News Continued from page 774
type of billing that her hospital has successfully used. Sanchez said allowing pharmacists to provide billable MTM services has had a “community impact or cultural impact” at the hospital by promoting and codifying pharmacists’ routine interactions with patients at the bedside. “When you . . . become that practitioner who is face-to-face and interact-
ing with the patients and caring for them, you change the dynamics of your role, becoming much more visible,” she said. “We’ve gotten some phone feedback and some letters, and [patients] really appreciate some of the care they’ve gotten.” She said pharmacy students who come to the nonprofit community hospital during experiential rotations are enthusiastic about using the SOAP documentation format.
Direct engagement as part of collaborative practice improves diabetes care
P
harmacists’ direct engagement with patients whose diabetes mellitus had not been under control has helped a health care organization better serve this population and save money, metrics suggest. The direct engagement is part of the Lindsey Valenzuela collaborative practice protocol between the medical group and pharmacists at Desert Oasis Healthcare for the management of patients with Teresa L. Hodgkins diabetes, said Lindsey Valenzuela and Teresa L. Hodgkins. Valenzuela is the director of medication management services at the health care organization, based in Palm Springs, California. Hodgkins until recently was the services’ administrator. She is now the health care organization’s associate vice president for clinical performance and outcomes. Better outcomes, lower costs. The year before the health care organization created the protocol-based program, Hodgkins said, 24% of seniors with diabetes in the Medicare Advantage plan had a glycosylated hemoglobin (HbA1c) level greater than 9%. 776
But then, with the program in operation, the prevalence of poorly controlled disease dropped by at least half. Hodgkins said less than 12% of those seniors had an HbA1c level greater than 9% in 2012 and 2013. “That’s in the five-star cut point,” she said, referring to the top grouping in the Centers for Medicare and Medicaid Services’ quality-rating system for Medicare Advantage, or Part C, plans. Hospitalizations also decreased. In 2010, before implementation of the protocol-based program, patients with diabetes accounted for 40% of the bed days in acute care hospitals for the Medicare Advantage plan, Hodgkins said. That percentage has dropped as well, she said. Through the program, which starts with a physician’s referral, Hodgkins said, the pharmacists at any particular time manage 120–150 of the health care organization’s 5000-some patients with diabetes. These 120–150 collaboratively managed patients primarily are enrollees in the organization’s capitated health care plans: the Medicare Advantage plan and the commercial health maintenance organization. “How we can improve the outcomes and ultimately reduce costs is how they
Am J Health-Syst Pharm—Vol 71 May 15, 2014
“In this kind of setting—which is the majority of [U.S.] hospitals anyway—a lot of times the pharmacists aren’t actually seeing the patients very much. So when [students] come to us, they realize that here they get to go and see the patients,” Sanchez said. “They feel like they are doing patient care. I hear a lot about that.” —Kate Traynor DOI 10.2146/news140036
justify having the program,” Hodgkins said of her health care organization. The organization has reported a return on investment for the program of approximately 5:1. Reasons for success. Valenzuela said the requirement for a physician’s referral works in the pharmacists’ favor. By virtue of the referral, she said, “the physician has vetted that the program is positive.” The result is that even patients who were initially reluctant to be treated by a pharmacist are likely to follow the pharmacist’s instructions. Hodgkins said her health care organization embarked on the diabetes care program hoping to decrease hospital utilization, prevent preventable admissions, and perform better on the diabetesrelated Medicare Part C and Healthcare Effectiveness Data and Information Set quality measures. In 2013, the California Association of Physician Groups recognized Desert Oasis Healthcare’s “Pharmacist-Enabled Diabetes Care Management” program as a case study in excellence. Hodgkins and Valenzuela ascribed the success of their program to some features the two considered unusual. Under the protocol-based program, they said, the pharmacists • Can make the changes described in the collaborative practice agreement Continued on page 778
News Continued from page 776
rather than recommend changes to the primary care physician and await a decision and action, • Conduct face-to-face visits with patients between their appointments with the primary care physician, in addition to telephoning patients, • Do not charge for visits, and • Target patients with poorly controlled disease.
“Because we don’t have a copayment for our visits,” Valenzuela said, “we can have contact and ‘touches’ with a patient on a very regular basis.” And providing those visits at no cost to patients was important to the medical director, Hodgkins said. Valenzuela said the medication management services’ office contacts each patient at least once a week to ask, How are you doing? Did you have any side effects? Did you pick up your medication? “I think patients feel somewhat connected to their pharmacist” as a result of that frequent contact, Valenzuela said. “They’re much more likely to call with problems [that arise] or to inform us when maybe they’re not following the program exactly as we prescribed.” Each day about two pharmacist fulltime equivalents, aided by support staff, manage patients’ diabetes, she said. Hodgkins acknowledged that the faceto-face visits consume time, “but that’s what helps bond the patient to the process” and produce the good outcomes. Direct engagement. Valenzuela said many of the program’s patients arrive at the first face-to-face visit with an HbA1c level well above 10%, perhaps as high as 18%. “They really don’t feel well,” she said. The first visit with a patient who needs to start insulin therapy takes about 60 minutes, Valenzuela said. The second visit, a week later, may take 30–45 minutes. She said that throughout the initial startup of insulin therapy, the pharmacist provides “intense coaching” to ensure the patient progresses well. At every visit, the pharmacist downloads the data from a patient’s blood glu-
778
cose meter, she said. “It’s a nice visual for the patient because, of course . . . to see any difference [in an HbA1c level] you’re talking months, but you can really see a difference and a change in their blood glucose profile in a week or two.” That improvement in the blood glucose profile gratifies the patient, Valenzuela said, and provides motivation to continue following the pharmacist’s plan. Hodgkins said all the pharmacists in the program completed an ASHPaccredited, hospital-based pharmacy residency program and, during the ambulatory care rotation, displayed “a calling” for that type of practice. “To be successful in ambulatory care,” Valenzuela said, “you really have to be able to change your message or change the approach of your message to the
News Briefs • FDA on March 28 approved the marketing of AstraZeneca LP’s delayedrelease esomeprazole magnesium oral capsule for nonprescription use. The product will have the brand name Nexium 24HR. Labeling for the nonprescription product will state that its intended use is for the 14-day treatment of frequent heartburn in adults. The right to market AstraZeneca’s nonprescription Nexium product line was acquired by Pfizer in 2012. • The ethiodized oil injection previously known as Ethiodol and marketed by Nycomed US Inc. is now known as Lipiodol and marketed by Guerbet LLC, according to documents at FDA’s website. As soon as the newly FDA-approved manufacturing site in Canada starts producing Lipidiol for the U.S. market, Guerbet said, importation of Lipiodol Ultra-Fluide from Europe will not be needed. FDA has allowed temporary importation of the European product since 2013. The FDA-approved labeling for Guerbet’s Lipiodol, an oil-based contrast
Am J Health-Syst Pharm—Vol 71 May 15, 2014
patient that’s with you at the moment. Some people have referred to it as the emotional quotient, or EQ. . . . That’s what we try and look for when we’re looking for a pharmacist to fill roles within our department.” The department added a coronary artery disease program in March 2013, she said. It focuses on patients who have just had coronary artery bypass grafting or stent placement. Preliminary data suggest this program, which starts with an intensive medication reconciliation over the telephone with patients in the first 48 hours after hospital discharge, decreases the 30-day readmission rate, Valenzuela said. —Cheryl A. Thompson DOI 10.2146/news140037
agent, includes a boxed warning about the possibility of pulmonary and cerebral embolism from inadvertent intravascular injection or intravasation. • Michael S. Flagstad, M.S., a member of the ASHP Foundation Board of Directors, died unexpectedly on April 15 at the age of 63. Mr. Flagstad was the chief executive officer of Visante Inc., a pharmacy and healthcare management consulting company with headquarters in St. Paul. Previously he served as a senior vice president at Express Scripts Inc. Mr. Flagstad started his pharmacy career as a clinical pharmacist at Des Moines’ Mercy Hospital Center. He went on to serve as the clinical coordinator at Ingalls Memorial Hospital in Harvey, Illinois, and then associate director of pharmacy at Shands Hospital at the University of Florida, in Gainesville. Before joining Express Scripts, he worked for Diversified Pharmaceutical Services, the pharmacy benefit manager for United HealthCare. Mr. Flagstad, a graduate of the University of Wisconsin Hospital and Clinics residency program, was the recipient of the 2000 Winston J. Durant Lecture Award.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
type of billing that her hospital has successfully used. Sanchez said allowing pharmacists to provide billable MTM services has had a “community impact or cultural impact” at the hospital by promoting and codifying pharmacists’ routine interactions with patients at the bedside. “When you . . . become that practitioner who is face-to-face and interact-
ing with the patients and caring for them, you change the dynamics of your role, becoming much more visible,” she said. “We’ve gotten some phone feedback and some letters, and [patients] really appreciate some of the care they’ve gotten.” She said pharmacy students who come to the nonprofit community hospital during experiential rotations are enthusiastic about using the SOAP documentation format.
Direct engagement as part of collaborative practice improves diabetes care
P
harmacists’ direct engagement with patients whose diabetes mellitus had not been under control has helped a health care organization better serve this population and save money, metrics suggest. The direct engagement is part of the Lindsey Valenzuela collaborative practice protocol between the medical group and pharmacists at Desert Oasis Healthcare for the management of patients with Teresa L. Hodgkins diabetes, said Lindsey Valenzuela and Teresa L. Hodgkins. Valenzuela is the director of medication management services at the health care organization, based in Palm Springs, California. Hodgkins until recently was the services’ administrator. She is now the health care organization’s associate vice president for clinical performance and outcomes. Better outcomes, lower costs. The year before the health care organization created the protocol-based program, Hodgkins said, 24% of seniors with diabetes in the Medicare Advantage plan had a glycosylated hemoglobin (HbA1c) level greater than 9%. 776
But then, with the program in operation, the prevalence of poorly controlled disease dropped by at least half. Hodgkins said less than 12% of those seniors had an HbA1c level greater than 9% in 2012 and 2013. “That’s in the five-star cut point,” she said, referring to the top grouping in the Centers for Medicare and Medicaid Services’ quality-rating system for Medicare Advantage, or Part C, plans. Hospitalizations also decreased. In 2010, before implementation of the protocol-based program, patients with diabetes accounted for 40% of the bed days in acute care hospitals for the Medicare Advantage plan, Hodgkins said. That percentage has dropped as well, she said. Through the program, which starts with a physician’s referral, Hodgkins said, the pharmacists at any particular time manage 120–150 of the health care organization’s 5000-some patients with diabetes. These 120–150 collaboratively managed patients primarily are enrollees in the organization’s capitated health care plans: the Medicare Advantage plan and the commercial health maintenance organization. “How we can improve the outcomes and ultimately reduce costs is how they
Am J Health-Syst Pharm—Vol 71 May 15, 2014
“In this kind of setting—which is the majority of [U.S.] hospitals anyway—a lot of times the pharmacists aren’t actually seeing the patients very much. So when [students] come to us, they realize that here they get to go and see the patients,” Sanchez said. “They feel like they are doing patient care. I hear a lot about that.” —Kate Traynor DOI 10.2146/news140036
justify having the program,” Hodgkins said of her health care organization. The organization has reported a return on investment for the program of approximately 5:1. Reasons for success. Valenzuela said the requirement for a physician’s referral works in the pharmacists’ favor. By virtue of the referral, she said, “the physician has vetted that the program is positive.” The result is that even patients who were initially reluctant to be treated by a pharmacist are likely to follow the pharmacist’s instructions. Hodgkins said her health care organization embarked on the diabetes care program hoping to decrease hospital utilization, prevent preventable admissions, and perform better on the diabetesrelated Medicare Part C and Healthcare Effectiveness Data and Information Set quality measures. In 2013, the California Association of Physician Groups recognized Desert Oasis Healthcare’s “Pharmacist-Enabled Diabetes Care Management” program as a case study in excellence. Hodgkins and Valenzuela ascribed the success of their program to some features the two considered unusual. Under the protocol-based program, they said, the pharmacists • Can make the changes described in the collaborative practice agreement Continued on page 778
News Continued from page 776
rather than recommend changes to the primary care physician and await a decision and action, • Conduct face-to-face visits with patients between their appointments with the primary care physician, in addition to telephoning patients, • Do not charge for visits, and • Target patients with poorly controlled disease.
“Because we don’t have a copayment for our visits,” Valenzuela said, “we can have contact and ‘touches’ with a patient on a very regular basis.” And providing those visits at no cost to patients was important to the medical director, Hodgkins said. Valenzuela said the medication management services’ office contacts each patient at least once a week to ask, How are you doing? Did you have any side effects? Did you pick up your medication? “I think patients feel somewhat connected to their pharmacist” as a result of that frequent contact, Valenzuela said. “They’re much more likely to call with problems [that arise] or to inform us when maybe they’re not following the program exactly as we prescribed.” Each day about two pharmacist fulltime equivalents, aided by support staff, manage patients’ diabetes, she said. Hodgkins acknowledged that the faceto-face visits consume time, “but that’s what helps bond the patient to the process” and produce the good outcomes. Direct engagement. Valenzuela said many of the program’s patients arrive at the first face-to-face visit with an HbA1c level well above 10%, perhaps as high as 18%. “They really don’t feel well,” she said. The first visit with a patient who needs to start insulin therapy takes about 60 minutes, Valenzuela said. The second visit, a week later, may take 30–45 minutes. She said that throughout the initial startup of insulin therapy, the pharmacist provides “intense coaching” to ensure the patient progresses well. At every visit, the pharmacist downloads the data from a patient’s blood glu-
778
cose meter, she said. “It’s a nice visual for the patient because, of course . . . to see any difference [in an HbA1c level] you’re talking months, but you can really see a difference and a change in their blood glucose profile in a week or two.” That improvement in the blood glucose profile gratifies the patient, Valenzuela said, and provides motivation to continue following the pharmacist’s plan. Hodgkins said all the pharmacists in the program completed an ASHPaccredited, hospital-based pharmacy residency program and, during the ambulatory care rotation, displayed “a calling” for that type of practice. “To be successful in ambulatory care,” Valenzuela said, “you really have to be able to change your message or change the approach of your message to the
News Briefs • FDA on March 28 approved the marketing of AstraZeneca LP’s delayedrelease esomeprazole magnesium oral capsule for nonprescription use. The product will have the brand name Nexium 24HR. Labeling for the nonprescription product will state that its intended use is for the 14-day treatment of frequent heartburn in adults. The right to market AstraZeneca’s nonprescription Nexium product line was acquired by Pfizer in 2012. • The ethiodized oil injection previously known as Ethiodol and marketed by Nycomed US Inc. is now known as Lipiodol and marketed by Guerbet LLC, according to documents at FDA’s website. As soon as the newly FDA-approved manufacturing site in Canada starts producing Lipidiol for the U.S. market, Guerbet said, importation of Lipiodol Ultra-Fluide from Europe will not be needed. FDA has allowed temporary importation of the European product since 2013. The FDA-approved labeling for Guerbet’s Lipiodol, an oil-based contrast
Am J Health-Syst Pharm—Vol 71 May 15, 2014
patient that’s with you at the moment. Some people have referred to it as the emotional quotient, or EQ. . . . That’s what we try and look for when we’re looking for a pharmacist to fill roles within our department.” The department added a coronary artery disease program in March 2013, she said. It focuses on patients who have just had coronary artery bypass grafting or stent placement. Preliminary data suggest this program, which starts with an intensive medication reconciliation over the telephone with patients in the first 48 hours after hospital discharge, decreases the 30-day readmission rate, Valenzuela said. —Cheryl A. Thompson DOI 10.2146/news140037
agent, includes a boxed warning about the possibility of pulmonary and cerebral embolism from inadvertent intravascular injection or intravasation. • Michael S. Flagstad, M.S., a member of the ASHP Foundation Board of Directors, died unexpectedly on April 15 at the age of 63. Mr. Flagstad was the chief executive officer of Visante Inc., a pharmacy and healthcare management consulting company with headquarters in St. Paul. Previously he served as a senior vice president at Express Scripts Inc. Mr. Flagstad started his pharmacy career as a clinical pharmacist at Des Moines’ Mercy Hospital Center. He went on to serve as the clinical coordinator at Ingalls Memorial Hospital in Harvey, Illinois, and then associate director of pharmacy at Shands Hospital at the University of Florida, in Gainesville. Before joining Express Scripts, he worked for Diversified Pharmaceutical Services, the pharmacy benefit manager for United HealthCare. Mr. Flagstad, a graduate of the University of Wisconsin Hospital and Clinics residency program, was the recipient of the 2000 Winston J. Durant Lecture Award.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
