Pharmacy News

Entries for March 2019

Creating Gender-affirming Pharmacy Practice Environments and Services

Nancy JW Lewis, Pharm.D., MPH

adjunct associate research scientist

University of Michigan College of Pharmacy

Consultant, Program Design and Research, Transcend the Binary

 

Stuart Rockafellow, Pharm.D.

consultant pharmacist

Northern Physicians Organization

 

Jack Earls

patient advocate and peer counselor

Transcend the Binary

 

Brayden A. Misiolek

executive director/oo-founder

Transcend the Binary

 The existence of health inequities within the U.S. are well documented.1-3 Such inequities are common among transgender/gender non-conforming (TGNC) individuals.2 who often have limited financial resources, face a scarcity of  competent, gender-affirming providers and have complex health needs.

 The TGNC Community

Defined as persons whose gender identities, gender expressions or behaviors do not conform to that typically associated with the sex they were assigned at birth,4 TGNC individuals compose about  0.6% of the U.S. population.5 They express their gender identities across a diverse spectrum that ranges from, and outside of, male and female. Selected gender identity terms are defined in Table 1.

TGNC individuals often encounter discrimination.6-10 In the 2015 National Transgender Survey (NTS),10 27,715 self-identified TGNC individuals reported discrimination in schools, workplaces, housing situations, and/or public places. High rates of physical and mental abuse, homelessness, low employment and economic hardship were also reported.10

The risk for discrimination extends into healthcare settings.9,11-14 The NTS reported that a third of respondents who saw a healthcare professional in the past year had at least one negative experience related to being transgender.9 A 2016 survey of 316 TGNC adults found that 41 percent of respondents indicated some degree of worry about discrimination with pharmacists.12  Thirteen percent of respondents reported that past experiences of purposeful embarrassment at a pharmacy caused them to avoid seeking healthcare most or some of the time. Experienced discrimination or worry about discrimination in healthcare settings is associated with anxiety, depression and overall poorer self-reported health.12, 15-17

Fear of discrimination within the traditional healthcare system leads some to seek alternative sources of care from other sources.18,19   The prevalence of hormone use with medications obtained outside of legitimate pharmacies is estimated to be as high as 70 percent among studied populations with rates varying based on geographical location and gender identity.14, 18,19

 Pharmacist and Pharmacy Technician Roles in Transgender Healthcare

Given that many (but not all) TGNC individuals seek hormone therapy to affirm their authentic gender (i.e., the gender to which they self-identify), pharmacy staff can play an important role in improving transgender healthcare.20-24  That role can be illustrated by the actions taken by one Michigan pharmacist, Darnell Jones.  In 2013, Darnell began practicing in the Palmer Park area of Detroit. He soon realized he was serving a community of TGNC patients that desperately needed access to medical care. Many patients obtained hormones from black market sources and few knew health providers that offered affordable, gender-affirming care. Darnell educated himself about transgender health, counseled patients about hormone therapy, established a referral process to transgender specialists and co-founded a TGNC advocacy organization, Transcend the Binary. Within a few years, his actions as a pharmacist and ally touched the lives of hundreds of TGNC individuals.

Darnell’s path to care began with researching the literature and discussions with TGNC patients and medical specialists. It is not uncommon for health professionals to have little or no formal education in transgender health. One study found that over 60 percent of pharmacy residents surveyed felt unprepared to provide care to TGNC patients.25 Fortunately, resources are available to assist pharmacy staff gain competency. The World Professional Association for Transgender Health (WPATH) Standards of Care26  is a foundational document for understanding transgender health. Organizations such as The Endocrine Society,27 University of California, San Francisco Transgender Health Clinic, 28 Lorde-Callen Clinic 29 and Fenway Clinic30 have published therapy guidelines. The National Center for Transgender Equality (https://transequality.org), Fenway Health (FenwayHealth.org) and Rainbow Health Ontario (https://www.rainbowhealthontario.ca) have online health professional educational resources. In Michigan, the Oakland County Pharmacists Association has partnered with TGNC advocates to offer a transgender health continuing education program. Numerous articles discuss appropriate pharmacological care for TGNC adult and/or adolescent patients. 31-38

The most meaningful learning, however, may be gained through interactions with TGNC individuals. Spending time at transgender medical practices, meeting with TGNC community members, and attending advocacy events can provide insight into the daily lives and health needs of this community. These interactions will likely highlight the numerous health-related risks existing within the TGNC community including depression, anxiety, suicidality, interpersonal trauma, substance abuse disorder, smoking and HIV/AIDS. 10, 17, 39-41

The foundation for transgender care is a non-threatening pharmacy environment.  Gender-affirming policies and practices respect the spectrum and fluidity of gender, protect patient confidentiality, engender trust in patient-pharmacy staff relationships and are responsive to patient needs. Table 2 lists actions that support a gender-affirming pharmacy practice and signal to TGNC patients that the pharmacy is a safe place to seek care. A gender-affirming pharmacy experience, however, begins when a patient walks through the building door. Therefore, all store staff should know how to provide gender-affirming service.

Potential services that pharmacy staff can implement to improve transgender care are described in Table 3. Pharmacists and pharmacy technicians wishing to establish gender-affirming practices should do so in consultation with individuals and organizations from the TGNC community so that services reflect an informed, intentional effort to respectful care.

 Conclusion

Transgender healthcare requires a skilled combination of evidence-based practice and culturally responsive care. It must understand and respond to the intersecting impacts of medical care, discrimination and social determinates that influence the health of this population. Pharmacists who undertake this challenging responsibility can improve the health of one of our most vulnerable populations.

 Table 1: Common Gender Terms

 Agender: genderless, internally identifies as neither male or female

Authentic gender: self-conception of gender identity

Bigender: gender identity is a combination of male and female

Cisgender: gender identity aligns with sex assigned at birth

Gender fluid: gender identity and presentation shift across gender spectrum

Genderqueer/gender nonbinary:  identity lies along or outside the gender spectrum

Transgender (or trans) female: identifies as female but assigned male at birth

Transgender (or trans) man: identifies as male but assigned female at birth

 (Adapted from references 4,36)

 

Table 2: Actions for Implementing a Gender-Affirming Pharmacy Practice

 Build bridges

 Post a notice that gender-inclusive care is provided, have LGBTQ-friendly pamphlets in the waiting area, or wear a lapel pin that has LGBTQ colors or indicates your chosen pronouns (e.g., she/her)

Establish a relationship with individual TGNC patients by letting them know that you wish to assist and support them in their therapy decisions

 Connect to the TGNC community by attending local TGNC events to gain first-hand knowledge of the needs and culture of this community

Visit the offices of local transgender specialists. Ask for opportunities to learn about their services and let them know that patients referred to you will receive respectful care

 Establish gender-affirming policies

 Collect and document preferred name and pronouns in the pharmacy profile for all patients and apologize immediately if the wrong name or the wrong pronoun is used

 Ensure that patients receive respectful care even if a specific staff member is uncomfortable dispensing hormone prescriptions for physical, mental and/or emotional alignment

 Create a consistent pharmacy policy about the dispensing of syringes and communicate that with all TGNC patients

 Establish a gender-neutral bathroom or a bathroom use policy that allows people to use the bathroom that is right for them

 Create a safe environment for patient care

 Use private areas for counseling 

 Ask, don’t challenge, patients about doses, dosage schedules or administration instructions that differ from general guidelines. These prescriptions offer opportunities for discussing patient therapy goals.

 Document verification of hormone prescriptions in the pharmacy profile so patients are not re-questioned about therapy appropriateness on future pharmacy visits.

 Avoid unnecessary personal questions that are not pertinent to patient care

 (References 42,43)

 

Table 3: Potential Services to Offer within a Gender-Affirming Pharmacy Practice

 Information and counseling about hormone therapy effects and side effects for patients who are considering whether such therapy is appropriate for them

 Information, education and therapy management for those prescribed hormone therapy

 Education about hormone injection techniques and assistance/coaching with initial hormone injections

 Assistance with obtaining hormone therapy at an affordable price, especially for those who have high co-payments or who lack prescription insurance

 Counseling about the use and safety of non-traditional health interventions commonly used by the TGNC community

 Referral information for gender-affirming medical providers and other health professionals or service and navigation organizations such as Trans Lifeline (1-877-565-8860), a national suicide and support hotline or Transcend the Binary (info@TranscendtheBinary.org), a Michigan-based advocacy and service navigation organization

 Offering of telephone or telecommunication counseling as an addition or substitute to in-pharmacy counseling

HIV screenings, counseling related to HIV pre-exposure prophylaxis (PrEP) and counseling and drug therapy management related to HIV treatment

 Tobacco cessation counseling

 Hepatitis C screenings, counseling and drug therapy management related to Hepatitis C treatment

 Hepatitis A immunizations

 Screenings, brief interventions and referrals to therapy for depression and substance abuse disorders

 (References 12, 20-24)

 

Contact:

Nancy JW Lewis, PharmD, MPH

njwlewis@umich.edu

248-805-4112

 

References

1.        Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report — United States, 2011. MMWR 2011;60(Suppl):1-114.

2.        IOM (Institute of Medicine.) The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press. 2011 (accessed 2017 April 14).

3.        National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press.

4.        American Psychological Association. Definitions Related to Sexual Orientation and Gender Diversity in APA Documents. https://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf. (Accessed 2019 Feb. 1)

5.        Flores AR, Brown TNT, Herman JL. Race and ethnicity of adults who identify as transgender in the United States. The Williams Institute. 2016. (accessed 2017 Aug. 17).

6.        Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Ann Emerg Med. 2014;63:713-720.

7.        Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013;103:1820-1829.

8.        Cruz TM. Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination. Soc Sci Med. 2014;110:65-73.

9.        Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M.  Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. (accessed 2017 Nov. 10).

10.     James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. 2016. (accessed 2015 Nov. 14).

11.     Lerner JE, Robels G. Perceived barriers and facilitators to health care utilization in the United States for transgender people: A review of recent literature. JHCPU. 2017;28:127-152.

12.     Lewis NJW, Batra P, Misiolek, B, et al. Transgender/gender non-conforming adults’ worry and coping actions related to discrimination: Relevance to pharmacist care. AJHP (in press.)

13.     Rodriguez, A , Agardh, Oppong Asamoah, B. Self-Reported Discrimination in Health-Care Settings Based on Recognizability as Transgender: A Cross-Sectional Study Among Transgender U.S. Citizens. Arch Sex Behav. (2018) 47:973–985.

14.     Sanchez NF. Sanchez JP, Danoff N. Healthcare utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. Am J Public Health. 2009;99:713-719.

15.     Meyer HH, Brown TNT, Herman JL, et al. Demographic characteristics and health status of transgender adults in select US regions: Behavioral Risk Factor Surveillance System, 2014. Am J Public Health. 2017;107:582-289.

16.     Seelman KL, Colon-Diaz MJP, LeCroix RH, Xavier-Brier M, Kattari L. Transgender noninclusive healthcare and delaying care because of fear: Connections to general health and mental health among transgender adults. Transgender Health. 2017;1:17-28.

17.     Streed CG, McCarthy EP, Haas JS. Association between gender minority status and self-reported physical and mental health in the United States. JAMA Intern Med. 2017;77:1210-1212.

18.     Mepham N, Bouman WP, Arcelus J, et al. People with gender dysphoria who self-prescribe cross-sex hormones: Prevalence, sources, and side effects knowledge. J Sex Med. 2014;11:2995–3001.

19.     Rotondi NK, Bauer, GR, Scanlon K, Kaay M, Travers R, Travers A. Nonprescribed hormone use and self-performed surgeries: “Do-it-yourself” transitions in transgender communities in Ontario, Canada. Am J Public Health. 2013;103:1830–1836.

20.     Bonner L. Pharmacists can be accessible, trusted providers for transgender patients. Pharmacy Times. 2016. http://www.pharmacytoday.org/article/S1042-0991(16)00356-X/pdf. (accessed 2018 Feb. 10).

21.     Cocohoba J. Pharmacists caring for transgender persons. Am J Health-Syst Pharm. 2017;74:170-4.

22.     Maxwell E, Salch S, Boliko M, Anakwe-Charles G. Discrepancies in lesbian, gay, bisexual, and transgender patient care and how pharmacists can support an evolved practice. Am J Pharm Educ. 2017;1:1-4.

23.     Newsome C, Colip L, Sharon N. Conklin J. Incorporating a pharmacist into an interprofessional team providing transgender care under a medical home model. Am J Health-Syst Pharm. 2017; 74:135-9.

24.     Radix AE. Pharmacists’ role in provision of transgender healthcare. Am J Health-Syst Pharm. 2017;74:103-104.

25.     Leach C, Layson-Wolf C. Survey of community pharmacy residents’ perceptions of transgender health management. JAPhA. 2016:56:441-445.

26.     Coleman E, Bockting W, Bother M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2011;13:165–232.

27.     Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal H et al. Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 94: 3132–3154, 2009

28.     Deutsch MB ed. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. Center of Excellence for Transgender Health. University of California, San Francisco. 2016.

29.     Callen-Lorde Community Health Center. Protocols for the provision of hormone therapy. Available at http://callen-lorde.org/transhealth/( accessed 2017 March 11).

30.     Makadon HJ, Mayer, KH, Piotter P, Goldhammer H. Fenway guide to lesbian, gay, bisexual, and transgender health, 2nd ed. Boston: The Fenway Institute; 2015.

31.     Bass M, Gonzalez LJ, Colip L, Sharon N, Conklin J. Rethinking gender: The nonbinary approach. AJHP. 2018;75:1821-1823.

32.     Bishop BM. Pharmacotherapy considerations in the management of transgender patients: A brief review. Pharmacotherapy. 2015;35: 1130-1139.

33.     Chew D, Anderson J, Williams K, et al. Hormonal treatment in young people With gender dysphoria: A systematic review. Pediatrics. 2018;141(4):e20173742

34.     Daniel H and Butkus R. Lesbian, gay, bisexual, and transgender health disparities: Executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;163:135-137.

35.     Gabe Murchison, G. Supporting & caring for transgender children. American College of Osteopathic Pediatricians, American Academy of Pediatrics and the Human Rights Campaign Foundation, 2016. (accessed 2019 Feb. 5)

36.     Klein DA, Paradise SL, Goodwin ET. Caring for transgender and gender-diverse persons: What clinicians should know. Am Fam Physician. 2018;98:645-653.

37.     Levine DA, and the Committee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013:e297-e313. Technical Report.

38.     Shumer De, Nokoff NJ, Spck NP. Advances in the care of transgender children and adolescents. Advances in Pediatrics. 63 (2016) 79–102.

39.     Nuttbrock L, Bockting W, Rosenblum A, et al. Gender Abuse, Depressive Symptoms, and Substance Use Among Transgender Women: A 3-Year Prospective Study. Am J Public Health. 2014;104:2199–2206.

40.     Trujillo MA, Perrin PB, Sutter M, Tabaac A, Benotsch. The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample. Int J Transgenderism. 2017;18:39–52.

41.     Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clinical Psychology Review. 2018;66:24–38.

42.     Human Rights Campaign Foundation. Providing LGBTQ-inclusive care and services at your pharmacy: a resource guide for pharmacists and pharmacy staff. June 2016. https://www.hrc.org/resources/providing-lgbtq-inclusive-care-and-services-at-your-pharmacy. (accessed 2017 Sept. 15).

43.     Community Conversation: Finding our Strength. (Community Forum Discussion). Transcend the Binary, Ferndale MI. Aug. 30, 2018.

 

Posted in: Innovative Practice
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.
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  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.
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