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STOP! Collaborate and Listen: Using Practice Agreements in Ambulatory Care
Jenna Carmichael, PharmD, BCOPHematology/Oncology MTM PharmacistGeisinger Health System, Henry Cancer CenterWilkes-Barre, PA
Disclosures
• Advisory board member, Boehringer Ingelheim
• This is not a presentation on setting up collaborative practice agreements
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Objectives
1. Discuss utilizing a collaborative practice agreement in providing new services
2. Review challenges and potential solutions in this new setting
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Pretest Question
You have started a new clinic providing MTM services in an ambulatory setting. All of the providers in the clinic with the exception of one are very excited to have you a part of the team. How do you approach the outlier?
a) Ignore them, you will have more than enough to do as isb) Try to discuss potential patients with this provider’s
nursec) Bring in food to entice the provider to like youd) Make yourself visible to the clinic staff and offer help
when needede) A, B and D
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Background
• Medication Therapy Disease-State Management (MTDM) started at Geisinger Medical Center in 1996• 2 pharmacists• Anticoagulation only
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Background
• Currently there are 52 pharmacists working in 47 locations• Anticoagulation• Diabetes• Hyperlipidemia• Hypertension• Polypharmacy• Anemia• Nonmalignant chronic pain• Heart failure• Multiple sclerosis • Hematology/Oncology
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Collaborative Practice
• Pharmacists work in tandem with physicians under collaborative practice to treat patients for specific disease states• Need to show competency in each disease state
• Initial and then yearly exam• Professional certifications encouraged
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Collaborative Practice
• Under the agreement, pharmacists are able to:• Order labs/tests• Modify current medications• Add on new medications
• Patients are managed over the phone or in person• Reimbursement from insurance is only for in person
visits
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STARTING NEW SERVICES
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First Things First…
• Decide what to focus your services on
• Collaborative practice agreement will guide you• However, plan for the future and make this as broad as possible
• Start with the service you feel is needed most or easiest to start• Every patient that comes into the clinic with BP > 160/90• Use the EMR and find every patient on DM drugs that doesn’t have
labs in the last year• Ask your collaborating physicians what they want you to focus on
first
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First Things First…
• Decide how you want your clinic to function• A lot of this depends on the building set up
• Is there room to see patients• How far do your patients have to travel if they were to come in
• Can some of this feasibly be done over the phone• If the patient needs labs, is there a lab closer to them and you can call
with results
• What role is your clinic playing• Drug/lab monitoring
• Warfarin, tacrolimus, Hgb for erythropoietin, lipids for statins• Disease state management
• Hypertension, diabetes
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Addressing Roadblocks
• Unfortunately, some providers will not be as willing to work with you as others
• Don’t push• You will likely have a lot of work to do without their patients• Work on establishing your services and your reputation among other
providers• Eventually your good work will speak for itself!
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Tips for Success
• Make yourself visible• If you are not doing anything, walk around the clinic
• You may overhear a problem that you can help with!• Use the physician-nurse relationship to your advantage
• Find out what the nurse does that you could help with• “I hear Mr. Peters called with a side effect from his metformin, do
you want me to call him back for you?”• Have a direct phone line
• Takes call volume off front desk• Patients like having a way to get to someone directly
• But then can get calls that are not entirely your scope
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Tips for Success
• Ask questions• If your provider is doing something a bit off guidelines…
• Tactfully ask why• If a new practitioner or new to this type of practice, use that to your
advantage and ask in the spirit of education
• Explain your process to your providers• You know what you are doing, but they may not• Particularly helpful when first starting new services
• Ask the provider their process and compare with yours• Everyone has their favorite “go to” medication for certain disease
states• Everyone likes to feel involved
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Tips for Success
• Be Available for Questions• Answer everything
• Renal dose adjustments, preferred agent to treat XXX infection, etc.• Be prepared for off the wall questions
• Be Nice• “Kill them with kindness”
• Treat everyone from the front desk staff up with respect• Everyone has bad days, don’t take it out on anyone• If someone is nasty to you, shake it off!
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Tips for Success
• Know when to ask for help
• If there are other clinics in your system, help each other out
• Try to resolve issues with staff on your own but also know when to bring in supervisors/management
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Building Additional Services
• Once you establish yourself as a medication expert, your providers will ask you to take on more patients/disease states• “You did such a good job getting Mrs. Jones’ A1c to goal, why
don’t you also help with her heart failure?”• “Thank you so much for catching Mr. Smith’s drug interaction,
he’s feeling much better. Can you look at Mrs. Roberts’ medications too?”
• Don’t try to take on so much that you cannot consistently provide quality care• Remember, taking care of patients is your top priority
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Posttest Question
You have started a new clinic providing MTM services in an ambulatory setting. All of the providers in the clinic with the exception of one are very excited to have you a part of the team. How do you approach the outlier?
a) Ignore them, you will have more than enough to do as isb) Try to discuss potential patients with this provider’s
nursec) Bring in food to entice the provider to like youd) Make yourself visible to the clinic staff and offer help
when needede) A, B and D
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