NACDS Institute: Expanding Pharmacy Care -

Innovative Models from the US & Abroad

August 22, 2015

Institute Agenda – Changing Your Business Model for Future

Success: Linda Garrelts McLean, RPh, CDE

Associate Dean & Professor, Washington State University College of Pharmacy

– Community Pharmacy Practice in Canada: Expanding Scope and Overcoming Barriers: David Edwards, PharmD, MPh

Associate Dean & Hallman Director, University of Waterloo School of Pharmacy

– Trends in Collaborative Practice Authority: Krystalyn Weaver, PharmD

Director of Policy and State Relations, NASPA

Changing Your Business Model for Future Success

Linda Garrelts MacLean, RPh, CDEClinical Professor and Associate DeanWashington State UniversitySpokane, WAlmaclean@wsu.edu

What would your business plan look like if……

……. Your pharmacy was paid to keep people healthy?

……. Your pharmacists increased access to primary care?

Instead of……

……. Solely dispensing drugs?

Health Care Reform Aims Better population health

Improved health care, including access

Decreased costsBetter CareBetter Health

Affordable Care

Making the case

Why is pharmacy needed at the table? Where are the gaps?

How...

Create a plan to overcome potential challenges associated with non-traditional pharmacy

Craft and execute collaborativedrug therapy agreements which support a pharmacist to function as a provider.

Strategy…

Implement pharmacist delivered care to increase access to primary care

Collaborate with other members of the healthcare team ….

to successfully implement a model of care in which the pharmacist practices at the top of the pharmacy license.

Construct ….

a reimbursement model of compensation for these services that increases profits.

Research Project:

INCREASE ACCESS TO QUALITY PATIENT CARE IN COMMUNITY PHARMACIES FOR MINOR ILLNESSES IN WASHINGTON STATE

Three phase analysis assessing feasibility and comparing care 3-phase analysis that will assess

feasibility and compare care provided by clinical community pharmacists for 20 minor ailments and conditions with care received in other care settings: physician offices, urgent care clinics, and emergency departments.

Three phase analysis assessing feasibility and comparing care provided by the pharmacist for minor ailments and conditions to three other care settings.

-Minor emergency

-Physician office

-Emergency department

Click icon to add picture

Conditions included in the study Bronchospasm, wheezing,

shortness of breath from asthma or COPD

Animal Bite (Human, Dog, or Cat)

Eye or nasal symptoms from seasonal allergies or other allergic conditions

Herpes virus infections (cold sores, genital herpes, shingles)

Allergic reactions from bee stings (not anaphylactic)

Acute otitis media Anaphylactic allergic reactions Lacerations and abrasions Nausea and vomiting (not

related to motion sickness)

Contraceptive pregnancy prevention

Conjunctivitis Nausea and vomiting caused by

motion sickness Wound infections from burns Migraine headaches Ear infections caused by bacteria Lack of fluoride for oral health Diarrhea that occurs while

traveling Uncomplicated urinary tract

infections Vaginal yeast infections Streptococcal pharyngitis

Feasibility and Sustainability Phase One

Superiority analysis of pharmacy site costs versus costs from the alternate care settings.

Phase Two

Equivalence analysis among care settings for quality of care of health outcomes per ailment or condition.

Phase Three

Partners Health plan

Community pharmacies in Spokane, Seattle and Vancouver I-5 corridor

Fixing Healthcare Can be as Close as Your Neighborhood Pharmacy!

http://www.forbes.com/sites/johnnosta/2014/04/10/fixing-healthcare-can-be-as-close-as-your-neighborhood-pharmacy/

How do we determine value?

ValueCOST

QUALITY

What you receive

What you pay

“As leaders we must think and act in transformative ways to advance the profession, ultimately improving health.”

-Acting Surgeon General RADM Scott Giberson

Thank you!

Questions for the team?

Julie AkersJulie.akers@wsu.edu

Community Pharmacy Practice in Canada: Expanding Scope

and Overcoming Barriers

David Edwards, PharmD, MPH Director, School of Pharmacy University of Waterloo

Health Care in Canada

• Universal coverage for medically necessary health care services (excludes dental, vision care)

• Primarily paid for and delivered by provinces

• Health care spending 40-50% of provincial budgets

Major Health Care Expenditures

28

Who pays for medications?

• Public funding ~ 40%• Over age 65, unemployed, low income

• Private Insurance ~ 40%• Provided by many employers

• Out of pocket payment ~20%• Includes co-pays and payments by uninsured

for medications

Pharmacy Practice in Canada

• As of January 2014: • 37,490 registered pharmacists in Canada (~ 1

pharmacist per 1,000 citizens)• 75% of pharmacists practice in community

pharmacy• 9,558 community pharmacies

• Mix of chain (Shoppers Drug Mart, Rexall), banner, franchise, grocery and independent pharmacies

Rationale for Expanded Scope of Pharmacy Practice

• Governments as the primary payer want:• Improved access to health care, reduced wait times • More cost-effective health care• Patient-focused care, improved co-ordination

• Expanded scope benefits patients and frees up physician time for other tasks

Pharmacists Scope of Practice 2005

Pharmacists Scope of Practice 2015

http://www.pharmacists.ca/index.cfm/pharmacy-in-canada/scope-of-practice-canada/

What can Pharmacists Do?

Pharmacists in many provinces can:

Renew and Extend Prescriptions (chronic conditions)

Adapt Prescriptions (change dose, formulation)

Therapeutic Substitution (eg. one ACE inhibitor to another)

Prescribe for minor ailments (eg. acne, allergic rhinitis, dysmenorrhea, headache, GERD, oral thrush, superficial skin infections, erectile dysfunction)

What can Pharmacists Do?

Pharmacists in many provinces can:

Order and interpret lab tests

Administer a drug by injection eg. immunizations

Provide emergency prescription refills

Initiate Prescription Therapy (need Additional Prescribing Authority designation – Alberta; limited to smoking cessation treatment in Ontario)

Alberta – The Promised Land (for Pharmacy)

Expanded Scope Varies by Province

Service Alberta Ontario Sask.

Emergency Refills Yes Yes Yes

Renew/extend prescriptions Yes Yes Yes

Change dosage/formulation Yes Yes Yes

Therapeutic Substitution Yes No Yes

Minor Ailment Prescribing Yes No Yes

Initiate Prescription Therapy Yes Smoking Cessation

Smoking Cessation

Order and interpret lab tests Yes Pending Pending

Administer a drug by injection Yes Flu Vaccine Only

Pending

http://www.pharmacists.ca/index.cfm/pharmacy-in-canada/scope-of-practice-canada/

Payment for Professional Services

Service Ontario Alberta Sask.

Medication Reviews $60 $60/$65 $60

Advanced Medications Reviews (diabetes, long-term care, etc.)

$75-$150 $100/$125

Medication Review Follow-up $25 $20/$25

Immunization $7.50 $20

Adapt or renew prescription 0 $20 $6

Refusal to fill 0 $20 1.5 x DF

Pharmaceutical Opinion $15

Therapeutic Substitution $20 0

Minor Ailments $18

Smoking Cessation $125/yr $300/yr

Emergency Refill 0 $20 $10

Supporting Expanded Scope: Regulated Pharmacy Technicians• Most provinces have regulated pharmacy

technicians• Accountable and responsible for the technical aspects

of both new and refill prescriptions, (i.e. the correct patient, drug dosage form/route, dose, doctor)

• Liability for actions• Independent double check• Ability to receive/transfer Rxs

Embracing the Opportunity?

• Immunizations, medication reviews widely available in pharmacies but …..• Many pharmacists are not adapting or renewing

prescriptions or doing therapeutic substititions• Fear of disrupting the health care hierarchy, relationship with

physicians

• Two years after govt. approval, only 30% of Ontario pharmacies offer smoking cessation services (Wong et al., Can Pharm J 2015: 148: 29-40)

• Number of pharmacists applying for advanced prescribing authority has been low but increasing …

Embracing the Opportunity? Not so fast ….

0

200

400

600

800

1000

2006 2008 2010 2012 2014 2016

Alberta Pharmacists with prescribing Authority

Number of pharmacists

www.pharmacists.ca/index.cfm/education-practice-resources/pharmacy-practice-research/canadian-pharmacy-practice-research-group/cpprg-webinars/cpprg-webinar-archives

Barriers to Implementing Professional Services

• Pharmacist Perspective• Workload, too little time (lack of support staff)• Workflow • Pharmacy design/lack of privacy• Lack of training/expertise/competence• Not enough reimbursement

• Conflict between business model and clinical practice model• Billing numbers for pharmacist employees, salary incentives

for professional services• Interference with patient-physician relationship• Personality characteristics of pharmacists

Are Pharmacists the ultimate barrier to practice change?

• Current pharmacy culture• Product-focused (thorough, careful, attentive to detail)• Information gatherer and disseminator • Paralysis in the face of ambiguity• Uncomfortable with clinical decision-making

• Lack of confidence, reluctant to take responsibility for patient care decisions

Rosenthal et al. Can Pharm J 2010; 143: 37-42

Barriers to Expanded Scope

• Government/payor perspective• Failure to practice to full extent of current scope

• Inconsistency in delivery of professional services in a highly visible profession

• Turf battles between professions• CMA resolution in 2007: “the right to prescribe medications independently for medical

conditions must be reserved for qualified practitioners who are adequately trained to take a medical history, perform a physical examination, order and interpret appropriate investigations, and arrive at a working diagnosis.”

• Limited evidence in support of the value of expanded professional services

Ongoing Research into Professional Pharmacy Services

• Ontario Pharmacy Research Collaborative • provide evidence of the quality, outcomes and value of recent

and emerging medication management services provided by Ontario pharmacists

• Funded by Ministry of Health ($5.8 million dollars over 3 years)

• Canadian Foundation for Pharmacy• The evaluation of pharmacy prescribing for minor ailments – the

clinical and economic value• The impact of community pharmacist interventions in

hypertension management on patient outcomes: A randomized controlled trial

Shifting the Focus from Product to Patient: The Role of Academia

The Role of Academia

1. Provide a curriculum that recognizes that most graduates will practice in the community

• Strong community experiences to develop decision-making skills and responsibility for patient care

2. Hire faculty members with community pharmacy expertise and interest in practice-based research

3. Recruit and admit students with an aptitude for patient-focused medication management

• Communication skills, critical thinking, problem-solving

Summary

• Alignment of interests of government (primary payer) and profession has resulted in significant expansion of scope of practice

• Pharmacists have been inconsistent in adopting expanded scope due to real and perceived barriers

• Academia has an important role in recruiting and preparing the patient-focused pharmacist of the future

Trends in Collaborative Practice Authority

Krystalyn Weaver, PharmD

About NASPA

The National Alliance of State Pharmacy Associations (NASPA), founded in 1927 as the National Council of State Pharmacy Association Executives, is dedicated to enhancing the success of state pharmacy associations in their efforts to advance the profession of pharmacy. NASPA’s membership is comprised of state pharmacy associations and over 70 other stakeholder organizations. NASPA promotes leadership, sharing, learning, and policy exchange among its members and pharmacy leaders nationwide.

Collaborative Practice Agreements

• Creates formal relationship between pharmacists and physicians or other providers

• Defines 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 healthcare team

Components of a CPA Authority

Statute/Regulations• Define collaborative practice authority and restrictions• HIGHLY variable

Agreement• Defined by collaborating practitioners• Defines the conditions of the relationship, delegation of

authority/expansion of scope, defines the parties• Legal document

Protocol• Defines the clinical parameters for the provision of care• Varying degrees of detail• May or may not be required by state laws/regulations

Existing Landscape

• Collaborative practice authority: 48 states• Proposed in AL and in the works in DE

• Pharmacist modification of therapy: 45 states

• Pharmacist initiation of therapy: 39 states

• Allow multiple pharmacists on one agreement: 25 states

• Many other parameters…

Services/Authority

• Modify therapy

• Initiate therapy

• Physical assessment

• Order labs• Interpret labs• Perform lab

tests

Requirements

• Continuing education requirements

• Pharmacist qualifications

• Liability insurance

Restrictions

• Disease state• Site of

practice• Drug

Who involved

• # of pharmacists

• # of prescribers

• # of patients• Types of

prescribers• Relationship

between patient and prescriber

• Pharmacist to prescriber ratio

Procedural requirements

• Patient involvement

• Agreements approved or reported to whom

• Length of time agreement valid

• Payment provisions

• Documentation

• Physician review

Elements Currently in State Law

Support for Collaborative Agreements

• Policy Considerations from the National Governors Association• Enact broad collaborative practice provisions that allow for

specific provider functions to be determined at the provider level rather than set in state statute or through regulation.

• Evaluate practice setting and drug therapy restrictions to determine whether pharmacists and providers face disincentives that unnecessarily discourage collaborative arrangements.

• Examine whether CPAs unnecessarily dictate disease or patient specificity.

Collaborative Practice Workgroup

Convened by the National Alliance of State Pharmacy Associations

Workgroup Objective

• Develop a set of elements that are considered to be the best practice for inclusion in collaborative practice provisions

• Developed through a consensus based process by a panel of experts convened by NASPA

• Can then be used as a resource for those advocating for changes to their collaborative practice provisions in their state

Committee ParticipantsState/National Organization NameNational NACDS Alex AdamsNational APhA Anne BurnsNational NCPA Carolyn HaNational ASHP Douglas ScheckelhoffNational ACCP Ed Webb

National AACPLynette Bradley-Baker

National ACPE Pete VlassesNational NABP Scotti RussellNational AMCP Susan OhState Iowa Anthony Pudlo

StateSouth Carolina Bryan Ziegler

State Maryland Christine Lee-WilsonState Michigan Dianne MillerState Pennsylvania Jennifer BacciState Minnesota Julie JohnsonState Arizona Kelly RidgwayState Alaska L. Michelle VaughnState Arizona Sandra Leal

Process: Developing Recommendations

• Step 1: Examine existing authority

• Step 2: Make recommendations

• Is this recommendation in the best interest of the patient receiving care under a collaborative agreement?

• Is this recommendation aligned with pharmacists’ education and training?

Process: Modified Delphi Method

1. Level-setting conference call

2. Distribution of survey with 3 weeks to complete

3. Collect and compile survey results

4. Call to discuss differences of opinions

5. Repeat 2-4 until consensus is reached

Workgroup Recommendations

Participants• Which providers?• Which patients?

Authorized services• What can be done under the agreement?

Requirements and Restrictions• Logistics• Education• Others

Workgroup Recommendations

Included in Laws and Regulations

Framework should be flexible to

facilitate innovation in care delivery

Decided by Individual ProvidersSafeguards should be established to ensure optimal

patient care

Participants

Included in Laws and Regulations• Any prescriber may collaborate with pharmacists• Single or multiple pharmacists/prescribers may be parties

to one agreement• Single, multiple and populations of patients can be on one

agreementDecided by Individual Providers• Specifically list which pharmacists and prescribers are

included in agreement• Identify the pharmacist training or credentials, if any,

necessary to provide delineated services• Identify which specific patients or patient populations are

included in agreement

Authorized Services

Included in Laws and Regulations• Initiation and modification of drug

therapy can be authorized in the agreement

Decided by Individual Providers• Specify which disease states are being

managed• Specify which specific services are

includes• Specify if/which protocols or clinical

guidelines are to be followed

Requirements & Restrictions

Included in Laws and Regulations• All medications may be managed under the

agreement, including controlled substances• Agreement should be available, upon request, to the

Board of Pharmacy

Decided by Individual Providers• Specify an appropriate level of patient consent for

services• Specify the timeframe for renewal of agreement• Specify the documentation processes• Specify the liability insurance needs, if any• Identify the continuing education requirements for

participation

CPA Applications

• Chronic Disease Management• Anticoagulation

• Cardiovascular disease/hypertension

• Diabetes

• Others

• Acute Treatment

• Public Health

Another Approach to Addressing Public Health

Needs

Statewide Protocols

• Used to address public health concerns

• Standard across the state, applies to all pharmacists

• Additional pharmacist education/training could be required

• Allows pharmacist to prescribe for conditions with no diagnosis or that are easily diagnosed

• Protocols can be in law (CA) or delegate authority to state boards (OR)

Statewide Protocols

• Naloxone

• Immunizations

• Smoking Cessation

• Hormonal Contraceptives

• Travel Medications

Case Study: Naloxone

HI

AK

DCMOWV

MS

NH

NC

FL

KY

WA

SC

OH

CAMDDE

TN

MANYRI*

IL

CT

VT

NJ

MI*

ME

MNOR

ID

MT ND

SD

NV*UT

AZ NM

TX

WY

CO

NE*

OK

KS

IA

WI

IN

PA

VA

AR

AL GA

LA

Based on data collected by NASPA (updated June 2015)

Statewide naloxone protocol or prescriptive authority for pharmacists

Broad** collaborative practice provisions

* Broad collaborative practice provisions but need a separate agreement for each pharmacist

Pharmacists are authorized to dispense without a prescription

Statewide protocol or prescriptive authority bill proposed in 2015 session**Broad = Allow initiation of therapy, community pharmacists authorized to participate, no drug restrictions (may need to specify within the agreement), laws/regulations silent regarding the relationship between the prescriber and the patient

Next Steps

• Examine your state’s collaborative practice authority• Best interest of the patient?

• Aligned with pharmacist education and training?

• Does the current authority present barriers or opportunities to enhance patient care?

• Do legislative or regulatory changes need to be made?

Questions?

Krystalyn Weaver, PharmDDirector, Policy and State Relationskweaver@naspa.us