Implementing Telestroke in the Inpatient Setting: Identifying Factors for Success.

BACKGROUND: Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at spoke hospitals participating in a newly established inpatient telestroke program to identify implementation barriers and facilitators. METHODS: This was a formative evaluation relying on semistructured qualitative interviews with 16 inpatient providers (physicians and nurse practitioners) at 5 spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis. RESULTS: Fifteen themes were identified in the data and mapped to the Integrated-Promoting Action on Research Implementation in Health Services framework. Themes related to the innovation (the telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of inpatient telestroke advanced practice providers and challenges with nurse empowerment. With regard to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in. CONCLUSIONS: Understanding barriers and facilitators to implementation is crucial to determining where programmatic changes may need to be made to ensure the success and sustainment of inpatient telestroke services.

Pharmacist-driven outreach initiative to increase prescribing of sodium-glucose cotransporter-2 inhibitors in eligible VHA patients with chronic kidney disease: a study protocol.

BACKGROUND: Patients with chronic kidney disease (CKD) are at increased risk for multiple adverse events, several of which have been proven to be less likely with the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). As a result, guidelines now recommend SGLT2i be given to those with mild to moderate CKD and type 2 diabetes. The objective of this study is to evaluate if a pharmacist-driven SGLT2i prescribing initiative among eligible patients with CKD and diabetes within the VA could more rapidly improve the adoption of SGLT2i via a pragmatic approach aligned with learning health systems. METHODS: Eligible patients will be identified through an established VA diabetes dashboard. Veterans with an odd social security number (SSN), which is effectively a random number, will be the intervention group. Those with even SSNs will serve as the control while awaiting a second iteration of the same interventional program. The intervention will be implemented in a rolling fashion across one Veterans Integrated Service Network. Our primary outcome is initiation of an SGLT2i. Secondary outcomes will include medication adherence and safety-related outcomes. DISCUSSION: This project tests the impact of a pharmacist-driven medication outreach initiative as a strategy to accelerate initiation of SGLT2i. The results of this work will not only illustrate the effectiveness of this strategy for SGLT2is but may also have implications for increasing other guideline-concordant care. Furthermore, the utilization of SSNs to select Veterans for the first wave of this program has created a pseudo-randomized interventional trial supporting a pragmatic learning health system approach. TRIAL REGISTRATION: ISRCTN12374636.

Community pharmacists' experience relying on select implementation strategies in the delivery of comprehensive medication management.

OBJECTIVE: Implementation strategies are methods or techniques that facilitate adoption, implementation, and sustainability of a clinical program or practice. There has been a lack of widespread adoption of comprehensive medication management (CMM) in community pharmacies. The objective of this evaluation was to expand understanding of how select implementation strategies impacted pharmacists' experience implementing and delivering CMM in the community pharmacy setting. METHODS: A community pharmacy CMM initiative, Slice of Partners in Excellence (PIE), employed a number of implementation strategies and key elements from the Institute for Healthcare Improvement's Breakthrough Series to support increased engagement and delivery of CMM within a local payer's CMM program. The program provides incentives to pharmacies for providing CMM to select patients and achieving predetermined quality metrics. To evaluate pharmacists' experience with the implementation strategies and the impact it had on implementing and delivering CMM, a focus group and survey were conducted. RESULTS: Some of the implementation strategies were more frequently highlighted as generating value to participants (coaching, community-wide problem-solving) than others (monthly webinars). Pharmacists identified a need for more formal education regarding billing, documentation and patient engagement supports. Pharmacists expressed a desire for ongoing implementation supports extending beyond this initaitive. CONCLUSION: Understanding the types of implementation strategies that are deemed as influential by pharmacists delivering clinical services in the community pharmacy setting is critical to maximizing patient access to these services in the future.

Leveraging quality improvement principles in comprehensive medication management pharmacy practice: A case example.

OBJECTIVE: To maximize the time pharmacists providing comprehensive medication management (CMM) services spend providing direct patient care by tracking their time spent on various activities. SETTING: Fifteen primary care clinics within an integrated health care system in Minnesota. PRACTICE DESCRIPTION: Eleven pharmacists provide comprehensive medication management services in 15 clinic sites; 12 primary care clinics, 1 family medicine residency training clinic, and 2 specialty clinics. PRACTICE INNOVATION: A team of pharmacists providing CMM developed and completed a self-reported workload sheet to document how much time they spent on various activities. These sheets were completed at 4 different points over 6 years to guide efficiency efforts to increase pharmacists' time spent in value-added activities such as direct patient care. EVALUATION: Beginning in 2014, each CMM pharmacist was asked to complete the workload tally sheet to track the time they spent on all their daily activities for a 5-day period. The workload sheets were collected in 2014, 2016, 2017, and 2019 and represent a snapshot of activity at 1 point during each year. Workload sheets from each pharmacist were compiled and analyzed each year to assess time spent in direct patient care and other value-added activities. RESULTS: From 2014 to 2019, CMM pharmacists increased their time providing value-added services from 47.1% to 72% and increased time in direct patient care from 26.7% to 52.5%. This was achieved through a number of workflow optimization strategies, including appropriation of staff to schedule and recruit CMM patients, developing expanded collaborative practice agreements, and creating documentation efficiencies. CONCLUSION: Collecting CMM pharmacist workload data across the years demonstrated the amount of time pharmacists were spending on various clinic-related activities and served to identify areas where workflow and processes could be improved to increase the time pharmacists spend in value-added services. As CMM practices continue to develop and expand, tracking and optimizing pharmacists' time is essential to leverage efficiency and value of pharmacy services.

Nationwide estimates of medication therapy management delivery under the Medicare prescription drug benefit.

OBJECTIVE: To describe the national delivery of medication therapy management (MTM) to Medicare beneficiaries in 2013 and 2014. METHODS: Descriptive cross-sectional study using the 100% sample of 2013 and 2014 Part D MTM data files. We quantified descriptive statistics (counts and percentages, in addition to means and standard deviations) to summarize the delivery of these services and compare delivery between 2013 and 2014. RESULTS: Medicare beneficiaries eligible for MTM increased from 4,281,733 in 2013 to 4,552,547 in 2014. Among eligible beneficiaries, the number and percentage who were offered a comprehensive medication review (CMR) increased from 3,473,004 (81.1%) to 4,394,822 (96.5%), and beneficiaries receiving a CMR increased from 526,203 (12.3%) to 767,286 (16.9%). In 2014, CMRs were most frequently delivered by telephone (83.2%) and provided by either a plan sponsor (29.0%) or an MTM vendor in-house pharmacist (35.0%). In 2014, pharmacists provided 93.5% of all CMRs, and other providers (e.g., nurses and physicians) provided 6.5% of CMRs. Few patients who received a CMR received more than 1 within the same year (2.2% in 2014). Medication therapy problem (MTP) resolution among patients receiving a CMR stayed roughly the same between 2013 and 2014 (19.2% vs. 18.7%, respectively; P < 0.001). Finally, most beneficiaries (96.9% in 2014) received a targeted medication review, regardless of whether a CMR was offered or provided. CONCLUSION: More than 4 million Medicare beneficiaries were enrolled in Part D MTM in both 2013 and 2014. However, less than 20% of eligible beneficiaries received a CMR during those years, and rates of MTP resolution were low. Future evaluation of Part D MTM delivery should examine changes in eligibility criteria and delivery over time to inform MTM policy and changes in practice.

The Complexities of Family Caregiving at Work: A Mixed-Methods Study.

The current project examined the impact of caregiving and caregiving-work conflict on employees' well-being. A sequential explanatory mixed-methods design (QUAN→qual) was utilized, and a total of 880 employees from a large health-care plan employer completed an online survey. Forty-five caregivers who completed the survey also participated in one of the five focus groups held 1 to 2 months later. Employed caregivers were significantly ( p < .05) more likely to indicate poorer physical and mental health than noncaregivers; among caregivers ( n = 370), caregiving-work conflict emerged as the most significant predictor of well-being and fully mediated the empirical relationship between burden and well-being. The focus group findings complemented the quantitative results; many of the challenges employed caregivers experience stem from their ability or inability to effectively balance their employment and caregiving roles. The results suggest the need to focus on caregiving-work conflict when constructing new or translating existing evidence-based caregiver interventions.

Strategies and steps fostering the success of medication management services in community pharmacies.

OBJECTIVES: To identify and describe the steps and strategies that community pharmacies with established medication management services have used to integrate medication management services into their practice settings. DESIGN: Qualitative case study with semistructured interviews and focus groups. SETTING: Community pharmacy organizations in Minnesota. PARTICIPANTS: Pharmacists and pharmacy leadership from 4 different pharmacy organizations including independent, chain, and health system pharmacies. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Qualitative case study analysis of community pharmacy management and pharmacists' perceptions of the factors that led to the establishment and sustainability of their medication management programs. RESULTS: Focus groups and interviews were undertaken with 25 pharmacists and pharmacy leaders from 4 distinct community pharmacy organizations from April to June 2015. Five themes emerged, representing specific implementation and continuation stages of medication management services in community practice: Deciding to Act, Setting the Stage, Executing the Service, Sticking to It, and Continuing to Grow. CONCLUSION: This study sheds light on key stages that have commonly occurred across community pharmacies that are delivering medication management services. The results of this work may serve as a road map for other community pharmacies looking to integrate medication management services into their own practice settings.

Evaluation of a Clinical Decision Support Tool to Guide Adoption of the American Heart Association Telemetry Monitoring Practice Standards.

BACKGROUND: The objectives of this study were to (1) evaluate telemetry use pre- and postimplementation of clinical decision support tools to support American Heart Association practice standards for telemetry monitoring and (2) understand the factors that may contribute to variation of telemetry monitoring in practice. METHODS AND RESULTS: First, we captured overall variability in telemetry use pre- and postimplementation of the clinical decision support intervention. We then conducted semistructured interviews with telemetry-ordering providers to identify key barriers and facilitators to adoption. During the study period, 399 physicians met criteria for inclusion and were divided into excessive and nonexcessive orderers. Distribution of telemetry use was bimodal. Among nonexcessive users, 24.4% of patient days were with telemetry compared with 51.6% among excessive users. On average, both excessive (6.1% reduction) and nonexcessive users (2.8% reduction) decreased telemetry use postimplementation, and these reductions were sustained over a 16-month period. Sixteen interviews were conducted. Physicians believed that the tool was successful because it caused them to more closely consider if telemetry was indicated for each patient. Physicians also voiced frustration with interruptions to their workflow, and some noted that they commonly use telemetry outside of practice standards to monitor patients who were acutely but not critically ill. CONCLUSIONS: Embedding telemetry practice standards into the electronic health record in the form of clinical decision support is effective at reducing excess telemetry use. Although the intervention was well received, there are persistent barriers, such as preexisting views on telemetry and existing workflow habits, that may inhibit higher adoption of standards.

Building health plan-pharmacist provider partnerships to optimize medication outcomes.

Over the years, the practice of medication management has taken on various terms and definitions. As a result, health plans have developed different approaches to identifying beneficiaries for medication therapy management (MTM), engaging pharmacists to provide MTM, and adopting standards for documentation and quality assurance. This variation leads to inconsistent delivery of MTM and potential quality concerns. Therefore, an environment needs to be created that allows for health plans to discuss and share approaches, challenges, and best practices. To achieve this, the University of Minnesota College of Pharmacy has served as an organizer and facilitator of an ongoing series of Minnesota Health Plan Summits to drive sustainable and mutually beneficial MTM programs and payment models across the state. In less than 2 years, the University of Minnesota College of Pharmacy has hosted and organized 4 Health Plan Summits with the objective of sharing ideas and identifying mutual goals (short- and long-term) across health plans and pharmacy providers of MTM services to optimize medication outcomes for the citizens of Minnesota and beyond. These meetings have led to several productive discussions and takeaways, including: (1) having a convener is essential for these types of connections and discussions, (2) health plans and pharmacists find value in these summits, (3) there is a range of experience in MTM program development across health plans, and (4) there are important opportunities to enhance understanding between health plans and pharmacist providers. In addition, 3 workgroups have been established in the following areas: (1) improve consistency in the design of MTM benefits across health plans for service and delivery, including provider credentialing, (2) increase transparency and education between plans and providers on the "fixed points" (such as CMS requirements) vs modifiable portions of plan design, and (3) create agreement on a single quality metric to target, collect data, and demonstrate value of MTM. For change to occur, it often must start locally, suggesting that the formal, facilitated convening of local health plan leaders and pharmacist providers to discuss building consistent and high-quality MTM programs is an essential strategy for MTM program adoption and growth. Including both groups of stakeholders should not only focus on payment, but also the mechanisms necessary to support implementation and create a win-win for both groups. In sharing our experience in Minnesota, we aim to inspire others to form regional initiatives that create structured, facilitated conversations that can produce new partnerships. Strategies that have supported our success are described and can be adopted once a regional entity, such as a school of pharmacy or other trusted entity, chooses to convene a group of invested stakeholders.

What is needed to sustain comprehensive medication management? One health plan's perspectives.

Implementation of comprehensive medication management (CMM) in the community pharmacy setting remains sporadic despite its prevalence in other pharmacy contexts. One health plan has been investing in CMM since 2010. Their experience and perceptions in the payer-provider partnership could offer unique insights into the sustainability of CMM in community pharmacy. As part of a broader academic-payer-provider partnership, perceptions of CMM sustainability were explored with key stakeholders in the health plan through a semistructured group interview. Five themes emerged: (1) distinction between CMM and other patient care opportunities, (2) building a CMM program that delivers value requires an investment in network development, (3) payment design influences sustainability, (4) lack of push from community pharmacies to pay for CMM, and (5) the importance of an ongoing facilitated learning and action collaborative. Given previously demonstrated positive return-on-investment, CMM in community pharmacies shows promise for being a sustainable practice model. However, increased reach and performance of networks, as well as number of payers in the market, will be critical to scaling CMM in the community pharmacy setting.

'Trying to fly the plane while we were building it'. Applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study.

OBJECTIVE: A learning health system (LHS) uses data to generate evidence and answer questions required to continually improve system performance and patient care. Given the complexities of practice transformation, an area where LHS is particularly important is the study of primary care transformation (PCT) as PCT generates several practice-level questions that require study where the findings can be readily implemented. In May 2019, a large integrated health delivery system in Minnesota began implementation of a population management PCT in two of its 40 primary care clinics. In this model of care, patients are grouped into one of five service bundles based on their complexity of care; patient appointment lengths and services provided are then tailored to each service bundle. The objective of this study was to examine the use of a LHS in PCT by utilising the Consolidated Framework for Implementation Research (CFIR) to categorise implementation lessons from the initial two PCT clinics to inform further implementation of the PCT within the health system. DESIGN: This was a formative evaluation in which semistructured qualitative interviews were carried out. Observational field notes were also taken. Inductive coding of the data was performed and resultant codes were mapped to the CFIR. SETTING: Two suburban primary care clinics in the Twin Cities, Minnesota. PARTICIPANTS: Twenty-two care team members from the first two clinics to adopt the PCT. RESULTS: Seventeen codes emerged to describe care team members' perceived implementation influences. Codes occurred in each of the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals and process), with most codes occurring in the 'inner setting' domain. CONCLUSIONS: Using an LHS approach to determine early-stage implementation influences is key to guiding further PCT implementation, understanding modifications that need to be made and additional research that needs to occur.

Barriers and facilitators to implementing pharmacist-provided comprehensive medication management in primary care transformation.

PURPOSE: How to effectively integrate pharmacists into team-based models of care to maximize the benefit they bring to patients and care teams, especially during times of primary care transformation (PCT), remains unknown. The objective of this study was to identify barriers and facilitators when integrating pharmacist-provided comprehensive medication management (CMM) services into a health system's team-based PCT using the Consolidated Framework for Implementation Research (CFIR). METHODS: Semistructured qualitative interviews were carried out with 22 care team members regarding their perceptions of the implementation of CMM in the PCT. Transcripts were coded to identify CMM implementation barriers and facilitators, and resulting codes were mapped to corresponding CFIR domains and constructs. RESULTS: Fifteen codes emerged that were labeled as either a barrier or a facilitator to implementing CMM in the PCT. Facilitators were the perception of CMM as an invaluable resource, precharting, tailored appointment lengths, insurance coverage, increased pharmacy presence, enhanced team-based care, location of CMM, and identification of CMM advocates. Barriers included limited clinic leadership involvement, a need for additional resources, CMM pharmacists not always feeling part of the core team, understanding of and training around CMM's role in the PCT, changing mindsets to utilize resources such as CMM more frequently, underutilization of CMM, and CMM scheduling. CONCLUSION: Clinical pharmacists providing CMM represent a valuable interdisciplinary care team member who can help improve healthcare quality and access to primary care. Identifying and addressing implementation barriers and facilitators early during PCT rollout is critical to the success of team-based services such as CMM and becoming a learning health system.

Evaluating the Experience of Organizations Implementing Medication Management Services Using a Variety of Implementation Strategies.

PURPOSE: The purpose of this project was to evaluate the experience of organizations who participated in a medication management learning collaborative and their perceptions of the different implementation strategies that were employed. METHODS: Using a utilization-focused evaluation approach, qualitative interviews were conducted with former participants (clinicians, managers, or other key stakeholders) of medication management learning collaboratives organized and delivered by Alliance for Integrated Medication Management (AIMM). The purpose of the learning collaboratives was to provide structure and facilitation to accelerate the implementation of medication management services. One-on-one semi-structured interviews were carried out with a lead member of 11 different organizations that participated in an AIMM collaborative about their experience in the collaborative and the different implementation strategies that were used. RESULTS: Three themes emerged: (1) perspectives on the implementation strategies, (2) external facilitators, and (3) additional benefits of being in the collaborative. Certain implementation strategies used by AIMM, such as coaching, were considered beneficial by almost everyone while other strategies, such as webinars, had mixed opinions. Participants also highlighted the importance of external facilitators, like dedicated time to work on implementation strategies, as well as the additional benefits like the professional development that comes from being in a learning collaborative and learning different implementation strategies. CONCLUSION: Implementation strategies may help accelerate the adoption and expansion of medication management services within and across organizations. The results of this evaluation shed light on the experiences of different organizations using select implementation strategies in their medication management implementation efforts. The perspectives of participants in this study may help other organizations in selecting and developing similar implementation strategies.

Adaptations made to delivery of comprehensive medication management in the community pharmacy setting during COVID-19.

BACKGROUND: As a result of COVID-19, numerous adaptations were made to health care delivery, including comprehensive medication management (CMM) delivered in community pharmacies. OBJECTIVE: Identify and describe the adaptations that have been made to the delivery of CMM among community pharmacies due to COVID-19. METHODS: Community pharmacies participating in a CMM implementation and research initiative had regular coaching calls throughout COVID-19 and completed a survey of changes that occurred as a result of COVID-19. Coaching notes and survey results were summarized and mapped to the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to systematically capture changes that occurred. RESULTS: A number of reactive adaptations were made to CMM delivery as a result of COVID-19, including increased virtual or remote delivery of CMM, delaying CMM visits to allow pharmacies to provide care directly related to the pandemic including COVID-19 testing and vaccines, wearing personal protective equipment (PPE) in visits, new ways of obtaining clinical patient information, and shifting CMM staffing models. CONCLUSION: Adaptations that occurred to CMM during COVID-19 allowed pharmacists to continue to serve their patients and meet public health needs.

Community pharmacists' perceptions of acceptability, appropriateness, and feasibility of a value-based care model for comprehensive medication management.

BACKGROUND: HealthPartners is an integrated health plan offering comprehensive medication management (CMM) under a value-based care model called Partners in Excellence (PIE). In PIE, participating organizations are incentivized to conduct CMM visits and are eligible for bonus payments if they achieve quality and engagement metrics. Engagement in PIE from community pharmacies has been lacking. Implementation science, specifically the assessment of implementation outcomes, provides key insights into the uptake of patient care services, such as CMM, into practice. OBJECTIVE: To evaluate the acceptability, appropriateness, and feasibility of the PIE program from the perspective of community pharmacists and pharmacy managers. METHODS: Semi-structured, one-on-one qualitative interviews were conducted with a group of 14 pharmacists and pharmacy managers participating in the PIE program. Interviews were coded inductively, and then codes were mapped to the implementation outcomes of acceptability, appropriateness, and feasibility. RESULTS: Twelve codes emerged from the interviews. Four codes (targeted conditions of PIE, achieving PIE metrics, comprehensiveness of PIE, and confusion and barriers) were mapped to acceptability; 3 codes (CMM documentation and billing, fitting CMM into limited time with patients, and community pharmacy's role in patient care) were mapped to appropriateness; and 1 code (collecting clinical patient information) was mapped to feasibility. Four codes (CMM payment model, targeting patients for CMM, personnel for CMM, and patient/provider buy-in of CMM) were considered a combination of more than 1 outcome. CONCLUSIONS: Although the acceptability, appropriateness, and feasibility of the PIE program was generally positive, participants cited a number of implementation challenges related to documentation and billing and producing a sustainable CMM model. The results shed light on how a value-based care model for CMM is perceived within community pharmacies and could inform the development and implementation of similar quality-based CMM programs. DISCLOSURES: This study was funded by the National Association of Chain Drug Stores (NACDS) Foundation and the UNC Eshelman Institute for Innovation. Pestka is affiliated with the University of Minnesota College of Pharmacy and reports grants from NACDS Foundation and UNC Eshelman Institute for Innovation for the conduct of the study; she has also received grants from UNC Eshelman Institute for Innovation and NACDS Foundation outside the submitted work. Stoa and Sorensen are also affiliated with the University of Minnesota College of Pharmacy. Blanchard is employed at the UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. This work was presented as a virtual poster at the 2020 American College of Clinical Pharmacy Annual Meeting, October 19-30, 2020.

Characterizing the reach of comprehensive medication management in a population health primary care model.

INTRODUCTION: As care teams adopt team-based models of care, it is important to examine the reach of interdisciplinary services, such as pharmacists providing comprehensive medication management (CMM). This study examined the reach of pharmacist-delivered CMM in the first 10 months of a population health-focused primary care transformation (PCT). METHODS: Using electronic health record data, descriptive statistics (counts and percentages, as well as means and standard deviations) were quantified to summarize the patients who received CMM in two PCT pilot clinics pre- and post-PCT. RESULTS: Patients who had at least one CMM visit increased from 554 during the pre-PCT window to 880 during the post-PCT window. However, when adjusted for the increased pharmacist full-time equivalents (FTE) included as part of the PCT, 462 and 330 patients/FTE were seen in the pre- vs post-PCT periods, respectively. When calculating the percentage of patients who received CMM, this increased from 2.3% of all primary care patients seen in the two pilot clinics before the PCT began to 4.4% after the PCT was implemented. Most patient demographics remained largely the same between the pre- and post-PCT periods. However, CMM patients seen in the post-PCT period had more medication therapy problems across all medication therapy problem categories compared to patients in the pre-PCT period. Additionally, patients receiving CMM had significantly more conditions and medications and higher hospitalizations and emergency department use compared to the general clinic population. CONCLUSIONS: Reach is an important implementation outcome to determine the representativeness of individuals participating in a given service. This study illustrates that pharmacists providing CMM see complex patients with a high propensity for medication therapy problems. However, opportunities exist to improve the reach of CMM and, in turn, enhance team-based care.

Delivering Care to High-Cost High-Need Patients: Lessons Learned in the Development of a Complex Care Primary Care Team.

As part of a population health-focused primary care transformation, in 2019 a health system in Minnesota developed a primary care team to exclusively care for high-cost high-need patients. Through its development and implementation, the team has discovered several key lessons in delivering care to complex patients. These lessons include the benefits of more integrative team-based care, the need and advantages of designated complex care team members, the importance of teamwork both within and outside of the complex care team, the need for frequent communication, and the importance of identifying mental health needs. In addition, there are several areas that require ongoing research and exploration, such as determining when a patient is able to graduate out of the program, how to enhance access to the complex care team, determining appropriate visit characteristics, and model feasibility. While addressing the needs of high cost high need patients is essential to improving quality of care and decreasing health care costs, there are several unique challenges and opportunities that come with caring for this patient population. Although this highly integrated model of care continues to evolve, the initial lessons learned may inform other health systems and care teams undertaking the care of complex patients.

Implementation of an Anticoagulation Practice Guideline for COVID-19 via a Clinical Decision Support System in a Large Academic Health System and Its Evaluation: Observational Study.

BACKGROUND: Studies evaluating strategies for the rapid development, implementation, and evaluation of clinical decision support (CDS) systems supporting guidelines for diseases with a poor knowledge base, such as COVID-19, are limited. OBJECTIVE: We developed an anticoagulation clinical practice guideline (CPG) for COVID-19, which was delivered and scaled via CDS across a 12-hospital Midwest health care system. This study represents a preplanned 6-month postimplementation evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. METHODS: The implementation outcomes evaluated were reach, adoption, implementation, and maintenance. To evaluate effectiveness, the association of CPG adherence on hospital admission with clinical outcomes was assessed via multivariable logistic regression and nearest neighbor propensity score matching. A time-to-event analysis was conducted. Sensitivity analyses were also conducted to evaluate the competing risk of death prior to intensive care unit (ICU) admission. The models were risk adjusted to account for age, gender, race/ethnicity, non-English speaking status, area deprivation index, month of admission, remdesivir treatment, tocilizumab treatment, steroid treatment, BMI, Elixhauser comorbidity index, oxygen saturation/fraction of inspired oxygen ratio, systolic blood pressure, respiratory rate, treating hospital, and source of admission. A preplanned subgroup analysis was also conducted in patients who had laboratory values (D-dimer, C-reactive protein, creatinine, and absolute neutrophil to absolute lymphocyte ratio) present. The primary effectiveness endpoint was the need for ICU admission within 48 hours of hospital admission. RESULTS: A total of 2503 patients were included in this study. CDS reach approached 95% during implementation. Adherence achieved a peak of 72% during implementation. Variation was noted in adoption across sites and nursing units. Adoption was the highest at hospitals that were specifically transformed to only provide care to patients with COVID-19 (COVID-19 cohorted hospitals; 74%-82%) and the lowest in academic settings (47%-55%). CPG delivery via the CDS system was associated with improved adherence (odds ratio [OR] 1.43, 95% CI 1.2-1.7; P<.001). Adherence with the anticoagulation CPG was associated with a significant reduction in the need for ICU admission within 48 hours (OR 0.39, 95% CI 0.30-0.51; P<.001) on multivariable logistic regression analysis. Similar findings were noted following 1:1 propensity score matching for patients who received adherent versus nonadherent care (21.5% vs 34.3% incidence of ICU admission within 48 hours; log-rank test P<.001). CONCLUSIONS: Our institutional experience demonstrated that adherence with the institutional CPG delivered via the CDS system resulted in improved clinical outcomes for patients with COVID-19. CDS systems are an effective means to rapidly scale a CPG across a heterogeneous health care system. Further research is needed to investigate factors associated with adherence at low and high adopting sites and nursing units.

A compass for care: Evaluating first-year pharmacy students' philosophy of practice.

INTRODUCTION: A philosophy of practice serves as the foundation for any patient care practice. Understanding the philosophies of practice held by students entering the profession is important as this presents potential opportunities for educators to help shape students' professional values/beliefs. The objective of this work was to evaluate how first-year pharmacy students (P1s) conceptualize their philosophy of practice as future pharmacists. METHODS: P1s at the University of Minnesota College of Pharmacy were asked to write their philosophy of practice that best described them as a future practitioner. A sample of 80 student responses were inductively coded to develop an initial coding scheme. These codes were applied and refined to a random sample of 32 responses (20%) where inter-coder reliability (ICR) testing was carried out at three stages. The final codebook was applied to all responses. RESULTS: The exercise was completed by 155 (92%) students, including the 80 student responses used for developing the initial coding scheme and the 32 responses used for ICR. Thirteen unique codes emerged from student responses describing their philosophy of practice that were grouped into four themes: community partner, commitment to the patient, professional responsibilities, and interprofessional team-based care. CONCLUSIONS: There was variability in how pharmacy students articulated their philosophy of practice. This presents an opportunity to shape students' philosophy of practice as they progress through pharmacy school so that they graduate with a uniform set of professional values and beliefs.

Patterns and predictors of older adult Medicare Part D beneficiaries' receipt of medication therapy management.

BACKGROUND: Medicare Part D medication therapy management (MTM) includes an annual comprehensive medication review (CMR) as a strategy to mitigate suboptimal medication use in older adults. OBJECTIVES: To describe the characteristics of Medicare beneficiaries who were eligible, offered, and received a CMR in 2013 and 2014 and identify potential disparities. METHODS: This nationally representative cross-sectional study used a 20% random sample of Medicare Part A, B, and D data linked with Part D MTM files. A total of 5,487,343 and 5,822,188 continuously enrolled beneficiaries were included in 2013 and 2014, respectively. CMR use was examined among a subset of 620,164 and 669,254 of these beneficiaries enrolled in the MTM program in 2013 and 2014. Main measures were MTM eligibility, CMR offer, and CMR receipt. The Andersen Behavioral Model of Health Services Use informed covariates selected. RESULTS: In 2013 and 2014, 505,658 (82%) and 649,201 (97%) MTM eligible beneficiaries were offered a CMR, respectively. Among those, CMR receipt increased from 81,089 (16%) in 2013 to 119,181 (18%) in 2014. The mean age of CMR recipients was 75 years (±7) and the majority were women, White, and without low-income status. In 2014, lower odds of CMR receipt were associated with increasing age (adjusted odds ratio (OR) = 0.99 (95% confidence interval (CI) = 0.994-0.995), male sex (OR = 0.93, 95% CI = 0.926-0.951), being any non-White race/ethnicity except Black, dual-Medicaid status (OR = 0.64, 95% CI = 0.626-0.650), having a hospitalization (OR = 0.87, 95% CI = 0.839-0.893) or emergency department visit (OR = 0.67, 95% CI = 0.658-0.686), and number of comorbidities (OR = 0.90, 95% CI = 0.896-0.905). CONCLUSIONS: CMR offers and completion rates have increased, but disparities in CMR receipt by age, sex, race, and dual-Medicaid status were evident. Changes to MTM targeting criteria and CMR offer strategies may be warranted to address disparities.