Didactic: Examples of Ambulatory Care

Ambulatory care

provision of integrated, accessible health care services by pharmacists who are accountable for addressing medication needs, developing sustained partnerships with patients, and practicing in the context of family and community

What services are commonly provided by am care clinical pharmacist?

- access services or care coordination

- chronic disease management

- comprehensive medication management

- drug information

- healthcare provider education, immunization screenings, and administration

- medication reconciliation

- MTM

- National Committee for Quality Assurance (NCQA) reporting

- ordering, interpreting, and monitoring lab tests

- participate in transitions of care, annual wellness visits, and group visits

- participate in the physician quality reporting system (PQRS)

- patient education and counseling

- preventative care or wellness screenings

- refil; authorization

- research and clinical trials

- shared visits with other healthcare providers

What services does the presenter have as an ambulatory care pharmacist?

- chronic disease state management per clinical protocol

- annual wellness visits (free to patients - Medicare)

- patient care through education/ counseling (med education, adherence, lifestyle)

- consult for other health care professionals

- medication access

- population health/ anticoagulation

What is a clinical practice protocol?

Most states (Ga) allow pharmacists to independently modify drug therapy under an approved protocol in conjunction with a physician (CDTM)

are CDTMs universal?

No, the physician and pharmacist come to an agreement on what they are comfortable with

Drug therapy modifications

adjustments of dosages, dosage schedules, and/or medications

Collaborative practice agreement

A formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions (hospital setting)

CPA vs CDTM

****

Statewide protocol

Some states allow pharmacists to prescribe under a statewide protocol with no special licensure needed, but they may require CE requirements

What kind of services are covered under Statewide Protocols?

- hormonal contraception

- travel health

- immunizations

- tobacco cessation

- naloxone

- chronic conditions- Idaho

What is Clinical Scope?

The care provided, protocols allowable - what are you able to do?

What is Payment?

Insurance! CMS regulated, reproducibility of services- we cannot directly bill unless we have a provider status

What is a major challenge for ambulatory care pharmacy?

lack of state or national provider status

CA / OR allow

pharmacists to bill Medicaid

CPT code 99201

new patients (~10 min)

CPT code 99212

established patients (~10 min)

CPT code 90471

immunization administration

Depending on the _________, pharmacist reimbursement may be equivalent vs _________ % the physician rate.

state, 85

How can pharmacists contribute to billable services?

under the supervision of the provider, physician bills for services pharmacists providers under their supervision

What services can pharmacists provide/bill under a physician?

- annual wellness visits

- chronic care management (CCM)

- remote patient monitoring (RPM)

- continuous glucose monitoring (CGM)

Supervision is ______ or _______ depending on the service provided.

direct; indirect

CMS

Centers for Medicare and Medicaid Services

Who defines supervision types (general/ direct)?

CMS

General supervision (Indirect)

When the service is not personally performed by the billing provider, it is performed under his/her overall direction and control, although the provider's presence is not required (not in the building but available)

Direct supervision

The provider must be present in the office suite and immediately available to furnish assistance and direction

Describe Medication management per protocol CDTM at SJ/C Eisenhower

diabetes, HPT, hyperlipidemia, osteoporosis, mental health, and anticoagulation support via medication selection/ initiation/titration, lab monitoring, in-person and phone follow-up (CCM, CGM, RPM, billing when possible), medication and device education (insulin, GLP1/PCSK9, CGM devices)

Describe drug information/ provider consults at SJ/C Eisenhower

accessible to 6 physicians / 1 NP during clinic for consults on complicated med issues like insulin dosing surrounding bariatric surgery, contraception choice in anticoagulated patients at high risk for repeat thrombosis experiencing viaginal bleeding, opioid tapering and conversions, mental health medication therapy plans, drug interactions with Paxlovid and other high-risk DDI meds

Describe annual wellness visits at SJ/C Eisenhower

annual visits to update patients' personalized prevention plan to help prevent disease and disability based on individual health and risk factors.

Pharmacists are able to conduct and bill for ....

AWV under the direct supervision of the provider

AWVs present an opportunity for

pharmacists to establish rapport with patients and physicians to promote future collaboration and optimization of pharmacotherapy regimens

Medication access assistance

- patient assistance programs

- prior authorizations

- therapeutic conversion to affordable therapy (4$ list or free)

- design medication regimens with reliable access

Transition of care calls

clinical phone calls to recently discharged patients

What is included in transition of care calls?

- med recs

- understanding the reason for admission

- reduction of readmission rates

- optimized billing for the provider hospital follow-up visit

Anticoagulation roles

- provider-based outpatient department

- adjust warfarin and LMWH

- periprocedural planning

- pharmacists see 20-35 patients daily

Population health is

contracted for SJ/C employees

What is included in population health?

- diet/ lifestyle counseling for HPT and hyperlipidemia

- pharmacotherapy recommendations for providers

What is a limit to pharmacotherapy recommendations to providers for population health?

not having direct access to providers

SJ/C Hepatitis C clinic

pharmacist-run clinic under CPA with supervising physician

What the pharmacist's role at a hepatitis C clinic?

choose medication to treat, give vaccinations, monitor labs, and side effects during treatment, adjust other medications that interact with DAA, promote effective screening for HCV/HIV

Hep C clinics are sustainable through

340B pricing

What training/ credentials are needed?

- residency training (PGY2 in am care)

- board-certified am care pharmacist (BCACP)

- additional certifications such as Certified Diabetes Educator (CDE) or anticoagulation board certification

- Ga CDTM with Board of Pharmacy