Practice Agreement Research Articles

P69 Assessing Pharmacist-Administered Influenza Vaccinations and the Potential Impact of State Policies on Vaccination Rates: A Claims Data Analysis

Pharmacists have been permitted to immunize in all US states for over a decade, historically under enabling laws and varying requirements such as collaborative practice agreements (CPAs). This study aimed to characterize trends in influenza vaccinations over time and evaluate whether changes in policies related to CPAs impacted annual influenza vaccination rates.

Implementation of pharmacist‐led HIV pre‐exposure prophylaxis management to increase access to care at an academic internal medicine practice

AbstractIntroductionThe ongoing human immunodeficiency virus (HIV) epidemic continues to require attention to reduce the number of new infections. HIV pre‐exposure prophylaxis (PrEP) has emerged as a highly effective strategy. Although its overall use in the United States has increased since initial approval, it is still underutilized, especially in populations disproportionately affected by HIV. One method for overcoming barriers to PrEP uptake includes utilizing pharmacists to increase access to care.MethodsFor this initiative, a pharmacist‐led PrEP service within a primary care practice was developed utilizing a collaborative practice agreement to enable ordering medications, lab tests, and immunizations. Following the sustainable initial implementation at the first site, expansion occurred to a second location. Data on referrals, patient demographics, and PrEP persistence were collected. Challenges, lessons learned, and future opportunities were also considered.ResultsSince initiating services at both practice sites, a total of 76 patients were referred from August 2018 through March 2022. The majority of patients had their sex listed as male (96%) within the electronic health record and was white (69.7%). The mean age of patients was 33 years (range, 20‐71). Of those who engaged with pharmacist‐led PrEP management, 33.9% (20/59) were retained in care for at least 1 year. There were no occurrences of seroconversion during pharmacist management. Throughout the course of implementation, areas of improvement were identified and addressed for process improvement.ConclusionOur experience supports that pharmacist‐led PrEP management in an outpatient primary care practice is a sustainable option to address certain barriers to care. However, the ability for pharmacist‐provided services may be limited by state pharmacy practice laws and/or lack of reimbursement opportunities for clinical services. Developing innovative practice models that integrate pharmacists in a variety of settings is imperative for further reducing HIV transmission.

A Pandemic, Not a Panacea

A Pandemic, Not a Panacea

THE SCOPE OF APPLICATION OF THE CONCEPTS OF NATIONALITY AND PERSONAL LAW TO THE LEGAL ENTITY

This article examines the areas of application of the nationality and personal law of a legal entity, which plays an important role in the relations of a legal entity in a foreign state and with foreign legal entities, ie public and private international legal relations. In this case, tax, investment and diplomatic protection are discussed separately as the main areas of focus on the nationality of the legal entity. It has also been proved based on the legislation of foreign countries, judicial practice, bilateral and multilateral international agreements, scientific doctrine on the application of the nationality and personal law of a legal entity in various fields are that nationality and personal law of a legal entity are separate concepts. More precisely, it was concluded that the nationality of a legal entity should be applied in public legal relations, and personal law in private international legal relations

Evaluation of a Standardized Tacrolimus Therapeutic Drug Monitoring Protocol in Stable Kidney Transplant Recipients.

Introduction: Transplant nurse coordinators have assisted in accurately adjusting tacrolimus doses under a collaborative practice agreement for kidney transplant recipients in the early post-operative period. This study evaluated the efficiency of a standardized tacrolimus therapeutic drug monitoring (TDM) protocol in stable outpatient recipients. Design: We conducted a single-center, retrospective study of adult patients who received a kidney transplant at least 3 years ago and were taking immediate-release tacrolimus. Before September 2019, transplant coordinators consulted transplant providers for management of all tacrolimus trough levels (Pre-Arm). Under the standardized protocol, coordinators directly responded to out-of-range tacrolimus trough levels (Post-Arm). The primary outcome was the time to intervention for out-of-range levels. Secondary outcomes included adverse events, time in therapeutic range, coefficient of variation (CV), and protocol compliance. Results: Of 1712 levels (from 174 patients), 259 levels (15.1%) were out-of-range. The overall time to intervention was 13.2 hours shorter (95% CI: -26.4 to -0.1 hours; P = 0.048) in the Post-Arm. There was no rejection, graft loss, or death during the study period. The time in therapeutic range was 89.3% (17.6%) vs 89% (19.4%; P = 0.816) and CV was 19.7% (15.8%) vs 18.4 (10.7%; P = 0.358) in the Pre-Arm and Post-Arm, respectively. Within the Post-Arm, the protocol required coordinators to independently intervene on 96 out-of-range levels (65.8%), which were accurately addressed 57.5% of the time. Conclusion: Implementation of a standardized TDM protocol improved efficiency without compromising major clinical outcomes or intrapatient variability (IPV) of tacrolimus levels for stable kidney recipients in the outpatient setting.

Evaluation of a program for outpatient sotalol loading with physician and pharmacist monitoring

BackgroundDose-dependent QT prolongation with class III antiarrhythmics mandates close monitoring often in an inpatient setting. Outpatient sotalol loading monitor provides an alternative to patients that is cost effective and allows preservation of hospital resources. ObjectivesThe objectives for this study include assessing adverse events, assessing patient adherence to monitoring and follow-up, comparing hospital cost and resource utilization, and evaluating patient satisfaction with outpatient sotalol loading program. Practice descriptionOne pharmacist in the antiarrhythmic clinic at OhioHealth Riverside Methodist Hospital completed 3-day outpatient sotalol loads under a collaborative practice agreement. Clinic services included pharmacotherapy management, medication counseling, and device education. Practice innovationThis service allows pharmacists to provide direct patient monitoring to provide increased patient access. Evaluation methodsAll data were collected via the electronic medical record, patient journal documentation, and a patient satisfaction survey. ResultsA total of 12 patients completed outpatient sotalol loading; 10 patients started in normal sinus rhythm, and 1 patient was cardioverted during the load. No patients experienced any adverse events during the loading phase. One patient completed a successful dose increase during the loading phase. All 12 patients attended the first visit, completed baseline laboratory tests, and uploaded electrocardiograms for all 3 days. A total of 11 patients were evaluated as a cost comparison for inpatient sotalol loading. On average, outpatient loading cost was $886.30, in comparison with $7571.76 for inpatient loading (P < 0.001). A total of 10 patients completed the satisfaction survey, and all of the patients preferred to complete this in the outpatient setting. ConclusionIn this study, 12 patients safely completed outpatient sotalol loading, with an overall decrease in the cost of their care in comparison with inpatient loading. This study showed that pharmacists can serve as physician extenders to continue to provide high-quality and safe care to patients in the antiarrhythmic space.

Accomplishing provider status: Getting pharmacists paid for their patient care services

Accomplishing provider status: Getting pharmacists paid for their patient care services

Pharmacist-led Smoking-Cessation Services in the United States - A Multijurisdictional Legal Analysis.

A challenge presents itself when pharmacy students and pharmacists have the knowledge, skills, and abilities to provide optimal patient care, which can prevent the healthcare industry from incurring expenditures reaching billions of dollars annually from chronic and acute disease state management, yet due to the lack of statutory or regulatory authority to independently prescribe and dispense smoking cessation products they are unable to tap into this potential. Prescriptive authority of pharmacists is not a novel concept; however, State Legislatures and Boards of Pharmacy have been slow to expand upon the pharmacist's scope of practice to include this authority. As a consequence, this inaction hinders the opportunity of almost 21.5 million patients, who attempt to quit smoking annually, the ability to access a U.S. Food and Drug Administration approved, evidence-based medication-assisted or nicotine replacement therapy prescribed by a pharmacist.2 Current legislative efforts, laws, and regulations regarding a pharmacist's prescriptive authority for tobacco cessation therapy vary greatly amongst the states and do not include reference to e-cigarettes or electronic nicotine delivery systems (e.g.,e-cigs, vape pens, vapes, mods, etc.). Additionally, pharmacists are often required to practice under a statewide protocol or enter into a collaborative practice agreement ("CPA") with a designated physician, which are often complex and create significant barriers for the pharmacist to practice at the top of their license and for the benefit of the patient. This legal and regulatory study reveals the following: 1) Those States that have addressed or attempted to address the pharmacist's prescriptive authority for tobacco cessation therapy, 2) the authority to independently prescribe vs. practice under a statewide protocol, 3) the products able to be prescriber or dispensed under the pharmacist's prescriptive authority or statewide protocol, and 4) the guidelines and/or protocols referenced within their respective State laws and regulations. States and their residents would benefit greatly from amending their laws and regulations to expand upon the pharmacist's prescriptive authority, granting them the ability to help their communities by performing services they are highly trained to perform.

States’ pharmacist immunization authority and the impact on adult influenza vaccination rates

BackgroundPharmacist-provided vaccinations are cost effective, readily accessible, and support the efforts of our nation’s public health goals. Pharmacist authority to administer vaccines varies state by state, and these authorities may have an impact on state influenza vaccination rates. ObjectiveTo analyze the impact of varied state pharmacist immunization authorities on adult and older adult influenza vaccination rates for the 2018-2019 influenza season. MethodsUsing data from the Behavioral Risk Factor Surveillance System, multiple logistic regression was performed to determine how pharmacist state immunization authority predicts influenza vaccination. Immunization authority was categorized into one of 3 mutually exclusive groups: independent authority, statewide protocol or standing order, or collaborative practice agreement (CPA). ResultsResults in the overall adult population showed a statistically significant lower adjusted odds of influenza vaccination in states with independent authority (0.937, 95% CI [0.889–0.986]) or statewide protocol or standing order (0.947, [0.906–0.990]), versus CPAs. In the older adult population, there was not a statistically significant difference in immunization between states with independent authority and those with CPA. ConclusionAlthough pharmacists are authorized to administer influenza vaccines, other factors (e.g., resources, service offerings, social determinants) including administrative barriers in pharmacist immunization authority are possibly limiting increases in influenza vaccination rates.

278 Developing AMILDA: An Intervention to Improve Symptoms and Medication Adherence among Latinx Adults with Depression and Anxiety

OBJECTIVES/GOALS: To develop the Adherence to Medications In Latinx adults with Depression and Anxiety (AMILDA) intervention using community engaged research principles, AMILDA will integrate culturally tailored messaging to improve depression and anxiety symptoms and adherence to antidepressant medications. METHODS/STUDY POPULATION: Bilingual steering committee members representing primary care and behavioral health professionals from 2 primary care clinics, and 1 lay community member met monthly for 1 year to develop the intervention. One clinic is an academic health center and the other is a federally qualified health center. Members identified, developed, and voted on the interventions components, therapeutic goals, and the mechanisms underlying its effectiveness that needed to be studied. To evaluate AMILDAs components, we conducted an observational study of health care providers (N=13) and Latinx adults with depression and/or anxiety (patients; N=26) from both clinics, and community pharmacists (N=9) from surrounding pharmacies to gather feedback. Based on their input, we revised the intervention. RESULTS/ANTICIPATED RESULTS: AMILDA consists of culturally tailored collaborative drug therapy management with a collaborative practice agreement between the physician and pharmacist. Patients recently started on an antidepressant receive language and culturally concordant motivational interviewing, teach back, and infographics; AMILDA is designed to improve symptoms, adherence, and health determinants. Most provider, pharmacist, and patient participants reported that AMILDA could be beneficial. Several participants indicated a lack of understanding about a US pharmacists scope of practice. Recommendations included ensuing language concordance, incorporating more statistics and scientific data, using images that are relatable, avoiding idioms and stereotypes, taking the time to build rapport, and being friendly. DISCUSSION/SIGNIFICANCE: AMILDA will be tested in a pilot effectiveness randomized controlled study to determine if it improves depression and anxiety symptoms and adherence to antidepressants among Latinx adults compared with enhanced usual care. The mechanisms to be assessed include self-efficacy, antidepressant knowledge, and personal health literacy.

CPNP 2022 Annual Meeting Poster Abstracts

CPNP 2022 Annual Meeting Poster Abstracts

Empowerment of Infrastructure Guarantee on Public Private Partnership (PPP) Projects in Indonesia: Implementation of the Balance Principle on the Effectiveness of the IIGF Guarantee Agreement

Infrastructure Guarantee is one of the government's much-needed support programs for PPP projects in Indonesia, with the goal of increasing creditworthiness, bankability, and investor trust. Until now, the usage of Infrastructure Guarantees has had its upsides as well as downsides, including complaints from private proponents about the lengthy evaluation process, payment of excessive fees, and the lack of scope of risk that the Indonesia Infrastructure Guarantee Fund Institute (IIGF) as guarantor can bear. In order to achieve an equal position between the Government Contracting Agency (GCA) and the Private Sector Entities (PSE) in the fulfilment of the PPP project in Indonesia, this study will examine the efficiency of the IIGF Guarantee Agreement using the principle of balance. The method of writing used in this paper is normative juridical method, which will be linked to the use of Guarantee Agreement in practice. The conclusion that can be drawn is that IIGF has provided a Guarantee Agreement in accordance with the balance principle, where the principle can also be seen in the risk allocation that has been agreed upon by the parties, apart from the arrangement of the Guarantee Agreement clauses. If an unbalanced position is later discovered, the parties can suggest action to restore balance so that the PPP project can be guaranteed until the concession time is completed. Keywords: PPP, Infrastructure Guarantee, Guarantee Agreement, Risk Allocation DOI: 10.7176/JLPG/119-04 Publication date: March 31 st 2022

Washington pharmacist Timothy Fuller dies at 75 years.

Timothy Stephen Fuller, collaborative practice trailblazer and longtime pharmacist–consultant for the Washington State Board of Pharmacy, died January 17 at his home in Sequim. He was 75 years old. Fuller was widely known for his research and advocacy on collaborative practice for pharmacists, an issue he championed during more than 2 decades of service with the pharmacy board. He was instrumental in establishing the nation’s first collaborative model for pharmacists to administer vaccines, and he helped normalize the profession’s role in providing emergency contraceptives and other drug therapies. In 1996, Fuller and editor Christopher P. Barry published the Handbook of Collaborative Drug Therapy Management. The handbook became a national blueprint for pharmacists to expand the reach and practical autonomy of the profession through collaborative practice agreements. “Throughout his career—as a pharmacy leader in hospitals and with the Washington Board of Pharmacy—Tim Fuller was committed to implementing cutting-edge solutions to optimize...

The Impact of a Hematopoietic Cellular Therapy Pharmacist on Clinical and Humanistic Outcomes: A RE-AIM Framework Analysis

The hematopoietic cellular therapy (HCT) pharmacist is an essential member of the multidisciplinary care team. Yet, standardized incorporation of a pharmacist at transplantation centers remains challenging. Implementation science uses theory-driven and systematic approaches to integrate interventions into clinical practice. We describe our experience implementing an HCT pharmacist at our center and conducted a program evaluation using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. We implemented 1 full-time equivalent pharmacist to provide medication management services through a collaborative practice agreement (CPA) to the allogeneic transplantation population at a medium-sized center in rural Pennsylvania over a 2-year period. The HCT pharmacist documented all in-person and telephonic care encounters in the electronic medical record. A pharmacist intervention tool was developed to document identified medication-related problems with corresponding interventions and magnitude of intervention. Summary statistics including frequency and percentages were presented for categorical variables in RE-AIM domain. Over the 2-year period, the HCT pharmacist monitored 40 allogeneic patients at our institution accounting for 1531 patient encounters. The average duration of follow-up was 299 days. The HCT pharmacist medication therapy services were able to reach all allogeneic transplants at our institute. The HCT pharmacist managed 388 medications and identified 2156 medication related problems for which the pharmacist provided 2959 interventions. Time in therapeutic range of immunosuppression was 73.9% when managed by the HCT pharmacist through a CPA. Of the 24 patients and 9 caregivers who completed the patient satisfaction survey, 25 (76%) were strongly satisfied with their care. Pharmacy services were gradually adopted and expanded to incorporate additional populations, including 121 autologous transplant and 272 hematology patient encounters. The role of the HCT pharmacist was justified with hospital administration and sustained as a designated pharmacist role at our center. The implementation of an HCT pharmacist service can positively impact patient care. The RE-AIM framework provides a methodological approach for programmatic evaluation and generalizability. © 2022 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

Implementation of the first pharmacist‐led diabetes clinic at Ministry of Health Hospitals, Saudi Arabia

AbstractBackgroundThe burden of diabetes mellitus (DM) is increasing and becoming a public health concern in Saudi Arabia, with one in every four adults living with diagnosed DM.AimsTo provide the framework for other MOH hospitals seeking to establish their own Pharmacist‐Led Diabetic Clinic (PLDCs).Materials &amp; MethodsThe PLDC service is provided through a collaborative practice agreement (CPA). This CPA allows the clinical pharmacist to educate, assess, monitor, order related laboratory tests, prescribe and modify medications within specified criteria.ResultsMany interventions have been reported to improve clinical outcomes in patients with DM. Such interventions include clinical pharmacists' roles, who have been at the forefront of providing patient‐centered care approaches in patients with DM.DiscussionGiven the high burden of DM and clinical pharmacists' potentials in delivering care to people with DM, we established the first Pharmacist‐Led Diabetic Clinic (PLDC) at one of the 286 Ministry of Health (MOH) hospitals, “King Salman Specialist Hospital in Hail Region”, in 2017.ConclusionThe PLDC was developed to improve quality of life, educate patients, and facilitate the implementation of evidence‐based research findings.

Impact of a pharmacist-led telehealth oral chemotherapy clinic

Oral oncolytics come with significant concerns of noncompliance due to complex regimens, adverse effects, and high overall costs. The Geisinger Oral Chemotherapy Clinic is a fully telephone-based medication therapy disease management (MTDM) program designed to integrate pharmacists as advanced practitioners in hematology/oncology clinics for comanagement of oral chemotherapy. To date, Geisinger has 11 oncology clinics and 3 full-time pharmacists designated to the management of oral chemotherapy. Pharmacists receive referrals for comanagement of patients starting oral oncolytics. Under a collaborative practice agreement, they can order laboratory tests as well as supportive care medications and refills. Pharmacists review planned therapies, perform medication reconciliations, and provide medication counseling. Once treatment has been initiated, pharmacists contact patients for laboratory and toxicity assessments. The clinic incorporates the use of customized smart data elements within the electronic medical record to collect data regarding pharmacist interventions and time allocations in the clinic. As of March 31, 2021, the clinic was actively following approximately 1,100 patients, resulting in an average of 80 to 90 encounters per day for new referrals, chemotherapy education, and laboratory and toxicity assessments. Approximately 2,113 patients were followed from December 1, 2019, to March 31, 2021, with 46,929 interventions documented. By obtaining provider buy-in for pharmacy services, acquiring enough personnel resources to meet the needs of the growing patient population and respective therapies, and proper utilization of technology, the program has thrived, allowing for increased provider and patient satisfaction. Future goals include expanding collection of pharmacist intervention metrics and analysis of patient perceptions of services provided by the clinic.

Survey of direct patient care and payment models among pharmacy practice faculty

AbstractIntroductionThe scope of pharmacy practice continues to expand into comprehensive medication management and direct patient care models, where practice‐based faculty play a central role. The extent to which schools/colleges of pharmacy have faculty embedded in health systems, physician practices, and other value‐based care settings involving practice plans is largely unknown.ObjectivesThe objectives of this project were to: (1) elucidate the perceptions, barriers, and implementation strategies related to direct patient care models, and (2) to further our understanding of how practice departments are employing practice plans, within schools/colleges of pharmacy.MethodsA 25‐item survey was distributed via email. Eligible respondents were pharmacy practice department chairs at United States‐based colleges/schools of pharmacy. Descriptive statistics were used to characterize workload allocations, direct patient care activities, and billing/reimbursement trends among practice faculty.Measurements and Main ResultsSurvey respondents included 43 institutions (32.6% institutional response rate) representing 1241 practice faculty and nearly 800 faculty involved in direct patient care activities. Faculty at private institutions tended to have a higher degree of effort in direct patient care (26.3% vs 4.3%) and were more involved in billing for services in the clinic setting, when compared with public institutions. Although Collaborative Practice Agreements were widely utilized, very few institutions employed practice revenue plans.ConclusionThe findings of our study indicate that pharmacy practice faculty provide significant effort in direct patient care that is critical to advancing the profession. These faculty practicing in primary and ambulatory care settings serve as role models to our student trainees, particularly in value‐based care settings. However, practice plan payment models appear to be rarely utilized. Failure to account for and recognize these valuable direct patient care activities may adversely impact the financial sustainability of schools and colleges of pharmacy in the future.

Pharmacy resident third party credentialing and reimbursement in a family medicine clinic

AbstractIntroductionWhile numerous studies have proven the impact of pharmacists on clinical outcomes, there is a paucity of data demonstrating successful reimbursement of pharmacist services by commercial and other payors. Furthermore, the level of reimbursement necessary to sustain a pharmacist resident position has not been evaluated and has potential to be a more achievable goal given the lower direct costs of a resident position.ObjectivesThe objective of this study was to qualitatively describe reimbursement and credentialing of a Post Graduate Year Two (PGY2) Ambulatory Care Pharmacy Resident in a newly established part‐time resident clinic.MethodsThis was a prospective quality improvement study evaluating credentialing progress and reimbursement data in a resident‐run Family Medicine clinic from 1 July 2020 to 25 June 2021. Patients underwent evaluation and management of chronic diseases by the PGY2 under a collaborative practice agreement. The primary outcome studied was total reimbursement received from resident‐provided pharmacy services. Secondary outcomes included percentage of charges reimbursed, number of billed encounters completed, and the number and type of third party payors with whom the resident was credentialed.ResultsDuring the study period, the PGY2 was credentialed with 11 third party payors and completed 232 billable encounters. $24 558 was billed during the study, comprising $18 533 and $6025 from evaluation and management and medication therapy management codes, respectively. Total reimbursement received for the resident's services was $13 765, approximately 56% of billed charges and 18.4% of the resident pharmacist's annual salary and benefits. This was primarily collected during the last 3 months of the study period.ConclusionsThe PGY2 was able to successfully become credentialed with various third party payors and receive reimbursement for covered services. This could provide a potential opportunity to fund some, if not all of a PGY2's salary and benefits.

Practical quantum key agreement protocol based on BB84

In this paper, we exhibit a practical quantum key agreement (QKA) protocol and give an analysis of its security. More precisely, we employ the hash function to prevent participants from cheating, so as to achieve the purpose of determining the key fairly by both participants. Our protocol is therefore computationally secure against internal attacks while still providing unconditional security against eavesdropping attacks. The quantum part of our protocol is similar to BB84, so it is simple to implement and has a wide range of applications.

The Impact of a Pharmacist-Led Hypertension Medication Management Program on Older People in a Skilled Nursing Facility.

Objective To illustrate the impact of a pharmacist-led hypertension medication management program on skilled nursing facility residents. Design Sixteen-week retrospective, observational study. Setting Long-term care, local skilled nursing facility. Patients, Participants Subjects with a diagnosis of hypertension and treated with at least one antihypertensive medication were identified using electronic health records. The subjects also needed to be enrolled in the Hypertension Medication Management Program, and were excluded if receiving hospice or psychiatric treatment or had active infection with COVID-19. Initially, 120 residents were eligible with 54 in an intervention and 66 in a control group. At 16-weeks, a total of 67 residents remained after some were lost to follow-up. Interventions Under a collaborative practice agreement, a pharmacist optimized medications, ordered monitoring of vital signs, and relevant labs in conjunction with standard physician care (intervention): these subjects were compared to those who received standard physician care alone (control). Results There was a significant difference in the proportion of subjects who attained treatment goals for diastolic BP, but not for systolic BP or mean arterial pressure. The proportion of subjects in the intervention group who had falls, hospitalization or death was not significantly different between groups. diastolic pressure (90.9% and 38.0%; P < 0.0001; 86.7% and 32.4%; P < 0.0001) but not for systolic and mean arterial pressure at 8 and 16 weeks. For secondary endpoints, there was clinical significance in de-prescribing incidence (P < 0.0001) but not for fall events, hospitalizations, and death. However, control group had 11% more falls and 1.2% more hospitalizations. Conclusion A pharmacist-led hypertension program appeared to impact skilled nursing facility residents by allowing attainment of maintaining diastolic blood pressure, goals de-prescribing events, and reducing fall incidence and hospitalization. The intervention has the potential to promote de-prescribing but does not appear to have increased the prevalence of serious adverse outcomes relative to standard practice.