introduction—what is the opportunity?

Introduction—What is the Opportunity?

Enhanced Services Boot Camp

Joe Moose, PharmD, CPESN® USA and Moose Pharmacy

Pharmacy is ChangingHow are You Changing?

Why is This Happening?Community Pharmacy Model Must Change

• Why is This Happening?• An Independent’s Model Must Change

The Future for Pharmacies Just Filling Prescriptions Fast and Cheap is Grim

• “Anyone having the feeling that independent pharmacy is in the state of crisis and we need CPR now. I am thinking it is time that everyone act as a single unit to bring instant change”

- Pharmacy Owner from Texas

• “Does anyone think we can actually survive if nothing changes?”

- Pharmacy Owner from Colorado

Comeback

Comebacks begin when someone believes it is

possible

Every setback begins with a

moment that you think it is all over

A setback is a setup

for a comeback

It is time for a pharmacy comeback!Where do we start?

Create a new payment model

Setback begins with a moment that you think it is all over; Recognition that we may be there.

Create a way to express our value.

Enhanced Services Networks



Objectives• Discuss common characteristics of pharmacies in a

community pharmacy enhanced services network• Discuss the role of community pharmacy in providing

medication management resources to the highest risk populations.

• Describe how pharmacies are positioning themselves to integrate with care teams to lower health care costs and participate in new models of care and reimbursement.

Healthcare Spend in America

90%

10%

Medical/Non-Pharmacy Spend

Outpatient Medication/Pharmacy Spend

Threats to Community Pharmacy

Pharmacies Can’t Sell Drugs Below

Cost

Pharmacies Need to Be in Narrow

Networks

Leveraging Frequent Patient “Touches” to Improve Medication Management

Leveraging Care Team Collaboration to Improve Medication Management

Pharmacists assist primary care physicians, care managers and others within the patient's care team with patient engagement, patient management, and to:

• Remove barriers preventing optimal medication adherence such as health literacy or cognitive deficits

• Offer specialized medication-related services such as non-English labeling or specialized packaging

• Support the patient’s understanding of medication administration and special storage instructions

98% of patients utilizing North Carolina enhanced services pharmacies felt that their care was coordinated amongst their various providers

Leveraging Enhanced Services to Improve Medication Management

All pharmacies are capable of providing the following core services:

• Face-to-Face Access: Providing each patient receiving a dispensed medication from the participating pharmacy ready access to unscheduled face-to-face meeting(s) with a pharmacist employed by the participating CPESN pharmacy during operational hours.

• Medication Reconciliation: Comparing a patient’s medication orders to all of the medications the patient has been taking to avoid medication errors during care transitions when they are vulnerable to medication errors

• Clinical Medication Synchronization: Aligning a patient’s routine refills to be filled at the same time each month and in conjunction pharmacist’s clinical disease state management and monitoring, to progress toward desired therapeutic goals

Leveraging Enhanced Services to Improve Medication Management

• Immunizations: Screening patients for ACIP recommended immunizations, educating patients about needed immunizations, and providing immunizations or referring to other health care providers

• Comprehensive Medication Reviews: Providing a systemic assessment of medications to identify medication-related problems, prioritize those problems, and create a patient-specific plan to resolve them working with the extended healthcare team

• Personal Medication Record: Creating a comprehensive list of current patient medications manually or from dispensing software

Importance of Targeting and Channeling Patients to High Performing Pharmacies

Community-Based, High-Performing Pharmacies

• All pharmacies are not the same• Some pharmacies only focus on the prescription and

filling it fast as they can… with little patient interaction

• Other pharmacies focus on patients• These pharmacies have strong relationships with the

patient and members of the patient’s local care team• These pharmacies provide enhanced services that have

proven to improve the health of complex patients

Strategic Considerations for Community-Based Pharmacy Networks

• Purpose of CPESN USA• Construct of CPESN USA Model• Overview of States with CPESN Development

Underway

What is Our Purpose?

1. To Aggregate Pharmacy Providers to Express their Value in

an Increasingly Consolidated Marketplace

2. To Catalyze a Services Marketplace where the

Sponsor/Plan has a Direct Relationship with

Pharmacy Providers (in aggregate)

Types of Enhanced Services

Medication Synchronization

Home Delivery

Point-of-Care Testing

Nutritional Counseling

Long-Acting Injections

24-Hour Emergency Services

Adherence Packaging

Home Visits

Collection of Vital Signs

Smoking Cessation

Compounding

Multi-Lingual Capabilities

Provide medication optimization activities and

enhanced services for patients

Focus on interventions that change patient

behavior lead to better health

Collaborate with the extended care team to improve patient health

A Clinically Integrated Network of Pharmacy Providers

A Clinically Integrated Network of Pharmacy Providers

Pharmacy Benefit Payer

Local Network Growth by Launch PhaseAugust 2016

Local Network Growth by Launch PhaseToday

CPESN:Next Generation Pharmacy

Reimbursement Model

CPESN® Networks – Minimum Service Set







• Comprehensive Medication Reviews: Providing a systemic assessment of medications to identify medication-related problems, prioritize those problems, and create a patient-specific pla`n to resolve them working with the extended healthcare team


Deployment of the CPESN Model• Care Team Integration• Pharmacist eCare Plan

Care Team Collaboration (Physician, Care Manager, Pharmacist)

• Joint home visits may be a way to establish a coordinated care plan for complex patients

• Pharmacies can assist care managers with patient engagement and longitudinal management

• Care managers and pharmacies can work together to address:• Barriers preventing optional medication adherence• Health literacy challenges, cognitive deficits, or lack of caregiver

support that require pill box fills, special packaging, or special labeling

• Other specialized medication-related needs that could be fulfilled by a pharmacy

• Patient understanding of special instructions for administration or storage

Pharmacist eCare Plan Basics

• It is a data repository and transmission standard• It contains the latest clinical data for a given patient (Active medication list,

drug therapy problems, lab results, vitals, health concerns, patient goals, and much more)

• It is not a platform• It is not a clinical documentation system• It is impartial to vendor (Can work with any system adopting it)• It is an “open” standard (Specifications are published)• It is not a CPESN USA construct; It is an industry standard

Pharmacist eCare Plan Functionality Active in the Marketplace

11 Technology Companies with eCare Plan active in the marketplace

4 Technology Companies with eCare Plan active in the marketplace via integration

CPESN® Quality Reports

What Makes the CPESN® Model Different?

• Community-based pharmacies that focus on high risk patients in a chronic care model

• Patient targeting• Panel management

• Patients instead of prescriptions

• Accountability on global outcomes and quality

• Shared metrics with the rest of the care team

Confidential – Do not reproduce or reuse without consent.

• Change packages and network support to enable practice transformation• Workflow changes related to

panel management, care team integration, and weaving together clinical components with enhanced services

• Approach to HIT• Pharmacist eCare Plans

• Local care team integration and care coordination

Enhanced Services Pharmacy Assessment Tool

Joe Moose, PharmDCPESN® USA

[email protected]

Financial Planning: Building the Business Case for Expanded Services


Tripp Logan, PharmD, L and S Pharmacy

Speaker DisclosureTripp Logan, PharmD

• NCPA Innovation Center Board Member• CPESN USA National Luminary / CPESN Missouri Lead Luminary

• Chief Operating Officer, Enhanced Service Pharmacy Alliance “ESPhA”

• Partner, MedHere Today Consulting• Vice President, L&S and Medical Arts Pharmacies• Missouri Department of Health and Senior Services / CDC -Community Health Worker Grantee

Speaker Disclosure

Tripp Logan, PharmD does not have (nor does any immediate family member have) actual or potential conflict of interest, within the last twelve months, a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias this presentation.

Personal Disclaimer“The content of this presentation reflects my personal experiences in our pharmacies, our consulting firm, and my service within pharmacy advocacy groups. Each pharmacist & pharmacy is unique, with a unique payer mix, unique set of offered services, unique opportunities, and most of all unique patient populations. The purpose of this presentation is to walk you through our ROI exploration process in our businesses. The purpose of this presentation IS NOT for it to be used as specific guidance on how you should operate your pharmacy practice, how you work within your current or future pharmacy contracts, or how you care for your unique set of patients.”

--Tripp Logan, PharmD

Most Taboo Words in Health Care:

Provider Profitability

Pharmacy Staff Orientation Speech:“As a community pharmacy, our primary responsibility is to the patients that walk

through our doors. If we make poor business decisions, we close

our doors, and FAIL EVERY PATIENT WE SERVE.”

The Community Pharmacy Conundrum:

Pharmacies must: 1. Think PATIENT FIRST – PAYER

SECOND2. While we ensure that our patients have

access to the medication they need,3. But most of all maintain pharmacy

profitability at the same time to keep the doors open

Patient walks in pharmacy & presents a prescription

Pharmacy reacts by filling prescription

Pharmacist counsels patient

Pharmacy profits from the filled prescription

Pharmacy waits for patient to come back to fill another prescription

Pharmacy’s value is defined by the volume of prescriptions filled each day, week, month, and year

The

Historically

Drove Pharmacy Value

Prescription

All Rxs ARE NOT The Same

Today……

Today……All Patients ARE NOT The Same

Today……

Today……What High

Quality Pharmacy Providers

SEE

Today……What High

Quality Pharmacy Providers

FEEL

Today……

“Payer” MTM/Incentive Programs

• 90 day supply conversion FFS• Traditional Medicare Part D FFS Comprehensive Medication

Reviews• Medicare Part D adherence interventions through MTM

vendors• Medicare Part D treatment gap interventions through MTM

vendors• Medicare Part D performance program using health plan

quality metrics• Medicare Part D / PBM incentive programs (non-DIR)

Are these incentives profitable for you?

Health Plan Strategies

“There is more value in hitting the measure's star rebate level, than a focus on the medical cost reduction”

-Medicare Part D Plan Executive, August 2017

PBM Strategies

“Patient reported outcomes shouldn’t be considered in metric driven programs. That type of third party information is regularly inaccurate”

-PBM Executive, July 2018

CLAIMS BASED PATIENT CENTRICFill Reminders Social Determinants

Med Sync Medication AccessGaps in Care Care Transitions

Medication Safety Clinical OutcomesCMR Care Management / Coordination

MMEs Health Care Cost ReductionDays supply Education

DIR reduction Empathy

Define Your Strategies

All Pharmacies Are Not The Same

Common Perception Reality

Rx Dispensing Only Rx Dispensing + Enhanced Services

What Makes Pharmacies Different?

• Individualized patient centric support (not population health management)

• Formulary navigation & out of pocket cost support • Out of pocket cost reduction support• Medication reconciliation support• Personalized home delivery / home visits• Medication optimization services

LOCAL Enhanced Services with Care Management Support

Enhanced Services…Which Ones? Medication Reconciliation

Clinical Medication Synchronization

Immunizations

Comprehensive Medication Reviews

Personal Medication Record

Home Visits

Pharmacogenomics

Travel Health

Naloxone Services

Smoking Cessation

Diabetes Prevention

Weight Loss

Long Acting Injections

Care Transition Support

Coverage Navigation Services

Multi-lingual Services

Chronic Disease Classes

Chronic Care Management

Community Health Worker Care Management

• Is this profitable (not just reimbursable)?• How long until a return on my investment (ROI)?• Will this tie us more closely to local providers?• Who do we target?• Is this good for my pharmacy’s image?• Does this fit my patient population?• Will my staff embrace it? • How can I afford it?• How will we measure it?• Is it scalable and sustainable? • What’s the labor cost?

Low Hanging Fruit……..

Increase in ADDITIONAL Rx Volume

*

*Armstrong T., Impact of the MedHere Today Program on Persistence and Adherence, A Descriptive Report; Pfizer, May 2011.

100 29Number of

patients receiving service

2,900Medication Optimization Service

Additional Rxs per patient

annually

Increasing Cash Flow……..

$500 20Pharmacy acq.

cost of each prescription

$10,000

Medication Optimization Service

Number of patients filling 1 Rx > $500/mo.

3-4 week CASH FLOW savings for pro-active medication management of 20 patients

Targeting Exercise1. Who is my most profitable third party

payer?2. Which prescriber accounts for the most

prescriptions from that payer? 3. What is my average margin per patient per

month from this third party payer and prescriber

4. How many patients do I have from that prescriber and how could I get more?

Targeting Exercise1. Who is my most profitable third party

payer?2. Which prescriber accounts for the

most prescriptions from that payer? 3. What is my average margin per patient

per month from this third party payer and prescriber


Local Results1. State Medicaid2. Multi-Site Mental and Behavioral Health Clinic3. Average 4 Rx/patient but most see multiple prescribers ($63 avg margin/mo)4. We see 88 patients/month

Targeting Exercise1. Who is my most profitable third

party payer?2. Which prescriber accounts for the

most prescriptions from that payer?

3. What is my average margin per patient per month from this third party payer and prescriber









Don’t Forget to Factor in average DIR, GER, BER….WTF

Internal Plan Assessment

Targeting Exercise1. Started with Research in Mental Health,

Medicaid, the Clinic2. Became familiar with some pharmacy best

practices in mental and behavioral health3. Learned who was on the board and who

was in administration4. Explored common barriers and pharmacy

solutions that could positively impact mental and behavioral health

Targeting Exercise: Gaps• Primary non-adherence

• Never get first fill

• Routine non-adherence• Doesn’t continue medication

• Formulary issues• patients unable to acquire

medication

• Lack of Care Coordination• Patients unable to navigate the

health care maze

• Transportation• Patients struggle with acquisition

of meds• Lack of communication among

providers• Patients receive sub optimal care

due to health care silos• Limited continuity of care

• Treatment often stops once the patient walks out of the clinic

Our medication optimization service

leads to improvements in medication

adherence across multiple chronic

conditions

Targeting Exercise: Use What You Have

*Armstrong T., Impact of the MedHere Today Program on Persistence and Adherence, A Descriptive Report; Pfizer, May 2011.

Targeting Exercise: Solutions?

Multi Dose Packaging

Targeting Exercise: Adherence Packaging

• How much does a vial cost?• How much does a cap cost?• How much does a label cost?• How much does a package / card cost?• How many vials equal the cost of one package /

card?• How many cards will each new clinic patient

purchase?

Business Planning

Targeting Exercise: Adherence Packaging

• Found packaging solution that allowed us to start with minimal investment and automation upgrade opportunities

• Estimated that patients with 10 or more prescriptions would cost us around $20/year to convert to packaging

• Estimated that each new clinic Medicaid patient is worth the cost of around 870 packages/cards annually

Results

Targeting Exercise: Questions for Clinic

• What can we do to help you?• Adherence packaging? 28 vs 30 day supply packages?• Increasing communication with the pharmacy?

• Reporting back on dispensing, refill status, adherence, clinical markers, etc?• Would extra patient monitoring post-visit help?

• PHQs, waist circumference, weight, blood glucose, 7,14,28 day package pickup/delivery to increase touch points, etc?

• Patient bring in package to office visit?• Suggestions?

Targeting Exercise: ROI• Held meetings with administrator for clinic needs assessment and

pharmacy service detailing• Hosted in service for case managers to detail pharmacy services• Immediately began receiving referrals from case managers for

packaging, care coordination, and other pharmacy services• Prescription volume & referrals from target clinic increased• Utilized packaging for other target patients, prescribers, & clinics• Continually working on refining workflow, reducing packaging

costs, & increasing referrals

Enhanced Service: PGXPatient Case

●Long time patient of our pharmacy ●21 y/o female with a Hx of behavioral health issues●3 hospitalizations in the past 2 years●Medications completely changed each time●Mental health providers referring her to other providers (we’re her only

constant)●Currently unstable (suicide risk)●Previously held a job and was functional member of the community●Currently at home and Mom can’t leave her alone●Mom on her last rope and asked what she should do?????

Enhanced Service: PGXWhat Happened?

●Recommended PGx Testing now (not wait for our pharmacists to complete training)●Mom called local Behavioral Health Clinic for testing ●Clinic called Mom to say testing is ready to pick up●Mom picked up 14 page report with no explanation ●Mom brought PGx report in to the pharmacy for pharmacist review●We determined current and prior regimens had a high likelihood of failure●We constructed recommendations for patient’s primary care provider●Mom set up a follow up meeting 5 weeks later to say……….

Enhanced Service: PGX●Initial Investment

●Training for pharmacists approximately $500 a piece x 6 pharmacists = $3,000●Staff Education and Service Launch Preparation

●Discussed in staff meetings and monthly newsletter months before service launch●Marketing Strategy

●Social media, print media, word of mouth, and direct to prescriber

Enhanced Service: PGX●Return on Investment

●28 swabbed on site & 37 remote consults in first 12mo (revenue exceeded investment)

●Patient retention for those swabbed (only pharmacy with PGX in their record)

●New patient referrals for PGX service (not prescription dispensing)●Opened many new doors for us with local prescribers & employers

Enhanced Service: PGX“When looking back out of the 10 patients we have been working on so far I already know that we have made a significant and potentially lifesaving modification in the care of one of our patients and that makes it all worth it!”

-Local Primary Care Provider Partner

Enhanced Service: CCM Service Modeling to Ensure ROI

“Community Health Workers (CHWs) are frontline public health workers who are trusted members of and /or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”

Community Health Worker Definition; American Public Health Association Policy Statement 20091, Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities; 2009

Enhanced Service: CHW

Why CHW’s in a Pharmacy?

Medicaid Programs & Health Plans often spend more on

CARE MANAGEMENT (medical side) than on PRESCRIPTION DRUGS

(pharmacy side)--North Carolina Medicaid and NC Health Choice Annual Report for State Fiscal year 2018July 1, 2017 – June 30, 2018

Enhanced Service: CHW ●Initial Investment

●Training for technicians $800 a piece x 4 pharmacists = $3,200 – CDC Grant = $0●Certificate completion incentive: $1.50/hr raise per CHW

●Staff Education and Service Launch Preparation ●Discussed in staff meetings and monthly news letter months before service launch

●Implementation Strategy●Local research led to grants, DHSS engagement, MO Medicaid engagement, etc

●Return on Investment●Secured CHW grant to explore ROI for CHWs in pharmacies ●Patient retention for those being supported by our CHWs●New patient referrals for CHW services (not prescription dispensing)●Opened many new doors for us with local prescribers & employers

How to Approach Payers/Providers?

• “Hey, we’ve just added a Community Health Worker to our team, can we connect her to your care managers & CHWs?”

• Providers are often unwilling to refer for prescriptions, but regularly refer for services.

• Offered PGx testing for primary care’s most complex patients via referrals

• Offer Care Coordination for complex patients via CHW referrals • EVERYONE recognizes the need for LOCAL / ACCESSIBLE care

coordination for at risk patients, it usually isn’t tied to prescriptions• Once we get referrals, we follow up, then go to them with more

services • Trusted LOCAL partners aren’t the norm

Our Path to Success1. We don’t succeed every time, but we learn every time2. Conduct routine local needs assessments3. Focus on filling local gaps/needs for patients in our

community4. Build business plans around opportunity5. Lean on colleagues and peers for best practice guidance6. Start small and scale each initiative7. Build upon what works, scrap what doesn’t, & repeat8. Share our story & successes outside of our pharmacies9. Continually pushing forward to avoid complacency

Leveraging Relationships LOCAL Focus

LOCAL PatientsFilling LOCAL Needs

Partnering with LOCAL ProvidersCapitalizing on LOCAL

Opportunities

Tripp Logan, PharmDL & S Pharmacy

[email protected]

Implementation Practices: Motivating and

Training your StaffEnhanced Services Boot Camp

Amina Abubakar, PharmD, AAHIVP, Rx Clinic Pharmacy

Objectives

• Outline staffing/workflow considerations needed for enhanced service delivery.

• Create job descriptions for key roles of pharmacy team members in a re-engineered practice.

• Develop mechanisms for “getting buy in” on your pharmacy culture.

• Apply best practices for engaging and training the pharmacy team to streamline operations.

• Develop mechanisms for giving feedback and managing resistance to change.

Implementation...why do pharmacists need it?

• It’s where the rubber meets the road• Our profession is at a critical point

• New Opportunities in a new world

• Growing Demands in our old world

• Without good implementation we we can’t get traction

Implementation Strategies Yield = Traction

• Goal of Traction: Prevent slip during acceleration or during a change in course of action

• What does it mean to get traction in your pharmacy?• Creation of the Systems

• People, people, people(Company culture)

• Maintenance

Creating the System

“Systems run a business. People run the systems” - Michael E. Gerber, author of the E-Myth

https://www.smartinsights.com/wp-content/uploads/2015/10/Screen-Shot-2015-10-14-at-13.17.30.png

Tips for Team Meetings

Mental preparedness for meetings: Permission Slips• “I give myself permission to be present here even though I’m getting

pulled all directions today”• “Permission to speak up even though I’m not the content expert here”• “Permission to ask for more time to think before I share my point of view”Meeting Minutes• Everyone takes their own notes• One volunteer to capture:

• Date, meeting intention, attendees, key decisions, tasks and ownership

Avoiding “group-think”: Turn & Learn• Post-it notes and write down how long a project will take and what needs

to be prioritize, then all share at the same time

Paint Done with TASC

“Paint done”Ask the group “what does done look like? Activity will unearth stealth intentions and unsaid expectations

TASC: The Accountability and Success ChecklistTask: who owns the task?Accountability: do they have the authority to be held accountable?Success: do we agree that they are set up for success (time, resources, clarity)?Checklist: do we have a checklist of what needs to happen to accomplish the task?

Action Plan for the System

Description Purpose Point Person Due Date Outcome

Become “clinically” Med Sync’ed and utilizing an enhanced role for technicians

By practicing at the top of our licenses, this will make economic sense and free the pharmacist for the development of more clinical activities

Amina - train pharmacists

Huyen - oversee operations and train technicians

August 1st 2019 Pharmacist available to focus on growing more clinical services to diversify income streams

System Built… what are the single points of failure?

Single points of failure: the part of a system, if it fails, the entire system will stop

Activity: Think about something that you are doing in your pharmacy that has a single point of failure

Call to Action: Commit to change it

Example of Workflow for Enhanced Services

People, People, People

“Leaders must either invest a reasonable amount of time attending to fears and feelings (of people), OR squander an unreasonable amount of time trying to manage ineffective and unproductive behavior”- Brene Brown

How well do you know your team?

Adding people, adds complexity

Four Tendencies

Activity: How will you convince the following people?

1. Upholder

2. Obliger

3. Rebel

4. Questioner

1. “How”, the rules, procedures

2. Benefit to others/company

3. Choices with consequences

4. “Why”, the purpose, outcomes

What are your people working on?

Is it at the top of their license?

The Key to a Successful Profit Design= Maximizing your whole team

Culture can make or break ImplementationValue alignment between the company and the people• Behaviors change, values don’t • People don’t compromise on values so sometimes it’s

better to part ways• Hire the right peopleEntitativity: the psychology of teamness• What does it feels like when you’re part of a high

functioning team? • Think about your emotional state when you feel like you

belong

Getting Your “Buy-in”

• Appeal to the right tendency

• Value Alignment

• Creating a Culture of Entitativity

• Strength Finding

Example: Position Agreement

1. POSITION IDENTIFICATION:The titles of the position, the manager’s position, and all reporting positions. The position identification shows where the employee fits in your Organization Chart and includes their official title within your company. For managers, consider adding the titles and result statements of their reporting employees as well since they’ll need to be aware of how they can support their team.2. RESULT STATEMENT:A statement of the result the position is required to produce. The result statement indicates what you want to have happen and why. It keeps everyone focused on the expected results of their positions.

Example: Position Agreement

3. WORK LISTING:A list of the work to be performed by the person occupying the position. It will include some combination of strategic and tactical work. Inherent in each work item listed is a system for how to perform the work.4. STANDARDS:Requirements for achieving the result and for performing the work. Standards are easiest to determine if you consider a given position and ask yourself what works and what doesn’t work as the employee performs this role.5. SIGNATURES:Both the manager and the employee accepting the position sign the Position Agreement. By doing so, employees indicate their agreement to accomplish the result, and managers agree to support their employees to achieve the result. Keep your company’s agreements consistent in their format and in the language used.

Maintenance

Remember, that it’s an infinite game. Unknown players will surface. Rules will change. The objective is to keep the game in play. Playing better today then they were yesterday.- Simon Sinek

Sustaining the Infinite Game

• Repetitive Assessment and Improvement of Systems• Identifying barriers and solving with detours• Update policies and procedures• Measure metrics

• Accountability and People Development• Clear is kind - Unclear is unkind• Providing productive and constructive feedback• Professional Development Plans

The Feedback Loop

Dialogue, not a lectureInput and Output

Coaching & Feedback: Inputs and Outputs

1. What more do I need to understand about the situation?a. Objective Facts using nonjudgementb. Identify Assumptions

2. What more do I need to understand about this person(s)?a. Questions for clarity: The power of “Tell me more”b. Create assumptions of positive intent = what is the most

Generous interpretation of their intentions/actions?3. What more do I need to understand about myself?

a. What is the story I’m telling myself?b. Why is this bothering me? What’s underneath my response?c. What part do I own in this?

4. Create your critical conversation

Critical Conversations Model

Resources

• The E-Myth - Michael E. Gerber• The Four Tendencies - Gretchin Rubins• Dare to Lead - Brene Brown• 5 Levels of Leadership - John Maxwell • The Infinite Game - Simon Sinek• The 4 Disciplines of Execution: Achieving Your Wildly

Important Goals - Chris McChesney, Sean Covey, and Jim Huling

Amina Abubakar, PharmD, AAHIVPOwner of Rx Clinic Pharmacy

Co-founder of Avant Institute of [email protected]

Workflow Best Practices



Objectives

• Describe components of a re-engineered practice.• Discuss how an ABM program can positively affect

pharmacy operations.• Outline staffing/workflow considerations needed for

offering enhanced services.

Workflow Operations in a Value-Based Payment System

• We need to re-engineer our practices to align with new payment models

• Technology should support us all moving to work at the top of our abilities

Different Approach to Payment and Delivery

Population Health Management

Fee for Service

Transformational Change in Frequency & Nature of Clinical Patient Interactions


Part D CMR

Initial NC CPESN attempts at Community Pharmacy Care Management

Inte

nsity

Inte

nsity

Inte

nsityTime (6+ months)

Time (6+ months)

Time (6+ months)

“Steady State” Community Pharmacy Care Management Model

Community Pharmacy Care Management

• Services provided locally by a community pharmacy in close coordination with other care team members, including other care managers that focus on optimal drug use.

• The objective of Community Pharmacy Care Management is to procure, update and re-enforce a team-based, patient-centered pharmacy care plan over time. This service line is longitudinal and coordinated with the rest of the care team.


Technology to Help Fill Prescriptions Fast, Accurately, & Cheap

Finding from NC State School of Industrial Engineering:

• If you are not efficient at the filling prescription process you will never get the enhanced services and clinical support process optimized.

• We don’t address problems/opportunities at the time we find them. We wait until the end of the filling process.

Evaluate Gaps in Pharmacy Workflow Operations

• Lack of Care Coordination• Limited to no f/u with new patients,

antibiotic use, Prior Authorizations

• Inventory Management• Out of critical medications on a routine

basis, actual counts do not match inventory in computer

• Limited to no access to pharmacist • Constantly busy to be accessible to patients

• Medication is not ready at promised time of pick up

• Unable to locate the medicine, still in progress

• Customer Service• Phone Rings and Rings…and Rings• Who greets the customer?• Problem Resolution

• Internal Communication Barriers• “Who talked to Ms. Jones earlier

today?”

Evaluate Opportunities in Your Service Population

• Trends of poor adherence• Primary non-adherence• Routine non-adherence

• Formulary issues• patients unable to acquire medication

• Lack of Care Coordination• Patients unable to navigate the health care

maze

• Complex medication regimens

• Transportation• Patients struggle with acquisition of

meds• Lack of communication among

providers• Limited continuity of care

• Treatment often stops once the patient walks out of the clinic

• Literacy challenges• Frequent visits to pharmacy• VIP Patients

Workflow Consideration Test

• Does adding this step(s) contribute to the good of our patients?

• Does adding this step(s) contribute to profitability or revenue producing?

• Will adding this step(s) be something that my staff will perceive as valuable?

• Is this sustainable?


If the Answer is No, Do Not Force It. Revise Your Plan

Slide Content authored by Tripp Logan

NO VALUE

SAME VALUE

MORE VALUE

UNRECOGNIZED VALUE

Joe’s Value Test

No value Same Value

More Value Unrecognized Value



• Comprehensive Medication Reviews: Providing a systemic assessment of medications to identify medication-related problems, prioritize those problems, and create a patient-specific plan to resolve them working with the extended healthcare team


The Appointment-Based Model

Appointment-Based Model (ABM):Coordinating all of a patient’s prescription medications to be picked up on the same date each month, coupled with communications from the pharmacy.

The Case for Synchronization

• What you can expect:• Streamlined workflow• Predictable workload• Decreased delivery runs• Better inventory control• Healthier bottom line• More time for enhanced services

• What you won’t miss:• “Manic Mondays”• Frequent flyers• Waiting for patients to

remember to call in a refill• Last-minute call-ins on Friday

afternoons or before holidays• Patients who run out of pills

7-10 Days Prior to the Appointment/Sync Date

• Call patient to review medications • Assess adherence

• Have you been to the doctor in the last month? • Have you been in the hospital in the last month? • Are you taking any new prescription or over-the-counter

medications? • Are there any other changes we need to be aware of at this

time?


• Initiate refill requests, PAs; contact prescribers as needed• Update the patient profile in the pharmacy management

system• Pharmacist reviews orders and resolves any drug therapy

problems identified by the program manager


• Review inventory/order products • Dispense product(s)• Call and remind patient to pick up prescriptions

Appointment/Sync Date

• Patient picks up medications• Pharmacist addresses any clinical issues

• Are we optimizing patient therapy? • How’s the patient’s adherence? • What services can we add on?

Tips on Implementation

• Designate a technician to run the daily operations• Best use of staff time• Something for them to “own”• Vested interest in success

• Leverage your technology• Identify non-adherent patients• Group patients by ‘sync’ date• Reports to help with patient calls• Robust sync programs

Rethink Workflow Operations

Involvement of Pharmacy Staff

“This CPESN model will remain a disruption until all staff are educated to participate”. Pharmacists need to engage and train pharmacy technicians, delivery drivers, and cashiers for roles supporting CPESN.

“You go into this project thinking you can be a super pharmacist, but you quickly realize that it needs to be a team effort.”

Different Expectations of Our Pharmacy Team

If we are going to be different in the marketplace…

…We need to deliver services differently

http://drive.google.com/file/d/1SagwtqspiXeO_I_V_1d9MBPI8fHMNJ1U/view

Meet Karrie- Adherence Specialist

“We take a proactive approach for our patients. We start the process by calling them each month and finding out what medications they need, what has changed and what concerns they may have…

They feel like they know me and they feel like they have a connection with our pharmacy. They know when they call Moose Pharmacy, they are more than a refill number.”

Scripts for Technician Touch Points

Immunization Screening Tool

Immunization Screening

Tool Workflow

1. Form placed at technician work station2. Technician to complete form if potential

DTP’s are identified3. Technician to send form in basket to the

pharmacist4. Pharmacist investigate the issue and takes

necessary steps to resolve DTP5. DTP documented in platform

Pharmacy Documentation 1.0Technician Tool: DTP Short Form

Update: All DTP’s are documented in dispensing system

Community Pharmacy Documentation 2.0Care Planning

What happens when your technician goes to lunch and a patient calls back

asking if their medication concern has been resolved?

Why Do We Need (e)Care Plans?

• It makes you more efficient in your own pharmacy• It is conducive for better care for the patient• It is our way of marketing all that we do to the

payers


What happens when your technician goes to lunch and a patient calls back asking if their medication concern has been resolved?

• What actions have been completed to date?• Where do you check to see progress?• Does everyone on your team know location to

check progress?


What happens when your technician goes to lunch and a patient calls back asking if their medication concern has been resolved?

• What actions have been completed to date?• Where do you check to see progress?• Does everyone on your team know location to

check progress?

Or do you ask the patient if the technician can call back upon return from lunch?

Getting Started with Care Planning

• Care Goal is a place to document specific patient encounters. It allows for interactions to be documented in a consistent manner that is retrievable.

• Set up automatic warning system to alert pharmacy staff that a care goal should be completed.

Opioid Dispensing Best Practices Starting Point

1. Monitor patients by using the Prescription Drug Monitoring Programs (PDMP) prior to dispensing any controlled substance.

2. Establish a relationship with your local providers who are prescribing opioid treatment to patients.

3. Naloxone Offered?4. Develop a checklist of questions to ask on each encounter

- Is this the first time the patient has been prescribed the opioid?- What is the intended diagnosis? - Is this the right therapy for the intended use?- Has the patient been educated on risk vs benefits of starting the

therapy

Documenting Opioid Encounters

Referral from Provider to Provider

Tools/Resources

• Simplify My Meds• Operations manual, patient forms • Marketing kit• Free to NCPA members (www.ncpanet.org/smm)

• Implementing Med Sync video series• <25 minutes• Step by step training• Great for pharmacy staff• www.youtube.com/NCPAvids

http://www.ncpanet.org/smm

http://www.youtube.com/NCPAvids

Joe Moose, PharmDCPESN® USA

[email protected]

[email protected]

Developing Your Pharmacy Branding Message to Make

Profitable ConnectionsEnhanced Services Boot Camp

Jay Williams, Pharmacy Directions

Elevator Speech

Importance of a Marketing StrategyWhy spend the time?

Articulate your brand clearly and consistently

Assess your uniqueness

Elements of a Successful Strategy

2. Create your brand position

1. Identify your target groups

3. Develop your key messages

4. Take action

1. Identify Your Target Groups

1. Group targets by characteristics not job titles

2. Understand targets based on their needs/desires

3. Lure your ideal patient

Example: Physicians in Dublin, Ohio verses Plain City, Ohio

Example: Care Managers typically have homebound patients, so pharmacies that deliver are needed

Ideal Patient?

Your Ideal Patient

Lure the ideal patient into your store

Identify your ideal patient

Create a retention strategy to keep ideal patients

Target Groups

The aim of marketing is to know and understand the customer so well that the

product or service fits and sells itself.Peter Drucker

Brand?

2. Create Your Brand Position

How well does it resonate with your target groups?How different is it from your competition’s position?

1. Consider the needs of all target groups

2. Evaluate your “Brand Strength”

3. Build your Brand

Brand Building Exercise

Brand

A brand for a company is like a reputation for a person. You earn a

reputation by trying to do hard things well.Jeff Bezos

3. Develop Your Key Messages

Example Messaging

J.D. Power U.S. Pharmacy Study – 2018

Independents were #1 overall

10,749 pharmacy customers surveyed between May and June 2018

J.D. Power U.S. Pharmacy Study – 2018

J.D. Power U.S. Pharmacy Study – 2018Key Takeaways

1. Beat Expectations – One key driver of overall satisfaction is having the prescription ready before you said it would be ready

2. Service with a Smile! – Another key driver of overall satisfaction is “pharmacy staff greeting the patient in a friendly manner”

3. Get Healthy – A key driver of overall satisfaction is the availability of health and wellness services.

Pharmacy Satisfaction PULSE – 2018

33,766 surveys were completed in May and June 2018

#1 in Satisfaction with Pharmacist & Pharmacy Staff

#1 in Satisfaction with Pharmacy Convenience

#1 in Satisfaction with Prescription Pricing

#1 in Satisfaction with Additional Medical Services

Independents were #1 overall

Pharmacy Satisfaction PULSE – 2018

Consumer Reports – 2018

Independents were rated #1 overall

Winter 2018 survey with 78,222 CR members reporting

Consumer Reports – 2018

Enhanced Services Messaging

Improve Patient Health

Focus on Patients; Not Prescriptions

Lower Health Care Costs

Collaborate with Health Care Team Members

Messaging

"People don't buy what you do. They buy why you do it.”

Simon Sinek

4. Take Action

1. Simple, easy-to-draft, easy-to-implement document2. Establish clear deliverables for your teams3. Test effectiveness, evaluate, then try new approaches

2. Create a “Strategy on a Page”

3. Try and try again

1. Build your brand

Strategy-on-a-Page

Taking Action/Risks

There are risks and costs to action. But they are far less than the long

range risks of comfortable inaction. John F. Kennedy

Taking Action/Risks

The biggest risk is not taking any risk...

In a world that changing really quickly, the only strategy that is

guaranteed to fail is not taking risks. Mark Zuckerberg

Summary

2. Create your brand position

1. Identify your target audiences

3. Develop your key messages

4. Take action

Thank You!Jay Williams

[email protected]

introduction—what is the opportunity?

Documents