Pilot Pharmacy Project at QueensCare Health Centers

CECILIA WU, PHARMDCLINICAL PHARMACIST

Bringing MTM to the Patient

Learning Objectives

Describe the goals of the BD Helping Build Health Communities™ grant.

Explain the rationale for the pilot pharmacy project and discuss the alignment with CRMC goals.

Develop a strategy for restructuring pharmacy workflow to improve diabetes medication use and monitoring.

The Grant – BD Helping Build Healthy Communities™

Program Goals – to expand access to care, improve healthcare in underserved communities Donations for medical supplies Grants for CHC’s with innovative models of care

Since 2013 – 36 health centers - awards for diabetes, HIV/AIDS, cervical cancer screening

2017, focus on innovative MTM (Medication Therapy Management)

The Idea…

Clinical Pharmacists can NOT see every uncontrolled DM pt

Many Patients NO SHOW to clinic appts, labs, etc.

But patients make it to the pharmacy regularly

A great opportunity for MTM (education, management)

Clinical Pharmacistsin health centers

Mission

Reduce the burden of chronic disease by advancing the role of pharmacists in the healthcare system

Vision

Establish a network of pharmacies in the community that provide high-impact Comprehensive Medication Management (CMM) services that is sustainable and aligned with population health priorities within health plans and health systems, as well as serve as access points for health and social services.

MTM Project Implementationfocus on the process…

Who are our patients?

What do they need? Which disease state(s) to focus on?

What are our strengths? What are our limitations?

What can we do to help our patients? What easy steps can we start with?

Background info

FQHC – 5 health centers in Los Angeles, 2 pharmacies

2018 - 24,162 unique pts 28% Pediatric 60% Adult (18-64 yrs) 12% Elderly (>65 yrs)

60% Non-English speaking Largest group Hispanic/Latino origin (70%)

78% Below Poverty Level

4,287 Diabetic patients (2018) ~1/4 have A1c > 9% or no lab in past year East LA health center worst DM control

Limited/fixed access –schedule 8-12 pt/day

In-depth interactionsLonger (15-30min) encountersSpecialist in chronic disease

Residency trainingCollaborative Practice

agreementFull chart access

Open access – no appts

Superficial interactionsShort encounters

Basic disease knowledgeUsually no residency

trainingNo Collaborative Practice

agreementLimited chart access

Clinical Pharmacists

In-house Pharmacy

Clinical Pharmacists

In-house Pharmacy

• Patient Rapport• Speak Language• More accessible

than PCP• Free access to

Pharmacist• One health

system

Simple Targeted MTM Interventions

Trigger Assessment Intervention

Rx Type, Fill, Check Pt pickup

MedicationA1c lab

1-3 questions by Tech

Consultation by RPh based on

pt response

Triggers for MTM – casting a wide net

Any Diabetes TESTING supply Rx (Glucometer, Test Strips, Lancets) proper glucometer, lancet use review SMBG goals

Any INSULIN Rx being picked up counsel on adherence tips

Will Call Pts with Overdue A1c (>4 mo.s) lab same day

Will Call Pts with Elevated A1c (>/=10%) discuss with patient

Sample Patient Interaction

Diabetic Patient comes to Pharmacy to pick up meds (ex: Test Strips)

Pharm Tech asks Patient:

-Problems using meter?-Know BG goals?-Know what to do if BG too

high/low?

Pharmacy Staff can provide education:

-Glucometer & Lancet Use-Review BG Goals-Review Hypoglycemia

management-Refer Patient back to PCP, or

Clinical Pharmacist, Nutritionist, etc

Patients had problems using their glucometer

Pharmacy staff reviews proper glucometer, lancet use

Patients didn’t know their BG goals

Pharmacy staff reviews BG goals & gives out SMBG goal stickers

Patients admit to skipping injections

RPh reviews Insulin Adherence Tips

How do we target uncontrolled Diabetics? Need clinical data

Pharmacy software & EHR software do NOT communicate

Manual chart review - Too time-consuming to check EHR for each DM prescription

Quick access list of data - A1c moving target (changes every few months)

Process can NOT slow down Pharmacy operations

Will Call IT program cross references Will Call report with EHR data

Med bags are flagged for intervention

Triggers for MTM - focused approach

Any Diabetes TESTING supply Rx (Glucometer, Test Strips, Lancets) proper glucometer, lancet use review SMBG goals

Any INSULIN Rx being picked up counsel on adherence tips

Will Call Pts with Overdue A1c (>4 mo.s) lab same day

Will Call Pts with Elevated A1c (>/=10%) discuss with patient

Overdue A1c

Same day A1c lab

Moved to top of Lab line

About ½ patients get A1c done same day

Elevated A1c

Frequency of MTM Interventions

A1c Data

# Patients Average A1c

Baseline (w/in 6 mo.s of 1st intervention)

427 9.32%

1st f/u A1c 349 8.97%

2nd f/u A1c 217 8.73%

3rd f/u A1c 85 8.35%

Number of Patients Served

Patient MTM Encounters 1077

Unique DM Patients 441

Distribution of A1c’s

56

126107

83

BaselineN = 427

57

135103

54

1st f/u A1cN = 349

36

99

53

29

2nd f/u A1cN = 217

14

48

15

8

3rd f/u A1cN = 85

< 7%

7 – 8.9%

9 – 11%

> 11%

Our Next Steps

Roll out in HW Pharmacy busier, more diverse (serves HW, EP, ER)

Add more clinical interventions at ELA pharmacy recommendations for therapy changes review glucometer readings

Target more Care Gaps (HEDIS measures) Eye Exams Podiatry

Challenges

Staff Training

Pharmacy staff were “shy” (not accustomed to talking to pts clinically)

Patient acceptance

Streamlining data collection, errors in data entry

Linking pharmacy operation to clinical data

Reproducible at 2nd pharmacy site?

Sustainability & funding sources

Things to think about…

Who are your patients?

What do they need?

What are your strengths? What are yourlimitations?

What can you do to help your patients? What easy steps can you start with?

Questions?

Supplemental SlidesFOR Q & A

Data Collection• Online app• HIPAA compliant• Data entered in

real-time

Tracking A1c – Microsoft Power BI

In-House PharmaciesHollywood East 3rd

Daily Rx #Average 333 Rxs(range 315-351)

Average 174 Rxs(range 166-185)

Staff1.2 RPh2 Tech

1 Assistant

1 RPh1-2 Tech

Patient Population

Hispanic, Armenian/Russian

KoreanHispanic

otheriPad

KL-60 RobotiPad

Consultation Room