steve simenson bpharm, faca, fapha...©2017 american college of apothecaries 3 “collaborative...
TRANSCRIPT
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©2017 American College of Apothecaries
Collaborative Practice in a Community Based Pharmacy
PracticeSteve Simenson BPharm, FACA, FAPHA
CEO – Managing PartnerGoodrich Pharmacy. Inc
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©2017 American College of Apothecaries
Disclosures
Steve Simenson has no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.”
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The American College of Apothecaries is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
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©2017 American College of Apothecaries3
“Collaborative Practice in a Community Based Pharmacy Practice” – has been approved for1.5 contact hours (0.15 CEUs) of continuing education credit. Attendees will be required to complete an online evaluation for each CE session they attend to verify attendance and acquiretheir CE. Attendees must provide their NABP e‐Profile ID and birthdate (MMDD) to receive credit
for any ACPE‐accredited CPE session.
It is the responsibility of the CPE taker to give correct information. If incorrect information is provided, the record will be rejected by the CPE Monitor and the CPE credit will not be awarded. If you complete an online evaluation for each CE session you attend at the conclusion of the conference, your CPE credits will be uploaded to the CPE Monitor System within 60 days of completion. If you do not see CPE activity displayed for a session that you attended and it has been more than 60 days since you submitted the CPE to the provider, please contact your CPE provider.
All sessions carrying the ACPE program number are approved for continuing education credit. The American College of Apothecaries, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. “Collaborative Practice in a Community Based Pharmacy Practice” session is co‐sponsored by the American College of Apothecaries.
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©2017 American College of Apothecaries
Learning Objectives
At the conclusion of this program, the participating pharmacist or technician will be able to:
– Identify the changing Payment model Landscape– Discuss the opportunities for Community Based
Pharmacy Practitioners– State the need to develop the tools, Collaborative
Practice Agreements, EMR/EHR Access and HCP Relationships to provide Quality Patient Care
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©2017 American College of Apothecaries
Our Story Welcome to Goodrich Pharmacy
Thank you for choosing us!
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©2017 American College of Apothecaries
Goodrich PharmacyAnoka, Andover, Blaine, Elk River and St. Francis Minnesota
• Community Pharmacy partnering with HP Riverwayand MultiCare Clinics
• EST 1884 Patient Care Services Launched 1996
• Number of FTE RPh: 14 • Pharmacy sites: 6• Partnering Clinics: 5• 11 CPA’s• Unique CMM, CMR and MTM
patients served in 12 months: – Onsite (Pharmacies): 900 unique
CMM patients and 700 unique DS-MTM patients.
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©2017 American College of Apothecaries
Evolution of Patient Care Practices– Therapeutic Substitution …Clinic requested– Blood Pressure monitoring and Management– Lipid Management research Project– Prescription Refill Management with Clinic– Pharmacist and Resident in Clinic– Immunizations…Influenza– Collaborative Practice Agreements– Patient Needs– Fill a Need or Solve a Problem
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©2017 American College of Apothecaries
Patient Care Services Offered• Univ of Minn COP Teaching and Residency Site• Board and Care Facility medication Consulting• Immunizations• Medication Therapy Management• Comprehensive Medication Reviews• Blood Pressure Monitoring and Management• Home Delivery, Adherence Packaging, Med Sync• Compounding Services• Practice Based Research • 11 Collaborative Practice Agreements…In
Pharmacies and in Clinics
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©2017 American College of Apothecaries
Why Now?
• “Meaningful Collaboration with Pharmacists to Improve Quality and Meet Patient Needs”
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©2017 American College of Apothecaries
Alternative Payment Models(APM)
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• What is driving the transition away from Fee for Service (FFS) towards APM?₋ APM reward high quality and cost effective care
which supports the delivery of high value healthcare
₋ “Volume to Value” with Value = outcomes/cost₋ APM encourage providers to invest in areas with
the greatest return
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©2017 American College of Apothecaries
Transforming care requires a transformed business model
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Strategic Aim: 75% of all care will be reimbursed via Alternative Payment Models (APM)
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©2017 American College of Apothecaries
Patient‐centered system by 2020 will provide care under a different mix of
payment models
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©2017 American College of Apothecaries
Best path to consistently describe our journey.
Fee‐for‐Service
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Full‐risk / Capitation
Loosely Integrated
Care
Highly Integrated
Care
Traditional Model
Future State
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©2017 American College of Apothecaries
The journey to value based payment requires deep focus and vigilance.
Fee‐for‐Service
Full‐risk / Capitation
Highly Integrated
Care
Future State • With each initiative, ensure thatthe interventions and initiativesare aligned
• Success is defined clinically and financially
• Models are created that allow flexibility yet remain consistent as possible for patients and providers
• Diverting from the center path results in financially unsustainable models, putting our mission at risk
Loosely Integrated
Care
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©2017 American College of Apothecaries1
Health Care is inherently Local
• There are things that can be performed centrally that can ease administrative burden and simplify implementation
• All of us can move down this path faster and moreeffectively together than we can separately
No one is in a better position to to embrace this new potential for care collaboration than Community Based Pharmacy Practice
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©2017 American College of Apothecaries
The Business Case: Value is Created by Better Episode Management through
Care Redesign
Cost
(revenu
e)
Traditional fragmented delivery
Value creation
Portion of savings to payer
New Model of CareTime
Availablemargin forgainsharing
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©2017 American College of Apothecaries
Collaboration with Pharmacists
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©2017 American College of Apothecaries
Integrating Pharmacist’s intoPatient Centered Health Care
• Do the right things well.
• Structure. Process. Outcomes.
• Align the Incentives,
• Improve the Outcomes,
• Control the
• Costs
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Build RelationshipsCreate Opportunity
Solve a Problem Fill a NeedDevelop CultureObtain Tools
CollaborateDevelop WorkflowAdd ValueMeasure Outcomes
Idea
PharmacistImproved Team BasedPatient Care
“The Best way to predict the future is to invent it” Alan Kay
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©2017 American College of Apothecaries
Benefits to Clinic Health Care Providers
• Improved Patient Outcomes raise Community Measure Scores
• Timely monitoring and follow up • Availability to HCP’s for Medication Consultation• Ability to tackle difficult Medication problems• Ability to improve Immunization Goals …add to EMR,
triage which specific type referred to which practice• Ability to help other HCP’s be more efficient, increases
capacity to see more patients• With coming MACRA driven pay for performance, fill
Gap’s in expertise• ………
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©2017 American College of Apothecaries
Pharmacists Meeting Patient Needs
• Improved Patient Satisfaction with all HCP’s• Improved Medication Adherence and Outcomes,
through med synchronization, monitoring and adherence packaging
• Empowers Patients to be Partners in Therapy• Improves communication of progress to HCP’s• Detects and Prevents more Medication ADR’s• Lowers overall Health care costs
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©2017 American College of Apothecaries
Best PracticesPhysicians and other Health Care Providers don’t want Pharmacists to bring them problems we can’t resolve… Pharmacists need the authority and tools to implement the solutions we recommend.
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Necessary Tools to Succeed:• Use EMR as other HCP’s in Clinic• In Pharmacy use EMR to:
• Check last Clinic Visit and Care Plan• Check Med list in Transitions of Care• Check for/add Immunizations • Check for New or D/C’d Medications• Schedule Patient appointment or refer to HCP’s• Research for patient Pharmacist Visit
• Use Collaborative Practice Agreements• Credentialing and Privileging
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©2017 American College of Apothecaries
Pharmacist’s Role in Team Based Care
• Pharmacist sees patient in Clinic and multiple times in Pharmacy to Monitor Progress.
• Communication channels are open to Clinic Staff and Pharmacy Staff with a single care plan and Goal & Outcome progress.
• Patient visit before or after patient Clinic HCP visit
• Pharmacist triages Patients and schedules patient visit or refers to appropriate HCP
• Goodrich Pharmacists Manage & Monitor Medications and Educate Patients on there use
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• Roles in and Out of Clinic
• Scheduled patient visits • Clinic Staff Consulting• Referals to other Health
Care Providers• Patient Follow up• Ordering necessary Labs• Documenting care in EMR• Managing patients
through Collaborative Practice Agreements
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©2017 American College of Apothecaries
Support From Innovative Health Systems
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• “There is so much potential in the use of medications”
• “I think of the growth in the cost of prescription medications and I think that medications are the #1 resource in treating chronic conditions”
• “I still think the pharmacist has been the least effectively used member of the health care team”
• “There are lots opportunity to connect pharmacists more effectively with patients then there has been in the past”
• With Chris Farrell Economic Journalist MPR News Presents November 3, 2015
“We are doing a lot of work changing the role of the Pharmacist as a member of the health care team”
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©2017 American College of Apothecaries
“Meaningful Collaboration with Pharmacists to
Improve Quality and Meet Patient Needs”
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©2017 American College of Apothecaries
Types of Services• Medication management services
– Chronic diseases– Hospice, palliative care and pain management– Mental health– Specialty clinics– Polypharmacy clinics– Refill clinics
• Wellness and prevention– Medicare Wellness Visits– Tobacco cessation– Immunizations including travel clinics– Weight management
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©2017 American College of Apothecaries
Patient Care Delivery• Settings:
– Community pharmacies– Physician’s office– Outpatient clinics– Patient’s bedside– Worksite health– Pharmacist consultant practice
• Delivery mode--Face-to-face• Appointment-based• “On the fly”
– Telehealth
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©2017 American College of Apothecaries
Example Programs Where Pharmacists Are Impacting Quality Measures
• CMS Programs– Quality Payment Program (QPP): MIPS/APMs– ACOs: Medicare Shared Savings Program (MSSP),
Next Generation ACO– Comprehensive Primary Care Plus– Part C and Part D Star Ratings Programs
• Private sector value-based ACOs and Medical Home programs
• Accreditation, certificate and recognition programs (e.g. NCQA for PCMH)
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©2017 American College of Apothecaries
Example High Priority MIPS Measures• Effective clinic care
– Diabetes: Hemoglobin A1C Poor Control > 9%– Controlling high blood pressure– Medication management for people with asthma
• Patient safety– Documentation of current medications in the medical record– Adherence to antipsychotics medications in schizophrenia– Use of high-risk medications in the elderly
• Communication and care coordination– Medication reconciliation post discharge (>65yrs)
• Community/population health– Pneumococcal vaccination status for older adults – not high priority– Preventive care and screening: influenza immunization – not high
priority
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©2017 American College of Apothecaries
Eric Hoffer…Learners and the Learned
“ In a time of drastic change it is the learners who inherit the future. The learned usually find themselves equipped to live in a world that no longer exists”
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©2017 American College of Apothecaries
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Why aren’t we practicing
like we learn?
Scope of PracticeScope of Practice Payment for Services
Payment for Services
Health Information Technology
Health Information Technology
Workflow/Time Restraints
Workflow/Time Restraints
Public Perception/Support
Public Perception/Support The Big One...The Big One...
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©2017 American College of Apothecaries
Patient‐Specific CPA
Population‐Specific CPA
Statewide Protocol
Unrestricted (Category‐Specific)
Continuum of Pharmacist Prescriptive Authority
Adams AJ, Weaver KK. The Continuum of Pharmacist Prescriptive Authority. Annals of Pharmacotherapy. June 2016.
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©2017 American College of Apothecaries
Collaborative Practice Agreements
Establishes a formal
relationship
Delegated patient care
functionsNegotiated conditions
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©2017 American College of Apothecaries
Statewide authorityStatewide authority
Allows pharmacists to
prescribe
Allows pharmacists to
prescribe
Address public health goals
Address public health goals
Do not require differential diagnosing
Do not require differential diagnosing
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©2017 American College of Apothecaries
Prevalence
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States with CPA Provisions
HI
AK
MO
WV
MS
NC
FL
KY
WA
SC
OH
CA
TN
MAN
Y
IL
VT
MI
ME
MNOR ID
MT ND
SD
NV U
T
AZ
NM
TX
WY
CO
NE
OK
KS*
IA
WI
IN
PA
VA
AR
AL
GA
LA
Based on data collected by NASPA (updated Dec 2015)
NH
RICTNJDEMDDC
Have CPA authority to somedegree
*Kansas is awaiting rule promulgation. Their law is vague regarding services and calls for rules to be issued
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Prescribing Under a Statewide Protocol* or Unrestricted (Category‐Specific) Authority
HI
AK
MO
WV
MS
NC
FL
KY
WA
SC
OH
CA
TN
MAN
Y
IL
VT
MI
ME
MNOR ID
MT ND
SD
NV U
T
AZ
NM
TX
WY
CO
NE
OK
KS
IA
WI
IN
PA
VA
AR
AL
GA
LA
Based on data collected by NASPA (updated August 2016)
NH
RICTNJDEMDDC
One statewide protocol for pharmacists
Two statewide protocols for pharmacists
Three or more statewide protocols for pharmacists
*Includes statewide standing orders
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©2017 American College of Apothecaries
Collaborative Practice Authority• State law authorizes pharmacist to enter into an agreement or protocol
with a provider• Collaborative practice agreement (CPA): A voluntary formal agreement in
which a licensed provider makes a diagnosis, supervises patient care, and refers a patient to a pharmacist under a protocol or agreement that delegates specific patient care functions to the pharmacist beyond the pharmacist’s regular scope of practice:– Functions can include initiating, modifying, and discontinuing patients’
medication therapy and ordering laboratory tests• Terminology* for the agreement varies in state law • Variability between states regarding types of functions, practice settings,
patient populations, and requirements for the agreement
*Collaborative drug therapy management agreement, collaborative pharmacy practice agreement, consuagreement, physician-pharmacist agreement, standing order or protocol, simply physician delegation
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©2017 American College of Apothecaries
Collaboartive Practice Agreements
• Date, Professional Supporters• Patient Population• Treatment Algorithm• Medication Ordering• Lab Monitoring• Patients Excluded• Triage and Referral Mechanism
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©2017 American College of Apothecaries
CPA Examples
• Broad – Less detailed….Diabetes one page plus signatures…. Diabetes
• More focused…more detailed…8 pages plus signature page…Hypertension
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Current Applications
Naloxone (11)
General Authority (3)
TB Testing (2) Fluoride (1)
Immunizations (17)
Smoking Cessation (4)
Epinephrine (1)
Contraceptives (3)
Limited Formulary (1)
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Why aren’t we practicing
like we learn?
Scope of PracticeScope of Practice Payment for Services
Payment for Services
Health Information Technology
Health Information Technology
Workflow/Time Restraints
Workflow/Time Restraints
Public Perception/Support
Public Perception/Support The Big One...The Big One...
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Washington State
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Ohio
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California
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Not to mention…
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©2017 American College of Apothecaries
Part D Enhanced Medication Therapy Management Model
• Testing if payment incentives and regulatory flexibility for Part D MTM can improve patient outcomes and lower Medicare costs
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Why aren’t we practicing
like we learn?
Scope of PracticeScope of Practice Payment for Services
Payment for Services
Health Information Technology
Health Information Technology
Workflow/Time Restraints
Workflow/Time Restraints
Public Perception/Support
Public Perception/Support The Big One...The Big One...
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Health Information Technology –
So What?
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Why aren’t we practicing
like we learn?
Scope of PracticeScope of Practice Payment for Services
Payment for Services
Health Information Technology
Health Information Technology
Workflow/Time Restraints
Workflow/Time Restraints
Public Perception/Support
Public Perception/Support The Big One...The Big One...
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Patient Care Activities
Technician Activities
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Potential Advanced Roles for Technicians
PDMP Check
Verbal orders/ transfers
Clinical Support
Tech‐check‐tech
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©2017 American College of Apothecaries
• Tech-Check-Tech (TCT) is a strategy to delegate the task of final product verification to specially trained technicians
• Typically limited to: – Refill prescriptions– Automated filling
machines– Unit-dose repackaging– Unit-dose carts
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©2017 American College of Apothecaries
TCT technicians typically/always do NOT perform:
• Clinical/DUR checks• Verification of
compounded or controlled medications
• Verification of their own work
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©2017 American College of Apothecaries
Demonstrated safety
Results of Same‐Sample Tech‐Check‐Tech Studies
Facility Practice Situation Sample Size
Accuracy Rateb Error Detection Ratec pa
Tech RPh Tech RPh
Tertiary care institution
Checking unit dose envelopes
15,252 99.9 99.8 97.0 94.3 <0.05
Specialty pharmacy
Checking pre‐filled syringes
10,608 99.83 99.86 …d … NS
Children’s hospital
Checking unit dose cart fills
8,645 98.95e … 100 100 …
a NS=not significant b Percentage of orders checks that were free from error c Percentage of errors in sample that were detected by the checker dNot reported e Calculated by authors
A meta‐analysis of all published
studies consistently show technicians to be
at least as accurate as pharmacists.
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Where TCT is allowed now
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Why aren’t we practicing
like we learn?
Scope of PracticeScope of Practice Payment for Services
Payment for Services
Health Information Technology
Health Information Technology
Workflow/Time Restraints
Workflow/Time Restraints
Public Perception/Support
Public Perception/Support The Big One...The Big One...
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©2017 American College of Apothecaries
But that is changing!
• Increased utilization of pharmacists has been supported by:– The National Governor’s Association – The US Public Health Service– The American Public Health Association – Independent research organizations– CMS & CDC– CDC– AAFP, ACP,ACOG and other Physician organizations– MMA (July 2017!)
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©2017 American College of Apothecaries
• Fear to leave the counter• Fear of physicians• Fear they are
incapable/incompetent• Fear of making a mistake• Fear of the unknown
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©2017 American College of Apothecaries
Impact of Pharmacists Beyond the Four Walls of the Community Pharmacy
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Multiple Locations
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©2017 American College of Apothecaries
Taking the First Step
• Our Organizations must establish recognition of the unique value of pharmacists in the eyes of other health care providers.
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©2017 American College of Apothecaries
Exploring Financial Models
Contract for Pharmacist Time…Clinic contracts for Pharmacist Services
delivered in Clinic and in Pharmacy
Shared Staff… Split time …Employee of Both Clinic & Pharmacy…Pay for hours worked at each site by location
Bill for Pharmacist Services…MTM, CMM or CMR’s
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©2017 American College of Apothecaries
Pharmacists Improving Quality
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” Pharmacists are establishing recognition of the unique value they provide in the eyes of Patients and other
health care providers.
Surveys reveal that our patients are satisfied with our programs. With annual scores consistently averaging above 85% .Annual Physician/HCP satisfaction is also high, above 80%. In our contracted clinics, satisfaction has trended upward the longer our pharmacists are in the clinic.Physicians and clinics are asking for more hours of in clinic Pharmacist time every year.It shows our Physician colleagues value us.
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©2017 American College of Apothecaries
Pharmacists Improving Quality (cont’d)
(14 Medical Directors)
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©2017 American College of Apothecaries
Pharmacists Improving Quality (cont’d)
(14 Medical Directors)
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©2017 American College of Apothecaries
What Can You Do?
Advocate
Teach
Support
Learn
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©2017 American College of Apothecaries
Provider Status &Why It
Matters
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©2017 American College of Apothecaries
The Patient Access to Pharmacists’ Care Coalition (PAPCC)
• Publically announced early March 2014• Currently more than 29 organizations and growing• Representing patients, pharmacists, and pharmacies, as
well as other interested stakeholders
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©2017 American College of Apothecaries
PAPCC – H.R. 592 and S. 109
Scope of Proposal• Pharmacists – State-licensed pharmacists with a B.S. Pharm. or Pharm. D.
degree who may have additional training and certificates depending on state laws
• Services – Services authorized under state pharmacy scope of practice laws• Patients – Services provided in/ for Medically Underserved Areas (MUA),
Medically Underserved Populations (MUP), or Health Professional Shortage Areas (HPSA)
• Reimbursement – Consistent with Medicare reimbursement for other non-physician practitioners, pharmacist services would typically be reimbursed at 85% of the physician fee schedule
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Are only a limited number of pharmacists eligible under
the federal bill?
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©2017 American College of Apothecaries74
“You never fail until you quit
trying”
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©2017 American College of Apothecaries
• A special Thanks to KRYSTALYN WEAVER, PHARMD
• VICE PRESIDENT, POLICY & OPERATIONS
• NATIONAL ALLIANCE OF STATE PHARMACY
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©2017 American College of Apothecaries
Need More Information?Steve Simenson
CEO – Managing PartnerGoodrich Pharmacy, Inc
[email protected]…….Place holder
Check out www.NASPA.us for more information!
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