Care team perspectives on community pharmacy enhanced services.

OBJECTIVES: To determine the awareness, collaboration, and perceived values and barriers of enhanced pharmacy services from care managers and primary care practice responders. METHODS: An electronic questionnaire was sent to 1648 primary care practices and 600 care managers that work in 76 North Carolina counties containing an enhanced-service community pharmacy. Questionnaires were distributed in January 2017 and responses collected for 7 weeks. The questionnaire collected data on the awareness and perceived value of enhanced pharmacy services, preferred method and level of communication for referral, and barriers to using enhanced services. Data were gathered with the use of Likert-type, rank-order, dichotomous, and multiple-choice questions. Data were analyzed with the use of descriptive statistics, and group mean responses were compared by means of t tests. RESULTS: Data analysis was performed in March 2017. Response rates were 5.4% (n = 89) from practice responders and 45% (n = 270) from care managers. In the responses received, 35% of practice responders and 88% of care managers were familiar with enhanced services offered by community pharmacies. A majority of respondents thought that enhanced pharmacy services are valuable, with more than 85% of practice responders agreeing that partnering with an enhanced-service pharmacy can help to improve patient health outcomes. Lack of knowledge of enhanced-service pharmacies, services offered, and the referral process were identified as significant barriers for practice responders. CONCLUSION: Community-based pharmacies have an opportunity to collaborate with patient-centered medical home teams to provide enhanced pharmacy services, but provider outreach and education on enhanced services offered and the referral process are necessary to maximize this collaboration.

Community pharmacists' attitudes toward providing care and services to patients with severe and persistent mental illness.

OBJECTIVES: To assess community pharmacists' attitudes toward working with patients who have severe and persistent mental illness (SPMI) and to identify perceived barriers to providing care and services to this population. DESIGN: This study was a cross-sectional survey of community pharmacists in North Carolina. The questionnaire, which was distributed electronically, included demographic questions about the responder and pharmacy in which they practiced, Likert-type scale questions assessing pharmacists' comfort and attitudes towards working with patients with SPMI, and barriers preventing provision of care. The survey remained open for 30 days after distribution. Descriptive and inferential statistics were used to analyze survey results. SETTING AND PARTICIPANTS: All community pharmacists actively licensed in North Carolina. MAIN OUTCOME MEASURES: Pharmacists' perceptions toward working with and delivering care to patients with SPMI. RESULTS: Of the 5582 pharmacists who received the survey, 458 completed it. Most respondents had been practicing 0-5 years (22%) or more than 20 years (51%) and the majority estimated that 0%- 25% of their patient population had SPMI. Ninety-one percent agreed that SPMI were real diseases, 81.6% agreed that patients with SPMI often misunderstand information about their medications, and 53.5% disagreed that patients with SPMI can independently manage their medications. Pharmacists responded that they felt confident monitoring efficacy and recognizing adverse effects of medications used to treat SPMI only 28.1% and 48.3% of the time, respectively. The key barriers identified in preventing community pharmacists from providing optimal care and services to this population are lack of time and lack of confidence in managing and monitoring medications used to treat SPMI. CONCLUSION: Although pharmacists had a positive attitude toward working with this population, multiple barriers were identified that prevented optimal care. Identifying solutions to overcome these barriers could help to improve the overall care and increase the likelihood of success in treating patients with SPMI.

Description of drug therapy problem resolution in a statewide care management program.

OBJECTIVE: To describe drug therapy problem (DTP) resolution as part of a statewide, team-based care management program. METHODS: This was a retrospective, observational study of DTPs documented between March 1 and August 31, 2015. Data were retrieved from a Web-based platform 5 months after the observation period. DTPs were placed into groups based on the credentials of the person who documented the DTP. Next, they were identified as being documented in a transitional or nontransitional care setting. DTPs were further classified into 1 of 3 categories: medication adherence, discrepancy, or optimization. Lastly, DTP resolution was assessed. Results were analyzed using descriptive statistics. RESULTS: During the 6-month study period, 135,100 DTPs were documented, with 99% (n = 133,847) being documented by social work care managers, nurse care managers, and pharmacy staff personnel. Pharmacy staff personnel documented the majority of DTPs (51.5%), and the majority of DTPs (55%) were identified in the transitional care setting. Nurse care managers resolved more discrepancy DTPs (59.3%), whereas pharmacy staff personnel resolved more optimization DTPs (47.2%). Social work care managers resolved more medication adherence DTPs (68.6%). CONCLUSIONS: Pharmacy staff personnel primarily identified and resolved opportunities to optimize medication use, whereas nurse care managers primarily identified and resolved medication discrepancies. Social work care managers primarily identified and resolved problems related to medication adherence. When each member of the interdisciplinary care team functioned at the top of their license, all types of DTPs were effectively identified and resolved.

Implementing an integrated care management program in community pharmacies: A focus on medication management services.

OBJECTIVES: To describe the initiation of a community pharmacy medication management service within a statewide integrated care management program. SETTING: One hundred twenty-three community and community health center pharmacies in 58 counties of North Carolina. PRACTICE DESCRIPTION: Independent and community health center pharmacies offering medication management as part of an integrated care management program to Medicaid, Medicare, dually eligible Medicare-Medicaid, and NC Health Choice beneficiaries in North Carolina. PRACTICE INNOVATION: Community pharmacies joined an enhanced service network created by Community Care of North Carolina to provide medication management services as part of an integrated care management program. EVALUATION: During the first 3 months of the program, 41% of pharmacies consistently documented the medication management services. Interviews were conducted with pharmacists from the inconsistent pharmacies to drive program improvements. RESULTS: Pharmacists at 73 community and community health center pharmacies were interviewed. The majority of pharmacists reported that challenges in "initiating services" and "documenting" were due to increased intensity of service and documentation compared with Medicare Part D medication therapy management requirements. Program changes to improve participation included revision of documentation requirements, authorization of technicians to transcribe pharmacists' interventions, additional documentation templates, workflow consultations, and feedback on documentation quality. CONCLUSION: Community pharmacies are capable of providing medication management integrated with care management. Some pharmacies have more difficulty initiating new services in the current workflow landscape. To facilitate implementation, it is important to minimize administrative burden and provide mechanisms for direct feedback. Pharmacy owners, managers, and leaders in pharmacy policy can use these findings to aid implementation of new services in community pharmacies.

Supporting Community Pharmacies with Implementation of a Web-Based Medication Management Application.

OBJECTIVE: Community pharmacists' role in clinical care is expanding in the United States and information systems are needed that extend beyond a dispensing workflow. As pharmacies adopt new systems, implementation support will be needed. This study identifies the barriers and facilitators experienced by community pharmacies in implementing a Web-based medication management application and describes the implementation strategies used to support these pharmacies. METHODS: Semistructured interviews were conducted with 28 program and research staff that provides support to community pharmacies participating in a statewide pharmacy network. Interviews were recorded, transcribed verbatim, and analyzed for themes using the Expert Recommendations for Implementing Change (ERIC). RESULTS: Findings suggest that leadership support, clinical training, and computer literacy facilitated implementation, while lack of system integration, staff resistance to change, and provider reluctance to share data served as barriers. To overcome the barriers, implementation support was provided, such as assessing readiness for implementation, developing a standardized and interoperable care plan, and audit and feedback of documentation quality. CONCLUSION: Participants used a wide array of strategies to support community pharmacies with implementation and tailored approaches to accommodate pharmacy-specific preferences. Most of the support was delivered preimplementation or in the early phase of implementation and by program or research staff rather than peer-to-peer. Implementing new pharmacy information system requires a significant amount of implementation support to help end-users learn about program features, how to integrate the software into workflow, and how to optimize the software to improve patient care. Future research should identify which implementation strategies are associated with program performance.

Lessons Learned from Using Global Outcome Measures to Assess Community Pharmacy Performance.

INTRODUCTION: As value-based and alternative payment models proliferate, there is growing interest in measuring pharmacy performance. However, little research has explored the development and implementation of systems to measure pharmacy performance. Additionally, systems that currently exist rely on process and surrogate outcome measures that are not always relevant to patients and payers. PROGRAM DESCRIPTION: This article describes the process used to design and implement a performance measurement program for a group of enhanced services pharmacies in North Carolina. This program was successful in measuring quality based on medication adherence, hospitalizations, emergency department visits, and total cost of medical care for nearly all North Carolina pharmacies. Measures were scored and combined into a single 11-point composite pharmacy performance score. To demonstrate the measures, we compared performance scores for enhanced services pharmacies (n = 119) to other North Carolina pharmacies (n = 1,616) during the baseline measurement period (March 1, 2015-May 31, 2015). Adherence measure scores for enhanced services pharmacies exceeded those of other pharmacies (P values < 0.0001-0.003), but total scores were not significantly different, with enhanced services pharmacy mean total scores of 6.54 vs. 6.29 for all other pharmacies (P = 0.115). OBSERVATIONS: The program described provides an example of a composite performance measurement system that can be used to support alternative pharmacy payment models and shows that case-mix adjustment is possible for broad outcomes such as those used in this program. The measures used for the program depend on timely feeds of medical claims. Payers and pharmacy networks implementing a similar program may need to explore alternative structure or process measures. IMPLICATIONS: As pharmacy payment models evolve, there may be value in collaboration between academics, pharmacists, and payers to bring different areas of expertise and perspectives into the performance measurement process. This program demonstrates that global outcome measurement is possible over a broad set of pharmacies and invites additional research to explore the validity of this and other methods to measure pharmacy quality and performance. DISCLOSURES: The program described in this article was supported by Funding Opportunity Number 1C12013003897 from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. Community Care of North Carolina received the grant and subcontracted with the UNC Eshelman School of Pharmacy to carry out this project. Shasky, Pfeiffenberger, and Trygstad are employed by Community Care of North Carolina. Urick and Ferreri are employed by the UNC Eshelman School of Pharmacy. Farley was employed by the UNC Eshelman School of Pharmacy during data collection for this project and reports consulting fees from UCB Pharmaceutical Company unrelated to this project. Pfeiffenberger reports membership on the Pharmacy Quality Alliance (PQA) task force on pharmacy level measures; Trygstad is a PQA board member; Urick is a member of a scientific advisory committee for PQA.

Evaluation of a novel web-based prior approval application for palivizumab prophylaxis of respiratory syncytial virus in a state Medicaid program.

BACKGROUND: Recent disproportionate increases in use of specialty medications, such as palivizumab (Synagis), compared with steady utilization of traditional medication use, have prompted complex utilization management strategies that require frequent evaluation to facilitate cost-effectiveness while preserving patient access. Clinical criteria utilized by North Carolina (NC) Medicaid for use of palivizumab for respiratory syncytial virus (RSV) prophylaxis are consistent with the most recent guidelines published in the Red Book: Report of the Committee on Infectious Diseases. Prior to the 2011-2012 RSV season, prior approval (PA) requests were submitted by facsimile using the NC Medicaid Synagis PA form. A web-based PA application, which includes automatic approval capability, monthly dose prompts to providers, and a standardized dose projection formula, was developed for the 2011-2012 RSV season. OBJECTIVES: To evaluate the timeliness of palivizumab coverage determination, compliance with palivizumab prophylaxis regimen, and the accuracy of the dose projection formula achieved with this novel web-based PA application for palivizumab prophylaxis in NC Medicaid recipients. METHODS: A historically controlled retrospective cohort study was conducted in which all palivizumab PA submissions and supporting documentation from the 2010-2011 and 2011-2012 RSV seasons were retrospectively reviewed for date and time of original submission and final coverage determination. Submissions from the 2011-2012 season were also retrospectively reviewed for number of doses approved, number of doses administered, date of administration of each dose, and actual dosage administered. These data were used to evaluate compliance and the projected versus actual beneficiary weight and dose to assess the accuracy of the dose projection formula. Submissions lacking required information were excluded. Time from PA submission to coverage determination was compared between seasons using a 2-sample t-test. The proportion of compliant recipients was calculated based on number of doses received and dosing interval of no more than 35 days. Accuracy of the dose projection formula was evaluated using a paired Student's t-test. RESULTS: Time to coverage determination decreased overall, on average, by 3.7 days (mean [SD] 8.5 [15.4] vs. 4.8 [9.3]; P<0.001) for the 2011-2012 season using the electronic web-based PA application compared with the traditional facsimile-based system used in the 2010-2011 season. Decreased time to coverage determination was observed in both PA requests that required medical review and those that did not. Of all palivizumab recipients who were eligible to receive at least 2 doses (n=1,233), 61.1% were fully compliant with all doses, and 86.9% received all but one documentable dose. Of those who received at least 2 documented doses (n=1,091), 62.8% received all doses within 35 days of the previous dose. When both definitions of compliance were applied concurrently, 39.3% of all palivizumab recipients were considered compliant; the mean difference between projected and actual doses was 7.1 mg (95% CI: 6.8-7.5; P=0.001) or 8.6% (95% CI: 8.0-10.0). Projected and actual doses did not vary significantly in the sensitivity analysis when excluding entries with ≥50% difference. CONCLUSIONS: The 2011-2012 web-based PA application improved the timeliness of palivizumab coverage determination compared with the 2010-2011 facsimile-based system. Observed compliance rates for NC Medicaid recipients were slightly lower than those reported in the literature when defined by number of doses received but were higher when defined by interval between doses. The dose projection formula used for the web-based application appears to be accurate for infants 0-2 years of age.

A+KIDS, a web-based antipsychotic registry for North Carolina youths: an alternative to prior authorization.

OBJECTIVE: The rise in use of antipsychotics among U.S. children is well documented. Compliance rates with current safety-monitoring guidelines are low. In response, the North Carolina Division of Medical Assistance established the Antipsychotics-Keeping It Documented for Safety (A+KIDS) registry. The initial objectives of the project were to successfully establish a Web-based safety registry and to obtain and evaluate clinical information derived from the registry. METHODS: In April 2011, A+KIDS began asking prescribers of antipsychotics for children age 12 and under to respond to a set of questions regarding dose, indication, and usage history. Antipsychotic registrations were examined by linking North Carolina Medicaid prescription claims to registry entries. Prescribers were classified into different types, and the number of patients and registrations per prescriber were examined. RESULTS: In the initial six months, 730 prescribers registered 5,532 patients, 19% below age seven. By month 6 of the registry, 72% of all fills were registered with the program. Top diagnosis groups for registry patients were unspecified mood disorders, autism spectrum disorders, and disruptive behavior disorders. Top target symptoms were aggression (48%), irritability (19%), and impulsivity (11%). Psychosis accounted for 5% of the target symptoms. Twenty-eight percent of children were receiving no form of psychotherapy. Twenty-five percent of all A+KIDS prescribers were responsible for 81% of the registrations. CONCLUSIONS: The A+KIDS registry initiative has been successful, as measured by rapid uptake, and is providing clinical information not available from claims data alone. Future efforts will allow for detailed examinations of antipsychotic utilization and further safety improvement.

Effects of a new sterile product preparation and delivery process on operational efficiency and cost.

PURPOSE: Process changes in a hospital pharmacy's batch preparation of sterile products to reduce product and human resource waste are described. SUMMARY: The pharmacy information system and direct observation were used in the collection of data on the existing i.v. room process, which generated batches of drug products every 12 hours. The daily numbers of doses prepared and doses credited, the percentage of doses credited, the cost of wasted doses, and the number of pharmacy technician hours wasted in the process were recorded. After a change to every-4-hour batch preparation and a modification of the schedule for delivering products to nursing units, data were again collected to determine savings of waste and costs. Fewer doses were prepared daily in the new batch process. The percentage of doses credited daily decreased from 26% to 18%, and pharmacy technician workload decreased by 3.05 hours. The reductions in waste led to a projected annual product cost saving of $122,000 and a workload reduction of 0.5 technician full-time equivalent. CONCLUSION: The implementation of a new i.v. room batch process improved operational efficiency by reducing the production of waste and led to a substantial projected annual cost saving.

Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies.

BACKGROUND: Medication discrepancies are unintended differences between medication regimens (ie, between a patient's home regimen and medications prescribed on admission to the hospital). OBJECTIVE: The goal of this study was to describe the incidence, drug classes, and probable importance of hospital admission medication discrepancies and discharge regimen differences, and to determine whether factors such as age and specific hospital services were associated with greater frequency of medication discrepancies and differences. METHODS: This was a retrospective cohort study of a random sample of adult patients admitted to the general medicine, cardiology, or general surgery services of a tertiary care academic teaching hospital between July 1, 2006, and August 31, 2006. A chart review was performed to collect the following information: patient demographic characteristics, comorbid conditions, number of preadmission medications, discrepant medications identified by the hospital's reconciliation process, reasons for the discrepancies, and discharge medications that differed from the home regimen. Potentially high-risk discrepancies and differences were identified by determining if the medications were included on either the Institute for Safe Medication Practices high-alert list or the North Carolina Narrow Therapeutic Index list. Univariate and multivariate logistic regression analyses were used to identify factors associated with medication discrepancies and differences. RESULTS: Of the 205 patients (mean age, 59.9 years; 116 men, 89 women; 60% white) included in the study, 27 did not have any medications recorded on admission. Of the 178 patients who did have medications listed, 41 had >or=1 discrepancy identified by the reconciliation process on admission (23%; 95% CI, 17-29); 19% (95% CI, 11-31) of these medications were considered to be potentially high risk. In the multivariate logistic regression model, age (odds ratio [OR] per 5-year increase = 1.16; 95% CI, 1.01-1.33; P = 0.035), presence of high-risk medications on admission (OR = 76.68; 95% CI, 9.13-643.76; P < 0.001), and general surgery service (OR = 3.31; 95% CI, 1.40-7.87; P < 0.007) were associated with a higher proportion of patients with discrepancies on admission. At discharge, 196 patients (96% [95% CI, 93<98]) had >or=1 medication change from their home regimen, with 1102 total differences for 205 patients. Less than half (44% [95% CI, 37-51]) of these patients were explicitly alerted at discharge to new medications or dose changes; 12% (95% CI, 7-18) were given written instructions to stop taking discontinued home medications. Cardiovascular drugs were the most frequent class involved at both admission (31%) and discharge (27%) in medication discrepancies or differences. CONCLUSIONS: Medication discrepancies on admission and medication differences at discharge were prevalent for adult patients admitted to the general medicine, cardiology, and general surgery services in this academic teaching hospital. Medication reconciliation processes have a high potential to identify clinically important discrepancies for all patients.