North Carolina

Pharmacist

Vol. 94, Number 3 Advancing Pharmacy. Improving Health. Fall 2014

Annual Convention Preview

October 26-28, 2014

Raleigh Convention Center, Raleigh, NC

Host Hotel: Sheraton Raleigh Downtown, Raleigh, NC See http://www.ncpharmacists.org/

for more information and to register/book hotel room

Theme: "Pharmacy's Modern Role in 2014"

Highlights

Immunization Certificate Program

MTM Certificate Program

Pragmatic Issues for NOACs

Tales from the Crypt...Well Actually, The Cath Lab

Pursuit of Provider Status

MTM & Diversity: "One Size Doesn't Fit All”

"Pharmacy's Modern Role" Panel Discussion

Key Note Address

Residency Showcase and Student Sessions

Pharmacist Impact on Core Measures

Pain Management and the Forgotten Patient

Value-Based Purchasing

Point of Care Testing, A New Opportunity for Pharmacist Services

HIV and HCV Tx Update

Challenges in Antimicrobial Stewardship

Guidelines for Cholesterol Management

Pharmacy Law Update/BOP Inspections

Immunization Update

Health-System Manager’s Forum

Pharmacist Fatigue

Hypertension Management

and much more

North Carolina Pharmacist, Fall 2014 2

North Carolina Pharmacist, Fall 2014 3

Official Journal of the North Carolina

Association of Pharmacists

109 Church Street · Chapel Hill, NC 27516

Fax 919.968.9430

www.ncpharmacists.org

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NC Assoc of Pharm

ASSOCIATION STAFF

EXECUTIVE DIRECTOR

Daniel L. Barbara, Sr., M.Ed.

MEMBERSHIP DIRECTOR

Teressa Reavis

EVENTS DIRECTOR

Sandie Holley

ADMINISTRATIVE DIRECTOR

Linda Goswick

BOARD OF DIRECTORS

PRESIDENT

Michelle Ames, Pharm.D.

PRESIDENT-ELECT

Ashley Branham, Pharm.D.

PAST PRESIDENT

Mary Parker, Pharm.D.

TREASURER

Dennis Williams, Pharm.D.

BOARD MEMBERS

Randy Angel, Pharm.D.

Andy Bowman, Pharm.D.

Paige Brown, Pharm.D.

Thomas D’Andrea, R.Ph., M.B.A.

Stephen Dedrick, R.Ph., M.S.

Lisa Dinkins, Pharm.D.

Leigh Foushee, Pharm.D.

Ted Hancock, Pharm.D.

Jennie Hewitz, Pharm.D.

Debra Kemp, Pharm.D.

LeAnne Kennedy, Pharm.D.

Kim Nealy, Pharm.D.

Becky Szymanski, Pharm.D.

North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists. An electronic version is published quar-terly at 109 Church St., Chapel Hill, NC 27516. The journal is provided to NCAP members through alloca-tion of annual dues. Subscription rate to non-members is $40.00 annually. Opinions expressed in North Carolina Pharmacist are not necessarily official positions or policies of the Association and do not necessarily represent the views and opinions of NCAP or of NCAP board members. Publication of an adver-tisement does not represent an endorsement. Noth-ing in this publication may be reproduced in any man-ner, either in whole or in part, without the express writeen permission of the publisher.

North Carolina

Pharmacist Vol. 94, No. 3 Fall 2014

Inside

From the Executive Director………………………………………………..4

From the President…………………………..………………………………...5

H.R. 4190 From the Perspective of New Practitioners………….6

New Practitioner Network Member Spotlight……………..……...9

2014 Pharmacy Residency Conference Photo Essay…….…….10

What Can We Do Without Provider Status?……….……..……...13

Pharmacists as Critical Members of the Integrated Care

Team…………………………………………………………………………...16

The Second Victim: Caring for the Caregiver………………..…...18

NCAP Calendar for Fall 2014

September 18th at 12:00 PM —Board of Directors Meeting

September 18th at 3:30 PM—Provider Status Taskforce

September 20th—Student Leadership Conference

October 3rd—2014 NC Pharmacy Leaders Forum

October 26th-28th—NCAP Annual Convention

November 20th at 12:00 PM—Board of Directors Meeting

November 20th at 3:30 PM—Provider Status Taskforce

North Carolina Pharmacist, Fall 2014 4

Fall 2014 promises to be an exciting time at NCAP.

At the start of a new school year, many of our members and

certainly our student pharmacists across the state are resuming

their roles as faculty, preceptors, and students. Our schools of

pharmacy are each in the process of implementing new pro-

grams, innovative ideas, and/or new curriculum. There is a

sense that pharmacy, not only in North Carolina, but national-

ly, is moving forward, endeavoring to keep pace with the ever-

changing landscape that is health care.

NCAP is certainly a part of the effort to ensure that

pharmacy remains at the cutting edge of health care and that

pharmacists, who have always been the trusted confidants of

and advocates for their patients, continue to be in a position to

provide the care that their patients need and deserve while

receiving appropriate recognition and compensation for doing

so. This is no small task, considering the extremely complex

environment of health care practice and reimbursement

(including the government and private sector health insurance

markets). Now, more than ever, it is essential that pharmacy

coalesce around and advocate for inclusion in the decision-

making process related to health policy and the development

and implementation of new practice models, services, and

reimbursement schema that advance quality healthcare,

streamline patient access to care, and ensure the solvency of

care providers.

To that end, and anticipating the need for the devel-

opment of solid public policy and position statements specifi-

cally tailored to the North Carolina practice environment,

NCAP has established a Provider Status Taskforce to study

the issue of state and federal level provider status efforts. By

collaborating with and learning from efforts underway at the

local, state, regional, and national level across the country and

across the associations representing various segments of phar-

macy practice, it is certain that we can work together to devel-

op and encourage the implementation of sound public policy

that is representative of both pharmacy interests and the inter-

ests of the patients pharmacy serves. The work and make-up

of this taskforce are representative of the diversity of pharma-

cy practice.

In addition to in-house efforts (as it were), NCAP is

once again actively participating in the development of the

program for the NC Board of Pharmacy-sponsored annual

Pharmacy Leaders Forum in early October. The purpose of

this forum is to provide pharmacy leaders from across the

state and across the various pharmacy disciplines an oppor-

tunity to discuss, find, and recommend solutions to issues and

challenges facing pharmacy now and in the near future. The

primary topic of the 2014 NC PLF is the “Role of Pharmacy

in NC.” Participants are tasked with considering the current

role of pharmacy in North Carolina and discussing the future

of pharmacy practice from a uniquely North Carolina per-

spective with the goal of developing clear, concise, and unify-

ing statements regarding the future of pharmacy practice that

will help guide advocacy efforts across the state in the coming

year.

Setting the stage for current and upcoming advocacy

efforts on behalf of our members and providing quality com-

prehensive information regarding both clinical and public

policy issues is the upcoming NCAP Annual Convention, a

preview of which was provided to you on the front cover of

this issue. The focus of this year’s convention is the

“Changing Role of Pharmacy,” and as you can well imagine

the diversity of subjects within that topic are nearly endless.

While providing the customary specific educational opportu-

nities related to pharmacy practice that are the hallmark of

our NCAP conventions, our speakers, presenters, and panel-

ists will attempt to help you, as participants and attendees gain

key insights into the many innovative practice models

statewide and nationally which are integral to discussing the

current and changing role of pharmacy and to gauging where

pharmacy will be in the future.

I look forward to continuing to work with you

throughout the fall season and to the exciting venues for col-

laborative discussion and learning NCAP offers. See you at

convention!

Most sincerely,

Daniel “Dan” Barbara, Sr., M.Ed.

Executive Director

North Carolina Pharmacist, Fall 2014 5

Greetings NCAP members!

I find it amazing that I am addressing you with my third jour-

nal message and more than half of my term as President of

NCAP now behind me. The calendar for the remainder of

2014 holds an extensive list of wonderful programs and

events, promising to make the last half of my term pass equal-

ly as quickly.

Convention planning continues to drive onward with our Edu-

cation Committee Co-Chairs Jenn Wilson and Sonia Everhart

providing excellent direction for programming. The theme

“Pharmacy’s Modern Role in 2014” fits perfectly with the hot

topics of HR 4190 and defining provider status for pharma-

cists now on the legislative forefront. NCAP is thrilled to have

Mollie Scott serving as our keynote speaker offering her per-

spective on this important topic. The North Carolina Alliance

for Healthy Communities (NCAHC) offers programming in

conjunction with convention, a new partnership NCAP is very

excited to see blossom. Needless to say, the annual conven-

tion offers a wealth of information relevant across all practice

settings which you will not want to miss!

Development of October’s 2014 Pharmacy Leaders Forum is

also in full swing with NCAP Executive Director Daniel Bar-

bara and Dean Ronald Ragan co-chairing the planning com-

mittee. Significant attention to the current and future roles of

pharmacy in North Carolina lies within the topics for this

meeting. Attendees will be tasked with developing a position

statement articulating the role of pharmacists in health care in

NC. The committee is excited to have a broad range of lead-

ers in pharmacy representing nearly every practice setting con-

tributing to what is destined to be a lively debate.

The annual Residency Conference held in July produced an-

other year of success. Attendance was exceptional! NCAP is

extremely grateful to Jamie Brown for his efforts and dedica-

tion to planning a truly wonderful event.

NCAP continues to work with the student groups from all NC

schools of pharmacy in an effort to finalize the “Student Phar-

macist Network” (SPN). The group intends to be a collective

student organization of NCAP representing all schools of

pharmacy, serving as a voice for our future pharmacists. A

united group of students presented to the NCAP Board of

Directors in July, showcasing extensive efforts in creating by-

laws and formal organization. I speak confidently for the Ex-

ecutive Committee and Board in expressing our enthusiasm

over expanding student involvement and excitement at formal-

izing SPN.

Provider Status and HR 4190 persist as hot topics both locally

and nationally. On a local level, NCAP’s Provider Status

Committee continues to shape up nicely under Patrick

Brown’s leadership as Chair. While national headlines report

progress across the country on the expanding definition of the

pharmacist as provider, this committee is eager to see action

in North Carolina. On a national level, APhA reports grow-

ing encouragement of HR 4190 with 31 elected officials issu-

ing their support in July alone, with a total of 94 co-sponsors.

I encourage each of you to find a way to contribute to the suc-

cess of the provider status effort by writing letters to your Rep-

resentatives or participating on a committee. As Ghandi said

best, “You must be the change you wish to see in the world.”

I look forward to seeing each of you at many of the NCAP

events this fall!

Michelle Ames, Pharm.D.

President

North Carolina Pharmacist, Fall 2014 6

by Amanda Kaye Peters, Pharm.D. and Autumn D. Carroll, Pharm.D.

H.R. 4190 was introduced in

the House of Representatives in

2014 and is more commonly known

as the Pharmacist Provider Status

Act. The bill is currently in the

Ways and Means Committee of the

House, and a companion bill is ex-

pected to be introduced in the Sen-

ate later this year. This bill repre-

sents a critically important advance-

ment in pharmacy practice, because

it seeks to increase access to clinical

pharmacy services throughout the

country. The proposed amendment

to Title XVIII of the Social Security

Act would recognize pharmacists as

health care providers, thereby allow-

ing for the expansion of clinical phar-

macy services for Medicare benefi-

ciaries residing in medically under-

served areas1. Rural and medically

underserved areas typically have a

shortage of primary care physicians,

and this disparity is expected to wors-

en with an overall projected 20,400

FTE shortage by 20202.

Healthcare systems are cur-

rently undergoing significant changes

while seeking to achieve the Triple

Aim, which includes improving care

for populations and individuals, low-

ering costs, and improving the pa-

tient experience3. The Patient Cen-

tered Medical Home (PCMH) mod-

el is a successful strategy for re-

organizing primary care that stresses

patient-centered care while allowing

each member of the healthcare team

to work at the top of his or her li-

cense. On average, a physician

spends 20.8 minutes in a face-to-face

encounter with a patient4.

During this

short amount of time, the physician

is expected to take an accurate histo-

ry, diagnose the problem, educate

the patient, and prescribe a medica-

tion. Managing chronic conditions

also requires frequent follow-up,

which may be delayed if access to

care is poor.

Pharmacists trained in am-

bulatory care are important mem-

bers of the health care team and

have the knowledge and skills neces-

sary to manage chronic conditions.

The role of pharmacists in the

PCMH has been defined by Marie

Smith to include medication therapy

management, optimization of pa-

tients’ regimens, assessing compli-

ance, and proposing cost-saving alter-

natives to current therapies5.

By uti-

lizing pharmacists in these roles, the

PCMH model allows physicians to

focus on diagnosis and treatment,

while ensuring appropriate follow-up

and long-term management by other

qualified healthcare professionals,

including pharmacists.

Although the role of phar-

macists in primary care has been

defined, there is a lack of pharmacy

presence in many primary care phy-

sician offices across the United

States. Inadequate reimbursement

has been the biggest barrier to the

inclusion of pharmacists in PCMHs.

Many pharmacists in physician offic-

es are co-funded by pharmacy

schools or grants and rely on cost-

saving analyses to show financial ben-

efit, which can take years to demon-

strate. Smaller offices in rural and

underserved areas not associated

with pharmacy schools simply cannot

afford the upfront investment of a

pharmacist salary, regardless of the

potential cost avoidance in the fu-

“Look at the world around you. It may seem like

an immovable, implacable place. It is not. With

the slightest push - in just the right place - it can

be tipped.”

― Malcolm Gladwell, The Tipping Point: How

Little Things Can Make a Big Difference

North Carolina Pharmacist, Fall 2014 7

ture. Because pharmacists are not

recognized as providers under the

Social Security Act, they cannot bill

at the level of service provided. In-

stead, the pharmacist may bill

“incident to” a physician for a five-

minute nurse visit (99211), which

averages around nineteen dollars in

reimbursement6. The management

of a complex chronic condition such

as diabetes requires more time, criti-

cal thinking, and problem-solving

than a five-minute visit allows. Ap-

proval of H.R. 4190 would allow

pharmacists to bill Medicare at the

level of service provided with the

likelihood that Medicaid and private

insurance companies would follow

suit. This change would increase re-

imbursement by approximately fifty

dollars per visit, more easily justifying

the cost of adding a clinical pharma-

cist to the patient care team.

Despite the financial barriers

associated with embedding pharma-

cists into the PCMH, several practic-

es in Western North Carolina have

incorporated Clinical Pharmacist

Practitioners (CPPs) in primary care

clinics. These pharmacists are

providing patient education, stressing

primary prevention measures, man-

aging chronic disease states, reconcil-

ing medications and coordinating

transitions of care, and leading Medi-

care Annual Wellness visits. The

CPP is a unique credential from the

NC Boards of Medicine and Phar-

macy and allows the pharmacist to

initiate, modify, and monitor drug

therapy in collaboration with a super-

vising physician7. At Mountain Area

Health Education Center (MAHEC)

Family Health Center, CPPs are im-

portant team members providing

coordinated whole person care.

CPPs manage clinics for pharma-

cotherapy consults, anticoagulation,

Medicare Annual Wellness Visits

(AWV), transitions of care, and em-

ployee wellness. MAHEC is an edu-

cational hub for medical students

and physicians training in family

medicine, OB/GYN, geriatrics, and

sports medicine, as well as pharmacy

students and pharmacists training in

ambulatory care. As recent graduates

of MAHEC and Mission’s PGY-1

ambulatory care pharmacy residency

program, we had the fortuitous op-

portunity to work in this collabora-

tive environment and see firsthand

the impact pharmacists can have in

primary care.

We received many consulta-

tions for the chronic disease state

management during our year at MA-

HEC, many of which required

monthly, and sometimes weekly fol-

low-up visits. One patient in particu-

lar, a 31-year-old female with uncon-

trolled type 2 diabetes, was being

seen by one of the resident physi-

cians. This patient was extremely

high risk, with established coronary

artery disease, a current smoker with

COPD, and peripheral neuropathy.

Prior to her visit with a pharmacist,

her most recent A1c was 11.4% on

Lantus 90 units twice daily and Hu-

malog 42 units with every meal. Be-

cause this patient was on extremely

high doses of insulin, the resident

wanted to transition to insulin regular

U-500 but was hesitant to do this on

her own. During a joint visit, we were

able to transition the patient to U-

500, and provide essential education

on administration and dosing. We

also provided education for the pa-

tient about all of her medications

and lifestyle changes that she could

make to improve her health. Now

the patient’s blood sugars are much

better controlled with an A1c of

8.2%, and the patient is pleased with

the switch. In this situation, potential-

ly fatal errors in dosing and admin-

istration may have been avoided with

a high-risk medication, and better

glycemic control was achieved

through collaboration with a pharma-

cist available on site. Moreover, this

team approach improved elements

of the Triple Aim by improving the

patient’s health along with her pa-

tient experience.

As new practitioners

searching for employment, it is frus-

trating to appreciate the potential

impact of pharmacists in primary

care only to face a financial road-

block to finding employment in this

area. Many physicians in Western

North Carolina, especially those

trained at MAHEC, realize the im-

portance of H.R. 4190 to increasing

patient access to pharmacists. In the

words of Dr. Jeff Heck, CEO and

family physician at MAHEC and

Dean of the UNC School of Medi-

cine’s Asheville Campus, “Primary

care will thrive and our patients will

be healthier if every practice has a

clinical pharmacist.” Imagine the

impact we could make on patient

health outcomes if all physicians had

the opportunity to see the value of a

pharmacist at their practice site.

The world of healthcare can

feel like an immovable, implacable

place, especially to new practitioners.

H.R. 4190 carries the promise of

significantly impacting the delivery of

healthcare and changing pharmacy

practice, allowing pharmacists to

have a seat at the table that we have

never had before. We feel we are at

a tipping point, and H.R. 4190 is the

push in the right direction to advance

clinical pharmacy services by dupli-

North Carolina Pharmacist, Fall 2014 8

cating the types of experiences we

had as pharmacy residents into rural,

underserved areas.

For more information about

H.R. 4190 and provider status for

pharmacists, go to www.ashp.org and

www.pharmacist.com. Links are

available on these websites with in-

formation regarding how you can

reach out to your own representa-

tives in Congress.

The authors would like to

thank Mollie Scott, Pharm.D.,

BCACP, CPP, for her review of our

manuscript.

References

1“To amend title XVIII of the

Social Security Act to provide

for coverage under the Medicare

program of pharmacist ser-

vices.” (H.R. 4190).

GovTrack.us. Retrieved May 30,

2014, from https://

www.govtrack.us/congress/

bills/113/hr4190

2“Projecting the Supply and De-

mand for Primary Care Practi-

tioners Through 2020 In Brief”.

US Department of Health and

Human Services. Retrieved May

30, 2014 from http://

bhpr.hrsa.gov/healthworkforce/

index.html.

3Institute for Healthcare Im-

provement. IHI Triple Aim

Initiative. http://www.ihi.org/

Engage/Initiatives/TripleAim/

Pages/MeasuresResults.aspx.

Accessed 8/12/2014.

4“15-Minute Visits Take A Toll

on the Doctor-Patient Relation-

ship”. Kaiser Health News. Re-

trieved July 17th, 2014 from

http://www.kaiserhealthnews.org/

stories/2014/april/21/15-minute-

doctor-visits.aspx.

5Smith M, Bates DW, Boden-

heimer T, et. al. Why Pharma-

cists Belong In The Medical

Home. HEALTH AFFAIRS.

2010;29(5): 906–913

6Centers for Medicare & Medi-

caid Services. Physician fee

schedule. http://www.cms.gov/

apps/physician-fee-schedule.

Accessed 8/13/14

7NCBOP: Clinical Pharmacist

Practitioners. http://

www.ncbop.org/

pharmacists_cpp.htm. Accessed

8/13/14.

8Gladwell, M. (2000). The tip-

ping point: How little things can

make a big difference. Boston:

Little, Brown.

North Carolina Pharmacist, Fall 2014 9

New Practitioner Network Member Spotlight

Tasha Woodall, Pharm.D., CGP, CCP

Tasha Woodall received her Pharm.D. from Purdue University in West Lafayette,

Indiana. Upon graduation, she came to Asheville, North Carolina to complete her

PGY1 Pharmacy Practice Residency in Ambulatory Care with Mission/MAHEC.

She earned her Certification in Geriatric Pharmacy (CGP) in 2013. Dr. Woodall

currently serves as Assistant Professor of Clinical Education for the UNC Eshelman School of Pharmacy and As-

sociate Director of Pharmacotherapy in Geriatrics at Mountain Area Health Education Center (MAHEC) in Ashe-

ville. At MAHEC, her practice sites include two continuing care retirement communities, where she works with

residents in the ambulatory setting.

Dr. Woodall became involved in NCAP to form a closer network with other progressive-minded pharmacists. She

recognizes the value of grassroots support that can be fostered at the state level, especially for legislation such as

H.R. 4190, which “has the potential to so greatly advance the level of care pharmacists are able to provide.” She

feels that NCAP enables her to learn from others how to work alongside pharmacist leaders to leave a legacy of

excellence for future generations of pharmacists.

Her piece of advice to other new practitioners: “Patience is a virtue: just because you know the extent of your own

knowledge base doesn’t mean other health care providers are equally as familiar. It takes time to build a trusting

relationship that can serve as a solid foundation for flourishing team-based care.”

North Carolina Pharmacist, Fall 2014 10

15th Annual Pharmacy Residency

Conference

Steve Kearney, Pharm.D., Co-Moderator, rep-

resenting Pfizer (co-sponsor of the 2014 Phar-

macy Residency Conference) introduces the

morning program.

Jamie Brown, Pharm.D., Co-Moderator and Chair of the NCAP

Residency Committee, introduces the afternoon program.

NCAP Executive Director Dan Barbara, M.Ed. encour-

ages residents to become and remain actively involved

in their state association and in the legislative process.

Rowell Daniels, Pharm.D., M.S.,

Director of Pharmacy, UNC

Medical Center and Executive As-

sociate Dean of UNC Eshelman

School Pharmacy, delivered the

Keynote Address entitled

“Punctilious Leadership.”

North Carolina Pharmacist, Fall 2014 11

Steve Kearney, Pharm.D., Co-Moderator, rep-

resenting Pfizer (co-sponsor of the 2014 Phar-

macy Residency Conference) introduces the

morning program.

The Fifteenth Annual Pharmacy Residency Conference boasted record attendance and participation resulting from the efforts of

the NCAP Residency Committee, the participating preceptors, and the encouragement of all participating schools of pharmacy.

Program roundtables for residents (led by the NCAP

New Practitioner Network) focused on “Getting the

Most Out of the Residency Year.”

Preceptors discussed “Developing Successful Residents

and Programs.”

Mary H. Parker, Pharm.D.,

Past-President of NCAP

(representing the NCAP

Executive Committee),

discussed “Advancing

Pharmacy Practice: Where to

Begin?”

North Carolina Pharmacist, Fall 2014 12

North Carolina Pharmacist, Fall 2014 13

What Can We Do Without Provider Status?

by Courtenay Gilmore Wilson,

Pharm.D., BCPS, CDE, CPP

Provider status remains one of

the main obstacles to fully integrating

clinical pharmacy services into ambula-

tory healthcare settings. The 2011 Re-

port to the Surgeon General highlighted

pharmacists in physician practices as a

way to increase access to care, improve

patient outcomes, and reduce healthcare

costs1. To meet these goals, the Report

stresses the importance of recognizing

pharmacists as providers as well as re-

forming payment structures to allow for

reimbursement of pharmacists’ cognitive

services. In March 2014, legislation was

introduced in the US House of Repre-

sentatives that seeks to recognize phar-

macists working in Medically Under-

served Communities as providers, which

would greatly expand the role of the

clinical pharmacist on the healthcare

team. However, even in the absence of

provider status, there are several options

available for pharmacists to generate

revenue for a physician practice.

Currently, many pharmacists

practicing in physicians’ offices utilize

the “incident to” method. This allows

pharmacists and other non-physician

healthcare providers (i.e. nurses) to bill

for their services under the physician’s

name2. For pharmacists, this method of

billing is limited to a Level 1 or 99211

visit, which is reimbursed at a rate of

about $193. With such low reimburse-

ment potential, billing solely with the

Level 1 visit is not a financially viable

way to sustain clinical pharmacy services.

In 2011, the Medicare Annual

Wellness Visit (AWV), which focuses

heavily on preventive care services, was

introduced as part of the Affordable

Care Act (ACA). This visit may be con-

ducted by any healthcare provider work-

ing under the direct supervision of a

physician, including pharmacists4. Aver-

age reimbursement rates are $160 for

the initial AWV and $110 for subse-

quent AWVs, presenting a significant

opportunity for pharmacists to generate

revenue for a physician’s office3. War-

shany, et al. recently described the im-

plementation of a pharmacist-

administered AWV clinic that success-

fully billed for AWVs conducted by the

pharmacist5.

In January 2013, Medicare in-

troduced new Transitional Care Man-

agement (TCM) codes in efforts to im-

prove care coordination and reduce re-

admissions6. Two required components

for utilizing these codes are: 1) commu-

nication with the patient within two days

of hospital discharge; and 2) medication

reconciliation6. Pharmacists may com-

plete these required components, allow-

ing for the physician to employ the

TCM code for the office visit, which is

reimbursed at a level significantly higher

than the Level 4 or Level 5 office visit3.

Due to the aging population

and the expansion of health insurance

coverage under the ACA, the U.S. is

faced with an expected shortage of pri-

mary care physicians. Consequently,

team-based care models, including the

Patient Centered Medical Home

(PCMH) and Accountable Care Organi-

zation (ACO), are gaining momentum as

a way to better utilize non-physician ser-

vices. These models offer new opportu-

nities for pharmacists in the ambulatory

care setting. In these settings where pay-

ment is driven by performance, the

pharmacist is the team member respon-

sible for maximizing patient outcomes

with comprehensive medication manage-

ment6. The 2014 Ambulatory Care Sum-

mit hosted by the American Society of

Health-System Pharmacists (ASHP)

released several briefing documents,

including one regarding outcomes evalu-

ation. This report outlines 23 of the 33

ACO core measures that may be im-

pacted by a pharmacist7. Thus, pharma-

cists are important members of the team

who may help achieve and maintain

these designations.

Achieving provider status re-

mains a priority for many pharmacists.

Until this occurs, we must take ad-

vantage of existing revenue streams that

allow pharmacists to establish a presence

in physician practices. By doing so, we

will be well positioned to capitalize on

the opportunities that provider status

will offer.

1Giberson S, Yoder S, Lee MP. Improving

Patient and Health System Outcomes through

Advanced Pharmacy Practice. A Report to the

U.S. Surgeon General. Office of the Chief

Pharmacist. U.S. Public Health Service. Dec

2011.

2Scott MA, Hitch WJ, Wilson CG, Lugo AM.

Billing for pharmacists’ cognitive services in

physicians’ offices: Multiple methods of reim-

bursement. JAPhA 2012; 52:175-180.

3Physician fee schedule. www.cms.gov/apps/

physician-fee-schedule/search/search-

criteria.aspx. Accessed February 10, 2014.

4Centers for Medicare & Medicaid Services.

Quick reference information: The ABCs of

providing the Annual Wellness Visit. http://

www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/

MLNProducts/downloads/

AWV_chart_ICN905706.pdf. Accessed Febru-

ary 10, 2014.

5Warshany K, Sherrill CH, Cavanaugh J, et al.

Medicare annual wellness visits conducted by a

pharmacist in an internal medicine clinic.

AJHP 2014;71:44-49.

6Centers for Medicare & Medicaid Services.

Transitional Care Management Services. http://

www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/

MLNProducts/Downloads/Transitional-Care-

Management-Services-Fact-Sheet-

ICN908628.pdf. Accessed February 10, 2014

7Patient-Centered Primary Care Collaborative.

The Patient Centered Medical Home: Integrat-

ing Comprehensive Medication Management to

Optimize Patient Outcomes. June 2012. http://

www.pcpcc.org/sites/default/files/media/

medmanagement.pdf Accessed February 10,

2014

8Kliethermes MA. Outcomes evaluation: Striv-

ing for excellence in ambulatory care pharmacy

practices. ASHP Ambulatory Care Conference

and Summit. March 2014.

North Carolina Pharmacist, Fall 2014 14

North Carolina Pharmacist, Fall 2014 15

North Carolina Pharmacist, Fall 2014 16

Pharmacists as Critical Members of the Integrated

Care Team by Samuel Stolpe, Pharm.D., Director,

Pharmacy Quality Alliance (PQA) & Maria

Scalatos, Pharm.D., Executive Fellow, PQA

The future of quality patient care

relies on learning from the success stories

and best practices of today in order to

shape the health care system of tomorrow.

Six Medicare plans were recently acknowl-

edged by the Pharmacy Quality Alliance

(PQA) for excellence in medication safety,

based on the Centers for Medicare & Medi-

caid Services’ (CMS) Star Ratings. The Chi-

nese Community Health Plan of California,

Humana’s Medicare plan in Illinois, and

four Kaiser Permanente regions (California,

Colorado, Hawaii and the Mid-Atlantic

region) were recognized for their achieve-

ment of a 5-star rating on the PQA

measures of medication safety and appro-

priate use that are included in the CMS Star

Rating Program for Medicare plans, as well

as achievement of at least a 4.5-star sum-

mary plan rating. The six awardees spoke to

the best practices that contribute to their

outstanding medication management, and

ultimately ensure optimal medication out-

comes.

With the advent of new quality

incentive structures put in place through

federal government programs, health plans

and PBMs are becoming increasingly fo-

cused on medication use quality. Pharma-

cists can contribute meaningfully to the

quality goals of these organizations as a

member of a virtual integrated care team.

Of the fifteen quality measures used by

CMS to evaluate Medicare Part D plans in

2014, five relate to medication safety and

adherence. These measures account for

nearly 50% of a given Part D sponsor’s star

rating, and represent a potential impact area

for pharmacist intervention. In fact, in a

systematic review of interventions to im-

prove adherence to medications for cardio-

vascular disease and diabetes, Cutrona, et

al. found that interventions in a pharmacy

conducted by a pharmacist improved medi-

cation adherence more than any other pro-

fessional in any other setting.

This represents a tremendous

opportunity for pharmacies. But to take

advantage of this opportunity, pharmacists

must transition their approach from a mind-

set of quality measurement resistance, to

quality measurement engagement. To facili-

tate this transition to becoming an engaged

partner, many community pharmacies are

using EQuIPP, the Electronic Quality Im-

provement Platform for Plans & Pharma-

cies. EQuIPP is a performance information

management platform that provides unbi-

ased, benchmarked data on the quality of

medication use to both health plans and

community pharmacies. It allows pharma-

cists at an individual store or corporate lev-

el, to see exactly how individual pharmacies

are performing on the medication use quali-

ty measures that matter to payors.

The unique position of pharma-

cists in the community setting grants en-

hanced patient access and excellent oppor-

tunities for medication management. Phar-

macists are increasingly viewed as a key

collaborative partner. Managing the quality

of medication use is now a recognized com-

ponent of ensuring optimal care. Collabo-

ration on shared quality targets and goals

connects pharmacies to other partners

along the care continuum.

Pharmacies are not exempt from

quality measurement. Health plans and

PBMs are already moving forward with

incentive and penalty programs for pharma-

cies based on quality performance. Phar-

macists are an integral part of the solutions

to meet payors’ quality needs. Being proac-

tive in this new quality environment is a

must. Moving forward, pharmacists should

look to initiate dialogue, establish and nur-

ture relationships, and seek opportunities to

deliver point-of-care interventions that drive

quality. Payors are not the only health care

organizations with quality goals. Other

health care organizations have performance

measures that they are accountable for that

can be directly influenced by pharmacists.

In addition to making contributions to

health plan quality goals, pharmacists can

reach out to local Accountable Care Organ-

izations (ACOs), and Patient Centered

Medical Homes (PCMHs) to look for col-

laboration points. Examples of areas that

pharmacists can impact include ACO

measures of medication reconciliation and

influenza immunization, or helping them

reach quality measure goals related to cho-

lesterol, A1Cs, and blood pressure through

appropriate medication management. Of

the 33 quality measures a federal Medicare

Shared Savings Program ACO has to meet,

at least 11 of them can be influenced by

community pharmacists. Focus should be

centralized on interventions that drive spe-

cific goals; communicating ways in which

pharmacists influence the safe and effective

use of medications and reach these goals

will lay the foundation for the pharmacist’s

role in integrated care teams.

1Pharmacy Quality Alliance. PQA Recognizes

Six Medicare Plans for Excellence in Medication

Use and Safety Based on CMS’ Star Ratings

[Press release]. http://pqaalliance.org/images/

uploads/files/Press%20Release%

202014_QualityAward.pdf. Accessed June 30,

2014.

2Cutrona S, Choudhry N, Shrank W, et al.

Modes of delivery for interventions to improve

cardiovascular medication adherence. The

American Journal Of Managed Care [serial

online]. 2010;16(12):929-942. Available from:

MEDLINE, Ipswich, MA. Accessed June 30,

2014.

3Center for Medicare and Medicaid Services.

ACO Quality Measures. http://www.cms.gov/

Medicare/Medicare-Fee-for-Service-Payment/

sharedsavingsprogram/Downloads/ACO-Shared-

Savings-Program-Quality-Measures.pdf. Ac-

cessed June 30, 2014.

North Carolina Pharmacist, Fall 2014 17

North Carolina Pharmacist, Fall 2014 18

The Second Victim: Caring for the Caregiver by Mariel Pereda, Pharm.D. Candidate,

Class of 2015, UNC Eshelman School of

Pharmacy

A medical error happens in

your organization. The first victim is the

patient and/or his/her family members.

Accordingly, many health care organiza-

tions have mechanisms in place to pro-

vide support to these first victims.

But what about the second victim?

Who is the second victim?

The second victim is the health

care provider involved in a medical er-

ror or patient event who has been trau-

matized by the event.1 The range of

effects on a provider can be from mild

and transient, to serious and persistent.

The degree to which a health care

worker is affected is not necessarily re-

lated to the severity or outcome of the

error. Many factors affect where an in-

dividual falls on the spectrum of reac-

tions, including individual characteris-

tics, cultural or environmental factors,

and the significance of the event itself.

In 2011, ISMP published the

story of a nurse who was involved in a

medication error that resulted in the

death of her critically ill patient. The

nurse was fired from the hospital where

she had worked for 27 years. Her state

licensing board issued a four-year pro-

bation period during which she was

required to be supervised during all

medication administration activities.

Despite her years of experience, she

was unable to find employment as a

nurse following the highly publicized

event. Seven months after the event,

she took her own life.2

Healthcare workers dedicate

their lives to helping others and can

become distressed when their mistake

results in harm. The case above high-

lights one extreme consequence. How-

ever, minor traumas can occur even

more frequently. These less extreme

responses are also harmful, since they

can affect an individual’s well-being and

professional performance.

After being involved in an er-

ror, second victims can experience both

emotional and physical distress.3 Com-

mon emotional and physical symptoms

are presented in Table 1.

It is not uncommon for second

victims have doubts about their compe-

tence and abilities following a medical

error. These doubts can lead to second-

guessing, difficulty making decisions,

requests to leave clinical care areas, or a

desire to leave their place of employ-

ment or profession entirely.

Many patient safety and quality

organizations recognize the second vic-

tim phenomenon, including the Agency

for Healthcare Research and Quality,

Institute for Healthcare Improvement,

National Quality Forum, National Pa-

tient Safety Foundation, The Joint

Commission, and The American Socie-

ty for Health Risk Management. Addi-

tionally, a number of medical and nurs-

ing organizations have published studies

and resources related to the topic, in-

cluding the American Medical Associa-

tion and the American Nurses Associa-

tion.

How do we care for second victims?

Just as there are “rights” of

medication safety, there are also rights

of the second victim. An easy acronym

to help you remember these is

“TRUST,” which stands for:1

T – Treatment that is just. The first step

in helping the second victim is acknowl-

edging that the second victim exists.

Second victims deserve not to be aban-

doned by their organization, managers,

and peers. Health care delivery occurs

in a complex system, and we cannot

assign full responsibility for a medical

error to one person.

R – Respect. Give second victims the

respect they deserve as human beings as

well as healthcare professionals. Sham-

ing remarks or actions are neither ap-

propriate nor constructive.

U – Understanding and compassion. Following a medical error, leadership

and peers should reach out to the indi-

vidual involved. Second victims often

need someone who understands their

situation, who is familiar with their

work, to empathize with them.

S – Supportive care. Second victims

should be encouraged to make use of

counseling services. Additionally, if the

situation calls for it, the individual

should be directed to legal services. It is

important to know how and where to

refer someone within and outside your

organization. Details on support pro-

grams for second victims follow in the

next section.

T – Transparency and the opportunity to contribute. An important part of

healing is the opportunity to participate

in the learning that takes place after the

event. Allow the second victim to pro-

vide insight into the event and potential

solutions moving forward.

Support Programs for Second Victims

Scott et al. identified a three-

tiered model for second victim support

systems.4

The first tier is the immediate

“emotional first aid.” This occurs at the

local or departmental level. The second

tier provides more aggressive support,

connecting individuals with patient safe-

ty or risk management experts. The

third tier involves referral to profession-

al counseling services. Some individuals

may only require the first tier of sup-

port while others may need a higher

level. Regardless, all levels should be

readily available.

The current body of literature

provides little guidance on what specific

elements to include in an effective sec-

ond victim support program. However,

some key elements to consider are:

Timing of Support

The initial period after the event is the

most crucial. A manager or supervisor

North Carolina Pharmacist, Fall 2014 19

Table 1:

Emotional Symptoms3 Physical Symptoms

3

Frustration Extreme fatigue

Anger Sleep disturbances

Extreme sadness/depression Increased blood pressure

Self-doubt/loss of confidence Muscle tension

Anxiety about returning to work Rapid heart rate/breathing

Difficulty concentrating

Flashbacks

should provide support immediately. A

protocol should make clear regarding

who is formally responsible for reach-

ing out to the second victim.

Relief from Clinical Duties

What is the protocol in the event that

the second victim is unable to return to

work in the days following the event? A

plan should be in place to address relief

from clinical duties in the aftermath of

a medical error.

Legal Concerns

Legal consultation should be sought

when building a program to ensure the

protection of conversations. Managers

should familiarize themselves with these

legal requirements.

Varying Levels of Support

Programs should provide varying levels

of support, ranging from peer discus-

sion groups to formalized counseling

services. The three-tiered model is one

way to structure a support program, but

other ways may be more appropriate

for your organization.

A Hospital-wide Commitment

A strong support program can only be

achieved with the support of hospital

leadership. Provide training to manag-

ers and employees on how to support

second victims.

One example of a well-

developed second victim response pro-

gram is the University of Missouri

Health System’s for YOU team, made

up of health care clinicians trained to

assist second victims. A dedicated pager

line connects individuals in need with a

team member 24/7. When peer sup-

port is not enough, the program can

connect individuals with an employee

assistance program or a clinical psy-

chologist.5

The program also provides

brochures for staff and their families to

help them understand the second vic-

tim experience. Additionally, the pro-

gram’s website features a “Share Your

Story” portal through which users are

invited to anonymously share their ex-

periences with or as second victims.5

This story-telling tool is an important

way to learn valuable lessons about the

second victim experience.

How do I get started?

Developing or enhancing your sec-

ond victim support program will take

time. Here are a few important first

steps that you can get started on today.

Identify which resources already exist in

your organization.

Identify who should be involved in

building a second victim program.

Develop a policy on caring for second

victims.

Develop training materials to introduce

the topic to staff.

North Carolina Pharmacist, Fall 2014 20

1Denham C. TRUST: The 5 Rights of

the Second Victim. Patient Saf. 2007;107-19

2ISMP Medication Safety Alert. July

2011.

3Scott SD, Hirschinger LE, et al. The

natural history of recovery for the

healthcare provider “second victim”

after adverse patient events. Quality & Safety in Health Care. 2009;325-30

4Scott SD, Hirschinger LE, et al. Caring

for Our Own: Deploying a Systemwide

Second Victim Rapid Response Team.

The Joint Commission Journal on Quality and Patient Safety. 2010;36:233

-40.

5University of Missouri Health System.

Understanding Second Victims . http://

www.muhealth.org/secondvictim

Ms. Pereda authored this paper during

her medication safety clerkship at Sec-

ondStory Health, LLC in Carrboro,

NC, June 2014. Correspondence can

be addressed to John Kessler, PharmD

at jkessler@secondstoryhealth.com

North Carolina Pharmacist, Fall 2014 21

North Carolina Pharmacist, Fall 2014 22