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Pharmacy Access Office Hours

Pharmacy Access Office Hours. Pharmacy Access Office Hours May 16, 2019 Focus Topic: Clinical Pharmacy 101.

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Pharmacy Access Office Hours

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  1. Pharmacy Access Office Hours Pharmacy Access Office Hours May 16, 2019 Focus Topic: Clinical Pharmacy 101 This session is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,375,000. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

  2. Webinar Logistics We strongly recommend calling in on your telephone Phone: 866-469-3239 Access Code: 632 274 023 # Your Attendee ID: Listed below the access code in the box under “Select Audio Connection”. To ask/ answer a question, or share a comments, please use the Chat box on the right hand side of the screen You can download these slides on Noddlepod, & from NACHC’s NEW340B/ Rx webpage: http://www.nachc.org/focus-areas/policy-matters/340b/ Or go to NACHC.org and search 340B

  3. Operational Updates • Focus Topic – Clinical Pharmacy 101 • Q&A • And Comment Box discussions throughout…

  4. OPERATIONAL UPDATES Colleen Meiman Senior Policy Advisor National Association of Community Health Centers cmeiman@nachc.org

  5. Additional Support for Rx Operations • Tim Mallett from 340Basics is now under contract with NACHC to provide Training and Technical Assistance (T&TA) to health centers on pharmacy operations. • Contract is funded through BPHC Cooperative Agreement, so: • Thank you BPHC! • Focus is operations, not advocacy. • To access Tim’s expertise, you can either: • email Colleen at Cmeiman@nachc.org or • email Tim directly at tmallett@340Basics.com and cc Colleen (This is probably the faster route….)

  6. Discriminatory Contracting • Health Centers – and other 340B providers -- are continuing to receive contract addendums from third-party groups offering reimbursement/ fee structures that are inconsistent with Congressional intent. • Because this topic relates to advocacy, we cannot discuss it in this forum.

  7. Are You on “Noddlepod”? An on-line platform, limited to members of the health center “family”, to discuss pharmacy and 340B-related issues. • Free & open to all health centers -- but as it’s not sponsored by BPHC, won’t go into details now. • Do NOT discuss confidential details of reimbursement, etc. • Sign up to join by emailing cmeiman@nachc.org or cdevoe@nachc.org It’s actually noDDlepod, not nOOdlepod– but I still thought the image might help.

  8. Outreach from “DecisionPoint Research? • DecisionPointResearch (DPR), an independent market research firm, has been hired by a major retail pharmacy chain to study FQHCs’ in-house pharmacies.  • If you or your colleagues are contacted by DPR, please contact Colleen Meiman at cmeiman@nachc.org before responding.

  9. Info on Medicaid & 340B For more info, contact Gavin Magaha at Apexus- gavin.magaha@apexus.com

  10. The Ceiling Price Database is LIVE! • Starting this month, 340B providers can verify that they are not being overcharged for 340B drugs.* • Info is available in a new section of the Office of Pharmacy Affairs Info System (OPAIS.) * Remember that the 340B CEILING price is not always the same as the 340B PURCHASE price, since the PURCHASE price may contain “sub-ceiling” discounts & distributor fees.

  11. Are You Overpaying for Vaccines or IUDs? • Neither vaccines nor IUDs are subject to mandatory discounts 340B. • BUT… as a 340B provider, you are eligible for discounts on vaccines, and $50 IUDs (similar to Mirena.) • For info on discounted vaccines, contact Apexus at 888.340.BPVP or apexusanswers@340Bpvp.com • For info on $50 IUDs, contact mdiallo@medicines360.org or go www.medicines360.org

  12. Miscellaneous • Recordings of most Rx Office Hours sessions are now available on the NEW NACHC Pharmacy website. • A couple months are missing due to Colleen’s IT learning curve…. • GAO now conducting a study of methods to avoid duplicate discounts. • Increased focus on contract pharmacy compliance. • If you are contacted by Kalderos, we advise you to respond promptly.

  13. Looking Ahead Upcoming Office Hours Topics • MAY: Clinical Pharmacy 101 (Matt Bertsch) • JUNE: TPAs? (Jim Donnelly) or Recent Trends in Audit Findings (Matt Atkins) • JULY: Pharmacy Charges - Sliding Fee Scale & Other Considerations

  14. More Learning Opportunities • For people new to 340B: • A “340B 101” webinar – in May (exact date TBD) • 340B University for FQHCs – Aug 17 in Chicago (right before NACHC CHI) • For people who work with 340B or their FQHC’s finances: • 340B Coalition Conference • July 15-17 in Washington DC • Three sessions focused specifically in FQHCs • Two will focus on “Three Strategies to Optimize the value of your 340B program.”

  15. Summary of Operational Updates • Email Tim Mallett at tmallett@340Basics.com for support with operational issues. (Please cc Cmeiman@nachc.org.) • Sign up for Noddlepod by emailing cmeiman@nachc.org or Cdevoe@nachc.org. • Contact Colleen if you are contacted by DecisionPoint Research. • The Apexus website has info about Medicaid and 340B in each state. • FQHCs can purchase discounted vaccines and $50 IUDs. • There are several upcoming learning opportunities around 340B, geared both to “newbies” and “old hands.”

  16. Please do the 1-minute evaluation

  17. Focus Topic: Clinical Pharmacy Programs in an FQHC • Speaker:Matthew Bertsch, PharmD • University of Arizona, College of Pharmacy Graduate • Class of 2012 • Director of Pharmacy • Sun Life Family Health Center • Residency Program Director • PGY1 Community-Based Pharmacy Residency Program • 340B Coalition Speaker/Facilitator • WC 2017, SC 2017, WC 2018, SC 2018, WC 2019

  18. Today’s Agenda • An overview of Sun Life • Pharmacy Care Initiatives • Sun Life wellness initiatives that would be impossible without 340B savings • Pharmacy residency program and residency projects • Anticoagulation • Weight management • Opioid management • Diabetes management • Affordable medication program • Chronic care management services and Annual Wellness Visits • Collaborative practice agreements • Developing smart business models around clinical programs • Conclusion

  19. 19 An Overview of Sun Life • Sun Life Family Health Center is a not-for-profit organization providing health care to Apache Junction, Casa Grande, Chandler, Eloy, Coolidge, Florence, Maricopa, Oracle and San Manuel.  • Sun Life Family Health Center is Pinal county's largest provider of primary health care services. Governed by a Board of Directors representing the patients and communities served by the organization, Sun Life serves over 47,000 patients, 28% of whom are children. What makes us different is our unfailing concern for the well-being of our patients, and our willingness to provide the best possible experience for every person that walks through our doors.

  20. An Overview of Sun Life A County Map • 13 sites • 6 pharmacies • From San Manuel to Maricopa • 114 miles • 2 hours • County road travel • Oracle • 4,500ft elevation • Maricopa • 1,175ft elevation • Eloy • The only pharmacy in town • Florence • The only pharmacy for 8 miles • San Manuel • The only pharmacy for 28 miles Center for Women – No In-House Pharmacy Clinic Sites– No In-House Pharmacy Center for Children– No In-House Pharmacy Dentistry Clinics with an In-House Pharmacy Chandler Center for Women – Off the Map

  21. Sun Life’s Pharmacy Program • 6 In-House Pharmacies • 7 FTE Pharmacists • A Community Based Pharmacy Residency Program • 2 FTE Pharmacists and 2 Pharmacy Residents • Pharmacy Administration Team • Oversees Community, Clinical, In-House Pharmacy Needs, 340B Program Administration, Clinical Integration

  22. Today’s Focus: Clinical Pharmacy Programs • What are “clinical pharmacists”? • Clinical pharmacists focus on providing direct patient care to optimize medication therapy and promote health and disease prevention. • Clinical pharmacists are often found in hospitals or ambulatory care settings, paired with more traditional providers. • How can a clinical pharmacy program add value to our patients’ care? • Clinical pharmacy can “advertise” for community pharmacy • Continuity of care between provider and pharmacist • Clinical pharmacy services can improve outcomes for patients • High risk measures/grant dollars • Clinical pharmacy can make for a more positive provider experience. • Can we offload providers with clinical pharmacists?

  23. The History of SLFHC Clinical Pharmacy Program • December of 2015 • Discussion between Director and PIC • December of 2015 through July of 2016 • Buildup – Physical space • Provider buy-in and C-Suite justification • HR Preparation – New position • First Contracted SLFHC Pharmacists • July 5th, 2016 • First two PGY1 Ambulatory Care residents started for SLFHC • New Orleans, LA; and Charlotte, NC • Retained one of the two • June 26th, 2017 • Second batch of residents started for SLFHC • SC; AZ; NV; CA • Retained 2 of the 4 • July 2nd, 2018 • Third batch of residents started for SLFHC • AZ; PA • April 25th, 2019 • Received ASHP accreditation confirmation • PGY1 – Community Pharmacy

  24. What do our clinical pharmacists do? • Primary services out of Casa Grande location • Expanded to: Florence, AJ, CG-CFW • Can assist all providers through the EHR and telephonically • Focused on diabetes education, gestational diabetes, pain management, anti-coag, ambulatory care • Medication Reconciliation Services • Serve as provider and staff resource • Assist in prior authorizations from nursing staff • Answer medication questions from patients • Meet one on one with patients • Monthly staff/provider lunch and learns • Patient education in rooms during provider visits • Place and interpret continuous glucose monitors • All of these activities are funded with 340B savings.

  25. Integrating pharmacy into diabetes education • Program is based on referrals from providers • Diabetes program consisted of • FTE CDE – Traveling and Teaching • Per diem Program Coordinator – Meter trainings, assessments, etc. • Per diem program assistant – Meter trainings, assessments, etc. • Appointments were backed up two months • Patients were not being seen in a timely fashion • Referral – First Visit (Assessment) – Group Classes - Graduation • Bottleneck was the assessment • Simply no manpower • Decided to integrate pharmacy resident into the program

  26. Integrating Clinical Pharmacy into Provider Workflow • Ambulatory Care portion of our workflow • Providers are overloaded with patients… • Tasked with treating disease states, meeting health plan metrics, maintaining productivity, UDS measures, etc. • Provider visit can look like… • What is your chief complaint? • Sick visit… • Chronic condition review... • …diabetes, hypertension, hyperlipidemia… • Review and target the metrics... • Colonoscopy, influenza vaccine, Medicare – scheduled for your annual wellness visit, medication review, medication adherence to statin/ACE or ARB…deciding new prescription therapy, sending prescriptions…charting everything, using the proper CPTII code… • Trying to sell the pharmacy… • Generate revenue…

  27. Integrating Clinical Pharmacy into Provider Workflow • Clinical pharmacists can assist with everything after the chief complaint… • PCP sees patient • PCP consults with clinical pharmacist • Clinical pharmacist can see the patient before or after the PCP visit, can schedule follow-ups with clinical pharmacist, etc. • Clinical pharmacist may be able to generate refills or prescriptions via standing order, and ensure proper therapy. • Clinical pharmacist makes recommendations to PCP • PCP closes out visit

  28. Pharmacy Care Initiatives • Clinical and Community Pharmacy Projects • Anticoagulation • Weight management • Opioid management • Affordable medication program • Chronic Care Management services • Annual Wellness Visits • Collaborative practice agreements • Developing smart business models around clinical programs

  29. Anticoagulation • Over the past year, our clinical pharmacist-directed anticoagulation monitoring service achieved significantly better INR control when compared against the patients of one physician. This study showed a 10.1% improved control in patient’s INRs when seen at the SLFHC anticoagulation clinic. This difference is similar to other studies which show 8% - 17.7% better INR control by clinical pharmacist-run anticoagulation clinics versus usual physician care. • Patients are referred to pharmacists for anticoagulation services for VKAs. These patients are controlled and monitored by the clinical pharmacy team. • Where appropriate, patients are also identified for changes to DOACs (then filled at Sun Life Pharmacies where possible…)

  30. Weight Management • Patients that were followed by a pharmacist lost weight. Patients that did not follow-up gained weight. More than 50% of the 12 patients lost at least 5% of their bodyweight, as predicted. This amount of weight loss has been correlated with positive cardiovascular outcomes. • This program has evolved from the ketogenic diet (before “keto” was popular with the masses) to general nutrition and weight management services.

  31. Opioid Management • With a team-based approach in a FQHC, a significant decrease in morphine equivalent dose was seen at 3 months. A 45% decrease in morphine equivalent dose was seen in 3 months, and a 0.23 in pain score. This showed that a team-based approach can manage pain with minimal opioids. • With National and State Opioid regulations aplenty, clinical pharmacists have stepped in to assist with the opioid epidemic by helping providers find suitable alternatives, helping patients and providers decrease MMEDs for patients, and offloading providers by assisting with prior authorizations.

  32. Diabetes Management • The mean hemoglobin A1C pre DSME classes was 8.66%, while the hemoglobin A1c post DSME class was 7.58%. The median hemoglobin A1c pre DSME was 8.1%, while the post DSME median was 7.1%. The p-value was statistically significant (<0.05). • Our CDE pool has grown from 1 headcount (an RN) to 2 (an RN and a clinical pharmacist). This team owns the all-important HBA1c >9 performance metric, and has nearly gotten it to goal.

  33. Chronic Care Management • Promoted an LPN to and LPN Care Manager to assist our quality department • Chronic Care Management • Quality metrics with a focus on Medicare Annual Wellness Visits • Also works as an intermediary between the quality department, clinical pharmacy and the health plans

  34. Annual Wellness Visits • Targeted 2 major health plans for a Performance Improvement Project • 445 Patients in one health plan • Outreach to those patients by Sun Life = 100% • 275 of those completed (61.8%) • 170 of those declined • 28 Patients in one health plan • Outreach to those patients by Sun Life = 100% • 15 of those completed (53.6%) • 13 of those declined

  35. Proving Clinical Pharmacy Profitability in the Future • Visits are typically not billed, not a DIRECTLY profitable model currently • How can we bring direct revenue to the program? • Annual Wellness Visits • Requires a provider to assist in the process, but leads to reimbursement plus incentive payments • Chronic Care Management • Clinical Pharmacists can perform CCM services for patients in certain settings • Indirect costs addressed • Provider satisfaction leading to decreased turnover, patient compliance with medications leading to increased incentive payments, compliance with UDS and payor metrics leading to increased incentive payments.

  36. Using Pharmacy Technicians differently • Empowering pharmacy technicians to work to the top of their license • Also to work differently • Pharmacy Operations (Resource) Supervisor • Pharmacy Operations Technician (340B Auditor and Contractor) • Certified Clinical Pharmacy Technician

  37. Collaborative Practice Agreements • Sun Life Pharmacists have initiated collaborative practice agreements/standing orders to assist providers in practice

  38. Developing Smart Business Plans • Get your CFOs on your side… • No matter how much we THINK we change healthcare for the better, where is the money flowing? • Do our changes contribute to direct revenue? • Are you paid for your services? • Can you attribute your interventions to increased prescription count? • Do our changes contribute to indirect revenue? • Are we moving quality metrics and getting paid by health plans even though the visit is not reimbursed?

  39. The In-House Pharmacy Discussion • Do we really need an in-house pharmacy if we capture all of our prescriptions via contract pharmacy? • Do you REALLY capture all scripts? • Medicaid? • Access to care? • Really, this is a WHOLE OTHER conversation for another time.

  40. Fringe Benefits of a Strong Pharmacy Program(A message for CFOs and CEOs in the audience) • Clinical Pharmacists now lead most of our quality measures Performance Improvement Teams • More departments are collaborating within the organization • Integrated Behavioral Health and Pharmacy share an Integrated Services Case Manager • Dental and Pharmacy have an expedited prescription and OTC program • In-House capture rates have increased 4.5% since tracking started (15 months) • Pharmacy is leading organizational initiatives such as customer service, standard operating procedures, and general workflow initiatives (prior authorizations, organization-wide refill practices, six sigma initiatives, etc.)

  41. This Man… • A personal philosophy, and one our department has embraced. • “No Risk It, No Biscuit” • If you don’t take the chances (personnel and clinical program creation), you will never reap the benefits. • Find employees you can TRUST, and let them do their jobs to the top of their license and position • If you cannot trust them to do so, you need to find other people.

  42. Today’s Agenda • An overview of Sun Life • Pharmacy Care Initiatives • Sun Life wellness initiatives that would be impossible without 340B savings • Pharmacy residency program and residency projects • Anticoagulation • Weight management • Opioid management • Diabetes management • Affordable medication program • Chronic care management services and Annual Wellness Visits • Collaborative practice agreements • Developing smart business models around clinical programs • Conclusion

  43. Additional Questions? Matthew Bertsch, PharmD Director of Pharmacy Residency Program Director, PGY1 Community Based Pharmacy Residency Program Sun Life Family Health Center 865 N. Arizola Rd. Casa Grande, AZ 85122 520-252-1308 (mobile number – call or text) matthew.bertsch@slfhc.org

  44. Please do the 1-minute evaluation

  45. General Q&AReminder: Qs submitted in advance get priority.

  46. Other Questions?

  47. Please do the 1-minute evaluation https://www.surveymonkey.com/r/ZVXFWVS

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