Expanding Pharmacy Services in a Health-System Primary Care Clinic: Factors to Consider

1. Expanding Pharmacy Services in a Health-System Primary Care Clinic: Factors to Consider Andrea Lee, PharmD PGY2 Health-System Pharmacy Administration Resident

2. Objectives • Identify methods to justify the expansion of sustainable primary care pharmacy services in a health-system clinic.

3. Health-Care Facility • Penobscot Community Health Care (PCHC) is a Patient Centered Medical Home serving over 60,000 patients annually at 16 practice sites • Totaling over 350,000 patient visits • 70% of patients are lower income • Largest and most comprehensive Federally Qualified Health Center (FQHC) in Maine • Shared Savings Accountable Care Organization (ACO) • Previously in a Pioneer ACO- 2013 • Rural health care facility providing comprehensive health care services to the greater Bangor area and surrounding communities Image: www.visitmaine.org

4. Outpatient Pharmacy Background • Three Outpatient Pharmacies • Roughly 80,000 prescriptions annually • Hours of Operation vary among locations • One pharmacy open weekday evenings and weekends starting October 2012 • 3 Full-time Pharmacists • Focus of time spent in dispensing roles

5. Clinical Pharmacy Services Background • Two* Clinical Pharmacists- Husson University Faculty • Four PGY1 Community Pharmacy Residents • 75% of time in clinics, 25% of time dispensing • Program developed in 2011 • Clinical participation from pharmacists within the integrated team is limited to Husson Faculty presence and resident rotation within practice sites • Current services include clinical consults, chart reviews, joint patient visits with primary care provider (PCP) • Administrators desire increased clinical pharmacy services within the organization

6. New Position Proposal • Pharmacy Business Model Innovation • Service Design: • 0.6 FTE – Pharmacy Staffing at Helen Hunt Health Center (HHHC) Pharmacy in Old Town, ME • 0.4 FTE – Clinical Pharmacy Integration conducting reimbursable patient visits • Allows for expansion of outpatient pharmacy hours in another location • Adds a desired imbedded clinical component

7. Benefits of the Proposed Position • Increased access to outpatient pharmacy services for Walk-in-Care Patients • Increased capture rate on new and refilled prescriptions • Improved oversight and documentation of continuity of care • Increased pharmacy presence within practice sites • Increased patient satisfaction and efficiency of the care experience • Increased touches on Medicare patients • Improved student/resident education

8. Overview of the Landscape in Old Town, ME • Pharmacy Locations • 3 pharmacies within 5 mile radius of health center • Walk-In-Care (WIC) Locations • HHHC is the only WIC open Weekends • EMMC Orono no longer provides WIC services (Sat Apptsonly) • UMaine Cutler Health Center- Mon-Fri only

9. Hours of Operation for Outpatient Pharmacy Extended Hours- HHHC Current Hours Proposed Hours Monday-Friday 8:30am – 8:00pm Saturday 9:00am – 4:00pm Staffing: 1.6 FTE (67hr) • Monday- Friday 8:30am – 5:00 pm Staffing: 1 FTE (40hr)

10. Historical Perspective on Extended Hours • Brewer location began extended hours October 2012 • Staffing component for PGY1 residents

11. Trends at Brewer Pharmacy – Extended Hours

12. Analysis of Brewer Pharmacy, cont. • Change in Patient Perception • Knowing that the pharmacy is open nights and weekends as a driver for growth • Objective Measure: Volume of refilled prescriptions filled during extended hours • Average Capture Rates of WIC RX’s around 40% • Varies by day, provider in WIC

13. Extrapolation to HHHC Pharmacy FINANCIAL IMPLICATIONS Additional Cost/Year to Extend Hours $177,242.00 • Includes salary, fringe, direct expenses, administration fees • Requires approximately 5550 additional prescriptions to break even • 13% rate in growth needed • Market Analysis- Questions to Consider • What is the WIC volume at HHHC in terms of Brewer? • What is the pharmacy’s current capture rate of prescriptions coming out of clinic?

14. Trends in Pharmacy Totals

15. Background on Medicare Annual Wellness Visit (AWV) • Fully paid for by Medicare Part B for beneficiaries 65 and older • No cost to eligible beneficiaries • Focused visit on “Health Risk Assessment (HRA)” • Health prevention • Disease detection • Coordination of screening • Pharmacists across the country have performed AWVs Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/

16. Billing for Annual Wellness Visit • AWV eligible for Medicare beneficiaries 66 years and older • Subsequent visits billable every year Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/ Warshany K et al. Am J Health Syst Pharm. 2014 Jan 1;71(1):44-9.

17. Benefits to the Organization • Utilization Drivers • Increase vaccinations (~1.25 vaccinations recommended per person, ~30% received vaccinations at time of visit) • Referrals for additional services; ie. lab, podiatry, dietitian, PT, audiology, mental health (~1 referral placed per patient) • Opportunities to improve quality metrics • Patient’s accessing electronic portal • Focus on a specific metric requiring improvement (eg. Mammogram, colonoscopy)

18. Feasibility of AWV Proposal • 5510 Medicare Beneficiaries 66 years and older at PCHC practice sites • Pharmacist to see 13 patients each week • Estimated Net Revenue $5,435 per year • Factors to consider • No show rates ~33% within institution • Start-up costs • Marketing of services • Provider and patient buy-in

19. Post Question • What factors should be considered when justifying sustainable primary care pharmacy services? • Understand the unique characteristics of the surrounding community to support expanded pharmacy services • Align proposed services with the clinical and financial priorities of the organization • Ensure payments for pharmacy services are within the scope of the organization’s reimbursement structure • Ensure a sustainable infrastructure of support is included in the proposal, including staffing levels, anticipated growth, shifts in payments, and future technology costs • All of the above

20. References • Centers for Medicare and Medicaid Services. Providing the annual wellness visit (AWV). www.cms.gov/ • Desselle SP, Zgarrick DP. Pharmacy management: essentials for all practice settings. 2nd ed. New York: McGraw Hill Medical, 2009. • WarshanyK, Sherrill CH, Cavanaugh J, et al. Medicare annual wellness visits conducted by a pharmacist in an internal medicine clinic. Am J Health Syst Pharm. 2014 Jan 1;71(1):44-9.

21. Questions?

22. Medicare Part B licensure Evaluating its potential in a federally qualified health center (FQHC) outpatient pharmacy system Kari London, PharmD PGY-1 Community Pharmacy Practice Resident Penobscot Community Heath Care April 26th, 2014

23. Objective • Understand the barriers and benefits of DME Supplier enrollment in the independent pharmacy setting • Focus: Diabetic testing supplies

24. Background • From 1980 to 2004 the number of people age 65 years and older diagnosed with diabetes increased almost two fold, from 2.3 million to 5.8 million1 • Prescription medications to treat diabetic complications, and antidiabeticagents plus testing supplies, are two of the largest drivers of expense at 18% and 12%, respectively2 • Medicare Part B coverage is an important means of mitigating prescription costs of these products

25. Background cont. • FQHC with 16 primary care practice sites • Pharmacy services • 3 outpatient pharmacies, residency program, faculty practice sites, pharmacy students • Exploring feasibility of piloting DME supplier enrollment at one pharmacy • Primary products on interest: diabetic testing supplies

26. Barriers • Program administrative costs

27. Barriers cont. • Program infrastructure • Software systems • Documentation requirements • Employee training • Inventory management

28. Barriers Cont. • Patient recruitment • Eligible patient population size • Low product reimbursement Diabetic Patient Capture Total Patient Capture

29. Benefits • Improved patient recruitment • The “Loss Leader” • i.e. gross ~$7,000/year of revenue on prescriptions for 1 patient • Increased services • Improved patient care • Patient Centered Medical Home • Coordination of care

30. The Numbers • Revenue per diabetic pt. / year

31. The Numbers cont. • Revenue projection

32. Conclusions • Administrative costs of implementing Medicare Part B billing pose the most significant barrier to program feasibility • Potential increase in capture of non-diabetic supply prescriptions may be sufficient to mitigate losses associated with filling diabetic testing supply prescriptions • Being a participating DME supplier for diabetic testing supplies presents a negligible loss ($535/ pharmacy/year) • Utilized conservative patient capture increase numbers and high estimate of revenue loss of diabetic supplies • Did not account for potential revenue loss from lost patients

33. References • Ashkenazy R, Abrahamson MJ. Medicare coverage for patients with diabetes. A national plan with individual consequences. J Gen Intern Med. 2006 Apr;21(4):386-92. • American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013; 36 (4): 1033-46. • DMEPOS. NABP National Association of Boards of Pharmacy. Website. http://www.nabp.net/programs/accreditation/dmepos. Accessed November 29th, 2013 • NHIC, Corporation. The DME MAC Jurisdiction A Supplier Manual. Website. http://www.medicarenhic.com/dme/supmandownload.aspx. Accessed December 6th, 2013.

34. Post question Potential threats to the success of Medicare Part B DME program for this FQHC pharmacy system include: • Low product reimbursements • High administrative costs • Documentation requirements • Eligible patient population size • All of the Above

35. Questions?

36. Impact of a interdisciplinary team approach in the treatment of high risk patients with chronic obstructive pulmonary disease (COPD):A pilot program in the primary care setting Zach Deabay, PharmD Penobscot Community Health Care PGY1 Pharmacy Practice Residents April 26th, 2014

37. Objectives • Discuss the interdisciplinary team approach in the management of COPD • Evaluate strategies utilized to improve disease state management and access to medications • Analyze effect of the program on healthcare utilization and strategies moving forward • Disclosure: Study funded by grant received from Cardinal Health. Did not influence implementation, execution, or analysis of study.

38. Background • Prevalence of COPD in the US is estimated at 23.6 million adults1 • Medicare patient with COPD have higher rates of hospitalization, ER visits, and home healthcare use than non-COPD peers2 • Total excess healthcare costs of ~$20,000/year higher • ~80% due to inpatient services • Studies looking at efficacy of self-management interventions to improve COPD management have demonstrated mixed results3,4

39. Overview • Components of Program • Education session with care manager and pharmacist • Rescue Pack • Providers choice of antibiotic +/- steroid for patients to keep at home • Patient must contact care manager or provider before use • Goals • Educate patient to better self-manage disease state • Optimize therapeutic regimen • Provider easier/quicker medication access to reduce severity of COPD exacerbation

40. Workflow • Pre-visit • Chart review by care manager • Pharmacotherapy review by pharmacist • Recommendations made to provider • Visit • Disease state assessment, education, and management techniques • Comprehensive medication assessment • Technique, compliance, barriers, perception • Post-visit • Care management follow-up • Rescue pack

41. Program Materials

42. COPD Diagnosis • Inclusion Criteria Met • Approval of PCP • Education Visit • Pre-visit Protocol Target Population Documented COPD exacerbation in prior 12 months prompting patient to seek acute medical attention (Emergency Department, Walk-In Care, Office Visit) • Other Inclusion Criteria • Patient desire to participate • Patient attendance of educational visit • Exclusion Criteria • History of non-compliance • Comorbidity affecting ability to self-manage disease state

43. Enrollment • First patient enrolled 8/29/13 • Enrollment ongoing • 52 patients enrolled to date • Current Smoker – 49% • Average # Medications – 10 • Average # Respiratory Medications – 3 • Oxygen Therapy – 20% • Females – 32 (62%) • Males – 20 (38%) • Age • Range – 42-91 years • Average – 65 years

44. Result Analysis • Patients required to be in study a minimum of 3 months before analysis performed • 26 patients meet this criteria • Additional 11 patients qualify in May • Analysis will include: • Primary endpoints • Hospitalizations • Use of emergency department and walk-in services • Death • Secondary endpoints • Rescue pack use (appropriate/inappropriate) • Number of exacerbations

45. Preliminary Observations • Majority of patients enrolled in program are prescribed rescue pack (>80%) • Of those prescribed rescue packs, most have not used them (<50%) • Most commonly prescribed combination is azithromycin/prednisone • Several patients have used the rescue packs inappropriately but majority of uses (>75%) have been appropriate • Program appears to be reducing utilization of emergency room • Possible shift from decreased ER visits to increased office visits

46. Program Benefit • Patient Benefits • Disease state education • Medication education • Pharmacotherapy review • Relationship with care manager • Easier access to medication • Organization Benefits • Patient care divided among team members • Accurate medication list • Assessment of medication compliance • Pharmacotherapy review • Improved patient outcomes* • Lower healthcare costs* *Being assessed in current study

47. Patient Case • 56 yof with COPD, typically waits if she is sick

48. Key Points • Interdisciplinary approaches utilize the expertise of all healthcare team members • Rescue packs provide quicker and easier access to medication and may be a useful tool, if used appropriately • It is essential to do educational visit Beforerescue pack medications are sent to pharmacy • Difficult to predict which patients are most appropriate for rescue packs • All patients expected to benefit from educational component

49. Assessment Question Benefits of enrollment in the COPD program include all of the following except: • Medication and disease state education • Patient ability to decide when their symptoms warrant antibiotic therapy • Quicker access to medications if deemed appropriate by provider • All of these are benefits of the program

50. References • Mannino DM, Braman S. The epidemiology and economics of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2007; 4 (7): 502-6. • Make B, Dutro MP, Paulose-Ram R, Marton JP, Mapel DW. Undertreatment of COPD: a retrospective analysis of US managed care and Medicare patients. Int J Chron Obstruct Pulmon Dis. 2012; 7: 1-9. • Effing T, Monninkhof EEM, van derValk PP, et al. Self-management education for patients with chronic obstructive pulmonary disease (Review). Cochrane Database Systm Rev. 2009 • Bucknall CE, Miller G, Lloyd SM, et al.Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomized controlled trial. BMJ 2012; 344: e1060 doi: 10.1136/bmj.e1060 • London, Kari. Chronic obstructive pulmonary disease management in high risk patients: Evaluation of a multidisciplinary team approach to reduce readmission rates within a federally qualified health center population. MSHP Conference. Jan 26, 2014.