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
(1) Initiating Services Methods (2) Accessing internal information (3) Accessing external information • Telephone interviews were conducted (4) Scheduling patients with pharmacists from all 73 (5) Performing patient interview inconsistent pharmacies to identify (6) Developing assessment implementation barriers (7) Developing a care plan • The pharmacy service was divided into (8) Documenting 10 action steps to guide the interview (9) Coordinating care with network and • Transcribed barriers were assigned to medical home (10) Performing follow-up each action step using an inductive Other barriers approach 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 Difficulty locating patient data information Difficulty using attribution reports Accessing external Difficulty obtaining information from primary care providers information 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 Phone vs. face-to-face interview 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 Challenges, % Reported, n Total N=146 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 0 0 Developing a Care Plan 0 0 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 Each region has a network pharmacist providing technical assistance to Technical pharmacies. Assistance Conduct Network pharmacists provided education about clinical management Educational of patients (e.g., disease state management, delivering information Outreach about naloxone). A university-based pharmacist visited pharmacies to answer questions about program requirements and set implementation goals. Audit and Quarterly reports were delivered to pharmacies about performance Feedback metrics. Academic pharmacists audited documentation quality and provided feedback/suggestions to pharmacies.
Findings (cont.) Strategy Description Tailor Educational approaches were adjusted for pharmacists based on their Strategies familiarity with clinical management of patients. Capture Some pharmacies identified lessons learned about delivering services and Share and coordinating care with other providers. Local Network staff identified these lessons learned and shared them with Knowledge other 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.
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