Considerations for Best Practice Developing a CDTM Practice€¦ · Medicine PGY2 Ambulatory...

Developing a CDTM Practice: Considerations for Best Practice

Charrell S. Porter, PharmD, BCACP

Elizabeth Harris, PharmD, BCACP

Conflicts of Interest

▪The presenters have no conflicts of interest to disclose.

Objectives

▪Define terminology relating to the practice of collaborative drug therapy

management (CDTM)

▪Describe the national landscape of CDTM

▪Explain the legal requirements for CDTM and components of a

collaborative practice agreement (CPA)

▪Identify potential billing and reimbursement options for pharmacist

services

▪Examine best practices for implementation of CDTM

Audience poll

▪Who works at an institution where pharmacists work collaboratively with physicians in ambulatory clinics making medication-related decisions?

▪Who is working in an institution or company that require pharmacists to be credentialed in CDTM?

Presenters’ Affiliations

Virginia Commonwealth University School of Pharmacy

PGY1 Pharmacy Practice-Sibley Memorial Hospital, Johns Hopkins

Medicine

PGY2 Ambulatory Care-Temple University School of Pharmacy

University of the SciencesPhiladelphia College of Pharmacy

Ambulatory and Community Pharmacy Practice

University of Pittsburgh School of Pharmacy

PGY1 Community Pharmacy Practice-University of Pittsburgh and

Giant Eagle, Inc.

Charrell S. PorterPharmD, BCACP

Elizabeth HarrisPharmD, BCACP

Collaborative Drug Therapy Management Roadmap

Understanding terminology

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Assess the externalclimate for CDTM

2

Determine provisionof services

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Find your physicianchampion (s)

4

Potential billing mechanisms

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Considerations for clinic operations

6Determine the legalrequirements

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Protocol development

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Collaborative Drug Therapy Management Roadmap

JCPP Defining the terms:Medication Management Services

A spectrum of patient centered, pharmacist-provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes.

-Joint Commission of Pharmacy Practitioners

Defining the Terms

Collaborative Drug Therapy Management (CDTM)

“ involving a collaborative practice agreement between one or more physicians and qualified clinical pharmacists who work within the context of a defined

protocol that permits the clinical pharmacist to assume responsibility for performing patient assessments; ordering drug therapy–related laboratory tests;

administering drugs; and selecting, initiating, monitoring, continuing, and adjusting drug regimens”

Defining the Terms

Collaborative Drug Therapy Management (CDTM)

“ involving a collaborative practice agreement between one or more physicians and qualified clinical pharmacists who work within the context of a defined

protocol that permits the clinical pharmacist to assume responsibility for performing patient assessments; ordering drug therapy–related laboratory tests;

administering drugs; and selecting, initiating, monitoring, continuing, and adjusting drug regimens”

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Purpose of CDTM

•Improve collaboration between pharmacists, physicians, patients, and Improve collaboration betweother healthcare providers

•other healthcare providersFree provider time and availability by allowing pharmacist to manage Free provider time and availabpatients between PCP visits

•patients between PCP visits Reduce the risk of adverse drug events and interactions

•Reduce the risk of adverse drug events and interactionsOptimize medication use for improved patient outcomes

•Optimize medication use for improved patient outcomesReduce delays in modifying drug regimens and unnecessary physician Reduce delays in modifying drug regimens and unnecessary phoffice visits, and increase patient compliance and adherence

Differences Between MTM and CDTM

Medication Therapy Management (MTM):

▪Review and identify problems/solutions for patient’s problems/solutions for patienentire medication regimen▪

g▪Must contact MD, recommend and Must contact MD, recommend and M

receive approval to make changes

Collaborative Drug Therapy Management:

▪▪Focus on specific disease state or Focus on spe Fsymptom and manage patient’s drug therapy for this condition ▪

gpy▪Pharmacist can make changesto drug

regimen, order labs, perform monitoring

order labs, perform orderlabs,performg independentlyfor this

condition as outlined in agreement with physician

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How can pharmacists be utilized in a clinic?

A.Counsel a patient regarding approaches to smoking cessation

B.Adjust insulin for a patient with diabetes who is not meeting treatment goals

C.Create a hypertension care plan with individualized treatment goals

D.Perform a comprehensive medication review to identify potential drug interactions

E.All of the above

State-by-State Differences

▪48 states permit some type of CDTM. Differences exist with:

▪Type of practice site▪Pharmacist qualifications▪Type of prescribers▪Defined prescriber-pharmacist

relationship▪Scope of services▪Documentation/notification

requirements▪Approval by state agency▪Length of agreement validity▪Liability requirements

Centers for Disease Control and Prevention. Advancing team-based care through collaborative practice agreements: A resource and implementation guide for adding pharmacists to the care team. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2017.

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Opportunities for CDTM in Practice

Immunizations

Formularymanagement

Refill authorization

Point-of-care testing

Disease state management

Immunizations

▪One of the first areas in which pharmacists engaged in CDTM through the use of protocols

▪Some states’ scope of CDTM is limited to immunizations and therapeutic injection services

▪Some states require either a protocol or prescription for all vaccines (PA)

▪LA: permits the administration of some/all vaccines without protocol or prescription to patients 17+

▪The need▪Despite availability of immunizations, vaccination rates remain low

▪The opportunity▪Physician champions (if protocol/prescription needed), particularly

for offices administering high numbers of non-Medicare Part Bcovered vaccines

Surveillance of Vaccination Coverage AmongAdult Populations 2015 (%)

Influenza44.8

Tdap23.1

Pneumococcal (19-64)23

Pneumococcal (> 65)63.6

Hepatitis A9

Hepatitis B25.6

Herpes zoster30.6

HPV (females)41.6

HPV (males)10.1 1. Centers for Disease Control and Prevention. Advancing team-based care through collaborative practice agreements: A resource and implementation guide for addingpharmacists to the care team. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2017.

2. Williams WW, Lu P, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations -United States, 2015. MMWR SurveillSumm2017;66(No.SS-11):1-28.

Formulary Management

▪The scope of CDTM in some states permits therapeutic interchange in which a pharmacy may substitute a drug within the same class due to the variability in prescription drug plan formularies

▪LA: therapeutic substitution is not allowed without the primary care provider’s explicit consent

▪The need▪Prescription claim rejections due to “drug not covered” or “prior authorization

required” accounts for ~30% of all claim rejections

▪The opportunity▪High priority patient populations who require prescriptions in a timely manner

(e.g. transitions of care)▪Providers with limited office hours

1. Centers for Disease Control and Prevention. Advancing team-based care through collaborative practice agreements: A resource and implementation guide for adding pharmacists to the care team. Atlanta, GA:Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2017.

2. HerrierRN, Spencer JR, Davis CD. Case study using descriptive analysis to estimate hidden costs in processing third party prescriptions. J Am Pharm Assoc(Wash). 2000 Sep-Oct;40(5):658-65.

Refill Authorization

▪Permits a pharmacist to extend prescription refills based on their assessment of the patient to remove administrative barriers and increase medication adherence

▪Some states allow this practice without a CPA▪LA: the ability to authorize up to a single

seven day supply of a prescription may be specified within the CPA between a pharmacist and physician

▪The need▪Lack of refills contributes to a significant

portion of medication nonadherence

▪The opportunity▪“Slow to respond” provider offices▪Provider offices with limited hours

1. Centers for Disease Control and Prevention. Advancing team-based care through collaborative practice agreements: A resource and implementation guide for adding pharmacists to the care team.Atlanta, GA. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2017.

2. Bailey GR, BarnerJC, Weems JK, LeckbeeG, Solis R, MontemayorD, Pope ND. Assessing barriers to medication adherence in underserved patients with diabetes in Texas. Diabetes Educ. 2012 Mar-Apr;38(2):271-9.

Bailey et al. Frequency of Reasons for Nonadherence

* Denotes statistical significance

Point-of-Care(POC)Testing

▪Performing a diagnostic test outside of a laboratory that produces rapid and reliable results to aid in identifying or managing chronic diseases and acute infections

▪The scope of CDTM in states may allow for ordering laboratory studies, interpreting laboratory studies, and/or performing laboratory tests

▪LA: may order, evaluate, and apply the results of laboratory tests directly related to the disease specific drug therapy managed under written protocol

▪Tests may not require the pharmacist to interpret the testing or formulate a diagnosis

▪The need▪Acute infectious screening, chronic disease screening, chronic disease monitoring

▪The opportunity▪Provider offices with limited appointment availability for acute and/or follow-up visits

1. Centers for Disease Control and Prevention. Advancing team-based care through collaborative practice agreements: A resource and implementation guide for adding pharmacists to the care team. Atlanta, GA:Centersfor Disease Control and Prevention, U.S.Department of Health and Human Services, 2017.

2. National Community Pharmacists Association. Point-of-care (POC) testing. Alexandria (VA): National Community Pharmacists Association. Available from: https://www.ncpanet.org/innovation-center/diversified-revenue-opportunities/point-of-care-(poc)-testing.

CDTM Roadmap


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CDTM Law: A look at Louisiana

Authorized Services

▪Disease states/drug therapy▪Limited to certain disease states unless approved by the board

▪Anticoagulation, diabetes, asthma, dyslipidemia, smoking cessation, vaccines

▪Drug therapy should be within the standard of care▪Predetermined by the physician and written in a protocol

▪Services provided▪Monitoring and modifying drug therapy▪Collecting and reviewing patient history▪Obtaining and reviewing vital signs▪Ordering, evaluating, and applying results of laboratory tests

▪Tests may not require the pharmacist to interpret testing or formulate a diagnosis

▪Administration of vaccines▪Refill authorization (up to a seven day supply)▪Providing disease or condition specific education and counseling

Collaborative Drug Therapy Management, 46 Louisiana Administrative Code §523 (2007).

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Protocols

▪Shall be:▪Written for each patient

▪A standard protocol may be adapted for each patient▪Signed by the physician and represent the physician orders▪Made part of the patient’s pharmacy record▪Appended to the CDTM agreement and filed at the pharmacy practice site

▪Shall contain:▪Pharmacist’s and physician’s phone number and contact information▪Patient’s demographic information▪The disease/condition to be managed▪The drug therapy to be utilized▪The type and extent of drug therapy management to be performed


Requirements and Restrictions

▪Registration▪Must apply to engage in CDTM via forms supplied by the board▪Notify board of any additional collaborating physicians

▪Patient Consent▪Patient’s written informed consent on collaborativenature

▪Contact information for follow-up visits with pharmacist and physician▪Opportunity to decline participation in CDTM at anytime without terminating

relationship with pharmacist and/or physician▪Provided written disclosures of any financial arrangements ▪Services provided ensure patient privacy and confidentiality

▪Renewal timeframe▪Registration of authority to engage in CDTM expires annually on the same day

as the pharmacist’s license▪Annual review of each patient’s written protocol


Requirements and Restrictions

▪Documentation and reporting process▪Requirements specified on the protocol▪Document all activities performed and physician consultations▪Submit patient status reports to the collaborating physician at least every 30

days

▪Liability▪None specified


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In your experience, who do you think has been the greatest operational obstacle with CDTM?

A.PhysiciansB.NursesC.PharmacistsD.Payers

Obstacles to CDTM

▪Difficulty obtaining physician acceptance

▪Lack of support from administration

▪Slow process for getting credentialing status

▪Inadequate knowledge of billing and clinical skills

▪Lack of cohesive vision for practice models

▪Insufficient space to perform services

▪Outcomes failing to meet expectations

Find and partner with champions!

CDTM Roadmap


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CDTM

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Perform a Market Analysis

▪Determining what is desired by the patients, providers, organization, and payers

▪Understand what are the gaps between the current level of care and desired level of care

▪Three questions should be addressed:

What are the unmet needs or problems?Who is managing patients in the area?

How well are the needs currently being addressed?

Develop the Mission and Vision of Your Practice

▪Mission: Describe the purpose of your program, why it needs to exist

▪Vision: Describe where the program is going, what it wants to achieve and accomplish

▪Provides a focus and guideline to assist in developing the services

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Clinic Operations

▪Consider how you and the patient will interact at each point of their clinic experience.

▪Referral system▪Scheduling patients▪Office space considerations▪Billing process▪Follow-up▪Documentation & communication▪Clinic work flow

Staffing Considerations

▪PGY1 and/or PGY2 pharmacy residents ▪Pharmacy practice and/or Ambulatory care

▪PGY2 Specialty residency or fellowship

▪Credentialing▪Board Certification

▪Pharmacotherapy (BCPS), Ambulatory Care (BCACP)▪Other Certifications

▪Consider 0.25 pharmacist FTEs for every 1 physician in the practice (depending on the size of the practice)

Patient-centered Primary Care Collaborative. Payment reform to support high-performing practice: report of the paymentreform task force—July 2010. https://www.pcpcc.org/sites/default/files/media/paymentreformpub.pdf.

Equipment and Costs

▪Consider the revenue and expenditures▪Staffing costs

▪Shared model pharmacy, hospital, university▪Materials

▪Point of care device and test strips (optional)▪CLIA license▪Also need lancets, gauze, band-aids, etc.

▪Computer system or other type of database▪Charts, paper, etc.

▪Site expenses ▪Office space rent▪Phone/fax service, security, etc.

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Managed Care Organizations

3 primary goals of an MCO

1.Improving the quality of patient outcomes,

2.Increasing patient satisfaction

3.Managing costs.

CDTM agreements between physicians and pharmacists can contribute to each of above goals. CDTM agreements take maximum advantage of the physician’s training and expertise in disease diagnosis and

the pharmacist’s training and expertise in drug therapy and disease management.

Benefits

The return on investment of CDTM practices calculated by the managed care organization is expected to be positive

Opportunities for CDTM within health

plans

Emergency contraception

Depression management

Smoking cessation therapy

Flu/antiviral therapy the quality of patient outcomes

Increasing patient satisfaction managing

costs

LA MCOs

Aetna Better Health

AmeriHealth Caritas

Healthy Blue (formerly known as Amerigroup

Louisiana, Inc.)

Louisiana Healthcare Connections, Inc

UnitedHealthcare

•Level 1 HCPCS codes are commonly referred to as CPT (Current Procedural Terminology) codes

•The “why” a service was provided is the diagnosis code, which currently is identified by the International

•Classification of Disease, 10th Revision (ICD 10).

•All pharmacists participating in CDTM required to apply for an NPI

•No charge•Turn around time is

usually 1-2 days•Can be done early in

the process

CMS 1450 form: •Hospital based

services•Medicare Part A

CMS 1500: •Outpatient services•Medicare Part B

Service providedHCPCS

(CPT) code

Why it was done:

ICD-10 code

Who did it: NPI

Final submitted

codes for the claim

https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do

Process for health care service billing

Billing: An Example

▪J.S. is a 48-year-old woman who presents to your community pharmacy for an initial MTM visit. The pharmacist discusses medication adherence, together with the medication’s possible adverse effects, and monitoring parameters. The visit takes 30 minutes to conduct. Which would be the most appropriate MTM CPT code(s) used to bill for services?

A.99605 onlyB.99606 onlyC.99605 and 99606D.99605 and 99607

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Elements of a CPA

●Participants○Pharmacists/prescribers○Additional training/credentialing○Patient population

●Authorized services○Disease states/drug therapy○Services provided○Protocols or guidelines to be followed

●Requirements/Restrictions○Patient consent○Renewal timeframe○Documentation process○Liability

Example description of services for smoking cessation CDTM:

To initiate, adjust and revise patient smoking cessation regimens using the

seven 1stline medications based on efficacy and safety. Pharmacists will revise

medications based on efficacy, signs and symptoms of nicotine withdrawal and

medication tolerance/adverse effects. Pharmacists will also take into

consideration contraindications, level of nicotine dependence, patient specific

factors/preferences and insurance coverage.

Participants

▪Practitioners▪Between a pharmacist and physician

▪Training and credentialing▪Pharmacist must hold a Doctor of Pharmacy degree

▪Board may review exceptions on a case-by-case basis

▪Patient population▪Adults 18 years of age and older

▪Exception: services for vaccinations and smoking cessation therapy▪Not pregnant or nursing


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What’s next?

▪Plan a start date▪Advertise your services

▪Are customers (patients and physicians) familiar with the concept of pharmacist-managed clinics?

▪Don’t forget your liability insurance!▪Perform quality assurance after 6-12 months

▪Evaluate outcomes, patient satisfaction, consider referring physicians opinions

▪Assess how closely therapy follows standards▪Prepare to adapt model, re-educate staff, etc. as needed

▪Review agreements annually (or as dictated by state law)

Opening Soon! Awesome pharmacy clinic providing services in smoking cessation, diabetes and high blood pressure management. Check us out!

Summary

▪Many patients with diabetes, chronic anticoagulation, hypertension, moderate to high CV risk, and other diseases remain undertreated

▪Pharmacists accessibility, knowledge of medications, and ability to communicate with patients and other providers enables them to intervene

▪Primary care practitioners are in high demand; disease state management by pharmacist can free their time for more patient visits

▪Understanding billing practices allows pharmacists to contribute financially to their institution

▪CDTM allows pharmacists to practice at the top of their game while serving unmet needs for positive patient outcomes

Thank You!

Considerations for Best Practice Developing a CDTM Practice€¦ · Medicine PGY2 Ambulatory...

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