Survey of Georgia community pharmacists' needs to engage in advanced community pharmacy services.

BACKGROUND: Community pharmacists improve health, reduce fragmentation in care, lower health costs, and improve health outcomes. In Georgia, pharmacists are able to enter collaborative drug therapy management protocols, such as hypertension management, with a collaborating physician, which may allow pharmacists to provide advanced community pharmacy services (ACPS), however few Georgia pharmacists have this licensure. No program(s) exist that empower pharmacists to successfully engage in ACPS across the state of Georgia nor trains pharmacists to successfully engage in collaborative practice. OBJECTIVE: The goal of this project was to explore community pharmacists' perception, confidence, and engagement in ACPS and how this can improve access to care in Georgia. METHODS: Six hundred one independent community pharmacists were sent an electronic survey May 13, 2022, with weekly email reminders through June 17, 2022. Results were analyzed with the independent sample t test. Thematic analysis was completed on open response survey questions. RESULTS: Ninety responses were received (15% response rate). In the majority of survey outcomes, no differences were found in needs for success between rural versus urban pharmacists. Pharmacies with a smaller technician-to-pharmacists ≤2 (staffing) ratios identified billing for services as a higher priority need for success for them to confidently engage in ACPS (P = 0.012) while pharmacies with a higher technician-to-pharmacists >2 (staffing) ratio agreed a larger need was in optimization of current workflow to allow for advanced community pharmacy service incorporation (P = 0.034). All community pharmacists agreed they would require expansion in staffing and the qualities desired for additional hires to support ACPS include ambition, proficiency, and communication skills. CONCLUSION: Numerous needs for success exist for community pharmacists to feel comfortable and confident to engage in ACPS. Addressing these needs may increase community pharmacist impact through increasing utilization of these services.

Collaborative drug therapy modification (CDTM): Facilitators, barriers, and perceptions of individual pharmacist participation in Georgia.

BACKGROUND: Georgia Board of Pharmacy (BOP) regulations permit pharmacists to engage in collaborative drug therapy modification (CDTM) with physicians, allowing them to perform patient assessments, adjust pharmacotherapy, and order laboratory tests. Pharmacist-led CDTM can positively affect health outcomes leading to reduced healthcare expenditures. CDTM is underutilized, with < 1% of Georgia pharmacists holding an active license to practice CDTM. OBJECTIVE(S): The objective of this study was to examine CDTM licensed pharmacists' perceptions of facilitators and barriers in providing CDTM. METHODS: Georgia-licensed CDTM pharmacists were invited to participate in a 60-minute qualitative interview. Interview questions were developed from electronic survey responses. The interview was designed to elicit information regarding perceived benefits and barriers to CDTM implementation. Guided by the Consolidated Framework for Implementation Research, thematic analysis was applied to identify themes using ATLAS.ti software to code. Themes were described qualitatively and prevalence of each was reported. RESULTS: Nine interviews were conducted, and data saturation was achieved at interview 6. After resolution of discrepancies, 100% coding agreement was reached among 2 independent researchers. Nine themes were identified, and each was categorized as a facilitator or barrier to establishing pharmacist-led CDTM in Georgia. Themes associated with facilitating were (prevalence %) (1) practice autonomy (100), (2) personal attributes (100), (3) having support (100), and (4) institutional logistics (88). Barrier themes included issues concerning (5) the Georgia BOP (100), (6) pharmacist autonomy (88), (7) lack of provider status (88), (8) institutional restrictions (75), and (9) personal development (e.g., confidence) (22). CONCLUSION: Facilitators to the establishment of pharmacist-led CDTM exist and pharmacists can capitalize on these to create successful CDTM programs. Barriers are varied, and it may be difficult to systematically address individual barriers such as pharmacist autonomy and personal development. Barriers associated with institutional restrictions, the Georgia BOP, and lack of provider status can likely be removed or addressed by policy.

Glucagon-like peptide 1 agonists for type 2 diabetes, weight loss, or both?

ABSTRACT: Glucagon-like peptide 1 agonists (GLP1s) and the novel glucose-dependent insulinotropic polypeptide/glucagon-like peptide 1 agonist are effective drugs for reducing A1C and weight in patients with type 2 diabetes. However, clinicians may find it difficult to discern which drug to prescribe in specific clinical scenarios. This article discusses evidence-based clinical use of these drugs.

Diabetes outcomes before and during telehealth advancements surrounding COVID-19.

BACKGROUND: Pharmacists can optimize outcomes related to type-2 diabetes (T2D) by taking advantage of telehealth opportunities despite the coronavirus 2019 (COVID-19) Public Health Emergency (PHE). OBJECTIVE: Identify and compare changes in T2D outcomes before (August 2019 through February 2020) and during (March 2020 through October 2020) the COVID-19 PHE. Secondary objectives were to identify and compare pay-for-performance metrics and additional fee-for-service submitted in these patients. METHODS: This study examined changes in T2D outcomes at one primary care office within a community health system. Pharmacists started regularly using Remote Patient Monitoring (RPM) services during the COVID-19 PHE to reduce in-person visits. Patients with an initial glycosylated hemoglobin (A1C) greater than or equal to 8% were included. Data collected included comorbidities, change in A1C, and diabetes and statin medication therapy adherence. Percentage of Healthcare Effectiveness Data and Information Set (HEDIS) and Merit-Based Incentive Payment System (MIPS) measures were met, and billing code frequencies were also assessed. RESULTS: In the pre-COVID-19 PHE group (N = 30), the average 3- and 6-month A1C reductions were 1.3% and 1.2%, respectively, and the reductions were 2.0% and 2.2% in the during-COVID-19 PHE group (N = 61). The percentage of patients appropriately initiated or maintained on statins was 96.2% in the pre-COVID-19 PHE group versus 82.6% in the during-COVID-19 PHE group. Related to HEDIS, statin adherence was 95.2% in the pre-COVID-19 PHE group and 84.2% in the during-COVID-19 PHE group, and A1C control was 41.7% versus 54%, respectively. A1C control related to MIPS was 60% before COVID-19 PHE versus 73.8% during the COVID-19 PHE. Diabetes medication adherence related to HEDIS and medication reconciliation related to MIPS was 100% for both groups. CONCLUSION: Data demonstrate the opportunity for pharmacists to maintain and improve clinical outcomes related to T2D despite the ongoing COVID-19 PHE through implementation of telephonic monitoring.

Integration and compensation of pharmacists into primary care medical groups.

OBJECTIVE: To demonstrate the expansion of an outpatient pharmacy program within a health system via annual wellness visits (AWVs) and disease state management patient encounters at outpatient medical groups. SETTING: A referral-based pharmacist-managed ambulatory care center, a department of a hospital, and 4 primary care medical groups of a community practice hospital health system in Savannah and Pooler, Georgia, and Bluffton, South Carolina. PRACTICE DESCRIPTION: St. Joseph's/Candler is a 714 bed, 2 hospital community practice heath care system located in Savannah, Georgia. The St. Joseph's/Candler Center for Medication Management (CMM) is a pharmacist-managed ambulatory care clinic that provides referral-based ambulatory care services in anticoagulation, diabetes, heart failure, tobacco cessation, transitional care, vaccinations, and wellness contracts for self-insured organizations, and has 147 referring physicians. Nurse Practitioners and Pharmacists evaluate and manage patients under their scope of practice and supervising medical director for the CMM. Pharmacists and Nurse Practitioners educate patients and collaborate with referring physicians for disease state management but do not carry prescriptive authority at CMM. CMM bills for services as a provider-based department of the hospital. CMM is recognized as an Anticoagulation Center of Excellence by the Anticoagulation Forum and is interventional with ambulatory care quality initiatives of the health system. Pharmacists in CMM are board-certified in ambulatory care provided by Board of Pharmacy Specialties and have completed a minimum of a 1-year post-graduate training program accredited by the American Society of Health-System Pharmacists. CMM has 4 off-campus satellite locations providing ambulatory care referral-based services. Since 2007, the CMM has primarily provided anticoagulation services via laboratory monitoring and management of warfarin. PRACTICE INNOVATION: Pharmacists transitioned from provider-based departments of a hospital to outpatient primary care medical groups. This transition changed their job description and the model for reimbursement of the pharmacists' salaries. Four pharmacists were present 60 hours per week from January 2018 to August 2018, and 80 hours per week (2 full-time clinical pharmacist positions) from September 2018 to December 2018, to conduct AWVs and disease state management patient encounters. These pharmacists divided their time between a department of a hospital and a traditional medical group of the same health system. EVALUATION: For calendar year 2018, 1770 AWVs and 468 disease state management patient care visits were provided exclusively by pharmacists to patients of the 4 primary care medical groups of this community practice health system. Patient visits for disease state management included diabetes, hypertension, hyperlipidemia, anticoagulation, and tobacco cessation. RESULTS: For the calendar year 2018, 1770 AWVs and 468 disease state management patient visits were provided exclusively by pharmacists, under the direct supervision of physician, to patients of primary care medical groups. CONCLUSION: This is an example of expanding direct patient care pharmacy services, within a health system, to primary care medical groups, without direct grant or university funding.

Managing Modern Antiretroviral Therapy in the Intensive Care Unit: Overcoming Challenges for Critically Ill People With Human Immunodeficiency Virus.

People with human immunodeficiency virus (HIV) have a 50% excess risk for intensive care unit (ICU) admission, often for non-HIV-related conditions. Despite this, clear guidance for managing antiretroviral therapy (ART) in this setting is lacking. Selecting appropriate ART in the ICU is complex due to drug interactions, absorption issues, and dosing adjustments. Continuing ART in the ICU can be challenging due to organ dysfunction, drug interactions, and formulary limitations. However, with careful consideration, continuation is often feasible through dose adjustments or alternative administration methods. Temporary discontinuation of ART may be beneficial depending on the clinical scenario. Clinicians should actively seek resources and support to mitigate adverse events and drug interactions in critically ill people with HIV. Navigating challenges in the ICU can optimize ART and improve care and outcomes for critically ill people with HIV. This review aims to identify strategies for addressing the challenges associated with the use of modern ART in the ICU.

Impact of Pharmacist Integration Into Primary Care on Reimbursement for Hospital Follow-Up Visits.

BACKGROUND: The financial and clinical impact of transitional care management (TCM) outcomes through pharmacist integration within primary care is not well described. OBJECTIVES: The primary objective of this study was to determine the financial impact of pharmacist conducted post-discharge phone calls. The secondary objectives included readmission rates and number of interventions. METHODS: A computer-generated list identified patients discharged from St. Joseph's/Candler Health System (SJ/C) with a listed primary care provider within the SJ/C Primary Care Medical Group at Eisenhower from November 1, 2019 to April 30, 2020. Eligible patients who received a post-discharge phone call from a pharmacist were compared to those who received a call by another staff member. Data was collected regarding the financial impact of pharmacist conducted post-discharge phone calls. Readmission rates and medication related interventions were also assessed. RESULTS: There were 104 patients discharged meeting criteria. Twenty-four patients were contacted by a pharmacist resulting in 20 subsequent hospital follow up appointments scheduled with the provider. Total amount billed for those appointments was $4220 (average of $211 per visit). Twenty-five calls were made by non-pharmacist staff with 23 appointments scheduled. Total amount billed for those appointments was $2445 (average of $106 per visit). Increased reimbursement was generated by a qualifying 2-way communication by the pharmacist as outlined by Center for Medicaid and Medicare Services enabling providers to bill for a TCM visit versus standard office visit. Pharmacists made 33 clinical interventions including medication reconciliation, medication procurement, referrals, lab orders, and education. One intervention was made by non-pharmacist staff. The 30-day readmission rate for pharmacist contacted patients was 8% versus 12% for non-pharmacist contacted patients. CONCLUSIONS: Pharmacist involvement in TCM while integrated into a primary care office is previously not well described. This data highlights an opportunity for pharmacists to demonstrate sustainability and improved outcomes related to TCM.

Successful treatment of Enterococcus faecalis bacteremia with dalbavancin as an outpatient in an intravenous drug user.

This report describes the treatment of a 35-year-old male who presented to the emergency department with an empyema, and who had a long hospital course complicated by a catheter-related bloodstream infection and a history of intravenous drug use. Blood culture results confirmed Enterococcus faecalis. He was not a candidate for outpatient intravenous therapy and needed 14days of treatment, but was able to be discharged with a 3-day supply of oral levofloxacin to complete treatment for his empyema and 1 dose of dalbavancin at an outpatient infusion center to treat his bacteremia. Due to the unique properties of dalbavancin, off-label use in specific populations may help facilitate transitions of care. This report outlines the successful use of dalbavancin and removal of the central catheter in the treatment of E. faecalis bacteremia.