North Carolina Pharmacist Summer Journal 2013

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North Carolina

Pharmacist Vol. 93, Number 3

Advancing Pharmacy. Improving Health.

Summer 2013

“Navigating the Changing Tide of North Carolina Pharmacy”

Don’t miss NCAP’s Annual Convention at the Raleigh Convention Center October 20-22, 2013 Save the date!

More information on page 8

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

North Carolina

Pharmacist Vol. 93, No. 3

Summer 2013

Inside • From the Executive Director............................................ 4 • From the President ........................................................ 5

BOARD OF DIRECTORS PRESIDENT Mary Parker PRESIDENT-ELECT Michelle Ames PAST PRESIDENT Jennifer Askew Buxton TREASURER Dennis Williams BOARD MEMBERS Randy Angel Andy Bowman Jennifer Burch Jena Ivey Burkhart Valerie Clinard Thomas D’Andrea Stephen Dedrick Leigh Foushee Alyce Holmes Debra Kemp LeAnne Kennedy Kimberly Lewis Natasha Michaels

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.

• NC General Assembly Expands

Pharmacists Immunization Authority .......................... 6

• Join Us for NCAP’s Annual Convention ......................... 8 • NCAP Residency Conference ...................................... 10 • Safety Solutions

The Human Factor in Patient Safety:

More Lessons from the Aviation Industry ................. 12

• NPN: What’s New in Transitions of Care ..................... 13 • NPN Spotlight: Courtenay Gilmore Wilson .................. 15 • NCAP’s Community Care Practice Forum Meeting ..... 17 • Chronic Care Practice Forum Update ........................ 20 • Pharmacy Time Capsules ............................................ 22 • Calendar ...................................................................... 22 North Carolina Pharmacist, Summer 2013 3

From the Interim Executive Director

I’m Back I feel so blessed to be able to write this letter to our members. Yes, I am back as the NCAP Interim Executive Director, filling in until a new Executive is recruited. This is my third time at the helm. In 1998 I filled in at North Carolina Pharmaceutical Association after Al Mebane left. In 2001 I filled in at NCAP after Dan Garrett left. That ended up lasting eleven years because I really enjoyed the job. I have had a lot of different roles in pharmacy, although I have been fortunate enough to do most of them in Chapel Hill, NC. But, being a state association executive is one of the best. It requires you to be engaged in all aspects of pharmacy practice at both the state and national levels. You have to know everything going on to do your job well, and you can have influence on as much of it as you want.

That is why I joyfully accepted this new offer to return to NCAP as Interim Executive Director.

In a recent blogpost, Tom Menigham, CEO of the American Pharmacist Association posted: “Recently, I received a job listing for the Executive Director of the North Carolina Association of Pharmacists (NCAP).

We get these ads from time to time as state exec positions turn over. I’ve had the privilege of knowing most, if not all, of the state execs in the United States over the last 25 years, and I can say they’ve been incredibly dedicated to our profession. I can also say they have one of the most essential jobs in the pharmacy profession in America.

“So, in the process of making you aware of this job opening, let me also share a tip of the hat to all state pharmacy association execs who go to bat for pharmacists everyday, in every state in the United States! We here at APhA have a great appreciation for what they do, and we value the partnership we have with them and the National Alliance of State Pharmacy Associations.

We wish our best to the folks in North Carolina as they search for a new exec.”

What a nice endorsement for the role of state association executives. Are you ready for a job change? Have you considered the NCAP opening? This job, like most, comes with its headaches, but you have a great and experienced staff in place.

There is a strong foundation of willing volunteers upon which to build the organization. As NCAP’s CEO, you also become part of the National Alliance of State Pharmacy Associations (NASPA). This group is really a brotherhood/sisterhood of great individuals who are committed to making each other better by willingly sharing information, experiences, procedures or just insights so that you can quickly develop as a state pharmacy executive. NASPA is led by Becky Snead and as an organization is focused on making sure state associations and their members are at the right tables, that their perspectives are shared and that state associations grow stronger. So, even if you have limited or no experience in state association work, the resources are in 4 North Carolina Pharmacist, Summer 2013

place to help you learn quickly. NCAP also has membership in the Association Executives of North Carolina (AENC). It is committed to providing high quality professional development and networking opportunities to help you develop your fullest potential and foster the recognition and respect of the association management profession. Members include CEOs and staff of associations across North Carolina, as well as representatives from the association service and hospitality industries.

So, this is also a broad resource that can be used to quickly learn about association management. Don’t use a lack of this type of experience as an excuse not to apply. If the Lord allows, I also plan to be around and am willing to help in any transition, if requested. I have maintained an office in the basement of the Institute of Pharmacy and plan to continue using it after this stint is over.

Now let me share a few observations about NCAP and make a few requests of our members. A time of transition can be difficult for any organization. Your Board, and especially the Executive Committee, have been very dedicated to keeping the organization progressing. The staff have done their part too. I see my role as providing stability, and I shoulder some of the responsibilities that the Executive Committee assumed. I am trying to provide leadership, but not push for the implementation of new activities right now. I hope I will gain more insights to help the new CEO get up and running quickly and maybe be able to help him or her implement changes that might be needed sooner.

October 20-22 is our next Convention. It would be a real encouragement to the Executive Committee and NCAP staff if this meeting was our largest ever. Please consider making it a priority to attend at least one day and hopefully the entire meeting. Due to the recent passage of Immunization legislation with an expanded role for pharmacists, we are making immunization a major focus in our Sunday programming, especially for pharmacists in the community. You can become certified, get your CE needed for recertification and learn how different pharmacies are planning to implement expanded immunization activities.

A major emphasis on Tuesday will be on Patient Centered Medical Homes. Some think that health care reform will alter practice for all areas of pharmacy. Even if you feel you will not be impacted, come and learn and validate that fact, or learn how you will need to change to be relevant in the new system.

Finally, let me request that you personally make a commitment to be part of the effort to obtain Provider Status recognition. If this is going to happen, it will need the participation of all pharmacists to ensure patients and our health care colleagues have access to our services. Go to http.www.pharmacists.com/ providerstatusrecognition and learn what you can do. I made a contribution to the APhA PAC and their Foundation. You don’t have to an APhA member to do this. v

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

Dear Members, There are several key achievements for NCAP that are featured in this journal, and many members and friends of the organization who have given time and energy to support these accomplishments.

• Fred Eckel has graciously agreed to support NCAP by accepting a call from the Board of Directors to serve as Interim Executive Director. I am grateful for his energy, organizational memory, and leadership of our staff. Fred’s experience is a huge asset, and we will leverage this as we move through with our website refresh and conversion, Acute Care Practice Forum transformation project, and Annual Meeting preparation.

• The Acute Care Practice Forum, under the leadership of Alyce Holmes, and the Ambulatory Care Task Force, led by Debra Kemp, agreed to develop a unified “Health Systems Pharmacy Practice Forum.” This measure (approved by your Board of Directors in June 2013) will provide a greater opportunity for all health systems pharmacists to collaborate and network on transitions of care, meaningful use activities, and key topics that are important to the inpatient and outpatient-focused health system clinician. I am excited at the opportunities to grow and advance this forum in the next six months. Be on the lookout for a needs assessment survey and additional calls for participation in this exciting transformation.

• HB 832 “Expanding Pharmacists Immunizing Authority” was signed into law by Governor McCrory on July 3, 2013. This is the culmination of four and a half years of work by our Immunization Task Force, Community Care Practice Forum, Board of Directors, and colleague organizations NC Retail Merchants’ Association and Association of Community Pharmacists. I am grateful to the contributions on NCAP’s behalf from: - Evelyn Hawthorne, our lobbyist - Linda Goswick, NCAP Administrative Director (who was responsible for Pharmacy Day in the Legislature) - Andy Ellen, President and General Counsel at NCRMA - Mike James, NCAP member and ACP Director of Government Affairs -Immunization Task Force members: Ashley Branham, Chair, Ouita Davis, Macary Marciniak, and Dennis Williams.

- Gene Minton, President, and Jay Campbell, Executive Director, for the NC Board of Pharmacy Efforts towards implementing this legislation continue as the six organizations work together to develop minimum standard screening and safety measures prior to the October 1, 2013 deadline set forth in the law.

Tasha Michaels, Dennis Williams, and I continue to assist the NC Immunization Registry Division in its rollout access planning activities. NCAP will continue to advocate for our profession in each of these activities.

• NCAP’s Residency Conference was held on July 12, 2013. Over 190 residents, residency program directors, and preceptors attended this outstanding day of programming in Greensboro, NC. Jamie Brown, Planning Chair, Sandie Holley of NCAP staff, and Melissa Durkee, Moderator, developed a great day of activities for a great bunch of attendees. Please make sure to meet these future leaders and clinicians throughout this year!

• Sally Slusher and Teressa Reavis of NCAP staff, Michelle Ames, and Fred Eckel continue to work with YourMembership.com and Affiniscape to build / update our new website. This process, as with any merger, has presented challenges, twists, and turns with the platform change. We anticipate this rollout will occur late 2013 / early 2014.

• The Education Committee, led by Minal Patel, has developed an impressive schedule of programming for our Annual Convention. Make sure to “save the dates” October 20-22 to attend this program at the Raleigh Convention Center. Advance registration will open shortly.

I remain grateful for those who provide leadership, mentorship, and assistance in our organization’s daily activities. I look forward to next quarter of activities together...see you in Raleigh!

Sincerely,

Mary Parker, PharmD, BCPS President

Advancing Pharmacy. Improving Health.

North Carolina Pharmacist, Summer 2013 5

NC Governor Pat McCrory (seated) meets with pharmacy representatives at the bill signing ceremony.

Standing, left to right: David Moody, Gene Minton, Mark Gregory, and NCAP President Mary Parker.

NC General Assembly Expands Pharmacists Immunization Authority On July 3, the Governor signed S.L. 2013-246, An Act to Protect the Public’s Health by Increasing Access to Immunizations and Vaccines through the Expanded Role of Immunizing Pharmacists.

The new legislation will allow immunizing pharmacists, who meet the requirements in the statute, to administer any CDC-recommended vaccination to any patient at least 18 years of age pursuant to a specific prescription order. Vaccinations include pneumococcal, zoster, hepatitis B, meningococcal, tetanus, tentanusdiptheria, and TDAP. Pharmacists may continue to administer the influenza vaccine to patients age 14 and over as specified in the current rules.

NCAP is grateful for the hard work of our Immunization Task Force, including Ashley Branham, Ouita Gatton, Macary Marciniak, and Dennis Williams. The NC Retail Merchants Association and Association of Community Pharmacists also brought forth diligent efforts to help bring this legislation to reality. NCAP will continue to work with NCRMA, ACP, NC Medical Society, NC Family Physicians and NC Pediatric Society to develop mandated screening questionnaires and emergency protocols by the October 1, 2013 deadline set forth in this law. Collaborative efforts with the NC Immunization Registry are in progress as well to develop processes to register, train, and meet requirements for contributing to the registry when vaccines are administered.

6 North Carolina Pharmacist, Summer 2013

North Carolina Pharmacist, Summer 2013 7

“Navigating the Changing Tide of North Carolina Pharmacy”

NCAP’s Annual Convention at the Raleigh Convention Center October 20-22, 2013 Registration coming soon!

Early Bird Rates end October 7 Hotel Information: Sheraton Raleigh Hotel 421 S. Salisbury Street, Raleigh, NC 27601 • 919-834-9900 Group Code: NC Association of Pharmacists Rate: $135 • Cut-off: September 27, 2013 8 North Carolina Pharmacist, Summer 2013

Join us for three days of quality continuing education programming, networking, and more!

Topics Include: • Immunization Update to Include New Vaccines • Preceptor Development • Preparing for the Expansion of Pharmacist-Provided Immunizing Services • Essential Guidelines for Acute Coronary Syndrome • Pharmacy Technician Law Review and Calculations • National Healthcare Transformation • Updates on Opportunities in Community, Chronic and Acute • Self-Regulation of the Practice of Pharmacy • Navigating Change in NC Pharmacy Practice Settings • Key Papers • Immunization Certificate Program • OTC Jeopardy • Making the Most Out of 4th Year Rotations • Clinical Pearls • Treatment of Multiple Myeloma • Pulmonary Arterial Hypertension • ACO in Community Pharmacy • Pharmacy Quality Initiatives • Project Lazarus • NC Immunization Registry • Next Five Years in North Carolina Pharmacy Keynote Speakers: • Steve Simenson, President of APhA • Jay Campbell, Executive Director of the NC Board of Pharmacy • Rebecca Snead, Execuitve Vice President and CEO of the National Alliance of State Pharmacy Associations Plus: Award Presentations, Rite of Roses, Installation of Officers, Residency Showcase, Exhibitors, NCAP Town Hall Meeting and Pharmacy School Receptions.

North Carolina Pharmacist, Summer 2013 9

NCAP Residency Conference NCAP’s Residency Conference was held July 20, 2013 at the Sheraton Greensboro Hotel at Four Seasons. Over 190 were in attendance for a day of outstanding programming for residents and preceptors.

10 North Carolina Pharmacist, Summer 2013

e-Prescribing PEER Portal is open for business!

The Pharmacy and Provider e-Prescribing Experience Reporting Portal and instructions on how to report can be found at: https://www.pqc.net/eprescribe Help us save lives‌ Report eRx problems TODAY!

North Carolina Pharmacist, Summer 2013 11

Safety Solutions

The Human Factor in Patient Safety: More Lessons from the Aviation Industry

By John M. Kessler, PharmD Chief Clinical Officer SecondStory Health, LLC

Without any doubt, healthcare is adopting many important safety system practices from the aviation industry. Table 1 lists just a few of these important lessons that are being adopted in acute care, chronic care, and community care settings.

Table 1 Formal safety management programs Root cause analysis/accident investigation Safety reporting systems for accidents/incidents Safety reporting systems for near misses Non-punitive reporting Confidential/Anonymous reporting Systems-based perspective on accidents/incidents Crew resource management (teamwork/communication) Human factors design and engineering Use of critical checklists Safety cultures and attitudes Prospective risk assessment Protocols and standardization Simulation training Timeouts, briefings, debriefings

Individually and collectively, practitioners are becoming more aware of how to adopt aviation’s safety experience into healthcare practices and policies. Positive results are being achieved, even if progress has been slow and uneven across the entire system. Most would also agree that more work is needed to fully implement all that could and should be done to decrease patient harm and the risk of harm.

What other aviation industry lessons can be adopted by healthcare?

Pilots are trained to develop and consider their personal minimums, using a process known by its acronym, PAVE. The PAVE checklist (Pilot, Aircraft, enVironmental, and External pressures) assigns personal minimums using a risk assessment tool targeted to the individual pilot. As examples, the Pilot assesses his/her personal experience and recency with the number of take offs/ landings in the last x days, along with the pilot’s physical state as indicated by hours of sleep, food/water intake, alcohol use, medication use, stressful events and illness. The Aircraft is assessed for its suitability for the mission and to assure its key components are in working order, including communications and rescue equipment. The enVironment is safe for flying with personal minimums for airport conditions, weather conditions, and electronic guidance systems for instrument landings. The External pressures are recognized and managed, including factors seemingly beyond the pilot’s control that affect scheduled trip times and stress due to disruptions or cancellations.

12 North Carolina Pharmacist, Summer 2013

Pilots are trained to develop their personal minimums and then assess their individual risk before each flight. If two or more areas indicate marginal scores, the risk may be too high to make that flight. The benefits of this tool include identifying and managing risks, even subtle risks, which affect human performance.

I’M SAFE The I’M SAFE checklist is another simple tool used by the aviation industry to increase pilot self-awareness of personal factors that affect safety and performance. Table 2 lists the elements of the checklist. How difficult would it be to mentally review the checklist before each work day? Individual performance may be adversely affected when marginal scores in one element signal an alert. If two or more elements are marginal, individual action is probably warranted to minimize risk.

Table 2 I’M SAFE Illness - symptoms Medication - Rx and OTC Stress - job, financial, health, family Alcohol - use in last 8 hours, 24 hours Fatigue - adequately rested Eating - adequately nourished

Translating the benefits to healthcare The factors that affect pilot performance are likely to be similar to those affecting healthcare workers. With a degree of inventiveness, you can imagine the elements in hospitals, pharmacies, automation, drug technologies, and patient volumes which correspond to the elements in airplanes, airports, cockpit controls, navigation systems, and environment.

Current efforts in patient safety most often focus on only 2 of the 3 factors that contribute to safety: 1) preventing systembased errors and 2) improving behaviors (i.e., “Just Culture”).

When human performance, the 3rd safety factor, is recognized and considered, it is usually after-the-fact, during a root cause analysis. The aviation industry has extensive experience using the above tools to increase pilot self-awareness and assess human performance risk before the flight. The I’M SAFE checklist and the PAVE checklist with relevant adaptations, can be used by individuals in the healthcare system to further reduce the risks and reduce the burden of harm to patients before care is rendered. v References: http://www.faa.gov/regulations_policies/handbooks_manuals/aviation/ pilot_handbook/ http://www.faa.gov/news/updates/?newsid=73025 http://www.faa.gov/training_testing/training/fits/guidance/media/personal%20minimums%20checklist.pdf

North Carolina Pharmacist, Summer 2013 13

New Practitioner Network

What’s New in Transitions of Care?

The healthcare system is a complex environment in which patients navigate in and out of home care, community pharmacies, primary care offices, hospitals and long-term care facilities.

Transitions between these settings presBy Kayla Hansen, PharmD, MS ent challenges for patients, caregivers, and healthcare providers. Adverse drug events are a known contributor to both hospital admission and morbidity and mortality following discharge. Fortunately, pharmacists’ roles are growing in all areas of healthcare and we have opportunities to facilitate smoother, Kimberly Lewis, PharmD, safer transitions of care.

CACP, BCACP, CPP Traditionally, acute care pharmacists have focused on the more immediate needs of the patient. More recently, significant emphasis has been placed on the role acute care pharmacists can play in successful transitions, both into and out of an inpatient facility. Numerous Kimberly Lovin Nealy, studies have described successful pharPharmD, BCPS macist interventions related to transitions of care, with two recently published articles highlighting the role of pharmacists in assuring safe transitions through a variety of targeted interventions.

The Cardiology Practice and Research Network of the American College of Clinical Pharmacy and the Heart Failure Society of America published a policy statement in May 2013.

Pharmacist participation in discharge education was identified as a significant opportunity to improve a portion of the transition process. Some organizations utilizing pharmacists in discharge education have realized reductions in readmissions and emergency department visits.1 The kidney transplant program at Providence Sacred Heart Medical Center and Children’s Hospital in Spokane, Washington recently published a description of the pharmacist’s role in kidney transplant management, emphasizing pharmacist participation in reconciliation of home medications as well as ensuring access by confirming insurance plan requirements and addressing cost-barriers.2 Likewise, transitional care roles in the outpatient arena are still being developed. While the responsibilities of pharmacists in the hospital setting have been established, such roles in the outpatient arena are still lacking. Because community pharmacists process and dispense prescriptions, patient counseling is closely related, although patients have the right to refuse counseling.3 Pharmacists working in primary care clinics are in a position to improve patient education and knowledge, while working directly with physicians to provide optimal care and medication therapy management (MTM). Pharmacists are instrumental in coordinating and providing MTM services by serving as a conduit amongst multiple providers. Being able to identify discrepancies with medications and communicate those issues to physicians is a unique position that other healthcare providers do not have.

14 North Carolina Pharmacist, Summer 2013

Outpatient pharmacists must step-up and mirror the progressive practice of hospital pharmacists in this respect.3 On January 1, 2013 new Current Procedural Terminology (CPT) codes became effective as an incentive to improve coordination of care post-hospital discharge. The codes, 99495 and 99496, cover communications, both electronic and telephonic, with patients when coupled with face-to-face interaction.4 Although pharmacists are not permitted to bill for their services, they are allowed to be a part of the patient care team.4 Additionally, new practice models such as Patient-Centered Medical Home and Pharmacy Practice Model Initiative aim, in part, to meet this need. In addition to these ongoing efforts, active communication between all stakeholders in patient care is imperative. v References 1. Mildred-Laforest SK, Chow SL, Didomenico RJ, et al. Clinical pharmacy services in heart failure: an opinion paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network. J of Cardiac Failure. 2013;19:354-369.

2. Maldonado AQ, Weeks DL, Bitterman AN, et al. Changing transplant recipient education and inpatient transplant pharmacy practices: a single-center perspective.

Am J Health-Sys Pharm. 2013;70:900-904.

3. Prescriptions for Excellence in Health Care Spring 2011 Download PDF, Prescriptions for Excellence in Health Care Newsletter Supplement: Vol. 1: Iss. 11, Article 1.

Available at: http://jdc.jefferson.edu/pehc/vol1/iss11/1. Accessed June 26, 2013.

4. Traynor K. Transitional care CPT codes may include pharmacists’ services.

Am J Health-Syst Pharm. 2013;70:748-750.

New Practitioner Spotlight

Courtenay Gilmore Wilson, PharmD, BCPS, CPP Courtenay Gilmore Wilson, PharmD, BCPS, CPP is an ambulatory care pharmacist, the Associate Director of Pharmacotherapy at MAHEC, and a co-funded Assistant Professor of Clinical Education for the UNC Eshelman School of Pharmacy. She is a North Carolina native, attended the University of Georgia for her undergraduate degree, and subsequently earned her PharmD from the UNC Eshelman School of Pharmacy.

She then completed her PGY-1 Pharmacy Practice Residency at the VAMC in Boise, ID, before returning to NC to settle in the Asheville area.

In her current role, she spends most of her clinical time at the MAHEC Family Health Center (FHC), predominantly serving uninsured and underinsured patients from western NC. The FHC is a family medicine practice with an embedded family medicine residency program and a PGY-1 pharmacy residency focused in ambulatory care (a partnership with Mission Hospital). She heads the Pharmacotherapy clinic at the FHC where she manages patients with a wide variety of chronic disease states including diabetes, hyperlipidemia, hypertension, and chronic pain. She also heads the MAHEC employee Chronic Conditions Management Program, which is a wellness program modeled after the Asheville Project®.

She has been a member of NCAP since 2008 as a student, and feels that “we are all very fourtunate to live in one of the most

Division of Display Options, Inc. Assisting Pharmacists since 1973 Rx Planning Specialists Craig Ashton • Roland Thomas 70 years combined experience in over 2,000 pharmacies.

progressive states for pharmacy practice. NCAP is a way to bring together pharmacists from around the state in order to continue advancing practice. Becoming involved with NCAP has allowed me to network with others in my area of specialty, which allows for sharing ideas and developing mentors.” She also sees the importance of advocacy for our profession and feels that “NCAP serves as the voice for our state to unify all the various practices and share our successes with others across the country.” v

Compounding Labs Pharmacy Planning & Design Patient Consultation Areas Merchandising Stocking Lozier Distributor Retail and Pharmacy Fixtures Custom Wood Work Professional Installation and Delivery

9517 Monroe Road, Suite A • Charlotte, NC 28270

1-800-321-4344 www.displayoptions.com

North Carolina Pharmacist, Summer 2013 15

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NCAP’s 2013 Community Care Practice Forum Meeting

NCAP’s 2013 Community Care Practice Forum meet-

ing was held August 2-3 at the Sheraton Myrtle Beach Convention Center Hotel. NCAP collaborates with NC Mutual Wholesale Drug Company to stage the event each year.

Attendees enjoyed time at the beach, dynamic speakers and networking among peers.

Ashley Branham, PharmD, of Moose Pharmacy in Con-

cord, NC, received NCAP’s 2013 Community Care Phar-

macist of the Year Award for her outstanding contribution

to pharmacy. Branham is the past Chair of the Community

Care Practice Forum. She is the director of clinical services at Moose Pharmacy and a clinical pharmacist at Cabar-

rus Family Medicine, where she serves as a preceptor to

pharmacy students. She also serves as an adjunct assis-

tant professor at the University of North Carolina Eshelman School of Pharmacy.

Community Care Practice Forum Chair Natasha Michaels (left) presents the Community Care Pharmacist of the Year Award to Ashley Branham.

North Carolina Pharmacist, Summer 2013 17

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

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North Carolina Pharmacist, Summer 2013 19

Chronic Care Practice Forum Update Greetings from the NCAP Chronic Care Practice Forum Executive Committee! This is our inaugural edition of what we hope to be a quarterly update from the Forum to our members to keep you abreast of pertinent practice, regulatory, and legislative issues that relate to our practice areas. We hope that you will find this information useful!

Clinical Practice Updates Chronic Antipsychotic Use (Rhonda Gentry) Withdrawal of chronic antipsychotic drugs for behavioral and psychological symptoms in older people with dementia Declercq T, Petrovic M, Azermai M, Vander Stichele R, De Sutter AIM, van Driel ML, Christiaens T Published Online: April 30, 2013

People with dementia often have behavioral problems that can be difficult for care givers to manage. Antipsychotic drugs are often prescribed to control symptoms and assist with controlling difficult behavior. Many people with dementia continue to take these drugs over long periods of time. This review investigates whether withdrawal of long-term antipsychotic treatment is feasible in older people with dementia suffering from behavioral symptoms (often called neuropsychiatric symptoms or NPS). These include agitation, aggression, hallucinations, anxiety, apathy, depression, delusions (beliefs that cannot be true), wandering, repeating of words or sounds, and shouting. Nine studies with 606 participants provided data for the review. Most of the participants were residents in nursing homes, but some were outpatients. The studies differed considerably in participants, methods and outcomes, so that is was not possible to combine most of the data numerically.

The evidence suggests that older nursing home residents or outpatients with dementia can be withdrawn from long-term antipsychotics without detrimental effects on their behavior. Caution is required in older nursing home residents with more severe NPS, as two studies suggest these peoples’ symptoms might be worse if their antipsychotic medication is withdrawn.

Moreover, one study suggested that older people with dementia and psychosis or agitation and a good response to their antipsychotic treatment for several months 20 North Carolina Pharmacist, Summer 2013

could relapse after discontinuation of their antipsychotic medication. We do not know if there are beneficial effects of withdrawal on intellectual processes, quality of life or ability to carry out daily tasks, or if the risk of harmful events is reduced by drug withdrawal. One study suggests that older people with dementia who continue to take antipsychotics might die earlier.

We recommend that programs that aim to withdraw older nursing home residents from long-term antipsychotics should be incorporated into routine clinical practice, especially if the NPS are not severe. More research is needed to identify people for whom withdrawal is not indicated and risk of relapse should be weighed against the risk of adverse events with long-term antipsychotic treatment.

See more at: http://summaries. cochrane.org/CD007726/withdrawalof-chronic-antipsychotic-drugs-for-behavioural-and-psychological-symptomsin-older-people-with-dementia#sthash. eTa3eD4G.dpuf

Treatment of Late-Life Depression (Amber McLendon) A meta-analysis was published in the American Journal of Psychiatry in June that questions the role of antidepressants in older adults with a recent development of depression. The analysis included patient level results from seven randomized, controlled trials of antidepressants (SSRIs, duloxetine and bupropion) for depression in patients age 60 and older living in the community (n=2283). Patients with a depression history 10 years or greater demonstrated a significant response to antidepressants compared to placebo (p=0.02; number needed to treat (NNT) of four). However, in those with a shorter duration of disease the NNT was much higher at 21. Those with depression for two years or less did not demonstrate a significant difference from placebo. The authors report that treatment with antidepressants may not benefit older adults with recent onset of disease. Other studies in older adults have demonstrated benefit with adjuvant antidepressants. Although this study was conducted in community dwelling patients, residents of long-term care facilities may also experience limited benefit from antidepressants such as SSRIs. In those residents who have not

responded within 2-3 months of treatment, additional or alternative treatments should be utilized.

References: Nelson JC, Delucchi KL, Schneider LS. “Moderators of Outcome in Late-Life Depression: a patientlevel meta-analysis” Am J Psychiatry 2013;170:651659.

New Treatment Option for DVT/PE Treatment (Laura MacCall) *View article on NCAP website: http://ncpharmacists.org/associations/4188/files/New%20Treatment%20 Option%20for%20VTE.pdf

Regulatory Update CMS Revisions to F309-Quality of Care and F329-Unnecessary Drugs A Closer Look at Appropriate Indications and Dosages of Antipsychotics in the Elderly (Heather Erskine) *View article on NCAP website: http://ncpharmacists.org/associations/4188/files/CMS%20Revisions.pdf

NCAP Annual Convention/ Chronic Care Practice Forum Social The NCAP Annual Convention is scheduled for Sunday, October 20th through Tuesday, October 22nd in Raleigh, NC at the Raleigh Convention Center. The host hotel is the Sheraton downtown. The CCF Executive Committee would like to host a social gathering for our members during the annual meeting as a networking opportunity. Please register for the meeting by the cut-off date if you plan to attend so that we can get a headcount of the number of CC members we might have at this social event. We hope that you will attend!

What Certification is that, and how do I obtain it?

Board Certified Pharmacotherapy Specialist (BCPS) (Jena Burkhart) The Board of Pharmaceutical Specialties (BPS) was created in 1972 as a Task Force on Specialties in Pharmacy

by APhA as a way to respond to changes occurring in health care and the pharmacy

profession. Of particular interest was the issue of specialization in pharmacy practice.

One of the specialties within BPS is Pharmacotherapy. The pharmacotherapy specialist has the responsibility for direct patient care, often functions as a member of a multidisciplinary team and is frequently the primary source of drug information for other healthcare professionals.

Eligibility Requirements: a) Graduation from a pharmacy program accredited by the ACPE or a program outside the US that qualifies the individual to practice in the jurisdiction. b) Current, active license to practice pharmacy in the US or other jurisdiction c) Completion of 3 years of practice experience with at least 50% of time spent in pharmacotherapy activities OR completion of a PGY1 residency d) Achieving a passing score on the Pharmacotherapy Specialty Certification Exam This is a highly recognized specialty that assists practitioners in continuing to practice at the highest level possible providing superior patient care. The examination covers a breadth of disease state topics, spanning from pediatrics to geriatrics, as well as drug literature and analysis/statistical questions. Recertification is required every 7 years. The BCPS specialty credentials pharmacists from all practice areas, from inpatient acute care to ambulatory care practice. Please see the website at www.bpsweb.org for more details on this certification.

Board Certified Ambulatory Care Pharmacist (BCACP) (Ted Hancock) After many years of petitioning and campaigning by pharmacists who were practicing coordinated, direct patient

care in the context of family, community, and sustained partnerships with patients, BPS recognized the first Board Certified Ambulatory Care Pharmacists in December 2011. The newest BPS certification focuses on patient advocacy, wellness, health promotion, triage, patient education and self-management.

The ambulatory care pharmacist may work in both an institutional and community-based clinic involved in direct care of a diverse patient population.

Eligibility Requirements: see above under BCPS. This is a rapidly growing specialty that assists practitioners in continuing to practice at the highest level possible providing superior patient care. The examination covers a breadth of disease state topics, spanning from pediatrics to geriatrics, as well as drug literature and analysis/statistical questions. Recertification is required every 7 years and can be achieved through continuing education or reexamination.

Pharmacists seeking certification matching their skill set often ask how the BCACP differs from the BCPS. The differences are highlighted in the side-byside comparison offered in Table 1.

Certified Geriatric Pharmacist (CGP) (Keely Ray) Have you ever noticed the credentials, CGP, and wanted to know what it meant and how to obtain it? Pharmacists who have earned their CGP are qualified as a Certified Geriatric Pharmacist.

The purpose of the Certified Geriatric Pharmacist (CGP) credential is to identify and recognize those pharmacists who have expertise and knowledge of drug therapy principles for older adults. Drug therapy in older adults involves identifying potentially inappropriate medication

use, polypharmacy, prescribing cascade, and the impact of medications related to falls, cognitive impairment, fluid imbalance, & other geriatric syndromes. For this reason, the CGP credential is ideal for pharmacists who will be providing MTM services. Geriatric expertise is especially valued in both in the long-term care setting as well as the hospital setting. This may not be surprising since more than half of hospital inpatients are over the age of 65. During the hospital stay, the primary focus of hospital personnel has generally been on the acute condition that led to the hospitalization. Increasing attention is now being paid to the chronic conditions of the older adult patient that may result in rehospitalization. Hospitals, therefore, are increasingly focused on chronic conditions of older adults. The certification credential may also be useful in qualifying for a job or promotion.

Eligible pharmacists must have an active license & a minimum of two years of experience as a licensed pharmacist. To become certified, eligible pharmacists must pass a written examination. The examination is offered in four test windows throughout the year. For detailed information regarding the testing window(s), registration deadline(s), application fee, computer-based exam, test centers, and additional resources please visit www.ccgp.org.

Recertification is required every five (5) years and may be achieved either by retaking the CGP examination or by means of the Professional Development Pathway.

Future Updates Have an idea you’d like to see in our next quarterly update? We’d love to hear from you! Please email your ideas/entries to Jena Burkhart at ivey@unc.edu. v

Table 1 Requirements and Focus Applicable practice experience1 Exam Domain 1 Exam Domain 2 Exam Domain 3 Exam Domain 4 Exam Domain 5 1

BCPS Three years Patient specific pharmacotherapy (60%) Mastery of pharmacotherapy literature (25%) Systems and population-based pharmacotherapy (15%) NA NA

BCACP Four years Direct patient care (50%) Practice management (20%) Mastery of pharmacotherapy literature (15%) Patient advocacy (10%) Public health (5%)

An ASHP accredited PGY1 residency, or one under ASHP consideration, may substitute for this requirement.

The areas addressed by the BCACP examination, not emphasized for BCPS, primarily focus establishing and maintaining practices at unconventional sites, counseling patients on national and regional health resources, collaborative care, disaster response, and a wide range of regulatory and legislative guidance specific to community healthcare. Specifics are available at http://bpsweb.org/pdfs/AmbulatoryCareContentOutline.pdf North Carolina Pharmacist, Summer 2013 21

Pharmacy Time Capsules

By Dennis B. Worthen, Lloyd Scholar, Lloyd Library and Museum, Cincinnati, OH 1988 - Twenty-five years ago: • American College of Physicians called for enhanced education in rational therapeutics including “increased communication with pharmacists, as health care professionals with particular knowledge in this area.”

• RU-486 (mifepristone) first marketed in France as a safe and effective method of early abortion.

1963 - Fifty Years Ago: • Oncovin (vincristine), an alkaloid derived from rosy periwinkle, was used as a folk medicine for diabetes.

Eli Lilly & Co. discovered it to be an effective treatment for several forms of leukemia.

1938 - Seventy-five Years Ago: • APhA undertook a national campaign to work with dental associations and dentists to increase appropriate prescribing.

1913 - One hundred Years Ago: • The University of Puerto Rico School of Pharmacy was formed.

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 22 North Carolina Pharmacist, Summer 2013

calendar September 21, 2013 Student Leadership Conference, Pinehurst, NC October 20-22, 2013 NCAP Annual Convention, Raleigh Convention Center, Raleigh, NC October 26, 2013 NCAP Technician Review Seminar, Moses Cone AHEC, Greensboro, NC October 27, 2013 NCAP Technician Review Seminar, Rex Hospital, Raleigh, NC November 2, 2013 NCAP Technician Review Seminar, Catawba Medical Center, Hickory, NC November 3, 2013 NCAP Technician Review Seminar, Mercy Hospital, Charlotte, NC March 19-21, 2014 NCAP Chronic Care Practice Forum Meeting, The Ballantyne Hotel & Resort, Charlotte, NC For more information visit www.ncpharmacists.org

North Carolina Pharmacist, Summer 2013 23