Collaborative Practice Agreement Research Articles

Integrating pharmacists into a kidney transplant clinic: Developing and implementing a collaborative pharmacy practice agreement

BackgroundCollaborative pharmacy practice agreements (CPPAs) grant patient care authorities to pharmacists (PharmDs) under a scope of practice without direct physician supervision. ObjectivesThe aim of this study was to discuss steps for developing and implementing a CPPA in an outpatient renal transplant clinic and assess changes in physician and nurse burden, integrated pharmacy growth, and patient safety. Practice descriptionA CPPA was developed between physicians and pharmacists and implemented into a renal transplant clinic and the integrated pharmacy over the course of several years. Practice innovationCPPA execution in a post-transplant clinic has not been previously described and is needed to help advance patient care delivery models. Evaluation methodsThis single center, retrospective study compared immunosuppressant prescriptions generated by each authorizer type (nurse, physician, pharmacist) across 3 time periods: before pharmacist integration, during CPPA development, and after CPPA implementation. Pharmacy manpower and patient safety concerns post-CPPA implementation were also reviewed. ResultsResults show that prescription authorization migrated from either a nurse or physician (57% and 43% respectively) in pre-PharmD period, to mostly by physicians (72%) in PharmD pre-CPPA period, and largely by pharmacists (85%) in PharmD post-CPPA period. Quarterly prescription volume increased (6019 in quarter 3 of 2015 vs. 14,806 in quarter 4 of 2018) and integrated pharmacy staff grew from 8 employees (Pre-PharmD period) to 20 in PharmD post-CPPA period. No safety concerns were reported in any time period. ConclusionCPPAs have the advantage of reducing physician and nurse workload related to prescribing and advancing the role of the pharmacist by utilizing their expertise to take over certain tasks. Lessons learned during the CPPA implementation process include identifying needs, promoting maximal utility of pharmacists, and maintaining optimal communication between the health care team.

A survey of pharmacists' roles in gastroenterology and hepatology

AbstractIntroductionPharmacists' roles have evolved over time to include direct patient care and optimization of medication related outcomes. However, one therapeutic area lacking an evaluation of pharmacist involvement is gastroenterology and hepatology (GI/liver). This area utilizes biologics and other treatment options with considerable cost and safety, thus pharmacists can have a significant impact in caring for patients with GI/liver conditions.ObjectivesIdentify the background training of pharmacists practicing in GI/liver and characterize their current practice landscape.MethodsA survey was developed and disseminated through the American College of Clinical Pharmacy (ACCP) GI/Liver/Nutrition and Ambulatory Practice and Research Networks (PRN) groups and through the American Society of Health System Pharmacists (ASHP) Section of Specialty Pharmacy Practitioners from November 30, 2020 to January 16, 2021.ResultsOf 42 unique responses received, respondents primarily practiced at an academic medical center in the ambulatory setting. Although respondents reported completing various types of post‐graduate training (residency and fellowship), 55% of respondents endorsed prior exposure to GI/liver during training. Common disease states managed were inflammatory bowel disease, hepatitis B and C, and cirrhosis. Half of respondents reported having a collaborative practice agreement and 67% reported independently seeing patients in clinic, developing therapy plans, and ordering/monitoring labs. Approximately 69% do not have dedicated time for research. Only 23% of respondents reported billing for clinical services.ConclusionIn this survey, pharmacists are involved in caring for patients with GI/liver conditions under collaborative practice agreements and primarily based in an outpatient clinic. Future growth of pharmacists in this therapeutic space will require increased formalized training of GI/liver conditions and strategies to optimize reimbursement.

A Pharmacist Collaborative Practice Agreement Improves Oral Oncolytic Workflow and Reduces Treatment Delays

A Pharmacist Collaborative Practice Agreement Improves Oral Oncolytic Workflow and Reduces Treatment Delays

Minnesota Policy on Pharmacist-Prescribed Contraceptives: Benefits, Limitations, and Opportunities for Improvement.

In August 2020, pharmacists were authorized to prescribe contraceptives in Minnesota outside of a collaborative practice agreement. To practice under this new authorization, pharmacists must complete formal contraceptive prescribing training and follow guidelines which include restrictions on patient's age and appropriate screening and assessment requirements. Allowing pharmacists to prescribe contraceptives has the potential to extend contraceptive access, decrease overall health care costs, and improve outcomes. However, barriers to the expansion of contraceptive prescribing by pharmacists may prevent widespread adoption of this practice in Minnesota. A key concern among pharmacists is a lack of reimbursement for providing this service. Other states adopting contraceptive prescribing by pharmacists which have not paid for this service have reported limited implementation and discontinuation of this service. To improve contraceptive access to Minnesotans, policymakers should consider expanding provider status to pharmacists and providing reimbursement to pharmacists for contraceptive services.

Improving Efficiency of the Barbershop Model of Hypertension Care for Black Men With Virtual Visits.

BackgroundThe LABBPS (Los Angeles Barbershop Blood Pressure Study) developed a new model of hypertension care for non‐Hispanic Black men that links health promotion by barbers to medication management by pharmacists. Barriers to scaling the model include inefficiencies that contribute to the cost of the intervention, most notably, pharmacist travel time. To address this, we tested whether virtual visits could be substituted for in‐person visits after blood pressure (BP) control was achieved.Methods and ResultsWe enrolled 10 Black male patrons with systolic BP ≥140 mm Hg into a proof‐of‐concept study in which barbers promoted follow‐up with pharmacists who initially met each patron in the barbershop, where they prescribed BP medication under a collaborative practice agreement with the patrons' physician. Medications were titrated during bimonthly in‐person visits to achieve a BP goal of ≤130/80 mm Hg. Once BP goal was reached, visits were done by videoconference. Final BP and safety outcomes were assessed at 12 months. Nine patients completed the intervention. Baseline BP of 155±14/83.9±11 mm Hg decreased by −28.7±13/−8.9±15 mm Hg (P<0.0001). These data are statistically indistinguishable from prior LABBPS data (P=0.8 for change in systolic BP and diastolic BP). Hypertension control (≤130/80 mm Hg) was 67% (6 of 9), numerically greater than the 63% observed in LABBPS (P=not significant). As intended, the mean number of in‐person visits decreased from 11 in LABBPS to 6.6 visits over 12 months. No treatment‐related serious adverse events occurred.ConclusionsVirtual visits represent a viable substitute for in‐person visits, both improving pharmacist efficiency and reducing cost while preserving intervention potency.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT 03726710.

Improving outcomes in opioid-associated cardiac arrest

Improving outcomes in opioid-associated cardiac arrest

Medication management for complex patients in primary care: application of a remote, asynchronous clinical pharmacist model

PURPOSE Drug therapy problems impact about one third of US adults, and these issues are likely to continue to worsen as the population of aging Americans increases. The objective of this study is to assess the feasibility of a remotely delivered Comprehensive Medication Management (CMM) for primary practice patients who are polypharmatic and at high risk for drug therapy problems. METHODS Using medical and prescription claims data, a list of Medicare Advantage beneficiaries at high risk for drug therapy problems were identified. Participants were enrolled in a 6-month CMM program from February – November 2020. In the program, their existing drug therapy was assessed by a pharmacist, Drug therapy problems were identified and resolved. A Collaborative Practice Agreement allowed the pharmacists to make prescription changes as needed. RESULTS Eighty-three percent (202) of contacted individuals agreed to participate in the study. All participants were on 5 medications or more, and 71% were on more than eight. A clinical pharmacist found that 86% of participants had a drug therapy problem according to classification criteria. Seventy-nine percent of all drug therapy problems identified were resolved upon completion of the study. CONCLUSION The findings of this study suggest that engagement of a remote clinical pharmacist can contribute to efficient resolution of most drug therapy problems identified in a primary care population. A service model using remote pharmacist services may be an effective means of improving team-based primary care medication management for this population.

Pharmacist‐led optimization of heart failure medications: A systematic review

AbstractMedications are a cornerstone of treatment of heart failure (HF) with reduced ejection fraction, thus pharmacists are valuable members of the multidisciplinary team approach to long‐term patient management. As pharmacists' scope of practice has expanded, growing evidence shows an evolution in pharmacists' roles in the care of patients with HF. To synthesize the literature describing implementation of pharmacist‐led medication titration and clinical assessments on outcomes in ambulatory patients with HF. MEDLINE, Embase, and Cochrane Controlled Register of Trials were searched from 2007 to March 18, 2020. English language articles that evaluated implementation of pharmacist‐led medication titration in ambulatory patients with HF. Studies with interventions that involved pharmacists prescribing to initiate, modify, or discontinue medications with independent authority or under a collaborative practice agreement were considered. Ten retrospective studies from 718 identified articles were included. All studies incorporated pharmacist‐led guideline‐directed medical therapy (GDMT) titration, two with independent pharmacist prescribing in a multidisciplinary HF clinic, and seven in a pharmacist‐only clinic. Patients were referred from both inpatient and outpatient settings and had an average reported range of 1–5.7 visits with pharmacists. While four studies exclusively included patients with HF and ejection fraction below 45%, the mean ejection fraction of all included patients ranged from 20% to 42%. Four studies showed an increased proportion of patients on GDMT or target doses after pharmacist prescribing. Four out of six studies showed a significant decrease in all‐cause hospitalizations and one of two studies reported a significant decrease in all‐cause mortality rate with intervention. This study found that pharmacist‐led medication optimization increased the use of GDMT in ambulatory patients with HF, and may be associated with fewer hospitalizations and deaths. Future randomized controlled trials should evaluate the impact of adding pharmacist‐led HF medication optimization to standard of care on clinical outcomes.

Implementation of Outpatient Pharmacist-led Hypertension Management for Under-Resourced Patients: A Pilot Study.

The purpose of this study was to implement and evaluate a pharmacist-led hypertension (HTN) program for under-resourced patients discharged from the emergency department (ED) or screened at community health events who are lacking a regular primary care provider (PCP) relationship. This was a single arm, prospective, pilot study to recruit patients from the Detroit Medical Center (DMC) Sinai Grace Hospital (SGH) ED and community health events. The outpatient pharmacist-led transitional care clinic (TCC) was implemented through a collaborative practice agreement (CPA) with ED physicians. Eligible patients 18 to 60 years with elevated blood pressure (BP) (> 140/90 mmHg) and lacking a PCP relationship were referred to the TCC for HTN management. The primary outcome measure was change in systolic and diastolic BP (SBP and DBP). Difference in BP values was evaluated using Wilcoxon Signed Ranks test and descriptive statistics were used to explain demographic data. There were 116 patients enrolled May 2017 to August 2018; 44 (37.9%) completed visit one [cohort 1], 30 (25.9%) completed at least three visits [cohort 2], and 16 (13.8%) completed five visits [cohort 3]. Most patients were African American (AA) 97.7%, 47.8% were male, and an average of 42.11 (SD 9.70) years. For cohorts 2 and 3, there was significant reduction in BP between TCC visits one and two and the reduction was maintained through five visits for patients that remained in the study. Patients who completed five visits (n=16) showed a significant change from visit one to visit five in SBP of -23 mmHg (p=0.002) and achieved BP goal with an average SBP 139 mmHg (SD 19.33) and DBP 90 mmHg (SD 10.17). The pharmacist-led TCC was successfully implemented. Outpatient pharmacists collaborating with ED physicians increased access to HTN management with a positive impact on BP outcomes in an under-resourced population.

Improvement of Inpatient Psychiatric Facility Quality Reporting program measure: Screening for metabolic disorders through pharmacy collaborative practice agreement

BackgroundSecond-generation antipsychotics are associated with lower risks of extrapyramidal symptoms, including tardive dyskinesia. However, many second-generation antipsychotics are associated with metabolic adverse effects, including weight gain, impaired blood glucose control, and hyperlipidemia. Metabolic monitoring for patients prescribed antipsychotic medication is 1 of several measures of the Centers for Medicare & Medicaid Services’ Inpatient Psychiatric Facility Quality Reporting program. Screening for metabolic disorders (SMD) must be obtained within the previous 365 days before the hospital discharge date. National data suggest that compliance with this measure is low. ObjectiveTo improve compliance of metabolic monitoring by 20% while ensuring that the quality improvement interventions did not cause any unintended adverse effects on other aspects of our system. Practice descriptionThis quality initiative was conducted at a large, 2000-bed academic medical center with approximately 80 inpatient psychiatric beds.Practice innovation: To improve the metabolic screening rates, a pharmacist collaborative practice agreement (CPA) was established as part of a quality improvement project. Previously, there were no formal processes at the institution to ensure that appropriate laboratory tests were conducted. Evaluation methodsUsing an uncontrolled before-and-after design, SMD data were gathered from 6 months before and 6 months after CPA implementation. Pearson chi-square test or Fisher exact test were used to compare the pre- and postintervention groups in this quasi-experimental design. ResultsCompared with the preintervention period, compliance of SMD monitoring increased by 21.2% in the postintervention phase—from 69.2% to 90.4% (P < 0.001). ConclusionThe empowerment of clinical pharmacists with a CPA significantly improved guideline-concordant metabolic monitoring of antipsychotics. These findings may have significant impact on the approach to the safe use of these essential psychotropic medications and provide a framework for other inpatient mental health facilities to optimally use the skills of their interdisciplinary team.

Implementing a pharmacist-led transition of care model for posttransplant hyperglycemia.

DisclaimerIn an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PurposeThe implementation of a pharmacist-managed transition of care program for kidney transplant recipients with posttransplant hyperglycemia (PTHG) is described.MethodsIn September 2015, a collaborative practice agreement between pharmacists and transplant providers at an academic medical center for management of PTHG was developed. The goal of the pharmacist-run service was to reduce hospitalizations by providing care to patients in the acute phase of hyperglycemia while they transitioned back to their primary care provider or endocrinologist. For continuous quality improvement, preimplementation data were collected from August 2014 to August 2015 and compared to postimplementation data collected from August 2017 to August 2018. The primary endpoint was hospitalizations due to hyperglycemia within 90 days post transplantation. Secondary endpoints included emergency department (ED) visits due to hypoglycemia and the number of interventions performed, number of encounters completed, and number of ED visits or admissions for hypoglycemia. A Fisher’s exact test was used to compare categorical data, and a Student t test was used to compare continuous data. A P value of <0.05 was considered to be statistically significant.ResultsForty-three patients in the preimplementation group were compared to 35 patients in the postimplementation group. There was a significant reduction in hospitalizations due to hyperglycemia in the postimplementation versus the preimplementation group (9 vs 1, P < 0.05); there was a reduction in ED visits due to hyperglycemia (5 vs 0, P = 0.06). There were no ED visits or hospitalizations due to hypoglycemia in either group. Clinical transplant pharmacists performed an average of 8.3 (SD, 4.4) encounters per patient per 90 days.ConclusionA collaborative practice agreement was created and successfully implemented. A pharmacist-managed PTHG program could be incorporated into the standard care of kidney transplant recipients to help minimize rehospitalizations due to hyperglycemia.

Postgraduate year two ambulatory care residency program evaluation with a tool for assessing ambulatory care pharmacist practice

AbstractIntroductionA standardized set of required competency areas, goals, and objectives are used in accreditation to create consistency in learning experiences across programs. The individual postgraduate year two (PGY‐2) ambulatory care residency program is subsequently tasked with designing activities to achieve the defined goals and objectives, which may lead to variability in the constructed activities across residency programs.ObjectivesThe primary objective of this study was to describe (define, assess, and stratify) the current landscape of direct patient care activities provided within PGY‐2 ambulatory care residency program training environments.MethodsThis was a national, descriptive, cross‐sectional study using the Tool for Assessing Ambulatory Care Pharmacist Practice (TAAPP). The TAAPP questionnaire was disseminated via electronic mail to PGY‐2 ambulatory care Residency Program Directors (RPDs) meeting inclusion criteria. RPDs were requested to complete the questionnaire and disseminate it further to two preceptors of required rotations and all 2017‐2018 residents.ResultsIn total, 108 responses were received out of a possible 595 and 10 were excluded due to the respondents not meeting inclusion criteria or the questionnaire was incomplete. Ninety‐eight (16.5% response rate) underwent descriptive and statistical analysis. Fifty‐two participants (53%) indicated they provide a comprehensive or broad delivery of direct patient care, 44 respondents (45%) provide activities within a moderate scope of practice, and 2 respondents (2%) engage in a narrow scope of practice. Forty‐seven of the pharmacists (36%) stated they were functioning under a disease state specific collaborative practice agreement (CPA), 40 (31%) under a broad or comprehensive CPA, 24 (19%) under a protocol‐driven, and 13 (10%) under a medication‐specific agreement.ConclusionVariability in PGY‐2 ambulatory care residency programs was found with just half of participants functioning under a broad scope of pharmacist practice. Opportunities exist for programs to further standardize and advance program training environments.

Adventures in getting paid

Adventures in getting paid

COVID-19 pharmacy student perceptions: pharmacists' impact during the COVID-19 pandemic

Pharmacists around the world are playing an active role in educating the public about COVID-19. First-year pharmacy students taking a healthcare course at Temple University in Philadelphia were asked to write papers based on the nature of a pharmacist’s contributions during the pandemic. 90% of the essays outlined the importance of community pharmacists, as they are the most accessible healthcare professional, providing immediate social interaction and drug expertise. They help minimize the need for hospital visits, limiting their time in public, therefore reducing their risk of becoming infected. For the pharmacies that have a drive-thru window, over-the-counter medications and other necessities can be sold to decrease the likelihood of transmission. Many students also proposed the opportunity for more leniency in prescribing power. Unless pharmacists are within a collaborative practice agreement, they cannot prescribe even maintenance medication. Due to the pandemic, it has become increasingly hard to reach the doctor or see them in person, as most offices have switched to telehealth. Clinical pharmacists operating out of hospitals have the opportunity to oversee proposed treatment options or experimental drugs, such as remdesivir. Retail pharmacies are emerging as key resources in this pandemic, and it is i

Pharmacist Versus Physician Provider Management of Hydroxyurea Therapy for Polycythemia Vera (PERMANACE)

Background: Cytoreduction utilizing hydroxyurea to achieve a hematocrit (HCT) &amp;lt;45% has improved clinical outcomes for patients with Polycythemia Vera (PV). Pharmacists, through a collaborative practice agreement with hematologists, are uniquely posited to act as physician extenders and therapeutically dose adjust hydroxyurea (HU). Since 2013, HU therapeutic drug monitoring for PV patients has been transitioned to pharmacists in our oral chemotherapy clinic. We conducted a retrospective cohort cross-over study to evaluate pharmacist versus physician HU management to achieve a therapeutic HCT &amp;lt;45%. Methods: We retrospectively queried our institutional electronic medical record to identify patients diagnosed with PV with a documented ambulatory HU prescription. Additionally, patients' HU must have been managed by a physician (Phys) and subsequently crossed over to a pharmacist (PharmD) with at least two documented encounters by each clinician type. Hematological parameters for therapeutic drug monitoring are outlined in Table 1. Descriptive statistics were used for demographic information and a random effects model was used to evaluate HU management between Phys and PharmD. We fit a generalized linear regression model with random intercepts for each patient, using SAS's PROC GLIMMIX and Laplace approximation method t-test for a significant difference in probability of a therapeutic measurement between PharmD and Phys managed patients. Odd ratios were also calculated and adjusted for age and sex. Statistical analysis was performed using SAS (SAS9.4 SAS Institute, Cary, NC) and R software (The R Group, Vienna, Austria), with p&amp;lt;0.05 considered statistically significant. Results: Between 1/1/2003 and 1/20/2020, 104 patients meet the inclusion criteria. This cohort was primarily female (53%), white (97%), and aged 71 years during PharmD management vs 69 years during Phys management. The median time of a patient's HU management by PharmD was 2.4 years (IQR 1.2-3.8), Phys was 0.7 years (IQR 0.02-4.2), and overall was 3.6 years (IQR 2-6.6). 3154 complete blood count measurements were collected in the PharmD cohort and 2007 were collected in the Phys cohort. HU management by PharmD vs Phys resulted in statistically significant increases of therapeutic HCT measurements (p&amp;lt;0.0001) and platelet (PLT) measurements (p&amp;lt;0.0001) as shown in Figure 1. These outcomes remained significant when adjusted for both age and sex: HCT 87.8% vs 74.7% (p&amp;lt;0.0001) and PLT 78.4% vs 70.1% (p=0.0001). There was no difference white blood cell (WBC) therapeutic measurements between cohorts nor when adjusted for age and sex. Patients in the PharmD cohort had higher odds of achieving therapeutic HCT (OR 2.44; 95% CI [1.92 - 3.10], p&amp;lt;0.0001) and PLT (OR 1.55; 95% CI [1.25 - 1.92], p=0.0001) goals (Table 1). In terms of hematological safety parameters, there was no significant difference in neutropenia (OR 1.30; CI 95% [0.51-3.25]) with PharmD vs Phys HU management. All grade neutropenia occurred in 35 (1.1%) and 18 (0.9%) of patients between the PharmD vs Phys cohort, respectively. Grade 3 neutropenia occurred in 1.1% of patients in both cohorts with no instances of Grade 4 neutropenia. Conclusion: These findings support the efficacy of pharmacist therapeutic drug management of HU for patients with PV. Pharmacists managing HU achieve a target HCT and PLT count more often than physician management. By acting as a physician extender, pharmacist HU management for PV patients can help decrease the clinical burdens on physicians without compromising efficacy. Disclosures No relevant conflicts of interest to declare.

Implementation of primary care clinical pharmacy services for adults experiencing homelessness

BackgroundIt is estimated that on any given night in the United States, more than half a million individuals experience homelessness. Within the homeless population, chronic conditions such as diabetes, heart disease, and human immunodeficiency virus are found at rates 3-6 times higher than in the general population. Despite this, access to appropriate treatment and preventive care remains difficult for those experiencing homelessness, and many barriers exist to achieving positive health outcomes. ObjectiveThe primary objective of this study was to determine the clinical impact and sustainability of implementing clinical pharmacy services in a clinic for adults experiencing homelessness. Practice descriptionAs a pilot service, a postgraduate year 2 ambulatory care pharmacy resident attended the Pedigo clinic for adults experiencing homelessness 1 half-day per week to provide independent cardiovascular risk reduction (CVRR) disease state management under a collaborative practice agreement. Practice innovationThe existing CVRR model was applied at a clinic location that did not previously have clinical pharmacy services. The provision of these services was adapted to meet the unique health needs of the homeless population. Evaluation methodsThe outcomes from having a clinical pharmacist in this clinic setting were retrospectively reviewed from September 2019 to March 2020. ResultsDuring the pilot period, the pharmacist conducted 28 encounters for 14 unique patients and made a mean of 4 clinical interventions per patient encounter. A total of 124 interventions occurred, including comprehensive medication review (n = 23; 82.1%), patient education (n = 21; 75%), medication regimen optimization (n = 18; 64.3%), and tobacco cessation (n = 18; 64.3%), among several others. Clinical outcomes (glycosylated hemoglobin level, blood pressure, and weight) remained stable with pharmacist management throughout the pilot period. ConclusionThe addition of a clinical pharmacist to the interdisciplinary care team for patients experiencing homelessness addresses a health care disparity and enhances the care provided to this vulnerable population.

New resource explores ways pharmacists lead smoking cessation efforts

Medical Arts Pharmacy in Fayetteville, AR, is the only local provider in the area offering smoking cessation counseling and support to patients. “There are a lot of people who need this service and doctors just don't have time to go through all the things we go through to help people be successful,” said Julie Stewart, PharmD, who has been practicing at the pharmacy for over 15 years. Word is out that pharmacists are in a perfect position to help patients quit tobacco. In January of this year, the Surgeon General released the first report on smoking cessation in 30 years, highlighting the important role pharmacists play in cessation efforts. “All pharmacists, along with other members of the health care team, play a critical role in screening patients for tobacco product use and in providing treatment options and supportive care to help patients quit,” said RADM Ty Bingham, PharmD, chief pharmacy officer with the U.S. Public Health Service. “We can improve access to evidence-based cessation services for individuals seeking to quit.” Evidence has shown that quit attempts are most successful when supported by evidence-based treatments, including pharmaceutical aids and counseling services, and the profession of pharmacy has made major strides to have a prominent role in tobacco cessation efforts over the decades. A new resource from APhA (www.pharmacist.com/tobaccocessation/promising-practices) was developed to highlight the ways in which pharmacists are engaging with tobacco cessation interventions. “These case studies showcase how pharmacists in different health care settings across the nation are maximizing their expertise to assist patients who use tobacco to quit, setting them on course for improved health and well-being,” RADM Bingham said. Across the United States, the pharmacy practice landscape varies for a number of reasons, including state pharmacy acts, patient populations, practice settings, payer relationships, and more. When the smoking cessation program started at Medical Arts Pharmacy in 2019, services were supported by grant funding that lasted for a 4-month period. Today, even without the financial support, pharmacists at Medical Arts still provide the service to patients at no cost. “We wanted to continue with the momentum we had from the program mostly in hopes of building our reputation and confidence in our process so we would have a good program in place when reimbursement does come,” said Stewart. Pharmacists are not recognized on the federal level or on the state level in Arkansas as health care providers who can bill and be reimbursed for services. Pharmacists at Medical Arts are compensated through the sale of tobacco cessation medications only—they are reimbursed for the cost of the medication and provided a nominal dispensing fee. Patients may also pay cash for the nicotine replacement therapies (NRTs) if their insurance does not cover them. For patients without insurance, the pharmacist collaborates with the Arkansas Department of Health, which provides NRTs at no cost to patients. However, the pharmacy does not receive a dispensing fee for the service. Pharmacists like Alexa Valentino who work on a health care team have an easier time with reimbursement for smoking cessation services. Valentino works at PrimaryOne Health, a federally qualified health center (FQHC) in the Columbus, OH, area. She came on board in 2013, a year after tobacco cessation had been established as a core patient care service provided by pharmacists at the FQHC. Pharmacists at PrimaryOne Health have expanded their ability to bill for tobacco cessation counseling services, primarily through payers, and have subsequently increased authority through a collaborative practice agreement for the management of tobacco use disorder. Typically, patients are referred to the pharmacist-provided tobacco cessation program by other practitioners in the center. “Our providers love that we provide this service and it was a great place to start to build relationships with providers and to build their trust in what we can do as pharmacists,” said Valentino, PharmD, BCACP, lead clinical pharmacist at PrimaryOne Health. Over the years, pharmacists there have been able to expand beyond smoking cessation to manage other disease states as additional needs were identified and new billing opportunities presented themselves to Ohio pharmacists. But Valentino said offering smoking cessation services to patients is a great place for pharmacists anywhere to start providing patient care services because other health care providers are eager for pharmacists to take it on.

Oncology pharmacists find success with collaborative practice agreement

Provider status will open the door for pharmacists to be compensated for advanced services they provide. At the same time, it can be used as a springboard for certain instances of prescriptive authority. As the march to provider status continues, pharmacists can use collaborative practice agreements (CPAs) to achieve a more advanced level of practice. While pharmacists can differ in familiarity with CPAs, it's important to hear the success stories. One such example is the CPA oncology pharmacists entered into at St. Luke's Cancer Institute in Boise, ID. St. Luke's Cancer Institute has a history of using CPAs. Oncology pharmacists in the facility have been able to prescribe antiemetic therapy after meeting with oncology patients and reviewing their treatment plans. After identifying new barriers—prescription approvals were taking longer than hoped—the oncology pharmacists were able to enter into a new CPA that allowed them to prescribe certain treatments to eliminate delays. “It took an average of 7 minutes for the [CPA group] to turn around one medication adjustment, compared to 3,311 minutes for the control group. It was a no-brainer after that,” said Amanda Wright, PharmD, oncology pharmacist at St. Luke's Cancer Institute, in a July 27 blog post from the Association of Community Cancer Centers. This new CPA gave oncology pharmacists at St. Luke's Cancer Institute the authority to sign refill prescriptions, adjust or round doses, and adjust dosing regimens if toxicities surfaced. Wright said these pharmacists now have higher job satisfaction and have reduced their workday by 20 minutes. A CPA is a document that specifically details which actions a pharmacist can take under the authority of another's license—typically that of a medical doctor. It clearly defines the pharmacist's scope of practice and specifies instances that fall outside of the pharmacist's expertise. Some issues persist that slow the adoption of CPAs throughout the country. One barrier relates to state law—some states allow CPAs to exist for pharmacists, and others are silent on the issue. Silence creates ambiguity and often has the same chilling effect as a state explicitly prohibiting CPAs. The other barrier relates to payment. Even if a pharmacist can enter into a CPA, getting paid for their time and service is fraught with uncertainty. Because pharmacists are not recognized as providers at the national level, inconsistent payment practices exist across states where CPAs are allowed. In a state that allows CPAs and also recognizes pharmacists as providers, more pharmacists will be able to enter into a CPA and also collect payment. However, in states that allows CPAs but don’t recognize pharmacists as providers, the adoption and implementation of CPAs are exceedingly low because pharmacists cannot receive compensation for their expertise. Until pharmacists win provider status nationally, CPAs are a great way to bridge the gap between where pharmacists are and where they need to be. As CPAs are put into practice more often, the case for provider status becomes stronger.

Factors that influence patient acceptance of clinical pharmacy services: A nationwide survey

ObjectiveExamine the factors that influence a patient’s likelihood of participating in clinical pharmacy services so that pharmacists can use this knowledge to effectively expand clinical services. MethodsAn online survey was distributed to U.S. citizens 55 years of age or older through a market research company. The survey assessed pharmacy and medication use, general health, interest in clinical pharmacy services, and general demographics. The specific clinical services examined included medication therapy management (MTM) and a collaborative practice agreement (CPA). Logistic regression and best-worst scaling were used to predict the likelihood of participating and determine the motivating factors to participate in clinical pharmacy services, respectively. ResultsTwo hundred eight (58.45%) respondents reported being likely to participate in MTM services, and 108 (50.6%) reported being likely to participate in the services offered by a pharmacist with a CPA, if offered. The motivations to participate in MTM were driven by pharmacist management of medication interactions and adverse effects (best-worst scores 0.62 and 0.51, respectively). The primary motivator to participate in a CPA was improved physician-pharmacist coordination (best-worst score 0.80). Those with a personal pharmacist were more likely to participate in MTM (odds ratio [OR] 2.43 [95% CI 1.41–4.22], P = 0.002) and a pharmacist CPA (2.08 [1.26–3.44], P = 0.004). Previous experience with MTM increased the likelihood of participating again in MTM (5.98 [95% CI 2.50–14.35], P < 0.001). Patient satisfaction with the pharmacy increased the likelihood of participating in a pharmacist CPA (1.47 [95% CI 1.01–2.13], P = 0.04). ConclusionPatients are interested in clinical pharmacy services for the purposes of medication interaction management, adverse effect management, and improved physician-pharmacist coordination. The factors that influenced the likelihood of participating included having a personal pharmacist, previous experience with MTM, and pharmacy satisfaction. These results suggest a potential impact of the patient-pharmacist relationship on patient participation in clinical services.

Pharmacist value-added to neuro-oncology subspecialty clinics: A pilot study uncovers opportunities for best practices and optimal time utilization.

To evaluate neuro-oncology clinician time utilization for medication management and identify a cost beneficial role for integration of a dedicated pharmacy specialists. A pharmacist was temporarily integrated into a neuro-oncology clinic for a 30-day period to evaluate the clinical practice and perform a 14-day clinical chart evaluation and patient interactions as part of a single institutional exploratory analysis. The pharmacist completed screenings for drug-drug interactions, new therapies, medication reconciliation, and advanced interventions as part of a collaborative practice agreement for pharmacist autonomy. Pharmacist time spent was calculated and documented within the patient encounters to support physician decision-making. A comparative estimate of pharmacist versus physician time utilization and cost for each was completed to derive a savings analysis for integration of a dedicated clinic pharmacist. During the 14-day clinical assessment, the pharmacist completed 147 encounters with 338 interventions. Of the encounters, 90% (n = 132) were higher complexity requiring plan modification, and approximately 48% (n = 162) of all interventions required ≥10 minutes of the pharmacist's time. Physician non-patient-facing time devoted to medication tasks was 5-hours weekly (0.125 FTE, full time equivalents), an estimated direct salary cost of $937/week ($45,000 yearly). Hire of a part-time pharmacist at 0.50 FTE would cover the clinical need with supported documentation and medication monitoring at a cost of $45,000/year. Defining the roles for dedicated neuro-oncology clinic pharmacists allows for cost-savings through re-allocation of physician time and improves subspecialty clinic operations as well as patient care.