Innovations and Challenges

for Pharmacist dealing with

Asthma Dimmy Sokhal, PharmD

Clinical Pharmacist

Hayat Pharmacy, Milwaukee WI

Objectives

Outline methods of identifying community pharmacy/clinic patients that

would benefit from pharmacist interventions to improve asthma care.

Describe interventions that can be implemented by pharmacists in the

community pharmacy and ambulatory clinic setting to improve care of

patients with asthma

Suggest measures to assess outcomes of pharmacist asthma care interventions

List challenges that need to be addressed to facilitate pharmacist care of

patients with asthma

Introduction

Locally owned pharmacy in Milwaukee

Dedicated to providing quality care to our patients

Free delivery for our patients to their doorstep based on their convenience

Simplify my meds® program

Medication Therapy Management (MTM) program or medication check-up

with pharmacist

Role of pharmacists

Identifying patient

Non-adherent

Multiple Emergency room visits

Declining quality of life

Role of Prescribers

Identifying patients

Results from spirometry

Requesting refill for rescue inhalers only

Making referrals

Describing the referral

Involving the patient

Interventions by Pharmacists

Medication Therapy Management (MTM) Comprehensive Medication Review &

Assessment

Intent is to work collaboratively with physicians

Enhance therapeutic outcomes

Aligning with evidence-based guidelines

No therapeutic changes are made without healthcare prescriber approval

MTM services at Hayat

Home MTMs

Pharmacists visit patient at their home

Educate on importance of adherence

Assist with tools for improving adherence

Lifestyle education

Training on appropriate administration of devices

8-10 Home MTMs/day

Referrals for MTM services at Hayat

Prescribers refer patients for MTM services at Hayat

Local MA plan

Staffing pharmacists

Self-referral where patients or caregivers request MTM services

MTM services at Hayat

Clinic MTMs

Collaboration with clinics

Work in collaboration with prescribers

Assist with medication reconciliation

Device training

Evaluate issues with adherence

Help set up goals for patients

MTM services at Hayat

MTMs post Hospital Discharge

Provide transition care in collaboration with home health services

Patient education on any medication related changes

Assisting with follow-up with PCP post discharge

Assisting with adherence

MTM Services Payers

Wisconsin Medicaid (Forward Health) covers MTM services for patients who

meet eligibility criteria

Billing for MTM services for Medicaid patients is done through Forward Health

Portal

Assessing outcomes for pharmacist’s

intervention

Decrease use of rescue inhaler

Better quality of life

Improved adherence to controller inhaler

Decreased emergency room visits

Assessing outcomes for pharmacist’s

intervention

Correct inhaler technique is recommended by guidelines for optimum asthma care

Study performed on predictors for appropriate administration

Education with health care professional (nurse/pharmacist)

Challenges faced by pharmacists

Lack of communication from prescribers

Pharmacists underutilized for their clinical skills

Pharmacists often are not aware of an Asthma Action Plan

Future Directions

Involving pharmacist in care for patients with Asthma

Increase in communication amongst different members on patient’s health

care team

Questions?

Dimmy Sokhal

CURRICULUM VITAE

DIMMY SOKHAL, PharmD

WI Pharmacist License Number: 17232-40

Address:

W234N7960 Mallard Ct

Sussex, WI-53089

Email: sokhal@wisc.edu

Cell: 734-776-0960

EDUCATION

Degree

Year

University PharmD 2013 School of Pharmacy, UW Madison

M.S. (Pharmacy) 2007 National Institute of Pharmaceutical Education and

Research, Mohali, INDIA

Bachelors in Pharmacy 2005 DIPSAR, Delhi University, New Delhi, INDIA

PROFESSIONAL EXPERIENCE

July 2014-Present

Clinical Pharmacist

Hayat Pharmacy,

5434 W Capitol Drive, Milwaukee

July 2013-June 2014

University of Wisconsin-School of Pharmacy PGY-1 Community Pharmacy Residency

Program at Access Community Health Center Pharmacy

Scaling up medication therapy management (MTM) services provided by pharmacists

Establishing pharmacy resident’s role in inter-professional health care team in medical

home

Implementing Wisconsin Pharmacy Quality Collaborative (WPQC) measures in to the

workflow of the pharmacy

Providing, documenting and billing for level 1 and 2 services

Performing continuous quality improvement by setting goals and preparing monthly

reports for clinic administration

Working with behavioral health team on quality improvement project to ensure

appropriate lab monitoring recommended for patient on psychotropic medications

Participating in United Way events to perform medication reviews for older adults in the

community

Teaching in pharmacotherapy labs at UW School of Pharmacy

Serving as a clinical instructor for Advanced Pharmacy Practice Experience for UW

School of Pharmacy students

Dimmy Sokhal

July 2007 – January 2008

Research Associate in the Department of Drug Regulatory Affairs at Ranbaxy Research

Laboratories, INDIA

Integrated the information from other scientific departments

Preparing Drug master files (DMF) for filing of generic products with various regulatory

agencies like FDA.

Review DMFs in progress prior to final submission

December 2003 – January 2004

Training in manufacturing tablets and capsules at Asclepius Pharmaceutical Limited,

New Delhi, INDIA

RESEARCH EXPERIENCE

July 2013 – June 2014

Title: Psychotropic medication review to facilitate monitoring in complex psychiatric patients

Performing chart reviews for patients who receive psychiatric consult

Documenting lab monitoring/AIMS assessment for patients who are not up to date and

routing to PCP

Scheduling and performing AIMS assessment for patients

Performing retrospective chart reviews to determine if pharmacists intervention contributed

in quality improvement

June 2006- June 2007

M. S. (PHARM.) DISSERTATION: “Design and Synthesis of N,N- Di-substituted Biguanides as

Potential Antidiabetic Agents”

Synthesizing various di-substituted biguanides by utilizing different synthetic schemes

Studying compounds computationally on a software: GAUSSIAN98W

Study relation between therapeutic activity and the conformation displayed biguanides

Studying reaction mechanism for synthesis of metformin computationally

PROFESSIONAL ASSOCIATIONS

Member since September 2009

Wisconsin Society of Pharmacy Students (WSPS)

American Pharmacist Association (APhA)

Pharmacy Society of Wisconsin (PSW)

American Society of Health System Pharmacists (ASHP)

Meetings attended

PSW Annual Meeting 2014

Great Lakes Pharmacy Residency Conference 2014

APhA Annual meeting, 2014

ASHP Midyear, December 2013

PSW annual meeting, September 2013

PEB Meeting, September 2013

PSW Geriatric Syndromes Preconference attendee, September 2012

PEB Meeting, August 2012

Wisconsin Pharmacy Examining Board Meeting attendee, July 2012

Dimmy Sokhal

Pharmacy Society of Wisconsin- Education Conference 2017

National Community Pharmacist Association Annual Conference 2016

Pharmacy Society of Wisconsin- Educational Conference 2016

American Diabetes Association Conference- March 5th

, 2016

Wisconsin Center for Nursing Conference- June 2015

Pharmacy Society of Wisconsin-Education Conference April 2015

Poster Presentation at APhA Annual meeting-2014

Great Lakes Pharmacy Residency Conference-2014

SPEAKING ENGAGEMENTS

Basic Life support (CPR and AED) by American Heart Association 9/13/2016-9/30/2018

Immunization Delivery by UW-Madison, School of Pharmacy 5/2012

ADVANCED PHARMACY PRACTICE EXPERIENCE (DPH-4)

Walgreens, Middleton (March 2013- May 2013)

Administered immunizations

Promoted immunizations offered at the pharmacy

UW Hospitals, General Medicine Unit (January 2013–March 2013)

Rounding with Gen Med team

Completing discharge summary

Performing medication reconciliation

Performing chart reviews

CVS Pharmacy, Middleton, WI (October 2012-December 2013)

Learned how to deliver best care with limited health related information about patient

Developed relation with senior living center

VA Epilepsy Clinic, Madison WI (August 2012 –October 2012)

Assessing adverse effects of antiepileptic medications

Staffing patients progress with attending

Completing documentation

UW Health, West Towne, Madison, WI (August 2012- October 2012)

Practiced utilizing resources like Epic

Performing dose checks, pre-verification and verification of prescriptions

Administering flu shots and encouraging patients to get immunized

Access Community Health Center Pharmacy, Madison, WI (July-August 2012)

CERTIFICATIONS

Dimmy Sokhal

Communicating with patients having financial issues

Handling prescriptions as per priority

Oakwood Village Pharmacy, Madison, WI (May-July 2012)

Communication with older adults

Organized talk on diabetes

Prepared med boxes for patient

Performed chart review for nursing home patients

PROJECT INVOLVEMENT

Projects at Hayat

Assisting with Medication Therapy management for patients

Improving adherence

Working with Medicare Advantage plan to help reduce hospital readmissions

Partnering with City of Milwaukee to help families with Asthma

Partnering with Milwaukee Fire Department in the Home Outreach Initiative

Preceptor for student pharmacist from University of Wisconsin, Concordia

University and Rosalind Franklin University.

QI Project for improving quality of care for patients on psychotropic medications

July 2013-2014 (Referred above under research experience)

Pharmacy Workflow Improvement July 2013- 2014

Teaching and training pharmacy staff

Pertaining to filling medications that are profiled

Educating on calculation of days supply for medications like insulin, inhalers,

etc.

Educating on identifying patients in workflow who qualify for WPQC

CMR/As

Scaling up WPQC CMRA’s delivered by pharmacists July 2013- 2014

Working with PCPs

Getting warm hand offs for performing medication reviews especially for

complex patients

Identifying, scheduling, documenting, billing and performing follow-ups for

patients

Comprehensive Medication Review project at Oakwood Village, Madison, WI

October 2011-December 2012

Completed data entry for project

Conducted follow up interview

Analysis of data collected

Dimmy Sokhal

PUBLICATIONS

Gallimore, Casey E.; Sokhal, Dimmy; Zeidler Schreiter, Elizabeth; Margolis, Amanda

R. Pharmacist medication reviews to improve safety monitoring in primary care

patients. Families, Systems, & Health, Mar 17, 2016.

Sokhal D, Kraus C. Insulin sensitizers for treatment of menstrual irregularities

associated with PCOS. Am Fam Physician. September 2015.

Sokhal D, Kraus C. Will insulin sensitizers treat menstrual irregularities associated

with PCOS? Evidence-Based Practice. 2013.

Lukazewski A, Martin B, Sokhal D, Hornemann, Schwartzwald A. Adverse drug

event (ADE) screening in older adults: detecting ADE risk, prevalence of self-reported

ADE and impact of interventions. The Consultant Pharmacist. October 2014

“Safety of NSAIDs vs Opioids in Older Adults,” in WPQC United Way July 2012

Newsletter.

VOLUTEERING EXPERIENCE

Volunteer at Senior Centers in Milwaukee to perform blood pressure, blood glucose checks

and educate on health topics.

Volunteered for Comprehensive Medication Review project at Oakwood Village: Worked

10 hours per week for total of 250 hours (October 2011-May 2012)

Ambassador Program (2011-2012), School of Pharmacy UW Madison

Volunteer for a community kitchen in Madison and Milwaukee once a month

REFERENCES AVAILABLE ON REQUEST

GHC-SCW Asthma Risk Project

Laya Esmaili-Rashid, RPH, Clinical Pharmacist

Association of Asthma Educators Annual Meeting - July 2017

I have no financial or other conflicts of

interest to disclose

Group Health Cooperative

of South Central Wisconsin

• Non-profit, member-owned cooperative health plan and primary

care delivery system that serves the greater Madison, WI area

• Approximately 70,000+ insured members

3/4 of those receive primary care services at 6

GHC-SCW owned clinics

• NCQA Health Plan Accredited since 1995

Best Performer in state for health care quality from 2006-

2014

• Team-based primary care, urgent care, pharmacy, integrated

behavioral health, health education and complementary medicine

services

History of Asthma Risk Report

• Asthma Committee created report in 2004, based on

NHLBI/NAEPP Asthma Guidelines

• Looked for a way to provide more seamless asthma

care within our organization

• Pilot project from January to June 2016 to conduct

outreach to members on the report

• Revamped report and workflows several times based

on clinic staff feedback

What is the Asthma Risk Report?

Report was designed to provide risk stratification of GHC

members with asthma by assigning risk scores for:

Inpatient visit for asthma in last 12 months (3 points)

ER visit for asthma in last 12 months (2 points)

Rescue medication in last 12 months greater than or

equal to 4 fills (2 points)

Urgent Care for asthma in last 12 months (1 point)

Oral steroid count in last 12 months (1 point)

Rationale

• Risk stratification and outreach to members who have

poorly controlled asthma

• Poorly controlled members with asthma more likely to

have future Urgent Care, ER, and hospital visits

• Targeted workflows help to address member’s

individual needs

• Proactive care can improve health outcomes and

save money for the member and organization

Asthma Mediation Ratio (AMR)

• AMR measures Controller Fills / (Controller Fills +

short-acting beta-agonist SABA Fills)

• A Ratio ≥ 0.50 indicates use of a controller

medication for 50% of their treatment period

• Measure endorsed by National Quality Forum (NQF)

and HEDIS measure

Asthma Control Test (ACT)

• Report also includes whether or not the member has

had an ACT conducted in the last 1 year (Y/N)

• For members who are on the risk report,

approximately 25% had an ACT in the last year

• Consistent with organizational rate for all

members with asthma but goal is at least 1x/year

Example Asthma Risk Report

Workflow Overview

• Clinical Pharmacist and Nursing staff review color-

coded Asthma Risk Reports each quarter

• Nursing staff focus outreach to members assigned to

a provider with an AMR > .50 (& risk score of 3)

• Clinical Pharmacists focus on members assigned to

a provider with AMR < .50 (& risk score of 3)

• Schedule appointments with PCP, Asthma Educator

and/or Clinical Pharmacist as needed

Clinical Pharmacist

Telephone Outreach

Visit with the

Clinical Pharmacist

– If patient using rescue inhaler > 2x/week, it may be due to non-adherence

– CP schedules an appointment with patient • Assess and address reason(s) for non-adherence:

– Incorrect technique/difficulties using devices – provide referral to Asthma Educator

– Forgetfulness

– Side effects

– Misunderstanding/lack of instruction

– Complex medication schedule

– Cost

• Discuss goals of therapy

• Update ACT score

• Follow-up with patient as needed

Asthma Risk Follow Up Letters

If multiple attempts have been made to reach the

patient by phone and patient has not responded,

Care Team members may send a Follow Up Letter

“Adult Asthma Risk Follow Up” and “Peds Asthma

Risk Follow Up” Letters available in Epic

Asthma Risk Questionnaire will also be available to

send via MyChart (patient portal)

MyChart Asthma Risk Questionnaire

Pilot Project - Outcomes

Baseline timeframe: January 2015 – December 2015

Post pilot timeframe: September 2015 – August 2016

N=

77

N=

94 N= 165

N= 186 N= 71

N= 78

N= 89

N= 95

Measuring our Success

Process Measures Track outreach conducted by various members of the

Care Team

Outcome and Cost Measures Total Percent of Premium

PMPM Pharmacy Costs

ER Visits/1000 members/Year

PMPM ER Costs

Laya Esmaili-Rashid, RPh

675 W. Washington Ave. Madison, WI. 53703

P: (608) 257-5178, ext. 1513 or (608) 661-7261 F: (608) 252-1401

LEsmaili-Rashid@ghcscw.com

Education

University of Wisconsin, Madison

Baccalaureate in Pharmacy – 1992

Employment

Group Health Cooperative of South Central Wisconsin

Clinical Pharmacist

2014 – Present

. Provide asthma outreach to target high-risk patients with

poorly controlled asthma and encourage follow-up with

clinical providers

. Collaborate with the primary care provider, Asthma

educator, and patient to develop an asthma treatment plan

. Educate patients on asthma therapies, goals of treatment,

and proper inhaler technique

. Monitor medication use and response to therapy, including

effectiveness, adverse effects, and adherence, and recommend

adjustments to therapy as needed

Group Health Cooperative of South Central Wisconsin

Staff Pharmacist

2009 – 2014

Wal-Mart Pharmacy – Madison, Wisconsin

Staff Pharmacist

1992 – 2009

Licensure and Certifications Licensed Pharmacist – Wisconsin WPQC Certified Professional Activities

Group Health Cooperative of South Central Wisconsin Asthma Pilot Project GHC Asthma Committee 2015 – Present