1. Principles for Incorporating Pharmacists in Team-based Care through Collaborative Practice Agreements
CDC Presentation
January 7, 2014
Benjamin M. Bluml, RPh
Senior Vice President,
Research and Innovation

2. The APhA Foundation Mission
“To improve people’s health through pharmacists’ patient care services.”
Designing innovative solutions for health care delivery…
Research
Recognition
Resources
7-Jan-14
Copyright © 2014, APhA Foundation.

3. APhA Foundation Activities
National Demonstration Projects
Health promotion / disease prevention
Health management programs
Public Education
Responsible medication use
Privacy, confidentiality, security
Quality Improvement
Pinnacle Awards
Advanced Practice Institute
Research
Practice-based research
Original scientific research
Incentive grant programs
7-Jan-14
Copyright © 2014, APhA Foundation.

4. Copyright © 2014, APhA Foundation.
Where we’re going…
Empowered patients
Increased collaboration
Enhanced safety
Improved outcomes
Reduced costs
“The best way to predict the future
is to invent it.” Alan Kay
7-Jan-14
Copyright © 2014, APhA Foundation.

5. What’s the best way to get there?
Put patients first
Optimize medication use
Improve communication
Manage information
Increase collaboration
“Interdisciplinary care is the best way to invent a preferred future for health care.”
7-Jan-14
Copyright © 2014, APhA Foundation.

6. National Distribution of Provider Groups
Source: JAPhA 1999; 39: * HPSA: Health Provider Shortage Area

7. Key Forces Defining Practice
Aging population
Increase in new prescription medications & volume
Greater demand for patient care
Expansion in community pharmacy
Movement of Rx products to OTC
Pharmacoinformatics
Pharmacogenomics
Nanotechnology and molecular machines
Broad Scope of Pharmacy Practice
7-Jan-14
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8. Creating the Basis for a Preferred Future…
7-Jan-14
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9. Our Research and Innovation Continuum
Convene
Pilot
Scaled Demonstration
IMProving
America’s
Communities
Together
Continuous Quality Improvement
Model Refinement
National Implementation
Model Development
Assess
… “Incubating Care Innovation”
Idea
7-Jan-14
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10. Copyright © 2014, APhA Foundation.
Convene
: Consensus Definition of MTM
: Depression Coordinating Council
: Alzheimer’s Coordinating Council
: COPD Roundtable
: Committee to Advance Pharmacogenomics in Pharmacy Practice
: Collaborative Practice Agreement Consortium
: Innovative and Appointment-based Adherence Model Consortium
7-Jan-14
Copyright © 2014, APhA Foundation.

11. Copyright © 2014, APhA Foundation.
Research
: Project ImPACT: Hyperlipidemia
: The Asheville Project publication
: Project ImPACT: Osteoporosis
: Patient Self-Management Program for Diabetes
: Diabetes Ten City Challenge
: Project ImPACT: Depression
: Alzheimer’s Screening Project
: Project ImPACT: Hypertension
: Project IMPACT: Diabetes
7-Jan-14
Copyright © 2014, APhA Foundation.

12. Copyright © 2014, APhA Foundation.
Applied Innovation
: People’s Pharmacy School
: Collaborative Practice Agreements Translational Tools
: Innovative and Appointment-based Adherence Model Translational Tool
: Diabetes Patient Credentialing
Strategic Plan
Project IMPACT Diabetes Diffusion
Data Management and Reporting Tool
Sustaining Research Projects through Programs
Partnering with APhA and Others for Broad Distribution
7-Jan-14
Copyright © 2014, APhA Foundation.

13. Copyright © 2014, APhA Foundation.
Demonstrated Outcomes (see APhA Foundation Research and innovation Summary)
Process of Care Models that Improve Outcomes
Adherence
Alzheimer’s
Diabetes
Depression
Economic Savings (per patient per year):
The Asheville Project: $1,622 - $3,356
Patient Self-Management Program: $918
Diabetes Ten City Challenge: $1,079
Project ImPACT: Depression: $983
Hyperlipidemia
Hypertension
Osteoporosis
7-Jan-14
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14. Copyright © 2014, APhA Foundation.
Demonstrated Outcomes (see APhA Foundation Research and innovation Summary)
Clinical Improvements – Diabetes Examples
Measure
HEDIS (2007)
PSMP (2003)
DTCC (2007)
A1c Testing
88%
100%
97%
A1c Control
(A1c < 9)
71%
94%
91%
Lipid Profile
84%
92%
Lipid Control
(LDL-C < 100)
44%
49%
63%
Eye Exams
55%
82%
81%
Flu Shots
77%
65%
7-Jan-14
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15. Copyright © 2014, APhA Foundation.
Building the Evidence (see APhA Foundation Research and innovation Summary)
Asheville
Started in 1997, 1 geographic area, 2 employers
Patient Self-Management Program
2002 to 2005, 5 geographic areas, 9 employers
Diabetes Ten City Challenge
2006 to 2008, 10 geographic areas, 29 employers
Project IMPACT: Diabetes
Presently, 25 geographic areas, disproportionately affected populations
Framework for spread – 2013 and beyond…
7-Jan-14
Copyright © 2014, APhA Foundation.

16. Advancing Service Delivery in Pharmacy Practice…
Health Promotion
Health Risk Assessment
Immunizations
Oral Health
Wellness Programs
Health Management
Asthma
Cardiovascular Disease (Dyslipidemia, Hypertension)
Coagulation Disorders
Congestive Heart Failure
Depression
Diabetes
Osteoporosis
…all with MTM
Selection Criteria:
- High prevalence
- High risk
- High cost
- Problem prone
7-Jan-14
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17. Medication Therapy Management
MTM Definition
A distinct service or group of services that optimize therapeutic outcomes for individual patients
MTM Core Elements
Medication Therapy Review (MTR)
Personal Medication Record (PMR)
Medication-related Action Plan (MAP)
Intervention and/or referral
Documentation and follow-up
Payment for MTM Services
CPT Codes: , 99606, 99607
7-Jan-14
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18. CDC/APhA Foundation Collaboration Primary Goal and Key Objectives
Goal – Create effective principles and translational tools to expand the implementation of innovative practice models whose success has been demonstrated
Project Objectives:
Convene Consortium
Bring key thought leaders together for informed dialog
Draft Model Language
Develop consensus on model principles and language
Create Translational Tools
Enhance implementation of model policy by targeted audiences
Strategic Outreach to Key Stakeholders
Distribution of model policy and translational tools nationwide
7-Jan-14
Copyright © 2014, APhA Foundation.

19. Consortium Convened (January 10-11, 2012 – Washington, DC)
John Beckner (Martin’s)
Marialice Bennett (OSU)
Ernest Boyd (OPA)
Laura Cole (St. Vincent’s)
Christopher DuPaul (CVS)
Scott Giberson (USPHS)
Anita Glicken (UC Denver)
Doug Hillblom (Optum)
Michael Hogue (Samford)
Daniel Luce (Walgreens)
J. Paul Martin (Asheville)
John O’Brien (CMS)
George Oestreich (MO)
N. Lee Rucker (AARP)
Steve Simenson (Goodrich)
Rebecca Snead (NASPA)
Margie Snyder (Purdue)
E. Kim Swiger (Mirixa)
Troy Trygstad (CCNC)
Sandra Leal* (El-Rio)
Jeffrey Kelman* (CMS)
Kristen Betts (CDC)
Siobhan Gilchrist (CDC)
Dyann Matson Koffman (CDC)
Marcie Bough (APhA)
Anne Burns (APhA)
Elizabeth Keyes (APhA)
James Owen (APhA)
Mindy Smith (APhA Foundation)
Lindsay Watson (APhA Foundation)
Benjamin Bluml (APhA Foundation)
* Unable to attend in person
12 States, 10 practice setting types; Pharmacy, Medicine, and Nursing represented
7-Jan-14
Copyright © 2014, APhA Foundation.

20. Consortium Meeting (January 10-11, 2012 – Washington, DC)
Stakeholder consensus on enabling spread of Collaborative Practice and MTM across U.S.
Meeting Activities:
Assemble key thought leaders for informed dialog
Capture successful aspects of innovative practice
Identify key challenges faced in implementation
Understand current legislation and State level policy
Create a wish list for inventing a preferred future
Identify key concepts/principles of empowerment
7-Jan-14
Copyright © 2014, APhA Foundation.

21. Copyright © 2014, APhA Foundation.
Climate for Change
Healthcare environment in the United States is undergoing unprecedented change…
Myriad of healthcare reform initiatives
Mounting evidence for the positive contributions of pharmacists
Federal government interest in pharmacist-provided services
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Surgeon General
Pharmacists are a dramatically underused resource that could help improve outcomes within our healthcare delivery system, if properly engaged as essential members of the healthcare team.
7-Jan-14
Copyright © 2014, APhA Foundation.

22. American Public Health Association Meeting – October 12, 2012
7-Jan-14
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23. Copyright © 2014, APhA Foundation.
Consensus
Seven key themes identified for successfully implementing and creating infrastructure for empowering collaborative, interdisciplinary care
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

24. Pharmacists’ Patient Care Services
Include the broad array of services that every pharmacist can provide based on their scope of practice, local privileges, and practice setting
Can include patient care services such as medication review, lab interpretation, disease screening, patient assessment and counseling, continuity of care, medication reconciliation, and referral as well as selecting, initiating, administering, monitoring, modifying, or discontinuing medication therapy
Exact scope of what pharmacists’ patient care services can encompass depends on each state’s practice act; therefore, initiating, modifying, or discontinuing medication therapy may be pursuant to physician authorization or the use of collaborative practice agreements
7-Jan-14
Copyright © 2014, APhA Foundation.

25. Collaborative Practice Agreements
Used to create formal relationships between pharmacists and physicians or other providers
Define certain patient care functions that a pharmacist can autonomously provide under specified situations and conditions
Many are used to expand the depth and breadth of services the pharmacist can provide to patients and the health care team
When a CPA is in place, a licensed health care provider makes a diagnosis, maintains ongoing supervision of patient care, and refers the patient to a pharmacist to provide patient care functions as authorized by the provider
These functions can include any or all of the pharmacists’ patient care services described above
Note: CPAs are not required for pharmacists to perform many patient care services (e.g., medication reviews, patient education and counseling, disease screening, referral).
7-Jan-14
Copyright © 2014, APhA Foundation.

26. Consensus Recommendation 1
Use consistent terminology and language that is readily understandable by all potential audiences.
General public (patients)
Providers (e.g., physicians, pharmacists, nurse practitioners, physician assistants)
Potential payers (e.g., federal, state, private insurers, self-insured employers)
Policy makers (e.g., state and federal representatives and senators, health affairs staff)
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

27. Consensus Recommendation 2
Allow health care providers who enter into the CPA to define the details of each agreement
Should be written, executed, reviewed, and renewed on terms set by the collaborating health professionals
Success centers on demonstrated competence, local relationships, and levels of trust among providers
Support for each provider to practice to the fullest extent of their license within the context of CPAs
Legislative or regulatory changes may be needed to allow these broad, unrestricted CPAs to exist or be fully implemented
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

28. Consensus Recommendation 3
Create and expand an infrastructure that embeds pharmacists’ patient care services and CPAs into care, while creating ease of access for patients
Two key components needed:
Infrastructure that embeds pharmacists’ patient care services into current care processes
Public education to help patients understand the services to which they will have access
Services need to be scalable, sustainable, and financially viable to properly optimize outcomes
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

29. Consensus Recommendation 4
Incentivize and facilitate the adoption of electronic health records and the use of technology in pharmacists’ patient care services
Effective services and CPAs are highly dependent on multidirectional sharing of information among the team
Interoperable systems must be integrated into current platforms to enable sending and receiving patient information, care notes, intervention records, lab and assessment values.
Adopting standards such as HL7 will provide a solid framework for exchange, integration, and sharing
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

30. Consensus Recommendation 5
Encourage pharmacists to maintain strong, trusting, and mutually beneficial relationships with patients, physicians, other providers; encourage those individuals to promote pharmacists’ patient care services
Local relationships and engagement in pharmacists’ patient care services creates understanding
People outside of pharmacy can serve as powerful advocates to help policy makers and others understand the value of CPAs and pharmacists’ patient care services (e.g., VA, TX, AL, OH)
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

31. Consensus Recommendation 6
Properly align incentives based on meaningful process and outcome measures for patients, payers, providers, and the health care system.
A combination of both process and outcome measures are essential for effective patient-centered, team-based care and properly aligned incentives for all stakeholders
Collaborative, interdisciplinary care that includes pharmacists’ patient care services has been proven to consistently lead to improved outcomes and controlled total costs for care over time
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

32. Consensus Recommendation 7
Examine and redesign health professionals’ practice acts, education curriculums, and operational policies to create synergy, promote collaboration and optimize support staff
One of the best ways to optimize the role of all providers on the health care team is for various health professions to simultaneously and collaboratively examine and revise their practice acts, emulating others that have worked well
CPAs that create interdisciplinary teams where each professional is practicing at the top of his/her license, and support staff is enabled to take on more roles as appropriate are essential for success
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

33. Copyright © 2014, APhA Foundation.
Compelling Evidence
Systematic review and meta-analysis1:
Pharmacist engagement in interdisciplinary health care with physicians and other providers can improve patients’ health considerably
Surgeon General 9-Jan-12 Report2:
Recognition of pharmacists as health care providers, clinicians and an essential part of the health care team
Provides the evidence health leaders and policy makers need to support evidence-based models of cost-effective patient care that utilizes…our nation’s pharmacists…
Access to U.S. Population2:
More than 60,000 community-based pharmacies employ greater than 175,000 pharmacists across the United States.
1 Med Care. 2010;48(10):
2 J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
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34. Copyright © 2014, APhA Foundation.
Conclusion
Pharmacists deliver many patient care services to sustain and improve health.
In an era of health care reform, advancing the level and scope of pharmacy practice holds promise to improve health and reduce costs for care.
Published evidence supports the role of pharmacists as essential members of the interdisciplinary health care team and emphasizes that pharmacists are well positioned to perform medication- and wellness-related interventions that improve patient outcomes.
The consortium participants’ seven recommendations provide methods and infrastructure for empowering collaborative, interdisciplinary care.
J Am Pharm Assoc. 2013;53:e132–e141.
7-Jan-14
Copyright © 2014, APhA Foundation.

35. Copyright © 2014, APhA Foundation.
Translational Tools
The APhA Foundation worked in partnership with representatives from the CDC Division of Heart Disease and Stroke Prevention to take the key recommendations from and develop an easy-to-understand tool kit for four target audiences (published by the CDC):
Resources for Pharmacists
Resources for Nurses, Physicians Assistants, and Other Providers
Resources for Government and Private Payers
Resources for Decision Makers
7-Jan-14
Copyright © 2014, APhA Foundation.

36. Looking Into the Crystal Ball…
Pharmacist Outreach Project
Collaborative Practice Principles
Case Studies in Patient Care
Million Hearts Campaign
CMS Health Care Innovation Awards
IMPACT Translation…
7-Jan-14
Copyright © 2014, APhA Foundation.

37. Inventing a Preferred Future…
Patient Access to
Needed Medications
& Pharmacy Services
Interoperability of
Pharmacy & Health
Information Technology
Medication Use
Quality & Safety
Align the Incentives, Improve the Outcomes, Control the CostsTM
7-Jan-14
Copyright © 2014, APhA Foundation. 37

38. Health Care Delivery Collaborations Common Goals to...
Improve patient care
Increase communication between and among patients / providers
Increase availability of objective measures
Reduce total cost for care over time
“Collaborate with your pharmacist to invent a preferred future.”
- Benjamin Bluml, RPh
7-Jan-14
Copyright © 2014, APhA Foundation. 38