Care for One Patient at A Time
Amina Abubakar has seen the trend and recognized the need for action early. She’s been working for the last couple of years on transitioning from dispensing to more patient-centered models at Rx Clinic Pharmacy. The new dynamic has become very clear to Abubakar: “I’ve always focused on patients in our pharmacy. This wasn’t a shift. It’s just been a shift in how we manage certain parts of the care we provide,” she says. “Dispensing is just giving patients what the doctor ordered, but the money has shifted to value-based interactions. Providing value by putting the patient in the center can save a lot of healthcare dollars.” It was this realization that encouraged her to move Rx Clinic Pharmacy toward the current model of doing chronic-care management for physicians. “This is valuable for them because they’re being measured just like we are,” says Abubakar. “That similarity has produced a big opportunity for us.”
Hobbs Pharmacy has also been working toward adjusting its care model to the new reality, according to Eric Russo. The organizing principle, as Russo explains it, is that any patient care process has to try and fit the solutions to the patient. “We look for different things that are going to help our patient population get better results from their medicine,” says Russo. “One of our big focuses has been moving to really engage patients about their medications and their conditions and give them tools to educate themselves and support our counseling.”
Care environments are different too, notes Marilyn Goulty. For example, Cutie Pharma-Care serves people in assisted-living facilities and group facilities for people with disabilities that operate under the auspices of the New York State Office of People with Developmental Disabilities (OPWDD). “Many of the caregivers in these facilities are trained in medication passes, but don’t have medical training,” notes Goulty. “We provide medication management services to these facilities.” She also notes that there is a big push in New York state for people to remain in their homes as they age or recover from a hospitalization. This demographic, points out Goulty, is also in need of simplified medication regimens and is often dependent on others to get their medications for them and administer them. “We understand this, and we offer synchronization and adherence packaging that means the caregivers can easily see where they are in a day’s dispensing. We support this care environment and help relieve the risk of medication error.”
The Process Is Central
The care process at Rx Clinic Pharmacy starts with the new patient intake process. This is when Abubakar’s staff takes time to learn about patients: what’s brought them to the pharmacy, what medications they’re taking, what their medical conditions are, and what their experience has been with their care so far.
While this process should be familiar from its use in physicians’ offices, it is not the standard yet in pharmacy. “I was teaching a class on clinical services to other independent pharmacies,” says Abubakar. “I got an overwhelming request from people saying, ‘Could you share your processes?’ I found out that what we do isn’t what a typical pharmacy does.” The intake process does take time, which may be why more pharmacies don’t do it, according to Abubakar. For pharmacies that are continuing to focus more on the prescription rather than the patient, it’s going to be hard to perceive the value here. But once you understand that this step is just the first element of a broader patient-centered approach, then you can begin to build your practice around it, as Abubakar has.
As Eric Russo mentioned, an important element of the care process at Hobbs Pharmacy is promoting health literacy, which can be a real challenge. But it also brings great rewards for patients. Typically, paper has been the means for trying to pass along knowledge to patients. But every pharmacist has his or her story about just how futile it can be to hand out what are often thick packets of printed material. “We understand that simply printing the paper patient information isn’t a solution for all patients,” says Russo. “There are people who either have low literacy or don’t retain those records. Too often we actually see the people throw the paper away.” In the best of circumstances, paper can be hard for a patient or caregiver to keep organized in any practical way.
Creating a patient care process in your pharmacy can mean reorganizing how your staff works, as well as looking to technology for innovative ways to support your goals. Amina Abubakar has done both at Rx Clinic Pharmacy. “We did an internal assessment and we asked, what are pharmacists doing that doesn’t require their license?” she explains. “That’s where we started because a lot of the time we hear pharmacists say, ‘I don’t know how you guys do it. I don’t have time to do MTMs [medication therapy management]. I’m on the phone and filling scripts all day.’” And this is true when you are working with a standard pharmacy model. But significant work preparing for MTM interactions can be delegated to technicians, just as much of the dispensing process can be.
“Let’s say we get paid $50 for an MTM,” says Abubakar. “If preparing for and providing the service takes a pharmacist two hours, then we’re already losing money. It’s great that the patient is happy, but how can we sustain this? We need to look at efficiency.” What Abubakar found was that much of the preparation for an MTM interaction was being handled by a pharmacist, when it could and should be handled by a technician. Another area she identified for improving efficiency was the number of times staff members were calling patients. There were calls for sync, calls for MTM, and then even calls for delivery. Clearly there was room to improve, and as a result Abubakar created a position called med sync/MTM technician.
“We said, ‘Why don’t we add one or two more minutes to the technician’s sync call to ask any questions that the pharmacist needs answered for MTM?’” she says. This eliminates the need for an extra call. Rx Clinic Pharmacy is using features in its PioneerRx pharmacy management system to support this new workflow and keep everything organized. “We utilized a feature within PioneerRx called snippets,” explains Abubakar. “The snippets are questions created by our pharmacists and based on a disease state. When a technician opens a patient’s profile to prepare for a call, she will see the appropriate snippets to ask as well.” For example, if a patient has diabetes the snippet will prompt the technician to ask about the patient’s last blood sugar and blood pressure readings. This is an efficient and structured way for important data to get into the patient profile. And it also allows the technician to triage a patient if he or she hears something that needs a pharmacist’s attention right away.
Abubakar is using PioneerRx to organize Rx Clinic Pharmacy’s patients into groups by clinical need as well. “We create a virtual facility in our system,” she explains. “For example, we have a facility that groups all the patients that have adherence issues.” Another example is the population of HIV patients that the pharmacy serves. “We know adherence for these patients is particularly critical,” says Abubakar. “We use the facility function in PioneerRx to make sure that technicians are using the right snippets when they speak with HIV patients. For instance, we need to ask about viral load.” The goal is to have the technician collect answers to all the questions a pharmacist would want to ask a specific patient, and get them into the same thread of information for the pharmacist to review before the MTM session. “We do this so that we don’t take valuable time from our pharmacists,” says Abubakar, “and so that we don’t overwhelm patients with phone calls being prompted by different platforms at different times.”
Once the technician has recorded the answers to all the snippet questions, he or she then tags the patient with the necessary MTM actions within PioneerRx. All the patients tagged for MTM flow into the pharmacist’s MTM queue. “So now the pharmacist knows exactly what the problem is that the patient is facing,” says Abubakar, “instead of spending time during the MTM doing an interview.”
And out of this re-envisioned process grows a real business plan, where technicians are doing all the data collection and entry, and pharmacists are focusing specifically on the billable MTM patient interactions.
Care in A Complex Environment
Marilyn Goulty also talks about how important technology is for triaging patients in the care process at Cutie Pharma-Care. The pharmacy has created a paperless flow that leverages the FrameworkLTC pharmacy management software from SoftWriters to allow staff visibility into all orders in the system as they are processed. The flow extends into the facilities in two ways.
First, there’s the flow of information that comes from deploying the SoftWriters’ FrameworkLink portal in the facilities so that nursing staff can log in to see the orders. “This closes a loop,” says Goulty. “And it reduces the burden of administrative tasks on the facility so that they have more time for residents.
Second, but no less important, is adherence packaging. Cutie Pharma-Care staff are currently using the manually filled Medicine-On-Time packaging, with plans to move to the company’s Versi-Fill II packaging automation soon. The headline benefits of packaging, according to Goulty, are the elimination of a missed medication due to synchronization and the time savings on med passes. “We have found that when a facility switches to Pharma-Care and Medicine-On-Time,” she says, “the medication pass time is essentially reduced 50% and there is a huge reducation in medication errors.”
Packaging has another benefit, perhaps less obvious, according to Goulty: The organization and synchronization it brings to a patient’s medications becomes part of the information flow for the pharmacy and the facility. It all combines, in Goulty’s view, to give the pharmacy staff a readily accessible and unified view of a patient’s regimen. “The packaging process turns out to be a critical element in ensuring that the pharmacist sees the complete patient,” says Goulty “Whether we’re running packaging reports that show the full med picture for a patient, or a pharmacist is literally looking at the labels we’re printing that show all the medications for each administration time, we’re adding an extra level of care and the pharmacist gets to know the patient that much better. This is very important in a long-term care pharmacy because we aren’t seeing and interacting with patients the way a retail-focused pharmacy does.”
Rx Clinic Pharmacy provides an example of how excellence in patient care is firmly rooted in understanding and efficiently serving the specific needs patients have. When this happens, the care process drives adherence and promotes favorable outcomes. There are many components that come into play here, and building a package tailored to the patient’s needs comes from having as many tools as possible available within your pharmacy.
So, for example, med sync programs are a great way to organize and simplify the patient’s regimen. But it’s not the only component of a real patient-focused care program, and not sufficient by itself. In fact, Marilyn Goulty has found that it has been more effective to look at packaging as the adherence driver and sync as a natural outcome of the packaging process. “The software we’re using from Medicine-On-Time easily allows us to synchronize the medications,” she says. “Patients find it easier to take meds as prescribed and we are offering a higher level of care with multiple levels of checks due to the packaging, the check by a pharmacist when the packages are delivered, and then a third and final one at medication administration.”
Eric Russo’s experience has also led him to understand that med sync is good, but not the final word in patient care. He was seeing that patients enrolled in the program at Hobbs Pharmacy were getting off schedule after just a few months. This led to a packaging initiative there as well. But Hobbs Pharmacy has found that it could step up patient care by improving patients’ access to educational materials through the MedsOnCue product from VUCA Health. This is a Web-based medication information and patient education tool that’s accessed through a QR code printed on each label at Hobbs Pharmacy. This information can replace the paper education materials. “One of the biggest things we’re doing with it right now is a patient-safety initiative.
We’re trying to engage people in their own healthcare. We want patients taking ownership,” says Russo. “We can give them a great tool for that with MedsOnCue. It works in a few different ways. For example, we now have a way for people — whether it’s the patient, a home care nurse, or the daughter or the son that comes in and helps — to easily identify the pill that’s in that bubble. If we’re packaging, putting maybe five pills into a bubble, and handing the patient five separate printouts of medication information, it can be very difficult for them to know which of those five pills is the diltiazem or the Coumadin.”
This function can be particularly important when the pharmacy sources different generics of the same medication and what the pill looks like changes. “MedsOnCue gives people easy access to the NDC-specific pill image just by scanning the QR code,” says Russo. “We even have a bag stuffer that asks, ‘Do your pills ever look different?’”
More Information, Better Care
But health literacy extends well beyond being able to identify which pill is which. There are really at least three levels. There’s the what: What is the pill? There’s the how: This can be most important for a device such as an inhaler. And then there’s the why: Why is the patient taking the medication? What condition is it addressing, and why is it helping the patient?
Hobbs Pharmacy is leveraging MedsOnCue’s video content to provide these three levels of education. This addresses the issues people may have with reading text explanations of a condition or a medication. And video is particularly important for showing how to use a medication, for example inhalers or insulin. Another plus is that the information is integrated together, so that a patient can easily follow a logical path when learning about a prescription. “So, for example,” says Russo, “somebody gets a Proventil inhaler, and we can direct them through MedsOnCue to the video of how to use it. Then there’s a feature called the ‘Inform Me’ button. They touch that and it takes them to more information, such as a condition video.”
This means, according to Russo, that there’s ready access to details about diabetes, for example, or high blood pressure. “It’s invaluable and really powerful to be able to offer these videos,” he says. “And we even find that the pharmacist will pull them up while talking with the patient. Then the patient is getting both that personal interaction with the pharmacist and the support of an on-demand video resource that continues to be easily accessible to them.” Russo has found that this rich content helps the pharmacist and patient focus on the topic at hand, and finish the interaction with a higher level of confidence that the patient understands all the important aspects of the care. “Instead of patients starting with the question ‘What’s this for?’” says Russo, “the videos educate them, and the conversation moves to ‘Well, why is it important to take my blood pressure medication?’” The better informed a patient-pharmacist conversation is, the higher the level of care possible.
The New Model
Building new patient care models turns out to be like dropping a pebble in a pond: The impact creates ripples, in this case benefits that flow out from new and thoughtful approaches to pharmacy practice. For example, the intake process at Rx Clinic Pharmacy has put staff in a position to begin solving problems for patients right away, with benefits radiating from the first point of contact.
Amina Abubakar provides an excellent example when she describes how a new senior patient may come into the pharmacy and mention during intake that he or she’s been buying incontinence supplies. “We can tell them that we’ll ask for a physician’s order for this, and then it will be covered by insurance,” she says. That’s an improvement for the patient on the one hand, and a boost to the pharmacy’s DME department on the other. And this information is often news to the physician.
Patient Care Is Not Optional
Is a well thought-out patient care process an option for today’s pharmacy? What about the pharmacy of tomorrow? The answer is that it’s almost certainly a necessity, since it’s where pharmacy is going to be able to provide the most value in the future. “If we can have an impact in the most complex case,” says Amina Abubakar, “the ones that are costing the system a lot of money, then we can easily show our impact at improving that care.”
Eric Russo envisions an important role for pharmacists in a process that engages the right actors in the patient’s care. “What I’ve found is that when we engage people, we are able to find the right person to be the advocate for the patient’s care,” he says. We need to be able to easily allow the right people to be informed about the patient’s medications and care. We need to take away the barriers from communication. Maybe a patient or caregiver doesn’t want to ask questions because she’s unsure what to ask, or doesn’t want to feel stupid and ask something as basic as why the patient’s taking a medication.” With the right process in place, patients and pharmacists can engage in more open, more thorough conversations.
The end result is that pharmacies building patient-carecentered practices are going to be recognized as game changers, according to Marilyn Goulty. “Cutie Pharma- Care is building up this reputation with facilities,” she says. “Our approach has a direct impact on people’s health. That’s really powerful. It takes everyone working together to make care better. It’s not just the nurse at the facility or the people passing the meds, it’s also the pharmacy, the techs, and the pharmacists. We are all providing an extra level of care.” CT
Will Lockwood is VP and a senior editor at ComputerTalk. He can be reached at firstname.lastname@example.org.