Applying Design-Thinking Principles to Practice-Based Pharmacy Research.

Design thinking is an approach to problem solving that focuses on a solution to a problem. This systematic approach can be applied to practice-based research or implementation projects in your practice setting. It may be useful for starting new projects as well as revisiting past projects that may not have yielded meaningful results. The design-thinking process begins with identifying a problem or knowledge gap and then the steps include: (1) understanding the problem, (2) observing the problem, (3) defining the problem, (4) brainstorming possible solutions, (5) prototyping the best solution, and (6) testing the solution.

A technical assistance program approach for pharmacist clinical services integration in primary care organizations.

BACKGROUND: Little is known about the use of technical assistance (TA) programs to facilitate the integration of pharmacist clinical services in primary care settings. OBJECTIVE: Design, implement, and evaluate a TA program to advance pharmacist integration and clinical services in primary care. PRACTICE DESCRIPTION: Structured TA program for developing new or enhancing current integrated pharmacist services was utilized in 4 primary care organizations (i.e., federally qualified health center, accountable care organization, and an academic and regional health system). PRACTICE INNOVATION: Holistic TA program with a logic model, organizational stages of pharmacist integration, project prioritization, and implementation plans. EVALUATION METHODS: A mixed-methods contextual inquiry approach for integration of pharmacist clinical services. Quantitative analysis was used for TA program activities, time spent, pilot project data, and a web-based survey for post-TA program assessment. Coincidence analysis was used to assess organizational commitment to TA services. Qualitative analysis was used for data collected through semi-structured key informant interviews and team meeting activity reports. RESULTS: TA program team spent 1872 hours over 11 months on program development, logistics, implementation, and project oversight. TA services included 88 onsite and virtual meetings, 11 onsite pharmacist coaching sessions, 6 workflow mapping sessions, and updating online learning resources. Primary care organizations that had already hired a pharmacist were more likely to uptake TA services. Most useful TA methods were webinar meetings (89%) and on-site pharmacist coaching (88%). TA project results were used for strategic planning (73%), pharmacist value/impact assessment (72%), pharmacist capacity modeling (68%), and workflow design (65%). A key learning from the TA program was the importance of a qualified pharmacist with clinical service experience in primary care settings and population health teams. CONCLUSION: TA program for the pharmacist clinical service integration has broad application to primary care organizations with diverse organizational structures, payer mixes, and practice settings.

Addressing Foodborne Illness in Côte d'Ivoire: Connecting the Classroom to the Community through a Nonmajors Course-Based Undergraduate Research Experience.

The integration of course-based undergraduate research experiences (CUREs) into science, technology, engineering, and mathematics (STEM) laboratory curricula has provided new avenues to engage students at all levels in discovery-based learning. Empirical research demonstrates that CUREs have the potential to foster students' development of scientific process and reasoning skills, attitudes, motivations, and persistence in STEM. Yet, these outcomes are largely reported for studies conducted in the United States, Canada, Europe, and Australia. It therefore remains unclear to what extent CUREs are impactful for students enrolled in alternate international university contexts. To address this concern, we conducted a quasi-experimental mixed methods study to investigate the impact of a one-semester food microbiology and public health (FMPH) CURE on nonmajors students' development of science identity, science communication and process skills, science community values, and science-society perceptions at a private institution in Côte d'Ivoire, West Africa. Content analysis of students' end-of-semester research poster products and thematic analysis of student responses to post-semester open-ended survey items revealed positive gains with respect to student learning and student perceptions of the relevancy of their research to diverse audiences. Paired t-test analyses of pre-/post-semester closed-ended survey responses likewise indicated significant gains in students' science identity and science community values development as well as their confidence in handling and treating foods to reduce the bacterial load on those foods. Collectively, these findings suggest that the FMPH CURE was a meaningful and relevant learning experience capable of promoting students' growth as scientists and scientifically-minded citizens.

Pharmacist Identification of Medication Therapy Problems Involving Cognition Among Older Adults Followed by a Home-Based Care Team.

BACKGROUND: Dementia, depression, and delirium alone or in combination (3Ds) can threaten independence among older adults, and polypharmacy may further accelerate decline. Clinical pharmacists can play an important role on multidisciplinary home-based care teams by identifying medication therapy problems (MTPs) involving cognition. Within a larger ongoing clinical trial, this paper describes cognition-related MTPs and pharmacist recommendations among older adults with 3Ds followed by a home-based care team. METHODS: We conducted a retrospective analysis of medication data among Medicare Advantage members aged ≥ 65 years living at home in Connecticut with International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes related to 3Ds; analyses include the first 105 subjects randomized to the home-based care team from March 2017 to January 2019. Advanced practice registered nurses conducted in-home medication reconciliations along with medical and cognitive assessments. Clinical pharmacists then conducted medication reviews centered on agents treating or exacerbating 3Ds. After review by the study advanced practice registered nurse, geriatrician, and psychiatrist, salient recommendations were forwarded to primary care providers for consideration. Medication therapy problems related to cognition were retrospectively abstracted and classified as: (1) indication: underuse or overuse; (2) effectiveness: ineffective agent or low dose (mainly for antidepressants); and (3) safety: undesirable effect (e.g., impaired cognition, dementia treatment side effects), unsafe medication (e.g., potentially inappropriate medications that can harm cognition), drug interaction, or high dose. RESULTS: Pharmacists identified 166 cognitive MTPs, with a mean (standard deviation) of 1.58 (1.35) [range 0-6] MTPs per subject. Indication MTPs represented 34% of total MTPs, of which 79% involved underuse and 21% overuse; effectiveness represented 13% of total MTPs; and safety represented over half (52%) of all MTPs, with benzodiazepines and anticholinergics frequently implicated. Recommendations commonly included medication reduction (discontinuation 23% and dose reduction 19%). We found MTPs involving cognition among most (79%) patients. CONCLUSIONS: Our study findings support the role of pharmacists on multidisciplinary teams to identify cognitively harmful medications, dementia treatment side effects, and untreated cognitive conditions. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT02945085.

Primary Care Teams and Pharmacist Staffing Ratios: Is There a Magic Number?

Primary care physician (PCP) shortages are predicted for 2025, and many workforce models have recommended the expanded integration of nurse practitioners and physician assistants. However, there has been little consideration of incorporating clinical pharmacists on primary care teams to address the growing number of patient visits that involve medication optimization and management. This article summarizes various estimates of pharmacist staffing ratios based on number of PCPs, patient panel size, or annual patient encounters. Finally, some steps are offered to address the practice- and policy-based implications of expanding primary care pharmacist activities at the local and state levels.

Implementing primary care pharmacist services: Go upstream in the world of value-based payment models.

There is a shift by payers and health plans away from volume-based payments toward value-based payments that are linked to clinical quality, clinical practice improvement activities, and certified electronic health records technology. These alternative payment programs include fee-for-service with performance-based incentives, advanced payments for care management, shared savings, and population-based payments. Alternative payment programs that focus on clinical quality and practice improvements are founded on patient-centered care principles and based on team-based care delivery. There will be opportunities to expand primary care teams to address chronic care management, care transitions, and high-risk populations - all of which present medication optimization and management challenges that can be delegated to pharmacists working closely with primary care clinicians. This commentary will discuss implementation considerations for pharmacist services, standardized documentation of medication-related problems, and "upstream" pharmacist interventions (closest to the point of care) that align with alternative payment models.

Strategies for community-based medication management services in value-based health plans.

BACKGROUND: Health plans are moving away from a volume-driven payment structure toward value-driven and risk-based contracts. There is very limited information on commercial payers' perspectives on coverage of medication management services (MMS) in value-based alternative payment models. While some health plans have experience with Medicare Part D Medication Therapy Management (MTM) programs, this experience does not promote the integration of pharmacists as health care team members. OBJECTIVES: The study objectives were to: (1) understand the evaluation process that health plan executives would use to determine benefit coverage for pharmacist-provided MMS in value-based health plans, (2) identify the facilitators and barriers that affect pharmacist-provided MTM services at the community pharmacy level, and (3) propose strategies for pharmacist-provided MMS in value-based health plans. METHODS: This study used qualitative research methods that involved structured key informant interviews with commercial health plan executives and focus groups with community pharmacists who had experience providing MTM services. RESULTS: Health plan executives agreed conceptually that MMS could be a valuable program and recognized its potential. However, the most substantial barriers that health plan executives expressed were funding MMS in today's fee-for-service payment models; lack of physician infrastructure to implement and manage MMS; and difficulty in collecting timely, accurate data to execute and assess MMS programs. Community pharmacists identified the most serious barrier to altering health outcomes through MTM as the current lack of integration of MTM with a coordinated health care team. MTM services are conducted as a separate program by pharmacists who do not have access to patient health records, are time-constrained, and poorly incentivized. CONCLUSIONS: The findings can inform the development of successful strategies for pharmacist-provided MMS that align with emerging value-based health plans and alternative provider payment models. Current MTM program barriers and facilitators are identified that could be addressed in future Part D MTM program policy changes.

Variability in state Medicaid medication management initiatives.

Many U.S. states have expanded Medicaid programs, with over 70 million beneficiaries now enrolled. States' interest in improving care quality and lowering costs has spurred experimentation with several medication management (MM) programs. The implementation of MM programs for beneficiaries has been sporadic, and program elements and implementation methods have been heterogeneous. A survey was conducted to: (1) determine covered MM services in state Medicaid programs, (2) report innovative MM program findings, and (3) identify challenges in creating sustainable MM programs. The survey was sent to state Medicaid pharmacy directors in February 2015. The survey data focused on the type and extent of pharmacist-provided MM services, MM provider qualifications, patient eligibility criteria and enrollment strategies, MM delivery settings and referral patterns, MM program evaluations, program costs and sustainability models, key implementation challenges, and future program enhancements. Many Medicaid programs generally followed Medicare Part D Medication Therapy Management requirements. Highly variable findings were due to different Medicaid eligibility criteria, pharmacist integration with health teams, access to electronic medical records (EMRs), and MM delivery methods/settings to optimize drug therapy regimens. Several implementation challenges were identified. Pharmacist integration on care teams and access to EMRs improves MM implementation. MM program evaluation funding and data support must be secured prior to program implementation. The findings and discussion here can assist states with limited or preliminary Medicaid MM experience to progress toward sustainable programs.

Pharmacists and the primary care workforce.

The primary care workforce shortage will be magnified by the growing elderly population and expanded coverage as a result of health care reform initiatives. The pharmacist workforce consists of community-based health care professionals who are well trained and highly accessible, yet underutilized. Some health care professionals have advocated that primary care teams should include pharmacists with complementary skills to those of the physician to achieve quality improvement goals and enhance primary care practice efficiencies. New primary care delivery models such as medical homes, health neighborhoods, and accountable care organizations provide opportunities for pharmacists to become integral members of primary care interdisciplinary teams.

Innovation in health care: a call to action.

Innovation in health care is difficult yet necessary in this era of health care delivery and payment reform. The Center for Medicare and Medicaid Services (CMS) Innovation Center and the CMS Partnership for Patients have announced priority areas to achieve better health, better care, and reduced costs through continuous improvement. Pharmacists possess the therapeutic knowledge and medication process expertise to create collaborative and innovative solutions that address medication use and safety problems. As a profession, we face a call to action. As pharmacy practitioners, educators, and researchers, we face an unprecedented opportunity to make a difference. So, either individually or collectively in our workplaces and pharmacist professional organizations, we must respond to this call to action. Some practical suggestions are offered to get us started on this journey.