Month: June 2015

Tales from the Counter 

Sometimes I lament that, as a pharmacy owner, I don’t get to spend as much time on the prescription counter working with patients anymore. I still enjoy the challenge of working on the counter and working with patients, and every day I spend in this capacity I see examples of how pharmacists bring real value to healthcare. I also regularly find examples demonstrating the importance of taking time with each patient to be a clinical interventionist. I wanted to share a recent encounter I had the other day, because it emphasizes one of the core tenants of the Thriving Pharmacist: making every encounter with the patient count.

Today, while doing routine CMM (Continuous Medication Monitoring), I noticed that a medication had not been filled in several months. Our clinical checking system (PharmClin) helps our pharmacists easily spot these types of problem in two ways. First, the system calculates compliance (as a PDC — percentage of days covered). When the PDC drops below a pre-set level (around 75%), the software creates an alert for the pharmacist. It is important to note that this is done for all medications each time the patient record is visited and without regard the the medication(s) being filled and checked on a given day. The second feature of PharmClin that is immensely helpful is the ability to document if problem (like compliance of a medication) has or has not already been addressed. It also allows the pharmacist to set a follow-up date for re-evaluation of the issue.

In the case today, this medication had dropped to a compliance rate of 75 percent three months ago. The PDC was low due to one late refill, the pharmacist note on that date indicated that we would continue to monitor the compliance and revisit it in 3 months. It is not uncommon compliance to rebound, and 90 days is a reasonable amount of time to observe and re-assess. Today the software once again alerted me to the compliance issue (the three months had now elapsed). Given both the worsening PDC and the previous course of action (simply to monitor), I generated an intervention and attached it to one of the prescriptions being picked up today. The note simply asked if the dosage of this medication had changed or if this medication had been discontinued. The pharmacist speaking with the patient at the register would then be able to collect any important details (why, side effects, ineffective etc.).

When the patient arrived this morning, the technician (seeing the intervention tag) called me over to the counter to speak with the patient. During the course of discussion, I was able to ascertain that while the medication was indeed working for him, he was not currently taking it due to a drug interaction. Not seeing any drug interactions noted in his profile, further inquiry was made. It turned out that the patient was receiving a mediation from the local university teaching hospital. This medication (Harvoni) did indeed have an interaction with the medication in question.

At this point, I was able to speak to the patient about the importance of a single pharmacy home, and making sure that that pharmacy home has a complete profile. As it turned out, the patient had simply assumed that we would know what the other pharmacy dispensed. If a new medication was prescribed that also interacted with Harvoni, we very likely would not have been aware of the potential for an interaction. After the patient left, I added Harvoni to his profile for inclusion in future screening during our CMM activities.

The intervention that I had with the patient today was not uncommon to pharmacy. Pharmacists around the country take the initiative to be clinical interventionists. It doesn’t take board certification, a residency, or a fellowship to be a successful interventionist. It takes a sound workflow and an desire to think and ask questions. The biggest difference for me, though, is the documentation being done by our pharmacy. Documentation, like the previous note and the alert for a follow-up, allows the pharmacist to continually refine the clinical picture for each patient and the plan of care. Software is an important part, and can enable the pharmacist perform and document meaningful CMM activities.

Who’s Paying Pharmacy to Resolve Insurance and PBM Issues?

Recently, I  spent over one hour to resolve an issue that should not have taken nearly as long as it did, nor should have been a problem from the start.  It had to do with a patient who needed blood glucose strips filled.  This patient uses an insulin pump, so she must check her blood sugars 7 times per day.  The patient’s physician had completed the prior authorization paper work and the patient did receive a letter from the PBM indicating that the strips had been approved for coverage.  And yet, when we went to fill the prescription, it got rejected because the product is an OTC.  The PBM was called and their representative basically read to me the rejection that I was already seeing on the computer screen.  So when I explained that the patient received a letter from them specifying that the strips are covered, the representative put me on hold and had to check her sources.  After some time had passed, the PBM representative came back on the phone to tell me that they cannot provide this override as it has to come from the plan because it is an OTC (Over the Counter) reject.  She then proceeded to tell me that I had to call the plan specifically as they would have to approve the override and she gave me the plan’s toll free number.  WHAT?!  The letter came from them (the PBM) to the patient, not from the plan!  The PBM representative insisted that this type of reject has to be overridden from the plan.  I repeatedly asked the PBM representative if the information on the strips could have been coded wrong, but she said, “No, it had to be overridden by the plan.”  So I proceeded to call the plan.

The plan representative was confused by my call.  She asked me if I had reached out to the PBM, and my answer was YES!  I told her what the PBM employee told me, and this just added confusion to the plan representative who said she would have to put me on-hold.  After some time she came back on the phone and she asked me to re-run the claim so she and another plan representative could see the reject.  Once I ran the claim, both representatives were now perplexed on why the claim would not go through.  The plan representative put me on-hold again and said she needed to do some more checking on why this claim was rejected.  After some time, someone at the plan hung up on me.   After some more time passed, I did get a call back from the plan representative who was very nice and helpful.  The plan representative informed me that the error was on the PBM side; they had coded the information incorrectly from the start.  Hmmmm!!! This is what I asked the PBM representative previously.  So either the PBM representative was lazy, misinformed, or not trained properly to check or identify if the transaction was miscoded.  Luckily, the plan representative was able to get into the PBMs system and make the necessary correction, and the claim did go through.

So, for those pharmacists who deal with these type of issues on a daily basis, they know exactly what I am talking about and the frustrations with these type of calls.  This happens way too often and provides no value to anyone. The complexities of the system created by the PBM are even beyond the PBM’s help desk employees, and even they could not help us correct the issue they created.  And who’s paying us to correct errors like this for them?  Community pharmacists are being bombarded with underwater MACs, DIR fees , clawbacks, and insufficient reimbursement for many medications.  And yet we are the ones who not only provide clinical services for our patients, but also resolve these claim processing errors.

If pharmacies are charged a fee by the PBM for each and every claim they submit to be processed, should not the PBM’s have to pay pharmacies for their work helping patients achieve their therapeutic outcomes–even if its to resolve processing errors made by the the PBM?  Indeed, if it were generally known how much time pharmacies spend working on PBM generated problems like this, they would likely be appalled. If the federal government has rules to reduce burdensome paperwork, should not the contracts signed by pharmacies (and on their behalf by their PSAO) have language that covers time wasted by the phararmacy on the behalf of the processor. In this case, a pharmacy technician would have cost the pharmacy about $30 in time. Where should we send the bill?

This is a open call out to all contracting organizations representing pharmacies (chain and independent). As our partners, stand up for us. Emphasize the value of pharmacies in assisting patients navigate the difficult world of the pharmacy benefit. Help the PBM industry respect our time and efforts. In the past, reimbursement for product helped offset pharmacy hours spent working these types of problems. Current reimbursement no longer allows pharmacy this luxury.

Remember, from the beginning, this was a clinical issue.  A patient with diabetes, with an insulin pump, requires testing above “normal” test strip usage.  All of the obstacles were administrative, and in no way helped the patient.  It took the pharmacist to uncover the convoluted mess created by administrative policy and clerical error.  It is always about the patient–let’s not forget this, and this needs to be emphasized to payers and PBMs!

Creating a Slack Based Workflow

Whenever visitors tour our pharmacy, one of the most common comments has to do with the level of our staffing. We typically have a minimum of 4 pharmacists working on any given day, with as many as 7 on select days. The use of extra pharmacists (what we call our slack resources) allows the flexibility to accomplish many ventures other “stripped down model” pharmacies cannot. This article will describe our workflow and the benefits it brings to a pharmacy practice.

Technician Driven

The most important part of our workflow is freeing the pharmacist to focus on the patient. This is accomplished by leveraging excellent technicians to do all data entry and filling processes. In our case, our pharmacy is involved in a pilot project allowing technicians that have received additional training to check refill orders without a pharmacist final verification of the product.

The Pharmacist Belongs on the Counter

Another important philosophy in our workflow is that the pharmacist needs to stay in the dispensing workflow. Even if the pharmacist is not doing the final verification step (for example, in the tech check tech pilot program above) the pharmacist is still reviewing the patient’s profile and clinical record in real-time. The pharmacist is tasked with creating and documenting interventions that need to be addressed with either the patient and / or the prescriber. By being on the counter, the pharmacist is accessible to gather information directly from the patient as needed to make clinical recommendations.

The pharmacist on the counter has one of the more difficult jobs in our practice. Their responsibilities include:

  • Final Verification of the drug product (all prescriptions, or for new prescriptions if a tech-check-tech program is in place)
  • Clinical profile review. Each patient’s records are reviewed any time a prescription is filled or a patient contacts the pharmacy with a concern or question.
  • Identify issues that need to be addressed at the point of sale (compliance, high risk medication use etc) and flag these for follow-up with the patient
  • Gather patient information specific to any issues identified
  • Document the additional information gathered
  • Schedule appropriate follow-up as required
  • Contact the prescriber by phone or fax regarding any problem(s) identified as needed

This is a significant amount of work to put on one person, and when the pharmacy becomes busy, this pharmacist needs a resource to delegate work. This is our slack pharmacist.

The Slack Pharmacist

It is important to develop a workflow that leverages this person to maximize their impact. It would be inefficient to have this resource sitting and waiting for the hand-off from our prescription counter. Our slack pharmacist’s responsibilities also include medication reviews for our patients residing in nursing homes we service, and our assisted living community patients. They are also involved in vaccination programs and other clinical services like cholesterol screenings, site visits and our medication sync program.

Our slack pharmacists are located a few feet from our prescription counter, in semi-private cubicles. This workspace allows the slack pharmacist to work individually with a patient, and to have ready access to the clinical records system and many of the other tools they use (blood pressure cuff, Cholestec machine, immunization supplies, injection supplies, patient charts etc). This proximity means that the counter pharmacist can easily hand-off patient care activities, SOAP note completion, physician calls and faxes during a busy time on the counter.

Pharmacists Enable Care

If it isn’t obvious by now, our practice places a significant emphasis on the talents and capabilities of our pharmacists. What visitors notice immediately after they count the number of pharmacists at our practice is that every single pharmacist is quite busy.  Taking care of patients is not possible if you don’t have the resources available, and simply filling prescriptions is not patient care. The pharmacist has excellent access to their patients, and they need to capture every encounter and make it count.

Medicare Part D and Clinical Opportunities

On a recent conference call, we learned that a significant Medicare Part D plan would NOT have any clinical opportunities for pharmacists in 2016. This is disappointing on many levels. The fact that Medicare will allow a plan to do this is troubling, especially with the increased lip service being paid by Medicare with respect to quality measures.

Pharmacists should be upset by this, but there is another facet to this that is equally troubling: Medicare Part D plans are not searchable based on clinical services offered. While the Medicare.gov plan discovery tool does display the presence of an MTM program it is not prominent and does not adequately describe the program’s context or extent (see the example below). These omission are significant, especially given the emphasis on quality being touted by Medicare. If a patient considers their local pharmacist to be an important part of their care, and desires to have clinical services (locally provided by their pharmacy) included in their drug plan, they are adrift with little guidance.

While it is possible that Medicare may eventually include clinical opportunities as a searchable term, and / or make differences  in how the services are provided more obvious to the end user, it may come down to companies like iMedicare to fill this void in the near term. This company can be used by pharmacies to quickly help their patients choose a plan based on the same information used by the Medicare.gov website. If iMedicare supplemented the information already being provided by Medicare with a description of MTM and clinical opportunities for the given plan, it would allow pharmacists to explain which plans include this important feature. These details on how each plan handles MTM are very valuable, as some plans do not use local pharmacists to perform these clinical services, or severely restrict the number of patients that are eligible. Given this additional information, patients would have a more complete understating of plans and could then make better decisions about their Medicare Part D plans

Why PBMs May Become an Extinct Species

The PBM Industry

The Pharmacy Benefit Manager (PBM) industry has gone from being a claims processor (simplifying paying claims for the insurance payor) to a manager of the entire pharmacy benefit for hundreds of millions of patients. Is not uncommon for a PBM to tout the savings they garner the system thru their management of the drug formulary, restrictions on expensive medications, and a variety of processes that come close, or even cross the boundary, between the PBM being a “manager” and the PBM acting as a physician or pharmacist.

The PBM industry generally takes credit for saving the health care system billions of dollars yearly. But being a pharmacist, I often have wondered how much of these “savings” are due to the PBM itself, and how much is directly attributable to the actual care providers. I find it interesting that the PBM industry is a pure middle-man in the health care industry. As an industry, they have very little on the line as they are not generally responsible for the total health spend. Manufacturing savings for the PBM may be as simple as creating downward pressure on the price paid for product and services. The PBM can effect savings in this manner without actually jeopardizing their own bottom line significantly. While the above characterization is certainly not complete, it does represent the essence of the entire industry.

Quality emphasis

CMS and others are beginning recognize that the current system places too much emphasis on product and not enough on service. Recent initiatives are starting to emphasize quality of service in the equation, and these measures are NOT something that a manager can do themselves. They require the providers (and in this case these are pharmacists) to accomplish. Pharmacists are key because they actually can see, speak to, and evaluate the patient and their medication use. Recently, some PBMs have even taken steps in the right direction and initiated programs to reward pharmacies for high quality work. While these initiatives emphasize metrics that are simplistic (mostly measuring compliance), and the actual financial rewards are not at levels that could sustain high quality performance in a pharmacy, they are steps in the right direction.

Pharmacist Impact

Pharmacists can have significant impacts on savings in healthcare. Our own pilot study that included 600 patients with a local payor is showing significant savings effected by pharmacists acting as clinical interventionists. These savings, calculated by the payor using a rigorous statistical analysis, show that a pharmacy can save the health care system several thousand dollars per patient per year.

Now the US Army is reporting similar results; using pharmacists as interventionists can create significant savings and a positive return on investment. And this type of evaluation is starting to catch the eyes of payors. In Iowa, the payor involved in our pilot is looking to create a network of high performing pharmacies by next year (2016), and that network would be paid using a different model than the one currently used in the industry.

Changing Times

The current iteration of the Star Measures are simplistic, but they are a good starting point. We fully expect that the Star measures will evolve to include actual disease state outcomes and measures that better reflect the savings in total health spend. These changes are not compatible with the current PBM centered “manager” model. A PBM cannot manage patients in this manner, only a provider with face-to-face access to the patient can do this.

Increased emphasis on outcomes means that the PBM, who does not have any skin in the game currently, will either become less important, or will need to shoulder more responsibility for the outcomes of the patient. Either way, the days of easy profit as a middle-man may be numbered.  The current methods leveraged by the PBMs to create a stripped down model of pharmacy will not improve outcomes. The cheaper  drug does not necessarily mean better healthcare outcomes and a lower total healthcare spend.

These changes have significant implications to pharmacists and pharmacies that have adopted the stripped down model of pharmacy. Going forward, it will not be enough to simply fill a prescription. It is what is done after the prescription is filled, that time spent with the patient, that will become important. Pharmacists need to rediscover their inner clinician. Those skills learned in pharmacy school will need to be polished and practiced once again, for many, for the first time since graduating pharmacy school. Pharmacists need to start stepping up their games now. Start making every encounter with your patients count!

The Future

Imagine a future where it is the pharmacy that has negotiating power. A payor will negotiate with a high performing pharmacy to have them included in their network. Pharmacies and pharmacists are paid for the care they provide based on real clinical outcomes. Savigs effected by pharmacy and pharmacist are shared with the  pharmacy and pharmacist. A vision like this is possible, and it is a far cry from where pharmacy stands today, begging to be included in narrow networks with impossibly thin margins. In order to get there from here, pharmacists need to start now.

Access to Lives: What does that mean and to whom?!

The other day, my business partner and I had a conference call with our wholesaler and our PSAO about the impact that DIR fees were having on our bottom line.  The representative from our PSAO kept emphasizing that the reason why they signed the contracts with some preferred networks (with very low pharmacy reimbursement) is because they wanted to make sure that their network of pharmacies had access to lives.  We do not disagree with this statement, but where our priorities began to diverge from our PSAO is when the PSAO representative described ways to increase revenue for those patients in the store. The emphasis was on selling them other items to make up for the losses on the drug product. The emphasis was not on clinical services, but what other products you may be able to offer patients coming to your practice.

What?!  We were in disbelief! From our perspective, access to lives means that we have an opportunity to provide clinical services that impacts the care of these patients.  If clinically we did our job, then patients should attain their therapeutic outcomes through safe and effective drug therapy regimens.  Those patients who achieve their therapeutic outcomes should be healthier and have less health care spend than those patients who do not achieve their therapeutic outcomes.   It is our contention that pharmacists SHOULD be paid a FAIR fee for high performance.  Obviously, with underwater MACs, DIR fees, claw-backs, and other PBM business practices, the payment for product has rapidly become insufficient to cover the costs associated with dispensing. Product reimbursement certainly leaves nothing to pay for a pharmacist’s clinical activities and cognitive services.  To add insult to injury, the performance payment from one PBM for our performance on pharmacy performance measures was extremely anemic.  This is unacceptable, and as a profession we should demand more from our strategic partners, which include our wholesaler, our PSAO, our network, our buying group, and the PBMs themselves.  At this point, the partnership seems to be benefiting everyone but the community pharmacist who is in the trenches taking care of patients (and who is getting paid less to do this).  It makes no sense.  But to have one of the strategic partners verbalize that we have to do more than just offer clinical services and look at other products that we can sale to patients as a way to enhance our revenue was enough to put us over the edge.

We want to be good community pharmacists.  We offer an extensive list of clinical services. We have partnered with a local payer, who has stayed committed to us because of the outcomes we have been able to generate with their clients (our patients), and we consistently achieve a high performance on our pharmacy performance measures on the EQuiPP platform.  We own two professional pharmacies that have small front ends.  We only sell medical related items and we already have a flourishing DME business.  So if our strategic partners are suggesting that we are suppose to sell paint and hardware or milk and eggs as a way to generate new revenue, then question if they are truly our partner.  It should be about patient care.  It should be about the services we provide.  It should be about the outcomes we achieve.  We have worked hard to change the paradigm of our practice, but now we are working just as hard to change the paradigm on how community pharmacist are paid.  It seems everyone within the drug distribution system is “making their money” including the all the strategic partners that have been mentioned previously, but the community pharmacist is left to provide the care, identify and resolve drug therapy problems, take calls from patients 24/7, be responsible for patient outcomes, and not paid sufficiently for any of it.  Access to lives should not be about finding new ways of selling products to improve the bottom line, but rather it should be about quality patient care, fair reimbursement for that care, and bonus incentives if expectations are met. How can anyone rationally look at the current system and say that it is fair and that pharmacist are reimbursed sufficiently?  The financial viability and survivability of independent community pharmacist is on the line.

As we move forward, we will continue to fight for what we believe is fair reimbursement for services rendered.  We will continue to put pressure on our strategic partners to help us in our quest for fair and equitable reimbursement.  In the short term, we also will continue to put pressure on our strategic partners to make sure that we are receiving the best price for our costs of good sold, including rebates.  We will continue to communicate with our legislators about fair reimbursement for pharmacists.  And we will continue to support our local, state, and national professional organizations as they continue to fight for pharmacists recognition as providers.  It has been a tough year, and next year looks to bring the same.  We also realize that we are not alone, as other owners have expressed similar concerns.  All of us can make a difference,  but we have to be willing to challenge the status quo and our help strategic partners to change.

Large Pizza and the 90 day Refill

The other day I sat contemplating the pricing of a large pizza. Yes, I am a bit of a math geek, and I was having trouble wrapping my head around why the price of a 16 inch pizza was only a couple of dollars more than a 12 inch pizza despite the exponential nature of the area as pizzas get larger (113 sq inches for a 12 inch pizza vs 153 sq inches for a 16 inch pizza, almost a 40% increase in size). I am sure someone has looked at all of the variables( ingredients needed, time required to assemble the pie, pizza oven space requirements, baking time etc.) and justified the discrepancy, but it still bothered me.

As I thought about this some more, it occurred to me that pharmacy (and more specifically the pharmacy benefit managers or PBMs) are doing the same thing. The emphasis on the 90 day refill is high in the industry, even to the point of incentivizing the patient with a lower copay (just like pizza) to “upsize” their prescription. Like the pizza industry, I am sure someone has measured all of the variables and come to the conclusion that, like the large pizza, 90 day fills are better.

But is this wisdom actually accurate? Whom does this benefit? Remember that the PBM industry has, by and in large, made this judgment using their variables. Is it good for the payor,  the patient, or the pharmacy? What is the goal or outcome that is being sought? To a pharmacist, the goal should be improved outcomes and a decrease in total health care spend. For some reason, I doubt that these are the outcomes cherished by the PBMs.

Benefits of a 90 day “Super Size” Rx

The Patient: 

A super size Rx may result in fewer trips to the pharmacy. This assumes that the patient doesn’t visit the pharmacy for other reasons, of course. Patients also pick up necessities at their local pharmacy (think OTC items), receive vaccinations, have their blood pressure checked or cholesterol tested, or to ask questions or advice from their pharmacist. Even after implementing a medication synchronization program, many of our “sync” patients still come the the pharmacy just as often as before. Indeed, fewer trips to the pharmacy may actually be a bad outcome for patients.

Compliance is often touted as a benefit of a 90 day refill. This, however, turns out to be somewhat difficult to prove. Claims data may show better compliance, but it is impossible to know if the patient is actually taking the medication properly and achieving the optimal outcomes with claims data alone. When a pharmacist takes time to talk with a patient, they can actually assess both compliance AND outcomes. Super size refills creates fewer interactions with the pharmacist to assess the patient and can actually delay the pharmacist’s ability to address compliance and intervene to improve outcomes.

Cost is used an incentive for Super Size refills. The patient will often pay less for a 90 day supply than they would for three 30 day supplies. For many patients, this savings, over multiple prescriptions and over the course of the year can be significant.

The Payor:

Insurance companies are the ultimate payor. In the case of Medicare Part D, the payor is Medicare. To the entity holding the purse strings, 90 day fills offer little real advantages. While it is possible that a supe rsize refill costs the payor less than a 30 day refill, drug costs are only a fraction of the costs that the insurance has to consider. Any savings, in the form of improved outcomes from medications can far exceed any savings for 90 day prescription fills. A recent program between a pharmacy in Iowa and a major insurance payor demonstrated that pharmacists can impact total health spend for their patients, and the degree of this impact can be very substantial. Overall, the payor may benefit more from an increase in patient-pharmacist interactions rather than a decrease.

The PBM:

Extended day supplies benefit the PBM in several ways. Many extended day contracts feature both decreased pharmacy reimbursement and decreased dispensing fees (the two places pharmacies are actually paid for their effort). This directly benefits the PBM by decreasing their cost. Another potential benefit is for the PBM to emphasize their own mail-order pharmacy. Extended day fills are really the only way this type of pharmacy can exist. Any emphasis on extended days supply creates opportunity for the PBM owned mail order pharmacies to extend their business.

The Pharmacy:

The pharmacy stands to loose the most from extended day supplies. While the PBM argues that extended day supplies are easier for the pharmacy (only having to fill a prescription 4 times a year versus 12 times a year), this benefit is negated by a myriad of negative economic impacts on the pharmacy, including decreased front end sales and diminished reimbursement of the prescription itself. A prescription, to a pharmacist caring for the patient, is a lot more than just a bottle, label, and drug product. It is a chance to make that encounter with the patient count. Pharmacy is a profession, not a product.

The Real Pharmacy Benefit: Pharmacists

In the end, the PBM industry has pushed its own agenda by forcing down reimbursement for drug product and emphasizing its own metrics. It is time for the patient and the payor / plan to start recognizing the importance what the pharmacist does and how it impacts patient care. It is also imperative that pharmacist step up, if they are not already working as a clinical interventionist. Every pharmacist should be working to make every encounter with their patients count!

Creating the Capacity for Patient Care

We are often asked how our practice evolved into what it is today with it’s diverse service offerings, a significant staff of pharmacists and technicians, and our ability to generate revenue beyond just dispensing medications.  It started almost a decade ago when Mike and I decided to change our model of community pharmacy practice.  Creating the capacity to provide patient care  services was not an overnight fix, rather it was an evolution based on trial and error, feedback from staff and patients, and market forces.  This is not saying that our practice developed out of random happenings, but rather we had laid a foundation for which we could easily adjust, improve, and add services as deemed necessary.

To create a capacity for patient care, we began by moving our practice to a technician driven dispensing model, repurposing pharmacists so that the majority of their time was spent evaluating patients’ medications, resolving drug therapy problems, and communicating with both patients and providers.  This required changes in job descriptions and responsibilities, new positions being developed, and staff training.  We put a lot of our focus on the dispensing pharmacist. Pharmacists traditionally focused performing final verification. In our practice, the pharmacist was asked to becoming a clinical interventionist–identifying and resolving drug therapy problems “on the run” in which we now called continuous medication monitoring (CMM).  To make this transition, we had to develop a different documentation system, because our dispensing system, much like all the others, is great for making sure we have all the information needed for dispensing a product, but very limited in terms of documenting patient care.  The system we created is now called PharmClin, and it leverages the information from our dispensing system and creates a clinical record, making it easier and more efficient for the dispensing pharmacist to provide CMM.   Moving the pharmacist into this new role also required education and training on how to quickly clinically assess patients’ medications, develop an intervention to resolve medication issues, and document their patient care activities.  Obviously, creating the technician driven dispensing process helped to free up the pharmacist more to focus their activities on patient care.  We saw the need to create a new position for a pharmacist to oversee the operations of our dispensing system.

In addition to the changes in dispensing, simultaneously we remodeled our pharmacy to include two patient care areas.  These areas are used to provide clinical services beyond the CMM process.  Services included immunizations, medication therapy management services (MTMs), adherence programs, health promotion services, and case management.    As our services continued to expand and more and more patients enrolling in them, it was time about adding some new positions.  We created a community pharmacy resident position, but quickly realized that we also needed to hire another pharmacist to oversee all of our clinical services.  Not only do these pharmacists manage our clinical services, but they serve as a resource for our dispensing pharmacists providing us with “slack resources” for more in-depth problems uncovered by the dispensing pharmacists, or providing more in-depth counseling to patients as needed.

Other features of our practice that help support our patient care services a marketing plan that we review monthly.  Every month we determine which services or practice areas we want our marketing efforts to focus on and what media we will use to “spread the word”.  We hired a marketing professional who oversees our marketing efforts.

We have remodeled our pharmacy several times in the past decade with each remodel planned to improve patient care processes. We created two patient care areas which also serve as offices for our clinical manager and our community pharmacy resident.  We expanded our dispensing counter to give our dispensing pharmacists more room for their CMM activities.  We also created a patient counseling area at the end of our dispensing counter.

We have implemented tech-check-tech services as part of a new practice model program in Iowa to free up our pharmacists to provide clinical services.  We also have implemented new technologies in the practice to improve our efficiencies including using a Parata robot, the Eyecon medication counter, an interactive voice response (IVR) system,  and automated programs that help with our medication synchronization program and help with patient selection into medicare plans.

With all of these changes, the following list provides the current patient care services we offer at Towncrest Pharmacy

Clinic Services: Med Check Program, Medication Adherence Program, Influenza and Pneumococcal Vaccinations, Zostavax Vaccination, Tdap Vaccination, Pharmaceutical Case Management (PCM), Medication Therapy Management (MTM), Nursing Home Consulting, CPAP service/Education, Ostomy Consultations, Drug Information Service, Compounding, Employer based health screenings

–Wellness Center: Cholesterol screening, Blood glucose screening, BP screening, Height and Weight, BMI

Specialized Focused: Mental Health, Wellness, Geriatrics, End of life/palliative care

As we have mentioned before, our practice has evolved to have this type of capacity to provide patient care services to all of our patients. Although it didn’t happen overnight, we realized that we had to make the initial changes to provide the foundation.