Collaborative Family Healthcare Association 17 th Annual Conference

H1b Friday October 16, 2015Impact of Clinical Pharmacist and Health Psychologist on Integrated Team Based Care: Transforming the System and Patient Care Experience to a Higher LevelAnne Van Dyke, Ph.D., ABPPElena Kline, PharmDLori Lackman-Zeman, Ph.D.Paul Misch, M.D. Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

Faculty Disclosure The presenters of this session • have NOT had any relevant financial relationships during the past 12 months

Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe the roles of clinical pharmacists and health psychologists on the integrated care team • List the areas of patient and provider satisfaction associated with having clinical pharmacists and health psychologists as part of the IC team • Describe process of doing a cost savings analysis to support adding a clinical pharmacist to your team • Identify the steps to implement system change which paves the way for sustainable IC team based care

Bibliography/References 1. Croghan TW, Brown JD. (2010). Integrating mental health treatment into the patient centered medical home. AHRQ Publication No. 10-0084-EF. Rockville, MD: U.S. Department of Health and Human Services 2. Mountainview Consulting Group (2013). Primary Care Behavioral Health Toolkit. pcpci.org. 3. Park I, Sutherland SE, Ray L, Wilson CG. (2014). Financial implications of pharmacist-led Medicare annual wellness visits. Journal of the American Pharmacists Association, Jul-Aug; 54(4):435- 40. doi:10.1331/JAPhA.2014.13234.

Bibliography/References 4. Patterson BJ, Solimeo SL, Stewart KR, Rosenthal GE, Kaboli J, Lund BC. (2015). Perceptions of pharmacists’ integration into patient- centered medical home teams. Research in Social and Administrative Pharmacy, Jan-Feb; 11(1):85-89. doi:10.1016/j.sapharm.2014.05.005. Epub 2014 May 29. 5. Peek CJ, Cohen DJ, deGruy III FV. (2014). Research and evaluation in the transformation of primary care. American Psychologist, 69 (4), 430- 442. 6. Peikes DN, Reid RJ, Day TJ, Cornwell DD, Dale SB, Baron RJ, Brown RS, Shapiro RJ. (2014). Staffing patterns of primary care practices in the comprehensive primary care initiative. The Annals of Family Medicine, Mar-Apr;12(2):142- 9.doi:10.1370/afm.1626.

Learning Assessment • A learning assessment is required for CE credit • A question and answer period will be conducted at the end of this presentation

Who We Are: Beaumont Family Medicine Beaumont Health is an 8 Hospital System in SE Michigan Beaumont – Troy ~500 bed hospital OUWB New Medical School Family Medicine Residency Program 14 faculty (MD & DO) 24 residents 1 Physician’s Assistant (PA) 35,000 patient visits / year

Who We Are: Beaumont Family Medicine The Integrated Care Team: Faculty Physicians Residents / Medical students Medical Assistants / Nurses Health Psychologists Health Psychology Doctoral Students Clinical Pharmacist (Pharm-D)

Integrated Care Team • Flinn Foundation Grant 2015 • Goal: collaboration with physician in addressing medication and behavioral health issues for whole-person care • Primary “customer” is the physician • Secondary “customer” is the physician’s patient

Integrated Care Team Health Psychologist Addresses: mental health and substance abuse issues health behavior and lifestyle change crisis intervention Employs MI and CBT Uses handouts, CDs, website resources

Integrated Care Team Clinical Pharmacist Medication reconciliation Identify discrepancies Provide patient-friendly medication lists Medication adherence Identify barriers Assistance programs Medication management Optimize dosing, monitor interactions, adjust for renal dysfunction, etc. Patient education Resident/attending education

Clinical Pharmacist • Increasing role with psychotropic meds • Shortage of outpatient psychiatrists with fewer medical students going into psychiatry • Patient insurance not always accepted by psychiatrists

Enhancing Knowledge on Psychiatric Medications • Review guidelines • Keep up with available literature • Participate in webinars/continuing education • Reach out to experts in the field • Follow-up with patients/residents after making recommendation to analyze progress

Logistics of IC Services • Physician request during patient’s medical visit • Pharmacist & health psychologist offer IC during precepting (at time of huddle & throughout patient care half day) • Anyone on the IC team can identify possible patients from daily schedule

Logistics of IC Services • 5 to 25 minutes spent during the medical visit • Patients can return up to 3 times for 30 min f/u IC visit • “Real time” collaboration with physicians • Chart note in EHR routed to physician • Reason patient seen • Clinical assessment of problem (beyond listing of symptoms) • Intervention with patient response as applicable • Recommendations and/or follow-up plan

Physician Survey: Barriers to Using IC Services • Adapted from "PRIMARY CARE BEHAVIORAL HEALTH TOOL KIT” – pcpci.org • Participation rate • n=31 (86%), 100% of faculty, 80% of residents • Wide variability between physicians as to which items were frequently and never a barrier • Presented survey results during noon lecture • Physicians shared strategies with each other • Generated process improvement ideas

Physician Survey: Barriers to Using IC Services(% who thought item was sometimes, frequently or very frequently a barrier) • IC providers are part-time, I don’t know when they are here = 79% (31% very frequently) • I forget by the end of the visit = 59% • Patient refused to see the IC provider = 55% • I don’t have time to talk to the patient about our IC services = 55% • Patient is already seeing a therapist who should be addressing everything = 52% • Not sure how to arrange same-day visits with the IC providers = 48%

Physician Satisfaction (n=31) • How helpful are the IC services for your patients? (1 = low, 10 = high) • mean = 7.4 • Range = 2 to 10 • How helpful are the IC services to you (i.e., helps you better serve patients)? • mean = 7.4 • Range = 2 to 10 • Feedback on how to improve IC services: • Improve logistics • Provide more feedback to physicians

Process Improvements as a Result of Survey Discussion • Increased coverage to all 10 half-day sessions • Posted IC schedule and daily changes • Increased presence during precepting • Identifying potential IC patients at beginning of session • Put up flyers about IC in exam room and lobby • Route EHR notes to physicians involved • System to identify where IC providers are • Provide more information about types of services IC can provide

IC Primary Care Intervention Guide

Clinical Measures • Software utilized to: • Determine potential cost-savings associated with pharmacist interventions • Track psychology interventions

Clinical Pharmacist: Types of Interventions

Clinical Pharmacist Total Clinical Pharmacist Interventions February 18th – September 12th (4 half days/week) 425 Interventions

Clinical Pharmacist % of Total Interventions/Category

Clinical Pharmacist Intervention Progression

Clinical Pharmacist Mental Health & Pain Interventions

Clinical Pharmacist Projected Cost Savings by Category

Clinical Pharmacist Projected Cost Savings: Overall February 18th – September 12th (4 half days/week) $366,622.00

Patient Surveys, n=319(administered anonymously after each contact) • During my visit today we talked about things that are important to me = 4.71 (1=strongly disagree, 5=strongly agree) • Today I learned at least one skill to help me manage my problems or concerns = 4.37 • I plan to do at least one thing differently based on what I learned today = 4.34 • 96.9% listed at least one thing they planned on doing differently or one skill they planned on using • Average confidence rating = 2.62 (1=not confident, 3=very confident)

Strategies for System ChangeTo Implement & Sustain Integrated Team Based Care Phase 1: Approval (Do your homework) Clarify purpose and desired measurable outcomes Identify Stakeholders (WIFM) Be armed with data Phase 2: Roll Out & Implementation Communication (x10) Education, coaching & support Phase 3: On-going Evaluation & Adjustments Plan-Do-Check-Act Cycle Aligned incentives

Sustainability • Peak Performing Organizations Got There By Applying Five Principles: • Match strategy and culture…as culture trumps strategy every time • 2. Focus on a few critical shifts in behavior…change is hard, so you need to choose your battles • 3. Honor the strengths of your existing culture…so major change feels more like a shared evolution vs. a top-down imposition *Harvard Business Review, “Culture Change that Sticks” by Booz & Co. execs Jon Katzenback, Ilona Steffen, and Caroline Kronley.

Sustainability • Peak Performing Organizations Got There By Applying Five Principles: • 4. Integrate formal and informal interventions…reaching people at an emotional level and tapping rational self- interest • 5. Measure and monitor cultural evolution…to identify backsliding, correct course where needed, and demonstrate tangible evidence of improvement *Harvard Business Review, “Culture Change that Sticks” by Booz & Co. execs Jon Katzenback, Ilona Steffen, and Caroline Kronley.

Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!

Patient Case • IC team engaged by physician for pain and nausea medication management and behavioral health support for 53YOM • Suicide attempt 3 days prior • No current suicidal ideation • Stroke survivor • Difficulty with information recall • Hx of GI issues • Intolerance to all PO narcotics, except morphine • Previously able to tolerate current morphine dose until recently • Unclear if nausea related to food intake vs morphine administration • Physician Plan: • Start pantoprazole daily before breakfast • Start ondansetron Q8H PRN for nausea • Continue morphine 15mg daily PRN • GI referral • RTC in 2 months or sooner if sxsworsen • Meet with Integrated Care Team

Patient Case • Health Psychology Intervention • Obtained hx on previous suicide attempts • Mainly d/t being overwhelmed by colitis and chronic pain • Interested in counseling services • Inquired if pt interested in being set up with a case manager for assistance with scheduling medical appts, transportation issues, and medication reminders • Pt agreeable • Health Psychology Plan • Contact case management through pt’s insurance (Molina) • Review counseling options • Provide contact information for possible referrals for cognitive and memory assessment

Patient Case • Clinical Pharmacist Intervention • Ptunable to answer questions regarding his medication regimen d/t poor recall • Clinical Pharmacist Plan • Before making changes, need to be sure an accurate hx obtained • Developed personalized pain/nausea chart for pt to fill out daily • Reviewed with patient – Pt demonstrated understanding through teach-back method – All questions answered • Instructed pt to take morphine before activities that typically cause pain • Follow-up in 2 weeks to review chart documentation. Pt understands to bring chart to clinic.

Patient CasePain/Nausea Chart

Patient CaseFollow-up Appointment #1 Pharmacist • Pt RTC in 2 weeks with chart filled out • Taking ondansetron Q8H scheduled • Taking pantoprazole before breakfast daily w/ no issues • Pt able to take morphine 1-2 times daily PRN which controlled pain • Taking prior to activities which cause pain • No nausea associated with morphine administration • Upon review of chart, determined nausea related to food intake • Reviewed case updates with physician • Advised pt to continue current regimen • Exception: Take ondansetron before food intake only, not on scheduled basis • Follow-up with PharmD in 2 weeks; continue to fill out pain/nausea chart Health Psychology • Scheduled series of counseling sessions • Ensured case management set up through pt’s insurance

Patient CaseInsurance Audit • Physician received audit from pt’s insurance company • Required to review/explain duplicate therapy listed • Physician requested PharmD assistance • PharmD reviewed listed medications • Alprazolam • Lorazepam • Diazepam • Hydrocodone/acetaminophen • Morphine • Only diazepam and morphine being rx’d by FMC physician • Muscle spasm/anxiety & chronic pain • Pt w/ allergy listed to hydrocodone/acetaminophen in chart • Had previously requested not to be rx’d this medication d/t GI intolerance

Patient CasePharmD Review • Lorazepam • Received 7 day supply x2 • Rx’d by psychiatrist; pt explanation valid • Alprazolam and hydrocodone/acetaminophen rx’d by neurologist Qmonthsince February 2015 • Per claim sheet, rx had been dispensed consistently • Pt adamantly denied being rx’d these medications • PharmD called all pharmacies listed in pt chart to see if rx had been picked up consistently • No prescriptions had been filled/picked up • Pt reports his wife picks up all of his prescriptions

Collaborative Family Healthcare Association 17 th Annual Conference