Perceived value of leadership experiences in a postgraduate year 2 ambulatory care pharmacy residency.

PURPOSE: Leadership experiences taught within the Kaiser Permanente Colorado (KPCO) postgraduate year 2 (PGY2) ambulatory care pharmacy residency program were evaluated. METHODS: KPCO leadership training incorporated 6 mandatory leadership sessions and offered a 6-week elective rotation. In this qualitative study, an 18-item semistructured interview guide was developed, tested, and administered telephonically to former KPCO PGY2 residents who had been in clinical practice for a minimum of 1 year. The primary outcome was the perceived value of the leadership experiences, and perceived gaps was the secondary outcome. Qualitative analysis was performed for open-ended questions. Responses were coded and key phrases were highlighted to illustrate major concepts and themes. RESULTS: Of 34 former residents, 29 (85%) completed the interview. Ninety-seven percent of participants reported that the leadership experiences provided value in their professional career; 89% reported value in their personal development. The 3 most common themes of perceived value that emerged from the interviews were exposure to leadership, managing and leading self and others, and clinical service development. Identified gaps included further exposure to senior leadership within the organization and a better understanding of the national pharmacy landscape. CONCLUSION: Leadership experiences during the PGY2 ambulatory care pharmacy residency at KPCO were perceived positively by former residents on a professional and a personal level.

Use of a pharmacy technician to facilitate postfracture care provided by clinical pharmacy specialists.

PURPOSE: The ability of a pharmacy technician to support the patient screening and documentation-related functions of a pharmacist-driven osteoporosis management service was evaluated. METHODS: A two-phase prospective study was conducted within a large integrated health system to assess a pharmacy technician's performance in supporting a multisite team of clinical pharmacy specialists providing postfracture care. In phase I of the study, a specially trained pharmacy technician provided support to pharmacists at five participating medical offices, helping to identify patients requiring pharmacist intervention and, when applicable, collecting patient-specific clinical information from the electronic health record. In phase II of the study, the amount of pharmacist time saved through the use of technician support versus usual care was evaluated. RESULTS: The records of 127 patient cases were reviewed by the pharmacy technician during phase I of the study, and a pharmacist agreed with the technician's determination of the need for intervention in the majority of instances (92.9%). An additional 91 patient cases were reviewed by the technician in phase II of the research. With technician support, pharmacists spent less time reviewing cases subsequently determined as not requiring intervention (mean ± S.D., 5.0 ± 3.8 minutes per case compared with 5.2 ± 4.5 minutes under the usual care model; p = 0.78). In cases requiring intervention, technician support was associated with a reduction in the average pharmacist time spent on care plan development (13.5 ± 7.1 minutes versus 18.2 ± 16.6 minutes with usual care, p = 0.34). CONCLUSION: The study results suggest that a pharmacy technician can accurately determine if a patient is a candidate for pharmacist intervention and collect clinical information to facilitate care plan development.

A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.

BACKGROUND: To determine whether a pharmacist-led, Heart360-enabled, home blood pressure monitoring (HBPM) intervention improves blood pressure (BP) control compared with usual care (UC). METHODS AND RESULTS: This randomized, controlled trial was conducted in 10 Kaiser Permanente Colorado clinics. Overall, 348 patients with BP above recommended levels were randomized to the HBPM (n=175) or UC (n=173) groups. There were no statistically significant differences in baseline characteristics between the groups; however, there was a trend toward a higher baseline BP for the HBPM group compared with the UC group (148.8 versus 145.5 mm Hg for systolic BP; 89.6 versus 88.0 mm Hg for diastolic BP). At 6 months, the proportion of patients achieving BP goal was significantly higher in the HBPM group (54.1%) than in the UC group (35.4%; P<0.001). Compared with the UC group, the HBPM group experienced a -12.4-mm Hg larger (95% confidence interval, -16.3 to -8.6) reduction in systolic BP and a -5.7-mm Hg larger (95% confidence interval, -7.8 to -3.6) reduction in diastolic BP. The impact of the intervention on BP reduction was even larger for the subgroup of patients with diabetes mellitus or chronic kidney disease. The HBPM group had more e-mail and telephone contacts and greater medication regimen intensification. The proportion of patients reporting high satisfaction with hypertension care was significantly greater in the HBPM group (58%) than in the UC group (42%), P<0.001. CONCLUSIONS: A pharmacist-led, Heart360-supported, home BP monitoring intervention led to greater BP reductions, superior BP control, and higher patient satisfaction than UC.

Evolution, current structure, and role of a primary care clinical pharmacy service in an integrated managed care organization.

The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.

Description of a team-based job improvement process within a large geographically dispersed primary care clinical pharmacy service.

OBJECTIVE: To describe the team-based job improvement process that Primary Care Clinical Pharmacy Services (CPS) used to enhance teamwork and improve job satisfaction during a 4-year period. SETTING: Health maintenance organization in Colorado from 2005 through 2008. PRACTICE DESCRIPTION: Kaiser Permanente Colorado is a group model, not-forprofit health maintenance organization that provides health services to approximately 490,000 members. Highly integrated clinical pharmacy services are offered at each of its 17 primary care medical offices in the Denver-Boulder metropolitan area. PRACTICE INNOVATION: A written survey consisting of three open-ended questions specifically directed at perceived positive and negative job-related features within Primary Care CPS was administered to team members. Six areas of focus emerged that were addressed by Primary Care CPS members within small groups. MAIN OUTCOME MEASURES: Pre- and postsurvey results from six identified focus areas were measured to address any impact of the team-based job improvement process. RESULTS: Positive responses increased from baseline by 48% for communication, 42% for new employee orientation, 25% for teamwork, and 25% for Primary Care CPS meetings (P < 0.05; chi-square test). Positive responses related to clinical practice increased 22%; however, this did not reach statistical significance. Perceived satisfaction with the documentation system for tracking clinical interventions declined 11% from baseline. CONCLUSION: Based on the initial successes with surveys and small-group discussions, Primary Care CPS continues to use this team-based job improvement process to resolve concerns or share best practices.

Actual versus projected cost avoidance for clinical pharmacy specialist-initiated medication conversions in a primary care setting in an integrated health system.

BACKGROUND: Primary care clinical pharmacy specialists (PCCPSs) are positioned to promote effective, safe, and affordable medication use. Documentation of performed interventions is difficult because the diversity of performed interventions in a variety of disease states in some practice settings. Validation of cost-avoidance projections is also difficult because traditional projection methods have several limitations. OBJECTIVE: To (1) compare projected medication cost avoidance (MCA) to actual MCA for medication conversions related to hyperlipidemia, hypertension, depression, and chronic pain initiated by PCCPS, and (2) estimate medication discontinuation that might be attributable to serious adverse drug events (ADEs) possibly associated with medication conversions. METHODS: This was a retrospective, longitudinal study conducted in a not-for-profit, integrated health system comprising approximately 470,000 members. Using a portable documentation tool, PCCPSs recorded projected annual MCA for medication conversions in 4 disease conditions (i.e., hypertension, dyslipidemia, depression, and chronic pain) in the 6-month period from December 1, 2003, through May 31, 2004. Actual annual MCA for these interventions for a 1-year follow-up period was calculated using integrated, electronic data from an administrative pharmacy database. Comparisons were made between projected MCA and actual MCA. Cost was defined as actual drug acquisition cost. In addition, an assessment of serious ADEs potentially related to the conversions was undertaken by reviewing electronic medical records of converted, nonpersistent patients. RESULTS: There were 704 medication conversions for 656 patients, of which 47 (6.7%) were for members who disenrolled in the health plan during the 12 months following the medication conversion date. The total projected MCA was $327,337 in 2004 dollars, or an average of $465 per conversion. For the 657 medication conversions in 609 patients that were evaluable (i.e., the member remained enrolled through 12 months follow-up), 466 (70.9%) persisted at 12 months, 138 (21.0%) discontinued the medication or converted to an alternative therapy, and 53 (8.1%) reverted to the original medication. Drug cost information was not available for some members, leaving approximately half (n = 331, 50.4%) of the 657 evaluable medication conversions with complete cost information available. For these 331 conversions, the overall projected MCA overestimated the actual MCA by 14.1% ($24,888 in aggregate or an average of $75 per conversion, P < 0.001). For persistent medication conversions with complete cost information (n = 278), the projected MCA ($160,225) was not significantly different compared with the actual MCA ($166,546, P = 0.477). For medication conversions that reverted to previous therapy (n = 53), the projected MCA ($41,644) overestimated by 4-fold the actual MCA ($10,435, P < 0.001). There were no emergency department visits or hospital admissions related to nonpersistent medication conversions. Compared with patients who were either nonpersistent or disenrolled at the 12-month follow-up, persistent patients did not significantly differ in chronic disease score but were slightly older (mean = 62.6 years, standard deviation = 13.1 for persistent patients vs. 59.2 [SD = 15.5] for nonpersistent or disenrolled patients). CONCLUSIONS: Projected medication cost avoidance for pharmacistinitiated medication conversions is valid for the 66% of medication conversions that persist but not for nonpersistent conversions or for patients who leave the health care system. The projected medication cost avoidance overestimated the actual cost avoidance by approximately 14%, suggesting that there is opportunity for improvement in the tool used to document medication conversions to more accurately measure cost outcomes from clinical pharmacy interventions.