North Carolina Pharmacist Winter Journal 2014

North Carolina

Pharmacist Vol. 94, Number 1

Advancing Pharmacy. Improving Health.

Winter 2014

Introducing Daniel L. Barbara, Sr. Executive Director, NCAP s eeding ing c o r P eet orum ders F ronic Care M a e L y ac Ch for the • Pharm Inside: Register Now •

Enjoy the view at NCAP’s

Chronic Care Practice Forum Meeting

March 19-21, 2014 The Ballantyne Hotel & Resort Charlotte, NC

16 Hours of Quality CE with featured speaker Kelly Jones Sessions include: • Reduction on Antipsychotic Medications in Nursing Homes • Everything but Insulin: An Intensive Medication Review • Evidence-Based Medicine Brain Teasers • Renal Refresher: Medication Therapy Management in CKD/ESRD • Primary Care New Drug Update 2014 • The Final Frontier? Seeking Out Precepting Opportunities and Where to Begin • Anticoagulation Review: Where Are We Now? • Journey to Starting Your Own Business/Practice: Considerations for Success • Special Disease State Medication Procurement and Clinical Management • Regulatory Update for Long-Term Care Pharmacy • Healing Acute and Chronic Wounds in LTC Settings: A Complex Challenge • Evolving Strategies for Stroke Prevention in Patients With Atrial Fibrillat • Caring for Spinal Cord Injury Patients in Rehab Setting • Golf, Exhibits, Poster Session and more!

Hotel cut-off date is March 5, 2014.

More information at www.ncpharmacists.org

Official Journal of the North Carolina Association of Pharmacists 109 Church Street • Chapel Hill, NC 27516 800.852.7343 or 919.967.2237 fax 919.968.9430 www.ncpharmacists.org

JOURNAL STAFF

North Carolina

Pharmacist Vol. 94, No. 1

Winter 2014

EDITOR Sally J. Slusher ASSOCIATE EDITOR Fred Eckel EDITORIAL ASSISTANT Linda Goswick Teressa Reavis

BOARD OF DIRECTORS PRESIDENT Michelle Ames PRESIDENT-ELECT Ashley Branham PAST PRESIDENT Mary Parker TREASURER Dennis Williams BOARD MEMBERS Randy Angel Andy Bowman Paige Brown Thomas D’Andrea Stephen Dedrick Lisa Dinkins Leigh Foushee Ted Hancock Jennie Hewitt Debra Kemp LeAnne Kennedy Kim Nealy Becky Szymanski 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. Publication of an advertisement does not represent an endorsement.

Nothing in this publication may be reproduced in any manner, either whole or in part, without specific written permission of the publisher.

Inside • From the Executive Director............................................ 4 • From the President ........................................................ 5 • Proceedings from the 2013 North Carolina Pharmacy Leaders Forum...................... 6 • Safety Solutions: Protecting Long-Term Care Patients from Getting Lost in Transition .............. 18 • New Practitioner Network: Work-Life Balance: A Resident’s Perspective............................................... 20 • NPN Member Spotlight: Lea Mitchell............................ 21 • 2013 NCAP President’s Club....................................... 22 • Candidates Sought for NCAP Awards, Election. ......... 26 • Pharmacy Time Capsules............................................. 29 • Calendar....................................................................... 29

North Carolina Pharmacist, Winter 2014 3

From the Executive Director

Greetings! I would like to take this opportunity to introduce myself as the new Executive Director of your North Carolina Association of Pharmacists. I am honored to have been chosen by the Board of Directors to serve in this capacity and appreciate this opportunity to assume the reigns of this important organization during a season of substantial change in health care and health care financing.

Pharmacists and the pharmacy industry are truly unique amongst the health care profession, and it is this uniqueness (a balance between care provider, patient advocate, and business leader) that places pharmacists at the cutting edge of the changing environment of health care policy, financing, and direct practice. Pharmacists have long been a familiar face of health care in the community, and while the profession has expanded and changed in recent decades, the principles and values espoused by NCAP and the NCAP membership are timeless.

My role in this organization, under the direction of and in collaboration with the Board of Directors, is to guarantee that NCAP is managed in such a manner as to assure that your goals and vision for the practice of pharmacy in North Carolina are articulated with honesty, clarity, and unanimity of voice. This will be accomplished through the continued development and implementation of membership recruitment and retention programs to ensure that NCAP is fully representative of the interests of a broad base of North Carolina pharmacists, the ongoing support of your established practice forums which are one of the avenues by which your membership are able to collaborate for the benefit of the many segments of pharmacy practice, and through robust and forthright advocacy for the practice of pharmacy statewide.

My set of professional experiences includes a number of positions in which I was called upon to develop and implement new public policy in very complex settings, and I very much enjoy the satisfaction that accompanies success in public policy advocacy resulting in a benefit to the community, much as the efforts of NCAP resulted in the expansion of immunization authority to pharmacists in North Carolina, a new public health tool which increased access to this vital service for community members.

I completed my undergraduate training at Southwestern Assemblies of God University in Waxahachie, Texas and spent the next several years in the elementary classroom and as the superintendent of a small rural Arizona school district.

Following graduate school at Regent University in Virginia Beach I left the elementary school classroom to begin a career of public and non-profit agency management. An Arizona native, I most recently served as the Executive Director of the Department of Health and Social Services for the Colorado River Indian Tribes of Arizona and California. In this capacity I oversaw a complex health and social services agency providing compre4 North Carolina Pharmacist, Winter 2014

hensive public health, behavioral health, and social services to the membership of the Tribe and surrounding community. It was through this experience that I honed skills in complex agency management, diplomacy, and public advocacy, spending many days successfully presenting the concerns of the membership to government agencies within DHHS, including CMS, the Indian Health Service, SAMHSA, and the CDC while advocating in conjunction with the various tribes of the state and in collaboration with many partner agencies for favorable consideration by the State Legislature regarding topics of great importance to the health care industry.

Prior to my time with the Tribes, I served La Paz County, Arizona as the Director of Community Resources, re-establishing and operating the La Paz County Food Bank System (a governmental non-profit organization), overseeing the operations of Adult Education Services, and unifying the County Library System in addition to the management of several community development programs.

I am new to North Carolina, but my wife is not, having been born and raised in Asheboro, and the attraction of the state (the sincerity and rich culture of the people here) coupled with my wife’s desire to return home, drew me. We moved here from the desert only within the past two weeks, enjoying your recent snowstorm while receiving text messages from colleagues back in Arizona that the thermometer had already reached 92 degrees in mid-February. I can honestly say that I am very grateful to be here.

My wife and I have four children (all of them under the age of ten), meaning that they will all likely be competing for enrollment slots in one or more of the fine academic institutions of this state, as we intend to make this state our permanent home.

In closing, I would like to express my sincere appreciation to the NCAP Board of Directors for this opportunity and Mr. Fred Eckel, who has served this organization selflessly for many years in various capacities, most recently serving as the Interim Executive Director. Mr. Eckel, whose wisdom and experience I have already found to be invaluable, will continue his service as the Executive Director Emeritus.

I look forward to navigating these changes with you and ensuring that your voices and the voice of your organization are heard and considered on an ongoing basis. Most importantly, I look forward to working with each and every one of you as you share your wisdom, experiences, concerns, and values with your colleagues and the greater North Carolina community through the North Carolina Association of Pharmacists.

Sincerely,

Daniel L. Barbara, Sr., M.Ed. Executive Director

North Carolina Association of Pharmacists 109 Church Street Chapel Hill, NC 27516 phone: 919.967.2237 • fax: 919.968.9430

Dear Members, 2014 is “off and running” with much happening around the NCAP office. In the midst of the busyness of the office, I am quite excited to begin my term as your President, continuing my involvement with the ongoings of the Association.

As we head into 2014, several thrilling events and amazing opportunities continue to unfold each day. To highlight a few of the current events: • The Search Committee has experienced a demanding year working to identify the next Executive Director to represent NCAP. The committee is thankful to report a successful search has come to completion with our new Executive Director Dan Barbara now onsite. NCAP shares both excitement and eagerness to move our Association forward with the help of Dan. We are pleased to welcome him to his new post. While the process has been lengthy, all those who generously donated their time have done so with the confidence of ensuring a Director who is perfectly fit for our association. Jennifer Buxton provided exceptional service to NCAP by serving as point person for coordinating the search process throughout 2013.

• With the success of passed House Bill 832: Expanding the Role of Immunizing Pharmacists in 2013, we look forward to the next legislative issue on the agenda: laying the groundwork for NCAP’s position on pharmacist provider status. The Board and Executive Committee will be calling on members to provide expertise and input as we begin constructing our strategy in the coming months. Only with the valuable insight of our members can we craft a solid stance on a very important issue likely to impact reimbursement in the future.

• The Chronic Care Practice Forum annual meeting is scheduled for March 19th through 21st at the Ballantyne resort in Charlotte. This energizing meeting is packed full of information, offering 15 hours of continuing education to attendees. Registration is now open on the NCAP website. A special thank you to Ted Hancock, Jena Ivey Burkhart and the Chronic Care planning committee for organizing what promises to be an outstanding three day event!

• NCAP’s new and improved website rollout occurred in January. The devoted effort of the NCAP staff has brought our organization up to date with a new online appearance. Please take some time to navigate the new site, update your member profile and offer any constructive feedback as we continue to improve our online community.

Looking ahead to what promises to be an eventful year, I do so with much gratitude to my fellow Executive Committee members, Mary Parker, Ashley Branham and Dennis Williams, along with the experienced guidance of Fred Eckel. With the dedication of this outstanding group, NCAP has continued to prosper.

A new year can only rightfully begin with a solid goal, mine being to actively involve more of our members in NCAP. In the words of William Arthur Ward, “Do more than belong: participate. Do more than care: help. Do more than believe: practice.” Being a member of NCAP has merit and benefit; being actively involved offers immense ways to find reward.

Sincererly, Michelle Ames, PharmD President

Advancing Pharmacy. Improving Health.

North Carolina Pharmacist, Winter 2014 5

Proceedings from the 2013 North Carolina Pharmacy Leaders Forum

By Michael Manolakis, PharmD, PhD Assistant Dean for Student Development & Associate Professor Wingate University School of Pharmacy

and

Bryant Summers, PharmD Drug Information Resident Wingate University School of Pharmacy

Background The North Carolina Leaders Forum (NCLF) was created for the purpose of gathering North Carolina pharmacy leaders to discuss the profession’s future needs in North Carolina. The first NCLF dates back to the early 1980s when community pharmacist and Board member Whit Moose proposed the meeting concept to David Work during his tenure as Executive Director of the NC Board of Pharmacy.1 The pharmacy leaders in attendance included representatives from the pharmaceutical industry (Burroughs Wellcome in the early years and Glaxo in the later years), the North Carolina Pharmaceutical Association, the North Carolina Retail Merchants Association, the chain pharmacies operating in NC, the UNC School of Pharmacy (Campbell University School of Pharmacy and Wingate University School of Pharmacy opened after this time), the North Carolina Society of Hospital Pharmacists and the American Society of Consulting Pharmacists (ASCP) North Carolina Chapter. The basic composition of the pharmacy leaders in attendance has not changed; however, practitioner representation now comes from NCAP, which was formed after the NCLF began. Two core organizing principles, which remain in effect today, are that the meeting convenes a wide cross-section of pharmacists and that it occur annually.

6 North Carolina Pharmacist, Winter 2014

The Board initiates planning for the NCLF each year and assumes responsibility for collecting the invitation list, event planning, and facilitating program content. The list of attendees grew to nearly 100 in the mid-2000s; however, achieving meaningful discussion was difficult with so many trying to speak. A decision was made in 2008 to limit attendance to 15 invitations for the Board, 15 for NCAP and five for each school of pharmacy (total of 15). Each entity extends their own invitations up to their limit.

The discussions among the attendees at the NCLF have been the precursor to a significant number of pharmacy accomplishments in North Carolina. The combined pharmacy association we know today as NCAP was first discussed at a Leaders Forum.

The seeds for the Asheville Project were sown here, as was support for moving forward with the CPP designation.

The North Carolina Leaders Forum has stood the test of time. This proceedings document from the 2013 NCLF serves to extend the reach of this year’s discussion and to engage more pharmacists with these very important and timely issues.

The 2013 North Carolina Leaders Forum The 2013 North Carolina Leaders Forum was held September 20 at the Proximity Hotel in Greensboro, NC. The forum opened with a discussion of provider status for pharmacists. A national perspective was delivered by Tom Menighan, CEO of the American Pharmacists Association (APhA). A state perspective was delivered by Rebecca Snead, RPh, Executive Vice President, National Alliance of State Pharmacy Associations.

Summary of Remarks by Thomas E. Menighan Thomas E. Menighan, BSPharm, MBA, FAPhA began his remarks by describing APhA’s efforts to secure provider status for pharmacists at the national level. APhA’s central activities focus on “promoting consumer access and coverage for pharmacists’ quality patient care services.” As he pointed out, every word in this sentence has meaning, the key element is coverage, and most importantly the focus in on the patient. The elevator speech, simply stated, is that when pharmacists are involved, costs go down

and quality goes up.

A key piece of background is that pharmacists are not authorized as health care providers in the Social Security Act. This is a significant problem for pharmacy, so APhA’s focus at the federal level includes where to plug pharmacy into Medicare Part B; where to fit pharmacy into the medical home; and where to fit pharmacy in Accountable Care Organizations (ACOs). The work of the Pharmacy Quality Alliance to identify measurable quality indicators is significant in the overall effort to move pharmacy forward. The Centers for Medicare and Medicaid Services (CMS) is using these quality indicators, which do relate to payment, so pharmacy has become more relevant. It is important to recognize that the changes to the payment model have increased the opportunity for pharmacy to fit, and this is a major opening.

The Affordable Care Act (ACA) opened a new door for pharmacy to be involved in the federal discussions about health care reform. This ties to the Federal ask…in other words, what we as a profession ask for in the law with respect to coverage for pharmacist services. Those who have pushed pharmacist services forward in North Carolina are familiar with the State ask and the private insurer ask, and we have had some success in these efforts. A recommended article that outlines strategies to fix the health care system that includes the pharmacist as part of the health care team is in the October 2013 issue of the Harvard Business Review. 2 The subject then shifted to barriers to provider status, and what pharmacy has to attend to in order to achieve success. These barriers include political realities. They also can be phrased as questions that an organized pharmacy profession needs to answer. They include: 1. The attention of the Congress is distracted by other national and international issues.

2. Discussions on Capitol Hill make it clear that we have to be “savers and not costers.” In other words, we are being held to a higher standard than providers who cost the health care system money, but this is the reality we face.

3. Trying to fit into the fee-for-service model will not happen.

4. We must determine what our federal ask will cost. This leads to questions that must be answered, including a) Which pharmacists will provide the services? b) Which patients will be served? c) Which services will be provided?

5. Digging into the provision of services, the question of scaling up the service delivery model requires attention. To scale nationally, which is essential for fitting into the Medicare program, specific services must be defined, they must be measurable, and they must be predictable.

6. The number of pharmacist providers nationally trails far behind the number of physicians and nurses. Delivering services requires a significant work force, so if we are going to roll out services to a national audience, every pharmacist must be prepared to participate. The question of whether we as a profession are ready for this is open for discussion.

7. The final barrier is whether or not the profession of phar-

macy is able to work together on the provider status issue or if we are too fragmented to succeed. The answer is that pharmacy is working together, and suggestions that national pharmacy organizations are too focused on their own members to cooperate is a myth. The 2008 coalition of pharmacy organizations that put forward health care reform principles for pharmacy was a model of cooperation that succeeded in articulating a national point of view for pharmacy in 2009, and this same model is being used today for provider status discussions.

The 14 organizations working in this coalition are developing a final principles document for publication, but all agree that pharmacists should be included as members of the health care team. An open question is where in the Social Security Act does pharmacy fit? There is a section on ACOs, which is a likely fit, but we can also walk back to services. For example, pharmacists can help diabetics (think dual eligible patients) rather than trying to provide MTM services to all Americans tomorrow. We have to be careful not to step too far back in our efforts to advance MTM with Part D as we work to expand our role in Part B. The coalition is looking for a strategy with a continuum of options. We need room to negotiate with “must haves” and “nice to have” elements. One “must have” is that as health care evolves, pharmacists are included, but this leaves open the question of what services should we advance today. A focus has emerged on transitions of care, which is an area of big expenditures that does benefit when pharmacists get involved. Two other services are medication review and pharmacotherapy consults. The coalition is also working to define the pharmacist who will provide these services. If it is a qualified pharmacist, the question is how are they qualified? Is it a certificate that takes a week, or is it board certification? This is all part of the broader discussion.

APhA has made provider status a significant association issue a few years back. They have invested financially and expect to continue their support in 2014 with a budget commitment. This is a challenge for any organization, but all are trying to find resources. Members can find resources on www.pharmacist.com, and APhA is also working with state affiliates to support their efforts. The next steps include identifying the Federal ask in a coordinated manner. A CBO-like score is being developed so policy makers’ questions can be addressed. Additional literature research is underway, which included finding gaps, along with identifying Capitol Hill champions for pharmacy.

Summary of Remarks by Rebecca Snead Ms. Snead opened her remarks noting that NASPA will support the unified federal ask that is being developed, but that there is lots of work to do at the state level. She believes that change happens at the state level and that North Carolina stands as evidence of this type of change.

When asked about which states recognize pharmacists as providers, she asks what you mean by providers. More specifically, are pharmacists listed in the professional practice code?

North Carolina Pharmacist, Winter 2014 7

Are they listed in the insurance code? Which state Medicaid programs list pharmacists as providers for something other than product? Which states value pharmacists for a service they provide?

If we look at states that provide payment to a pharmacist for a service or services provided, 27 states are identified. They pay pharmacists for some activity, ranging from providing an immunization to smoking cessation, MTM, and diabetes counseling.

A total of 20 states indicate that Medicaid recognizes pharmacists as providers, although not all pay pharmacists for patient care services. If you look at the state employee plans, there are six that pay pharmacists for MTM services. Two were discontinued (IA, WA), but Minnesota, Maryland and Virginia recently launched programs.

In further breaking down pathways to provider status at the state level, Ms. Snead focused on the various ways this can happen. A first question is are you listed as a health care provider in the business professional code/general laws in your state? If not, is this a barrier for state dollars to reach you? It may not be if the Medicaid program pays you. But if it is a barrier, what needs to be done to resolve this? Does the barrier apply to all pharmacists or a sub-set of pharmacists? And, if you can initiate therapy by prescription, is this accepted by third-party payers? This is a proxy for provider status, albeit an important one.

Are you listed in your insurance code? If so, is this an opportunity for you? And will this impact Medicaid? It should be noted that distinctions need to be drawn for the Employee Retirement Income Security Act (ERISA) exempt plans. Medicaid programs and beneficiaries can benefit from payments for pharmacists’ services, and this is seen as an opportunity. Importantly, CMS has shown a willingness to work in this area and NASPA has had some success in this matter.

The pharmacy practice act is the other area to focus on; specifically what adjustments are needed and what would these changes provide you? A number of states have revised their collaborative practice agreements this past year. Immunization services are a focus here with activity related to lowering administration age and broadening immunizations that pharmacists can provide as a means to further integrate the pharmacist into the health care team. Some states have carved out services for advanced practice pharmacy.

Finally, we have the new world of the health insurance exchanges. NC has selected to go with the Federal exchange. Are pharmacists listed as providers? Preventative services are key, and pharmacists can play a role. Essential health benefits are broken out; are pharmacists services included? And where is pharmacy in the roll out of the coverage? Where are our patients?

So, the question is complex in that there are many pathways to look at, but it does create an opportunity to move forward.

Legislation on provider status has been advanced in three states this year and each from a different entry point. One northeastern state has strong collaborative practice agreements; however, prescriptions are not covered because payers are saying that pharmacists are not listed as providers. Organized pharmacy responded by getting the pharmacist added to the list. Claims still will not 8 North Carolina Pharmacist, Winter 2014

pay because of NCPDP issues, but the point is that this barrier issue is off the table.

In Indiana the focus was the Medicaid program, and pharmacist services were added to the list of covered services. If the question is whether Indiana Medicaid will start paying for pharmacist services tomorrow, the answer is no, but the barrier is removed. Again, this is a step in the right direction.

In California the effort has been multi-dimensional and work involved making changes to the professional practice code, making practice act changes, opening up the collaborative practice act to be less restrictive, and bringing attention to advanced practice pharmacists who can do even more under collaborative practice agreements. This set forth an opportunity to move the entire enterprise of pharmacy forward and relates to the strategy that Dr. Menighan outlined in his remarks.3 Collaborative practice agreements are in place in 48 states and they are step one in establishing team-based care that includes pharmacists. Authority varies under collaborative practice, but remember that the legislative authority is one piece and the other is regulatory process. This may delay efforts, which NC experienced in the early years with immunization administration.

Summary of Remarks by Will Lang

Will Lang, Vice President for Policy and Advocacy, American Association of Colleges of Pharmacy, reviewed the provisions of the Affordable Health Care Act that are relevant to pharmacy.

The Affordable Care Act (ACA) is the culmination of health policy discussions that have been going on for decades and there really is nothing new in it. This includes exchanges in the public and private sector, tax credits, and essential health benefits.

The top line questions for today’s discussion include a) What are the overall goals of the ACA? b) What are the contributions of academic and professional pharmacy to meeting those goals? c) What are the implementation opportunities for academic and professional pharmacy in NC? Remember, with the ACA the top priorities are to increase access, provide high quality care, and a focus on wellness and health promotion. This is set against a backdrop that many are familiar with; specifically in the US we spend more on health care than most other countries, but our outcomes are poorer. We don’t live as long as individuals in countries that spend much less on health care.

The audience was polled on the question of what we are looking for in a re-organized health care system. Answers included full recognition as providers beyond dispensing services, being a true partner in collaborative care, and more time at the bedside.

So, if we want these things, what are we doing at the state level to demonstrate we are doing this? That we have the capacity to get this work done, and that shows evidence of success? There are provisions in the ACA that can help with this and the comments

by Ms. Snead were echoed…specifically, change happens at the state level.

Turning to the priority on access, people need insurance and should focus on an essential health benefit, which includes a

prescription benefit. It does not include counseling or management of the medications. By way of background, the legislation was progressing nicely for pharmacy as it was being developed, but it was passed very quickly at the end and this is when the MTM piece that organized pharmacy had been working on was dropped. Medicaid expansion under the ACA, which was a design element in the law to increase access to care, was not put forward in NC, so we have many citizens in our state that will not have access to Medicaid. Interestingly, NC’s refusal to expand Medicaid leads to a bias against the poor who could have had access to the program’s benefits. The ACA was not designed to meet the specific needs of this segment of the population.

The quality priority is on improving the care that Medicaid and Medicare beneficiaries receive, particularly the coordination of that care. An example is the discharge from the hospital and the effort to understand what medications you should be taking when your stay is complete. This is where the primary care medical home model comes into the discussion to help guide patients through these transitions by connecting all of the providers. This discussion includes the term “care teams” and it includes “pharmacist,” but the “care team” term is not well defined by CMS at this time. In addition, the Center for Medicare and Medicaid Innovation was set up to identify and fund projects that help the US health care system move beyond the FFS model and to focus on quality of care and the sharing of financial risk. There are multiple innovation project sites in NC. The website is www. innovation.cms.gov, which is where you can learn about the work of the Innovation Center.

The work of the Innovation Center is coordinated at the state level by Innovation Advisers. There are four Innovation Advisers in North Carolina and more information about the Advisers program can be found at the following link: http://innovation.cms. gov/Files/fact-sheet/InnovationAdvisorFactSheet.pdf.

The ACA is also focused on expanding quality beyond Medicaid and Medicare. This is another building block to take into consideration as pharmacists think about what they can do to create change at the state level. The initial report can be found at the web link in the reference below.4 The national strategy to complete this work includes the following priority areas: 1. Making care safer by reducing harm caused in the delivery of care.

2. Ensuring that each person and family is engaged as partners in their care.

3. Promoting effective communication and coordination of care.

4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.

5. Working with communities to promote wide use of best practices to enable healthy living.

6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

An additional area for the pharmacy leaders in NC to look into for funding innovation models is PCORI, or the Patient Centered Outcomes Research Institute. This is funded by the federal government at present and will eventually transition to private funding through a fee that insurers will pay. The web link is http://www.pcori.org/. The mission of PCORI is to [help] people make informed healthcare decisions, and improves healthcare delivery and outcomes, by producing and promoting high integrity, evidence-based information that comes from research guided by patients, caregivers and the broader healthcare community.5 Two other items to be familiar with as you consider state level work are the Agency for Healthcare Research and Quality (AHRQ)6 and the National Health Care Work Force Commission.7 While the Work Force Commission has not been funded, the idea of collaborating across professions is foundational to their work. AHRQ is the agency that has a focus on funding MTM initiatives, among many other areas of research, and any pharmacist providing MTM services should know about AHRQ as they may be a source of funding for this work.

The third priority of the ACA is the focus on prevention and wellness. Of note is that this is the first time that prevention and wellness have been the center of national attention. The ACA led to the development of a National Prevention and Wellness Strategy.8 The recommendations contained in the report include items that pharmacists may be doing at a local level, so reviewing it is important for pharmacy. Related to this is the US Preventive Services Task Force, which was originally created in 1984.9 The ACA instructed AHRQ to provide support to this Task Force.

These services will resonate with pharmacists and becoming familiar with this source of funding is encouraged. A third report, which points to the role that pharmacists can play, comes from the Community Preventive Services Task Force.10 A funding resource is through the Community Transformation Grants.11 As pharmacy leaders we should know how this money is being spent as it may be able to benefit pharmacy.

In closing, the language of public policy is what we as pharmacy leaders need to speak in order to be effective and influential. We must read and understand the reports just mentioned, identify the gaps, and describe how we as pharmacists are filling in (or can fill) these gaps. The NC Institute of Medicine is a resource for pharmacy to understand this language and show how evidence-based initiatives can be used to meet public health needs.12

Summary of Remarks by Pharmacy School Deans The Deans from North Carolina’s four schools of pharmacy, including Dean Robert Blouin from UNC Eshelman School of Pharmacy, Dean Ronald Maddox from Campbell University College of Pharmacy and Health Sciences, Dean Robert Supernaw from Wingate University School of Pharmacy, and Dean Ronald Ragan from High Point University School of Pharmacy (opening in 2016) developed their remarks for the NCLF attendees by considering the following questions:

North Carolina Pharmacist, Winter 2014 9

• What steps are schools of pharmacy taking to ensure that pharmacists practice at the “top” of their training?

• How are schools preparing graduates for increasingly interprofessional care practice models?

• How are schools preparing students to identify and flourish in new pharmacy business models?

• What is the role of schools in offering post-graduate education and/or “beyond licensure” certification programs to ensure pharmacists are positioned to be meaningful players in evolving health care models?

Summary of Remarks by Dean Blouin Changes to the curriculum require looking out five to seven years to determine where schools should be in their efforts to shape the next generation of pharmacists. The current influencers of change include health care reform, individuals who are younger than 18, since they learn in a different way due to their high level of digital sophistication, and the highly communicative nature of health care practice. Asking and answering questions like these, as well as considering what the student of 2022 will be like when they begin pharmacy school, are driving curricular reform at UNC. The reform that UNC is contemplating can be broken into three areas. First, UNC recognizes that the traditional classroom is going away and flipping the classroom to engagement and away from lecture is required. This is a means to develop problem solving and critical thinking skills. Second, to develop as a professional knowledge should be applied to real world situations. In other words, learning must be done in context to add relevance. Third, students should be oriented to the research method, not be researchers but rather to be contextual learners.

Summary of Remarks by Dean Maddox Recognizing that the ACA will provide health coverage for an additional 800,000 North Carolina residents, how will we meet their needs? How will we supplement the efforts of the physician? How will this increase in volume be translated into value?

And how will pharmacists integrate with the medical home model?

Campbell recognizes that collaboration is required to improve patient care, and working together to solve problems is being built into the education efforts. This includes inter-professional education. Efforts are currently underway to integrate the curricula for all of Campbell University’s health science programs.

Going beyond curricular integration, efforts are also focused on certificate programs, expanding residency training, and joint degree offerings.

Summary of Remarks by Dean Supernaw A critical evaluation of the ACA leads one to recognize that preventing unwanted medical events is where pharmacy can plug into a reformed health care system. Consider the “wellness and prevention pharmacist” as a future role. This aligns with an insurance industry that is investing heavily in wellness initiatives as there is a substantial revenue opportunity here. Further, 10 North Carolina Pharmacist, Winter 2014

why can’t pharmacists look to potential revenue sharing models where the pharmacist serves as the health care professional who engages, monitors, and manages the patient to make healthy life style changes that produce positive health outcomes?

If we focus on smoking cessation as an example, is the curriculum preparing pharmacists to be coordinators of smoking cessation programs? We can conclude that the basic skill set for this work is present. Further, nothing in the ACA precludes the pharmacist from becoming part of the inter-professional health care team. To help pharmacists achieve this role, a simulation lab is currently being built at Wingate University to help the student pharmacist learn this inter-professional team role, which will include participation from the physician assistant, physical therapy, nursing and pharmacy programs.

Summary of Remarks by Dean Ragan Today’s health care system has changed, and pharmacists must be focused on providing outcomes and not just on filling prescriptions. Further, the practice world is an inter-professional one. This is not a future state, it is today. The student pharmacist at High Point will be in a program which teaches that all things pharmacy are their responsibility, and that they must apply their knowledge in a practice world that demands communication and collaboration.

The curriculum at High Point will focus on teaching communication skills. Further, medical chemistry – this foundational, basic science knowledge – will be taught within the context of patient care. Critical reasoning skills will be developed, and experiential education that incorporates inter-professional collaboration will occur early and often in the curriculum. Finally, faculty will be incentivized to study care models that advance pharmacy practice.

Small Group Work Building on the information presented by the speakers, Forum attendees were broken into work groups of ten to discuss a series of questions, and to then report to the larger group a summary of what they discussed. A working goal was to establish action items for North Carolina pharmacy. The questions and the groups’ responses follow below.

In summary, the work groups were looking forward and considering the changing health care system, including the changing payment models as they contemplated curricular changes and the need to advocate and to work toward provider status for pharmacists in North Carolina. The various perspectives that the attendees brought to the discussions are captured in their discussion notes.

Group A 1. Our practice environment is rapidly changing. During the next ten (10) years what knowledge and/or skills do you think pharmacy students need on graduation day (not after a residency) that they currently do not have, or not enough of?

North Carolina Pharmacist, Winter 2014 11

a. Perspective on clinical practice/real world, hands-on practice b. Budgeting/sustainability concepts c. ROI (return on investment) thought process d. Effective communication skills e. Professional advocacy/legislation continues in importance f. Transition into practice and life at a general concepts level g. “Real life practice” – real world applications of law (raised by a non-pharmacist attendee) h. Basic business class understanding i. “Big picture relevance” 2. How can we change the practice model in high-volume retail outlets to facilitate pharmacist-managed individualized care, regardless of what we call it? a. Advanced pharmacy tech roles; either tech-check-tech or other models like the VA system b. Technology c. Expectations of pharmacist d. “Manage up” with key thought leaders about roles 3. What does “practicing at the top of your training” mean to you as pharmacy leaders? Should pharmacists be trained to diagnose disease? Please distinguish should we be trained from could we be trained! a. Importance of knowing differential diagnosis to facilitate care → not necessary to diagnose13 b. Team-based care model recognition c. Recognition of different roles for team’s members; d. Pharmacist as drug expert on team e. Focus shifted to: How to define “top”? f. Top of training i. At a high level in your path (Clinical/administrative practice) ii. Organization involvement necessary iii. Community/service, professional activities should be included g. Oath of a pharmacist Group B 1. How does the profession fit into current and developing health care initiatives at the federal and state levels? a. Community vs. hospital pharmacists b. Generational differences c. Areas of practice d. Pharmacists need to be heavily involved in prevention and wellness e. Pharmacists who are in different areas of practice need to have better interchange for the good of the patient f. Pharmacists need strategies to decrease healthcare costs

i. Need reimbursement models that don’t focus on the product g. Pharmacists to have a role in wellness 12 North Carolina Pharmacist, Winter 2014

2. Do all the interventions pharmacists use have some defined outcome if implemented with fidelity, are any evidence-based? (combined with Q3 responses) 3. What is the capacity of the existing workforce to consistently implement these interventions? Who supports our efforts? a. Asheville project is a WORN OUT example b. We are not there yet c. This move will take a long time d. Healthcare is changing faster than we are as a group e. We need unity on outcomes f. We do NOT have the workforce capacity to consistently implement interventions g. Support for student pharmacists must also be attended to as we develop Group C 1. How can pharmacy educators better train pharmacy students and pharmacists to fill the current and projected void in primary healthcare providers? a. Group discussion began by defining a primary care provider.

Further, discussion of question one occupied their work time, so they didn’t get to questions two or three. b. Define unique outcomes that student pharmacists can learn and contribute in a primary care setting c. Delineate the competencies required of primary care providers and how we can integrate these standards into our continuing education (CE), curriculum, and residency training d. Extend beyond teaching to advocacy and being effective communicators for the profession e. Identify the best practice models in NC/nationally and learn about the strategies for tracking outcomes in these patient care settings f. Quality studies to demonstrate outcomes 2. How can we ensure that pharmacists are properly reimbursed for their services?

3. How can we better integrate a pharmacist into the medical home model of health care?

Group D Background: Under the provisions of the Affordable Care Act, ACOs consisting of physicians and other “healthcare providers” will be eligible to share in the dividend associated with healthcare cost savings based upon the ACO’s ability “to satisfy a standard that will be outcome-based.”

1. How should pharmacists and pharmacy students be comprehensively prepared to assume an important role in ACOs? a. Pharmacists will have to prove their role in ACOs; marketing and customer service needed

North Carolina Pharmacist, Winter 2014 13

b. Students are trained to provide service, BUT go into practice where this conflicts with traditional incentives such as dispensing c. Students must be ready for primary care practice roles that serve to “bend the cost curve” d. Students need to learn how to market to a team and how to set up a business plan e. Medication adherence is a key issue; partnerships around improving adherence f. MED REC (especially with hospitals) 2. What specific roles should pharmacists play in an ACO in order to help meet standards related to BMI, BP, dyslipidemias, and tobacco use cessation? a. Point 1; the most expensive prescription is one that isn’t filled b. For BMI – local initiatives c. BP – adherence and monitoring d. Lipid – adherence and titration of meds 3. What strategies should pharmacists employ to become part of an ACO in order to share the dividend? a. Formulary management; set up for an appropriate return b. Free up pharmacists’ time (increase pharm tech roles) c. Risk sharing acceptance with ACOs and on health care teams d. Negotiation skills needed for contracts i. Likely with health systems and not individual practice ii. Willing to go to top level leadership iii. This will be different than current negotiation requirements Group E 1. Given that the schools of pharmacy are planning substantial changes in their curriculum over the next few years, how will these changes affect the kind of student it seeks to recruit into their programs and will it demand a change in the admission process? a. Yes, it will demand change

b. Even more self-motivated than today c. A willingness to change and adapt to the changing future of pharmacy, whether in practice or in the classroom d. Good communicators using verbal skills e. Group interview process – interaction with team; this can help identify the student who work together well and communicate effectively 2. These changes in the schools’ curriculum are likely to place new pedagogical demands on the faculty. How are the schools planning to prepare/train faculty for these changes? a. Financial funding and time for faculty training and skill development b. Perhaps faculty who do research and teach, but are stronger researchers than classroom teachers, move to the research environment to keep stronger teachers in the classroom? c. Support for adjunct faculty 3. What role will/should technology play in the pharmacy curriculum of the future? a. Recognizing first that we don’t even know what the technology is going to be b. Learn how to teach students this new technology, how to teach faculty and patients to learn and use it; how it will interact with the provider relationship c. Embrace technology in both the classroom and on clinical rotations to AUGMENT not replace pharmacist interaction; doesn’t replace face-to-face interactions so communications is still necessary Group F 1. How does inter-professional education promote team-based care? a. It is important; students need to be trained in this environment b. An appreciation for all disciplines and need to train across disciplines c. We learn to rely on one another d. Synergy to solve problems; improve consistence of care e. Prepare for new healthcare models f. Removal of bias through training and understanding g. Patient problems are solved h. With schools, inter-professional education should occur early in their education and in real-life situations Recommendation: • All pharmacy schools should be creating inter-professional education opportunities for students.

• Work to create inter-professional experiences that are patientcentered and built around real patients.

• Creating opportunities for students to share experiences so they can learn from each other and across professional disciplines. Perhaps this sharing can occur via a symposium.

14 North Carolina Pharmacist, Winter 2014

2. Should NC pharmacy work with private employers, the state employee health plan, and Medicaid to obtain provider status and move the pharmacist into the health care team? a. Yes, focus on provider status at the state level b. To prepare students, schools should teach about quality improvement/quality achievement indicators, new models of care, ACOs. Teaching should include experiencing this in an inter-professional way with a focus on quality improvement and population management. c. Enhance the profession to be ready for reform as we are not ready today; increase manpower to take on a higher level of care Recommendations: • Work through political advocacy and reduce barriers • Advocate for provider status on the state level 3. Do we need to consider scope of practice changes in NC for pharmacists to practice at the top of their license? a. No, our state is considered an innovate state which has the CPP designation that is a top of the license designation b. We need to step back and revitalize what we have c. Motivate people to use what is available d. Overall, feel that NC is progressive and supportive of pharmacists e. Create a new credential to provider status? Must show our value!!!

Recommendations: • Motivate and revitalize pharmacists to use what is already available • Need a new credential to show value of a RPh, goal is consistent care 4. Should it be the focus of NC pharmacy to work with the NC health information exchange? a. Yes, this will aid in patient care; provide well-rounded care to patients b. Improve continuity of care c. Data drives good decisions Recommendation • Yes

Closing Presentations The afternoon closed with three informational sessions. The first session focused on medication safety and improving patient outcomes. It was presented by Melissa King, BS, PharmD, Medication Safety Officer from Duke University Medical Center and Kathy Chastain from the North Carolina Board of Nursing. This presentation was important for pharmacy leaders to hear because

it took a discussion about medication safety from the hospital pharmacy at Duke into the nursing world, essentially providing an inter-professional learning opportunity for attendees.

Summary of Remarks by Melissa King Dr. King shared her wisdom and experiences about medication safety and just culture. The term, just culture, has specific meaning. It is about creating an organizational culture that holds people accountable to patient safety, but creates a balance between a blame-free culture and a punitive culture. A premise to just culture is that safety increases in an environment where members of the pharmacy staff are free to discuss what went wrong when a mistake is made, and further that individuals are held accountable. The overarching duty of the pharmacist is not to cause harm. In the practice world, individuals are responsible for their choices, for reporting, for contributing to solutions, and for continuous learning. Managers are responsible for listening to their staff, taking actions, and holding others accountable.

Summary of Remarks by Kathy Chastain The Nursing Board embraced just culture in 2005. Ms. Chastain made the point that errors were managed using punitive measures prior to just culture, and that with a just culture model in place, the fear to talk about problems has decreased. When behaviors are reckless (such as theft), they are dealt with appropriately, but this is outside of where just culture is used. From a nursing perspective, she believes that just culture has contributed to a safer clinical setting when considering pharmacy and nursing practices in hospitals, but this is not the case in long term care practice. The challenges with long-term care tie in part to a lack of routine, pharmacists not being on-site, an increasing number of medications being used that creates risk, and process / systems challenges. Ms. Chastain emphasized that critical thinking skills are also necessary and that solutions don’t just arrive with new technology.

••• 2013 NCAP lobbyist Evelyn Hawthorne, and ACP Vice President for Government Affairs Mike James provided reports from the 2013 North Carolina General Assembly Session.

Summary of Remarks by Evelyn Hawthorne It was a busy legislative year with focus on the budget, pharmacy practice and Medicaid, and crime, specifically the controlled substance registry. It is expected that this will be seen again. The pharmacists immunizing bill did pass this year, although it was scaled back in negotiations. This will allow pharmacy to get started in this space and establish a track record.

Pharmacist Gene Minton was recognized for a leadership role and a voice of reason in the negotiations to advance this bill. This was also supported by the Retail Merchants Association, Walgreens and Kerr Drug.

North Carolina Pharmacist, Winter 2014 15

Summary of Remarks by Mike James This legislative year was challenged by efforts to determine what people were thinking and trying to accomplish, especially with Medicaid. Pharmacy leaders need to stay focused on what is going to happen in the future. The Governor announced that Medicaid is broken and managed care is in the discussion, but there is no final decision. How this will impact dollars spent for Medicaid is an open question, and how it will be managed is up in the air and something we should pay attention to.

We also have to pay attention to recognition of the pharmacist as a provider in the state of NC. We have some language that refers to this, but it is not in plain language and we need to get this on the books. This may be an effort in the short session that comes up next May. Expect that Mike and others will reach out looking for support.

••• The final session of the 2013 NCLF – Telemedicine and Telepharmacy: Upholding Standards of Care/Role in the Patient Home – was delivered by Sheila Davies, Coordinator of Albermarle Hospital’s Telepsychiatry Project and Janice Huff, MD, North Carolina Medical Board.

Summary of remarks by Sheila Davies Telehealth is in use across North Carolina. Telepharmacy is not highly utilized yet, but in other states, particularly North Dakota, it is used.14 Payers are now reimbursing for telemedicine.

An active project in NC is in telepsychiatry, which is funded by the Duke Endowment, and is in place at 18 NC hospitals. The problem was a significant, multi-day wait for psychiatric services for patients in the small, rural hospitals where the hospital can’t afford to have a psychiatrist on staff. The program provides 365 day per year coverage from 8 am to 6 pm. Hospitals pay for usage, so it is a manageable expense. A challenge is credentialing, which is a process step and it is being managed. The Duke Endowment is repeating their funding as outcomes are very positive. Medication use is being managed much better with the psychiatrist involved. The specific outcomes include a decrease in involuntary commitments; a decrease in patient length of stay which is a primary program goal; and the 30 day recidivism rate of returning to the emergency department is decreasing.

A second initiative that started in 2013 is a pilot in Hyde County, NC. This is a rural, Tier 1 county that does not have a provider. The telemedicine cart has an HD camera, an otoscope, and vitals monitoring equipment. A nurse is onsite to assist. The only limitation is palpation, but robotic gloves are being developed that can be used. A secondary challenge is that there is no pharmacy in the county. Connections have been made with a close pharmacy. Another limitation is that you can’t receive reimbursement for well child visits. Infants through seniors have been seen for acute issues.

Health information exchange is a challenge on the technical side, but there is no legal concern here. Funding is a challenge, 16 North Carolina Pharmacist, Winter 2014

as the specialty equipment technology is expensive. Reimbursement is not mandatory, but payers are starting to participate, but provider adoption is still a problem. As mentioned, pharmacy access is a challenge when a patient may have an hour drive to a pharmacy following a telemedicine visit.

Summary of remarks by Janice Huff This area of practice is rapidly evolving field and it is being actively monitored by a Medical Board task force. Regardless of what the “tele-X” is, the NC Medical Board views it as a tool in the appropriate care of a patient as long as it follows local custom and current standards of care. This means that the appropriate diagnosis is made, the appropriate prescriptions are ordered, the appropriate medical records are completed and the appropriate follow up care occurs. If this is in order, then this is just a tool in appropriate care. The Hyde County initiative is one of the best the Medical Board has seen as this increases access for those truly in need.

One aspect that is being discussed is the actual physician-patient relationship. The Medical Board distinguishes between an initial visit and a follow-up visit. The traditional model has the initial visit as face-to-face and a follow up can be done via phone call, face-to-face, or by appointment the next day. The follow up is at the physician’s discretion. Hyde County has come as close to achieving the traditional model using the new technology. An effort in Georgia was referenced for additional information.15 v ____________________________________________________ 1. The information contained in the Background is drawn from personal email correspondence with North Carolina pharmacists Fred Eckel, Steve Caiola, and Jay Campbell.

2. http://www.iqg.com.br/uploads/biblioteca/the_strategy.pdf; accessed on 2/9/14.

3. Since the 2013 NCLF was held, the goal of having CA pharmacists recognized as health care providers by the state became a reality on October 1 when Gov. Jerry Brown signed SB 493 into law. State Sen. Ed Hernandez, OD, (D-24) wrote the legislation, which is effective January 1, 2014. More information can be found at http://www.cpha.com/Advocacy/ Pharmacist-Provider-Status; accessed 2/9/14.

4. http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm#fig2; accessed 2/10/14.

5. http://www.pcori.org/about-us/mission-and-vision/; accessed 2/10/14.

6. http://www.gao.gov/press/nhcwc_2010sep30.html; accessed 2/10/14.

7. http://www.ahrq.gov/; accessed 2/10/14.

8. http://www.surgeongeneral.gov/initiatives/prevention/strategy/; accessed 2/10/14.

9. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/uspstf/index.html; accessed 2/10/14.

10. http://www.thecommunityguide.org/about/task-force-members.html; accessed 2/10/14.

11. http://www.cdc.gov/nccdphp/dch/programs/communitytransformation/; accessed 2/10/14.

12. http://www.nciom.org/; accessed 2/10/14.

13. Words shown with underline or bold were done by the work groups and their emphasis is displayed as originally drafted.

14. http://www.ndsu.edu/telepharmacy/; accessed 2/11/14.

15. http://www.gatelehealth.org/; accessed 2/10/14.

2013 North Carolina Pharmacy Leaders Forum Attendees

NC Board of Pharmacy Gene Minton, President NCBOP; Drugco Discount Pharmacy, Littleton J. Parker Chesson, Jr., Board Member; Durham Joey McLaughlin, Board Member; Realo Discount Drugs, New Bern William A. (Bill) Mixon, Board Member, Measured Dose Pharmacy Carol Yates Day, Board Member, Duke University Health Systems, Inc. Clinton Pinyan, General Counsel to NCBOP - Brooks, Pierce, McLendon, Humphrey & Leonard, LLP Mollie Scott, Regional Assoc. Dean & Clinical Assoc. Professor, UNC Eshelman School of Pharmacy-Asheville Andrea Faison, Vidant Medical Center, Greenville, NC Al Lockamy, former NCBOP board member David Moody, NC Mutual Wholesale Drug Co. Lisa Weeks, NC DMA, Pharmacy Services Mark Gregory, Kerr Drug Amanda Fuller Moore, NC Department of Public Health Tom Murry, Representative, NC House, District 41 Jay Campbell, Executive Director, NC Board of Pharmacy Kristin Moore, Director of Operations, NC Board of Pharmacy Stacie Mason, Staff, NC Board of Pharmacy UNC Eshelman School of Pharmacy Robert Blouin, Dean Phil Rodgers, Assistant Dean for Pharmacy Practice Partnerships Division of Practice Advancement and Clinical Education Steve Dedrick, Director of Continuing Education Ben Pennell, Student; Senate President Tracy Olejniczak, Student; CAPS Chair Campbell University College of Pharmacy & Health Sciences Ronald Maddox, Dean Andy Bowman, Director of Continuing Education Mark Moore, Associate Dean Connie Barnes, Vice Chair, Dept. of Pharmacy Practice Wingate University School of Pharmacy Robert Supernaw, Dean Michael Manolakis, Assistant Dean for Student Development Associate Professor Wesley R. Haltom, IPPE Director Jerry McKee, Regional Dean; Hendersonville Campus Ashley Theissen, Student; President, Student Senate North Carolina Association of Pharmacists Fred Eckel, Interim Executive Director Jennifer Buxton, Deputy Director, Pharmacy Services at Cape Fear Clinic (Past President of NCAP) Randall Angel, CEO Servant Pharmacy Jena Ivey Burkhart, Clinical Assistant Professor, UNC Eshelman School of Pharmacy Jennifer Burch, Independent Pharmacy Owner, Central Pharmacy Thomas D’Andrea, VP of Pharmacy Services, Neil Medical Group Mary Parker, NCAP President, Clinical Pharmacist, Durham VA Hospital Leigh Foushee, Director of Alumni Relations, Cambell University College of Pharmacy & Health Sciences Alyce Holmes, Pharmacy Director, Harnett Health System LeAnne Kennedy, Clinical Specialist-Oncology, Wake Forest Baptist Health Kimberly Lewis, Assistant Professor of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences Ashley Branham, Director Clinical Services, Moose Pharmacy Paige Brown, Asst. Professor & Interim Director of Experiential Education, Campbell University College of Pharmacy & Health Sciences Jennie Hewitt, Clinical Pharmacy Specialist, VA-Raleigh Guest Speakers Steve Caiola, Forum Facilitator Evelyn Hawthorne, Legislative issues post-GA session; Federal legislative issues Mike James, Legislative issues post-GA session; Federal legislative issues Melissa King, Medication Safety/Just Culture algorithm Tom Menighan, Provider Status for Pharmacists/APhA & NASPA Becky Snead, Provider Status for Pharmacists/APhA & NASPA Janice Huff, MD, Telemedicine/Telepharmacy: Upholding Standards of Care/Role in the Patient Home Sheila Davies, Telemedicine/Telepharmacy: Upholding Standards of Care/Role in the Patient Home Kathy Chastain, Medication Safety/Just Culture Algorithm Will Lang, Vice President for Policy & Advocacy, American Assoc. of Colleges of Pharmacy Ron Ragan, Dean, High Point University School of Pharmacy North Carolina Pharmacist, Winter 2014 17

Safety Solutions

Protecting Long-Term Care Patients from Getting Lost in Transition

By Alexander T. Jenkins, PharmD, MS

Manager, Ambulatory Pharmacy Services Medication Safety Officer Department of Pharmacy WakeMed Health & Hospitals

Despite all of the ongoing initiatives to improve medication safety from the organizational level to the national level, a seemingly forgotten patient group at risk is the resident population of long-term care (LTC) facilities. It is estimated that over three million patients depended on medical care provided at LTC facilities in 2013 and greater than 1.4 million patients can be found living in LTC facilities at any given time.1,2 Furthermore, LTC patients are often hospitalized for acute medical conditions or exacerbations of chronic conditions that require a higher level of care. Transferring LTC patients to and from hospitals is a complex process due in large part to their extensive medication needs (an estimated one third of all LTC residents take at least nine medications daily).3-6 Adding the inherent complexity of LTC patients to an already error-prone inter-facility transfer process creates even more opportunities for errors to occur.

Because LTC-to-hospital transfers are such high risk processes, the transition of this vulnerable patient population requires a standardized approach.

As with all transitions of care, it is

18 North Carolina Pharmacist, Winter 2014

incumbent on all healthcare professionals involved in LTC transitions to share accountability in the handoff process regardless of whether or not the transferring facilities are within the same healthcare organization. Most of the reported medication errors originate in the hospital, but it is equally important for the receiving LTC facility to have strong admissions procedures that involve medication reconciliation. It has been reported that greater than 50% of LTC admissions involve an error in documentation between the discharge summaries and transfer records, and there is at least one medication discrepancy in 70% of all admissions.1-6 It is well documented that medication reconciliation is a challenge to many healthcare organizations because there are potential failure points at both admission and discharge, but consider that every hospitalization of a LTC resident includes two admissions and two discharges if that patient returns to the LTC facility. Therefore, the number of potential failure points in the LTC transfer process is two-fold higher than in medication reconciliation on the average patient being admitted to a hospital.

Fundamental safety risks of having multiple pass offs with variable standards of communication and documentation is often augmented by a lack of resources available to identify and resolve discrepancies in the admission paperwork. When patients are admitted to LTC facilities, medication orders are often reviewed by a nurse and verified verbally over the phone by a prescriber who may be unfamiliar

with the patient, and it may take up to 48 hours for the physician to assess the patient. Therefore, the LTC nurses are responsible for reconciling the hospital discharge summaries, prescriber transfer orders, inpatient medication administration records (MARs), and progress notes in order to verbally communicate the previous medication therapy to the LTC physician.

Relaying an accurate drug therapy regimen to the physician using information that may contain multiple discrepancies is an incredibly challenging task that sets the LTC nurse up for failure unless standardized safe practices are established.

Last year, ISMP reported on a patient death that resulted from a medication error that occurred during transfer from a hospital to a LTC facility.1 A patient was being transferred back from a hospital with medication orders that included an order for insulin. Information received by the LTC nurses included documentation of the most recent doses given (listed on the orders and progress notes) but the referral/transfer form, discharge summary, and MAR did not specify the actual insulin doses. Seeing only the 100 units/ mL concentration, the LTC nurse errantly assumed the dose was 100 units/mL and verified the dose with the LTC physician over the phone. The physician verified the medication orders by instructing the nurse to “continue the same orders� so the nurse transcribed the list of medications and sent them to the pharmacy to be filled. Even though the orders included an unusually high dose of insulin (100 units in the morning and evening), the prescriptions were filled. After receiving one dose of insulin, the patient experienced severe hypoglycemia and died shortly after being transferred back to the hospital.

This error showed how a complex inter-facility transfer process, characterized by clinical assumptions (the physician assumed he knew the patient’s orders from the hospitalization), lapses in communication, discrepancies in documentation, and incomplete information, resulted in a fatal medication error. While we hope that this incident is a rarity, similar incidents unfortunately occur far too frequently. Error rates as high as 21% have been reported in acute care to LTC transitions and as many

as 60% of these errors have been lifethreatening or fatal.1-9 These statistics are staggering, but the challenges of improving the safety in transitions between acute care and LTC are not insurmountable if safe practices are adopted consistently across the care continuum.

Improving safety in LTC transitions requires an evaluation of the failure points in order to identify the opportunities for preventing medication errors from occurring and reaching the patient. Consider the following recommendations for improving the safety of this risky process.

• Establish a strong verbal orders process that involves writing down the orders and reading them back for confirmation, and complete orders are always required (i.e. “continue same meds” or “continue same orders” are incomplete orders). Any orders with incomplete information, such as an insulin order with concentration and no dose, should always be clarified prior to processing.

• Medication orders should have an indication specified.

• A high alert medications list should be published for the LTC facility, and

procedures should be established with independent double checks whenever possible.

• Implement standardized admission orders for LTC facilities that include the most common medication orders by indication.

• Maximize the pharmacy relationship with the LTC facility to include clinical interventions and consultation beyond what is necessary to meet the regulatory requirements. If possible, include the pharmacy in LTC admission medication reconciliation.

• Develop a process that provides the LTC nurse with admission documentation as early as possible in order to allow time for review and reconciliation.

For a detailed safety review of LTC transfers and safe practice recommendations, see the recommendations from ISMP.1 There are many opportunities for improvement in transitions of care between LTC and acute care facilities.

Addressing these opportunities with a comprehensive approach that includes consistent implementation of redundancies, independent double checks, standardized documentation, and verification

procedures will increase the safety of a high risk patient transfer process. v References: 1. From the hospital to long-term care: Protecting vulnerable patients during handoffs. ISMP Medication Safety Alert 2013;18(15):1-4.

2. Department of Health and Human Services, Centers for Medicare & Medicaid Services. CMS 2012 nursing home plan. Action plan for further improvement of nursing home quality. www.ismp. org/sc?id=12 3. Desai R, Williams CE, Breene SB, et al. Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. Am J Geriatr Pharmacother 2011;9(6):413-22.

4. Handler SM, Wright RM, Ruby CM, et al.

Epidemiology of medication-related adverse events in nursing homes. Amer J Geriatr Pharmacother 2006;4(3):264-72.

5. ISMP Canada. Medication incidents occurring in long-term care. ISMP Canada Safety Bulletin 2010;10(9):1-3.

6. Coleman EA, Berenson RA. Lost in transition challenges and opportunities for improving the quality of transitional care. Ann Intern Med 2004;141(7):533-6.

7. Tija J, Bonner A, Briesacher BA, et al. Medication discrepancies among hospital to skilled nursing facility transitions. J Gen Intern Med 2009;24(5):630-5.

8. Truax BT. Medication errors in long-term care.

Patient Safety Tip of the Week. Patient Safety Solutions. July 21, 2009.

9. Gurwitz JH, Field TS, Aworn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000;109(2):87-94.

North Carolina Pharmacist, Winter 2014 19

New Practitioner Network

Work-Life Balance: A Resident’s Perspective

By Molly Howard, PharmD PGY1 Pharmacy Practice Resident, Durham VA Medical Center

No one ever told me that it would be easy to juggle the responsibilities of residency while trying to keep things balanced in other areas of life. I anticipated being pushed and having to juggle multiple projects along with clinical practice responsibilities. The question is how to do that while maintaining work-life balance.

There is certainly enough work to do, so shouldn’t I just be working all the time?

Trying to determine my priorities and work-life balance has definitely been one of the many challenges of my PGY1 residency.

Although knowing that there is always more to do, working all the time is unsustainable. Not making time for myself and those I love is a sure way to burn out, which could not only harm my personal relationships and mental health, but ultimately put my patients at risk.

Part of what I am hoping to improve upon is described in Stephen Covey’s The 7 Habits of Highly Effective People. Covey describes a method of time management and prioritization in which one prioritizes what is most urgent or important by “putting first things first.” The key is “not to prioritize what’s on your schedule, but to schedule your priorities.” Part of this is determining the things in life that are your priorities and thus non-negotiable. What do you have to do on a daily, weekly, or monthly basis to be happy?

20 North Carolina Pharmacist, Winter 2014

What sorts of things are you willing to let go by the wayside?

These important things are ones that need to be scheduled into life in order to keep a full calendar from making important things seem impossible. Whether that is spending time with friends and family, exercising, or just relaxing, if it is important, time should be set aside for it. These are things that help us relax and recharge, protecting our capability to continue working hard and dedicating ourselves to an effective residency year.

For me, the most important part of what helps me obtain a work-life balance is loving what I do. Enjoying learning new things, gaining experience, and caring for patients definitely makes the stress of residency more enjoyable. Having a passion for wanting to be the best pharmacist I can be in the future allows me to take satisfaction in working hard.

Enjoying and appreciating my co-workers is also vital. I certainly love spending time with my co-residents and other pharmacy staff, as having great people to work with helps to make work feel a little less burdensome and a lot more fun. You can share methods to deal with the common stresses of residency as well as be there to help one another get through difficult times.

Overall, achieving effective work-life balance is a continual struggle, no matter if you are a resident or a seasoned practitioner. Prioritizing and setting aside time for things that are most important to you is vital for balance, and will put you in the best position to care for both yourself and your patients. v

New Practitioner Network Member Spotlight: Lea Mitchell Leah Mitchell received her PharmD from Campbell University College of Pharmacy and Health Sciences in May 2012. Upon graduation, she accepted a PGY-1 residency with a focus in administration at Novant Health Forsyth Medical Center in Winston-Salem, NC, which is part of a not-for-profit, integrated healthcare system that serves patients and communities across four states. The residency program set her up for success and landed her a position as the Pharmacy Supervisor at Novant Health Rowan Medical Center in Salisbury, NC. The 268-bed hospital offers multiple services including maternity, rehabilitation and specialty care.

In her current position she manages 32 pharmacists and technicians, precepts students, participates in medication safety efforts and oversees daily operations of an in-patient pharmacy. The work can be challenging, but Leah looks forward to accepting the challenge each day with an open mind. Because of her experience and her staff, she knows she’ll learn something new that will help her develop better care for the Salisbury community. As one member of a two-person management team, the job provides opportunity to be involved in areas of pharmacy that cannot be learned in school or during a residency.

She began her involvement with NCAP as a student at Campbell in an effort to expand her network outside of the walls of her school. Although new in her career, Leah has learned to appreciate the web of connections that she has made with practitioners both within and outside of her hospital network. It did not take long for her to recognize that our state has one of the most involved pharmacist networks and she looks forward to additional opportunities that NCAP will bring. v

North Carolina Pharmacist, Winter 2014 21

2013 NCAP President’s Club On behalf of the NCPhA Endowment Fund, we wish to thank the following for their support in 2013. Tax-deductible contributions can be made on your membership renewal form, on the NCAP website, or by mailing a check to the NCPhA Endowment Fund, 109 Church Street, Chapel Hill, NC 27516.

Platinum ($1,000 + ) Billy Allen, Pollocksville, NC J. Davie Waggett, Wilmington, NC Gold ($100 - $999) Carl Bennett, Jr., Morganton, NC Vestal Irving Boyles, Statesville, NC Colleen Brandsema, Chapel Hill, NC Valerie Brooks, Cary, NC J. Frank Burton, Greensboro, NC Robert Lee Carr, Rose Hill, NC Randy Crawford, Rocky Mount, NC William Duke, Greenville, NC Mary Ledbetter Fischer, Shallotte, NC Stephen W. Fuller, Salisbury, NC Kathryn Langenkamp, Greenville, NC Neil Rochette, Greensboro, NC Penny Shelton, Raleigh, NC Maura Smith, Hendersonville, NC Melinda Travis, Newton, NC Charles White, Lexington, NC Richard Whitesell, Winston-Salem, NC Silver (up to $99) Stephen Wayne Cagle, Charleston, SC Robert M. Cisneros, Jr., Buies Creek, NC LeAnne Davidson Kennedy, Winston-Salem, NC George Fred Kirkpatrick, Jr., Winchester, VA David Line, Charlotte, NC Timothy Victor Marcham, Aberdeen, NC William T. Rhodes III, Lumberton, NC Ronald Jackson Winstead, Emerald Isle, NC

22 North Carolina Pharmacist, Winter 2014

North Carolina Pharmacist, Winter 2014 23

Online Offerings: Pharmacist Refresher Course and QA/Law Course

NCAP has partnered with the Connecticut Pharmacy Association to offer The Pharmacist Refresher Course, an online course designed for pharmacists who wish to return to community pharmacy practice after an absence from practice for three or more years. The course consists of three modules, all of which have been approved for ACPE credits. The first two modules are online and composed of weekly study segments that allow course participants to work at their own pace, on their own time. The third module consists of a three-week, 90-hour live experience in a community pharmacy. Only those who participate in all three modules will earn a Pharmacist Refresher Course Certificate from Charter Oak State College. Those taking modules One and/or Two for personal enrichment will earn ACPE credits through CPA. This course will give home study law credit to any pharmacist wanting to learn about quality assurance strategies and North Carolina’s pharmacy laws.

The QA/Law Course can be used to prepare for reciprocity into North Carolina, or for those who want an update on Pharmacy Law and Quality Assurance. Students must follow a two-week course schedule. Online discussion boards and instructor monitoring and interaction keep you on track throughout the course. The course is offered the first two full weeks of every month. This course is accredited by ACPE for 15 hours of home study law education.

For more information visit www.ncpharmacists.org

24 North Carolina Pharmacist, Winter 2014

North Carolina Pharmacist, Winter 2014 25

Candidates Sought for NCAP Election, Awards

Election

Deadline for candidates to enter: June 1, 2014 NCAP Board of Directors NCAP will elect a President-Elect (to serve as President in 2016, 3-year term), a Treasurer (3-year term) and three At-large Board Members (3-year terms). Please send your bio to Mary Parker, Past President of NCAP: mhpandcbp@mac.com Health-System Practice Forum The Practice Forum will elect a Chair-Elect (3-year term), three Executive Committee members (3-year terms) and one Delegate to ASHP (3-year term). Please send your bio to Becky Szymanski, Chair: becky.szymanski@carolinashealthcare.org Chronic Care Practice Forum The Practice Forum will elect a Chair-Elect (3-year term) and four Executive Committee members (3-year terms). Please send your bio to Ted Hancock, Chair: thancock@wilmingtonhealth. com Community Care Practice Forum The Practice Forum will elect a Chair-Elect (3-year term) and one Executive Committee member (3-year term). Please send bio to Lisa Dinkins, Chair of the Practice Forum (lisa.dinkins@gmail. com).

Awards

Deadline for Nominations: June 1, 2014 It is a privilege for the North Carolina Association of Pharmacists to recognize excellence within the profession. NCAP will present the following awards at the Convention, October 26-28, 2014 in Raleigh, NC. The Board of Directors invites NCAP members to nominate deserving members for these awards.

Nominations must be in writing (see nominations form is on the website www.ncpharmacists.org or you may request from Linda Goswick). Submit nominations to the NCAP Awards Committee, c/o Linda Goswick, 109 Church Street, Chapel Hill, NC 27516 (FAX 919-968-9430 or e-mail linda@ncpharmacists.org). Past nominations must be resubmitted to be considered.

Bowl of Hygeia Award (sponsored by American Pharmacists Association and National Alliance of State Pharmacy Associations): Criteria for this award are: (1) Licensed to practice pharmacy in NC; (2) Has not previously received the Award; (3) Is not currently serving nor has he/she served within the immediate past two years on its awards committee or as an officer of the Association in other than an ex officio capacity; (4) Has compiled an outstanding record of community service, which, apart from his/her specific identification as a pharmacist, reflects well on the profession.

Cardinal Health Foundation Rx Champions Award: This award recognizes a pharmacist for his/her work within the pharmacy community to raise awareness of the serious public health problem of prescription drug abuse.

Don Blanton Award: Presented to the pharmacist who has contributed most to the advancement of pharmacy in North Carolina during the past year. This award was established by Charles Blanton in memory of his father, Don Blanton, who served the North Carolina Pharmaceutical Association as President 1957-58.

Excellence in Innovation Award (sponsored by Upsher-Smith Laboratories): Presented to a pharmacist practicing in North Carolina who has demonstrated Innovative Pharmacy Practice resulting in improved patient care.

Distinguished Young Pharmacist Award (sponsored by Pharmacists Mutual Companies): Criteria for this award are: (1) Entry degree in pharmacy received less than 10 years ago (2004 or later graduation date); (2) Licensed to practice pharmacy in NC; (3) Actively practices retail, institutional, managed care or consulting pharmacy; (4) Participates in national pharmacy associations, professional programs, state association activities and/or community service.

Please send nominations for this award to Kim Nealy, Chair of the New Practitioner Network (k.nealy@wingate.edu).

26 North Carolina Pharmacist, Winter 2014

North Carolina Pharmacist, Winter 2014 27

28 North Carolina Pharmacist, Winter 2014

Pharmacy Time Capsules

By Dennis B. Worthen, Lloyd Scholar, Lloyd Library and Museum, Cincinnati, OH

1989 The second Pharmacy in the 21st Century (P21) conference held in Williamsburg. The concept of pharmaceutical care was formally introduced by Hepler and Strand and enthusiastically accepted.

1964 The survey, Mirror to Hospital Pharmacy was published. Data included that less than 40% of all hospitals employed approximately 2,000 full-time pharmacists.

1939 Western Massachusetts School of Pharmacy opened in Willimansett, MA although never accredited.

1914 The federal Harrison Narcotic Act passed to regulate and tax the importation, production, and distribution of narcotics.

1889 Walden University (Meharry Pharmaceutical College) opened in Nashville.

One of a series contributed by the American Institute of the History of Pharmacy, a unique non-profit society dedicated to assuring that the contributions of your profession endure as a part of America’s history. Membership offers the satisfaction of helping continue this work on behalf of pharmacy, and brings five or more historical publications to your door each year. To learn more, check out: www.aihp.org

2014 CALENDAR 3/8 NCAP Technician Review Seminar, Raleigh

e-Prescribing PEER Portal is open for business!

The Pharmacy and Provider e-Prescribing Experience Reporting

3/9 NCAP Technician Review Seminar, Greensboro 3/19-21 NCAP Chronic Care Practice Forum Meeting, Charlotte 3/22 NCAP Technician Review Seminar, Hickory

Portal and instructions on how to report can be

3/23 NCAP Technician Review Seminar, Charlotte

found at:

7/18 NCAP Residency Conference, Greensboro

https://www.pqc.net/eprescribe

9/20 Student Leadership Conference, Pinehurst 10/26-28 NCAP 2014 Annual Convention, Raleigh

Help us save lives‌ Report eRx problems TODAY!

For more information visit www.ncpharmacists.org North Carolina Pharmacist, Winter 2014 29