care services. The ACAB has compiled these resources and created new tools that can be found on the PSW website (http://www.pswi.org/ Resources/Ambulatory-Care-Pharmacy/ Practice-Management-Resources). Through these surveys, three Wisconsin pharmacists were identified by the ACAB to showcase best practice ambulatory care services, and those pharmacists have offered to share their insight and experiences here.

Beth Buckley

Family Medicine at Ascension All Saints Hospital Wisconsin Avenue Campus The clinical pharmacist role in Family Medicine at Ascension All Saints Hospital Wisconsin Avenue Campus started in 2003 and was based on the vision of a new medical director who trained in California with pharmacists and believes pharmacists are vital members of the primary care team. As the clinic is located in an underserved area, many patients are more complex due to inconsistent medical care leading to complicated disease states. Originally, the pharmacist mainly provided education on medication management of chronic diseases, such as diabetes, hypertension, asthma, and hyperlipidemia, to the 18 Medical College of Wisconsin (MCW)

family medicine residents training in clinic. As the clinical pharmacist, I began to transform the pharmacist’s role by building strong relationships in clinic and utilizing resources available through the American College of Clinical Pharmacy (ACCP) and the Society of Teachers of Family Medicine (STFM). Initially, the pharmacist spent time in clinic precepting medical residents and discussing therapeutic decisions with the medical team. Additionally, we introduced weekly pharmacotherapy review sessions and created a newsletter to communicate medication-related questions and developments. Through this team approach, I was able to identify the medical residents’ knowledge deficits and educational needs, which was vital to the success of the pharmacist’s role. The medical residents were also able to discover the knowledge base of a pharmacist and our potential role in patient care. The pharmacist was involved in patient care in two ways, via referral or “curbside” consults. A referral could be completed to request pharmacist involvement in answering drug information questions, completing profile reviews, or providing direct patient care and education. Due to the pharmacist’s visibility in the clinic, providers also involved the pharmacist by requesting “curbside” consults. As providers saw improved adherence and goal attainment in patients referred to the pharmacist, more time was allotted to direct patient care in the pharmacists' schedule. Diabetes care emerged as the top referral due to the large amount of uncontrolled diabetes and the need for patient education. In addition, many referrals are made for medication therapy management of a variety of chronic diseases due to improved access to affordable medication via 340B and Dispensary of Hope programs. When MCW ended the family www.pswi.org

medicine residency program in clinic, there was a large turnover of faculty and providers, and the clinical pharmacist position was no longer supported full time. Instead, the new medical director worked with the pharmacy department to create a model where Ascension community pharmacists spend part of their day in the ambulatory care setting. A collaborative practice agreement was developed that authorized pharmacists to prescribe and order labs, which helped justify our competence and role to the new clinic providers. Current pharmacy services are offered in clinic six half-days per week. Overall, we have shown that pharmacists improve access to care, adherence to medication regimens, and measured outcomes, such as hemoglobin A1c and blood pressure. We have published data on the types of interventions made and the impact our pharmacists have had on our patient population. Provider and clinic staff surveys have also reinforced our pharmacists’ positive impact on patient care and the need for our services. We plan to expand our services to provide added benefit. However, our rate limiting steps continue to be billing and justification of salary.

Katie Higgins

Aurora Specialty Pharmacy Specialty medications are typically high cost, may be limited by ability for distribution, and can be challenging in transitions of care. Common specialty disease states include oncology, hepatitis C, multiple sclerosis, autoimmune disorders, and HIV. Two years ago, Aurora Health Care identified the need for both inpatient and outpatient pharmacy teams to be alerted when a patient is admitted to an inpatient setting and has a specialty medication on their prior-toadmission medication list. This created an opportunity to enhance the Aurora Specialty Pharmacy services, where clinical pharmacists collaborate with other members of the health care team to ensure patients have access to high cost medication along with high touch management of care in a timely manner. A group of pharmacists from both the inpatient and outpatient settings proposed a process to address these challenging

transitions of care. When medication reconciliation occurs upon admission, if the patient has a specialty medication on their medication list, a message is sent to the Aurora Specialty Pharmacy team via the electronic health record. Additionally, an alert displays to the inpatient pharmacy team. This alert helps increase the inpatient pharmacy team’s awareness that the patient is taking a specialty medication and improves communication regarding medications with specific requirements, such as requiring a specialist provider consult to prescribe the medication or special acquisition requirements for the medication due to formulary restrictions. As a pharmacist at the Aurora Specialty Pharmacy, I am notified when a patient enrolled in Aurora Specialty Pharmacy is admitted and is taking a medication that should not be interrupted or may cause the patient to be at risk for drug-drug interactions. Our workflow also allows the Aurora Specialty Pharmacy team to stay current on care plans for oncology patients, which may be changed during the patient’s hospital stay. Our team-based approach has improved communication between the outpatient Aurora Specialty Pharmacy team and the inpatient pharmacy team and providers, reducing challenges encountered during transitions of care and ensuring our patients are receiving the highest quality of care. Aurora Health Care recently merged with Advocate Health Care in Illinois forming Advocate Aurora Health. As a health system, we are currently in a transition phase, working to get all clinics and hospitals within the health system onto the same electronic health record. Once completed, the Aurora Specialty Pharmacy workflow will be utilized for all patients who experience transitions of care while taking a specialty medication dispensed from the Aurora Specialty Pharmacy. My role as a specialty pharmacist will continue to expand as the Aurora Specialty Pharmacy continues to expand its service area.

Michelle Maynard

Froedtert Neurosciences Clinic Prior to 2016, the Froedtert Neurosciences Clinic never had an ambulatory care pharmacist. Neurology is a rapidly expanding area of ambulatory

pharmacy practice as advances in the treatment of many neurologic diseases, the cost of care, and need for adherence have increased. My primary role began as part of the multiple sclerosis (MS) team educating patients about their disease modifying therapy (DMT), a practice endorsed by the American Academy of Neurology 2018 Practice Guideline. In order to expand this role, I followed a few guiding principles: • Listen to the ideas from providers and staff for how they would like the pharmacist to help. Many requests may not fit your scope, but if you are able to help triage issues, this strategy can help you gain trust within the team. • Meet with clinic administrators to learn their priorities. You can then tailor your activities to help achieve these priorities. • Shadow your providers for a few days. Look for ways that your involvement can streamline their work, increase their productivity, and/or decrease their workload. • Don’t overlook clinic workflows. Pharmacists are often in a unique position to help design and disseminate information about medication use in any setting. In this role, I also worked to ensure baseline laboratory screenings were completed and patients were up to date with recommended vaccinations. Our clinic’s screening rate improved after providing education to our team on which screening labs were needed and creating a document to interpret results. In the past year, four patients with prior hepatitis B exposure were identified, and treatment plans were reassessed. An additional 24 patients were given vaccination recommendations during a 4-month period from October 2017 to February 2018. Vaccinations included influenza, tetanus, pneumococcal or varicella. The acceptance rate for pharmacist-recommended vaccinations was 50%. Eventually, my role expanded to the Amyotrophic Lateral Sclerosis (ALS) interdisciplinary clinic. I began offering periodic assistance with recommendations for which medications could be crushed, as many ALS patients develop difficulty swallowing medications. Since January

2019, pharmacists in the neurology and gastrointestinal clinics have partnered to create a process for more formalized medication administration recommendations for all prescribers when transitioning from oral to enteral routes and to provide caregiver instruction and follow up. There are several other areas in clinic where neurology pharmacists can contribute our expertise and expand the pharmacists’ role. Pharmacists can provide recommendations for symptom management such as sialorrhea, pain, anxiety, and depression. Many patients have questions about their medications and about nutraceuticals to delay disease progression. A neurology pharmacist’s role is certainly not limited to multiple sclerosis and ALS care! Epilepsy and Parkinson’s Disease care are more frequently encountered opportunities, but additional opportunities to expand pharmacist involvement in the future

include headache, sleep medicine, stroke prevention, traumatic brain injury, myasthenia gravis, neurosurgery, and memory disorders.

Conclusion

As demonstrated by the highlighted best practice accounts, PSW members and ambulatory care pharmacists are doing great work to improve patient care and advocate for our profession in diverse ways. In addition to professional resources available nationally and tools developed by the ACAB, our own member pharmacists can provide valuable guidance to those who wish to initiate a pharmacist’s role or pursue further growth in an existing role in the ambulatory care setting. Andy Cannon is a PGY2 Ambulatory Care Resident at William S. Middleton Memorial Veterans Hospital in Madison, WI. Josh Nachreiner is a PGY-1 Pharmacy Resident at UW Health in Madison, WI. Beth Buckley is

an Associate Professor, Department of Pharmacy Practice at Concordia University Wisconsin School of Pharmacy and an Ambulatory Care Pharmacist at Ascension All Saints Hospital Wisconsin Avenue Campus in Mequon and Racine, WI. Katie Higgins is a Specialty Pharmacy Coordinator at Advocate Aurora Health in Menomonee Falls, WI. Michelle Maynard is an Ambulatory Clinical Pharmacist at Froedtert Health Care in Milwaukee, WI. Amy Mahlum is an Ambulatory Pharmacy Clinical Coordinator at Advocate Aurora Health in Milwaukee, WI. Elyse Weitzman is a Clinical Pharmacist, Primary Care at Froedtert & The Medical College of Wisconsin in Milwaukee, WI. Ashley Lorenzen is the Associate Chief of Pharmacy – Clinical Services at Oscar G. Johnson VA Medical Center, Iron Mountain, MI. Kate Hartkopf is the Pharmacy Manager, Ambulatory Care Services at UW Health Pharmacy Services in Middleton, WI.

Specializing in certifying pharmacy technicians because patient safety matters. 24 The Journal

July/August 2019

Choose PTCB. Choose Excellence.

ptcb.org www.pswi.org

Features

PRECEPTING SERIES:

Meeting Precepting Challenges with Layered Learning by Jeremiah L. Barnes, PharmD, BCPS, Sabrina K. Haskell, PharmD, MBA

he practical and logistical hurdles associated with precepting multiple learners are by no means novel observations; debates of optimal class sizes, teacher-to-learner ratios, and individualized instruction have long characterized academic communities. More recently, however, increased enrollment in pharmacy programs has seen the conversation transition from school grounds to hospital hallways as greater numbers of learners arriving for student rotations and residency training demand new methods of experiential education. One such approach to manage more learners is through layered learning. The purpose of this article is to briefly summarize published examples of layered learning in pharmacy practice and present experiential site-based challenges that can be met by applying layered learning principles.

Background

Layered learning practice models

www.pswi.org

(LLPMs) have been defined and described in varying degrees and settings, but common components include the implementation of a preplanned system, an open approach to communication, underlying resourcefulness, and prioritization of feedback and evaluations.1,2 When applied effectively, LLPMs can be mutually beneficial to both learners and the experiential site. Along with potential improvements in the personalization and depth of the practice experience for the learner, LLPMs can enable the site to better incorporate learners, balance precepting responsibilities, and facilitate practical means of learner assessment.1,2 As such, through LLPMs, preceptors can instruct multiple learners while simultaneously distributing workload and reallocating time for clinical and administrative responsibilities.

LLPM Structure

Layered learning practice models employ a teaching strategy typified by multiple layers of learners underneath a

senior pharmacist preceptor.1 Each layer has pre-designated responsibilities, with higher level learners acting in preceptor roles for lower level learners. An example of layered learning responsibilities for each preceptor and learner level is provided in Figure 1. While LLPMs were first described by the University of North Carolina Hospitals, Loy et al. subsequently outlined the successful implementation of a LLPM to an existing program at the Durham Veterans Affairs Medical Center.1,2 Importantly, the article describes in detail four key steps within a successful LLPM: orientation, pre-experience planning, implementation, and post-experience evaluation. First, during orientation, preceptors and residents become familiar with the LLPM, discuss the expectations of the resident, and review resources (i.e. precepting guides, examples of previous student schedules, etc.). Next, in pre-experience planning, responsibilities are outlined, the student rotation schedule is confirmed, and the resident initiates contact with the student learner. Implementation includes an July/August 2019

The Journal 25

FIGURE 1. Example of Layered Learning Responsibilities

orientation for the student to the LLPM, followed by the resident serving as primary preceptor for the rotation. Finally, postexperience evaluation takes place in written and verbal formats between all learner and preceptor levels to promote LLPM quality improvement.

LLPM Benefits

Though not invulnerable to implementation barriers and pitfalls, LLPMs can support favorable settings for experiential teaching and learning. The precepting challenges addressed by LLPMs include the ability to: Host Multiple Learners Generally, the first considerations given to precepting multiple learners are the capabilities to incorporate a given number of learners at a site and to maintain target preceptor ratios. One recent publication sought to address the concept of utilizing learners and preceptors in a layered model to further patient care.3 This study by Bates et al. described a team-based LLPM in which a resident and pharmacy student provided discharge medication 26 The Journal

July/August 2019

reconciliation and counseling services under the supervision of a precepting pharmacist. Overall, the LLPM facilitated an increase in medication interventions and patient encounters, supporting the utility of layered learning in the advancement of pharmacy services and meaningful incorporation of learners. Moreover, a 2017 systematic review by Loewen et al. characterized and evaluated various learner: preceptor ratios across medical professions, including a “tiered or learner-aspreceptor” approach reflective of LLPMs.4 While potential difficulties associated with inadequate preceptor exposure, conflict between learners, and increased administrative or operational requirements were noted, the “tiered” approach improved preceptor time restrictions, shared learner knowledge, and site placement capacity. Interestingly, this review identified the 2:1 and 2+:2+ learner: preceptor ratios as potentially optimal, highlighting the advantages of intentionally precepting multiple learners at a given time. Adapt Preceptor Roles One of the more notable challenges a

preceptor can face is a mismatch between the depth of instruction and a learner’s needs or abilities. This discrepancy can be especially troubling if fixed workload or rotation responsibilities call for a degree of independence either below or beyond a learner’s capacity. Thankfully, an implicit advantage of LLPMs is the ability to adapt teaching strategies to the individual learner. When advanced learners take part in overseeing the core responsibilities of beginner learners, a given learning objective can be adjusted to reflect any of the four precepting roles: direct instruction, modeling, coaching, and facilitation.5 For example, a learner with no experience conducting medication histories would likely benefit from additional coaching compared to a student who works as a medication reconciliation intern. While available academic literature primarily highlights this advantage through utilization of pharmacy residents, the principle can certainly extend outside of residency programs. Preceptors may place introductory learners with more advanced pharmacy students, pharmacy technicians, or non-pharmacy staff for www.pswi.org

the purposes of patient care observation, reinforcement of operational processes, or exposure to clinical services. Intentional scheduling of overlapping learner levels helps ensure the indicated preceptor roles and learning opportunities are employed in each instance. By and large, it is this conformability that affords the shared learner knowledge and precepting time improvements offered by LLPMs.

importantly, patients benefit from expanded pharmacy services made possible through the effective precepting of multiple learners.

Evaluate Resident Performance According to the American Society of Health-System Pharmacists Accreditation Standards for Pharmacy Residency Programs, the ability to employ the four preceptor roles is an expectation of all pharmacy residents.5 Adoption of these roles often entails a multifaceted approach. Previously described challenges encountered by residents in new precepting responsibilities range from exemplifying professionalism standards to evaluating student performance, necessitating varying degrees of guidance from senior co-preceptors.6 Additionally, without intentionally scheduled precepting experiences, demonstrating and evaluating competency in these preceptor roles can become functionally difficult. In practice, layered learning helps streamline assessment of this residency program standard. When implemented consistently, LLPMs not only guarantee overlap of learner levels, but also establish the framework necessary for the support and comprehensive evaluation of pharmacy residents. In turn, residents are benefited genuine, organized opportunities to precept and mentor other pharmacy learners as an integral part of their residency program.

Conclusion

In summary, LLPMs in experiential pharmacy education have the potential to benefit all participants. Senior preceptors can maximize the number of learners they manage and enhance their productivity in clinical practice; residents gain the experience of teaching multiple types of learners at various levels while building their leadership skills and autonomy; students can start patient care activities with efficiency and utilize resident and senior preceptors for career path guidance and mentorship. Ultimately, and most

Jeremiah Barnes is an Internal Medicine Clinical Pharmacy Specialist and Sabrina Haskell is a PGY-2 Internal Medicine Pharmacy Resident at the Clement J. Zablocki VA Medical Center in Milwaukee, WI.

References

1. Loy BM, Yang S, Moss JM, Kemp DW, Brown JN. Application of the layered learning practice model in an academic medical center.

Hosp Pharm. 2017;52(4):266-272. 2. Pinelli NR, Eckel SF, Vu MB, Weinberger M, Roth MT. The layered learning practice model: lessons learned from implementation. Am J Health-Syst Pharm. 2016;73(24):2077-2082. 3. Bates JS, Bule LW, Amerine LB, et al. Expanding care through a layered learning practice model. Am J Health-Syst Pharm. 2016;73(22):1869-1875. 4. Loewen P, Legal M, Gamble A, Shah K, Tkachuk S, Zed P. Learner: preceptor ratios for practice-based learning across health disciplines: a systematic review. Med Educ. 2017;51(2):146-157. 5. American Society of Health-System Pharmacists. Required competency areas, goals, and objectives for postgraduate year one (PGY1) pharmacy residency standard. https://www.ashp.org/-/media/ assets/professional-development/residencies/docs/ required-competency-areas-goals-objectives. Published March 8, 2015. Accessed March 28, 2019. 6. Hammond DA, Norris KR, Phillips MS. Embracing challenges when co-precepting pharmacy students. Hosp Pharm. 2014;49(4):348-354.

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Review Article

The Evolution of Sterile Compounding Practices by Michael Ganio, PharmD, MS, BCPS, CPHIMS, FASHP

he United States Pharmacopeia (USP) Compounding Expert Committee released the final version of the updated General Chapter <797> Pharmaceutical Compounding â&#x20AC;&#x201C; Sterile Preparations on June 1, 2019. The release marks the second revision of the chapter that was first published in 2004.1 As pharmacy practice has advanced, so has the practice of compounding sterile preparations. Unfortunately many of the advances have come as the result of harm caused by contaminated or inaccurately prepared sterile products. USP is a nonprofit, nongovernment organization that was founded in 1820 by a group of 11 physicians. The Pure Food and Drugs Act of 1906 established USP as an authority to set official standards; the Act was passed partially as the result of dangerous and worthless medicines. USP Chapters numbered below <1000> are FDA-enforceable standards; chapters <1000> or above offer guidance. In 1938, the Food and Drug Administration (FDA) was passed to improve the safety of medications after a sulfanilamide elixir containing diethylene glycol killed 107 patients in 1937. The law granted the authority to enforce USP standards. The 1997 FDA Modernization Act established section 503A applying federal law to pharmacy compounding. The Modernization Act was ruled unconstitutional by the Supreme Court in 2002, providing some of the motivation for rewriting General Chapter <1206> 28â&#x20AC;&#x192; The Journal

July/August 2019

Sterile Drug Products for Home Use and renumbering the chapter below <1000> to make the standard enforceable by the FDA.2,3 Most recently in 2013, in response to the New England Compounding Center tragedy that killed 64 patients in 20 states, the Drug Quality and Security Act (DQSA) was passed. The DQSA reestablished section 503A and established section 503B, creating the category of outsourcing pharmacies.4 Prior to 2004, both the American Society of Health-System Pharmacists (ASHP) and USP (in the form of Chapter <1206>) offered sterile and non-sterile guidelines. When Chapter <797> was published in 2004, it became the first nationally enforceable standard for sterile compounding practices. The chapter described minimum quality requirements for compounding sterile preparations and places an emphasis on facilities and engineering controls, administrative controls, staff competencies, environmental monitoring, and storage and stability limits.3

Advances in Technology

Automation and technology in sterile compounding have advanced substantially since the first Chapter <797>. The 2002 ASHP National Survey of Pharmacy Practice reported 33% of hospitals used either large-volume compounding devices (e.g. repeater pumps) or additive compounding devices for total parenteral nutrition preparation.5 The 2017 ASHP National Survey measured the use of newer technologies, like barcode ingredient

verification, gravimetric validation, fully automated robotic devices, and workflow management software.6 Several articles highlight the improved safety and enhanced error detection of these technologies with minimal detrimental (or even improved) effect on operational efficiency.7-9 Despite the documented safety enhancement of these technologies, adoption still remains relatively low. The 2017 ASHP National Survey reported 64% of all hospitals use no technology for sterile product preparation.6 Potential barriers to implementation include cost, physical space, informatics staff capacity, impact on operational efficiency, technology limitations, and general lack of knowledge of technologies available. The current Chapter <797> includes a section on automated compounding devices, specifically related to parenteral nutrition preparation. The most recent proposed revisions to Chapter <797> incorporate some information on workflow management technologies and robotics. However, the chapter stops short of making any specific recommendation on the use of these technologies, or on technologyassisted methods to verify accuracy of compounded sterile preparations.10

Advances in Safety

The updated chapter <797> is scheduled to become official on 12/1/2019, the same date as General Chapter <800> Hazardous Drugs â&#x20AC;&#x201C; Handling in Healthcare Settings. Chapter <800> was first introduced in 2014; the official date has been delayed until 12/1/2019 to align the compounding www.pswi.org

chapters and to allow institutions more time to make the necessary facility and administrative changes. The risk of working with hazardous drugs was first addressed over 35 years ago in ASHP’s 1983 publication Recommendations for handling cytotoxic drugs in hospitals.11 In 2004, the National Institute of Occupational Safety and Health (NIOSH) published an alert with examples of FDA-approved drugs that are deemed hazardous to workers and also contained general policies on handling hazardous drugs.12 The risks of occupational exposure to hazardous drugs have been well documented and include reproductive toxicity and DNA damage.13-16 Despite the evidence of potential harm caused by exposure to hazardous drugs, there have been no enforceable standards on handling hazardous drugs until Chapter <800>.

Implementation

The facility requirements, engineering controls, and administrative controls required in Chapters <797> and <800> can represent substantial direct and indirect costs to hospital pharmacy budgets. While the standards are intended to improve the quality and safety of compounded products, the direct cost of compliance will likely include facility construction, capital equipment, and disposables (e.g. garb/ personal protective equipment, closedsystem transfer devices). The required external exhaust capabilities may pose additional challenges to Chapter <800> compliance. Successful approaches to compliance with Chapters <797> and <800> have included performing a gap analysis, forming an interprofessional collaborative of stakeholders, establishing timelines and milestones, and building in contingency plans. Because the scope of USP <800> extends well beyond pharmacy, the interprofessional team should include leadership representatives from nursing, environmental services, epidemiology, and quality. When construction is necessary, pharmacy leadership should also be involved with the selection of an architect and contractor to ensure they have the proper expertise to design and build to correct specifications.17,18 While Chapters <797> and <800> set www.pswi.org

a high minimum standard to meet, the cost of noncompliance may be greater.19 The Pew Charitable Trusts tracked 1,416 compounding-related adverse events, including 115 deaths, between 2001 and 2017. The most common cause of compounding errors was contamination, highlighting the need for the quality controls established in regulations and standards.20

Future Advancements

Changes to Federal law, FDA rules, and the evolution of USP compounding chapters have made sterile compounding a complex field requiring expertise in both practical and regulatory knowledge. In February of 2018, the Board of Pharmacy Specialties recognized sterile-product compounding as a specialty and will begin offering certification in the fall of 2019.21 Pharmacists will have the opportunity to develop and demonstrate expertise in the standards and best practices associated with sterile compounding to ensure the field continues to advance in the future. Michael Gaino is the Director of Pharmacy Practice and Quality at ASHP.

References

1. United States Pharmacopeia and National Formulary (USP 27-NF22). Chapter <797> “Pharmaceutical Compounding–Sterile Preparations.” Rockville, MD: United States Pharmacopeial Convention; 2004. 2. U.S. Food and Drug Administration. Milestones in U.S. food and drug law history. https:// www.fda.gov/AboutFDA/History/FOrgsHistory/ EvolvingPowers/ucm2007256.htm. Published February 1 2018. Accessed March 31, 2019. 3. Newton DW, Trissel LA. A primer on USP Chapter <797> pharmaceutical compounding— sterile preparations and usp process for drug practice standards. National Home Infusion Association. http://www.nhia.org/members/documents/ usp_797_primer.pdf. Accessed March 31, 2019. 4. U.S. Food and Drug Administration. compounding laws and policies. https://www.fda.gov/ Drugs/GuidanceComplianceRegulatoryInformation/ PharmacyCompounding/ucm606881.htm. Published July 23, 2018. Accessed March 31, 2019. 5. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2002. Am J Health Syst Pharm. 2003;60(1):52-68. 6. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017. Am J Health Syst Pharm. 2018;75(16):1203-1226. 7. Reece KM, Lozano MA, Roux R, Spivey

SM. Implementation and evaluation of a gravimetric i.v. workflow software system in an oncology ambulatory care pharmacy. Am J Health Syst Pharm. 2016;73(3):165-173. 8. Roberts PA, Willoughby IR, Barnes N, et al. Evaluation of a gravimetric-based technology-assisted workflow system on hazardous sterile product preparation. Am J Health Syst Pharm. 2018;75(17):1286-1292. 9. Moniz TT, Chu S, Tom C, et al. Sterile product compounding using an i.v. compounding workflow management system in a pediatric hospital. Am J Health Syst Pharm. 2014;71(15):1311-1317. 10. United States Pharmacopeia. General Chapter <797> pharmaceutical compounding—sterile preparations. http://www.usp.org/compounding/ general-chapter-797. Accessed March 31, 2019. 11. Stolar MH, Power LA, Viele CS. Recommendations for handling cytotoxic drugs in hospitals. Am J Health Syst Pharm. 1983;40(7):1163–71. 12. Centers for Disease Control and Prevention. NIOSH alert: preventing occupational exposures to antineoplastic and other hazardous drugs in health care settings. DHHS (NIOSH) 2004-165. 13. McDiarmid M, Egan T. Acute occupational exposure to antineoplastic agents. J Occup Med. 1988;30(12):984-987. 14. Valanis B, Vollmer WM, Steele P. Occupational exposure to antineoplastic agents: self-reported miscarriages and stillbirths among nurses and pharmacists. J Occup Environ Med. 1999;41(8):632-638. 15. Dranitsaris G, Johnston M, Poirier S, et al. Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and meta-analysis of the literature. J Oncol Pharm Pract. 2005;11(2):69-78. 16. Suspiro A, Prista J. Biomarkers of occupational exposure to anticancer agents: a minireview. Toxicol Lett. 2011;207(1):42-52. 17. Mekoba BC, Turingan EM, Roberts PA, et al. A pharmacy-led United States Pharmacopeia (USP) chapter 800 compliance collaborative at an academic medical center. Am J Health Sys Pharm. 2018;75(15):627–632. 18. Gilbreath J. Lessons learned in complying with <797> and <800>. Pharmacy Purchasing & Products. 2019;16(2):8. 19. Kastango E. The bottom line on USP compliance: what is your risk? Beckers Hospital Review. https://www.beckershospitalreview.com/ human-capital-and-risk/the-bottom-line-on-uspcompliance-what-is-your-risk.html. Published August 31, 2017. Accessed April 1, 2019. 20. The Pew Charitable Trusts. U.S. illnesses and deaths associated with compounded or repackaged medications, 2001-2017. http://www.pewtrusts.org/-/ media/assets/2018/03/dsp_us_illnesses_and_deaths_ associated_with_compounded_medications_or_ repackaged_medications. .pdf?la=fr&hash=BBD2D35 01C774B10034493F83C40E8C27CE859E3. Published March 2018. Accessed April 1, 2019. 21. Board of Pharmacy Specialties. Compounded sterile preparations in pharmacy. https://www. bpsweb.org/bps-specialties/compounded-sterilepreparations-pharmacy/. Accessed April 1, 2019.

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The Journal 29

Review Article

Writing Club

"MORTAR & PENCIL" CONCORDIA UNIVERSITY WISCONSIN SCHOOL OF PHARMACY WRITING CLUB:

Federally Qualified Health Centers: A Practice Advancement Opportunity for Pharmacists by Alyssa M Schaller, 2021 PharmD Candidate, Ian R Giebel, 2021 PharmD Candidate, Killian J Mielotz, 2021 PharmD Candidate, Lauren N Nevinski, 2021 PharmD Candidate

he role of the pharmacist has greatly expanded beyond the familiar, friendly face behind a counter dispensing medication. Today, pharmacists serve as vital members of the healthcare team and use their unique expertise and insight to optimize patient care across health systems. This growth has allowed pharmacists to use the most of their Doctor of Pharmacy degrees, and to truly be known as the “medication experts.” Pharmacists now practice in a variety of unique pharmacy practice settings, including local ambulatory care clinics, large academic hospitals, and small health clinics focused on providing care for underserved populations. The focus of this article will be on pharmacists within small health clinics, specifically Federally Qualified Health Centers (FQHCs), and the role they play in serving underserved patients. This article will define FQHCs, describe the role and importance of pharmacists in these centers, and discuss involvement of student pharmacists in FQHCs.

What is a FQHC?

According to the Health Resources and Services Administration (HRSA), “Federally Qualified Health Centers are community-based healthcare providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas.”1 These nonprofit or public, community-based organizations are typically outpatient clinics within medically underserved areas that qualify for specific reimbursement systems under Centers for Medicare and Medicaid Services. A medically 30 The Journal

July/August 2019

underserved area is defined by HRSA as an area having too few primary care providers, high infant mortality rates, high poverty rates, or a high elderly population.2 In an interview with Dr. Francesca Napolitano and Dr. Sarah Ray (December 2018), pharmacists who both work in FQHCs in the Milwaukee area, they described patients typically seen at FQHCs as ranging in age from 30-80 years and uninsured or enrolled in Medicare or Medicaid. FQHC patients are frequently challenged by multiple comorbidities, complex social and living situations, low health literacy, and come from many different ethnic and racial backgrounds. Clinics and health centers that have the FQHC designation provide primary care to their patients as well as additional services such as behavioral health, chronic disease management, preventive care, specialty care, ancillary services, translation, and social services, regardless of a patient’s ability to pay. An FQHC will operate under a governing board of directors comprised primarily of active patients of the health center. Additionally, it must be a nonprofit or public community-based organization and have an ongoing quality assurance program. By law, FQHCs cannot charge more than a nominal fee to individuals whose incomes are below the Federal Poverty Level (FPL). Additionally, if a patient’s income is 101-200% the FPL, they must be charged using a sliding fee scale with discounts based on family size and income.2,3 As shown in Figure 1, 69% of America’s population was at or below the FPL in 2018, while 22% was at 101%200% the FPL.4 FQHCs are reimbursed through Medicare and Medicaid under a prospective payment system based on

national rates, location of the FQHC, and the services provided. A pharmacyrelated benefit for patients is the 340B Drug Pricing Program, which allows for FQHCs to purchase prescription and nonprescription medications for outpatient use at a reduced cost. In addition to dispensing medications at reduced costs to patients, pharmacists at FQHCs play an important role in providing unique services to enhance patient care.

Pharmacists in FQHCs Pharmacists who practice in FQHCs work directly with other healthcare providers and patients to improve disease state understanding, increase medication adherence, and improve patient quality of life for patients with limited access to the health care system. Pharmacists can bring a unique set of skills and clinical knowledge to FQHCs, which can lead to better disease state management and improved patient outcomes. Francesca Napolitano, PharmD, works with underserved patients at Milwaukee’s Progressive Community Health Centers where she performs medication therapy management (MTM) services for patients, provides patient and provider education, and works to improve quality of care for patients visiting the clinic. The unique services pharmacists can provide within FQHCs play a vital role in improving patient outcomes and disease state management for underserved patients. Pharmacists at FQHCs work under collaborative practice agreements with primary care providers to share the workload with physicians and provide more one-on-one MTM and disease-state care. According www.pswi.org

3 Open to Everyone

underserved communities

Patient-Majority Governing Boards

Regardless of insurance status or ability to pay, and offer sliding fee scale options to low-income patients

At least 51% of every health center's governing board must be made up of patients

FIGURE 1. Socioeconomics of the Populations Served by Health Centers in America in 2018.4 (Reprinted with permission)

Who do Health Centers Serve? In 2018, health centers will serve

over 28 million patients including:

over 13 million people in poverty

8.4 million children

Most Health Center Patients Are Uninsured or Publicly Insured (2017)

1.4 million

homeless patients

nearly 1 million agricultural workers

Most Health Center Patients Are Members of Racial & Ethnic Minority Groups (2017)

over 350,000 veterans

Most Health Center Patients Are Low-Income (2017)

Medicaid 49% Other Public 1% Medicare

82% are Uninsured or Publicly Insured

18%

Private

Above 200% FPL

Uninsured

to Dr. Napolitano, “The providers [at FQHCs] are very over-scheduled and sometimes may only be able to see the patient for 5-10 minutes… By providing medication management for chronic health conditions, pharmacists are able to take control of those health conditions and allow providers to focus on other health problems that arise.” Under collaborative practice agreements, pharmacists can adjust medication regimens, reiterate the importance of adherence to medications and lifestyle adjustments, and provide extensive education on medications and lifestyle modifications for disease states ranging from diabetes, hypertension, hyperlipidemia, and asthma, to tobacco cessation and anticoagulation therapy management. A study done by Rodis J, et al, examined the effects of pharmacist involvement in chronic disease outcomes through MTM services.5 Specifically, this study evaluated the number of patients www.pswi.org

63%

23%

At the Federal Poverty Level 69% (100% FPL) or Below

91% are LowIncome

Racial / Ethnic Minority

meeting A1c and blood pressure goals as a primary objective. According to the study, A1c at goal was defined as less than 9% and blood pressure at goal was defined as less than 140/90 mmHg.5 The results of the study showed that 223 out of the 422 patients with uncontrolled diabetes achieved an A1c less than 9%, which was a 52.84% increase in controlled diabetes.5 For blood pressure, 283 out of the 434 patients with uncontrolled hypertension achieved a blood pressure of less than 140/90 mmHg, accounting for a 65.21% increase in controlled blood pressure.5 These goals were achieved through pharmacy involvement in MTM which allowed for identification of medication-related problems. The different medication-related problem categories that pharmacist(s) identified included indication, efficacy, safety, and compliance.5 An identified limitation within this study is the elevated A1c goal of less than 9%, since the American Diabetes Association’s current

22%

101% FPL to 200% FPL

A1c goal is less than 7%.6 Also, some guidelines suggest that a blood pressure goal of less than 130/80 mmHg or lower is more appropriate for diabetic patients.6,7 The care pharmacists provide at FQHCs is not only beneficial to patients, but it is also professionally rewarding. Sarah Ray, PharmD and Associate Professor of Pharmacy Practice at Concordia University Wisconsin, works at MLK Heritage Health Center with Milwaukee Health Services, Inc. To her, the most rewarding part of working at an FQHC is helping patients, stating: “Some patients come to us very despondent and feel hopeless about their illness. We empower them to manage their disease and reach their goals.” The opportunity for interprofessional collaboration and greater autonomy are also highlights of working at FQHCs; however, the benefits come at a cost. For example, inconsistent funding, scarce resources, and follow-up issues due to patient socioeconomic factors can complicate work July/August 2019

The Journal 31

at FQHCs.

Role for Student Pharmacists

Meeting all the patient and provider needs at FQHCs with limited staffing can be taxing on pharmacists themselves. In order to relieve this added stress on pharmacists, FQHCs may receive grants for student pharmacists and fourth-year students on rotations to help with their daily tasks. These resources not only benefit the FQHCs, but also provide an opportunity for students to be coached on disease state management of complex patients at FQHCs. The addition of students, interns, and clinical pharmacists at clinics will allow for expanded services and greater patient management. Student involvement with staff pharmacists can allow for further research and development of expanded disease state management, improvement of patient education materials, and greater time spent focusing on MTM for patient outcomes. FQHCs provide much needed care and support to patient populations who often struggle to receive adequate healthcare, and pharmacists at FQHCs make vital contributions to improving patient outcomes and positively impacting quality standards. Dr. Napolitano states, “FQHCs are held to quality standards that are related to funding… Pharmacists can directly help with many aspects of care that directly impact those quality measures.” Because of this, she sees room for growth in FQHCs

32 The Journal

July/August 2019

by incorporating more clinical pharmacists and even expanding the specialty-care services provided by pharmacists. Dr. Ray also sees potential for pharmacists to bill for their services provided, and the potential to be involved in clinical committees. Clinical pharmacists at FQHCs fill a unique niche in providing patient care and comprehensive health services to struggling patients, and the benefits and opportunities for future growth make working at FQHCs an attractive and rewarding job opportunity for pharmacists. Alyssa Schaller, Ian Giebel, Killian Mielotz, and Lauren Nevinski are 3rd Year Doctor of Pharmacy Candidates at Concordia University Wisconsin School of Pharmacy in Mequon, WI.

This article has been peer-reviewed. The contribution in reviewing is greatly appreciated!

& Services Administration. https://data.hrsa.gov/ tools/shortage-area/mua-find. Published 2018. Updated February 2019. Accessed February 2019. 3. U.S. Department of Health & Human Services. Federally qualified health centers. Rural Health Information Hub. https://www. ruralhealthinfo.org/topics/federally-qualifiedhealth-centers#populations-served. Published 2002. Updated 2019. Accessed February 2019. 4. National Association of Community Health Centers. America’s Health Centers. National Association of Community Health Centers. http://www.nachc.org/wp-content/ uploads/2018/08/AmericasHealthCenters_ FINAL.pdf. Published August 2018. Updated August 2018. Accessed February 2019. 5. Rodis JL, Sevin A, Awad MH, et al. Improving chronic disease outcomes through medication therapy management in federally qualified health centers. J Prim Care Community Health. 2017;8(4):324-331. 6. American Diabetes Association. Standards of medical care in diabetes – 2019. Diabetes Care. 2019;42(suppl 1):S61-S70. 7. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;000:e1-e98.

References

1. U.S. Department of Health & Human Services. Health Resources & Services Administration. Health Resources & Human Services. https://www.hrsa.gov. Published 2018. Updated 2019. Accessed February 2019. 2. U.S. Department of Health & Human Services. Medically underserved area find. Health Resources

www.pswi.org

Review Article

Behind the Scenes Look at Quality Measurement by Karly Low, PharmD

ngoing focus exists to develop and endorse standardized quality measures that improve patient care and are readily implemented and understood by all parties across the healthcare spectrum, including patients.1 Given the shift in the healthcare landscape from fee-for-service to value, quality measures are continually developed and updated to track and advance patient care. Centers for Medicare and Medicaid Services (CMS) defines quality measures as tools to “quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care”.2 Quality measures are utilized for benchmarking, surveillance, regulation, reimbursement, and as an overall strategy to improve health outcomes. Measure consumers range from providers, payers, employers, and patients. Quality measurement can also be integrated into accrediting functions by organizations such as The Joint Commission, Utilization Review Accreditation Commission (URAC), and the National Committee for Quality Assurance (NCQA). Measure types are classified as structural or systemfocused (e.g. number of nursing care hours per patient day or the adoption of health technology), process (e.g. percentage of patients adhering to mood stabilizers for www.pswi.org

bipolar disorder), or outcome (e.g. rates of hospital readmission or rates of surgical site infections).3 What does this mean for the pharmacy workforce and practice advancement? Given the vast utility of quality measures for performance improvement and value-based payment, understanding and effectively incorporating quality metrics into pharmacy’s workflow is essential to demonstrate the impact of pharmacists and medication management services on patient care outcomes.4 Quantifying opportunities in quality from a pharmacy perspective and directly linking pharmacy interventions to quality measures provides a platform to expand services. Aside from impacting outcomes in a measurable way, pharmacists have the opportunity to engage in the measure development process prior to implementation into their practice setting. The National Strategy for Quality Improvement in Health Care (National Quality Strategy) was published in 2011 on behalf of the U.S. Department of Health and Human Services (HHS). The National Quality Strategy (NQS) mandated by the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act) serves as a guide to improve access, quality, efficiency, and affordability of healthcare for Americans.5 An initial goal of NQS was to align quality measures across HHS programs and with the private sector to improve consistency of data collection

and to increase the use of valid, reliable measures.6 To achieve these goals and guide efforts of the healthcare community, NQS outlines three broad aims which are better care, healthy people/healthy communities, and affordable care (“The Triple Aim”).6 Clinical quality measures addressed within the strategy are divided into the categories of person-centered care, patient safety, healthy living, effective treatment, and care coordination. According to the 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy, through 2013, over 57% of its 191 quality measures showed improvement and 32% demonstrated no change.7 Of these measures, over 80% of person-centered care measures improved and over 60% of effective treatment, healthy living, and patient safety measures improved.7 The CMS value-based programs support the initiatives of NQS across the care continuum. In acute care settings, CMS has an assortment of value-based programs, including Hospital ValueBased Purchasing, Hospital Readmission Reduction, and Hospital Acquired Conditions Reduction program.8 These programs promote value-based care by the use of Medicare payment incentives to providers based on the quality of care provided rather than the quantity of care.8 The Quality Payment Program provides a July/August 2019

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FIGURE 1. Measure Development Process

framework for quality improvement and measurement in outpatient settings (i.e. Medicare Part B) and the Medicare Part C and D Star Ratings measure the quality of medicare advantage and prescription drug plans, respectively. It is through the latter programs that community pharmacies engage in quality measurement. In 2017, due to the numerous reporting programs and available measures, CMS launched the Meaningful Measures Initiative to distinguish and prioritize measures most critical to improving patient outcomes.9 The initiative’s framework outlined 19 meaningful measure areas with an aim to focus efforts on high priority issues, enhance quality impact, and reduce the data reporting burden on providers.

Measurement Development and Endorsement Process The measure development process incorporates testing and continuous quality improvement to achieve valid, reliable, usable, and evidence-based measures.10 Multiple healthcare industry stakeholders serve as measure developers including professional associations, government agencies, and health systems. A measure developer may or may not also be a 34 The Journal

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measure steward. According to CMS, a measure developer creates, edits, and submits measures to a designated measure steward, whereas a measure steward is “an individual or organization that owns a measure and is responsible for maintaining the measure,” specifically when submitting for endorsement.11 Examples of measure stewards include CMS, the Pharmacy Quality Alliance (PQA), the Centers for Disease Control and Prevention (CDC), Physician Consortium for Performance Improvement (PCPI), and NCQA. Various steps comprise the measure development process and can differ depending on the developer. Development steps often include conceptualization, specification, and testing prior to measure endorsement (Figure 1).10,12,13 The process begins with measure conceptualization to identify gaps in current practice or measure landscape and define the intended topic, scope, and outcome. Specification includes proposing data requirements and data sources and involving stakeholders to confirm the metric need. Measure testing is performed to assess the feasibility of measure implementation and ensure the measure accurately meets the anticipated outcomes. Among measure developers, common attributes within the development

process include consensusbuilding initiatives, guidance from expert work groups, and solicitation for public input. Following measure development, measure stewards may submit measures for endorsement. The National Quality Forum (NQF) is a non-profit, nonpartisan, membership-based organization and nationally recognized measure endorser. NQF was created in 1999 following recommendations from the President’s Advisory Commission on Consumer Protection and Quality in Healthcare as an entity dedicated to promoting and measuring healthcare quality. NQF’s role as a multi-stakeholder group convener for measure evaluation and endorsement has been reaffirmed in landmark legislation seeking to improve healthcare quality in the United States such as the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, ACA, and Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015. Measures endorsed by NQF are utilized by public and private entities and are considered the gold standard for healthcare quality measurement.14 Once a measure or set of measures are submitted to NQF, they are evaluated by expert standing committees, followed by consideration by the NQF Consensus Standards Approval Committee (CSAC) for endorsement.15 The standing committees’ evaluation is based on five standardized criteria which are importance of measure and report, scientific acceptability of measure properties, feasibility, usability and use, and related and competing measures.16 NQF’s review process incorporates a variety of participants including clinicians, payers, employers, and patients and integrates a public comment period to gain consensus from all healthcare industry stakeholders prior to endorsement.16

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Quality Measure Selection into Reporting Programs

In addition to quality measure endorsement activities, NQF convenes the Measure Applications Partnership (MAP). The NQF MAP process reviews and recommends measures to HHS for incorporation into federal reporting programs.17 Annually, NQF assembles a variety of stakeholders (e.g. consumers, businesses and purchasers, health plans, clinicians and providers, communities and states, and suppliers) to provide consensus and guidance on measures used in Medicare, Medicaid, CHIP, and the Quality Rating System for the Health Insurance Marketplace.17 MAP reviews the annual list of measures under consideration (“MUC List”), issued by HHS by December 1, to determine whether measures should be recommended for use in CMS programs.18 Additional measures used in reporting programs include those developed by NCQA and the Leapfrog Group. Each of these organizations use quality measures to grade healthcare providers in federal and commercial networks. NCQA is a private, nonprofit membership organization founded in 1990 that develops measures and standards for health plans, providers, and medical practices. NCQA began developing the Healthcare Effectiveness

Data and Information Set (HEDIS) in 1992 as a performance improvement tool. HEDIS measures are composed of over 90 standardized performance measures that are updated annually within the domains of Effectiveness of Care, Access/Availability of Care, Utilization, Risk Adjusted Utilization, and Measures Collected Using Electronic Clinical Data Systems.19 HEDIS results permit evaluation and comparison across health plans and are utilized by both commercial plans and CMS. NCQA also offers accreditation programs, certification programs, physician recognition programs, and health plan report cards.19 The Leapfrog Group is a nonprofit membership organization comprised of public and private health plan purchasers. The Leapfrog group coordinates a voluntary collecting and reporting system of hospital data related to safety and quality. Leapfrog results are utilized by health plans, consumers, and purchasers.20

Opportunities to Influence Quality Measure Development and Selection As the medication experts, pharmacists can and should play an important role in quality measure development, endorsement, and selection. One mechanism to influence measure development is by participating in

public comment periods. Following the submission of measures to NQF for endorsement, and the initial consideration by the respective standing committee, the committee’s draft list of recommendations is made available and NQF’s 16week public comment period opens.21 Comments are submitted to the relevant standing committee for consideration prior to the committee’s recommendation to the CSAC for possible endorsement. NQF also seeks public input on the utilization of NQF-endorsed measures in practice and comments can be submitted at any time through the NQF webpage.22 In addition, CMS routinely solicits public comment on proposed quality measures under development.23 The annual MUC List is available for public comment annually in December just prior to consideration by MAP. Aside from public comment periods, pharmacists are encouraged to participate in measure development teams. For example, PQA, a non-profit membership organization that develops measures related to medication-use, provides opportunities for members to engage and contribute. PQA incorporates a variety of advisory bodies and expert panels throughout the measure development process.24 NQF also accepts nominations for varying individual and organizational opportunities, highlighting another opportunity for

TABLE 1. Opportunities in Measure Development and Endorsement Quality Measure Organization

Opportunities for Involvement

Website

Pharmacy Quality Alliance

Offers multiple opportunities to shape and inform measure development from Stakeholder Advisory Panels to Measure Development Teams.

https://www.pqaalliance.org/participate-inthe-process

Centers for Medicare and Medicaid Services Technical Expert Panels

Organizes a group of stakeholders and experts who contribute direction and thoughtful input to the measure developer.

https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/ MMS/Technical-Expert-Panels.html

National Quality Forum – Public Comment

Measure review and endorsement facilitated by numerous projects from Admissions and Readmissions to Trauma Outcomes. By identifying a project of interest, one can determine measures being considered and member comment opportunities.

http://www.qualityforum.org/projectlisting. aspx

National Quality Forum – Nomination to a Project

Nominations to various projects and initiatives occur on an annual basis. Nominations need to be generated by a NQF member organization (e.g. ASHP, APhA, PQA, or AMCP).

http://www.qualityforum.org/nominations/

National Quality Forum Measure Applications Partnership

Nominations are accepted every spring. Nominations need to be generated by a NQF member organization (e.g. ASHP, APhA, PQA, or AMCP).

https://www.qualityforum.org/map/

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engagement.25 A number of professional associations serve as measure developers and often seek member input in a variety of development stages. Examples of opportunities for involvement in measure development and endorsement are listed in Table 1. Above are just a few examples of measure stewards offering engagement opportunities throughout the measure development process. Numerous measure stewards exist as demonstrated by the NQF Quality Positioning System (QPS), which houses NQF-endorsed measures and lists more than 100 measures stewards. Considering the necessity for public input throughout measure development and selection, several opportunities exist to contribute to this process.

Implementation

Due to the number of quality measures related to medication use, pharmacist interventions can result in a positive impact on measure outcomes and offer opportunities to demonstrate pharmacist’s value to the healthcare system.4,5 As health plans and payers continue developing incentives based on performance, pharmacist interventions can improve quality outcomes and ratings for their pharmacy and the health system. CMS created the Part C and D Star Rating System to improve the health outcomes of Medicare beneficiaries and allow consumers to better compare the quality of health plans. The system assigns an annual rating displayed as 1 (poor) to 5 (excellent) stars and are displayed on the Medicare Plan Finder. Plans receiving a 5-star rating can market year-round and beneficiaries may switch to a 5-star plan outside of the open-enrollment period. Medicare Advantage plans are also incentivized financially for scoring well on star ratings with the CMS Quality Bonus Payment System. A health or drug plan’s Star rating is determined based on quality and performance measures. Measures are developed by entities such as PQA and NCQA. PQA focuses measures on five domains including Adherence, Appropriate Medication Use, Medication Safety, Medication Therapy Management, and Quality Improvement Indicators.26 The 36 The Journal

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2020 Medicare Part D Star Ratings will include 5 measures developed by PQA. These measures relate to medication adherence for diabetes, hypertension, and cholesterol medications, statin use in patients with diabetes, and the rate of completion for Comprehensive Medication Reviews.27 Independent Care Health Plan saw a significant improvement in Star ratings from 2013 to 2014 after the implementation of a medication adherence program.28 Patients prescribed at least one oral antidiabetic, antihypertensive, or statin and flagged as high risk for non-adherence were identified for inclusion. Patients were educated on the importance of adherence and offered monthly scheduled home delivery of their medications. The program resulted in a 2 star improvement for each of the adherence measures related to diabetes and cholesterol and a 1 star improvement for the measure relating to hypertension medications. Positive outcomes such as these can ultimately tie to reimbursement and demonstrate the impact of pharmacy services.28 A recent article by Vanderholm et al highlights innovative strategies for pharmacists to improve the Statin Use in Persons with Diabetes measure adopted by CMS.29 The authors highlight historically limited provider acceptance when pharmacists recommend statin therapy for patients with diabetes that meet guideline-directed criteria for primary prevention atherosclerotic cardiovascular disease. Given the strong safety profile of statins and longtime success of pharmacistmanaged statin therapy via collaborative practice agreements, the authors advocate for pharmacist limited prescriptive authority of statins. In July 2018, Idaho was the first state to authorize this practice for pharmacists in efforts to close the gap in care.29 The immense volume of measures can introduce inconsistency, redundancy, and measurement burden amongst stakeholders. The Institute of Medicine (IOM) aimed to address these issues by convening the Committee on Core Metrics for Better Health at Lower Cost for identification of measures that truly improve patient outcomes. In 2015, the committee published a standard set of

15 measures and recommendations that could be implemented nationally across all sectors.30 The core set of measures were developed as a tool to improve efficiency, reduce unnecessary measurement, align stakeholders with a consistent benchmark, and guide future measurement development efforts.30 In 2014, American Society of HealthSystem Pharmacists (ASHP) convened the Pharmacy Accountability Measures (PAM) Work Group with a similar goal to identify a suite of existing quality measures that most closely demonstrated the value of pharmacist’s care.31 The work group selected measures aligning pharmacy services with improved medication use and improved outcomes to reflect pharmacist accountability towards enhancing patient care. Measures were identified with the intent for universal adoption across pharmacy dashboards and to enable benchmarking consistencies across healthcare organizations. Measures identified by the PAM Work Group were categorized into anticoagulation therapy, glycemic control, antibiotic stewardship, and pain management.31 The PAM Work Group recently released an updated set of recommendations which added behavioral health and cardiovascular control as therapeutic categories, published in the June 15 issue of the American Journal of Health-System Pharmacists.32 Multiple quality measures incorporated into public and private programs can be viewed within searchable databases available online. NQF’s QPS database can be utilized to navigate the organizations endorsed measures and is accessible at www.qualityforum.org/QPS. Measures hosted in QPS can be identified by measure steward, measure type, care setting, clinical condition, and more. Additionally, the CMS Measures Inventory Tool, accessible at, www.cmit.cms.gov/CMIT_public/ ListMeasures, houses measures utilized within federal payment and reporting programs.

Conclusion

Quality measurement provides an opportunity to quantify the value of a pharmacist’s patient care services, expand innovative services, and create a framework for recognition and reimbursement www.pswi.org

opportunities. Therefore, ensuring measures exist that encompass the value of pharmacy services and accurately capture pharmacist contributions towards patient outcomes is necessary.33 As outlined above, consensus development among affected parties is a key component of measure development and application. A wide array of stakeholders are involved throughout this process and pharmacists are well-equipped to contribute at all levels of metric development, application, and maintenance. By understanding the measure development process, the organizations involved, and the opportunities to impact metric use, the pharmacy workforce can leverage their expertise to demonstrate and improve the value of care they provide. Karly Low is the ASHP Executive Fellow in Association Leadership and Management. Acknowledgment: The author would like to acknowledge Anna Legreid Dopp, PharmD, Director, Clinical Guidelines and Quality Improvement, ASHP for her support in writing this article. Disclosures: The authors declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.

References

1. Panzer RJ, Gitomer RS, Greene WH, et al. Increasing demands for quality measurement. JAMA. 2013;310(18):1971-1980. 2. Centers for Medicare and Medicaid Services. Quality Measures. www.cms.gov/ medicare/quality-initiatives-patient-assessmentinstruments/qualitymeasures/index.html. Updated March 5, 2019. Accessed May 10, 2019. 3. Agency for Healthcare Research and Quality. Types of health care quality measures. www.ahrq. gov/talkingquality/measures/types.html. Updated February 2015. Accessed May 10, 2019. 4. Carmichael J, Jassar G, Nguyen PA. Healthcare metrics: where do pharmacists add value? Am J Health Syst Pharm. 2016;73(19):1537-1547. 5. Agency for Healthcare Research and Quality. 2011 Report to congress: national strategy for quality improvement in health care. www.ahrq.gov/ workingforquality/reports/2011-annual-report.html. Updated October 2018. Accessed May 10, 2019. 6. Agency for Healthcare Research and Quality. The national quality strategy: fact sheet. www.ahrq.gov/workingforquality/about/ nqs-fact-sheets/fact-sheet.html. Updated November 2016. Accessed May 10, 2019. 7. 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy. Rockville, MD: www.pswi.org

Agency for Healthcare Research and Quality; April 2016. AHRQ Pub. No. 16-0015. 8. Centers for Medicare and Medicaid Services. CMS value-based programs. www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/ Value-Based-Programs/Value-Based-Programs.html. Updated July 2018. Accessed May 10, 2019. 9. Centers for Medicare and Medicaid Services. Meaningful measures hub. https://www. cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityInitiativesGenInfo/ MMF/General-info-Sub-Page.html. Updated October 2018. Accessed May 14, 2019. 10. Adirim T, Meade K, Mistry K, et al. A new era of quality measurement: the development and application of quality measures. Pediatrics. 2017;139(1):e20163442. 11. Centers for Medicare and Medicaid Services. Blueprint for the CMS Measures Management System. /www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/ MMS/Downloads/Blueprint.pdf. Updated February 2019. Accessed May 10, 2019. 12. Pharmacy Quality Alliance. Developing measures that matter. www.pqaalliance.org/ measure-development. Accessed May 10, 2019. 13. Centers for Medicare and Medicaid Services. Quality measure development and management overview. www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/MMS/ Downloads/Quality-Measure-DevelopmentLifecycle-Overview.pdf. Accessed May 10, 2019. 14. National Quality Forum. NQF’s work in quality measurement. www. qualityforum.org/about_nqf/work_in_quality_ measurement/. Accessed May 10, 2019. 15. National Quality Forum. How endorsement happens. www.qualityforum.org/Measuring_ Performance/ABCs/How_Endorsement_ Happens.aspx. Accessed May 10, 2019. 16. National Quality Forum. Measure evaluation criteria and guidance for evaluating measures for endorsement. www.qualityforum.org/Measuring_ Performance/Submitting_Standards/2018_Measure_ Evaluation_Criteria_and_Guidance.aspx. Updated September 2018. Accessed May 10, 2019. 17. National Quality Forum. Measures applications partnership. www.qualityforum.org/Show_Content. aspx?id=30279. Accessed May 10, 2019. 18. Centers for Medicare and Medicaid Services. Pre-rulemaking (measures under consideration). https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/ MMS/Pre-Rulemaking-MUC.html. Updated April 2018. Accessed May 10, 2019. 19. National Committee for Quality Assurance. HEDIS and performance measurement. www. ncqa.org/hedis/. Accessed May 10, 2019. 20. The Leapfrog Group. How our ratings are used. www.leapfroggroup.org/ratings-reports/howour-ratings-are-used. Accessed May 10, 2019. 21. National Quality Forum. Public commenting with member support. www.qualityforum.org/ Measuring_Performance/Consensus_Development_ Process_s_Principle/Public_Commenting_with_ Member_Support.aspx. Accessed May 14, 2019. 22. National Quality Forum. Measure developer guidebook for submitting measures to NQF.

www.qualityforum.org/Measuring_Performance/ Measure_Developer_Guidebook.aspx. Updated August 2018. Accessed May 14, 2019. 23. Centers for Medicare and Medicaid Services. Public comments. https://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/ MMS/Public-Comments.html. Updated September 2018. Accessed May 14, 2019. 24. Pharmacy Quality Alliance. A unique opportunity to shape and inform measure development. www.pqaalliance.org/participatein-the-process. Accessed May 14, 2019. 25. National Quality Forum. NQF committee nominations. www.qualityforum. org/nominations/. Accessed May 14, 2019. 26. Pharmacy Quality Alliance. PQA measure overview. www.pqaalliance.org/assets/ Measures/2019_PQA_Measure_Overview. pdf. Updated 2019. Accessed May 22, 2019. 27. Pharmacy Quality Alliance. PQA measure use in CMS’ Part D quality programs. www.pqaalliance. org/medicare-part-d. Accessed May 22, 2019. 28. Leslie RS, Tirado B, Patel BV, Rein PJ. Evaluation of an integrated adherence program aimed to increase Medicare Part D star rating measures. J Manag Care Spec Pharm. 2014;20(12):1193-1203. 29. Vanderholm T, Renner HM, Stolpe SF, Adams AJ. An innovative approach to improving the proposed CMS Star Rating “statin use in persons with diabetes.” J Manag Care Spec Pharm. 2018;24(11):1126-1129. 30. Institute of Medicine 2015. Vital signs: core metrics for health and health care progress. Washington, DC: The National Academies Press. https://doi.org/10.17226/19402. 31. Andrawis MA, Carmichael J. A suite of inpatient and outpatient clinical measures for pharmacy accountability: recommendations from the Pharmacy Accountability Measures Work Group. Am J Health Syst Pharm. 2014;71(19):669-678. 32. Andrawis MA, Ellison C, Riddle S, et al. Recommended quality measures for health system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group. Am J Health Syst Pharm. 2019;76(12):871-885. 33. McBane S, Trewet MS, Havican SN, et al. ACCP white paper tenets for developing quality measures for ambulatory clinical pharmacy services. Pharmacotherapy. 2011;31(7):723.

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Original Work

The State of Pharmacist Credentialing and Privileging in Wisconsin by Marshall Johnson, PharmD, Katherine Sencion, PharmD, Melissa M. Shively, PharmD, Dmitry Walker, PharmD, Craig R. Grzendzielewski, PharmD, MBA, BCPS, Kristin Widmer, MS, PharmD, Courtney M. Putz, PharmD, Rida Abbasi, PharmD

he healthcare system is changing at a rapid pace and continues to increase in complexity. In order to meet the needs of patients, some organizations have established a credentialing and privileging process in order to validate pharmacist’s competence and capabilities in providing patient care services. Credentialing and privileging of pharmacists is gaining traction as the profession expands direct patient care and specialized roles amidst provider status and reimbursement for services. Founded in 1999, the Council on Credentialing in Pharmacy (CCP) is a coalition of 10 national pharmacy organizations committed to providing leadership, guidance, public information, and coordination for credentialing and privileging programs relevant to the pharmacy profession. Credentialing is defined by the Council on Credentialing in Pharmacy as the process of granting a credential, or the process by which an organization or institution obtains, verifies, and assesses an individual’s qualifications to provide patient care services.1 This can vary by institution or organization. The concept of credentialing pharmacists is well described by Jordan et al. For example, the pharmacy department credentials its staff by requiring and validating a pharmacist’s pharmacy degree and license.2 Privileging allows for an expanded scope of pharmacist practice that is recognized at the institutional level and formally elevates the pharmacist to that of a non-physician provider. Privileging is defined by the Council on Credentialing in Pharmacy as the process by which a healthcare organization, having reviewed an individual care provider’s credentials and performance and found them satisfactory, authorizes that individual to perform a specific scope of patient care services within 38 The Journal

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Abstract Background: Credentialing and privileging are known mechanisms for establishing pharmacists in direct patient care and specialized roles. The need to understand the current state of credentialing and privileging practices across Wisconsin, as well as identify successes and barriers to implementing these practices, was a primary focus for PSW’s Pharmacy Advancement Leadership Team from 2017-2018. Methods: A descriptive survey was developed and distributed to Wisconsin pharmacy leaders to evaluate the current state of credentialing and privileging of pharmacists across the state. Results were analyzed and discussed with stakeholders at the 2018 PSW Educational Conference. Results: Survey results illustrate that Board of Pharmacy Specialties certification is the most common post-graduate licensure credential, with cost being the most commonly cited barrier to obtaining certification credentials. Survey respondents indicated collaborative practice agreements as the most common method of pharmacist privileging, with lack of structure for required activities reported as the most common barrier. Discussion with subject matter experts at the 2018 PSW Educational Conference confirmed these survey results. Conclusions: Our review of the state of pharmacist credentialing and privileging in Wisconsin demonstrated variable benefits and challenges of utilizing these mechanisms, based on the practice environment and availability of financial resources. Despite this variability, there is opportunity to standardize how pharmacists define clinical competence beyond licensure. Credentialing and privileging not only enables pharmacists to provide advanced clinical services, but also ensures that they are providing the best possible care to patients. It is imperative that this be a focus of pharmacy organizations across the country, as the profession continues to establish means for pharmacists to practice at the top of their license.

that organization.1 Clinical privileges are both facility specific and individual specific. For example, some institutions might elect to have a well-defined list of clinical privileges (e.g., renal dosing adjustment, anticoagulation management), whereas

others may have a general all-encompassing privilege.2 The need to better understand the current state of credentialing and privileging practices across Wisconsin, as well as identify successes and barriers www.pswi.org

became a primary focus of the Pharmacy Advancement Leadership Team (PALT) for the 2017-2018 year. PALT is the Pharmacy Society of Wisconsin (PSW) team comprised of administrative pharmacy residents from across the state of Wisconsin. This group focuses on select priorities, annually, to make contributions to the advancement of pharmacy practice within the state.

Survey Methods

Questionnaire PALT developed a descriptive survey to assess the current practices related to credentialing and privileging of pharmacists throughout the state of Wisconsin. This survey was distributed to Wisconsin pharmacy leaders via PSW email listservs. Survey recipients represented various practice settings such as academic medical centers, non-academic medical centers, community teaching hospitals, critical care access centers, government medical centers, ambulatory care clinics, and community pharmacies. Survey items included: facility demographics, current state of credentialing practices, current state of privileging practices, and the perceived institution culture and potential barriers surrounding pharmacist credentialing and privileging. Questions were structured as multiple choice, multiple selection, yes-no, Likertscale, and open-ended response. Credentialing Survey recipients were asked 8 questions with regard to credentialing practices at their institution. Questions focused on the makeup of credentialed and noncredentialed pharmacists within their practice site, requirements for credentialing that may be in place for particular practice settings, and the potential for financial support to obtain credentials. Because the Board of Pharmaceutical Specialties (BPS) offers widely recognized certifications, questions centered on the frequency of BPS and non-BPS credentials. Privileging The Council on Credentialing in Pharmacy identifies examples of pharmacist privileging such as collaborative practice agreements (CPA) to facilitate team-based patient care.1 Types of privileging options

included in the survey were chosen based on services provided through CPAs at local health systems. Given the variable nature of pharmacist roles throughout practice sites, the survey sought to identify current privileging practices through the state (Figure 1). Common areas of pharmacist privileging surveyed included laboratory monitoring, inclusion of ordering labs per protocol based on disease state/current medication, medication initiation or dosing services, such as warfarin or vancomycin, and medication adjustment services, like renal dose adjustment or route conversion. Other options within the survey included: medication order verification (chemotherapy), transitions of care to include medication reconciliation review and medication history, patient education such as high-risk medication counseling or disease state specific counseling, emergency response services (cardiac arrest, rapid response), prescribing medications, as well as a free text option.

Survey Results

Demographics A total of 52 responses were received after survey distribution from November to December of 2017. Responses were geographically dispersed across the state (Figure 1) and represented a variety of practice settings (Table 1). A majority of respondents, 96%, identified their practice setting as a hospital or health-system, with 13% having a pharmacist presence within an ambulatory care clinic. Eighty-nine percent of respondents were from a practice with 49 or less pharmacist full-time equivalents. Credentialing The results of the survey illustrate that Board of Pharmacy Specialties (BPS) is the most common post-graduate credential. Six percent of respondents indicated that more than 75% of their pharmacists are BPS certified, while 69% indicated less than 25% of pharmacists hold BPS certification. Moreover, most organizations provide financial support for initial certification, but not for recertification. Additionally, non-BPS certifications are less common â&#x20AC;&#x201C; 96% of respondents report having 25% or fewer pharmacists holding these certifications, with the remaining 4%

FIGURE 1. Distribution of Survey Respondents across Wisconsin

TABLE 1. Summary of Survey Respondents across Wisconsin No. of Participants

Facility

Ascension

Advocate Aurora

Bellin Memorial Hospital

Children's Hospital of WI

Cumberland Healthcare

Fort Healthcare

Froedtert Hospitals

Gundersen St. Joseph's Hospitals

HSHS Eastern Wisconsin Division

Madison VA

Mayo Clinic

Memorial Hosp Inc.

Mercyhealth

Southwest Health

SSM Health St. Clare Hospital

St. Croix Regional Medical Center

UW Health

Vernon Memorial Healthcare

Westfields Hospital

TABLE 2. Summary of Responses Regarding Experience with Inter-professional Support Please comment on interprofessional support that has been provided for pharmacists at your institution related to pharmacist credentialing and privileging Responses

n (%)

Physician Champions

9 (75%)

Pharmacy and Therapeutics Delegation Protocols

2 (16%)

Continuing Education sessions sponsored by pharmacy department

reporting more than 75% of pharmacists holding additional certifications. Financial support from employers for non-BPS certification and recertification is not common. Privileging Survey respondents indicated collaborative practice agreements as the most common method of pharmacist privileging, followed by internal departmental privileging. While

1 (8%)

interprofessional support was not found to be a common practice, responses do indicate that the use of physician champions to promote pharmacist credentialing and privileging was successful for 9 institutions (Table 2). Still, 36% of respondents indicated a lack of privileging methods for pharmacists at their institution (Figure 2). Figure 3 summarizes pharmacist privileging areas. Finally, results do not lend to a clear association between the institutionâ&#x20AC;&#x2122;s current

state of pharmacist privileging and the perception of pharmacist level of practice (Figure 4). Barriers The most commonly cited barrier to pharmacists obtaining credentials beyond licensure was cost (24%), followed by lack of educational support (18%) and lack of recognition of advanced credentials by other professions (18%) (Table 3). Some respondents commented on the lack of board exams in their area of practice, as well as the large need for pharmacists to fill more traditional roles in their institution. Regarding pharmacist privileging, the most common barrier is a lack of structure for activities that lead to privileging (22%), followed by lack of reimbursement (15%) (Table 4).

Discussion For sharing and discussion of these survey results at the state level, it was decided to bring this topic to the 2018

FIGURE 2. Pharmacist Privileging Method by Practice Setting Type

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FIGURE 3. Summary of Pharmacist Privileging Areas

PSW Educational Conference for discussion at the Health-System Leadership Forum. Along with survey results, a panel of leaders representing best strong practices across the state were gathered to share their insights on credentialing and privileging. This panel included: Diane Erdman, PharmD, BCPS, CDE, CPPS, BCACP (Ascension Wisconsin), David Hager, PharmD, BCPS (UW Health) and David Grinder, RPh, MS (Monroe Clinic). The panelists were asked a series of questions to help facilitate discussion and

compare the practices at their institutions. Questions regarding pharmacist credentialing explored: (1) processes that other providers (i.e. physicians, nurse practitioners) use to become credentialed, (2) specific credentials that may be required for pharmacists in different practice settings, and (3) handling of pharmacist competencies within respective institutions. Regarding pharmacist privileging, the group discussed: (1) how their respective organizations allow pharmacists to pursue privileging, (2) what activities are associated

with those privileges, (3) what barriers are faced to pursue privileges including differences from physician and advanced practitioner privileging processes and (4) the motivation to pursue privileging for pharmacists. Several current practices and future visions were brought forth in the panel discussion. Discussion surrounding credentialing was robust, however, board certification was considered by the clear majority as a crucial step for practicing at the top of a pharmacistâ&#x20AC;&#x2122;s license. Making

FIGURE 4. Perception of Pharmacist Practice Compared to State of Privileging

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The Journal 41

TABLE 3. Summary of Responses Regarding Barriers for Credentialing What barriers exist within your organization that prevents your pharmacists from obtaining advanced credentials (beyond licensure)? Responses

n (%)

Financial

21 (24%)

Lack of educational support (CE/educational opportunities)

16 (18%)

Recognition of advanced pharmacist credentials among other health care disciplines

16 (18%)

Non-pharmacy leadership support

9 (10%)

Lack of front-line pharmacist interest

13 (15%)

No barriers

5 (6%)

Other

7 (8%)

TABLE 4. Summary of Responses Regarding Barriers for Privileging What barriers exist within your organization that prevents your pharmacists from obtaining privileges? Responses

n (%)

No current structure developed for privileging pharmacist activities

21 (22%)

Inability to bill for services

14 (15%)

Recognition of benefits of pharmacist privileging by other health care disciplines

13 (14%)

Financial

11 (12%)

Lack of educational support (CE/educational opportunities)

8 (9%)

Lack of individuals with advanced credentials to support privileged activities

8 (9%)

Non-pharmacy leadership support

7 (7%)

No barriers

6 (6%)

Inability to complete the medical staff privileging process

4 (4%)

Other

2 (2%)

this a requirement was primarily a concern for large hospitals given the challenges surrounding cost of certification. More diversity in current practices was discovered when discussing privileging pathways. The two primary mechanisms expressed by the panel and members of the audience were delegation protocols (e.g. pharmacists dosing vancomycin) and through the medical staff office. Several pharmacists were challenged with the flexibility or rigidness of pharmacy scope of services defined through these 42â&#x20AC;&#x192; The Journal

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pathways. It was also identified that leaders within health-systems had fewer concerns with reimbursement strategies and were primarily focused on patient safety as well as developing and maintaining competence of their privileged staff. As such, administrative burden associated with competency audits and maintaining privileging pathways was cited as an additional barrier. Panelists and members of the audience voiced the need for additional resources in pharmacist credentialing and privileging

activities, particularly according to the size and type of the hospital (critical access hospitals <25 hospital staffed beds, academic medical centers, small and large community hospitals). The group expressed a vision in which these activities are benchmarked against peer hospitals or medical centers. The ideas discussed during the educational conference align with survey responses to resources needed for achieving pharmacist credentialing and privileging (Table 5). Overall, there is agreement on the benefit of credentialing and privileging within the state of Wisconsin; yet, the process to set up pharmacist privileging individualized to institutional culture is time consuming to manage and requires leadership approval for making rapid change. The interest in optimizing and leveraging the credentialing and privileging processes in order to raise the level of patient care, combined with the barriers that have been encountered by the organizations that have already tied to leverage credentialing and privileging demonstrate a need for standardized materials and benchmarking tools for institutions to implement and monitor the success of their privileging and credentialing efforts. State and national pharmacist professional organizations could positively impact pharmacist practice and patient care by dedicating resources to exploring credentialing and privileging pathways for pharmacist across the continuum of pharmacy practice.

Conclusion This review of the state of pharmacist credentialing and privileging in Wisconsin has demonstrated that the benefits and challenges of utilizing these mechanisms will vary, based on the practice environment and availability of financial resources of the organization. Despite this variability, it is clear that there is an opportunity to provide standard resources to PSW members pursuing credentialing and privileging systems in their institutions. Based on our findings, the pharmacy profession in Wisconsin is interested in pursuing further discussion and exploring the most effective ways to leverage credentialing and privileging to provide advanced clinical services, ensuring quality www.pswi.org

care for patients. It is imperative that further exploration of credentialing and privileging be a concrete focus of pharmacy organizations across the country as the profession continues to establish means for pharmacists to practice at the top of their license. Francisca Ikhumhen, Nichole Gervenak, and Rong Tang are 3rd Year Doctor of Pharmacy Candidates at Concordia University Wisconsin School of Pharmacy in Mequon, WI.

This article has been peer-reviewed. The contribution in reviewing is greatly appreciated!

Acknowledgement: The authors would like to thank Sarah Sorum, PharmD for her efforts in survey distribution and her direction. The authors would also like to thank Tom Woller, Phillip Brummond, Todd Karpinski, Brook DesRivieres, Steve Rough, and Andrew Wilcox for their feedback and support. Disclosure: The authors declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.

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TABLE 5. Summary of Responses Regarding Resources Needed Across the State What resources from state and/or national pharmacy organizations would enable you to advance credentialing/privileging within your organization? Responses

n (%)

Examples of Credentialing and Privileging Best Practices • Example pathway to privileging • Templates from other sites • Sample privileging packet • Training requirements prior to practicing in specialized areas

8 (42%)

Provider Status

7 (37%)

ROI on privileging pharmacists

1 (5%)

Licensing of technicians

1 (5%)

Group membership for access to CE

1 (5%)

None: barriers related to organizational culture

1 (5%)

References

1. Council on Credentialing in Pharmacy. Credentialing and privileging of pharmacists: a resource paper from the Council on Credentialing in Pharmacy. Am J HealthSyst Pharm. 2014;71(21):1891-1900. 2. Jordan TA, Hennenfent JA, Lewin JJ 3rd, Nesbit TW, Weber R. Elevating pharmacists’ scope of practice through a health-system clinical privileging process. Am J HealthSyst Pharm. 2016;73(18):1395-1405.

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The Journal 43

Original Work

Implementation of a Pharmacist-Optimized Education and Transition (POET) Service Advances Pharmacy Practice at a Community Teaching Hospital by Kristen L. Longstreth, PharmD, BCPS, Aubrey Abbas, PharmD, Janelle Rhodes, PharmD, Barry Shick, BSPharm, MSHPA, David J. Gemmel, PhD

ransition of care services led by pharmacists at discharge can decrease 30-day readmission rates, improve patient safety, and reduce costs.1-3 The “PMIT” (pharmacist-provided medication management in interdisciplinary transitions in a community hospital) study demonstrated benefit for patients and financial favorability for the hospital when transitions of care pharmacists were embedded into an interdisciplinary team.1 This study reported an 11% absolute reduction and a 50.2% relative reduction in 30-day readmission rates when transition services are performed by a pharmacist. It concluded that for every dollar spent on a pharmacist’s time, twelve dollars were saved. Zemaitis et al compared pharmacist-led services to a historical control and found a 27% reduction in the 30-day readmission rate.2 Pharmacists made 546 medication interventions in 690 patients over one year. Additionally, a meta-analysis including 17 studies and 21,342 patients found a 67% reduction in adverse drug related events leading to hospital readmissions, a 28% reduction in emergency department (ED) visits, and a 19% reduction in hospital readmissions when comparing pharmacist conducted medication reconciliation to usual care.3 National pharmacy organizations have outlined transition of care best practices and identified opportunities for pharmacist participation.4-5 St. Elizabeth Youngstown Hospital (Youngstown, Ohio) is a member of Bon Secours Mercy Health, one of the largest Catholic health care systems in the 44 The Journal

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Abstract Objective: The purpose of this quality improvement project was to implement and evaluate a pharmacist-led education and transition of care service at discharge. Method: Pharmacists performed the following core activities for patients with a planned discharge to home on one intermediate telemetry unit: reviewing discharge medication reconciliation, correcting the home and discharge medication lists, identifying and resolving drug therapy problems, and providing patient education on medication changes. A retrospective chart review was conducted post-discharge to evaluate the effect of the service during a pilot period (December 2016 to June 2017) on the following: pharmacist identification and correction of medication reconciliation discrepancies and drug therapy problems, hospital readmissions and emergency department visits at 30 days post-discharge, and patient satisfaction scores on the nursing unit. A second follow-up retrospective chart review was later conducted on patients who received the pharmacist-led services from May to October 2018. Results: During the pilot period, pharmacists identified 336 unintentional discrepancies on discharge medication reconciliation and solved 392 drug therapy problems. The 30-day readmission rate was reduced by 26.4% and the 30-day emergency department visitation rate was decreased by 71%. Hospital Consumer Assessment of Healthcare Providers and Systems survey scores improved during the pilot period by an average of 14% for related categories. A follow-up retrospective chart review of the service demonstrated that 30-day readmissions were further reduced by 28.2% over the pilot program period. Conclusions: Implementation of a pharmacist-led transition of care service at discharge is beneficial. The results of the pilot and follow-up study support service expansion to additional hospital nursing units.

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United States. The tertiary care, universityaffiliated, teaching and community hospital is licensed for 550 beds and includes the region’s only Level 1 Trauma Center. The pharmacy department operates 24 hours a day with approximately 30 professional and 25 supporting staff members. In an effort to expand the pharmacy’s ability to assist with transitions of care in the ED, an admission medication reconciliation program was implemented in 2014. In this program, a pharmacy technician and interns work to obtain accurate and complete home medication lists for patients, allowing the ED clinical pharmacist to focus on resolving admission medication reconciliation discrepancies and assisting with direct patient care. During a six-month pilot of the ED program, a total of 19,734 errors were identified and corrected (mean of 3.7 errors per patient). Common errors identified on the admission home medication lists included: missing medications, extra medications that were previously discontinued, and incorrect medication doses. Currently at St. Elizabeth Youngstown Hospital, this program includes one full time pharmacy technician and 11 part time pharmacy interns who provide medication reconciliation assistance seven days a week. The program’s success has allowed for expansion of the model to two additional Bon Secours Mercy Health hospitals within the Youngstown region. After observing the benefits of the pharmacy’s reconciliation service in the ED, it was identified that improvements were needed with transitions of care at the time of patient discharge from an inpatient hospital stay. The discharge medication reconciliation process requires careful coordination, often involving several specialists and/or hospitalists who may not provide care for the patient post-discharge. It was noted by the ED pharmacy medication reconciliation staff and clinical pharmacists rounding on patient care teams that medication reconciliation mistakes made at discharge often carried over into the home medication list for the next admission. A quality improvement project was designed by the pharmacy department to implement and evaluate a discharge pharmacist-led transition of care service. In addition to improving transitions of care and education at discharge, intended

FIGURE 1. POET Service Progress Note Documentation Template Patient Demographics Name*:_______________________________________________________ Medical Record Number*:_______________________________________ Gender*:____________ Age*: __________ Birthdate*:_______________ Primary Care Physician*:_________________________________________ Primary Care Physician phone number*:____________________________ Readmission Risk (%):_________ Patient plans to participate in SEYH Meds to Beds Services (Y/N):______ Pharmacist Review and Summary of Medications Date of last review/update:_______________ Category

Comments

New Medication Started Change in Outpatient Medication (Dosage Form, Route, Dose, or Frequency) Discontinued Outpatient Medication (or on Hold During Admission) Other

Pharmacist Patient Education: Date

Person Educated

Content of Education

Documentation of Pharmacist Interventions and Follow-up Plan: The following Pharmacist Transition of Care Services were completed: □ Reviewed and summarized medication changes □ Entire home medication list was reviewed for accuracy (list sources: ) □ Home medication list was updated or corrected □ Discharge medication list was updated or corrected □ Patient education was provided on new medications □ Patient education was provided on medication changes □ Reviewed the After Visit Summary (AVS) with patient Additional Interventions: □ Inpatient prescriber was contacted and the following pharmacy recommendations were accepted: □ Other interventions: Pharmacist*:_____________________________________________ Date*:_____________ Time spent counseling on medications: _____ minutes *Data is populated automatically by the hospital’s EHR

FIGURE 2. POET Service Medication Reconciliation Documentation Template Medication Reconciliation Unintentional Discrepancy Category Documentation: ____ Admission Medication Reconciliation ____ Discharge Medication Reconciliation Unintentional Discrepancy Category (list number in each category below): Inaccurate Incorrect or Extra Medication: Incorrect Dose: Incorrect Route of Administration: Incorrect Frequency: Incorrect Dosage Form: Other: Incomplete Omitted Medication: Omitted Dose: Omitted Frequency: Other: Total number of discrepancies: The discrepancies identified above were the result of a: ____ Medication history error ____ Reconciliation error ____ Both history and reconciliation errors were made

outcomes of the service included: expanding unit-based pharmacy services to improve pharmacist identification and correction of drug therapy problems, reducing hospital readmissions and ED visits at 30-days post-discharge, and improving Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

The Practice Advancement Program Description In late 2016, a pharmacist-optimized education and transition (POET) service pilot program was developed on an intermediate telemetry unit. This unit was selected for having the highest readmission rate in the hospital. Patients with atrial fibrillation, heart failure, and chronic obstructive pulmonary disease are commonly admitted to this 28-bed nursing unit. Prior to implementation, several 46 The Journal

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of the hospital’s centralized pharmacists participated in a training program led by a clinical pharmacist. Medication reconciliation training materials were developed for the hospital’s electronic health record (EHR) as well as tip sheets on the following: obtaining accurate and complete home medication lists, identifying and correcting medication reconciliation discrepancies, providing patient education using the teach-back approach, and the suggested daily transitions of care workflow. Four pharmacists rotate through one role Monday through Friday to provide education and transition of care services to patients located on the intermediate telemetry unit. The service is currently limited to those patients with a planned discharge to home. The pharmacist begins each day by attending quality flow rounds with the unit’s nursing staff, case manager, and social worker. During the daily quality flow rounds, nurses give a brief summary

of their patients, the discharge plan for each patient, and any barriers to discharge that need addressed by case management or social work. Attending the quality flow rounds in the morning helps the pharmacist to prioritize their chart review of patients during the remainder of the day. The pharmacist works at a designated computer station on the nursing unit, utilizing a patient list in the EHR to determine when a discharge order has been placed and when discharge medication reconciliation has been completed by the provider. Patients with active discharge orders are prioritized first; however, as time allows, the pharmacist also works ahead to review patients who are expected to be discharged in the near future. The pharmacist reviews progress notes, laboratory data, recorded vital signs, the medication administration record (MAR), and relevant microbiology results for each patient. If discharge medication reconciliation has been completed by the discharging provider, it is then reviewed by the pharmacist to identify the potential unintentional discrepancies (i.e., medication changes that cannot be explained by the chart review) and additional drug therapy problems. The pharmacist corrects both the home and discharge medication lists as needed after speaking with patients, providers, and/ or outpatient pharmacies. The pharmacist then reviews the medication portion of the discharge paperwork with the patient and provides education on new medications, medications that were discontinued, and medication doses/frequencies that were changed during hospitalization. The patient is also informed of when doses are due next for each new and continued medication. The pharmacist provides patient education materials when counseling on new medications. These materials are prepared by the pharmacy department and stored on the hospital’s intranet system for printing on the nursing unit as needed. The medication handouts are written in an easy to read, patient-friendly language and focus on the medication purpose and common side effects. Although the focus of the POET service is discharge reconciliation, if time allows, the pharmacist also reviews admission reconciliation for patients who did not have www.pswi.org

a home medication list reviewed by the ED pharmacy medication reconciliation staff and those patients with a home medication list or admission medication reconciliation that is not marked as complete in the EHR. Additional activities involve identifying and overcoming barriers to medication access post-discharge and pharmacist encouragement of medication adherence. This includes assisting with the pharmacy’s growing meds to beds program, a service which offers patients their first fill of discharge medications before leaving the nursing unit. A progress note is documented in the EHR by the pharmacist at the time of initial chart review to outline the medication changes that have occurred during the hospitalization and to record the transition of care activities that were completed by the pharmacist (Figure 1). The progress note can be copied in the EHR and revised throughout hospitalization when new medication information is obtained and/or additional pharmacist activities are completed. Use of a consistent progress note that can be easily updated helps to avoid redundant activities between the pharmacists as they rotate through the role. The pharmacist’s review of medication reconciliation, including the number and type of reconciliation discrepancies identified, is documented as an intervention in the EHR for pharmacy department tracking (Figure 2). The pharmacist also documents medication interventions that were made to solve the reconciliation discrepancies and additional drug therapy problems in the EHR using the following categories: drug discontinuation, drug initiation, drug therapy change, dosage adjustment, and miscellaneous. An intervention is also recorded to document patient education and adverse drug event prevention. In late 2018, the pharmacists also incorporated documentation of intervention categories that contributed to the hospital’s antimicrobial stewardship efforts (e.g., bug-drug mismatch, de-escalation of antimicrobial therapy and dose optimization).

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TABLE 1. Readmission and Emergency Department (ED) Visitation Rate (at 30 days) Outcome*

Nursing Unit Baseline (Historical Data from 2016)

Pilot Program Results (December 2016 to June 2017)

30-day readmission rate

31.8%

23.4% (26.4% relative reduction over baseline)

Readmissions per patient

2.35

1.26 (46.4% relative reduction over baseline)

40.7%

11.8% (71% relative reduction over baseline)

30-day ED visitation

*Patients who expired prior to 30 days post-discharge were excluded from readmission and ED visit outcome analysis. Patients with a scheduled readmission were excluded from readmission outcome analysis.

Program Evaluation (Methods) The pharmacy department received institutional review board approval to evaluate the effects of the POET service during a pilot period (December 2016 to June 2017) and compare the results to the nursing unit’s historical data on the 30-day readmission rate, 30-day ED visit rate, and HCAHPS scores. Patients with a planned discharge to home who received the POET services were included in the pilot study. Patients with a planned discharge to a long-term care facility or skilled nursing unit did not receive the pharmacist-led services and were not included in the pilot study. Patients who left the hospital against medical advice were excluded from analysis. The transition of care activities performed by the pharmacist were discontinued if the patient was transferred to another nursing unit prior to discharge, however these patients were included in the quality improvement analysis and evaluated for program outcomes. To perform the retrospective data collection, all patients who received any transition of care services performed by the pilot pharmacy service were included on a patient list in the EHR that was accessed post-discharge by one clinical pharmacist (program coordinator). The patients were followed for 30 days post-discharge. Data was collected on the following outcomes for the pilot patients: pharmacist identification and correction of medication reconciliation discrepancies, drug therapy problems, adverse drug events (as documented by the pharmacists in the EHR as progress notes and interventions); hospital readmissions at 30 days post-discharge; and ED visits

without admission at 30 days postdischarge. Although one clinical pharmacist performed the retrospective chart review to collect patient data, the discrepancies and drug therapy problems for each patient were identified by one of several POET service pharmacists. Adverse drug events were classified by the one clinical pharmacist as high risk (e.g., low dose of a life-saving drug, omitted order for a life-saving medication) or medium risk (e.g., high risk medication for the elderly, medication continued at discharge that was meant to be stopped, medication that could exacerbate a patient’s condition). Descriptive statistics were used to analyze the patient data.

Program Benefits (Results)

During the pilot period, pharmacists interacted with 497 patients and identified 336 unintentional discrepancies on discharge medication reconciliation. Of these discrepancies, 217 (65%) were due to inaccurate information and 119 (35%) were due to incomplete information. Examples of discrepancies due to inaccurate information include: extra medication(s) and incorrect dose, frequency, route of administration or dosage form. Examples of discrepancies due to incomplete information include: missing medication(s) and missing dose or frequency. Discrepancies at discharge were caused by provider reconciliation errors (51%), history errors due to incomplete or inaccurate home medication information (18%), or a combination of reconciliation and history errors (31%). Discrepancies due to reconciliation errors were commonly attributed to inappropriate therapeutic duplication and accidental July/August 2019

The Journal 47

TABLE 2. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Data

HCAHPS Survey Data

Nursing Unit Baseline (Historical Data from 2016)

Nursing Unit Average During POET Pilot Program (December 2016 to June 2017)

% Increase in Score Over 2016

Overall Rating of the Hospital

62.4

71.2

14.1%

Communication with Nurses

77.6

87.6

12.9%

Help from Hospital Staff

57.5

67.9

18.1%

Explain about Medications

52.2

60.1

15.1%

Discharge Instructions

78.2

85.7

9.6%

Care Transitions

42.1

48.8

15.9%

re-initiation of medications that were held/ stopped at admission due to an adverse event. In addition, the primary provider often completed discharge medication reconciliation prior to reviewing a specialist’s current recommendations and/ or orders for the patient. Pharmacists solved 392 drug therapy problems, including correction of reconciliation discrepancies, with a provider recommendation acceptance rate of 90.6%. Pharmacist recommendations to solve drug therapy problems included: drug discontinuation (32%), drug initiation (20%), therapy change (7%), and dose change (22%). In addition, 19% of the drug therapy problems were solved with miscellaneous recommendations such as monitoring vital signs and obtaining prescriptions for medication refills prior to discharge. After reviewing the drug therapy problems identified, the clinical pharmacist performing data collection classified 126 of the drug therapy problems (32%) as significant enough that an adverse event and/or readmission was probable if appropriate action was not taken. A total of 104 adverse events were prevented (25 high risk events and 79 medium risk events). Examples of prevented adverse events included duplicate anticoagulation therapy, concomitant prescription of sacubitril/valsartan with an ACE inhibitor, and omitted orders to continue antiplatelet agents and antibiotic therapy at discharge. The program resulted in a decreased 30-day readmission rate and a decreased 48 The Journal

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30-day ED visit rate (without admission) when compared to the nursing unit’s historical data from 2016 (Table 1). The number of readmissions per patient was also decreased. The HCAHPS survey scores improved during the pilot period by an average of 14% (when compared to nursing unit historical data from 2016) for the following categories: overall rating of the hospital, communication with nurses, help from hospital staff, communication about medications, discharge instructions, and care transitions (Table 2). It is important to note that the hospital continuously works to improve patient satisfaction and that the increase in HCAHPS scores cannot be attributed solely to the pharmacy-led service. Using data from the pilot study and cost information supplied by the hospital’s finance department, cost savings related to avoided patient admissions and ED visits were estimated at $851,000 per year. In addition, estimated savings from the accepted pharmacist medication interventions and the adverse events prevented (calculated using intervention cost data provided by the EHR) were approximately $1,000,000 per year. The total estimated cost avoidance and cost savings for the program equates to 14 times the pharmacist cost of providing the service. Of note, estimated savings related to pharmacist interventions were substantiated by a hospital finance report showing a decreased length of stay and an operational margin or financial

improvement of $890,000 per 6 months or $1,780,000 per year for patients who were involved in the pilot program. Yearly cost avoidance and cost savings associated with the pharmacist pilot program would range from $1,851,000 to $2,631,000 when using two of the above three savings figures.

Program Follow-up

In 2018, the pharmacy department received institutional review board approval to continue evaluation of the POET service and determine the patient populations that most benefit from pharmacist-led interventions. This followup study collected data on 418 patients who were discharged to home (from May 1 to October 31, 2018) after receiving pharmacy-led transition of care services. Data was collected in a similar manner as the pilot study. In addition, the follow-up study collected data to determine program benefit for the following patient subgroups: age (greater than or equal to 65 years and less than 65 years); the EHR’s readmission risk score (low, medium and high risk); admission diagnosis associated with the Centers for Medicare and Medicaid Services (CMS) readmission penalties (i.e., heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, coronary artery bypass graft surgery, pneumonia, and elective primary total hip and/or knee arthroplasty); payor financial class (commercial, Medicare, Medicaid, self-pay, and other); and patient enrollment in the health system’s population health program. During the follow-up study period, there were 382 discharge medication reconciliation reviews performed and the pharmacists identified 293 unintentional medication reconciliation discrepancies. Of these discrepancies, 173 (59%) were due to inaccurate information and 120 (41%) were due to incomplete information. Pharmacists provided recommendations to solve 470 drug therapy problems, including prevention of 96 adverse events prior to discharge. The POET service demonstrated a continued benefit at reducing the 30-day readmission rate. Readmissions decreased to 16.8% in the follow-up study, which is a 28.2% relative reduction over the pilot program period and a 47.2% relative reduction over the nursing unit’s www.pswi.org

historical baseline prior to POET service implementation. The ED visit rate within 30 days of discharge remained static at 11.7% when compared to the pilot study rate of 11.8%. Data from the follow-up study revealed that the POET service had the largest benefit on reducing readmission for the following patient groups: patients with higher readmission risk scores and patients with an admission diagnosis of heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, or pneumonia. The HCAHPS survey scores on the POET nursing unit were higher when compared to other nursing units in the hospital during the same time period.

Discussion

In addition to the benefits of reducing readmissions and ED visits, increasing patient satisfaction, and improving patient safety; the pharmacy department has received positive feedback on the POET service from patients, nurses, and providers. The program has resulted in further pharmacy decentralization and expansion of clinical pharmacy services to additional patients on a telemetry nursing unit that was previously without a dedicated clinical pharmacist. Pharmacist face-to-face interactions with providers have increased and pharmacists participating in the program at our hospital have experienced increased job satisfaction. The program also now serves as an additional training environment for pharmacy residents and students, who can serve as pharmacist extenders to increase the number of patients reached by the program. Learner feedback has been very positive and expansion to include longitudinal residency activities is under consideration. This may include incorporating a post-discharge follow-up component to the POET service, such as telephone communication after discharge. When implementing a pharmacy-led transition of care and patient education hospital program, the development of a dedicated pharmacist role is necessary to consistently provide the service. The pharmacist scheduled for the service at our hospital is present on the nursing unit for the entire shift. Previously, the pharmacy department’s attempts to provide this service were less successful when the www.pswi.org

model included pulling pharmacists from other roles during slower order verification periods. An organized training program was important for our pharmacists prior to participation and as program changes occurred. In addition to a comprehensive orientation to the hospital’s medication reconciliation process, it is imperative that pharmacists understand and complement the current nursing unit workflow to facilitate effective communication and efficient patient discharge. This includes establishing a process for timely identification of patients who will be discharging to maximize the time available for pharmacist reconciliation review and patient education. Pharmacists were also required to develop a better understanding of case managers’ and social workers’ roles on the nursing unit to collaborate effectively and overcome discharge medication therapy barriers. It is helpful to designate a program coordinator to develop the program structure and provide consistent training to participating pharmacists, residents, and students. The coordinator can also serve as a point person to assist with pharmacist questions and discharge issues that may occur. In the early stages of program implementation, it is important to allow adequate time to collect and analyze outcome measures to support the current program and justify program expansion. The program coordinator can also assist with these activities. During program development, pharmacists may find that it is helpful to discuss the service and outcome measures with hospital administration early in the planning stage to ensure that the most important patient population to target and the most valuable data to collect have been identified and agreed upon. Our initial program targeted all patients on one telemetry nursing unit with a plan to discharge to home. However, based on the results of the follow-up study, we are currently discussing the possibility of program modification to prioritize specific patient groups on several nursing units (such as patients with higher readmission risk scores or a disease state associated with the CMS readmission penalties). One of the largest challenges

experienced by our program is the inability to increase the number of patients that can be reached by the pharmacist each day. This number varies depending on patient complexity and the number of active discharges, but usually ranges from 5 to 10 patients per day. Due to the large number of discrepancies and drug therapy problems at discharge and the time required to identify and resolve these issues, we are currently unable to review additional patients without expanding our service to include additional pharmacists or pharmacist extenders. It can also be challenging to provide the complete discharge transition of care service to each patient and resolve all identified problems prior to discharge, as some patients may leave the nursing unit soon after the discharge order has been placed by the provider. The pharmacists work closely with the nursing staff to attempt to identify discharges prior to the provider placing the discharge order. Whenever possible, patients with a planned discharge to home are also reviewed prior to the actual discharge day so that drug therapy problems can be identified and resolved ahead of time.

Conclusion

With the implementation of the practice advancement of a pharmacist-led education and transition of care services at discharge, an intermediate telemetry nursing unit at our hospital experienced a decrease in both the 30-day readmission rate and ED visit rate, an improvement in nursing unit patient satisfaction scores, and increased pharmacist identification and resolution of medication reconciliation discrepancies and drug therapy problems. The results of the pilot program study and the follow-up study support continuation of the program, program growth with increased pharmacist participation, and expansion to additional hospital nursing units. Kristen Longstreth is a Clinical Pharmacy Specialist and PGY1 Pharmacy Residency Director, Aubrey Abbas is a PGY1 Pharmacy Resident, Janelle Rhodes is a Pharmacist, Barry Shick is the Chief Pharmacy Officer, and David Gemmel is the Director, Department of Research at St. Elizabeth Youngstown Hospital July/August 2019

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in Youngstown, OH. Acknowledgments:The results of the first POET

This article has been peer-reviewed. The contribution in reviewing is greatly appreciated!

pilot program study were presented as a poster at the 2017 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in Orlando, Florida on December 4, 2017 and published online as a Practice Advancement Initiative Case Study on the ASHP website. The study methodology for the follow-up POET study was presented as a poster at the 2018 ASHP Midyear Clinical Meeting in Anaheim, California on December 5, 2018. The following pharmacists are acknowledged for their contribution to the work reported in the manuscript: Jacqueline Frank, Pharm.D., Pharmacist at St. Elizabeth Youngstown Hospital during the pilot study, Danielle Gill, Pharm.D., Pharmacist, St. Elizabeth Youngstown Hospital

Ashley Hunkus, Pharm.D., Pharmacist, St. Elizabeth Youngstown Hospital, Kiley Moore, Pharm.D., Pharmacist, St. Elizabeth Youngstown Hospital, Brian Sabol, Pharm.D., Clinical Pharmacist, St. Elizabeth Youngstown Hospital Disclosures: Kristen Longstreth had full access to all the data in the first pilot study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Aubrey Abbas had full access to all the data in the follow-up study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.

References

1. Rafferty A, Denslow S, Michalets EL. Pharmacist-provided medication management in interdisciplinary transitions in a community hospital (PMIT). Ann Pharmacother. 2016;50(8):649-655. 2. Zemaitis CT, Morris G, Cabie M, et al. Reducing readmission at an academic medical

center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program. Hosp Pharm. 2016;51(6):468-473. 3. Mekonnen AB, McLachlan AJ, Brien JE. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open. 2016;6:e010003. doi: 10.1136/bmjopen-2015-010003. 4. Cassano A. American Society of Health System Pharmacists and American Pharmacists Association. ASHP-APhA Medication Management in Care Transitions Best Practices. https://www. ashp.org/-/media/assets/pharmacy-practice/ resource-centers/quality-improvement/learnabout-quality-improvement-medicationmanagement-care-transitions.ashx. Published Feb 2013. Accessed May 24, 2019. 5. American College of Clinical Pharmacy. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-e337.

PSW News

Expanding Access to Medication-Assisted Treatment: Emergency Department-Initiated Buprenorphine/Naloxone by Choua Thao, PharmD

pioid-related overdoses in the emergency department (ED) have skyrocketed alongside increasing national rates in recent years. Despite growing awareness of the opioid epidemic, there was still a 30% increase in overdoses presenting to the ED in 2017.1 Specifically in the Midwest, this number is alarmingly higher with a 70% increase from 2016 to 2017.1 Because of the astounding jump, the Centers for Disease Control (CDC) has recognized the ED as an opportunity to increase access to substance abuse treatment. Pharmacists are also recognized as “an essential part of the 50 The Journal

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healthcare team.”2 The CDC encourages pharmacist participation in the substance abuse treatment teams. Substance abuse treatment or medication-assisted treatment (MAT) combines pharmacologic treatment and “behavioral therapy” to treat substance abuse disorders.3 It is a multifaceted approach which includes counseling and managing withdrawal symptoms with medications FDA-approved for substance abuse. These include medications such as buprenorphine, naloxone, and methadone. For more information regarding MAT regulations, visit the Substance Abuse and Mental Health Services Administration

(SAMHSA) website or refer to the Code of Federal Regulations.3,4 The PSW MAT FAQ sheet is also available with information summarizing the prescribing and dispensing of these medications. Because EDs are typically the first place someone is taken after an overdose or withdrawal, initial screening for substance abuse here could help identify patients who have substance abuse disorders. Essentially, the ED could be the access point of a public health initiative to start treatment and refer patients to a treatment program. Despite the laws requiring providers to be part of an opioid treatment program or obtain a DEA waiver, MAT can be www.pswi.org

dispensed (not prescribed, however) to patients over a 72-hour period maximum.4 Even with this exception, providers can still be hesitant, and stigma related to MAT medications is still prevalent. Thankfully, pharmacists can help encourage and educate providers. MAT medications not only reduce opioid cravings and withdrawal, but also lack the same high as illicit use.5 Secondly, there is still a fear of diversion. When the rare occasion of buprenorphine/ naloxone diversion happens, it is used for treatment of withdrawal; its intended use.5 As pharmacists know, the naloxone component of buprenorphine/naloxone does not allow for abuse of the medication. Educating, not only patients and providers, but also the public in support of developing public health efforts can be a way to expand access to MAT. Some roles according to the CDC include2: 1. Recognizing and intervening on improper opioid prescribing and dispensing patterns 2. Collaborating with other providers for proper dosing of opioids 3. Monitoring of withdrawal symptoms and side effects 4. Counseling on safe use and proper disposal of opioids 5. Determining appropriate dispensing of naloxone (per Wisconsin standing order) Additionally, there has been some evidence showing possible benefits to starting MAT in the ED. A 2015 randomized clinical trial found success with screening for opioid dependence and initiating MAT in the ED.6 The authors compared a varying combination of screening, referral to treatment, brief intervention, and buprenorphine/naloxone treatment. Those who received initial treatment of buprenorphine/naloxone along with counseling had a better chance of staying in a treatment program at 30 days- 78% engagement versus 37% and 45% in the other groups with no medication. The participants also reported a significant reduction in days of “illicit” opioid use from 5.4 days to 0.9 days (95% CI, 0.5-1.3) as compared to 2.3 (95% CI, 1.7-3.0), and 2.4 days (95%, 1.8-3.0) in the other groups.6 Continuing research is underway. www.pswi.org

Expanding access to Medication-Assisted Treatment (MAT) is one of the research priorities of the 2018 National Institute of Health’s initiative called Helping to End Addiction Long-termSM (HEAL).7 The goal of the initiative is to decrease opioid misuse and establish innovative ways to manage pain with substances that are not addictive. Choua Thao is a Doctor of Pharmacy and MBA graduate of Concordia University Wisconsin School of Pharmacy in Mequon, WI.

References

1. Centers for Disease Control and Prevention. Opioid overdoses treated in emergency departments. https://www.cdc.gov/ vitalsigns/opioid-overdoses/index.html. Updated March 16, 2018. Accessed April 20, 2019. 2. Centers for Disease Control and Prevention. (2016). Pharmacists: on the front lines [Brochure]. https://www.cdc.gov/ drugoverdose/pdf/pharmacists_brochure-a.pdf. 3. Substance Abuse and Mental Health

Services Administration. Medication-assisted treatment (MAT). https://www.samhsa.gov/ medication-assisted-treatment. Updated April 26, 2019. Accessed April 27, 2019. 4. Code of Federal Regulations, Title 21, Chapter II, Part 1306- § 1306.07 5. National Institute on Drug Abuse. NIDA. effective treatments for opioid addiction. https:// www.drugabuse.gov/effective-treatmentsopioid-addiction-0. Updated November 1, 2016. Accessed April 30, 2019. 6. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. 7. National Health Institutes of Health. Heal Initiative Research Plan. https://www.nih.gov/ research-training/medical-research-initiatives/healinitiative/heal-initiative-research-plan. Published April 2018. Updated April 18, 2019. Accessed May 3, 2019.

This handout can be found on the PSW website at: http://www.pswi.org/Portals/17/ Documents/MAT FAQ.pdf

Medication Assisted Treatment (MAT) FAQs What is Medication Assisted Treatment (MAT)? According to Code of Federal Regulations, Title 42, Chapter I, Subchapter A, Part §8.2, Medication Assisted Treatment means “the use of medication in combination with behavioral health services to provide an individualized approach to the treatment of substance use disorder, including opioid use disorder.” What is an X-waiver (DATA 2000 waiver)? Per SAMHSA, waivers allow qualified practitioners to treat opioid dependency with buprenorphine products in a setting other than an opioid treatment program. Which providers can obtain a waiver to prescribe buprenorphine? Per SAMHSA, a physician (MD/DO) with DEA authority to prescribe schedule III, IV, and V medications who meets any ONE of the following qualifies for an x-waiver and may apply for an x-waiver: • Holds a subspecialty board certification in addiction psychiatry from the American Board of Medical Specialties • Holds an addiction certification from the American Society of Addiction Medicine (ASAM) • Holds a subspecialty board certification in addiction medicine from the American Osteopathic Association • Has had at least 8 hours of qualified training provided by ASAM • Confirmed participation as an investigator in a clinical trial leading to the approval of a narcotic CIII-V for detoxification treatment • Have other training or experiences approved by the state medical licensing board (state in which the treatment is provided) or the U.S. Department of Health and Human Services Per SAMHSA, a nurse practitioner or physician’s assistant who meets the following qualifies for an x-waiver and may apply for an x-waiver: • Completion of 24 hours of training provided by: The American Society of Addiction Medicine, American Academy of Addiction Psychiatry, American Medical Association, American Osteopathic Association, American Nurses Credentialing Center, American Psychiatric Association, American Association of Nurse Practitioners, American Academy of Physician Assistants, or any other organization that the Secretary of Health and Human Services determines is appropriate. 2017 Wisconsin Act 262 clarifies that qualified nurse practitioners and physician’s assistants may obtain a waiver, regardless of their supervising physician’s waiver status.

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www.pswi.org

Meeting Recap

Providing Perspective on the Future of Pharmacy: A Recap of the PSW Educational Conference by Nicholas Friedlander, 2020 PharmD Candidate

arlier this year the Pharmacy Society of Wisconsin (PSW) returned to the Monona Terrace Convention Center in downtown Madison for the annual Educational Conference. Practicing pharmacists, technicians, residents, and student pharmacists from around the state gathered to collectively review and reflect on the current state of the pharmacy profession and explore future directions. In line with the collaborative spirit of the profession, the conference atmosphere encouraged attendees to gain valuable insights both from expert speakers and from one another. This year’s Educational Conference ran concurrently with the Wisconsin Pharmacy Residency Conference (WPRC) and took place over an eventful two days, beginning on Tuesday, April 9th. The Pharm to

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Tables charitable organization returned to the Educational Conference for the third consecutive year for another successful food drive. Food and monetary donations from attendees have already helped to combat hunger in communities across the state. The day’s first general session, led by Thomas Thibodeau, a professor and director at Viterbo University, focused on the benefits of approaching leadership with a servant mentality and the value of maintaining a positive mindset in the workplace. Professor Thibodeau used vibrant and illustrative personal stories to underscore the importance of pharmacy staff finding purpose in their everyday work and striving to support the greater good through their efforts. It was a rousing call to action for attendees and an excellent, energizing way to start the conference. The second general session focused

on the fascinating topic of precision medicine and the emerging role of pharmacogenomics in clinical practice. The perceived impact of genetics on medication safety and efficacy has progressed from theoretical to practical in recent years and pharmacogenomic testing is now frequently used in clinical settings across the country. Two experts on the topic, Dr. Ulrich Broeckel from the Medical College of Wisconsin and Dr. Cyrine-Eliana Haidar from St. Jude Children’s Research Hospital, provided key insights on some of the critical interactions between genes and drugs, many of which are utilized across a variety of patient populations and in a range of clinical settings. Later in the day the Educational Conference hosted its largest poster session to date. Over 100 posters were presented at this year’s session covering topics

www.pswi.org

ranging from didactic pharmacy education strategies to multiple sclerosis medication adherence programs. In addition to serving as an educational opportunity for attendees, the poster session provided pharmacy students, residents, and practicing pharmacists with a unique opportunity to share their work with others and sharpen their presentation skills. Tuesday’s afternoon sessions focused on a wide variety of topics and were split across several areas of the conference center, allowing attendees to choose the sessions that applied most directly to their practice or sparked their interest the most. Sessions offered included talks from residents, professors, and practicing pharmacists on electronic health record considerations for opioid stewardship, expanding technician roles, and the role of improvisation in team-based healthcare, among other subjects. Afternoon WPRC sessions focused on a host of practical and specialized topics ranging from statin prescribing in HIV patients, to proton pump inhibitor deprescribing in primary care settings. The second morning of the conference featured an educational session on cannabis-derived products known as cannabinoids, the annual Christian Pharmacists Fellowship International breakfast, and several other breakfast opportunities for conference attendees to open the day. The day’s first general session focused on the medical and legal issues associated with both cannabis and cannabinoids, including cannabidiol and tetrahydrocannabinol (commonly known as CBD and THC, respectively). Recent legislative changes and a massive upswing in the popularity of cannabinoid research, as well as consumer products, underscore the importance of the issue for pharmacists and other health professionals. A panel of three specialists, Doug Englebert RPh, MBA, Dr. Cecilia Hillard, and Dr. Annabelle Manalo, represented a range of professional backgrounds, and offered unique perspectives on the issue and future directions. The session provided invaluable information on a topic of increasing significance. The second general session detailed Wisconsin Pharmacy Quality Collaborative (WPQC) efforts to enhance pharmacist www.pswi.org

Above: Curtis A Johnson Award recipeint, Sara Greisbach (left) with JPSW Pharmacist Editor, Amanda Margolis (right).

roles in a hypertension management pilot program. Alan Lukazewski RPh, Dr. Tim Bartholow, and Dr. Kari Trapskin provided a detailed overview of the pilot program which utilized WPQC-certified pharmacists to make adherence-related interventions for at-risk patients with hypertension. Results of the pilot program, which included reduced patient perceived barriers to adherence and an impressive degree of patient engagement, served to highlight the value of pharmacists in providing direct patient care. Later in the morning, Matt Mabie RPh, president of PSW, delivered a briefing to members outlining recent progress within PSW, as well as some of the current challenges facing the organization. He discussed the critical role that PSW has played in advocating for legislation that enhances the role of pharmacy in healthcare and enables professionals to practice at the top of their license. He spoke at length about PSW initiatives that are advancing the profession of pharmacy across the state and ensured members that the organization is strong and continues to move in a positive direction. As with the first day of the conference, Wednesday’s afternoon sessions featured a variety of PSW and WPRC events that ran in parallel across the conference center. The wide variety of sessions focused on a remarkably diverse array of topics, enabling attendees to customize their experience. The afternoon included talks on pharmacist

roles in human papillomavirus (HPV) vaccination, implementation of wellness services in community pharmacy settings, and preceptor strategies to improve interprofessional education, among many others. Thanks to the presenters, organizers, support staff, and attendees, this year’s Educational Conference was a resounding success. With more than 80 scheduled events over a two-day period, the conference offered attendees access to an incredibly vast array of meaningful professional and educational content from which to choose. The conference was a truly unique opportunity for pharmacy technicians, students, residents, and professionals from all pharmacy backgrounds to discuss recent advances in the field of pharmacy, network with one another, and, in keeping with the spirit of the Educational Conference, learn from each other. Nicholas Friedlander is a 4th Year Doctor of Pharmacy Candidate at the University of Wisconsin-Madison School of Pharmacy in Madison, WI.

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Pharmacy Reflections

Advancing Ambulatory Care Pharmacy Practice Across Michigan Through Collaboration with a Payer by Nicole G. Rockey, PharmD, BCACP, Hae Mi Choe, PharmD, Julie K. Geyer, David Bye II

ealth care delivery in the United States is changing in an effort to reduce health care costs, improve quality, and enhance the patient experience. One strategy being adopted by the primary care community to address cost, quality, and access to care is providing multidisciplinary, team-based care. Ambulatory care clinical pharmacists can be valuable contributors to these patient-care teams. Michigan Medicine, the large healthcare system operated by the University of Michigan, has helped demonstrate the value of having clinical pharmacists on the patient care team with clinical pharmacists having been successfully integrated into its primary care clinics for over 9 years. At Michigan Medicine, 11 clinical pharmacists (equal to 5.2 full-time equivalents) are embedded into 14 primary care clinics as integral members of the patient care team. These clinical pharmacists provide disease management services for patients with diabetes, hypertension, and hyperlipidemia and comprehensive medication reviews for patients with medication-related problems. They utilize access to the electronic medical record and disease registries, operate under a collaborative practice agreement, and communicate with providers to address gaps in care, improve medication adherence, and help patients achieve treatment goals. The Michigan Medicine model of embedding clinical pharmacists into primary care clinics has received several awards including the Innovative Pharmacy Practice Award from the Michigan Pharmacists Association and the Best Practice Award from the American Society of Health-System Pharmacists in 2011 as well as being profiled as 1 of 5 best integrated pharmacy practice models in the 56 The Journal

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nation by The Advisory Board Company in 2014. Interest in replicating this successful practice model began to build.

Collaboration Between a Payer and a Physician Organization With the utilization of Healthcare Effectiveness Data and Information Set (HEDIS), Medicare star ratings, and the Marketplace Quality Rating System, payers and health care providers are becoming more accountable for providing quality health care services, resulting in the change from fee-for-service to valuebased payment.1-3 Payers and physician organizations (POs) striving to improve quality measures at reduced costs sets the stage for more collaboration between the two. In 2015, as part of their effort to collaborate with physicians and hospitals that are transforming the delivery and quality of care, Blue Cross Blue Shield of Michigan’s (BCBSM) Value Partnerships Program partnered with Michigan Medicine to implement Michigan Pharmacists Transforming Care and Quality (MPTCQ). The primary goal of MPTCQ is to improve patient care and outcomes through integration of clinical pharmacists in direct patient care across the state of Michigan. With this integration, improvements in several quality measures are expected. Michigan Medicine was selected to serve as a coordinating center for MPTCQ. The MPTCQ Coordinating Center helps embed clinical pharmacists in primary care sites across the state by providing support and training for both the clinical pharmacists and the PO leadership at the selected POs. In this partnership with BCBSM, MPTCQ drives the clinical content, operations, pharmacist and PO

leadership training, and data collection and evaluation while BCBSM provides financial support and guidance on the collaborative process initiative.

The MPTCQ Process

Starting in 2015, MPTCQ recruited POs from across the state to participate in the 2-year MPTCQ program; eligibility criteria included a readiness assessment and demonstration of adequate PO and practice site infrastructure to support this initiative. In collaboration with MPTCQ, these POs agreed to hire one clinical pharmacist as the Pharmacy Transformation Champion (PTC), identify two to three practice sites that had at least two full-time practicing physicians ready to work with the PTC in this team-based approach to patient care, and to meet the PO and PTC expectations listed in Table 1. During the 2 years they participated in the program, the POs receive funding from BCBSM to help offset a portion of the cost of employing the PTC. This funding is meant to incentivize POs to invest in building this practice model with the goal of being sustainable at the end of the program. BCBSM also fully funds the MPTCQ Coordinating Center which provides training and mentorship to the PTC and the PO leadership to help integrate the PTC into primary care clinics and plan for sustainability and program expansion. The Coordinating Center sets monthly patient encounter goals for the PTC to help them work their way up to seeing at least 8 patients per day. The Coordinating Center provides a variety of training including a 2-day intensive clinical and administrative “boot camp”, clinical webinars, and a website with a toolkit and best practice resources. They also have regular contact with the POs through the www.pswi.org

program to provide ongoing support. The Coordinating Center schedules telephone calls between the PTC and the MPTCQ process improvement pharmacist every 2 to 4 weeks covering both clinical and administrative/practice building issues, calls between the MPTCQ program director and PO leadership every 1 to 2 months, quarterly collaborative meetings with all participants, and site visits. The Coordinating Center also analyzes the data collected by PTCs and distributes the data back to the POs on a monthly basis so that they can track their progress and compare their successes to peers.

Impacting Ambulatory Care Pharmacy Practice Across Michigan Twenty-one Michigan POs have participated in the MPTCQ program. Together with these 21 POs, MPTCQ has supported 30 pharmacists practicing in 52 clinic sites across the state. From late 2015 through 2017, MPTCQ pharmacists had 23,701 patient encounters with 7,685 unique patients. In addition to the original PTCs, MPTCQ PO participants have hired 10 additional pharmacists to be embedded into other primary care clinics within their organizations. Both the PTCs and the additional pharmacists hired by the POs are utilizing their collaborative practice agreements to make therapeutic interventions assisting patients to achieve their treatment goals. To help demonstrate the effectiveness of the MPTCQ program, PTCs are collecting quality and descriptive data on their patient encounters, and MPTCQ is collecting patient and PO leadership satisfaction data and plans to report on program outcomes in future publications. This collaboration between a payer and a PO to help spread a pharmacy practice model is unique. The model has made integrating clinical pharmacists into primary care teams across Michigan more feasible and sustainable for POs that previously did not have pharmacists practicing in the primary care setting. MPTCQ is transforming the role of the clinical pharmacist and advancing pharmacy practice in the state of Michigan.

www.pswi.org

Nicole Rockey is the Process Improvement Pharmacist, Hae Mi Choe is the Program Director, and Julie Geyer is the Program Manager at MPTCQ in Ann Arbor, MI. David Bye is the Senior Health Care Analyst for Value Partnerships at Blue Cross Blue Shield of Michigan in Detroit, MI. Disclosure: The authors declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.

References

1. National Committee for Quality Assurance. Hedis measures and technical resources. https://www. ncqa.org/hedis/measures/. Accessed April 2019. 2. Medicare.gov. Star ratings. https://www. medicare.gov/find-a-plan/staticpages/rating/ planrating-help.aspx. Accessed April 2019. 3. Centers for Medicare and Medicaid Services. Quality rating system (QRS). https://www.cms.gov/ Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityInitiativesGenInfo/ACA-MQI/ Quality-Rating-System/About-the-QRS.html. Updated December 27, 2018. Accessed April 2019.

TABLE 1. Program Expectations Expectations – Physician Organization and Practice Unit Participation To successfully participate in this project, physician organization and practice units will be expected to do the following: 1. Sign Participant Agreement 2. Identify/hire Pharmacy Transformation Champion 3. Identify practice sites and introduce program to practice site leadership and staff 4. Collaborate with Pharmacist Transformation Champion to provide disease management and comprehensive medication review services established by the MPTCQ Coordinating Center 5. Assist in establishing collaborative practice agreement with Pharmacist Transformation Champion and physicians 6. Provide private office space/work area for Pharmacist Transformation Champion to conduct private one-on-one clinical appointments with patients 7. Provide support for scheduling appointments for Pharmacist Transformation Champion 8. Provide electronic access to the full medical record to Pharmacist Transformation Champion 9. Attend collaborative-wide meetings 10. Thoroughly and accurately collect data for all patients, regardless of insurance provider 11. Respond to queries from the Coordinating Center in a timely manner 12. Contribute data and information that could be used in peer-reviewed publications 13. Collaborate with practice sites to devise an improvement plan based on data collected by the Coordinating Center 14. As the program matures and the organization finds value in the pharmacist’s contribution, we expect each physician organization will fund additional clinical pharmacists, thus expanding the clinical program across their practice sites

Expectations – Pharmacy Transformation Champion To successfully participate in this program, Pharmacy Transformation Champion will be expected to do the following: 1. Provide disease management and comprehensive medication review services established by the MPTCQ Coordinating Center 2. Dedicate four days per week at the practice sites delivering direct patient care and one day per week for program planning and development 3. Collect patient data, as directed by Coordinating Center 4. Participate in regular conference calls with the Coordinating Center for mentoring, training and follow-up 5. Participate in Boot Camp in an intensive process and administrative training in the fall (2 days) 6. Complete care management training through a CMRC delivered or approved program 7. Attend quarterly meetings to learn of program updates, share best practices, discuss program successes and challenges, review quality data and outcomes, etc 8. Participate in site visits by the Coordinating Center 9. Collaborate with other Pharmacy Transformation Champions MPTCQ = Michigan Pharmacists Transforming Care and Quality, CMRC = Care Management Resource Center

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Pharmacy Reflections

Ambulatory Care Pharmacy Practice Advancement: Diffusing Strong Practices by Ellina Seckel, Edward Portillo, Molly Lehmann, Andrew Wilcox, Ryan Vega

Ambulatory Care Pharmacy Practice Advancement History of Innovation for Ambulatory Care Pharmacy Practice Nationally within the Department of Veterans Affairs (VA), pharmacists have been practicing as advanced practice providers for nearly 50 years. Locally at the William S. Middleton Veterans Affairs Hospital, there is a history of influential pharmacy practice leaders that have paved the way for the advanced pharmacy practice model that exists today. In 1974, ambulatory care pharmacy practice was in its infancy at the Madison VA, with pioneer Cab Bond leading the way. At that time, Cab had initiated an ambulatory care practice in the Rheumatology Clinic. To paint a picture of health care at that time, common treatment for rheumatologic diseases included titrating aspirin until the patient’s ears started to ring, then decreasing to the highest tolerable dose. Then, in 1975, Art Schuna was hired at the Madison VA and was tasked with developing his own role. As Cab began working in psychiatry clinics administering prolixin (injectable fluphenazine antipsychotic) and developing a lithium monitoring service, Art focused his energies on furthering pharmacy practice within Rheumatology Clinic. As luck would have it, Art worked alongside a medical resident who wanted to become a rheumatologist, Alan Bridges. Dr. Bridges would later become Madison VA’s Chief of Staff and a prominent supporter of advancing ambulatory care pharmacy practice. His experiences working with Art undoubtedly influenced his view of what pharmacist providers could do. In 1983, seeing another opportunity to advance practice, Art started one of the first ambulatory care pharmacy residency programs which has been a critical platform 58 The Journal

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FIGURE 1. Roles and Responsibilities of Primary Care Pharmacist Providers • Conduct patient appointments to provide individualized medication treatment and follow-up • Assess for medication effectiveness and adverse drug reactions and prescribe (initiate, change, continue, or discontinue) medications as needed to optimize treatment outcomes • Perform lab monitoring as clinically indicated • Use shared decision-making to promote collaborative, evidence-based, patient-centered care • Refer to other services as appropriate such as specialty clinics and mental health services • Participate in or lead group/shared medical appointments • Utilize electronic consults to advise other providers on medication questions • Perform proactive population management to identify high-risk patients for intervention • Participate in team meetings for complex or high-risk case reviews and recommendations • Provide education for students, residents, and other team members to optimize health outcomes • Serve as a subject matter expert for the facility and pharmacy in conjunction with the interdisciplinary team, including involvement with process improvement committees and quality management • Provide guidance to primary care providers on prescribing within the formulary, thereby serving as a liaison between primary care providers and the formulary team

for pharmacy practice advancement at the Madison VA. Current Pharmacist Provider Role in Primary Care- Madison VA Practice models have evolved to present day ambulatory care pharmacists holding a scope of practice. The scope of practice includes prescriptive authority that allows for a high level of autonomy in post diagnostic comprehensive medication management. This high level of autonomy creates a model where pharmacists, serving as a healthcare provider, care for and

partner with patients on their health care. As of May 2018, the VA employed 4,111 pharmacist providers who hold a scope of practice.1 At the Madison VA, primary care pharmacist providers work collaboratively with primary care teams consisting of a primary care provider (MD, DO, or NP), RN care manager, licensed practical nurse, and scheduler. Other team members include social workers, dieticians, and mental health professionals. Primary care pharmacist providers care for patients through a variety of modalities. www.pswi.org

Patients receive care through face to face, telephone, video to home, and group or shared medical appointments, as well as through chart reviews and secure electronic messaging with patients (e.g., secure email). Use of telehealth modalities is particularly helpful in increasing access to care for rural patients. Primary care pharmacist providers have scheduled appointments for each of these modalities, targeting 80% direct patient care with a minimum of 50 scheduled appointment slots per week. When seeing patients, primary care pharmacist providers focus on medication appropriateness, effectiveness, safety, adherence, and develop individualized treatment plans (Figure 1). Treatment by pharmacist providers includes initiation, modification and discontinuation of medications for conditions including, but not limited to, diabetes, hypertension, dyslipidemia, hypothyroidism, vitamin deficiencies, heart failure, chronic obstructive pulmonary disease, pain, anemia, asthma, gout, benign prostatic hyperplasia, restless legs syndrome, neuropathy, osteoarthritis, osteoporosis, hepatitis C, and post-bariatric surgery management. Care plans also include placing needed referrals, assessment of diet, lifestyle, and patient goals.

Diffusing Best Practices

National VA Diffusion of Best Practices The Department of Veterans Affairs is the nation’s largest integrated health system, serving nine million Veterans through 172 medical centers and 1,069 outpatient clinics. In such a large health system with medical centers across the country, pockets of innovation exist which lead to novel models of care delivery, services, and promising practices. Over the past decade alone, the Department of Veterans Affairs has been a leader in discovery for techniques treating traumatic brain injury, heart bypass surgery techniques, and data analytics through launching one of the world’s largest databases for review of health and genetic information. Opportunities exist to spread this innovation not only within the VA, but also in private sector health systems. However, the process of disseminating and implementing best practices within healthcare is lengthy as it takes an average www.pswi.org

TABLE 1. VHA Diffusion of Excellence Shark Tank Competition Overview Elimination Round

Process Requirements

Application submission by team

Application review by evaluators/semi-finalists are chosen

Application review by VHA leaders/finalists are chosen

Finalists pitch best practices at online-based national competition

Gold Status Practices are chosen to be implemented at other VA facilities

of 10 years to effectively spread programs and services. The VA serves as a national leader not only through design and implementation of large-scale initiatives, but through employee-driven grass-roots efforts led by individuals from all areas of the VA Organizational Chart. There is a common saying: “when you’ve seen one VA, you’ve seen one VA.” This saying references the idea that while the VA is an interconnected single health-care system, there are variabilities in the way singular VAs function. While this could be seen as creating inconsistency, it also allows for innovation and more autonomy at local VAs. The Department of Veterans Affairs launched the VA Diffusion of Excellence Program in 2015 as a national initiative to identify, disseminate, and sustain employeedriven grass-roots best practices across the VA. The rapid diffusion of best practices over a six-month period is unique to VA’s Diffusion of Excellence Program. The Diffusion of Excellence initiative supports grass-roots employees’ best practice diffusion efforts through the provision of resources such as research experts (VA Quality Enhancement Research Initiative), project managers (Atlas research and project management), and front-line employees serving as Diffusion Fellows. This helps to cultivate an innovation ecosystem within the VHA with focus on improving the health care experience of our nation’s Veterans. A crucial part of the success of the Diffusion of Excellence initiative is the Shark Tank competition. The Shark Tank competition is modeled after the famous American business-related television

series and is the mechanism for selecting nationally recognized best practices within the VA. Best practices selected as “winners” of the Shark Tank competition are recognized as Gold Status Practices by the Diffusion of Excellence program. The first ever Shark Tank competition occurred in 2015 and subsequently has had 4 cohorts of competition between 2015 and 2018. The newest cohort is currently submitting applications for their best practices, with the Shark Tank competition to occur before the end of 2019. Since its inception in 2015, this national competition has led to expansion of 36 promising practices to over 400 locations across VHA. Within the pharmacy department at the Madison VA, team members have submitted their best practices to the national competition and, through a series of elimination rounds (Table 1), two best practices have been recognized as Gold Status Practices from over 1,000 practices submitted nationally over the four cohorts. Given this success, the initiative has attracted national attention outside of the VA including USA Today2, Kaiser Health News3, Gray DC News4, and Wisconsin Health News5.

Madison VA Diffusion of Excellence Gold Status Practices Gold Status Practice 2015: Increasing Access to Primary Care Using Pharmacist Providers Through a multi-modal approach, a team at the Madison VA positioned pharmacist providers to offload 27% of July/August 2019

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TABLE 2. VHA Diffusion of Excellence Shark Tank Competition Overview Gold Status Practice

Service/Practice Description

Increasing Access to Primary Care using Pharmacist Providers

Shifting post-diagnostic chronic disease appointments from primary care providers to pharmacist providers and conducting new patient intake calls

Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE)

Interprofessional transitions of care service for postdiagnostic COPD disease state management

Pharmacist Role

Outcomes

Implementation Sites

Provider conducting chronic disease management appointments and new patient calls

• Offloaded 27% of primary care provider appointments, increased referrals to pharmacist providers by 13.8% • Improved team satisfaction • Saved primary care providers 20 minutes on average for new patients

Madison VA El Paso VA Kansas City VA Dublin VA >20 other VAs nationally Selected for national implementation

Provider conducting COPD disease state management based on current GOLD guidelines

• Increased primary care access within 30 days of discharge by 38.6% • Decreased hospital and emergency department readmission rates • Control group readmission rate 18.4% • Intervention group readmission rate 0%

Madison VA Fayetteville VA Selected for national implementation

COPD = Chronic Obstructive Pulmonary Disease; CARE = Coordinated Access to Reduce Exacerbations

primary care provider appointments, increase referrals, improve team satisfaction, and save primary care providers 20 minutes on average for new patients, which was able to be reallocated for other necessary patient care needs. The practice has grown and evolved since being designated a Gold Status Practice in 2015 (Table 2). The Clinical Pharmacy Practice Office (CPPO) has been incredibly supportive and has partnered closely with the Madison VA and Diffusion of Excellence program in order to spread this strong practice nationwide. Spread of the practice has resulted in increased access, patient satisfaction, team satisfaction, improved clinical outcomes, and improved performance measures. In reference to the care a Veteran received from a pharmacist provider: “Just wanted to let you know when the opportunity arises, how much I like and appreciate the care I've been getting from the VA-- You guys do good work here, completely counter to anything in the national press, and I'm grateful to be a patient. Thanks.” Chief of primary care response to true team integration of pharmacist providers: “I can't believe you guys. The nurses love you. The PCPs do too. You guys are really lifting people’s spirits and making them happy to be part of the team” Gold Status Practice 2018: COPD CARE Chronic Obstructive Pulmonary Disease (COPD) occurs within the 60 The Journal

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United States Veteran population at a threefold increase compared to the civilian population. At the Madison VA specifically, COPD is the second leading cause of hospital readmissions within 30 days postdischarge. In 2015, an interprofessional training program, COPD CARE (COPD Coordinated Access to Reduce Exacerbations), was piloted in one Madison VA primary care clinic for 19 patients with the intent to provide baseline education for interprofessional healthcare providers and spread an effective COPD transitions of care service (Table 2). As a result of the COPD CARE service pilot, Veteran primary care access within 30 days following discharge increased by 38.6% in comparison to standard of care.6 Additionally, hospital and emergency department readmission rates due to COPD exacerbations were reduced by 18.4% in comparison to standard of care. The service engages Veterans in interprofessional care with pharmacist providers and nurse care managers during this transitionary period and employs evidence-based best practices including medication optimization (via COPD GOLD guidelines), inhaler technique review, and inhaler adherence assessment to aid disease state management.6 The service also provides Veterans with an opportunity to learn more about their disease, develop a COPD action plan for acute exacerbation treatment in an outpatient setting, and

be referred to supportive services such as pulmonary rehabilitation and tobacco treatment clinic for additional coexisting disease state management. The service has grown and evolved since being piloted in 2015 and was recognized as a Gold Status Practice in 2018. Currently, the COPD CARE service is in the early stages of national diffusion, and training of interprofessional team members is occurring at both the Madison and Fayetteville VAs.

Creating a Platform for Practice Advancement

Secret Sauce at the Madison VA: Practice advancement locally occurs due to a variety of factors, many of which are interconnected. Though there are too many to describe fully, the below highlights a few critical facets including high caliber/ large training programs, practice model optimization, executive leadership support, and promoting positive workplace culture/ hiring the right team members. High Caliber/Large Training Programs: One that contributes significantly to practice advancement factor is the large array of training programs which has grown from 1 resident in 1982 to now 17 residents (10 ambulatory care [PGY1 and PGY2], 1 general practice, 2 health-system pharmacy administration, 3 PGY2 mental health, and 1 PGY2 pain/palliative care), www.pswi.org

3 VALOR student interns per year, and 65 rotation students per year. As of 2019, a total of 200 pharmacists have completed residency training at the Madison VA over 37 years. These learners are critical to performing background assessments, research, project implementation (large and small scoped), and overall significantly increasing the bandwidth for practice advancement projects to be implemented that permanent staff would never be able to absorb on top of their day to day responsibilities. Of note, the two Gold Status Practices were developed from PGY2 pharmacy administration residency projects. Practice Model Optimization: There has been formal emphasis on optimizing ambulatory care pharmacist practice models in order to ensure patients are getting the highest caliber care possible. This includes ensuring pharmacists do not perform non-clinical tasks. For example, ambulatory pharmacist providers have adequate clinical and administrative support, including dedicated space, and other team members schedule appointments, check in patients, perform vitals, and device teaching as needed. In addition, pharmacist providers are removed from traditional operational pharmacy roles; they do not perform prescription processing or review of non-formulary consults. Pharmacist providers have structured appointments and schedules as previously noted, which includes dedicated time each week to perform population management. The population management measures they focus on are derived from facility leadership priorities and target underperforming metrics. Pharmacist providers have an integral role in leading weekly interdisciplinary team meetings; many of the teams would may meet without the pharmacists’ leadership. Madison VA pharmacy department also partners closely with the national CPPO. This team assesses models across the nation and looks to the future of pharmacy practice to create and release guidance on optimal clinical pharmacy practice models. The CPPO also creates a venue to share practice models as well as learn from other sites across the nation. www.pswi.org

Executive Leadership Support: Support for pharmacy practice advancement from facility executive leadership has been integral to long-term success. As previously noted, Madison VA Chief of Staff, Dr. Alan Bridges, trained in rheumatology clinic alongside Art Schuna. Dr. Bridges has long been a supporter of pharmacist practice to ensure the highest quality care and access for Veterans. Pharmacy Chief, Dr. Andrew Wilcox, has executed the philosophy of positioning pharmacy to solve facility problems and challenges. Over time, this strategy has resulted in sustained leadership support via administrative support and resource approvals. This in turn, has led to advancement of pharmacy services. Positive Workplace Culture/Hiring: Finally, positive culture as driven by the high performing pharmacists is reflected in formal rankings. The Madison VA Pharmacy Service was ranked as #1 (out of 138) Best Places to Work for VA Pharmacy Services in 2017 and #5 (out of 139) in 2018. Much of the success of practice advancement is due to the grass-roots efforts developed and implemented by employees who utilize their passion, vision, and innovation to improve patient care. To foster this culture, pharmacy leadership embraces the importance of innovative thinking and a servant-leadership mentality. In addition to supporting employees one-on-one, leadership also invests time and resources into focused initiatives to enhance employee satisfaction and positive workplace culture. Some of those initiatives include following the Institute for Health Improvement’s initiative Improving Joy in the Workplace, adapting the VA’s approach to Whole Health and Employee Wellness, and a focus on promoting self-care and mindfulness in a community of colleagues who care about one another. The hiring process is also strategically designed to bring onboard those with the right attitude to support this culture. The culmination of effects from the long-standing residency program, expansive training opportunities, focus on practice optimization, positioning pharmacists to solve facility problems, and arguably most important, nurturing a positive

workplace culture through human to human connection and community are irreplaceable components of Madison VA’s practice advancement recipe. Ellina Seckel, Edward Portillo, Molly Lehmann, Andrew Wilcox, Ryan Vega Disclosure: The authors declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.

References

1. Seckel ES, Jorgenson TJ, McFarland MS. Meeting the national need for expertise in pain management with clinical pharmacist advanced practice providers. Journal of Joint Commission. In press. 2. USA Today. http://www.usatoday.com/ story/news/2016/10/24/kaiser-va-treats-patientsimpatience-clinical-pharmacists/92479132/. Published October 24, 2016. Accessed April 15, 2019. 3. Kaiser Health News. http://khn.org/news/vatreats-patients-impatience-with-clinical-pharmacists/. Published October 25, 2016. Accessed April 15, 2019. 4. Gray DC News. http://www.wsaw.com/content/ news/Trying-to-escape-its-dark-past-the-VA-holdsfirst-ever-Innovation-Demo-Day-390347202.html. Published August 16, 2016. Accessed April 15, 2019. 5. Wisconsin Health News. http:// wisconsinhealthnews.com/?p=12625. Published April 28, 2016. Accessed April 15, 2019. 6. Portillo E, Wilcox A, Seckel E, et al. Reducing COPD readmission rates: using a COPD care service during care transitions. Fed Pract. 2018;35(11):30-36.

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Pharmacy Reflections

Medical Staff Credentialing and Privileging of Hospital Pharmacists by Dave Grinder, MS, Sharon Pinnow, PharmD, Kimberly A Lintner, PharmD, BCPP, Kyle Schimek, PharmD, BCPS

harmacy practice has evolved to become a patient care practice with less emphasis on management of product. This evolution has been fostered by protocols and collaborative practice agreements (CPAs). In 2013 Wisconsin Statute 450.033 was enacted and states: “A pharmacist may perform any patient care service delegated to the pharmacist by a physician.” This provided a clearer legal framework for protocols and CPAs that were in use in the years before 2013. The Centers for Medicare & Medicaid Services (CMS) requires that protocols/standing orders describe specific clinical criteria for their use to yield minimal practice variation. This requirement minimizes critical thinking and autonomy of practice. What might be the next evolutionary step in the practice of pharmacy? This paper considers the potential of medical staff credentialing and privileging as a method to advance pharmacy practice. Credentialing has two definitions within healthcare.1 The first definition involves the process of individuals obtaining credentials. Pharmacists can obtain a variety of credentials beyond their pharmacy degree. The Council on Credentialing in Pharmacy (CPP), a coalition of 10 national pharmacy organizations, developed guiding principles for the various credentialing programs for pharmacists.2 In a 2017 survey of hospital pharmacies, the American Society of Health-System Pharmacists reports that credentialing of hospital pharmacists continues to increase. They are referring to credentialing as completion of a residency or obtaining board certification.3 Many organizations offer certifications for pharmacists that may or may not be exclusive to pharmacists. For example, the Board of Pharmacy Specialties (BPS) offers post graduate board certification exclusively to pharmacists in 11 specialties as of February 2019. As another example, the National Asthma Educator

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Certification Board (NAECB) offers a certification process for a variety of healthcare professions to become asthma educators. Certification can be obtained as a diabetes educator, a pain educator, an anticoagulation specialist, an antimicrobial stewardship specialist, a health information technology specialist, to name a few. The National Commission for Certifying Agencies (NCCA) assures that certification programs meet standards for development, implementation, and maintenance of certification programs. The NAECB plans to apply for NCCA accreditation in 2019. BPS is accredited by the NCCA. In many professions, these additional certifications may lead to significant changes in scope of practice. For example, a registered nurse may obtain certification as an advanced practice nurse prescriber (APNP). There are seven national organizations that provide certification for an APNP. The State of Wisconsin grants prescriptive authority to Wisconsin registered nurses who obtain APNP certification. There are no other State licensure requirements. The second definition of credentialing describes the process by which an employer verifies a candidate’s credentials required for a job. For hospital pharmacists, the hospital’s human resources department will verify that the candidate has a valid license to practice pharmacy in that state. Individual hospitals may require additional credentials for employment such as advanced cardiac life support or board certification in pharmacotherapy. The American College of Clinical Pharmacy (ACCP) has advocated for specific credentials required for pharmacists to practice in an intensive care unit, but this is currently a decision of an individual hospital.4 More recently, ACCP has advocated for adoption of a set of competencies for pharmacists practicing in critical care.5 Privileging is the process an

organization uses to approve a scope of service an individual is allowed to provide based on their credentials and experience.6 Within pharmacy practice, privileging has had a minor role in determining the scope of practice of an individual pharmacist.7 A common but informal method of privileging of hospital pharmacists is administered by the hospital pharmacy department.7 For example, a pharmacist may be required to complete specific training or demonstrate competence before they can manage parenteral nutrition or provide pharmacokinetic dosing adjustments. This form of privileging may help assure quality of service, but it does not establish scope of service. In the hospital, a pharmacist’s scope of service, beyond the State’s pharmacy practice act, is driven by medical staff approved protocols, standing orders, and/or policies. Ambulatory care pharmacists in the Aurora Health System have been credentialed and privileged by the ambulatory pharmacy services since 2005.8 The credentialing and privileging process described at Aurora parallels the medical staff process. While this may help assure quality of service, the scope of service is still driven by CPAs in place at Aurora.

Medical Staff Credentialing and Privileging The medical staff credentialing process evolved out of the need for hospitals to oversee independent, non-employed physicians who took care of patients within the organization’s facility. Most physicians and surgeons were community based and admitted patients to a variety of hospitals. The medical staff addressed this need for oversight through the credentialing and privileging process. The medical staff determines the minimum education, training, and certification required to care for patients within the hospital. It also determines what services can be provided www.pswi.org

by those meeting the credentialing requirements as documented by a list of privileges. In 1989, the Joint Commission (TJC) established standards for the medical staff credentialing and privileging process. There are many TJC medical staff standards that address credentialing and privileging requirements. Table 1 briefly describes those standards. (See TJC website for the elements of performance within each standard.) A key concept in these standards is the professional practice evaluations that should occur on a regular basis. A focused professional practice evaluation (FPPE) should occur in the first 6 months of employment. It involves a detailed review of medical records by a member of the medical staff to verify that clinical decisions made were appropriate. Thereafter, an ongoing professional practice evaluation (OPPE) should occur. This includes chart review as described as well as examination of patient outcome data that are currently being identified at Monroe Clinic. In 2012, CMS announced revised conditions of participation for medical staff credentialing that allows hospitals the flexibility to expand the definition of medical staff to include advanced practice providers (APRNs, PAs, pharmacists, etc.) and grant them privileges consistent with their scope of practice. Their hope is that these new members “may perform duties for which they are qualified through training and education and as allowed within their state scope-of-practice laws. This will allow physicians to more effectively manage their time so that they may focus on more medically complex patients.” (Federal Register May 16, 2012)

Pharmacist Credentialing and Privileging Pharmacists in the Indian Health Services have been privileged to provide independent patient care since 1997. Pharmacists in the Veterans Affairs (VA) system have been medical staff credentialed and privileged since 1995. Privileging for a VA pharmacist is a called a “scope of practice determination” and describes the extent of clinical services that a pharmacist can provide. In the non-government sector, forces www.pswi.org

TABLE 1. The Joint Commission Medical Staff Standards Regarding Credentialing and Privileging Standard

Description

MS 06.01.01

Prior to granting a privilege, the resources necessary to support the requested privilege are determined to be currently available, or available within a specified time frame.

MS 06.01.03

The hospital collects information regarding each practitioner’s current license status, training, experience, competence, and ability to perform the requested privilege.

MS 06.01.05

The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.

MS 06.01.07

The organized medical staff reviews and analyzes all relevant information regarding each requesting practitioner’s current licensure status, training, experience, current competence, and ability to perform the requested privilege.

MS 06.01.09

The decision to grant, limit, or deny an initially requested privilege or an existing privilege petitioned for renewal is communicated to the requesting practitioner within the time frame specified in the medical staff bylaws.

MS 06.01.11

An expedited governing body approval process may be used for initial appointment and reappointment to the medical staff and for granting privileges when criteria for that process are met.

MS 06.01.13

Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.

MS 07.01.01

The organized medical staff provides oversight for the quality of care, treatment, and services by recommending members for appointment to the medical staff.

MS 07.01.03

Deliberations by the medical staff in developing recommendations for appointment to or termination from the medical staff and for the initial granting, revision, or revocation of clinical privileges include information provided by peer(s) of the applicant.

MS 08.01.01

The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.

MS 08.01.03

Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

MS 09.01.01

The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on reported concerns regarding a privileged practitioner’s clinical practice and/or competence.

MS 10.01.01

There are mechanisms including a fair hearing and appeal process for addressing adverse decisions regarding reappointment, denial, reduction, suspension, or revocation of privileges that may relate to quality of care, treatment, and services issues.

MS 12.01.01

All licensed independent practitioners and other practitioners privileged through the medical staff process participate in continuing education.

have driven medical staff credentialing and privileging of pharmacists in ambulatory care first. Ambulatory care services are traditionally established with the use of CPAs. The nature of a CPA is less specific than that of a hospital protocol which enhances the need for the medical staff credentialing and privileging process. The Washington State Pharmacy Quality Assurance Commission recognizes the prescriptive authority of pharmacists, within the limitations of a collaborative

drug treatment agreement (CDTA), that have completed the medical staff credentialing and privileging process.9 The medical staff credentialing and privileging process has been used within hospitals to expand the scope of practice of hospital pharmacists.10 Ambulatory care pharmacists at Monroe Clinic have been medical staff credentialed and privileged since 2008. In 2018, hospital pharmacists at Monroe Clinic completed the medical staff July/August 2019

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TABLE 2. Passive vs Active Approaches to Practice Passive

Active Medication Reconciliation

1. Pharmacy technician obtains medication list from: a. Patient interview b. Calling outpatient pharmacy c. Electronic health records (EHR) d. Nursing home records 2. Pharmacy technician enters list into EHR 3. Pharmacist reviews list for accuracy 4. Physician reconciles medications 5. Second pharmacist verifies orders

1. P harmacist obtains medication list from: a. Patient interview b. Calling outpatient pharmacy c. EHR d. Nursing home records 2. Assesses barriers for adherence a. Educates on and addresses barriers to adherence 3. Pharmacist enters list into EHR 4. Pharmacist reviews pertinent labs, imaging, history of present illness, and past medical history and makes formal recommendations for prior to admission medication for admission 5. Pharmacist files detailed medication reconciliation note documenting above details 6. Physician reviews pharmacist’s orders 7. The same pharmacist verifies prior to admission orders and new admission orders, while keeping in mind patients’ wishes and adherence barriers

Antimicrobial Stewardship

1. Pharmacist ensures appropriate dose for a given indication as noted in medication order

1. Pharmacist reviews cultures, imaging and labs to confirm appropriate medication and dose for a given indication 2. Pharmacist daily reassessment and revisions based on new findings 3. Pharmacist deescalating therapy from IV to oral and broad spectrum to narrow spectrum agents 4. Pharmacist timely addressing of positive cultures for inpatients and outpatients 5. Pharmacist use of tools to facilitate stewardship (MRSA screens, procalcitonin, preliminary organism identification) 6. Pharmacist conducts review of allergies and intolerances to ensure most appropriate therapy utilized.

Discharge

1. Pharmacist reviews medication list at discharge for errors and omissions

1. Pharmacist and prescriber determination of medications for discharge (to address appropriate duration of therapy, eliminating medications that led to hospitalization, dosing in consideration of response to therapy) 2. Pharmacist facilitating transitions of care (ensuring prescriptions are routed to the preferred pharmacy, quantities are appropriate, cost of therapy is reasonable for patient, prior authorizations are facilitated, continuation of intravenous product is arranged, addressing needs of next care facility) 3. Pharmacist bedside teaching to include review of changes and common side effects, reasons medications were stopped, what to anticipate

credentialing and privileging process to advance their practice. Six months after completing the process and working in their “new” environment they provide the following reflection on the process and its implications for pharmacists, physicians, and patient care. Pharmacist Perspective on Credentialing and Privileging Both pharmacists and physicians treat 64 The Journal

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patients according to universal principles. Physicians recite the Hippocratic Oath, which champions the idea of “do no harm.” A lesser known directive of the Hippocratic Oath is to treat patients to the best of one’s ability. Similarly, during the Oath of a Pharmacist, pharmacists pledge to “apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.” Between “do no harm” and “treat to the best of one’s

ability” lies a gap. Imagine the directives to be at either end of a clinical spectrum. At one end lies the passive “do no harm” and at the other, the active “treat patients to the best of one’s ability.” Pharmacists practice somewhere along this continuum, whether it be by individual aptitude, by the constraints of protocols and workflows, or by the environment of interprofessional support. The scope of pharmacy practice is broad. An editorial included with the 2014 Standards of Practice for Clinical Pharmacists Guideline from the ACCP, states that the lack of standardized and reproducible practice by which clinical pharmacists optimize patients’ medicationrelated outcomes has been an Achilles’ heel for clinical pharmacy practice.11 The wide variations in how pharmacists practice can be seen in the extent in which they are involved in direct patient care. Few differences exist in the job descriptions for non-specialized, inpatient clinical pharmacists from hospital to hospital. Yet the tasks they perform differ extensively. For example, one Antimicrobial Stewardship Pharmacist may monitor antibiotic usage trends and the appropriateness of current therapy based on sensitivity data or indication. Another Antimicrobial Stewardship Pharmacist may perform these services and be responsible for de-escalating therapy based on MRSA screening or procalcitonin levels. Table 2 details how routine responsibilities of pharmacists can take divergent paths, both passive and active. At Monroe Clinic, pharmacists practice at the active end of the spectrum. Table 2 details the process of obtaining medication histories and performing medication reconciliation. The active medication reconciliation process is more time-consuming compared to the passive process, but it is rich in detail, accuracy, and value. Pharmacists are uniquely situated to improve patient adherence and thus, outcomes when performing medication histories. Pharmacy schools have long taught methods of assessing and addressing poor medication adherence. Most often, this is taught and performed through motivational interviewing. With medication reconciliation, only through active pharmacist participation can the www.pswi.org

value of this training be applied. Despite the value of active pharmacist involvement, many health care systems adopt processes which encourage passive participation. An example is the implementation of remote order verification for inpatient orders. When pharmacists are removed from patient contact, addressing barriers to adherence for newly prescribed medications becomes difficult. In the 2010 document ASHP Guidelines on Remote Medication Order Processing, the American Society of Health-System Pharmacists (ASHP) advocates that the pharmacist be physically accessible to the patient when feasible.12 Only when this is not possible does ASHP encourage the development of remotely delivered pharmacist care as a supplement to onsite care. Despite the clear devaluation of pharmacists’ skills and ASHP recommendations, remote order verification is becoming more widely adopted in health systems. What metric should be used to evaluate a medication reconciliation service? Should the goal be to perform a medication reconciliation within in a certain time? Or should the goal be to perform medication reconciliation in a percentage of patients? The ability to meet these goals is increased if the service is defined as simply getting an accurate list of medications on file for the physician. It is much more difficult to meet these goals when medication reconciliation is performed as defined by the active definition supplied in Table 2 with its myriad of additional tasks. Omitting functions from the active description of medication reconciliation to meet time or frequency goals is short sighted. Those deleted tasks do not always simply disappear. Instead, the responsibility for performing them shifts to someone else or worse they are ignored. In the end, patient care suffers. Pharmacist Perceived Benefits of Medical Staff Credentialing and Privileging of Hospital Pharmacists In a time when health care organizations are trying to accomplish more with less, medical staff credentialing and privileging of pharmacists is a means by which to shift tasks away from physicians and give them more time to www.pswi.org

focus on aspects of patient care at which they alone excel. This was the vision of CMS in 2012. Medical staff credentialing and privileging of pharmacists allows for more timely interventions, which in turn imparts a greater efficiency to patient care and offers a unique opportunity for practice advancement. The entire process by which a pharmacist identifies a problem, relays the information to the physician, waits for a response, and finally makes an intervention can be streamlined when necessary to the much-abbreviated version in which the pharmacist identifies a problem and makes an intervention. The FPPE and OPPE process requires pharmacists to document medication changes with an associated rationale. When readily available to everyone on the patient care team, concise but comprehensive progress notes improve communication among all members of the care team thus improving safety and efficiency. Pharmacists at Monroe Clinic are working together to master the art of writing progress notes. These progress notes are used to conduct the required FPPE and OPPE, the results of which become a very relevant competency assessment when shared with the pharmacist by the physician. Thus, the annual competency assessment process becomes much more impactful and less time-consuming than departmental designed competency assessments. The current FPPE process includes an evaluation of: 1) doses are adjusted appropriately, 2) medications are monitored appropriately, 3) prior to admission medications are managed correctly, 4) dosage forms are adjusted appropriately, 5) antibiotics are managed correctly, 6) plans for follow-up are documented, 7) care provided within the list of privileges? To evaluate performance against these parameters appropriate documentation by the pharmacist must be placed in the chart. For department leadership, medical staff credentialing and privileging of pharmacists eliminates the need for the time-consuming process of reviewing and revising protocols. The medical staff approved protocols at Monroe Clinic became the basis for creating the initial list of privileges granted to the hospital pharmacists. For example, a privilege of hospital pharmacist states

“Adjust dosages of medications based on renal function.” The renal dosing protocol that specified dosage changes by medication based on estimated creatinine clearance was abandoned. As a matter of convenience and consistency, the information in the old protocol will be kept current by the staff as needed and used as a reference. For the pharmacist, there is, first and foremost, the realization that one can make a difference. People that pursue careers in health care know that the patient should come first. However, it is difficult to perform one’s job in a satisfactory way when organizations put in place or adopt workflows and processes that minimize one’s ability to practice at the top of his or her license. Hence, the medical staff credentialing and privileging of pharmacists elevates them from decision consenters to decision makers, allowing them do what pharmacists do best; directly impact patient care through the judicious application of evidence-based drug therapy. Medical staff credentialing and privileging also engenders a sense of pride among the pharmacists when they are recognized as highly proficient professionals by a group outside their own department. Pharmacist Perceived Barriers to Medical Staff Credentialing/Privileging There are three general barriers to successful medical staff credentialing and privileging of pharmacists created by pharmacists, medical staff, and leadership. The responsibility and accountability that comes with the autonomy of clinical decision making can be daunting and one that not all pharmacists are ready to accept. For some pharmacists, education, training, and experience may not have developed the required skills for them to play such an active role in patient care. Acceptance by the medical staff takes time. Medical staff credentialing and privileging for the pharmacist requires an elevated level of respect and recognition of the pharmacist’s expertise in medication management by physicians. For this to develop, pharmacists must have the opportunity to demonstrate their knowledge and skillsets prior to any attempt at credentialing and privileging. Hospital leadership must be supportive of the efforts required to develop a working July/August 2019

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relationship with physicians. Some pharmacists are expected to provide clinical pharmacy services for 90 or more patients per day. It is impossible to provide active pharmacist services with responsibility for this number of patients. Leadership at Monroe Clinic has been supportive of active pharmacist services for many years which has resulted in a patient to pharmacist ratio closer to 15. Strategies to overcome these barriers involve creating an environment where pharmacists are free to ask questions, offer input, and learn. Continuous learning within the pharmacy is assisted by pharmacy residents, family medicine residents, and the pharmacists themselves. There is an organizational structure to support ongoing learning, skill development, and clinical performance reviews to maintain the requirements of credentialing.

Conclusion

Granting of provider status to pharmacists is an ongoing discussion at the federal level. In the meantime, the medical staff credentialing and privileging of pharmacists by organizations is a potential alternative by which to accomplish practice advancement. While waiting for nationwide agreement on recognizing pharmacists as providers, medical staff credentialing and privileging puts pharmacists in a position to more directly impact patient care. At Monroe Clinic, the hospital pharmacists obtained medical staff credentialing and privileging to further their autonomy and to advance the pharmacists’ ability to provide direct patient care. In the American Society of HealthSystem Pharmacists 2019 Forecast respondents were asked about the likelihood that “Pharmacists in at least 50% of health-systems will be subject to the same credentialing and privileging their state requires for other advancedpractice providers.” Seventy-six percent of respondents indicated very likely or somewhat likely. As more institutions go down this path more insights will be developed, and a tipping point may be reached that leads to massive but required change. There is comfort in having literature to 66 The Journal

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guide one’s treatments, and there is comfort in having proven processes to guide one’s practices. The pharmacists at Monroe Clinic acknowledge that gaps exist, and changes are needed though there is so much that remains undefined. Medical staff credentialing and privileging is Monroe Clinic’s collective commitment to entering the uncertainty together knowing that pharmacists can use their talents to advance their practice. Trepidation understandably exists with this undertaking, but consider again the Oath of the Pharmacist: “I will embrace and advocate changes that improve health care.” The potential rewards for patients, pharmacists, the immediate and affiliated practice sites, and health care overall make the effort more than worthwhile.

implementation of a credentialing and privileging model for ambulatory care pharmacists. Am J Health Syst Pharm. 2006;63(17):1627-1632. 9. Hammer KJ, Segal EM, Alwan L, et al. Collaborative practice model for management of pain in patients with cancer. Am J Health Syst Pharm. 2016;73(18):1434-1441. 10. Jordan TA, Hennenfent JA, Lewin JJ, Nesbit TW, Weber R. Elevating pharmacists’ scope of practice through a health-system clinical privileging process. Am J Health Syst Pharm. 2016;73(18):1395-1405. 11. Yee GC, Haas CE. Standards of practice for clinical pharmacists: the time has come. Pharmacother J Hum Pharmacol Drug Ther. 2014;34(8):769-770. 12. ASHP guidelines on remote medication order processing. Am J Health Syst Pharm. 2010;67(8):672-677.

Dave Grinder, is the Director of Pharmacy at Monroe Clinic - SSM Health in Monroe, WI. Sharon Pinnow, Kimberly Lintner and Kyle Schimek are Clinical Pharmacists at Monroe Clinic - SSM Health in Monroe, WI. Disclosure: The authors declare no real or potential conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria.

References

1. Council on Credentialing in Pharmacy. Credentialing and privileging of pharmacists: a resource paper from the Council on Credentialing in Pharmacy. Am J Health Syst Pharm. 2014;71(21):1891-1900. 2. Council on Credentialing in Pharmacy. (2014). Credentialing and privileging of pharmacists: a resource paper from the Council on Credentialing in Pharmacy. Washington, DC: Council on Credentialing in Pharmacy. 3. Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017. Am J Health Syst Pharm. 2018;75(16):1203-1226. 4. Dager W, Bolesta S, Brophy G. An opinion paper outlining recommendations for training, credentialing, and documenting and justifying critical care pharmacy services. Pharmacotherapy. 2011;31(8):135e-175e. 5. Saseen JJ, Ripley TL, Bondi D, et al. ACCP clinical pharmacist competencies. Pharmacother J Hum Pharmacol Drug Ther. 2017;37(5):630-636. 6. Philip B, Weber RJ. Enhancing pharmacy practice models through pharmacists’ privileging. Hosp Pharm. 2013;48(2):160-165. 7. Galt K. Credentialing and privileging for pharmacists. Am J Health Syst Pharm. 2004;61:661-670. 8. Claxton KL, Wojtal P. Design and www.pswi.org

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July/August 2019

The Journal 67

Pharmacy Reflections

Investing in Pharmacy Technician Resources by Rebecca J. Bryan, RHIT, CPhT, Adam E. Gregg, PharmD, BCPS

ntegrating highly skilled pharmacy technicians into patient care is essential within all pharmacy practice settings. In order for pharmacy practice to advance, the profession must ensure pharmacy technicians are qualified to support the immediate and growing demands on the care delivered by pharmacists and pharmacy technicians. In 2017, Gundersen Health System formally initiated a process to address the challenges and threats to ongoing technician recruitment and retention. The goal was to provide a framework upon which technicians would have an enhanced capacity to successfully fulfill the current functions within the department across practice settings, as well as laying the foundation for future expansion and advancement of those functions. This process of investment in our technician workforce and resources has focused on three key areas: 1) Building the pool of talent; 2) Defining pathways for advancement; and 3) Highlighting avenues for personal and professional development. As the work of our technicians has grown in scope and complexity, the skills necessary to jump into the role successfully have increased. As an acknowledgement to the additional depth of skills and expertise necessary for the role, Gundersen leadership established that Certified Pharmacy Technician (CPhT) certification will be required of all pharmacy technicians across the health system as of October 2019. Though a critical – and necessary – decision, we also recognized that this created some potential barriers to future recruitment and hiring of technicians. Historically, many of the applicants for open technician positions have not had any previous work experience within pharmacy, nor any specific education that readies them for expedient acclimation into the role. This has often resulted in a protracted training and on-boarding period for new technician hires. In turn, this has delayed the ability to more immediately meet the staffing needs of the department,

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July/August 2019

which has put a higher proportion of the workload on other staff to shore up those gaps. Additionally, we recognized the obstacles posed by changes to the Pharmacy Technician Certification Board (PTCB) requirements that, effective in 2020, candidates shall have completed a PTCBrecognized technician training program as a term of eligibility to sit for the Pharmacy Technician Certification Exam (PTCE). In surveying options to help mitigate some of these potential barriers, we elected to establish our own internal technician training program. Our global philosophy has been to take our current process for on-boarding and put it “on steroids”: in other words, utilize the current framework for new technician orientation, standardize and unify the training across all pharmacy settings, and make each element more robust and structured. Without previous experience, education, or credentials, a new technician will be hired into a trainee role. The employee begins with didactic modules that teach fundamentals of pharmacy and technician practice. Much of the curriculum is provided via completion of web-based, self-paced modules. This is supplemented by in-person teaching delivered by lead technicians and other internal content experts, which integrates instruction about department-specific processes and procedures. Upon successful completion of didactic modules, the trainee progresses to off-line simulation exercises that reinforce and allow application of material learned in a directly supervised and coached environment. With successful demonstration of key skills in simulation, the trainee finally proceeds to experiential training. This is facilitated by lead technicians, and occurs in service lines across the department, including community, hospital, and long-term care. Using our previous competency-based orientation structure as a model, the trainees work toward demonstration of mastery of processes and technician functions through repetition

and application of skills in real time. While remaining under supervision, the trainees begin contributing to department workflow and expanding productivity while completing their final training. We hope to realize multiple benefits of embedding a formalized training program within our health system. Rather than rely on an external source, it has positioned Gundersen to build a pool of future technicians that are more equipped to support the current and future needs of the department and organization. The program is structured to align with technician training program standards jointly issued by the American Society of Health-System Pharmacists (ASHP) and the Accreditation Council of Pharmacy Education (ACPE). As such, upon satisfaction of all requirements of the program, trainees will be eligible to sit for the PTCE, with the intent of achieving certification as a capstone to their curriculum. Further, the program creates increased versatility of our technicians; this facilitates cross-coverage between varying service lines and paves the path for technician advanced and hybrid roles that increasingly blur the lines between more traditional practice capacities. A second arm of our departmental strategy to invest in technicians centered on establishing defined pathways of career advancement for technicians. A core team was created consisting of managers from inpatient, outpatient and long-term care pharmacy, along with personnel from human resources (HR). Partnering with HR from the concept phase forward was invaluable and provided HR with the opportunity to better understand the vital and valuable role of the pharmacy technician. HR was able to describe retention rates and actively participate in the discussions and planning for changes to the job descriptions, compensation and career ladder. In addition, the desire to require certification for all existing and future pharmacy technicians was a natural progression with the work. HR was well www.pswi.org

versed in the complexity of work done in the pharmacy as well as the variation in state requirements for pharmacy technicians and became the pharmacy department’s ally for adding certification as a requirement of employment. Defining and retooling job descriptions was the first step in our journey. The team conducted brainstorm meetings focusing on determining the ideal number of job descriptions, establishing requirements for each job description, and aligning functions within the multiple practice settings in the department. The team created out-ofscope work for responsibilities that were being done by non-technician personnel (including clerks and delivery drivers) to clearly focus on the core pharmacy technician area of responsibility. The desired outcome was the need for three job descriptions. Utilizing the ASHP/ ACPE program requirements for entrylevel technicians as a guide, the three job descriptions were able to be condensed down to two: pharmacy technician-intraining and certified pharmacy technician. Surprisingly, the team quickly realized that a career ladder, later clarified as a career “tree”, had been slowly created over the years (see Figure 1). Unique job descriptions had been developed to meet the needs of pharmacy offering growth opportunities for pharmacy technicians to advance their career path while supporting the growing needs within the pharmacy and within patient care. The advanced positions are filled by highly skilled pharmacy technicians with a niche expertise in areas such as diversion oversight, automation, billing and reimbursement, and purchasing. A third pillar of technician growth has been developing avenues to increasingly and deliberately engage them in their own personal and professional development. Technicians have been strongly encouraged to complete Gundersen workshops focused on fostering healthy relationships. This curriculum has included completing the Myers Briggs Type Indicator assessment as a tool to more closely articulate individual preferences and characteristics, as well as recognize other preferences that may influence co-workers’ perspectives and decision making. We have built on this with internal programming that specifically www.pswi.org

FIGURE 1. Gundersen Health System Pharmacy Technician Career Tree

Clinical Manager

Purchasing Assistant

Pharmacy Purchasing Specialist

Pharmacy Inventory Technician

Patient Accounts Receivable

Pyxis Technician

Billing & Diversion Technician

Cold Chain Pharmacy Support Specialist

Lead Technician

Point of Sale Coordinator

Pharmacy Technician CPhT

Pharmacy IV Compliance

Pharmacy Technician Trainee

examines how this plays into inter-personal communication and resolving conflict. Lead technicians have participated in book clubs, discussing elements of personal and team leadership. Our technicians have driven our department involvement with Project SEARCH, a Gundersen partnership with local school districts in which students with developmental and intellectual disabilities complete year-long on-the job training within the health system. In addition to the intrinsic rewards of helping mentor these students, this relationship has planted the seeds for our technician staff to become more effective teachers and preceptors within our training program. Finally, technicians have deepened their professional engagement through contribution to pharmacy organizations on a local, state, and national level. As a specific example, in the previous two years, five Gundersen technicians have delivered either poster or podium presentations at

Pharmacy Society of Wisconsin meetings as an avenue for sharing their experience and expertise with their colleagues across the state. Pharmacy is dependent on having highly skilled pharmacy technicians within all practice settings. Creating a multi-armed framework that offers opportunities for staff development is essential to ensuring pharmacy technicians are qualified to support the immediate and growing demands within pharmacy and ensure all personnel – pharmacist and technician - are functioning at the top of their ’training’ to advance pharmacy practice and provide exceptional patient care. Rebecca Bryan is the Project Manager, Pharmacy Services and Adam Gregg is the Program Manager, Pharmacy Continuing Professional Development at Gundersen Health System in La Crosse, WI.

July/August 2019

The Journal 69

Pharmacy Reflections

A Reflection on UW Health Practice Advancement by David Hager, PharmD, BCPS

W School of Pharmacy clinical residency programs started in 1990-1991, and by 1992 the graduating class was four residents. The basis of this program was the previously existing internship program. In speaking with Pat Cory, who was a resident graduating out of the 1993 class, some things have changed a lot since then. Resident “rotations” were staffing 36 hours a week in your designated area with a project day every other week for the other 4 hours. It was not uncommon to be online staffing 30 contiguous days with this schedule. To ensure clinical competency you learned as much as you could outside of rotation and your additional didactic learning came in the form of coffee with Tom Thielke the Pharmacy Director. There were many clinical pioneers on the floors creating a larger and larger role for clinical pharmacists, such as Mike Madalon, Bob Breslow, and Bill Tanke from whom to learn. They built on Dave Angaran’s work that established clinical services and pushed us into medication histories in 1970, discharge teaching in 1972, and added kinetics services, warfarin management, and code participation. Resitrak and PharmAcademic did not yet exist, but that also meant there wasn’t a formal resident evaluation process. Office space for residents was minimal. Medication orders were on triplicate forms. The medication carts were delivered twice a day for the floor pharmacists to reconcile against the MARs and to check in the medications. Pharmacists intervened daily on poor handwriting and transcribed the labs into the monitoring books. Length of stay averaged 14 days. Resident recruitment was directly through the UW-Madison School of Pharmacy with many coming through Tom Thielke’s elective course at the SOP. Now fast forward 13 years. Philip Trapskin takes over the program in 2006 when the PGY1 program still had 4

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residents and UW Health has had 13 residents overall since it had added a critical care resident in 2001. During these years we have about 40 applicants a year to the PGY1 program. More and more of our preceptors are past residency graduates of the program and new practice leaders have emerged – people like Jeff Fish, Aaron Steffenhagen, Sheila Aton and Bill Simmons, enabling us to broaden our experiences for clinical residents, offering fewer required rotations and more electives. This, combined with the implementation of the electronic health record, creates an environment where practice advancement takes off. No longer do pharmacists have to transcribe labs, the drugs are all checked before they arrive on the floor, we have full access to notes that we can read instead of finding the paper chart. In 2011 Philip submits a successful business case and we expand to 6 residents and selects from 100 applicants. Clinical residents again expand clinical services by successfully building cases for our infectious disease and anticoagulation stewardship programs. Philip begins our course to be the nation’s leader in training and developing residents within the integrated practice model by implementing rubrics for evaluations, a novel design for ResiTrak that helps shape the current PharmAcademic and the creation of the “Weekend Preceptor” model. Today, we are up to 9 residents in the PGY1 program alone and 29 residents total. We have 15 distinct residency programs. We have evolved under the philosophy that care could not be delivered and a patient could not be cared for safely without a pharmacist who knows 100% of their patients. We now have arguably one of the most advanced pharmacist transitions of care model in the world with pharmacists fully responsible for medication therapy at both admission and at discharge. At discharge, advanced technicians ensure

medication access prior to the day of discharge. We have meds to beds services, pharmacist’s pend the discharge orders for providers to sign, another pharmacist then reviews those orders for accuracy against the plan on 100% of patients, and we communicate about the admission to the community pharmacist or next care provider that cares for that patient. We have post-discharge transitions of care pharmacists to assist high risk patients or those who are screened to be non-adherent to their medications and we own the transition for high risk medications like IV antibiotics and warfarin. Additionally, we ensure vaccines are given, we check for problems with opioids through the Prescription Drug Monitoring Program (PDMP) and we still council 100% of patients and we do all this with a length of stay of 4.5 days. The churn has climbed and to compensate our pharmacist to patient ratios have declined. Daily, we have a huddle structure with all inpatient teams to make sure leadership and pharmacists are routinely meeting to both celebrate success and troubleshoot challenges. Our pharmacists now teach or coordinate and teach in 2 graduate courses and 6 professional courses at the UW-Madison School of Pharmacy. In an inventory we recently completed, almost we devote the equivalent of 400 hours a week of inpatient pharmacist time to training students. We have clinical pharmacists and residents in leadership roles nationally in pharmacy organizations. We have both a clinical PGY1 and PGY2 resident on the ACCP Resident Advisory Committee and we have a PGY 2 resident on the ASHP New Practitioners Forum. We had 32 professional pharmacy leadership appointments in 2017 overall. We have a www.pswi.org

staff where more than 90% of pharmacists are residency trained and nearly 100% of board eligible pharmacists are board certified. We have a commitment to publication and published 34 articles in 2017. As clinical practice has moved forward, our residency programs have benefited and as our residency program has advanced, pharmacy practice has benefited. Where are we going? In 2019 our focus for inpatient practice advancement will be on three things: 1. Having a fully service-based weekday AM practice model at our University Hospital. Moving away from connecting pharmacists with geographic locations like units and to patient care teams. Being aligned with our physician service lines will create closer ties between physicians and pharmacists. It prevents the inefficiency and confusion for providers of having different types of care and different recommendations on the same day from different pharmacists and it sets us up for future practice advancement as those

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relationships deepen. 2. Expanding co-location of our pharmacists with providers in team rooms wherever feasible. Being physically present means more opportunities to proactively influence at the time of prescribing. 3. Measuring our value and performance. We are now a healthsystem with patients at multiple hospitals and related clinics. Our new CEO is a physician and we have a new president. Pharmacy salaries and drug spend must demonstrate value to the organization. One of the 2019 goals is to recognize where the pharmacists consistently contributions to the practices we have endorsed and identify areas for improvement and reorganization to continue demonstrating value. In the next three years the big three I’d like to tackle are: 1. Monitoring and documentation. What does that mean in today’s environment and how can we get to a more patient and provider focused

future state? 2. Recognition for clinical skill. How can we ensure we recognize pharmacists for the high-quality care they provide, acknowledge their individual strengths, and position them to their, the patients’ and the organization’s best advantage? 3. Scholarship. How do we achieve all our inpatient pharmacists being known not only for the care they provide and how do we visibly demonstrate our vision of being “The nation’s leader in pharmacy”, through scholarly work?. I invite all readers of this reflection to think back on where your pharmacy practice has come from, what that journey has looked like, where you would like to be in three years and what are your big three to tackle. David Hager is the Director of Clinical Pharmacy Services at UW Health in Madison, WI.

July/August 2019

The Journal 71

Pharmacy Insurance

Tomorrow. Imagine That.

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2019 SCHOLARSHIP WINNERS Pharmacists Mutual is proud to support students who are interested in serving in an independent or small chain community pharmacy or an underserved geographic or cultural community. Each student listed received a $2,500 scholarship.

ABIGAIL SCOTT - University of Oklahoma ALEXIS DAYTON - Ohio Northern University ALLIE TAYLOR - Samford University BRYAN QUINN - University at Buffalo The State University of New York CARLY HUFFMAN - University of Montana CYNTHIA SMITH - Auburn University DAVID LU - Northeastern University ELIZABETH CRONAN - Mercer University HEATHER HEMBREE - University of South Carolina JACOB LOMAX - Ohio Northern University JONATHAN LITTLE - University of Oklahoma JORDYN NORDE - St. Louis College of Pharmacy LACY EPPERSON - University of Missouriâ&#x20AC;&#x201C;Kansas City MATTHEW JOLLEY - University of Utah MEGAN BAKER - Washington State University SAMANTHA HOPPE - South Dakota State University SEAN VINH - East Tennessee State University SHELLEY MUELLER - Southwestern Oklahoma State University TIFFANY CHAN - University of the Pacific TIFFANY SMITH - South University

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