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specialty skills
Survey Showcases Health-System Specialty Care
By Karen Blum
Phoenix—Health-system specialty pharmacies (HSSPs) have developed robust patient care services that encompass the patient journey from before specialty medication selection through treatment monitoring and optimization, according to results of the 2022 ASHP National Survey of Health-System Specialty Pharmacy Practice.
Survey results, presented at the 2022 ASHP Summer Meetings and Exhibition, also found that HSSPs collect and use patient outcomes to drive monitoring and interventions, and that HSSP pharmacists and technicians integrated into specialty clinics serve as a valuable clinical and educational resource for other clinic staff.
However, there is room for improvement for HSSPs in areas such as communicating outcomes metrics with stakeholders, using collaborative prescribing agreements and contributing to scientific literature, said Autumn Zuckerman, PharmD, AAHIVP, BCPS, CSP, the director of health outcomes and research at Vanderbilt Specialty Pharmacy, in Nashville, Tenn.
The survey, developed by ASHP and the Vanderbilt Health System Specialty Pharmacy Outcomes Research Consortium, involving 26 health systems, built on ASHP’s first national survey on health-system specialty pharmacy practice from 2020 (Am J Health Syst Pharm 2021;78[19]:1765-1791), Dr. Zuckerman said.
This year’s survey was designed to demonstrate the benefits of HSSPs by showcasing clinical services they provide, she said. It contained 119 questions in six domains: general capabilities, pretreatment, treatment initiation, treatment monitoring, continuity of care services, and education and research.
The online survey was open in March and April 2022, and representatives from 127 organizations participated, representing a wide range of practice sites and demographics based on such factors as 340B eligibility and prescription volume (Figures 1 and 2).
Following are some survey highlights:
General capabilities. More than half of respondents said they provide services such as prior authorization (PA) completion and denial assistance, financial assistance enrollment, and specialty medication selection or recommendations for all patients prescribed specialty medications at their health system, regardless of where they fill their prescriptions. More than half also said they provide enhanced services such as injection training, transitions of care coordination and disease monitoring for patients who fill their prescriptions at the HSSP.
In other findings, at least 80% said they frequently or always documented services such as process and status of insurance navigation and financial assistance procurement; patient response to therapy; initial patient counseling notes; and medication reconciliation results in electronic health records (EHRs) visible to providers and clinic staff, Dr. Zuckerman said.
Collaborative practice agreements and collaborative drug therapy management programs were uncommon in HSSPs, with 47% saying they did not use them in any of their clinics. HSSPs were most likely to report their financial performance, prescription volume and other metrics to health-system leadership, followed by health clinic providers and staff, but were much less likely to report metrics to patients.
Pretreatment. Respondents reported that 63% of the time, pharmacists embedded in specialty clinics always review provider medication selection and alert them with concerns, Dr. Zuckerman said. Other common roles were discussing medication selection with providers or making therapy selection.
For pretreatment assessments, all respondents said they use EHRs to assess patients’ baseline disease status, comorbidities and conditions, and current medication list and previous therapies taken, and 51% said pharmacists actively coordinate with clinics and patients to complete pretreatment workup when needed. Counseling patients before medication selection occurs occasionally, and when it does, it is usually during an in-person provider visit.
Treatment initiation. Nearly all respondents said they use patient assistance programs, manufacturer copay and free drug programs, and disease state foundation support to reduce patient financial burden (Figure 3), with some respondents reporting fund collections in excess of $20 million, said Nicholas Gazda, PharmD, BCPS, CSP, the assistant director of pharmacy at Cone Health, in Greensboro, N.C.
Initial medication counseling most often is conducted by telephone, 73% of respondents said, but some do this during separate clinic visits, provider visits or via video, Dr. Gazda said. Additionally, more than 80% reported that pharmacists were involved in screening and/or counseling for recommended immunizations.
Treatment monitoring. About 79% said patients receive one to 10 touch points during their first year, exclusive of refill assessments, Dr. Zuckerman said, and 95% reported tracking disease-specific outcomes in at least some patients. Most (92%) said they use disease-specific outcomes reporting to meet accreditation requirements, although many other uses were cited (Figure 4, page 38).
Approximately 71% said a single negative response or side effect in patients will trigger pharmacist intervention, while 54% said a negative trend will trigger pharmacist intervention. Standard clinic protocols and patient/disease factors were the most commonly reported considerations to determine the frequency of assessments, with medication adherence, duration of therapy and patient complexity being the biggest determining factors. Telephone was the most common method used for monitoring patients.
Continuity of care. About 69% of HSSPs go beyond traditional fulfillment to offer clinical services such as chronic disease therapy management, collaborating with other team members to help with social determinants of health, being involved in preventive wellness programs and more, said Melissa Ortega, PharmD, FASHP, the system executive director of ambulatory services at Wellforce, the parent of Tufts Medical Center, in Boston (Figure 5, page 38).
In addition, 22% reported managing Risk Evaluation and Mitigation Strategies, or REMS, program medications
340B-covered entity, 99%
Have offered specialty pharmacy services for 7+ years, 48%
Affiliated with an academic medical center, 64%
Figure 1. Characteristics of survey respondents.
30,001-45,000, 16%
10,001-30,000, 20% >45,000, 30%
<5,000, 20%
5,001-10,000, 12% 00 0
Figure 2. Prescription volume.
>$20 million, 14% Unsure, ure, 10% %
Not tracked, racked, 7% 7%
$10 million$20 million, 10%
$5 million$10 million, 13%
<$1 million, 7%
$1 million-$5 million, $1 39%
Figure 3. Amount of funds gained from financial assistance programs annually.
TOC Team Addresses Polypharmacy, Cuts Readmissions
By Sherree Geyer
Phoenix—A pharmacist-led transitions of care (TOC) program achieved modest reductions in hospital readmissions among geriatric patients, a group challenged by polypharmacy, inadequate follow-up and other issues that can compromise post-discharge care, according to a new study presented at the 2022 ASHP Summer Meetings and Exhibition.
The study is the first of its kind to evaluate the effects of a pharmacist TOC service on hospital readmissions within a senior care primary care setting, reported lead researcher Jennifer Shieh, PharmD, a pharmacy resident at Stanford Health Care, in Cupertino, Calif.
The TOC program was facilitated by a collaborative practice agreement between pharmacists and primary care providers (PCPs) in Stanford Health’s Senior Care Clinic, she noted.
“Our goal was to implement postdischarge TOC pharmacists in the Senior Care Clinic at Stanford,” Dr. Shieh explained. “We notified a pharmacist whenever a geriatric patient in their clinic was discharged from the hospital to home to conduct three- to five-day post-discharge phone calls to identify potential needed interventions aimed at optimizing medications.”
The interventions included medication deprescribing and dose adjustment, improving medication access, performing medication reconciliation, and addressing medication adherence.
To assess the effectiveness of this approach, Dr. Shieh and her colleagues conducted a prospective, single-center study of patients who were discharged home from the Senior Care Clinic between October 2020 and January 2021. Using electronic health record data, they compared patient outcomes of that group with a historical control group of patients who were discharged between October 2019 and January 2020.
Thirty-two patients in the intervention group and 37 patients in the historical control group were included in the final data analysis.
One key finding was the success the team had in quickly reaching a high proportion of patients with their interventions: Of the 32 patients in the intervention group, 28 (87.5%) were contacted within three to four days after discharge, Dr. Shieh reported.
Moreover, PCPs accepted the majority of pharmacist-proposed interventions. The pharmacist identified 65 interventions, of which 49 (75.38%) were implemented by the PCPs.
As for readmissions, although the numbers were small, Dr. Shieh and her colleagues documented modest improvements: five (15.63%) patients in the intervention group were readmitted within 30 days post-discharge, compared with seven (18.92%) patients in the historical baseline group.
“The results of our project were, generally, all very positive,” Dr. Shieh said. “We saw all-cause, 30-day readmission rates lowered by 3.3% and ED [emergency department] visits reduced by about 2.3%. When we look at the pilot versus control group, our small sample size was, most likely, the limiting factor that prevented statistical significance. If we extrapolate to a full-time pharmacist, we would see more readmissions, ED visits and adverse drug events prevented, which would produce a cost avoidance.” The global COVID-19 pandemic also impeded research efforts. “It [the research] occurred during COVID-19, so some patients may have been hesitant to present to the hospital. We targeted a very high-risk population, but want to expand it,” added Dr. Shieh, who called geriatric patients “the most high-risk at our facility.”
The stakes are high for addressing readmissions in this vulnerable patient population, she noted. Nearly 20% of Medicare patients are readmitted to the hospital within 30 days after discharge, and more than half of those readmissions are caused by medication-related adverse events.
Dr. Shieh reported no relevant financial disclosures.
ASHP SP SURVEY
continued from page 36
for all referred patients, and 86 respondents reported being involved in efforts to avoid medication waste, such as ensuring on-hand medication quantity is assessed prior to requesting refills. About half of HSSPs participate in managed care activities such as collaborating with health-system accountable care organizations to influence risk-based contracts or formulary decisions, and 48% are involved in population health efforts.
Furthermore, 61% noted that pharmacists are involved in identifying and managing social determinants of health variables such as financial resource strain and health literacy, and 79% of respondents said pharmacists were involved in transitions of care coordination in areas such as arranging for delivery of medication to the home at the time of hospital discharge. Most HSSPs use the EHR patient portal to communicate with patients.
Education and training. More than 80% of HSSPs provide one or more education sessions to clinic staff each year, said Jennifer Donovan, PharmD, the vice president of clinical services at Shields Health Solutions, in Stoughton, Mass. That education is most often provided by an embedded pharmacist or inservices to other healthcare professionals. Additionally, 62% provide education to medicine learners in areas such as specialty pharmacy services and insurance requirements.
The speakers reported no relevant financial disclosures.
Waste avoidance programs
Reporting for payor contracts
Reporting to manufacturers
Adjusting frequency of patient monitoring
Reporting to clinic providers Developing and executing quality improvement and/or research projects Identifying patients who need a pharmacist intervention Accreditation requirements
0 10 2030405060708090100 Preconception care services Sexual health counseling Other Nutrition support services Genetic counseling Preventative/wellness health screenings Smoking cessation programs Immunization clinic Non-specialty chronic disease management (e.g., diabetes, COPD) Provision of urgent or emergent medication supply when necessary Referral to health-system services such as nutrition, social work, etc. Does not apply 69% of HSSPs offer more than fulfillment services
0 10 20 30 40 50
