Pharmacy News

The pharmacy news section of the MPA Web site is designed to provide members with immediate access to timely and relevant information about pharmacy and our Association. In this section, you will find information on MPA activities, Association members, the latest issues impacting the pharmacy profession and press releases from MPA and its affiliates.

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Practice Advancement Requires Aspirational and Measurable Outcomes
Nancy C. MacDonald, Pharm.D., BCPS, FASHP
Transition of Care Coordinator
Department of Pharmacy Services
Henry Ford Hospital

Earlier this month, I participated in the ASHP Practice Advancement Initiative (PAI) 2030 Advisory Panel. I received the pre-reading assignments shortly after accepting the invitation. Although I had read most of the documents previously, I felt my role on the Advisory Panel required me to read the information with a different end in mind. Rather than performing an assessment of pharmacy practice at my site and how it needs to advance, I had to have a much broader assessment. I had to focus on where pharmacy practice should be for all types of health systems and practice sites (smaller, larger, academic, community, rural). This assessment and idea generation required me to focus on outcomes which are both aspirational and measurable.

Along with the ASHP Foundation 2019 Pharmacy Forecast, the required readings included the ASHP Minimal Practice Standards for Pharmacies in Hospitals and Ambulatory Care Pharmacy Practice Services. Many Michigan health systems have implemented the inpatient standards as they have been incorporated into accreditation standards. However, many sites might find the ambulatory care standards challenging. This was also evident in 2018 at the MSHP Ambulatory Care Pharmacy Leadership Workshop held last June.   The workshop attendees identified strategic planning, financial health, pharmacy extenders and the use of technology as the opportunities for ambulatory care practice in Michigan. These opportunities were incorporated into the 2019 MSHP Committee charges to help sites throughout Michigan advance practice. However, after participating in the advisory panel, I am not sure all Michigan health systems have identified measurable outcomes to gauge their progress on advancing practice and transforming Michigan ambulatory care practice.
 

To develop practice advancement initiatives, we must be familiar with the disruptive forces of health care, how they will challenge pharmacy practice and what outcomes we will measure. Developing ideas and metrics for the next 11 years is daunting yet invigorating. I envision pharmacy practice different than it is today. Advances in technology and optimized use of current technology will enable us to provide services differently than in the past. It will also allow us to more easily identify patients who need our care. These aren't new concepts, but we need to identify the outcomes we will measure earlier in our endeavors than later. It is also important to share these with your colleagues at local, state and national meetings. This will allow us to learn from each other and continue to advance pharmacy practice in Michigan.

I suggest you challenge yourself to think differently. Pretend someone asks YOU to develop ideas for where pharmacy practice should be in 2030. How do you anticipate pharmacy practice will advance over the next 11 years? What outcomes will you use to measure practice advancement? Brainstorm with your staff to develop aspirational and measurable outcomes to advance practice at your site.   Although you might find it daunting, let it be inspiring as well!
Posted in: Member News
Northern Michigan Society of Health-System Pharmacists Regional Society Update
Brad Beaman, Pharm.D., BCPS, 
Clinical Pharmacist
Munson Medical Center, Northern Region Representative

Northern Michigan remains chilly during these winter months, but Northern Michigan Society of Health-System Pharmacists (NMSHP) members eagerly await upcoming meetings in the spring. NMSHP is currently on winter break, following its last two meetings in October and November.  

The October meeting was held at the Otsego Club in Gaylord, where Dan Gerard, pharmacist at McLaren Northern Michigan, discussed novel treatment options for distributive shock. The November meeting also took place at Munson Medical Center, where Adam Utley, infectious disease pharmacist at McLaren Northern Michigan, gave an informative presentation on vancomycin.

NMSHP is working towards two meetings in the upcoming spring, April 18 and May 16. The April meeting is currently being planned with regards to our CE offering. This meeting is to be held at MidMichigan Medical Center in Alpena. The May meeting of 2019 will feature the residents of Munson Medical Center presenting their research projects. This is to take place at Munson Medical Center. CE will be available at all spring NMSHP meetings, so look no further for a reason to come spend a day in beautiful northern Michigan!

For more information on upcoming meetings, please contact NMSHP president Keith Nowak at Keith.Nowak@midmichigan.net.
Posted in: Member News
Aimovig

Zainab Alsamarae, Pharm.D.
PGY-1 Resident
St Joseph Mercy Hospital

Over 13 percent of Americans suffer from migraines and of these individuals, more than 90 percent miss work during a migraine attack. To date, there are a number of preventative treatment options for patients with migraines. Many preventative treatment options aid to reduce migraine attack frequency, quantity of migraines, or severity of each migraine. In order for patients to meet criteria for prophylactic pharmacotherapy, they must demonstrate at least two migraines a month with effects lasting at least three days or endorse uncommon migraine conditions such as a prolonged aura.1,2

There are several types of migraines including with aura, without aura, without headache, with brainstem aura, hemiplegic, retinal or chronic. The two most common of these are patients who present with or without aura. Those who suffer from migraines with aura experience visual disturbances that preface the headache by an hour. However, aura isn't always associated with a visual disturbance; patients may also experience neurological disturbances such as numbness, tingling in the extremities or confusion. In patients who experience a migraine without aura, symptoms can be variable and may include blurred vision, nausea, mood changes or increased sensitivity to sound or light.2

First-line agents in patients who meet criteria for pharmacologic therapy would receive beta-blockers, anticonvulsants, antidepressants, or NSAIDs. Ideally, patients would initially trial one of these agents for 2-3 months and then the prescriber may adjust the dose until relief is achieved. In patients who do not find the prescribed agent effective, these patients would be prescribed an alternative first-line agent. At this point, if a patient still does not find relief, a combination of two first-line agents may be warranted to be effective. Though many patients are on these agents, there are many adverse drug reactions associated that may be a barrier to adherence.

Aimovig, approved in May 2018 is the only pharmacologic that holds a FDA-labeled indication for the preventative treatment of migraine in adults. Aimovig is a human monoclonal antibody that is a calcitonin gene-related peptide receptor antagonist that has been studied in patients with episodic and chronic migraines. Patients who experience 4-14 migraine days per month have what is known as an episodic migraine. A chronic migraine is seen in patients who experience more than 14 headache days a month with more than seven migraine days per month. The calcitonin gene-related peptide works as a vasodilator which increases during a migraine attack. By blocking the calcitonin gene-related peptide receptor, vasoconstriction occurs to resolve the headache.3

There were three pivotal studies that were published that got aimovig approved. All three studies compared aimovig to placebo and assessed the change from baseline in mean monthly migraine days, a reduction from baseline in mean monthly migraine days, and a change from baseline in monthly acute migraine-specific medication days. Both aimovig 70 mg and 140 mg consistently demonstrated statistically significant results in all measured outcomes among all three studies.4

New guidelines have yet to be published to suggest aimovig's place in therapy among the current approved prophylactic agents. This is a well-tolerated medication that is administered via a subcutaneous injection monthly. Aimovig's desirable differences including the route of delivery and frequency of administration make this agent unique and more favorable in comparison to the current available prophylactic agents.
However, at this time, a head-to-head study of aimovig compared to other agents currently used for prophylaxis is needed to gain a better understanding of aimovig's benefit against current recommended agents for migraine. Overall, this is marketed as a well-tolerated agent that has reports of injection site reactions. At this point, aimovig is a promising agent that offers benefits in reducing monthly migraine days, reduction from baseline in mean monthly migraine days and a change from baseline in monthly acute migraine-specific medication days in patients with episodic and chronic migraines.5

References:

  1. Migraine Research. https://migraine.com/migraine-statistics/. Migraine Research Foundation. 2019.

  2. Modi S. MD, Lowder D. PharmD. Medications for Migraine Prophylaxis. American Family Physician. https://www.aafp.org/afp/2006/0101/p72.html. 2006 Jan 1;73(1):72-78.

  3. Moawad H MD. Therapies for Migraine Prophylaxis. Neurology Times. https://www.neurologytimes.com/headache-and-migraine/therapies-migraine-prophylaxis. 2018.

  4. Aimovig Package Insert. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761077s000lbl.pdf. 2018.

  5. Silberstein S.D., Holland S, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. http://n.neurology.org/content/78/17/1337.full. 2012; 78 (17).

Posted in: Member News
Transitions of Care: Best Practices
Amber Lanae Martirosov, Pharm.D., BCPS
Clinical Pharmacy Specialist, Ambulatory Care, 
Henry Ford Health Systems
Clinical Assistant Professor, Department of Pharmacy Practice
Eugene Applebaum College of Pharmacy and Health Sciences Wayne State University

In 2013, the Centers for Medicare and Medicaid Services instituted a penalty for hospital readmissions. This motivated health systems throughout the United States to transform their discharge processes and improve 30-day readmission rates.6,7  Across the country, pharmacists serve as valuable members of the interdisciplinary team and demonstrate significant impacts on financial and patient outcomes, including transitions of care (TOC) interventions.1 Pharmacy-driven TOC programs include, but are not limited to, medication reconciliation. The impact of pharmacist-driven medication reconciliation has been highlighted by the Joint Commission and benchmarked as a national safety goal to prevent adverse drug events.4 Other successful TOC programs include interventions that are classified based on pre-discharge, post-discharge and bridging (See Table 1). The purpose of this article is to provide guidance on developing pharmacy-driven TOC services and highlight TOC services across Michigan.

Pharmacists can serve to make key TOC services within a multi-disciplinary approach or can develop pharmacy-driven TOC services. Table 1 highlights TOC best practices evaluated in pharmacy literature. The fundamental component of a successful TOC program requires preparing a business plan with attainable and measurable goals. Many considerations need to be made including identifying a patient population, determining how patients will be referred and allocating the appropriate amount of time for TOC activities. Additionally, programs must have clear lines of communication between the healthcare team, a proper process for documentation, a plan to demonstrate benefit or value, specific staffing responsibilities and consideration of financial resources.3

An important aspect of developing a TOC service is having proper staffing with defined roles. A great example of defining roles is at Johns Hopkins Medicine. This TOC model consists of a pharmacist team leader with residents, students and technicians supporting the workflow. Technicians and students enter referral orders, perform medication history interviews, contact community pharmacies for prescription history and deliver medications to patients at bedside before discharge. This allows for the pharmacist to focus their time attending multidisciplinary rounds, providing patient education and optimizing therapy with medication reconciliation.2,3

One of the main barriers to establishing any new service is demonstrating a financial benefit to the healthcare system. The costs associated with allocating new staff and resources must be offset by cost savings and potential revenue. Ni and colleagues performed a budget impact analysis by modeling a TOC service from Kern Health System in California. Over six months, the TOC service reduced readmissions by 32 percent and saved the health plan $2,139 per patient referred to the program (approximately $4.3 million in total healthcare costs). The average cost of the service was $99 per patient.5 In addition to cost savings from a TOC service, pharmacists can also help obtain direct revenue opportunities to the health system through billing TOC codes. Billing codes introduced in 2013 allow for billing incident-to physician transitions of care management.1 Table 2 details the rules for TOC billing and highlights where pharmacists can have an impact.

Many practice sites in Michigan including Detroit Medical Center, Henry Ford, Muskegon Health and University of Michigan have been recognized as best practice winners for their pharmacist-led TOC models. Consider evaluating these programs or reaching out to the pharmacy departments at these sites for more guidance on preparing successful programs. Additionally, Figure 1 provides step-wise considerations for creating a TOC service in your institution. With these tools and guidance from best practice winners, Michigan pharmacists have the opportunity to become national leaders in transitions of care services.
  
Table 1: Best Practices for Successful TOC Programs
Pre-Discharge Interventions
  • Identifying patients at risk for adverse events or readmissions
  • Proving patient education and patient friendly informational handouts
  • Creating a specific TOC patient documentation record
  • Communicating with outpatient providers and pharmacists
  • Being part of a multidisciplinary discharge team
  • Performing medication reconciliation
  • Ability for inpatient providers to view outpatient notes
  • Pharmacists, residents, students, and technicians have defined and complimentary roles

Post-Discharge Interventions
  • Following up with patients via phone-call, clinic visits, or home visits
  • Ability for outpatient providers to view inpatient notes
  • Documentation of outcomes including improved HCAHPS score, reduced readmissions and sustained positive impact on patient care
  • Documentation of financial impact and return on investment
  • Pharmacists, residents, students, and technicians have defined and complimentary roles
  • Established ways to provide patients with assistance programs when needed

Bridging Interventions
  • Referring patients to services through multiple outlets
 
Billing Codes
Practice Setting
2017 Medicare Payment
99496 (within 7 days)
Physician-based (PB) and hospital-based (HB)
  • $236.53 (PB)
  • $165.33 (HB)
99495 (within 14 days)
  • $167.15 (PB)
  • $114.10 (HB)
Rules:
Several complex requirements including:
  • Patient established with billing provider
  • Interactive communication within two business days
  • Face-to-face visits within 14 calendar days (Must be with MD, DO, NP, CNP, PA, certified nurse midwife)
*Claim date must be 30 days from discharge. If patient readmitted before 30 days, TCM claim not reimbursable
Pharmacist Role:
Non-face-to-face component: Phone call within two days of discharge
  • Medication reconciliation
  • Disease-state education
  • Schedule appointment within seven or 14 days
  • Triage urgent needs
Face-to-Face Component:
  • Discuss medication-related issues with the team
  • Provide medication reconciliation and disease- state education
  • Develop a plan with the team
 
 



References:

  1. Spike TOC, Pope BDD, Vanlandingham M. Teed Up for a TOC Spike. 2013;(September):32-5.
  2. Malacos K. Pharmacy technicians in transitions of care. Pharm Times [Internet]. 2016;82(5):3-5. Available from: http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L610499105%5Cnhttp://vb3lk7eb4t.search.serialssolutions.com?sid=EMBASE&issn=00030627&id=doi:&atitle=Pharmacy+technicians+in+transitions+of+care&stitle=Pharm.+Times&title=Pharmacy+Times
  3. Cassano A. Best Practices from the ASHP-APhA Medication Management in Care Transitions Initiative. 2013.
  4. Alex S, Adenew A, Arundel C, Maron D, Kerns J. Medication Errors Despite Using Electronic Health Records: The Value of a Clinical Pharmacist Service in Reducing Discharge-Related Medication Errors. Q Manag Heal Care. 2016;25(1):32-7.
  5. Ni W, Colayco D, Hashimoto J, Komoto K, Gowda C, Wearda B, et al. Budget Impact Analysis of a Pharmacist-Provided Transition of Care Program. J Manag Care Spec Pharm [Internet]. 2018;24(2):90-6. Available from: https://www.jmcp.org/doi/10.18553/jmcp.2018.24.2.90
  6. Rennke S, Ranji SR. Transitional Care Strategies From Hospital to Home: A Review for the Neurohospitalist. The Neurohospitalist. 2015;5(1):35-42.
  7. Hospital Readmissions Reduction Program (HRRP) Archives [Internet]. Services, Centers for Medicare & Medicaid. 2018. Available from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HRRP-Archives.html.
Posted in: Member News
An Update on Controlled Substances Rules

 

Bryan Liptak, Pharm.D. 
PGY-1 Resident;  
Timothy Ekola, Pharm.D., MBA Director of Pharmacy 
Sparrow Health System / Comprehensive Pharmacy Services  

On Jan. 4, 2019, the Michigan Department of Licensing and Regulatory Affairs (LARA) Board of Pharmacy updated their controlled substance rules. One important rule change to take note of is that opioid and other controlled substances awareness training is required for all controlled substance licensees who prescribe or dispense controlled substances.  Controlled Substance Rule 338.3135 also prohibits the delegation of other licensees, unless the delegated licensee complies with the training requirement. It specifically states that advance practice registered nurses, registered professional nurses and licensed practical nurses must comply with the rule to be delegated to prescribe, dispense or administer a controlled substance.

The opioid and controlled substances awareness one-time training must cover all of the following standards:

  1. Use of opioids and other controlled substances
  2. Integration of treatments
  3. Alternative treatments for patient management
  4. Counseling patients on effects and opioid-associated risk
  5. Stigma of addiction
  6. Utilizing Michigan Automated Prescription System (MAPS)
  7. State and federal laws pertaining the prescribing and dispensing controlled substances
  8. Security and disposal requirements of prescriptions
Note that the standards may be obtained from more than one program. The department may select and audit licensees and request documentation of proof of completion of training. Controlled Substance Rule 338.3135 takes effect for initial licenses issued after Sept. 1, 2019, and with the first renewal cycle for controlled license renewals.

The complete details to this rule change, as well as all other rule changes to the Controlled Substances rule set, can be found at www.Michigan.gov/LARA or www.Michigan.gov/BPL.
Posted in: Member News
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