1. Pharmacist as Care Extenders in Your Practice
Collaborate with pharmacists to improve patient outcomes Nn
Noble Thomas
Clinical Pharmacist Practitioner

2. Objectives Define, Pharmacist Extender Define the types of Pharmacist
Show the Value of having a Pharmacist Collaborator
Methods and Challenges of adding a pharmacist team member
To Explain Practice Agreements
Understand the role of an Advance Practice Pharmacist
What is the Physician’s responsibility for having a Pharmacist Extender on the team.
How to get paid for services provided

3. physician extender - A Definition
a health care provider who is not a physician but who performs medical activities typically performed by a physician. It is most commonly a nurse practitioner or physician assistant.

4. Integrating pharmacy services into your practice’s offerings can have numerous benefits for patients and providers alike. Providers will have the added support they need to improve adherence, medication reviews and patient understanding. Whether you achieve this by working with a pharmacist, your practice should be able to deliver more effective, higher quality team-based care.

5. Can Pharmacist Benefit My Practice?

6. Is A Pharmacist .. A Pharmacist?

7. What the difference in Pharmacist:
Clinical,
Retail,
Community
Advance Practice Pharmacist
Others

8. Pharmacists may:
optimize drug therapy per protocol
escalating and deescalating therapy
substituting medications with safer and/or less costly alternatives
managing drug interactions
improving patient and team education and medication adherence
perform medication reconciliation for the most challenging patients with multiple co-morbidities.
More ….

9. Pharmacy Education
Physician Education

10. Pharmacy Curriculum
harmacy/pharmD/curriculum.html

11. Physician Curriculum
in/medicine/md/curriculum.html

12. Type of Relations ( not exhaustive)
Embedding
Community Partnering
Hospital
Institutional
Consulting - Long term Care, Office
Clinical Research
Telemedicine
Industry
Others

13. It all starts from - the collaborative practice agreement (CPA)

14. What does it mean to embed a pharmacist?
Embedding a pharmacist means to fully integrate them into the care team. Pharmacists work closely with the physician and other members of the care team and they may also see their own panel of patients.
Clinical pharmacists are trained to help manage chronic diseases, and are experts in medication management and in identifying barriers to medication adherence.

15. University of Michigan Health Services Patient Centered Medical Home (PCMH) pharmacists see on average 13 patients per day, with 45% of these visits occurring in the clinic and 55% in the form of phone consults.

16. Seven steps to integrate pharmacists into your team
Identify the roles pharmacists can play
Decide how your practice can benefit from including a pharmacist
Find your pharmacist match
Prepare and set expectations for your team and patients

17. Seven steps to integrate pharmacists into your team
Determine the resources the pharmacist needs and the impact on the physician’s workflow
Measure impact

18. Identify the roles pharmacists could play
Pharmacists' roles vary in different practices depending on patient type, care team needs, financial considerations and state law requirements.
pre-appointment medication reconciliation for the most complex patients (phone option)
meet with individual patients to provide medication education, address barriers to adherence and answer patient questions
pharmacist may perform medication reviews for high-cost, high-need and/or complex patients,
improve effectiveness, simplify the regimen, manage drug-drug interactions, improve medication safety, cost alternatives
increase or decrease medications according to agreed upon protocols
reference state's Pharmacy Practice Act.

19. When I have a patient with difficult to control diabetes or hypertension, I refer them to our clinical pharmacist. They are able to see the patient frequently, spend more time with them, and motivate them to change the many lifestyle factors that are crucial to managing chronic conditions. It makes my job much easier, and the patients are also very satisfied.
Yeong Kwok, MD •

20. How pharmacist can improve the outcome of individual patients?
Together, physicians and pharmacists can develop protocols to optimize drug therapy to achieve clinical outcomes.
deescalating therapy- which leads to fewer medication interactions and side effects, and can reduce costs and save time.
brown bag medicine reviews,
The pharmacist then goes through the bag and reviews all the medications to identify older and possibly discontinued medications, duplicate therapies, medications filled by another physician that the practice may not have been aware of
adherence - identifying and resolving barriers for patients.

21. How can a pharmacist benefit my practice?
Work with physicians to optimize drug therapy to achieve positive clinical outcomes
Improve patient and care team education
Improve patient medication adherence
Streamline medication reconciliation and refills
Provide effective, higher quality team-based care

22. Tools/Resources available to your practice
Tool for identifying the right pharmacy support
Needs assessment worksheet
Checklist for on-boarding pharmacists
“Meet the Pharmacist” flyer template
Quality opportunities checklist
Pharmacy technician notes template

23. Prepare and set expectation for your team and patients
Designate a physician champion who can explain to the team and other practice leaders the valuable role the pharmacist or pharmacy technician will play to enhance patient care. If you are planning to embed a clinical pharmacist within your practice, explain to the team exactly what this means by clearly defining roles and creating decision trees to lessen confusion and conflict. If you are planning to develop a relationship with a community pharmacist, offer guidance on your approach to sharing medical information and who on the team will be communicating with the community pharmacist about treatment plans.

24. How can I encourage patient to work with pharmacist
Create an introductory letter or biography of the embedded pharmacist to share with patients. Display a picture and description of the pharmacist's services in the practice and/or on your practice's website. A quick "meet and greet" during a patient's visit with a physician can be the most influential approach to encourage patients to work with a new team member. Then, schedule the patient for a separate visit with the pharmacist if needed.

25. Tools/Resources available to your practice
Use the Identifying the right pharmacy support tool and the Needs assessment worksheet to determine which type of pharmacy support role can benefit your practice:
Clinical Pharmacist
Community/Retail Pharmacist
Pharmacy Technician
Advance Practice Pharmacist (APP, CPP in NC)

26. How do decide where to use skills
How visible should he be?
Virtual visits
How many daily visits

27. Reimburse by private payers
Review agreements with payers carefully to determine your options. Commercial health plans that focus on medication adherence and medication reconciliation during transitions of care may provide opportunities to reimburse care management services. Legal and coding specialists should be consulted as well.

28. Incident to” billing
The Centers for Medicare & Medicaid Services (CMS) defines "incident to" services as those services that are furnished incident to physician professional services in the physician's office (whether located in a separate office suite or within an institution) or in a patient's home.9 This gives non-physician practitioners, such as pharmacists, a potential mechanism for billing for their services that relate to the physician's care plan.13
CMS guidance indicates that pharmacists can bill Medicare for services as "incident to" physician services if certain requirements are met. Services must be within the pharmacist's scope of practice as dictated by the state's Pharmacy Practice Act, among other requirements.5,6,9,10 Check with your local CMS carrier for guidance.
Not all commercial health plans will reimburse for "incident to" services, so be sure to check your contracts before attempting to bill.

29. MTM programs are all the same
MTM programs focus on efficacy, safety and cost by improving medication use, reducing the risk of adverse events, preventing drug interactions, improving medication adherence and finding cost-effective treatment regimens. MTM is a covered benefit for all Medicare Part D beneficiaries who meet defined eligibility criteria.7 A pharmacist's services under MTM include annual comprehensive medication review and quarterly targeted medication review.

30. Signing off on Charts and notes
Scope of practice for pharmacists varies by state law and your organization's policies. It is discouraged to establish a precedent where the pharmacist sends the physician all of their notes as this could increase the physician's workload needlessly. Work together for several months and identify the types of notes that should be flagged for a physician's signature or as an FYI. For instance, one practice asked the pharmacist to include one to two lines at the top of a significant note that summarizes the major changes for the physician. This summary captures changes in a patient's condition or the addition of a new medication. Follow this same advice if you are sharing notes with patients by participating in a program such as OpenNotes.

31. incoming request and messages
Decide what types of messages should flow directly into the pharmacist's inbox or in-basket. These could include specific medication questions or problems and general guidance on treatment options. Next, assign the pharmacist to a specific clinician's team pool. The team can redirect those notes that require the pharmacist's attention. Refill requests should go to the team pool in-basket first. The medical assistant assigned to the team pool can then queue up that prescription for the pharmacist to review and approve per the collaborative practice agreement, if applicable under state law. This diverts the refill request from the physician's in-basket to increase efficiency and productivity for the entire team. If your practice has a licensed practical nurse or registered nurse, they may also perform medication refills based on protocol instead of the pharmacist.

32. does physician need to refer to pharmacist?
Nuances of payment often determine who must refer patients to the pharmacist. For example, if you are billing Medicare for the pharmacist's service as "incident to" a physician's service, a physician will have to make the referral.8

33. Measure impact
There are various ways you can measure the impact of embedding a pharmacist or pharmacy technician within your practice. Some suggestions on what to measure include:
• Clinical outcomes, such as improved blood pressure control or decreases in A1c levels for individual patients as well as the population as a whole
• Impact on process metrics for a selected population; for example, improvement in nephropathy screening for patients with diabetes
• Monitoring/documenting medication changes such as adding, discontinuing and adjusting doses of medications
• Improvement in medication adherence measured by self-reporting or pharmacy claims data
• Decrease in medical and pharmacy costs

34. Our on-site pharmacist is an integral part of our efforts to better coordinate and provide continuity of care. The input provided is particularly helpful in the management of our complex patients with multiple chronic conditions.
Mark Fendrick, MD

35. What type of agreement?
If you embed a clinical pharmacist, he or she may work as an independent contractor or an employee. The type of relationship the clinical pharmacist has with your practice will be outlined in the formal agreement between the two parties. These agreements need to comply with all federal and state laws and be drafted by competent legal counsel. If your practice is part of a larger organization, it is best to coordinate through the overarching administration.

36. Re-organize clinic for pharmacist?
You don't have to overhaul your space when you embed a pharmacist. All they need is a private space with a desk, a phone and an exam room. The pharmacist can take advantage of any open exam room that gives privacy. They will need access to a computer in the exam room as well as common equipment such as blood pressure monitors. The pharmacist or pharmacy technician should be co-located with other team members and attend the daily huddle.

37. How is it working at other practices?
Northville, MI
Ann Arbor, MI
Milwaukee, WI
Steps in Practice Summary = Location Featured Here
Summarize the description of the steps in practice section in a bulleted format
Keep it concise and straight to the point
Think about what information would be helpful to a practice manager that is presenting this information
Review other module pitch decks for examples

38. The Asheville Project: Short-term outcomes of a community pharmacy diabetes care program
Objectives:
To assess short-term clinical, economic, and humanistic outcomes of pharmaceutical care services (PCS) for patients with diabetes in community pharmacies
Design:
Intention-to-treat, pre–post cohort-with-comparison group study.
Setting:
Twelve community pharmacies in Asheville, N.C.
Patients and Other Participants:
Eighty-five patients with diabetes who were employees, dependents, or retirees from two self-insured employers; community pharmacists who completed a diabetes certificate program and received reimbursement for PCS.
Interventions:
Patients scheduled consultations with pharmacists over 7 to 9 months. Pharmacists provided education, self-monitored blood glucose (SMBG) meter training, clinical assessment, patient monitoring, follow-up, and referral. Group 1 patients began receiving PCS in March 1997, and group 2 patients began in March 1999.
Main Outcome Measures:
Change from baseline in the two employer groups in glycosylated hemoglobin (A1c) values, serum lipid concentrations, health-related quality of life (HRQOL), satisfaction with pharmacy services, and health care utilization and costs.

39. The Asheville Project: Short-term outcomes of a community pharmacy diabetes care program
Results: Patients used SMBG meters at home, stored all readings, and brought their meters with them to 87% of the 317 PCS visits (3.7 visits per patient). Patients‘ A1c concentrations were significantly reduced, and their satisfaction with pharmacy services improved significantly. Patients experienced no change in HRQOL. From the payers’ perspective, there was a significant $52 per patient per month increase in diabetes costs for both groups, with PCS fees and diabetes prescriptions accounting for most of the increase. In contrast, both groups experienced a nonsignificant but economically important 29% decrease in non-diabetes costs and a 16% decrease in all-diagnosis costs
Conclusion:
A clear temporal relationship was found between PCS and improved A1c, improved patient satisfaction with pharmacy services, and decreased all-diagnosis costs. Findings from this study demonstrate that pharmacists provided effective cognitive services and refute the idea that pharmacists must be certified diabetes educators to help patients with diabetes improve clinical outcomes.

40. Conclusion:
A clear temporal relationship was found between PCS and improved A1c, improved patient satisfaction with pharmacy services, and decreased all-diagnosis costs. Findings from this study demonstrate that pharmacists provided effective cognitive services and refute the idea that pharmacists must be certified diabetes educators to help patients with diabetes improve clinical outcomes
Journal of the American Pharmacists Association
Volume 52, Issue 6, November–December 2012, Pages , ,

41. Utilization of Collaborative Practice Agreements between Physicians and Pharmacists as a Mechanism to Increase Capacity to Care for Hematopoietic Stem Cell Transplant Recipients
Biol Blood Marrow Transplant Apr; 19(4): 509–518.
Survival following hematopoietic stem cell transplantation (HSCT) has improved and the number of allogeneic HSCTs performed annually in the United States is expected to reach 10,000 by The National Marrow Donor Program created the System Capacity Initiative to formulate mechanisms to care for the growing number of HSCT recipients. One proposed method to increase capacity is utilization of pharmacists to manage drug therapy via collaborative practice agreements (CPAs). Pharmacists have managed drug therapy in oncology patients with CPAs for decades; however, there are limited HSCT centers that employ this practice. Engaging in collaborative practice and billing agreements with credentialed pharmacists to manage therapeutic drug monitoring, chronic medical conditions and supportive care in HSCT recipients may be cost-effective and enable physicians to spend more time on new or more complex patients. The goal of this paper is to provide a framework for implementation of a CPA and address how it may improve HSCT program capacity.

42. Positive Impact of a Pilot Pharmacist-Run Diabetes Pharmacotherapy Clinic in Solid-Organ Transplant Recipients
David M. Newland, Angelina R. Edwards, Reed C. Hall, Pamela R. Maxwell
Diabetes Spectr May; 31(2): 167–176. doi:  /ds

43. Adherence to Oral Anticancer Medications: Evolving Interprofessional Roles and Pharmacist Workforce Considerations
Pharmacy (Basel) Mar; 6(1): 23.
To help meet patient demand, the oncology pharmacist workforce needs to help educate non-specialist pharmacists and other healthcare professionals. Oncology pharmacists should collaborate and share information with others involved in providing oncology care to patients, such as pharmacists practicing in specialty clinics. In conclusion, oncology pharmacists have an increased role in interdisciplinary patient care, patient care management, educational intervention and counseling for patients, and information provision to other healthcare professionals.

44. Our on-site pharmacist is an integral part of our efforts to better coordinate and provide continuity of care. The input provided is particularly helpful in the management of our complex patients with multiple chronic conditions. “ ”
Mark Fendrick, MD
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45. Questions ?

46. Can I created a collaborative practice agreement for escalating therapy?

47. Yes

48. Can a pharmacist help my patient with uncontrolled hypertension?

49. Yes
A pharmacist can teach a patient how to monitor their blood pressure at home and promote medication adherence. If collaborative agreements are allowed by state law, they may be able to adjust therapy to achieve blood pressure goals.

50. How can pharmacist help my patients with diabetes?
Physicians may find it helpful to co-manage certain patients with a pharmacist, such as patients with diabetes. For example, pharmacists can provide education, optimize lifestyle choices and titrate medication doses by protocol based on home glucose readings for patients on insulin. Some practices have found that A1c levels improve in co-managed patients.

51. How can pharmacist help educate my care team?
By being on site, the pharmacist can serve as a resource to the entire care team by providing updates regarding new medications, generic availability, guideline updates or other prescribing information. The pharmacist can inform the team about medications that are no longer recommended for geriatric patients or point out medications within a therapeutic class that are now available as generics.

52. Our clinical pharmacist is a great help in sorting out how my elderly patients are setting up and taking their medications. They have the time to sort through pill bottles. They can discard expired meds, or meds no longer prescribed. They can advise on medications that may be discontinued or consolidated when there is poly-pharmacy. They can give me insight into whether a patient may be too impaired to safely manage their own medications.
Christa Williams, MD

53. Advance Practice Pharmacist

54. CLINICAL PHARMACIST PRACTITIONER
"CPP Agreement" means a written agreement between the CPP, Primary Supervising Physician and any Back-Up Supervising Physician by which the Supervising Physician(s) have provided written instructions to the CPP for patient- specific and disease-specific drug therapy, which may include ordering, changing, or substituting therapies or ordering tests.

55. All certificate programs must contain a core curriculum, including the following components:

56. . designing, implementing, monitoring, evaluating, and modifying or recommending modifications in drug therapy to insure effective, safe, and economical patient care;

57. . identifying, assessing, and solving medication- related problems and providing a clinical judgment as to the continuing effectiveness of individualized therapeutic plans and intended therapeutic outcomes;

58. . conducting physical assessments, evaluating patient problems, and ordering and monitoring medications and laboratory tests;

59. . administering medications;
. referring patients to other health professionals as appropriate;
. administering medications;
integrating relevant diet, nutritional, and non-drug therapy with pharmaceutical care

60. providing emergency first care
using clinical data to optimize therapeutic drug regimens; .
 collaborating with other health professionals;
documenting interventions and evaluating pharmaceutical care outcomes;
integrating pharmacy practice within healthcare environments;
integrating national standards for the quality of healthcare; and
conducting outcomes and other research.

61. A Supervising Physician who has a CPP Agreement with a CPP shall:
be readily available for consultation with the
keep meeting requirements
review each order written by the CPP.

62. Thank You

63. Noble Thomas R.Ph, CPP