Health System Pharmacy Practice

• These are study notes pertaining to pharmacy practice.

Health System Pharmacy Practice

• Pharmacists in a hospital provide clinical services.
• Specific services include medication histories and reconciliation, patient education and follow-up, and monitoring drug therapy and adverse effects.
• They also attend CPR events and teach students, residents, nurses, and physicians.
• Pharmacists oversee drug distribution, sterile product preparation, and unit-dose systems/technology.
• They also assure medication safety, serve on committees, and "manage" medication use and costs.

Department of Pharmacy Challenges

• Financial challenges include increased expenses for labor, equipment, supplies, and facilities.
• Reimbursement levels are not keeping up, and there are changes in reimbursement models like value-based vs. fee for service where value = benefit/cost.
• Quality challenges involve balancing service (better/faster/cheaper) with a focus on high quality to decrease costs.
• The process is the steps taken toward achieving a goal and the outcome is the end results of those steps.
• There are hundreds of measures that impact reimbursement.
• Safety concerns include medications posing the largest safety risk, even with 99.9% accuracy being insufficient. Around 3 million doses are administered per year.
• Regulatory challenges include federal and state regulations, CMS with two billing audits, DEA, FDA, LARA, URAC, and TJC.
• Human resource challenges: low recruitment, labor shortage with 3.8% unemployment (competition), high turnover, training to a high level, and employee retention (engagement and resilience).
• Technology is constantly changing, requiring new software and solutions that are expensive to buy and maintain, along with staff training and optimization.

Training and Adaptations in Hospital Pharmacy

• Residency is preferred for hospital pharmacy practice.
• MS, MBA, or MHA degrees are beneficial for administrative roles.
• Essential skills include energy, patience, passion, communication, teamwork, flexibility, and resilience.
• Institutional pharmacies have adopted safety checklists and attention to detail, similar to the airline industry, to promote safety.

Quality and Safety in Healthcare

• Quality of care is the degree to which health services increase the likelihood of desired outcomes and are consistent with current professional knowledge.
• Domains of healthcare quality include safety, efficiency, effectiveness, equitability, timeliness, and patient-centered care.
• Quality is reported through clinical measures (how providers deliver services), patient perspectives (assessments by patients), and outcomes (affected by quality received).

Healthcare Accreditation Organizations

• The National Committee for Quality Assurance (NCQA) accredits health plans and promotes value-based care and outcome-driven evaluation. Formed as a private NPO to develop quality standards and performance measures.
• The Joint Commission accredits hospitals and develops safety and quality standards. A 1951 independent NPO that conducts surveys and audits.
• The Pharmacy Quality Alliance (PQA) supports improved medication use and quality care through performance assessment, monitoring, and quality improvement indicators. A 2006 national NPO.
• The Agency for Healthcare Research and Quality (AHRQ) conducts research on healthcare delivery and patient safety, develops tools for providers and policymakers, and promotes evidence-based clinical practice. A 1989 federal agency.
• The Centers for Medicare and Medicaid Services (CMS) regulates Medicare Part D and Medicaid pharmacy benefit programs, sets PBM standards, and oversees Star Ratings. A 1965 federal agency.
• Healthcare Effectiveness Data Information Set (HEDIS) domains measure performance of care and service, including effectiveness, access/availability, experience, utilization, and health plan descriptive information.

Medication Safety Definitions

• An adverse drug event (ADE) is an untoward medical occurrence during treatment that doesn't necessarily have a causal relationship.
• An adverse drug reaction (ADR) is a noxious and unintended response to a drug at normal doses, directly caused by the medication.
• A medication error is a preventable event that may lead to inappropriate medication use or patient harm.
• A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm, subject to review.

Medication Use Process Errors

• Prescribing errors include dosage selection, abbreviations, as needed orders without indications, illegible orders, documented allergies, and look-alike/sound-alike medications.
• Transcribing errors include verbal orders requiring human interpretation.
• Dispensing errors include wrong time on label for administration.
• Administering errors involve wrong patient, medication, dose, route, or time.
• Monitoring errors occur during transitions of care.

Human Error and Safety Strategies

• Acknowledge risk, prevent initial errors, and fix system problems.
• Culture of Safety shifts focus from errors & outcomes to safe system design and managing behavioral choices.
• Implement clear and transparent processes for evaluating errors, it creates culture of accountability and learning.

Preventing Medication Errors

• Use both brand and generic names, include indication on prescriptions, and configure computer selection screens.
• Change appearance of product names (TALL man lettering), store drugs in different areas, use barcode scanning and two-person checks.
• Track medication errors to improve the system.

Drug Use Management Definitions

• Drug Use Review: structured review of prescribing, dispensing, and patient medication use.
• Drug Use Evaluation: in-depth review focused on specific drug, condition, or population.
• Drug Use Management: a system-wide effort to manage drug use.

Long-Term Care (LTC)

• Long-term care (LTC) is health, personal, and social services over time for people who have lost or never acquired functional capacity/cognitive impairment.
• Medicare covers SNF for 100 days, hospice care and does NOT cover custodial care.
• Medicaid is the largest public payer for LTC, covering custodial care.

Who Needs LTC Services

• Older adults
• Patients with chronic diseases like end-stage renal disease, Alzheimer's, Parkinson's, stroke
• Patients needing rehabilitation or with terminal illnesses or disabilities.

Community vs. Institutional LTC

• Community LTC is between independent living and institutional care.
• It Includes assisted living, home health, hospice, and adult day services.
• Institutional LTC provides comprehensive care around the clock.
• It includes skilled nursing, specialized cognitive care, and correctional facilities.

Payment Types for LTC

• Medicare covers SNF for the first 20 days, then requires co-insurance.
• After 100 days, the patient is responsible for costs.
• Medicaid covers LTC with "spend down" provisions, where individuals must deplete assets to qualify.
• LTC insurance and out-of-pocket payments are additional options.
• The costs increase from home care, assisted living to nursing home care.

ADLs vs IADLs

• Activities of Daily Living (ADLs): bathing, dressing, toileting, transferring, caring for incontinence, eating.
• Instrumental Activities of Daily Living (IADLs): housework, managing money/meds, shopping, phone use, caring for pets, responding to emergencies.
• Aging-in-place define: staying in the same home and community as they age and as care needs change.

Drug Regimen Reviews

• Drug Regimen Review (DRR): Analyzes to optimize therapy and identifies unnecessary medications.
• Drug Utilization Evaluation (DUE): Criteria-based, ongoing review of medications contributing to outcomes.
• Drug Utilization Review (DUR): Reviews past misuse patterns and counsel patients.

LTC Facilities and Medication Reviews

• A drug regimen review (DDR) is required at least monthly for each resident.
• It must look for things like, excessive dose, without adequate monitoring or indications, and ADRs.
• Must review resident's medical chart.
• The pharmacy must report irregularities to the physician and facility.
• There must be policies for monthly DRR- timeframes/procedures

Psychotropic Drugs in LTCs

• Psychotropic drugs affect associated w mental processes and behaviors and should only be used when needed for a diagnosed condition.
• Gradual dose reduction and behavioral interventions should be tried.
• PRNs are limited to 14 days.

Pharmacist Opportunities in LTC

• Consultation, Distributive

Home Health Care

• Home health care helps patients unable to care for themselves due to illness or disability.
• It aims to restore patients to optimal well-being in a familiar environment and is cost effective.
• Pharmacists dispense, infuse, provide medical equipment; and select patients, create care plans, compound, monitor therapeutic usage, communicate, and distribute information.

Home Infusion Practice

• Conduct infusion of antibiotics, chemo, parenteral, pain management, inotropes, blood products and manage equipment.

Improving Medication Safety at Home

• Conduct drug regimen reviews, analyze medication utilization patterns, and educate patients/healthcare providers.

Home Care Benefits Over Institutions

• Improves population health, lowers costs, and enhances both patient and provider experiences.
• This leads to better outcomes.

Comprehensive Medication Review (CMR)

• CMR considers patient history, current status, labs, cognitive/psychosocial status, family support, prescribed treatment, concurrent prescriptions, OTC meds.
• It maintains compounding procedures, monitors drug interactions, focuses on patient education, and recognizes/reports adverse drug reactions.

Medication-Related Problems in Home CMR

• Unnecessary or duplicate therapy and high doses of medication.

Ambulatory Care

• Adverse drug events in ambulatory care affect 5-30% of patients and cost $30-130 billion/year.

Collaborative Drug Therapy Management (CDTM)

• CDTM is the development of a collaborative practice agreement (CPA) between healthcare providers and pharmacists.
• CPA allows qualified pharmacists to perform patient assessments, order labs, administer drugs, and adjust drug regimens.
• Process of approval: Content expert develops collaborative in collaboration with other providers à Input solicited from team that will be impacted à approval from governing body - pharmacy leadership, providers (department leaders), P & T committee and credentialing committee
• Services: anticoagulation, oncology, anemia management, symptom management, primary care, diabetes, hypertension, hyperlipidemia, smoking cessation and paxlovid

Ambulatory Care Pharmacist at Michigan Medicine

• Attend CKD clinics, psychiatry, anticoagulation and palliative care services, transplant clinics, oncology clinics, medOps program and provide post ICU for adults/peds and transitions of care (HF, central).

Impact on Patient Outcomes

• Ambulatory care pharmacist services improve outcomes for diabetes, hypertension, and hypercholesterolemia by scheduling patients for consultations.
• Results in follow up appointments for disease control and medication management and comprehensive medication review services.
• Can improve LDL levels, BP measurements, and A1C levels in patients with these conditions.

Ambulatory Care Pharmacist and COVID-19

• Blended model of remote/in-clinic presence with video visits and drive through.

Clinical Decision Support

• Best Practice Alerts (BPA) fires for medical assistants to repeat BP after patient has been sitting quietly for 5 min
• BP recheck and pharmacist follow up (Smartset)

Sustainability of Ambulatory Care Pharmacists

• Use facility fee, incident to physician, MTM community setting, immunizations and care management.

Population/Public Health

• Population: health outcomes of a defined group, addressing the drivers and determinants of health
• Pharmacy manages at-risk populations, chronic diseases, improves adherence/education and is accessible with no appointments or fees.

Public Health Role of Pharmacists

• Pharmacists help with public health outcomes.
• Crucial to administering vaccinations, screening for disease, and health coaching

Pharmacist Immunization Impact

• Increased immunization rates and resulted in millions of additional immunizations.

Social Factors Affecting Health

• Increases in CAD rates are correlated decreases education.
• Low education increases likelihood of smoking, being sedentary and having unhealthy diet

Disparities in Access to Pharmacies

• Lack of pharmacies in poor, urban, and rural areas.
• Independent and small chain pharmacies have lower rate of offering immunizations.

Expedited Partner Therapy (EPT)

• Expedited partner therapy treats partners of diagnosed STIs without medical evaluation.
• Health care providers provide patient with antibiotics or prescriptions for thier partners and It reduces reinfection

Opioid Antagonist Availability

• Helps improve access to substance abuse disorder.

Prescription Drug Monitoring Programs

• Help predict probability of receiving or continuing a controlled substance prescription through electronic databases.

Pharmacy Benefit Manager (PBM)

• PBM manages pharmacy benefits and aids their clients in administering the policy.
• Put manufacturers meds on formulary and negotiates price.

Drug Rebates

• Drug rebates are paid by the manufacturer to the PBM after it has been dispensed.

Pharmacy Network Pricing

• AWP (average wholesale price) - the discount (based on what the PBM negotiated with the manufacturer).
• Pharmacy network is a group of pharmacies that have contracted with PBMS to provide prescription medications to members at agreed upon prices and terms.
• PBM controls costs, managages formulary and secures rebates.

Utilization Management

• PBM uses prior authorizations, step therapy, and quantity limits.

Rebate Management

• Drug rebates are negotiations between PBM and manufacturers.
• The most beneficial for PBM.
• access rebates: consistent % of WAC that PBMs get back or performance rebates.

PBM Clinical Programs

• Medication therapy management, adherence programs, specialty pharmacy case management
• Additional examples are opioid management, diabetes and cardiovascular risk management and smoking cessation or lifestyle programs

Community Pharmacy Panel

• CPESN USA organizes local networks of community pharmacies into a unified platform.
• Credentialing pothole is the process by which pharmacists are verified for their qualifications, licensure, and competence.
• A Prescription Drug Affordability Board (PDAB) addresses the rising cost of prescription drugs by negotiating directly with drug manufacturers.
• Current legislative and policy priorities for the Michigan Pharmacists Association includes allowing pharmacists to issue prescriptions for hormonal contraceptives.

Services Offered by Community Pharmacies

• Such as medication therapy management, immunizations and chronic disease management.