Implementation outcomes associated with a value-based care model of comprehensive medication management in community pharmacies.

OBJECTIVE: Although the delivery of comprehensive medication management (CMM) in community pharmacies has been shown to improve health outcomes, inconsistent adoption hinders the benefit patients receive. Our objective was to examine the implementation of a novel value-based care model and the impact of educational and coaching support for pharmacists on patient access to CMM. The underlying care model provides a payment for CMM services combined with incentives to document and improve clinical outcomes and patient engagement. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: In addition to fee-for-service payments, performance-based incentives were provided to 12 participating pharmacy organizations to promote pharmacist documentation of clinical values (blood pressure and tobacco status for patients with vascular disease and additionally hemoglobin A1c [HbA1C] for patients with diabetes). To promote patient engagement, pharmacies that engaged a higher proportion of attributed patients received additional incentives. OUTCOME MEASURES: Implementation outcomes included penetration (the proportion of eligible patients who received CMM), adoption (variation in penetration across organizations), and fidelity (documentation of all required clinical values). Comparisons were made using t-tests and chi-square testing. RESULTS: Among 1240 eligible patients, 478 (35.8%) had documentation of any service by a participating pharmacist during a one-year implementation period. Using diabetes as an example, documentation was consistently highest for tobacco status (38.1%), followed by blood pressure (29.7%), and HbA1C (38.1%). CMM recipients on average were older, used more medication, and were more likely to have at least one comorbid condition than non-recipients. 41.8% of patients with vascular disease had documentation of both blood pressure and tobacco status while 24.4% of patients with diabetes had blood pressure, tobacco, and HbA1C documentation. CONCLUSIONS: Improving pharmacist access to a patient's medical records could help improve access to CMM services for patients under value-based care models that rely on patient targeting and clinical measurements.

Meeting the New AACP Competencies in Genetics and Clinical Pharmacogenomics at the University of Minnesota.

Objective: Pharmacogenomics (PGx) is increasingly being used for creating individualized treatments for patient care. Healthcare professionals, especially pharmacists, need to understand how genetic variation impacts the efficacy and toxicity of medications. Due to the breadth and complexity of PGx-related information, it has been challenging to determine what information should be included in pharmacy curricula and how best to educate students. Methods: The University of Minnesota College of Pharmacy recently began the process of incorporating into the curriculum expanded competencies for PGx from the American Association of Colleges of Pharmacy (AACP) Pharmacogenomics Special Interest Group (PGx-SIG). We evaluated our curriculum for PGx content, determined what was currently being taught and identified educational gaps. Results: A review of our Doctor of Pharmacy curriculum showed substantial PGx content, although it was inconsistently taught throughout the required courses and in some courses absent. We revised the content of existing courses incorporating content that meet most of the PGx-SIG recommended competencies. Conclusion: There are and will be major changes in our understanding of the influences of PGx on individualized medical treatment. As our understanding grows, information on PGx in pharmacy curriculums will need to keep pace with these changes. We have begun this process at the University of Minnesota by doing a full review of PGx related information and making appropriate revisions in the pharmacy curriculum.

Community pharmacists' experience relying on select implementation strategies in the delivery of comprehensive medication management.

OBJECTIVE: Implementation strategies are methods or techniques that facilitate adoption, implementation, and sustainability of a clinical program or practice. There has been a lack of widespread adoption of comprehensive medication management (CMM) in community pharmacies. The objective of this evaluation was to expand understanding of how select implementation strategies impacted pharmacists' experience implementing and delivering CMM in the community pharmacy setting. METHODS: A community pharmacy CMM initiative, Slice of Partners in Excellence (PIE), employed a number of implementation strategies and key elements from the Institute for Healthcare Improvement's Breakthrough Series to support increased engagement and delivery of CMM within a local payer's CMM program. The program provides incentives to pharmacies for providing CMM to select patients and achieving predetermined quality metrics. To evaluate pharmacists' experience with the implementation strategies and the impact it had on implementing and delivering CMM, a focus group and survey were conducted. RESULTS: Some of the implementation strategies were more frequently highlighted as generating value to participants (coaching, community-wide problem-solving) than others (monthly webinars). Pharmacists identified a need for more formal education regarding billing, documentation and patient engagement supports. Pharmacists expressed a desire for ongoing implementation supports extending beyond this initaitive. CONCLUSION: Understanding the types of implementation strategies that are deemed as influential by pharmacists delivering clinical services in the community pharmacy setting is critical to maximizing patient access to these services in the future.

How Comprehensive Medication Management Contributes to Foundational Elements of Primary Care.

Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield's 4 Cs of Primary Care. We illustrate how the delivery of CMM supports first contact through increased provider access, continuity through empanelment, comprehensiveness by addressing unmet medication needs, and coordination through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care.

Ready, set, go!: exploring use of a readiness process to implement pharmacy services.

BACKGROUND: Readiness is an essential precursor of successful implementation; however, its conceptualization and application has proved elusive. R = MC2 operationalizes readiness for use in practice. The purpose of this study was to (1) describe the application of R = MC2 to assess and build readiness in nine healthcare sites responsible for implementing medication management services and (2) gain insights into the sites' experience. METHODS: This mixed methods exploratory study used data collected as part of a process evaluation. Understanding application of the readiness process (Aim 1) involved examining team members' involvement (who?), readiness challenges and readiness building strategies (what?), strategy execution (how much?), and resulting changes (for what purpose?). To understand the sites' experience with the R = MC2 system (Aim 2), interviews were conducted with six of the sites to identify facilitators, barriers, and lessons learned. Data sources included a document review (e.g., sites' action plans), survey results, and interview data. RESULTS: Sites included primary care and specialty clinics, pharmacies within health systems, and community pharmacies. Teams consisted of 4-11 members, including a lead pharmacist. The teams' readiness activities clustered into five broad categories of readiness building strategies (e.g., building the operational infrastructure for service integration). Of the 34 strategies identified across sites, 68% were still in progress after 4 months. Engaging in the readiness process resulted in a number of outputs (e.g., data management systems) and benefits (e.g., an opportunity to ensure alignment of priorities and fit of the intervention). Based on the interviews, facilitators of the readiness process included assistance from a coach, internal support, and access to the readiness tools. Competing priorities and lack of resources, timely decision-making, and the timing of the readiness process were cited as barriers. The importance of service fit, stakeholder engagement, access to a structured approach, and rightsizing the readiness process emerged as lessons learned. CONCLUSIONS: These findings provide valuable insights into the application of a readiness process. If readiness is to be integrated into routine practice as part of any implementation effort, it is critical to gain a better understanding of its application and value.

The Philosophy of Practice for Comprehensive Medication Management: Evaluating Its Meaning and Application by Practitioners.

OBJECTIVE: Philosophy of practice is the foundation of any patient care practice because it provides a set of professional values and beliefs that guide actions and decisions in practice. Study objectives were to understand how pharmacists providing comprehensive medication management (CMM) describe their philosophy of practice and compare how participants' philosophies align with predefined tenets of a CMM philosophy of practice. METHODS: An instrument with closed and open-ended items was developed and administered online to the lead pharmacist at 36 clinics participating in a large CMM study. Participants were asked to describe their philosophy of practice, rate how well their current practice activities align with five predefined CMM philosophy of practice tenets, and provide examples of how they carry out each tenet and how they could improve. Responses were coded, and descriptive analysis was used to calculate participants' practice alignment with the five philosophy of practice tenets. RESULTS: Thirty pharmacists completed the instrument. Twelve codes emerged that participants used to describe their philosophy of practice. These codes were mapped to five predefined tenets of a philosophy of practice. Only 3 (10%) participants included all five tenets in their philosophy of practice, 8 (26.7%) included four, 8 (26.7%) included three, 6 (20%) included two, and 5 (16.7%) included one tenet. Overall, participants rated their alignment with the five tenets highly. "Embracing a patient-centered approach" received the highest mean score of 9.17/10; "Meeting a societal need" had the lowest mean score of 8.37/10. CONCLUSION: Participants described their philosophy of practice with significant variability. CMM requires a single and consistently applied philosophy of practice to guide practice and the role of the practitioner. We propose five core tenets that resulted from this assessment to be embraced by pharmacists providing CMM and included in their philosophy of practice.

The Active Implementation Frameworks: A roadmap for advancing implementation of Comprehensive Medication Management in Primary care.

Implementation of evidence-based health services interventions is complex and often limited in scope. The Active Implementation Frameworks (AIFs) are an evidence-based set of frameworks to use when attempting to put into practice any innovation of known dimensions. This article describes the novel application of the AIFs to facilitate the implementation and improvement of Comprehensive Medication Management (CMM) in primary care practices to optimize medication use and improve care for patients.

A qualitative evaluation of medication management services in six Minnesota health systems.

PURPOSE: The initiation, establishment, and sustainability of medication management programs in six Minnesota health systems are described. METHODS: Six Minnesota health systems with well-established medication management programs were invited to participate in this study: Essentia Health, Fairview Health Services, HealthPartners, Hennepin County Medical Center, Mayo Clinic, and Park Nicollet Health Services. Qualitative methods were employed by conducting group interviews with key staff from each institution who were influential in the development of medication management services within their organization. Kotter's theory of eight steps for leading organizational change served as the framework for the question guide. The interviews were audio recorded, transcribed, and analyzed for recurring and emergent themes. RESULTS: A total of 13 distinct themes were associated with the successful integration of medication management services across the six healthcare systems. Identified themes clustered within three stages of Kotter's model for leading organizational change: creating a climate for change, engaging and enabling the whole organization, and implementing and sustaining change. The 13 themes included (1) external influences, (2) pharmacists as an untapped resource, (3) principles and professionalism, (4) organizational culture, (5) momentum champions, (6) collaborative relationships, (7) service promotion, (8) team-based care, (9) implementation strategies, (10) overcoming challenges, (11) supportive care model process, (12) measuring and reporting results, and (13) sustainability strategies. CONCLUSION: A qualitative survey of six health systems that successfully implemented medication management services in ambulatory care clinics revealed that a supportive culture and team-based collaborative care are among the themes identified as necessary for service sustainability.

Accelerating quality improvement within your organization: Applying the Model for Improvement.

OBJECTIVE: To discuss the fundamentals of the Model for Improvement and how the model can be applied to quality improvement activities associated with medication use, including understanding the three essential questions that guide quality improvement, applying a process for actively testing change within an organization, and measuring the success of these changes on care delivery. DATA SOURCES: PubMed from 1990 through April 2014 using the search terms quality improvement, process improvement, hospitals, and primary care. STUDY SELECTION: At the authors' discretion, studies were selected based on their relevance in demonstrating the quality improvement process and tests of change within an organization. SUMMARY: Organizations are continuously seeking to enhance quality in patient care services, and much of this work focuses on improving care delivery processes. Yet change in these systems is often slow, which can lead to frustration or apathy among frontline practitioners. Adopting and applying the Model for Improvement as a core strategy for quality improvement efforts can accelerate the process. While the model is frequently well known in hospitals and primary care settings, it is not always familiar to pharmacists. In addition, while some organizations may be familiar with the "plan, do, study, act" (PDSA) cycles-one element of the Model for Improvement-many do not apply it effectively. The goal of the model is to combine a continuous process of small tests of change (PDSA cycles) within an overarching aim with a longitudinal measurement process. This process differs from other forms of improvement work that plan and implement large-scale change over an extended period, followed by months of data collection. In this scenario it may take months or years to determine whether an intervention will have a positive impact. CONCLUSION: By following the Model for Improvement, frontline practitioners and their organizational leaders quickly identify strategies that make a positive difference and result in a greater degree of success.

Access to patients' health records for drug therapy problem determination by pharmacists.

OBJECTIVES: To evaluate differences in the number and type of drug therapy problems (DTPs) identified by pharmacists with and without access to patients' primary care health records; determine the confidence level of pharmacists in their assessment of DTPs with and without access to health records; and determine the type of information pharmacists need to confirm their assessment. METHODS: The study design was an exploratory and comparative evaluation of comprehensive medication management assessments. Pharmacists initially completed patient assessments without access to the patient's primary care health record. Pharmacists documented the visit according to the standard of care and documented the assessment in a standardized study form. Pharmacists then reviewed the patient's primary care health record and documented a revised assessment in the standardized study form. The standardized form included sections about the number of DTPs, the classification of DTPs, the pharmacist's confidence level in identifying DTPs, and the information needed to increase the pharmacist's confidence level in identifying DTPs. RESULTS: Pharmacists evaluated 24 patients and identified 132 DTPs. After reviewing patients' primary care health records, 31 DTPs were deemed "false DTPs," 3 DTPs were recategorized, and 9 new DTPs were identified. Practitioner confidence levels in DTP determination improved after reviewing patients' primary care health records. The health information most frequently identified as desirable after the initial review was laboratory tests. CONCLUSION: Pharmacists identified more DTPs with lower confidence levels without access to patients' primary care health records. Fewer DTPs were deemed "confirmed DTPs" and confidence in the practitioners' assessments improved after review of the primary care health records. Access to primary care health records can help community pharmacists build an efficient and comprehensive medication management practice.

Access to patients' health records for drug therapy problem determination by pharmacists.

OBJECTIVES: To evaluate differences in the number and type of drug therapy problems (DTPs) identified by pharmacists with and without access to patients' primary care health records; determine the confidence level of pharmacists in their assessment of DTPs with and without access to health records; and determine the type of information pharmacists need to confirm their assessment. METHODS: The study design was an exploratory and comparative evaluation of comprehensive medication management assessments. Pharmacists initially completed patient assessments without access to the patient's primary care health record. Pharmacists documented the visit according to the standard of care and documented the assessment in a standardized study form. Pharmacists then reviewed the patient's primary care health record and documented a revised assessment in the standardized study form. The standardized form included sections about the number of DTPs, the classification of DTPs, the pharmacist's confidence level in identifying DTPs, and the information needed to increase the pharmacist's confidence level in identifying DTPs. RESULTS: Pharmacists evaluated 24 patients and identified 132 DTPs. After reviewing patients' primary care health records, 31 DTPs were deemed "false DTPs," 3 DTPs were recategorized, and 9 new DTPs were identified. Practitioner confidence levels in DTP determination improved after reviewing patients' primary care health records. The health information most frequently identified as desirable after the initial review was laboratory tests. CONCLUSION: Pharmacists identified more DTPs with lower confidence levels without access to patients' primary care health records. Fewer DTPs were deemed "confirmed DTPs" and confidence in the practitioners' assessments improved after review of the primary care health records. Access to primary care health records can help community pharmacists build an efficient and comprehensive medication management practice.

Personalizing public health: your health avatar.

OBJECTIVES: To describe the creation of a health avatar, with the goals of providing patients with complete health information from various sources, establishing an interactive and customizable platform, empowering users to determine how the health information best fits or speaks to their personal needs, and providing perspective by comparing the health status of the individual with that of the individual's community. SUMMARY: The Internet is rapidly becoming integrated into Americans' daily lives. According to the 2007 Health Information National Trends Study, 69% of U.S. adults had access to the Internet and 23% reported using a social networking site. The impact of social media has further grown, and an estimated 50% of adults in America have a profile on social media. The potential for using cyber communities to improve health messaging is great. Several health care organizations have implemented the use of social media in a variety of ways to varying degrees of success. We propose a platform that automatically gathers information and reflects the health status of an individual back to the user. An avatar, which is a representation of a user, could be created and assigned characteristics that allow users to appreciate their health status. The health avatar platform also would allow users to compare their personal status with that of their community. The overall goal is to engage and then motivate users to improve their overall health status. CONCLUSION: Medicine must acknowledge the evolving relationships that the next generation of patients will have with technology. The health avatar is a platform that incorporates a connection with the health system through electronic medical records and connects individuals to the greater community.

The expanding role of Minnesota pharmacists in primary care.

Changes to pharmacy education have paralleled changes in the role pharmacists play in primary care. Today, pharmacists are often members of the health care team, providing medication management services to help patients control chronic illnesses and working to prevent adverse drug events by educating and guiding prescribers. This article describes the role of pharmacists today and what they are doing to improve outcomes related to patient care.