North Carolina
Pharmacist
Vol. 94, Number 3
Advancing Pharmacy. Improving Health.
Annual Convention Preview October 26-28, 2014 Raleigh Convention Center, Raleigh, NC Host Hotel: Sheraton Raleigh Downtown, Raleigh, NC See http://www.ncpharmacists.org/ for more information and to register/book hotel room
Theme: "Pharmacy's Modern Role in 2014" Highlights Immunization Certificate Program MTM Certificate Program Pragmatic Issues for NOACs Tales from the Crypt...Well Actually, The Cath Lab Pursuit of Provider Status MTM & Diversity: "One Size Doesn't Fit All� "Pharmacy's Modern Role" Panel Discussion Key Note Address Residency Showcase and Student Sessions Pharmacist Impact on Core Measures Pain Management and the Forgotten Patient Value-Based Purchasing Point of Care Testing, A New Opportunity for Pharmacist Services HIV and HCV Tx Update Challenges in Antimicrobial Stewardship Guidelines for Cholesterol Management Pharmacy Law Update/BOP Inspections Immunization Update Health-System Manager’s Forum Pharmacist Fatigue Hypertension Management and much more
Fall 2014
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Official Journal of the North Carolina Association of Pharmacists 109 Church Street · Chapel Hill, NC 27516 Fax 919.968.9430 www.ncpharmacists.org Like us on Facebook: https://www.facebook.com/ pages/North-Carolina-Association-of-Pharmacists/ 136657113055347?fref=ts Follow us on Twitter: NC Assoc of Pharm
ASSOCIATION STAFF EXECUTIVE DIRECTOR Daniel L. Barbara, Sr., M.Ed. MEMBERSHIP DIRECTOR Teressa Reavis EVENTS DIRECTOR Sandie Holley ADMINISTRATIVE DIRECTOR Linda Goswick BOARD OF DIRECTORS PRESIDENT Michelle Ames, Pharm.D. PRESIDENT-ELECT Ashley Branham, Pharm.D. PAST PRESIDENT Mary Parker, Pharm.D. TREASURER Dennis Williams, Pharm.D. BOARD MEMBERS Randy Angel, Pharm.D. Andy Bowman, Pharm.D. Paige Brown, Pharm.D. Thomas D’Andrea, R.Ph., M.B.A. Stephen Dedrick, R.Ph., M.S. Lisa Dinkins, Pharm.D. Leigh Foushee, Pharm.D. Ted Hancock, Pharm.D. Jennie Hewitz, Pharm.D. Debra Kemp, Pharm.D. LeAnne Kennedy, Pharm.D. Kim Nealy, Pharm.D. Becky Szymanski, Pharm.D. North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists. An electronic version is published quarterly at 109 Church St., Chapel Hill, NC 27516. The journal is provided to NCAP members through allocation of annual dues. Subscription rate to nonmembers is $40.00 annually. Opinions expressed in North Carolina Pharmacist are not necessarily official positions or policies of the Association and do not necessarily represent the views and opinions of NCAP or of NCAP board members. Publication of an advertisement does not represent an endorsement. Nothing in this publication may be reproduced in any manner, either in whole or in part, without the express
North Carolina
Pharmacist
Vol. 94, No. 3
Fall 2014
Inside
From the Executive Director………………………………………………..4
From the President…………………………..………………………………...5
H.R. 4190 From the Perspective of New Practitioners………….6
New Practitioner Network Member Spotlight……………..……...9
2014 Pharmacy Residency Conference Photo Essay…….…….10
What Can We Do Without Provider Status?……….……..……...13
Pharmacists as Critical Members of the Integrated Care Team…………………………………………………………………………...16
The Second Victim: Caring for the Caregiver………………..…...18
NCAP Calendar for Fall 2014 September 18th at 12:00 PM —Board of Directors Meeting September 18th at 3:30 PM—Provider Status Taskforce September 20th—Student Leadership Conference October 3rd—2014 NC Pharmacy Leaders Forum October 26th-28th—NCAP Annual Convention November 20th at 12:00 PM—Board of Directors Meeting November 20th at 3:30 PM—Provider Status Taskforce
writeen permission of the publisher.
North Carolina Pharmacist, Fall 2014 3
Fall 2014 promises to be an exciting time at NCAP. At the start of a new school year, many of our members and certainly our student pharmacists across the state are resuming their roles as faculty, preceptors, and students. Our schools of pharmacy are each in the process of implementing new programs, innovative ideas, and/or new curriculum. There is a sense that pharmacy, not only in North Carolina, but nationally, is moving forward, endeavoring to keep pace with the everchanging landscape that is health care. NCAP is certainly a part of the effort to ensure that pharmacy remains at the cutting edge of health care and that pharmacists, who have always been the trusted confidants of and advocates for their patients, continue to be in a position to provide the care that their patients need and deserve while receiving appropriate recognition and compensation for doing so. This is no small task, considering the extremely complex environment of health care practice and reimbursement (including the government and private sector health insurance markets). Now, more than ever, it is essential that pharmacy coalesce around and advocate for inclusion in the decisionmaking process related to health policy and the development and implementation of new practice models, services, and reimbursement schema that advance quality healthcare, streamline patient access to care, and ensure the solvency of care providers.
primary topic of the 2014 NC PLF is the “Role of Pharmacy in NC.” Participants are tasked with considering the current role of pharmacy in North Carolina and discussing the future of pharmacy practice from a uniquely North Carolina perspective with the goal of developing clear, concise, and unifying statements regarding the future of pharmacy practice that will help guide advocacy efforts across the state in the coming year. Setting the stage for current and upcoming advocacy efforts on behalf of our members and providing quality comprehensive information regarding both clinical and public policy issues is the upcoming NCAP Annual Convention, a preview of which was provided to you on the front cover of this issue. The focus of this year’s convention is the “Changing Role of Pharmacy,” and as you can well imagine the diversity of subjects within that topic are nearly endless. While providing the customary specific educational opportunities related to pharmacy practice that are the hallmark of our NCAP conventions, our speakers, presenters, and panelists will attempt to help you, as participants and attendees gain key insights into the many innovative practice models statewide and nationally which are integral to discussing the current and changing role of pharmacy and to gauging where pharmacy will be in the future.
I look forward to continuing to work with you To that end, and anticipating the need for the devel- throughout the fall season and to the exciting venues for colopment of solid public policy and position statements specifi- laborative discussion and learning NCAP offers. See you at cally tailored to the North Carolina practice environment, convention! NCAP has established a Provider Status Taskforce to study the issue of state and federal level provider status efforts. By collaborating with and learning from efforts underway at the Most sincerely, local, state, regional, and national level across the country and across the associations representing various segments of pharDaniel “Dan” Barbara, Sr., M.Ed. macy practice, it is certain that we can work together to develExecutive Director op and encourage the implementation of sound public policy that is representative of both pharmacy interests and the interests of the patients pharmacy serves. The work and make-up of this taskforce are representative of the diversity of pharmacy practice. In addition to in-house efforts (as it were), NCAP is once again actively participating in the development of the program for the NC Board of Pharmacy-sponsored annual Pharmacy Leaders Forum in early October. The purpose of this forum is to provide pharmacy leaders from across the state and across the various pharmacy disciplines an opportunity to discuss, find, and recommend solutions to issues and challenges facing pharmacy now and in the near future. The
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Greetings NCAP members!
I find it amazing that I am addressing you with my third journal message and more than half of my term as President of NCAP now behind me. The calendar for the remainder of 2014 holds an extensive list of wonderful programs and events, promising to make the last half of my term pass equally as quickly.
united group of students presented to the NCAP Board of Directors in July, showcasing extensive efforts in creating bylaws and formal organization. I speak confidently for the Executive Committee and Board in expressing our enthusiasm over expanding student involvement and excitement at formalizing SPN.
Provider Status and HR 4190 persist as hot topics both locally and nationally. On a local level, NCAP’s Provider Status Committee continues to shape up nicely under Patrick Brown’s leadership as Chair. While national headlines report progress across the country on the expanding definition of the pharmacist as provider, this committee is eager to see action in North Carolina. On a national level, APhA reports growing encouragement of HR 4190 with 31 elected officials issuing their support in July alone, with a total of 94 co-sponsors. I encourage each of you to find a way to contribute to the success of the provider status effort by writing letters to your Representatives or participating on a committee. As Ghandi said best, “You must be the change you wish to see in the world.”
Convention planning continues to drive onward with our Education Committee Co-Chairs Jenn Wilson and Sonia Everhart providing excellent direction for programming. The theme “Pharmacy’s Modern Role in 2014” fits perfectly with the hot topics of HR 4190 and defining provider status for pharmacists now on the legislative forefront. NCAP is thrilled to have Mollie Scott serving as our keynote speaker offering her perspective on this important topic. The North Carolina Alliance for Healthy Communities (NCAHC) offers programming in conjunction with convention, a new partnership NCAP is very excited to see blossom. Needless to say, the annual convention offers a wealth of information relevant across all practice settings which you will not want to miss! I look forward to seeing each of you at many of the NCAP events this fall! Development of October’s 2014 Pharmacy Leaders Forum is also in full swing with NCAP Executive Director Daniel Barbara and Dean Ronald Ragan co-chairing the planning committee. Significant attention to the current and future roles of pharmacy in North Carolina lies within the topics for this meeting. Attendees will be tasked with developing a position statement articulating the role of pharmacists in health care in NC. The committee is excited to have a broad range of leaders in pharmacy representing nearly every practice setting contributing to what is destined to be a lively debate.
Michelle Ames, Pharm.D. President
The annual Residency Conference held in July produced another year of success. Attendance was exceptional! NCAP is extremely grateful to Jamie Brown for his efforts and dedication to planning a truly wonderful event.
NCAP continues to work with the student groups from all NC schools of pharmacy in an effort to finalize the “Student Pharmacist Network” (SPN). The group intends to be a collective student organization of NCAP representing all schools of pharmacy, serving as a voice for our future pharmacists. A
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“Look at the world around you. It may seem like an immovable, implacable place. It is not. With the slightest push - in just the right place - it can be tipped.” ― Malcolm Gladwell, The Tipping Point: How
Little Things Can Make a Big Difference
H.R. 4190 was introduced in the House of Representatives in 2014 and is more commonly known as the Pharmacist Provider Status Act. The bill is currently in the Ways and Means Committee of the House, and a companion bill is expected to be introduced in the Senate later this year. This bill represents a critically important advancement in pharmacy practice, because it seeks to increase access to clinical pharmacy services throughout the country. The proposed amendment to Title XVIII of the Social Security Act would recognize pharmacists as health care providers, thereby allowing for the expansion of clinical pharmacy services for Medicare beneficiaries residing in medically underserved areas1. Rural and medically underserved areas typically have a shortage of primary care physicians, and this disparity is expected to worsen with an overall projected 20,400 FTE shortage by 20202. Healthcare systems are currently undergoing significant changes
by Amanda Kaye Peters, Pharm.D. and Autumn D. Carroll, Pharm.D.
while seeking to achieve the Triple Aim, which includes improving care for populations and individuals, lowering costs, and improving the patient experience3. The Patient Centered Medical Home (PCMH) model is a successful strategy for reorganizing primary care that stresses patient-centered care while allowing each member of the healthcare team to work at the top of his or her license. On average, a physician spends 20.8 minutes in a face-to-face encounter with a patient4. During this short amount of time, the physician is expected to take an accurate history, diagnose the problem, educate the patient, and prescribe a medication. Managing chronic conditions also requires frequent follow-up, which may be delayed if access to care is poor. Pharmacists trained in ambulatory care are important members of the health care team and have the knowledge and skills necessary to manage chronic conditions. The role of pharmacists in the PCMH has been defined by Marie Smith to include medication therapy
management, optimization of patients’ regimens, assessing compliance, and proposing cost-saving alternatives to current therapies5. By utilizing pharmacists in these roles, the PCMH model allows physicians to focus on diagnosis and treatment, while ensuring appropriate follow-up and long-term management by other qualified healthcare professionals, including pharmacists. Although the role of pharmacists in primary care has been defined, there is a lack of pharmacy presence in many primary care physician offices across the United States. Inadequate reimbursement has been the biggest barrier to the inclusion of pharmacists in PCMHs. Many pharmacists in physician offices are co-funded by pharmacy schools or grants and rely on costsaving analyses to show financial benefit, which can take years to demonstrate. Smaller offices in rural and underserved areas not associated with pharmacy schools simply cannot afford the upfront investment of a pharmacist salary, regardless of the potential cost avoidance in the fu-
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ture. Because pharmacists are not recognized as providers under the Social Security Act, they cannot bill at the level of service provided. Instead, the pharmacist may bill “incident to” a physician for a fiveminute nurse visit (99211), which averages around nineteen dollars in reimbursement6. The management of a complex chronic condition such as diabetes requires more time, critical thinking, and problem-solving than a five-minute visit allows. Approval of H.R. 4190 would allow pharmacists to bill Medicare at the level of service provided with the likelihood that Medicaid and private insurance companies would follow suit. This change would increase reimbursement by approximately fifty dollars per visit, more easily justifying the cost of adding a clinical pharmacist to the patient care team. Despite the financial barriers associated with embedding pharmacists into the PCMH, several practices in Western North Carolina have incorporated Clinical Pharmacist Practitioners (CPPs) in primary care clinics. These pharmacists are providing patient education, stressing primary prevention measures, managing chronic disease states, reconciling medications and coordinating transitions of care, and leading Medicare Annual Wellness visits. The CPP is a unique credential from the NC Boards of Medicine and Pharmacy and allows the pharmacist to initiate, modify, and monitor drug therapy in collaboration with a supervising physician7. At Mountain Area Health Education Center (MAHEC) Family Health Center, CPPs are important team members providing coordinated whole person care. CPPs manage clinics for pharma-
cotherapy consults, anticoagulation, Medicare Annual Wellness Visits (AWV), transitions of care, and employee wellness. MAHEC is an educational hub for medical students and physicians training in family medicine, OB/GYN, geriatrics, and sports medicine, as well as pharmacy students and pharmacists training in ambulatory care. As recent graduates of MAHEC and Mission’s PGY-1 ambulatory care pharmacy residency program, we had the fortuitous opportunity to work in this collaborative environment and see firsthand the impact pharmacists can have in primary care. We received many consultations for the chronic disease state management during our year at MAHEC, many of which required monthly, and sometimes weekly follow-up visits. One patient in particular, a 31-year-old female with uncontrolled type 2 diabetes, was being seen by one of the resident physicians. This patient was extremely high risk, with established coronary artery disease, a current smoker with COPD, and peripheral neuropathy. Prior to her visit with a pharmacist, her most recent A1c was 11.4% on Lantus 90 units twice daily and Humalog 42 units with every meal. Because this patient was on extremely high doses of insulin, the resident wanted to transition to insulin regular U-500 but was hesitant to do this on her own. During a joint visit, we were able to transition the patient to U500, and provide essential education on administration and dosing. We also provided education for the patient about all of her medications and lifestyle changes that she could make to improve her health. Now the patient’s blood sugars are much
better controlled with an A1c of 8.2%, and the patient is pleased with the switch. In this situation, potentially fatal errors in dosing and administration may have been avoided with a high-risk medication, and better glycemic control was achieved through collaboration with a pharmacist available on site. Moreover, this team approach improved elements of the Triple Aim by improving the patient’s health along with her patient experience. As new practitioners searching for employment, it is frustrating to appreciate the potential impact of pharmacists in primary care only to face a financial roadblock to finding employment in this area. Many physicians in Western North Carolina, especially those trained at MAHEC, realize the importance of H.R. 4190 to increasing patient access to pharmacists. In the words of Dr. Jeff Heck, CEO and family physician at MAHEC and Dean of the UNC School of Medicine’s Asheville Campus, “Primary care will thrive and our patients will be healthier if every practice has a clinical pharmacist.” Imagine the impact we could make on patient health outcomes if all physicians had the opportunity to see the value of a pharmacist at their practice site. The world of healthcare can feel like an immovable, implacable place, especially to new practitioners. H.R. 4190 carries the promise of significantly impacting the delivery of healthcare and changing pharmacy practice, allowing pharmacists to have a seat at the table that we have never had before. We feel we are at a tipping point, and H.R. 4190 is the push in the right direction to advance clinical pharmacy services by dupli-
North Carolina Pharmacist, Fall 2014 7
cating the types of experiences we had as pharmacy residents into rural, underserved areas. For more information about H.R. 4190 and provider status for pharmacists, go to www.ashp.org and www.pharmacist.com. Links are available on these websites with information regarding how you can reach out to your own representatives in Congress. The authors would like to thank Mollie Scott, Pharm.D., BCACP, CPP, for her review of our manuscript. References 1
“To amend title XVIII of the Social Security Act to provide for coverage under the Medicare program of pharmacist services.” (H.R. 4190). GovTrack.us. Retrieved May 30, 2014, from https:// www.govtrack.us/congress/ bills/113/hr4190 2
“Projecting the Supply and Demand for Primary Care Practitioners Through 2020 In Brief”. US Department of Health and Human Services. Retrieved May 30, 2014 from http:// bhpr.hrsa.gov/healthworkforce/ index.html.
4
“15-Minute Visits Take A Toll on the Doctor-Patient Relationship”. Kaiser Health News. Retrieved July 17th, 2014 from http://www.kaiserhealthnews.org/ stories/2014/april/21/15-minutedoctor-visits.aspx. 5
Smith M, Bates DW, Bodenheimer T, et. al. Why Pharmacists Belong In The Medical Home. HEALTH AFFAIRS. 2010;29(5): 906–913 6
Centers for Medicare & Medicaid Services. Physician fee schedule. http://www.cms.gov/ apps/physician-fee-schedule. Accessed 8/13/14 7
NCBOP: Clinical Pharmacist Practitioners. http:// www.ncbop.org/ pharmacists_cpp.htm. Accessed 8/13/14. 8
Gladwell, M. (2000). The tip-
ping point: How little things can make a big difference. Boston: Little, Brown.
3
Institute for Healthcare Improvement. IHI Triple Aim Initiative. http://www.ihi.org/ Engage/Initiatives/TripleAim/ Pages/MeasuresResults.aspx. Accessed 8/12/2014.
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New Practitioner Network Member Spotlight
Tasha Woodall, Pharm.D., CGP, CCP Tasha Woodall received her Pharm.D. from Purdue University in West Lafayette, Indiana. Upon graduation, she came to Asheville, North Carolina to complete her PGY1 Pharmacy Practice Residency in Ambulatory Care with Mission/MAHEC. She earned her Certification in Geriatric Pharmacy (CGP) in 2013. Dr. Woodall currently serves as Assistant Professor of Clinical Education for the UNC Eshelman School of Pharmacy and Associate Director of Pharmacotherapy in Geriatrics at Mountain Area Health Education Center (MAHEC) in Asheville. At MAHEC, her practice sites include two continuing care retirement communities, where she works with residents in the ambulatory setting. Dr. Woodall became involved in NCAP to form a closer network with other progressive-minded pharmacists. She recognizes the value of grassroots support that can be fostered at the state level, especially for legislation such as H.R. 4190, which “has the potential to so greatly advance the level of care pharmacists are able to provide.” She feels that NCAP enables her to learn from others how to work alongside pharmacist leaders to leave a legacy of excellence for future generations of pharmacists. Her piece of advice to other new practitioners: “Patience is a virtue: just because you know the extent of your own knowledge base doesn’t mean other health care providers are equally as familiar. It takes time to build a trusting relationship that can serve as a solid foundation for flourishing team-based care.”
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15th Annual Pharmacy Residency Conference
Steve Kearney, Pharm.D., Co-Moderator, representing Pfizer (co-sponsor of the 2014 Pharmacy Residency Conference) introduces the morning program. Jamie Brown, Pharm.D., Co-Moderator and Chair of the NCAP Residency Committee, introduces the afternoon program.
NCAP Executive Director Dan Barbara, M.Ed. encourages residents to become and remain actively involved in their state association and in the legislative process.
Rowell Daniels, Pharm.D., M.S., Director of Pharmacy, UNC Medical Center and Executive Associate Dean of UNC Eshelman School Pharmacy, delivered the Keynote Address entitled “Punctilious Leadership.�
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Steve Kearney, Pharm.D., Co-Moderator, representing Pfizer (co-sponsor of the 2014 Pharmacy Residency Conference) introduces the morning program.
The Fifteenth Annual Pharmacy Residency Conference boasted record attendance and participation resulting from the efforts of the NCAP Residency Committee, the participating preceptors, and the encouragement of all participating schools of pharmacy.
Program roundtables for residents (led by the NCAP New Practitioner Network) focused on “Getting the Most Out of the Residency Year.”
Preceptors discussed “Developing Successful Residents and Programs.”
Mary H. Parker, Pharm.D., Past-President of NCAP (representing the NCAP Executive Committee), discussed “Advancing Pharmacy Practice: Where to Begin?”
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What Can We Do Without Provider Status? by Courtenay Gilmore Wilson, Pharm.D., BCPS, CDE, CPP Provider status remains one of the main obstacles to fully integrating clinical pharmacy services into ambulatory healthcare settings. The 2011 Report to the Surgeon General highlighted pharmacists in physician practices as a way to increase access to care, improve patient outcomes, and reduce healthcare costs1. To meet these goals, the Report stresses the importance of recognizing pharmacists as providers as well as reforming payment structures to allow for reimbursement of pharmacists’ cognitive services. In March 2014, legislation was introduced in the US House of Representatives that seeks to recognize pharmacists working in Medically Underserved Communities as providers, which would greatly expand the role of the clinical pharmacist on the healthcare team. However, even in the absence of provider status, there are several options available for pharmacists to generate revenue for a physician practice.
opportunity for pharmacists to generate revenue for a physician’s office3. Warshany, et al. recently described the implementation of a pharmacistadministered AWV clinic that successfully billed for AWVs conducted by the pharmacist5. In January 2013, Medicare introduced new Transitional Care Management (TCM) codes in efforts to improve care coordination and reduce readmissions6. Two required components for utilizing these codes are: 1) communication with the patient within two days of hospital discharge; and 2) medication reconciliation6. Pharmacists may complete these required components, allowing for the physician to employ the TCM code for the office visit, which is reimbursed at a level significantly higher than the Level 4 or Level 5 office visit3.
Due to the aging population and the expansion of health insurance coverage under the ACA, the U.S. is faced with an expected shortage of primary care physicians. Consequently, team-based care models, including the Currently, many pharmacists Patient Centered Medical Home practicing in physicians’ offices utilize (PCMH) and Accountable Care Organithe “incident to” method. This allows zation (ACO), are gaining momentum as pharmacists and other non-physician healthcare providers (i.e. nurses) to bill a way to better utilize non-physician services. These models offer new opportufor their services under the physician’s 2 name . For pharmacists, this method of nities for pharmacists in the ambulatory care setting. In these settings where paybilling is limited to a Level 1 or 99211 ment is driven by performance, the visit, which is reimbursed at a rate of pharmacist is the team member respon3 about $19 . With such low reimbursesible for maximizing patient outcomes ment potential, billing solely with the with comprehensive medication manageLevel 1 visit is not a financially viable 6 way to sustain clinical pharmacy services. ment . The 2014 Ambulatory Care Summit hosted by the American Society of In 2011, the Medicare Annual Health-System Pharmacists (ASHP) Wellness Visit (AWV), which focuses released several briefing documents, heavily on preventive care services, was including one regarding outcomes evaluintroduced as part of the Affordable ation. This report outlines 23 of the 33 Care Act (ACA). This visit may be con- ACO core measures that may be imducted by any healthcare provider work- pacted by a pharmacist7. Thus, pharmaing under the direct supervision of a cists are important members of the team physician, including pharmacists4. Aver- who may help achieve and maintain age reimbursement rates are $160 for these designations. the initial AWV and $110 for subseAchieving provider status requent AWVs, presenting a significant
mains a priority for many pharmacists. Until this occurs, we must take advantage of existing revenue streams that allow pharmacists to establish a presence in physician practices. By doing so, we will be well positioned to capitalize on the opportunities that provider status will offer. 1
Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice. A Report to the U.S. Surgeon General. Office of the Chief Pharmacist. U.S. Public Health Service. Dec 2011. 2
Scott MA, Hitch WJ, Wilson CG, Lugo AM. Billing for pharmacists’ cognitive services in physicians’ offices: Multiple methods of reimbursement. JAPhA 2012; 52:175-180. 3
Physician fee schedule. www.cms.gov/apps/ physician-fee-schedule/search/searchcriteria.aspx. Accessed February 10, 2014. 4
Centers for Medicare & Medicaid Services. Quick reference information: The ABCs of providing the Annual Wellness Visit. http:// www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNProducts/downloads/ AWV_chart_ICN905706.pdf. Accessed February 10, 2014. 5
Warshany K, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. AJHP 2014;71:44-49. 6
Centers for Medicare & Medicaid Services. Transitional Care Management Services. http:// www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNProducts/Downloads/Transitional-CareManagement-Services-Fact-SheetICN908628.pdf. Accessed February 10, 2014 7
Patient-Centered Primary Care Collaborative. The Patient Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. June 2012. http:// www.pcpcc.org/sites/default/files/media/ medmanagement.pdf Accessed February 10, 2014 8
Kliethermes MA. Outcomes evaluation: Striving for excellence in ambulatory care pharmacy practices. ASHP Ambulatory Care Conference and Summit. March 2014.
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Pharmacists as Critical Members of the Integrated Care Team by Samuel Stolpe, Pharm.D., Director, conducted by a pharmacist improved medi- quality. Payors are not the only health care Pharmacy Quality Alliance (PQA) & Maria cation adherence more than any other pro- organizations with quality goals. Other Scalatos, Pharm.D., Executive Fellow, PQA fessional in any other setting. health care organizations have performance measures that they are accountable for that The future of quality patient care This represents a tremendous can be directly influenced by pharmacists. relies on learning from the success stories opportunity for pharmacies. But to take In addition to making contributions to and best practices of today in order to advantage of this opportunity, pharmacists health plan quality goals, pharmacists can shape the health care system of tomorrow. must transition their approach from a mindreach out to local Accountable Care OrganSix Medicare plans were recently acknowl- set of quality measurement resistance, to izations (ACOs), and Patient Centered edged by the Pharmacy Quality Alliance quality measurement engagement. To faciliMedical Homes (PCMHs) to look for col(PQA) for excellence in medication safety, tate this transition to becoming an engaged laboration points. Examples of areas that based on the Centers for Medicare & Medi- partner, many community pharmacies are pharmacists can impact include ACO caid Services’ (CMS) Star Ratings. The Chi- using EQuIPP, the Electronic Quality Immeasures of medication reconciliation and nese Community Health Plan of California, provement Platform for Plans & Pharmainfluenza immunization, or helping them Humana’s Medicare plan in Illinois, and cies. EQuIPP is a performance information reach quality measure goals related to chofour Kaiser Permanente regions (California, management platform that provides unbilesterol, A1Cs, and blood pressure through Colorado, Hawaii and the Mid-Atlantic ased, benchmarked data on the quality of appropriate medication management. Of region) were recognized for their achievemedication use to both health plans and the 33 quality measures a federal Medicare ment of a 5-star rating on the PQA community pharmacies. It allows pharmaShared Savings Program ACO has to meet, measures of medication safety and approcists at an individual store or corporate levat least 11 of them can be influenced by priate use that are included in the CMS Star el, to see exactly how individual pharmacies community pharmacists. Focus should be Rating Program for Medicare plans, as well are performing on the medication use qualicentralized on interventions that drive speas achievement of at least a 4.5-star sumty measures that matter to payors. cific goals; communicating ways in which mary plan rating. The six awardees spoke to The unique position of pharmapharmacists influence the safe and effective the best practices that contribute to their cists in the community setting grants enuse of medications and reach these goals outstanding medication management, and hanced patient access and excellent oppor- will lay the foundation for the pharmacist’s ultimately ensure optimal medication outtunities for medication management. Phar- role in integrated care teams. comes. macists are increasingly viewed as a key Pharmacy Quality Alliance. PQA Recognizes With the advent of new quality collaborative partner. Managing the quality Six Medicare Plans for Excellence in Medication incentive structures put in place through of medication use is now a recognized com- Use and Safety Based on CMS’ Star Ratings federal government programs, health plans ponent of ensuring optimal care. Collabo- [Press release]. http://pqaalliance.org/images/ and PBMs are becoming increasingly foration on shared quality targets and goals uploads/files/Press%20Release% cused on medication use quality. Pharma- connects pharmacies to other partners 202014_QualityAward.pdf. Accessed June 30, 2014. cists can contribute meaningfully to the along the care continuum. quality goals of these organizations as a Cutrona S, Choudhry N, Shrank W, et al. Pharmacies are not exempt from member of a virtual integrated care team. Modes of delivery for interventions to improve quality measurement. Health plans and Of the fifteen quality measures used by cardiovascular medication adherence. The PBMs are already moving forward with American Journal Of Managed Care [serial CMS to evaluate Medicare Part D plans in incentive and penalty programs for pharmaonline]. 2010;16(12):929-942. Available from: 2014, five relate to medication safety and cies based on quality performance. PharMEDLINE, Ipswich, MA. Accessed June 30, adherence. These measures account for macists are an integral part of the solutions 2014. nearly 50% of a given Part D sponsor’s star to meet payors’ quality needs. Being proacCenter for Medicare and Medicaid Services. rating, and represent a potential impact area tive in this new quality environment is a ACO Quality Measures. http://www.cms.gov/ for pharmacist intervention. In fact, in a must. Moving forward, pharmacists should Medicare/Medicare-Fee-for-Service-Payment/ systematic review of interventions to imlook to initiate dialogue, establish and nur- sharedsavingsprogram/Downloads/ACO-Sharedprove adherence to medications for cardioSavings-Program-Quality-Measures.pdf. Acture relationships, and seek opportunities to cessed June 30, 2014. vascular disease and diabetes, Cutrona, et deliver point-of-care interventions that drive al. found that interventions in a pharmacy 1
2
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The Second Victim: Caring for the Caregiver by Mariel Pereda, Pharm.D. Candidate, Class of 2015, UNC Eshelman School of Pharmacy
professional performance.
After being involved in an error, second victims can experience both emotional and physical distress.3 ComA medical error happens in your organization. The first victim is the mon emotional and physical symptoms patient and/or his/her family members. are presented in Table 1. Accordingly, many health care organizaIt is not uncommon for second tions have mechanisms in place to pro- victims have doubts about their compevide support to these first victims. tence and abilities following a medical error. These doubts can lead to secondBut what about the second victim? guessing, difficulty making decisions, Who is the second victim? requests to leave clinical care areas, or a The second victim is the health desire to leave their place of employcare provider involved in a medical er- ment or profession entirely. ror or patient event who has been trauMany patient safety and quality matized by the event.1 The range of organizations recognize the second viceffects on a provider can be from mild tim phenomenon, including the Agency and transient, to serious and persistent. for Healthcare Research and Quality, The degree to which a health care Institute for Healthcare Improvement, worker is affected is not necessarily re- National Quality Forum, National Palated to the severity or outcome of the tient Safety Foundation, The Joint error. Many factors affect where an in- Commission, and The American Sociedividual falls on the spectrum of reacty for Health Risk Management. Additions, including individual characteristionally, a number of medical and nurstics, cultural or environmental factors, ing organizations have published studies and the significance of the event itself. and resources related to the topic, including the American Medical AssociaIn 2011, ISMP published the tion and the American Nurses Associastory of a nurse who was involved in a tion. medication error that resulted in the death of her critically ill patient. The How do we care for second victims? nurse was fired from the hospital where Just as there are “rights” of she had worked for 27 years. Her state licensing board issued a four-year pro- medication safety, there are also rights of the second victim. An easy acronym bation period during which she was to help you remember these is required to be supervised during all “TRUST,” which stands for:1 medication administration activities. Despite her years of experience, she T – Treatment that is just. The first step was unable to find employment as a in helping the second victim is acknowlnurse following the highly publicized edging that the second victim exists. event. Seven months after the event, Second victims deserve not to be abanshe took her own life.2 doned by their organization, managers, and peers. Health care delivery occurs Healthcare workers dedicate in a complex system, and we cannot their lives to helping others and can become distressed when their mistake assign full responsibility for a medical error to one person. results in harm. The case above highlights one extreme consequence. How- R – Respect. Give second victims the ever, minor traumas can occur even respect they deserve as human beings as more frequently. These less extreme well as healthcare professionals. Shamresponses are also harmful, since they ing remarks or actions are neither apcan affect an individual’s well-being and
propriate nor constructive. U – Understanding and compassion. Following a medical error, leadership and peers should reach out to the individual involved. Second victims often need someone who understands their situation, who is familiar with their work, to empathize with them. S – Supportive care. Second victims should be encouraged to make use of counseling services. Additionally, if the situation calls for it, the individual should be directed to legal services. It is important to know how and where to refer someone within and outside your organization. Details on support programs for second victims follow in the next section. T – Transparency and the opportunity to contribute. An important part of healing is the opportunity to participate in the learning that takes place after the event. Allow the second victim to provide insight into the event and potential solutions moving forward. Support Programs for Second Victims Scott et al. identified a threetiered model for second victim support systems.4 The first tier is the immediate “emotional first aid.” This occurs at the local or departmental level. The second tier provides more aggressive support, connecting individuals with patient safety or risk management experts. The third tier involves referral to professional counseling services. Some individuals may only require the first tier of support while others may need a higher level. Regardless, all levels should be readily available. The current body of literature provides little guidance on what specific elements to include in an effective second victim support program. However, some key elements to consider are:
Timing of Support The initial period after the event is the most crucial. A manager or supervisor North Carolina Pharmacist, Fall 2014 18
Table 1:
Emotional Symptoms3
Physical Symptoms3
Frustration
Extreme fatigue
Anger
Sleep disturbances
Extreme sadness/depression
Increased blood pressure
Self-doubt/loss of confidence
Muscle tension
Anxiety about returning to work
Rapid heart rate/breathing
Difficulty concentrating Flashbacks
should provide support immediately. A way to structure a support program, but protocol should make clear regarding other ways may be more appropriate who is formally responsible for reachfor your organization. ing out to the second victim.
A Hospital-wide Commitment
Relief from Clinical Duties What is the protocol in the event that the second victim is unable to return to work in the days following the event? A plan should be in place to address relief from clinical duties in the aftermath of a medical error.
A strong support program can only be achieved with the support of hospital leadership. Provide training to managers and employees on how to support second victims.
One example of a welldeveloped second victim response proLegal Concerns gram is the University of Missouri Health System’s for YOU team, made Legal consultation should be sought up of health care clinicians trained to when building a program to ensure the assist second victims. A dedicated pager protection of conversations. Managers line connects individuals in need with a should familiarize themselves with these team member 24/7. When peer suplegal requirements. port is not enough, the program can Varying Levels of Support connect individuals with an employee Programs should provide varying levels assistance5 program or a clinical psychologist. of support, ranging from peer discussion groups to formalized counseling The program also provides services. The three-tiered model is one brochures for staff and their families to
help them understand the second victim experience. Additionally, the program’s website features a “Share Your Story” portal through which users are invited to anonymously share their experiences with or as second victims.5 This story-telling tool is an important way to learn valuable lessons about the second victim experience. How do I get started? Developing or enhancing your second victim support program will take time. Here are a few important first steps that you can get started on today. Identify which resources already exist in your organization. Identify who should be involved in building a second victim program. Develop a policy on caring for second victims. Develop training materials to introduce the topic to staff. North Carolina Pharmacist, Fall 2014 19
Denham C. TRUST: The 5 Rights of the Second Victim. Patient Saf. 2007;107-19 1
be addressed to John Kessler, PharmD at jkessler@secondstoryhealth.com
ISMP Medication Safety Alert. July 2011. 2
Scott SD, Hirschinger LE, et al. The natural history of recovery for the healthcare provider “second victim� after adverse patient events. Quality & Safety in Health Care. 2009;325-30 3
Scott SD, Hirschinger LE, et al. Caring for Our Own: Deploying a Systemwide Second Victim Rapid Response Team. 4
The Joint Commission Journal on Quality and Patient Safety. 2010;36:233 -40. University of Missouri Health System. Understanding Second Victims . http:// www.muhealth.org/secondvictim 5
Ms. Pereda authored this paper during her medication safety clerkship at SecondStory Health, LLC in Carrboro, NC, June 2014. Correspondence can
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