h1b friday october 16, 2015 impact of clinical pharmacist and health psychologist on integrated team...

H1b Friday October 16, 2015Impact of Clinical Pharmacist and Health Psychologist on Integrated Team Based Care: Transforming the System and Patient Care Experience to a Higher Level

Anne Van Dyke, Ph.D., ABPPElena Kline, PharmD

Lori Lackman-Zeman, Ph.D.Paul Misch, M.D.

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe the roles of clinical pharmacists and health psychologists on the integrated care team

• List the areas of patient and provider satisfaction associated with having clinical pharmacists and health psychologists as part of the IC team

• Describe process of doing a cost savings analysis to support adding a clinical pharmacist to your team

• Identify the steps to implement system change which paves the way for sustainable IC team based care

Bibliography/References

1. Croghan TW, Brown JD. (2010). Integrating mental health treatment into the patient centered medical home. AHRQ Publication No. 10-0084-EF. Rockville, MD: U.S. Department of Health and Human Services

2. Mountainview Consulting Group (2013). Primary Care Behavioral Health Toolkit. pcpci.org.

3. Park I, Sutherland SE, Ray L, Wilson CG. (2014). Financial implications of pharmacist-led Medicare annual wellness visits.

Journal of the American Pharmacists Association, Jul-Aug; 54(4):435- 40. doi:10.1331/JAPhA.2014.13234.

Bibliography/References4. Patterson BJ, Solimeo SL, Stewart KR, Rosenthal GE, Kaboli J, Lund BC.

(2015). Perceptions of pharmacists’ integration into patient-centered medical home teams. Research in Social and Administrative Pharmacy, Jan-Feb; 11(1):85-89. doi:10.1016/j.sapharm.2014.05.005. Epub 2014 May 29.

5. Peek CJ, Cohen DJ, deGruy III FV. (2014). Research and evaluation in the transformation of primary care. American Psychologist, 69

(4), 430- 442.

6. Peikes DN, Reid RJ, Day TJ, Cornwell DD, Dale SB, Baron RJ, Brown RS, Shapiro RJ. (2014). Staffing patterns of primary care practices in

the comprehensive primary care initiative. The Annals of Family Medicine, Mar-Apr;12(2):142- 9.doi:10.1370/afm.1626.

Learning Assessment

• A learning assessment is required for CE credit

• A question and answer period will be conducted at the end of this presentation

• Beaumont Health is an 8 Hospital System in SE Michigan

• Beaumont – Troy ~500 bed hospital

• OUWB New Medical School • Family Medicine Residency

Program– 14 faculty (MD & DO)– 24 residents– 1 Physician’s Assistant (PA)– 35,000 patient visits / year

Who We Are: Beaumont Family Medicine

The Integrated Care Team:• Faculty Physicians• Residents / Medical

students• Medical Assistants / Nurses• Health Psychologists• Health Psychology Doctoral

Students• Clinical Pharmacist (Pharm-D)

Who We Are: Beaumont Family Medicine

Integrated Care Team

• Flinn Foundation Grant 2015

• Goal: collaboration with physician in addressing medication and behavioral health issues for whole-person care

• Primary “customer” is the physician

• Secondary “customer” is the physician’s patient

• Health Psychologist– Addresses:

mental health and substance abuse issues health behavior and lifestyle change crisis intervention

– Employs MI and CBT– Uses handouts, CDs, website resources


• Clinical Pharmacist– Medication reconciliation

Identify discrepancies Provide patient-friendly medication lists

– Medication adherence Identify barriers Assistance programs

– Medication management Optimize dosing, monitor interactions,

adjust for renal dysfunction, etc.– Patient education– Resident/attending education


Clinical Pharmacist

• Increasing role with psychotropic meds

– Shortage of outpatient psychiatrists with fewer medical students going into psychiatry

– Patient insurance not always accepted by psychiatrists

Enhancing Knowledge on Psychiatric Medications

• Review guidelines• Keep up with available literature• Participate in webinars/continuing education• Reach out to experts in the field• Follow-up with patients/residents after making recommendation

to analyze progress

Logistics of IC Services

• Physician request during patient’s medical visit

• Pharmacist & health psychologist offer IC during precepting (at time of huddle & throughout patient care half day)

• Anyone on the IC team can identify possible patients from daily schedule

Logistics of IC Services

• 5 to 25 minutes spent during the medical visit• Patients can return up to 3 times for 30 min f/u IC visit• “Real time” collaboration with physicians • Chart note in EHR routed to physician

– Reason patient seen– Clinical assessment of problem (beyond listing of symptoms)– Intervention with patient response as applicable– Recommendations and/or follow-up plan

Physician Survey: Barriers to Using IC Services

• Adapted from "PRIMARY CARE BEHAVIORAL HEALTH TOOL KIT” – pcpci.org

• Participation rate– n=31 (86%), 100% of faculty, 80% of residents

• Wide variability between physicians as to which items were frequently and never a barrier

• Presented survey results during noon lecture– Physicians shared strategies with each other– Generated process improvement ideas

Physician Survey: Barriers to Using IC Services(% who thought item was sometimes, frequently or very frequently a barrier)

• IC providers are part-time, I don’t know when they are here = 79% (31% very frequently)

• I forget by the end of the visit = 59%• Patient refused to see the IC provider = 55%• I don’t have time to talk to the patient about our IC services =

55%• Patient is already seeing a therapist who should be addressing

everything = 52%• Not sure how to arrange same-day visits with the IC providers

= 48%

Physician Satisfaction (n=31)

• How helpful are the IC services for your patients? (1 = low, 10 = high)– mean = 7.4– Range = 2 to 10

• How helpful are the IC services to you (i.e., helps you better serve patients)?– mean = 7.4– Range = 2 to 10

• Feedback on how to improve IC services:– Improve logistics– Provide more feedback to physicians

Process Improvements as a Result of Survey Discussion

• Increased coverage to all 10 half-day sessions• Posted IC schedule and daily changes• Increased presence during precepting• Identifying potential IC patients at beginning of session• Put up flyers about IC in exam room and lobby• Route EHR notes to physicians involved• System to identify where IC providers are• Provide more information about types of services IC can

provide

IC Primary Care Intervention GuideCONCERNS SAMPLE INTERVENTIONS

Mental Health Disorders (depression, anxiety/panic, bipolar, ADHD, anorexia, etc.)

Diagnostic assessmentCognitive Behavioral Therapy

Mindfulness Meditation

Sub-clinical emotional symptoms (sadness, worry, anger, guilt, coping with stress, etc.)

Relaxation techniquesBehavioral activation

Mindfulness Meditation

Child behavior, Family, and/or Marital problems

Parenting skillsBehavior Change Strategies

Abuse/neglect/violence/bullying Safety Plan

Difficulties in school/occupational/activities of daily living functioning

Memory assessment

Sleep difficulties, including chronic insomnia

Relaxation techniquesSleep Hygiene Strategies

Clinical Measures

• Software utilized to:

– Determine potential cost-savings associated with pharmacist interventions

– Track psychology interventions

Clinical Pharmacist: Types of InterventionsInterventions

Major Category Sub-Category

Allergy Prevented Minor Prevention

Appropriate Therapy Additional Drug Required Appropriate Labs Recommended

No Drug Ordered No Indication

Pt On Drug Recently

Chart Review ADR Chart Review Medication Review

Contraindication ADR Prevention (Minor) Pregnancy

ADR Prevention (Major)

Dosing Issues Anticoagulant Dose (Initial) Anticoagulant Dose Adjustment (f/u)

Dose Adjustment (Other) No Route

Therapeutic Recommendation Wrong Interval/Rate

Drug Interaction DI (Major) DI (Minor)

Duplicate Therapy Pt on Drug in Same Class

Other DI Consult Other

Pt education

Total Clinical Pharmacist Interventions

Clinical Pharmacist

February 18th – September 12th (4 half days/week)

425 Interventions

% of Total Interventions/CategoryAllergy Prevented

0.5%

Appro-priate

Therapy16%

Chart Review16%

Con-traindica-

tion3%

Dosing Issues26%

Drug In-teraction

2%

Duplicate Therapy

0.5%

Other36%

Clinical Pharmacist

Intervention ProgressionFeb(start 2/18)

March April May June July August Sept(end 9/12)

Total 10 64 62 62 36 76 71 44

Psych Med Mgmt (%)

4(40%)

28(44%)

26(42%)

22(35%)

13(36%)

26(34%)

25(35%)

16 (36%)

PainMgmt (%)

2(20%)

7(11%)

5(8%)

5(8%)

0(0%)

6(8%)

5(7%)

1 (2%)

CombinedTotal (%)

6(60%)

35(55%)

31(50%)

27(44%)

13(36%)

32 (42%)

30(42%)

17(39%)

Clinical Pharmacist

Intervention ProgressionFeb(start 2/18)

March April May June July August Sept(end 9/12)

Total 10 64 62 62 36 76 71 44

Psych Med Mgmt (%)

4(40%)

28(44%)

26(42%)

22(35%)

13(36%)

26(34%)

25(35%)

16 (36%)

Pain Mgmt (%)

2(20%)

7(11%)

5(8%)

5(8%)

0(0%)

6(8%)

5(7%)

1 (2%)

Combined Total (%)

6(60%)

35(55%)

31(50%)

27(44%)

13(36%)

32 (42%)

30(42%)

17(39%)

Clinical Pharmacist

Mental Health & Pain InterventionsType of Intervention # of Interventions % of Total

InterventionsPsych Med Management 160/425 38%

Type of Intervention # of Interventions % of Total Interventions

Pain Management 31/425 7%

Combined Mental Health & Pain Interventions

191/425 45%

Clinical Pharmacist

Projected Cost Savings by CategoryInterventions

Major Category Sub-Category # of Interventions Savings/Intvn Total Cost Savings

Allergy Prevented Minor Prevention 1 $18 $18

Appropriate Therapy Additional Drug Required

48 $5332 $255,936

Appropriate Labs Recommended

10 $1112 $11,120

No Drug Ordered 2 $5332 $10,664

No Indication 5 $892 $4,460

Pt On Drug Recently 3 $136 $408

Chart Review ADR Chart Review 5 $67 $335

Medication Review 65 $67 $4,335

Contraindication ADR Prevention (Minor)

2 $18 $834


9 $417 $162

Pregnancy 1 $117 $117

Clinical Pharmacist



Dosing Issues Anticoagulant Dose (Initial)

2 $700 $1,400

Anticoagulant Dose Adjustment (f/u)

6 $700 $4,200

Dose Adjustment (Other)

35 $1717 $60,095

No Route 3 $12 $36

Therapeutic Recommendation

63 $67 $4,221

Wrong Interval/Rate 2 $700 $1,400

Drug Interaction DI (Major) 4 $356 $1,424

DI (Minor) 3 $99 $297


3 $700 $2,100

Other DI Consult 60 $51 $3,060

Other 20 $0 $0

Pt education 75 $0 $0

Clinical Pharmacist



Allergy Prevented Minor Prevention 1 $18 $18

Appropriate Therapy Additional Drug Required

48 $5332 $255,936

Appropriate Labs Recommended

10 $1112 $11,120

No Drug Ordered 2 $5332 $10,664

No Indication 5 $892 $4,460

Pt On Drug Recently 3 $136 $408

Chart Review ADR Chart Review 5 $67 $335

Medication Review 65 $67 $4,335

Contraindication ADR Prevention (Minor)

2 $18 $834


9 $417 $162

Pregnancy 1 $117 $117

Clinical Pharmacist



Dosing Issues Anticoagulant Dose (Initial)

2 $700 $1,400

Anticoagulant Dose Adjustment (f/u)

6 $700 $4,200

Dose Adjustment (Other)

35 $1717 $60,095

No Route 3 $12 $36

Therapeutic Recommendation

63 $67 $4,221

Wrong Interval/Rate 2 $700 $1,400

Drug Interaction DI (Major) 4 $356 $1,424

DI (Minor) 3 $99 $297


3 $700 $2,100

Other DI Consult 60 $51 $3,060

Other 20 $0 $0

Pt education 75 $0 $0

Clinical Pharmacist

Projected Cost Savings: Overall

February 18th – September 12th (4 half days/week)

$366,622.00

Clinical Pharmacist

Patient Surveys, n=319(administered anonymously after each contact)

• During my visit today we talked about things that are important to me = 4.71 (1=strongly disagree, 5=strongly agree)

• Today I learned at least one skill to help me manage my problems or concerns = 4.37

• I plan to do at least one thing differently based on what I learned today = 4.34

• 96.9% listed at least one thing they planned on doing differently or one skill they planned on using– Average confidence rating = 2.62 (1=not confident, 3=very

confident)

• Phase 1: Approval (Do your homework)– Clarify purpose and desired measurable

outcomes– Identify Stakeholders (WIFM)– Be armed with data

• Phase 2: Roll Out & Implementation– Communication (x10)– Education, coaching & support

• Phase 3: On-going Evaluation & Adjustments– Plan-Do-Check-Act Cycle– Aligned incentives

Strategies for System ChangeTo Implement & Sustain Integrated Team Based Care

Culture vs. Strategy

Culture Strategy Why Culture Wins and Eats Strategy

Emotional LogicalEmotions have the

potential to overpower rational thinking

Based on the Past Based on the FutureMost people make

decision based on past experience

People Driven Business Driven Most people tend to do what is best for them

Sustainability

Peak Performing Organizations Got There By Applying Five Principles:

1. Match strategy and culture…as culture trumps strategy every time

2. Focus on a few critical shifts in behavior…change is hard, so you need to choose your battles

3. Honor the strengths of your existing culture…so major change feels more like a shared evolution vs. a top-down imposition

*Harvard Business Review, “Culture Change that Sticks” by Booz & Co. execs Jon Katzenback, Ilona Steffen, and Caroline Kronley.

Sustainability

Peak Performing Organizations Got There By Applying Five Principles:

4. Integrate formal and informal interventions…reaching people at an emotional level and tapping rational self- interest

5. Measure and monitor cultural evolution…to identify backsliding, correct course where needed, and

demonstrate tangible evidence of improvement

*Harvard Business Review, “Culture Change that Sticks” by Booz & Co. execs Jon Katzenback, Ilona Steffen, and Caroline Kronley.

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Patient Case• IC team engaged by physician for pain and nausea medication management and

behavioral health support for 53YOM– Suicide attempt 3 days prior

No current suicidal ideation– Stroke survivor

Difficulty with information recall– Hx of GI issues

Intolerance to all PO narcotics, except morphine Previously able to tolerate current morphine dose until recently

– Unclear if nausea related to food intake vs morphine administration

• Physician Plan:– Start pantoprazole daily before breakfast– Start ondansetron Q8H PRN for nausea– Continue morphine 15mg daily PRN– GI referral– RTC in 2 months or sooner if sxs worsen– Meet with Integrated Care Team

Patient Case• Health Psychology Intervention

– Obtained hx on previous suicide attempts Mainly d/t being overwhelmed by colitis and chronic pain Interested in counseling services

– Inquired if pt interested in being set up with a case manager for assistance with scheduling medical appts, transportation issues, and medication reminders

Pt agreeable

• Health Psychology Plan– Contact case management through pt’s insurance (Molina)– Review counseling options– Provide contact information for possible referrals for cognitive and

memory assessment

Patient Case• Clinical Pharmacist Intervention

– Pt unable to answer questions regarding his medication regimen d/t poor recall

• Clinical Pharmacist Plan– Before making changes, need to be sure an accurate hx obtained

Developed personalized pain/nausea chart for pt to fill out dailyo Reviewed with patient – Pt demonstrated understanding

through teach-back method – All questions answered– Instructed pt to take morphine before activities that typically cause

pain– Follow-up in 2 weeks to review chart documentation. Pt understands

to bring chart to clinic.

Patient CasePain/Nausea Chart

Patient CaseFollow-up Appointment #1

Pharmacist• Pt RTC in 2 weeks with chart filled out

– Taking ondansetron Q8H scheduled – Taking pantoprazole before breakfast daily w/ no issues– Pt able to take morphine 1-2 times daily PRN which controlled pain

Taking prior to activities which cause pain No nausea associated with morphine administration

o Upon review of chart, determined nausea related to food intake

• Reviewed case updates with physician– Advised pt to continue current regimen

• Exception: Take ondansetron before food intake only, not on scheduled basis

– Follow-up with PharmD in 2 weeks; continue to fill out pain/nausea chart

Health Psychology• Scheduled series of counseling sessions• Ensured case management set up through pt’s insurance

Patient CaseInsurance Audit

• Physician received audit from pt’s insurance company– Required to review/explain duplicate therapy listed– Physician requested PharmD assistance

• PharmD reviewed listed medications– Alprazolam– Lorazepam– Diazepam– Hydrocodone/acetaminophen– Morphine

• Only diazepam and morphine being rx’d by FMC physician– Muscle spasm/anxiety & chronic pain

• Pt w/ allergy listed to hydrocodone/acetaminophen in chart– Had previously requested not to be rx’d this medication d/t GI intolerance

Patient CasePharmD Review

• Lorazepam – Received 7 day supply x2 – Rx’d by psychiatrist; pt explanation valid

• Alprazolam and hydrocodone/acetaminophen rx’d by neurologist Qmonth since February 2015– Per claim sheet, rx had been dispensed consistently– Pt adamantly denied being rx’d these medications

• PharmD called all pharmacies listed in pt chart to see if rx had been picked up consistently– No prescriptions had been filled/picked up

• Pt reports his wife picks up all of his prescriptions

Patient CaseControlled substance screen

• To further investigate hydrocodone/acetaminophen and alprazolam scripts, physician ran controlled substance screen on pt– Scripts were filled at Walgreen’s (not listed as preferred

pharmacy)

• FMC physician called neurologist office and advised to stop prescribing hydrocodone/acetaminophen and alprazolam– Under assumption wife may be taking his meds

• Pt reports to PharmD that his wife admitted to picking up/taking these medications– Pt apologetic; was unaware this was going on

• States anxiety is increased since incident with wife– PharmD conducted chart review

Had previously tried the following medications for anxiety control with no improvement/intolerance:o Buspirone, paroxetine, mirtazapine, buproprion, citalopram,

venlafaxine, clonazepam• Recommend to start escitalopram 5mg daily

– Physician in agreement – will start today• Health Psychology

– Reviewed relaxation techniques– Scheduled for follow-up counseling sessions

• Follow-up home visit with FMC resident & PharmD in 1 month

Patient CaseFollow-up Appointment #2

Patient CaseHome Visit

• Unique odor/un-kept• Wife leaves and stays outside for entirety of visit• Caregiver to disabled grandson• Complete medication review

– Morphine and diazepam kept in lock-box

• Pt requests personalized medication sheet – Pt to pick up in clinic next day

• Discarded cyclobenzaprine – pt no longer taking • Pt tolerating escitalopram 5mg daily, increase dose to 10mg daily• RTC in 1 month

h1b friday october 16, 2015 impact of clinical pharmacist and health psychologist on integrated team...

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