Expanding Clinical Services in Iowa Pharmacies: A Multi-Case Study

1. The Work System of Value-Based Programs in Pharmacy: A Multi-Case Study Joel Hoyman, Samantha Johnson, Matti Mason & Michael Parisi-Mercado Preceptor: Dr. Bill Doucette

2. Background • Evolution of pharmacy in Iowa • Change in the role of the pharmacist • Iowa Pharmacy Association (IPA) New Practice Model • Community Pharmacy Enhanced Services Network (CPESN) Iowa • Focus on providing clinical services • Lower payments forcing pharmacies to seek other revenue streams • Purpose: discuss changes that pharmacies across the state of Iowa have made to expand their offering of clinical services • Utilize the System Engineering Initiative for Patient Safety (SEIPS) work system model • Focus on 5 work system areas • Tools & technology, people, tasks, organization, environment

3. Systems Engineering Initiative for Patient Safety (SEIPS) work system model

4. Objectives • Determine how many pharmacies utilizing the New Practice Model or members of CPESN have addressed changes in their work system to be successful in this new value-based program. • i.e. : changes to provide new services, technology, staff organization • Identify strategies these pharmacies used that aided in their success, as well as what obstacles may have impeded their success in the new program. • i.e.: medication therapy management (MTM) , immunizations, Medication Synchronization (MedSync)

5. Methods • Qualitative study • List of pharmacies • IPA New Practice Model Participants • CPESN Iowa Members • 106 pharmacies contacted • Letter via email • Recorded phone interview with willing pharmacy participants • Utilized an interview guide • Semi-structured interview focused on five work system areas of interest • Interviews transcribed, coded • Matched responses to work system area

6. Case 1 Tools & Technology • Eye-Con Pill Counter • Dispensing software: ComputerRx • Documentation: ComputerRx • Looking at utilizing Prescribe Wellness as well Tasks • Medpacks • MedSync • Immunizations • MTMs • Adherence Packaging People • 1 clinical pharmacist, 1 staff pharmacist • New Practice Model pharmacy Chain Pharmacy 700-800 Rx/week Pharmacists: 2 Technicians: 3 Population: 60,000

7. Case 1 Environment • Private counseling room • Also utilized for immunizations, long-acting injections • Transition of care program with local hospital • Good physician--pharmacist relationships Organization • Technician-run adherence packaging • Emails, quarterly reviews Chain Pharmacy 700-800 Rx/week Pharmacists: 2 Technicians: 3 Population: 60,000

8. Case 2 Tools & Technology • Eye-Con Pill Counter • Refill App • Central Fill • Documentation: Patient Reporting Software Tasks • MedSync • ReadyRefill • Adherence Packaging • Immunizations • MTM People • One new experienced tech hired; mostly just trained current employees. • New Practice Model Pharmacy Chain Pharmacy 1500 Rx/week Pharmacists: 3 Technicians: 4 Population: 8,000

9. Case 2 Environment • Private Counseling/Immunization Room • Great physician--pharmacist relationship • Local hospital main clinic will often call with drug questions, etc. Organization • Memos, bi-annual meetings • More counseling on refills than in the past • Face-to-face patient interaction/communication • Techs checking prescriptions frees pharmacists Chain Pharmacy 1500 Rx/week Pharmacists: 3 Technicians: 4 Population: 8,000

10. Case 3 Tools & Technology: • ScriptPro robot • Electronic faxing • Omnifiller for MedSync program Tasks: • MedSync • Adherence packaging • Immunizations • Point of care testing • Shared duties between pharmacists • Technicians involved in inventory management, entering and filling prescriptions, answering phone People: • No new hires • No changes in staffing or scheduling Independent Pharmacy Prescriptions: 2,000 per week Pharmacists: 4 Technicians: 5 Population: approximately 24,000

11. Case 3 Environment: • Room with table and chairs where they provide immunization • Consultation area Organization: • Not enough communication when informing of changes • Will implement monthly meetings Independent Pharmacy Prescriptions: 2,000 per week Pharmacists: 4 Technicians: 5 Population: approximately 24,000

12. Case 4 Tools & Technology: • Parata Robot • Eye-Con Pill Counter • Phone system automatically calls patients when prescriptions are ready • Using QS1, not very MTM friendly Tasks: • MedSync • MTM’s • Free Vitamin Program for children People: • Recently hired a pharmacist • In charge of MTM’s • Technicians do the bulk of the MedSync Independent Pharmacy 1,400 Rx/wk Pharmacists: 3 Technicians: 8 Pop. 4,000

13. Case 4 Environment: • Standard counseling area • New room for immunizations and private counseling • Prescribers call at any time of the day Organization: • Technicians are in charge of all portions of filling except checking • Doing much more calling patients than in the past Independent Pharmacy 1,400 Rx/wk Pharmacists: 3 Technicians: 8 Pop. 4,000

14. Results 8 Pharmacies responded & completed an interview • 5 independent • 3 chain Initial Findings: • Multiple clinical services offered: MTMs, MedSync, Immunizations • Many are giving more responsibilities to technicians • Not many changes in staffing *still in progress*

15. Strengths & Limitations Strengths: • Coded interviews in pairs • Use of a proven conceptual framework • Use of semi-structured interviews • Sample of pharmacies from the CPESN and IPA New Practice Model should be more progressive. Limitations: • Wasn’t face-to-face, on-site • Limited sample size • Didn’t do a checkback process • Different people did interviews

16. Next Steps • Write a case report for each case • More thorough comparisons • Develop quantitative approach • Survey questions • Gain larger study population

17. questions?