Implementation of an integrated care management program in - - PowerPoint PPT Presentation

Implementation of an integrated care management program in community pharmacies: Identifying barriers and employing implementation strategies

Stefanie Ferreri, PharmD Chris Shea, PhD Megan Smith, PharmD Kea Turner, MPH

The project described was supported by Grant CMS-1C1-14-001 from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The research was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.

Community Pharmacy

• What comes to

mind when you think of a community pharmacist?

Stefanie Ferreri

Everyday activities may include:

• Dispensing prescription

medications

• Counseling patients about

their medications

• Liaising with doctors

about prescriptions

• Recommending over-the-counter

medications

• Compounding medications

But did you know…….

The “New” Community Pharmacist

• Provides Disease State Management
• Hypertension, Osteoporosis, Diabetes
• Cholesterol, Asthma, COPD, Smoking Cessation
• Performs Labs
• TSH, LFT, Lipids
• Administers Immunizations
• Offers Comprehensive Medication Reviews
• Optimizes medications
• Coordinates Care with Members of the Health Care Team
• Medication reconciliation
• Transitions of care

Background: CMS Health Care Innovations Award

Project Title: Optimizing the Medical Neighborhood: Transforming Care Coordination Through the North Carolina Community Pharmacy Enhanced Services Network (CPESN) Area of focus: models that test specific provider’s ability to transform financial and clinical models Moving community pharmacy from fee-for-service payment models to pay-for-performance models (value-based care)

Background: An integrated care management program in community pharmacies

• Program implemented in March 2015
• 123 community and community health center pharmacies
• Expectation
• Complete an initial medication assessment on one patient per month as part of

the care management program

• Reality
• 41% (n=50) of pharmacies consistently

documented the initial medication assessment the first 3 months

• 59% (n=73) of pharmacies were not

consistently documenting initial medication assessments

Identifying barriers

Qualitative Content Analysis

Initial Medication Assessment within the ICM Program

Methods

• Telephone interviews were conducted

with pharmacists from all 73 inconsistent pharmacies to identify implementation barriers

• The pharmacy service was divided into

10 action steps to guide the interview

• Transcribed barriers were assigned to

each action step using an inductive approach

(1) Initiating Services (2) Accessing internal information (3) Accessing external information (4) Scheduling patients (5) Performing patient interview (6) Developing assessment (7) Developing a care plan (8) Documenting (9) Coordinating care with network and medical home (10) Performing follow-up Other barriers Suggested solutions General notes

Qualitative Findings of Barriers

Steps Barrier Themes Initiating services

Unclear program expectations/requirements Lack of adequate resources to perform comprehensive medication reviews Lack of time Staffing and workflow challenges to incorporate into their business practice

Accessing internal information

Difficulty locating patient data Difficulty using attribution reports

Accessing external information

Difficulty obtaining information from primary care providers

Scheduling patients Incorrect contact information Patient resistance Patient no-shows Patient has transportation difficulty

Qualitative Findings of Barriers

Steps Barrier Themes Coordinating care Unclear of role of care team members Difficulty identifying appropriate team member Ineffective means of communication Performing follow-up Lack of system for managing follow-up needs Difficulty to collaborate with other pharmacy team members for follow-up Performing patient interview Phone vs. face-to-face Difficulty working with caregiver Documenting Time consuming Difficult to use pharmacy system Lack of confirmation of successful documentation Unclear of required information for documentation

Quantitative Findings of Barriers

Challenges Reported, n Total N=146 Challenges, % Initiating Services 43 29.5 Accessing Internal Information 27 18.5 Accessing External Information 10 6.8 Scheduling Patients 20 13.7 Performing Patient Interview 2 1.4 Conducting Assessment Developing a Care Plan Documenting 36 24.6 Coordinating Care 7 4.8 Performing Follow-up 1 0.7

Documenting implementation strategies

Background

• Detailed documentation of implementation strategies is important

for several reasons, including

• Improving evaluation of implementation strategies
• Facilitating replication of strategies in practice.
• Purpose: Our study aimed to document implementation strategies

being employed within the network of CPESN pharmacies.

Methods

• 35 one-hour interviews with individuals leading implementation

strategies across the entire network:

• Network staff
• CPESN program collaborators (i.e., network operational staff, university

research team members)

• Pharmacy staff
• Semi-structured interview guide based on Proctor et al.’s guidance for

describing implementation strategies (i.e., name it, define it, specify it) and Powell et al.’s compilation of implementation strategies.

Proctor et al. (2013). Implementation strategies: recommendations for specifying and reporting. Implementation Science, 8:139. Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., et al. (2015). A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10(1), 21.

Findings: Selected Implementation Strategies

Strategy Description

Centralize Technical Assistance Each region has a network pharmacist providing technical assistance to pharmacies. Conduct Educational Outreach Network pharmacists provided education about clinical management

• f patients (e.g., disease state management, delivering information

about naloxone). A university-based pharmacist visited pharmacies to answer questions about program requirements and set implementation goals. Audit and Feedback Quarterly reports were delivered to pharmacies about performance metrics. Academic pharmacists audited documentation quality and provided feedback/suggestions to pharmacies.

Findings (cont.)

Strategy Description

Tailor Strategies Educational approaches were adjusted for pharmacists based on their familiarity with clinical management of patients. Capture and Share Local Knowledge Some pharmacies identified lessons learned about delivering services and coordinating care with other providers. Network staff identified these lessons learned and shared them with

• ther participating pharmacies.

Lessons Learned about Documenting Strategies

• Documenting strategies via interviews involves educating participants

about D&I concepts.

• Operationalizing strategies (e.g., specific actions taken, timing,

implementation outcome affected) can be difficult for interviewees.

• Documenting strategies via interviews alone is not ideal.
• Prior to program implementation, collaboratively planning for

strategy documentation with those who will be employing the strategies could facilitate more effective documentation and utilization of implementation resources.

Summary

• Community pharmacy is ripe for implementation research.
• Our work was exploratory, aiming to identify barriers and

implementation strategies being employed in the network.

• Financial incentives alone do not appear sufficient to change

practice for many pharmacies.

• More needs to be known about how to roll out implementation

strategies within a network of pharmacies with varying needs/capabilities.