Feature | Clinical Performance
|NCPA Pharmacist of the Year Randy P. McDonough, R.Ph., Pharm.D., left, and pharmacy co-owner and software company development partner, Mike Deninger, R.Ph., Ph.D., who implemented a clinical practice model at Towncrest Pharmacy to drive new revenue and reinvent the traditional pharmacy model.|
“Free up the pharmacist” is the mantra that drives the vision of Randy P. McDonough, R.Ph., director of clinical services, and co-owner Mike Deninger, RP.h., Ph.D., for Towncrest Pharmacies and Towncrest Compounding in Iowa City, Iowa, and Solon Towncrest Pharmacy in Solon, Iowa.
“We are a community pharmacy that provides clinical services,” says McDonough. “I think over the years, we’ve all used the word retail, and we have commoditized what pharmacists do as product distribution. And we do much more than that.”
These entrepreneurs are talking about a paradigm shift — to where pharmacists are free to handle medication reviews and continuing medication monitoring (CoMM) with every patient. “We don’t just want to get paid to dispense a product,” says McDonough, “but rather paid to make sure the patient has a positive outcome.”
McDonough’s leadership and commitment to innovation in pharmacy practice were the reasons he was awarded the National Community Pharmacists Association’s (NCPA’s) Willard B. Simmons Independent Pharmacist of the Year award in 2016. The recognition highlights McDonough and Deninger, chief technology officer of their related software and consulting company, Innovative Pharmacy Solutions, who together set a goal to transform the delivery of pharmacy services, one that is built on a clinical model to take pharmacy further into the accountable care healthcare model and value-based reimbursement that are transforming the health-care industry.
The Value in Patient Encounters
More than a decade ago McDonough could see the shift to what is now called accountable care and value-based reimbursement and realized pharmacy had to reposition itself in a clinical role, not just a distributor role. When he and Deninger became co-owners of their practice, McDonough talked to Deninger about the need for a clinical documentation record for patient care, including SOAP (subjective, objective, assessment, and plan) notes that can be communicated directly to the physician. From those first wish-list items, McDonough and Deninger have built a full-fledged clinical system that documents SOAP notes, medication-related problems, pharmacists’ interventions, and physician communication. It also provides feedback to the pharmacist to highlight drug therapies that are of interest to payers or associated with a performance metric platform, e.g., EQuIPP (Electronic Quality Improvement Platforms for Plans and Pharmacies). PharmClin, by Innovative Pharmacy Solutions, patent-pending clinical documentation software, gives a community pharmacist the tools to incorporate continuous medication monitoring (CoMM) into everyday practice and conduct regular comprehensive medication reviews (CMRs).
“We say ‘make every encounter count,’” says McDonough. “The best time to conduct a clinical intervention — to collect data and identify any problems — is when the patient is in front of the pharmacist. The pharmacist still has to ask the right question and make a clinical decision, but the software allows them to quickly document it as well.
Towncrest is a 3,000-square-foot pharmacy with 1,000 square feet dedicated to the nursing home and group home business. The compounding division serves 500 patients. The main floor (1,500 square feet) houses the dispensing functions, incorporating CoMM, clinical services, durable medical equipment, and health-related over-the-counter products. In many ways, this presents as a typical “retail” pharmacy, yet a closer look at the workflow reveals a process where pharmacists have more responsibility to assess the drug therapy of each patient. To do this, the pharmacy workflow moves to one where technicians handle the bulk of the dispensing process, including verification by techicians (tech-check-tech), a new practice model that is currently in the third phase of a pilot study by the Iowa Board of Pharmacy; there are slack resources to redistribute pharmacists where needed; and pharmacists document their clinical work in PharmClin software that interfaces with the pharmacy management system. This process-driven practice gives pharmacists more time and responsibility to assess drug therapies, identifying and resolving medication-related problems for each patient and at every encounter.
“What’s incredible to me is I’ve been behind the counter when all these things are in effect, the tech-check-tech and all the other pieces are running,” says Deninger, “and it’s amazing how much more efficient I can be clinically. It’s amazing what I can do when I’m free from just checking prescriptions. My clinical work went up 100% with the number of interventions and SOAP notes I did in a five- or six-hour shift.”
The Towncrest philosophy led McDonough and Deninger to build the consulting and clinical documentation software. “When we started this, I was the only one doing SOAP notes, and I was doing 10 to 15 SOAP notes a week,” says McDonough. Today the pharmacists collectively document between 2,000 to 3,000 clinical interventions a month.
A Clinical-Focused Workflow
Towncrest uses a pyramid approach to clinical care. Each patient receives CoMM, followed by closer monitoring for those with disease-specific problems. Patients enrolled in clinical medication synchronization at Towncrest come to the pharmacy on an appointment model after the pharmacy staff have performed CoMM, have questions ready to ask the patient, and are prepared to collect more information to resolve any medication-related issues.
High-risk patients, the pinnacle of the pyramid and most costly to a payer, receive comprehensive medication reviews (CMRs). With CMRs, pharmacy staff will call patients and schedule a face-to-face visit either at the pharmacy or at the patient’s home. Pharmacists continue to perform targeted interventions integrating CoMM for each patient each time a prescription is filled, whether a refill or a new prescription. If a medication-related problem is found, the pharmacist can either take care of it at the counter or, if it is a more complicated medication-related problem requiring a more intensive visit with the patient, the patient is transferred to a slack resource pharmacist in one of the clinical patient care areas. On any one day there will be an overlap of three to five pharmacists, all busy providing patient care services.
“When doing CoMM you are not just looking at the drug going out the door at that time, you are looking at the whole picture,” explains Deninger. “Patients may be used to having a personal relationship with their pharmacist, but they may not be as familiar with the pharmacist asking more clinical questions like ‘How is your blood glucose level?’ The patient might wonder why we’re asking because they aren’t picking up a diabetic medication, but we’re looking at the whole picture. This new relationship — a therapeutic relationship — increases the responsibilities of the pharmacists to ensure that their patients are achieving their therapeutic outcomes with safe and effective medications. For deliveries, the slack pharmacists will call and document the information.”
Towncrest’s outcomes-based process and documentation was in place before EQuIPP was shaping the healthcare scene, points out McDonough. With the documentation software, McDonough was confident he could show the financial benefit of a pharmacist’s clinical expertise. He secured a $50,000 grant from the Community Pharmacy Foundation to do a study, looking at the pharmacy’s own data. His results prove his theory: They documented that pharmacists made 17,000 clinical interventions with just over 50% drug therapy problems of the drug dispensed, and 60% interventions that had nothing to do with the drug dispensed at the time. In the clinical model, pharmacists were identifying issues beyond what was being dispensed because the pharmacist was looking at the patient comprehensively.
“I felt confident that we had a process in place where we could affect performance metrics, and we could affect patient outcomes and affect healthcare costs,” says McDonough. With this data in hand, McDonough presented the results to one of the largest payers in the state, stressing the financial impact proactive clinical work with patients can have. What McDonough found is that the payer has risk-stratified all its beneficiaries. If the pharmacy can prevent a patient from moving from one risk level to another, it saves tens of thousands of dollars. “If patients are on drug therapy, then they better be achieving the outcomes, because if they aren’t, they are going to have an event that is going to be costly to the payer,” says McDonough.
The payer ran a pilot program with Towncrest in 2014. The results were so positive, it’s rolling out a high-performance network of pharmacies, in which the pharmacy will be paid differently based on how it impacts performance measures and total cost of care. Patients who used Towncrest 100% of the time saw a reduction in healthcare costs and improved overall clinical care. Even for those who shopped around, the more they came to Towncrest, the better the outcome, says McDonough. “And that was coming from the payer claims,” he says.
The Paradigm Shift
McDonough and Deninger echo what other innovative business owners are saying about the future of community pharmacy: If the bread and butter of a pharmacy is making money from filling scripts, then it’s absolutely necessary to find additional revenue. Their work has shown how clinical interventions can result in new revenue, creating opportunity with medication therapy management fees by servicing group homes, and in the case of Towncrest, receiving performance bonuses, too.
|ClinPharm allows pharmacists at Towncrest to improve patient outcomes by recording every intervention in the pharmacy’s continuous medication monitoring (CoMM) and comprehensive medication review (CMR) programs.|
As the clinical metrics continue to point to the reimbursement model in pharmacy, McDonough and Deninger have become part of the community pharmacy enhanced network in Iowa. Right now there are over 80 pharmacies in the network, where pharmacies can be part of a high-performance network and have the power to go to health systems, ACOs (accountable care organizations), and payers to show the value of core services offered. “It will be huge in a value-reimbursement system,” says McDonough.
Adds Deninger, “It’s one thing to say work outside the box, but you have to make sure you synergize to work with other groups doing the same kind of things.”
This doesn’t happen overnight in a pharmacy. The results at Towncrest reflect a decade’s worth of work. McDonough says to start small — learn more about each patient and keep a record of the medication that’s being dispensed and being monitored appropriately. Evaluate your pharmacy’s workflow and see where you can add slack resources. Think of a new way of doing things.
“We want to shift the paradigm of pharmacy,” says McDonough. “Our work with the payer shows people it can be done. We can see what happens when you’re proactive with patient care.” CT
Maggie Lockwood is VP and Director of Production at ComputerTalk. She can be reached at email@example.com.