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#FSHP2019 #FSHP2019

Paul W. Bush, PharmD, MBA, BCPS, FASHP Future of in the Chief Pharmacy Officer Healthcare Setting Duke University Clinical Professor University of North Carolina Eshelman School of Pharmacy Professor of Pharmacy Practice Campbell University College of Pharmacy and Sciences

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#FSHP2019 #FSHP2019 Learning Objectives Disclosure 1. Describe the characteristics of an optimal I do not have (nor does any immediate family member pharmacy service have): 2. Differentiate management – a vested interest in or affiliation with any corporate models offering financial support or grant monies for this continuing education activity 3. Understand the evolution of pharmacy practice – any affiliation with an organization whose models philosophy could potentially bias my presentation 4. Identify the pharmacy team’s role and deployment in population health management 5. Review future medication management demands and workforce trends to ensure a successful pharmacy service line.

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#FSHP2019 Duke University Hospital #FSHP2019

• Academic medical center of the Duke University Duke University is a world-class hospital and network supported by outstanding and renowned clinical Health System which includes 3 faculty, nurses and care teams. Duke's services span the full as well as services such as , home care continuum of care, from primary care to medical and surgical and , diagnostic services, & health & wellness specialties and , all dedicated to putting our patients at the forefront of everything we do. • Provides an environment to facilitate research and education activities as services to our patients, their loved ones and each other • Over 8,000 employees inclusive of 950+ residents, 40 hospitalists, and over 2000 volunteers • In partnership with over 1,400 that are employed by the faculty practice group, PDC

Duke University Hospital Duke Regional Hospital Duke Raleigh Hospital

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#FSHP2019 #FSHP2019 Duke University Hospital

• Care across the life continuum including highly specialized, complex care, such as: • Stem cell/bone marrow transplant • Pediatric cardiac intensive care • Comprehensive Cancer Center • Level 1 Trauma Center • Solid Organ Transplant • TJC Disease specific accreditation for VAD and stroke

DEPARTMENT OF PHARMACY

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#FSHP2019 #FSHP2019 Annual Report Duke Pharmacy Mission and Vision

pharmacy.duke.edu

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#FSHP2019 #FSHP2019 Patient-Centered Staff Deployment

• Inpatient • Team-based • Service-based • Unit-based • • Interdisciplinary team-based • -based CHARACTERISTICS OF AN • Refill management OPTIMAL PHARMACY SERVICE • Population health

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#FSHP2019 #FSHP2019 Clinical Services

• Admission and discharge care transitions • Ambulatory prescription dispensing pharmacies • Medication history and reconciliation • Specialty pharmacy • Discharge coordination and education • Ambulatory pharmacies • Anticoagulation • Clinic support pharmacy • Therapeutic monitoring • Infusion center pharmacies • Comprehensive medication management • Investigational drug/research pharmacy • Rapid response and resuscitation • Antimicrobial Stewardship • Clinical service

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#FSHP2019 #FSHP2019 Programs and services Committees • Center for Medication • Prior authorization • Pharmacy Credential & • Work Culture Committee Policy and Safety service Privileging Committee • Employee Activities • • Medication assistance • Pharmacy Research Committee Diversion Prevention program Committee • • Nutritional support • Meds to Beds Quality Oversight • Pharmacy Education Committee • Transplant pharmacy • Pharmaceutical Committee services utilization management • Shortage Management • Antimicrobial program • Stewardship • Revenue management Professional Development • Service • Information systems – • Repackaging Service Willow and Beacon teams

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#FSHP2019 #FSHP2019 Health System Committees Training and Education Programs • Pharmacy Governance • Pharmaceutical • Pharmacy and Contracting and Supply • ACPE-approved continuing education Chain Value Analysis Medication • Residency training program Management Committee • Technician training program • Formulary and • Smart Pump Quality and Informatics Utilization Oversight • Student clerkship experiential training Committee • Medication Safety • Residency Program • Sterile Preparations Directors Oversight Committee

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#FSHP2019 #FSHP2019 Layered Learning Extends Services Research

precept pharmacy residents, who teach and precept pharmacy students • Program designed to enhance Pharmacy staff and resident knowledge and participation in • Pharmacy residents and students deliver direct patient care research • Identify and arrange extra-departmental research • Increases the staff resources available to provide services such as support resources for Pharmacy staff and residents medication histories and • Statistical consulting services reconciliation, facilitating bedside delivery of discharge , • Site-Based Research/Institutional Review Board and patient education on new and high risk medications • Other support, as needed

• Results in higher quality of patient care for a greater number of patients and increased patient satisfaction

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#FSHP2019 #FSHP2019 Medication Management Services • A spectrum of patient-centered, pharmacist provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and with the goal of improving health outcomes • Includes the following elements: • Patient‐centered approach to care – the service is individualized for a specific patient, focuses on the patient's needs and concerns, and involves the patient in the care process • Assessment of medication appropriateness, effectiveness, safety and adherence. Consideration should be given to accessibility and cost of medication MEDICATION MANAGEMENT • Collaborative approach to care that involves the patient, caregiver(s), pharmacists, and other healthcare providers • Focus on health outcomes • Pharmacists deliver Medication Management Services using the Pharmacist's Patient Care Process

https://jcpp.net/wp-content/uploads/2018/05/Medication-Management-Services-Definition-and-Key- Points-Version-1.pdf 21 22

#FSHP2019 #FSHP2019 Comprehensive Medication Pharmacist’s Patient Care Process Management

• Defined as the standard of care that ensures each patient’s medications (i.e., prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended • CMM includes an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes • This all occurs because the patient understands, agrees with, and actively participates in the treatment regimen, thus optimizing each patient’s medication experience and clinical outcomes

https://www.accp.com/docs/positions/misc/CMM%20Brief.pdf Joint Commission of Pharmacy Practitioners – May 2014 23 24

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Comprehensive Medication #FSHP2019 #FSHP2019 Management

PRACTICE MODELS

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#FSHP2019 #FSHP2019 Pharmacy Practice Models Models • Manner in which pharmacy department’s staff is • Drug distribution centered model distributed to fulfill: • Mostly distributive pharmacy with limited clinical services - the departmental mission of ensuring that patients achieve optimal outcomes from the use of • Clinical specialist centered model - the departmental responsibility for leading improvements • Separate distributive and clinical specialist roles in the medication-use process • Patient centered integrated model • How pharmacists, pharmacy technicians, and other • Clinical generalist model with limited differentiation of pharmacy staff: roles—nearly all pharmacists have distributive and clinical responsibilities - spend their time - interface with patients, health professionals outside of • Comprehensive model pharmacy, hospital executives, information systems, • Similar to the Patient Centered Integrated Model but recognizes devices, and vendors the clinical pharmacist specialist as an indispensable member of the pharmacy team

AJHP 2009: 66;926-46 AJHP 2011: 68;1396-1397

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#FSHP2019 #FSHP2019 Factors Driving Practice Change

• More patients, increased demand • Value based care models that tie payment to performance • Movement away from transactional payments • Pressure to reduce costs, reward performance • Health care systems are challenged to improve PRACTICE CHANGE quality and cost of care • Health care executives require pharmacy department operations to be more efficient and contribute to improved care

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#FSHP2019 #FSHP2019 Factors Driving Practice Change Factors Driving Practice Change • Financial pressures are forcing health systems to pursue significant changes in how pharmacy • Professional leadership resources are used • Professional education/development • Health care executives expect that pharmacists • Practice standards will: • Changes in pharmacy education/residency • ensure that medications will be used in the most cost- training effective manner • help ensure compliance with quality-of-care standards • Advances in drug therapeutics • participate in care management • Growth in medication-related technologies • Pharmacy departments need to organize their • Practice initiatives workforce and services so that pharmacists can • Changes in payment for health care increase their contribution to the overall health of • Accreditation standards their health system

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#FSHP2019 #FSHP2019 Current State of Pharmacy Practice Practice Transformation

• Pharmacists are widely involved in direct patient care • Considerations for 2019 • Pharmacist involvement in clinics growing • Expanding role of pharmacists • Automation/technology in medication use is • Expanding role of technicians commonplace • Realizing the benefits of technology • Pharmacy technician development is underway, and • Specialty pharmacy deployment is continuing • Collaborative practice/Provider status • Residency training/certification continue to grow • Health care reform – expansion of value-based care • Specialty pharmacy is growing, especially at larger hospitals • Bigger focus on sterile compounding and hazardous • Transitions of care receiving a great deal of focus

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#FSHP2019 #FSHP2019 Expectations for Inpatient Care Expectations for Ambulatory Care

• Assure a complete and • Monitor the patient’s response accurate medication history to medication therapy • Drug therapy management (DTM) is available from • Reconcile medication in the • Adjust medication doses based ; upon on patient response or a pharmacist for health system outpatients admission, transfer, and pharmacokinetic characteristics • Pharmacist resources are deployed based on discharge of the medication medication complexity • Develop the medication-related • Monitor critically important patient care plan and discuss it medication serum • Collaborative practice is utilized to define with the patient concentrations and other responsibility and authority • Participate in patient care clinically important laboratory rounds analyses • Resources are focused on facilitating continuity of • Review medication orders • Establish processes to ensure care before the first dose is medication‐related continuity of care for discharged patients • Health system/regional pharmacist networks assure administered patients are referred for follow-up in their local • Review patient‐specific • Provide discharge education to medication profiles patients area

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#FSHP2019 #FSHP2019 Population Health Management

• Explicit efforts of health systems to improve the health status of the population of patients they serve (not simply to provide sickness care) • Concomitant goal is to reduce the cost of caring for the population they serve • Pharmacists, and their ability to impact cost and POPULATION HEALTH outcomes through effectively managing the medication continuum across levels and sites of MANAGEMENT care, are critical to the success of the healthcare system

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#FSHP2019 Population Health Program Design#FSHP2019 Population Health Strategies

•Effective medication management •Preventative care •Improve post-acute care •Integrate behavioral health and primary care •Engagement in community health • Mobile technologies can be key tools for patient engagement and shared decision-making

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#FSHP2019 #FSHP2019 Population Health Management Pharmacy Services

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#FSHP2019 #FSHP2019 Quality Measures – Population Health Sample Medication-related MSSP Approach Quality Measures

Measure Description ACO-12 Medication Reconciliation Post-Discharge ACO-14 Preventative Care and Screening: Influenza Immunization

ACO-15 Pneumonia vaccination status for older adults

ACO-42 Statin Therapy for the Prevention and Treatment of CVD

ACO-30 IVD: Use of Aspirin or Another Antithrombotic Stewardship of Patient Resources ACO-34 • Data collected through CAHPS survey • Whether care team discussed medication Rx costs ACO-27 DM: A1c Poor Control ACO-28 Hypertension (HTN): Controlling High Blood Pressure

ACO-8 Risk-Standardized, All Condition Readmission

ACO-35 Skilled Facility 30-Day All-Cause Readmission Measure

ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes

ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure

ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

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#FSHP2019 #FSHP2019

Promoting a Resilient Work Environment and a Healthy Work - Life Balance MEDICATION MANAGEMENT DEMANDS AND WORKFORCE TRENDS

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#FSHP2019 Caring for Patient #FSHP2019 Avoiding Harm Respecting Patient Striving for Justice

Growing Demands Burdensome Tasks Increased Stress

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#FSHP2019 #FSHP2019 Burnout Burnout is Not…

Begins with a high and persistent levels of stress • Having a bad day at work that can eventually you to feel irritable, cynical, and disengaged • Feeling overwhelmed for a day or two • Experiencing a bad mood Three hallmarks of burnout are: • Wanting time-off from work • Emotional exhaustion • Depersonalization • Lowered sense of self-worth which to decreased productivity and effectiveness

Ultimately, burnout can produce hopelessness, feelings of failure, and resentment

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#FSHP2019 #FSHP2019 Drivers of Burnout in Healthcare Why? Professionals

Risk Factors Associated With Burnout • Time pressure, Am J Health-Syst Pharm. 2017; 74:e576-81 • Lack of control over work processes, Risk Factor Example • Role conflict, Workload Job demands exceeding limits; limited time to rest, recover, and restore. • Poor relationships between groups and with leadership, Control Role conflict; absence of direction in the workplace

Reward Inadequate financial, institutional, or social reward in the • Combined with personal predisposing factors, and the workplace; lack of recognition emotional intensity of clinical work put staff at high risk Community Inadequate opportunity for quality social interaction at work; inadequate development of teams

Fairness Perception of equity from an organization or leadership

Values Organizational values are incongruous with an ’s personal values or beliefs

Job-person incongruity Personality does not fit or is misaligned with job expectations and coping abilities 51 52

#FSHP2019 #FSHP2019 Burnout is a Patient Care Problem Quality and Safety • -~8000 surgeons • Medical Malpractice Medical Litigation Burnout -~7000 surgeons Error • Health-care associated - Mean burnout hospital nurses Bi-directional relationship independent predictor Higher levels of burnout associated • Patient mortality ratios with increased odds of reporting a • Teamwork scores medical error in subsequent 3 months - Mean EE physicians & nurses Self-perceived medical error ICU associated with worsening burnout & depressive symptoms Shanafelt Ann Surg 2009; Balch J Am Coll Surg 213; West JAMA 2006, 2009; Jones Bodenheimer T, Sinsky C. From triple aim to quadruple aim: care of the patient requires care J Appl Psychol 1988; Cimiotti Am J Infect Control 2012; Welp Front Psychol 2015; of the provider. Ann Fam Med. 2014;12(6):573-6. Welp Crit Care 2016 53 54

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#FSHP2019 #FSHP2019 Health Care Costs

↑Medical Errors ↑Malpractice claims ↑Turnover • 1.2-1.3 x salary ($82-$88,000 per RN in 2007) Evidence of Burnout • $500,000 to >$1 million ↑Absenteeism ↓Job productivity ↑Referrals ↑Ordering

Jones J Nurs Am 2008; Fibuch Leadersh J 2015; Buchbinder Am J Manag Care 1999; Kushnir, Fam Pract 2014; Bachman Soc Sci Med 1999; Parker J Behav Med 1995, Toppinen-Tanner Behav Med 2005, Hilton J Occup Environ Med 2009 55 56

Maslach Burnout Inventory - #FSHP2019 Burnout: Clinical Pharmacists #FSHP2019 Human Services Survey Tool • Medical Personnel • Emotional exhaustion • Measures feelings of being emotionally overextended and exhausted by one’s work • I feel emotionally drained from my work • Depersonalization • Measures an unfeeling and impersonal response toward patients • I don’t really care what happens to some patients • Personal Accomplishment • Measures feelings of competence and successful achievement in one’s work • I have accomplished many worthwhile things in this job • Response options (frequency): never, a few times a year or less, once a month or less, a few times a month, once a week, a few times a week, every day

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Burnout: Clinical Pharmacists #FSHP2019 Burnout: Pharmacy Technicians #FSHP2019 • Durham and colleagues measured burnout in health system clinical pharmacists (n=329) • DeAngelis and colleagues measured burnout in pharmacy technicians (n= 879) • 53.2% reported scores indicating a high degree of burnout on at least 1 subscale of the MBI-HSS • Certified pharmacy technicians (PTCB) • 8.5% had scores indicating burnout on all 3 subscales. • 67.7% reported a high degree of burnout on at least one of • Emotional exhaustion 22.9% three subscales of the MBI-HSS • Emotional exhaustion 53.5% • Depersonalization 6.2% • • Reduced personal accomplishment 36.3% Depersonalization burnout 38.8% • Reduced personal accomplishment 30.1% • Conclusion: more than half of health-system pharmacists assessed themselves as being at risk for • Conclusion: Higher prevalence of burnout than other burnout. health care workers such as physicians and health- system pharmacists

Durham ME, Bush PW, Ball AM. Evidence of burnout in health-system pharmacists AJHP.2018:; 75 (Suppl 4) e801-8 DeAngelis JT, Kelm M, Bush PW. To be published

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#FSHP2019 #FSHP2019 Burnout: COP Faculty Clinician Well-being and Resilience • El-Ibiary and colleagues measured faculty burnout in • Well-being US College of Pharmacy (n=758) • The presence of positive emotions and moods (e.g., • 41.3% exhibited high emotional exhaustion scores contentment, happiness), the absence of negative • Women had significantly higher emotion exhaustion and emotions (e.g., depression, anxiety), satisfaction with life, lower personal accomplishment scores than men fulfillment and positive functioning. • Faculty who had a hobby had significantly lower • Physical well-being (e.g., feeling very healthy and full of emotional exhaustion scores, lower depersonalization energy) is also viewed as critical to overall well-being. score, and higher personal accomplishment scores • Resilience • Faculty working in newer Colleges of Pharmacy (est. < 5 • The set of individual skills, behaviors, and attitudes that years) were associated with lower deperson-alization and contribute to personal physical, emotional, and social well- lower personal accomplishment scores. being, including the prevention of burnout. • These can include self-care strategies, safety nets for crises, organizational support, peer support, financial management, life-needs support, and other forms of health promotion.

Am J Pharm Educ. 2017;81(4):75

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#FSHP2019 #FSHP2019

Organizational Strategies

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#FSHP2019 #FSHP2019 Strategies to Promote Policy on Clinician Engagement and Reduce Burnout Well-being and Resilience

• To affirm that burnout adversely affects an individual's well-being and healthcare outcomes; further, • To acknowledge that the healthcare workforce encounters unique stressors throughout their education and careers that contribute to burnout; further, • To declare that healthcare workforce well-being and resilience requires shared responsibility among healthcare team members and between and ; further, • To encourage individuals to embrace resilience and well-being as a personal responsibility that should be supported by organizational culture; further, • To encourage the development of programs aimed at prevention, recognition, and treatment of burnout, and to support participation in these programs; further, • To encourage education and research on stress, burnout, and well-being; further, • To collaborate with other to identify effective preventive and treatment strategies at an individual, organizational, and system level. Mayo Clin Proc. 2017;92(1):129-146 65 66

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#FSHP2019 #FSHP2019 Supporting Pharmacy Technicians Why Expand Technician Roles?

• Improved patient care • Enhanced nursing/pharmacy communication • Improved business processes • Operational efficiency • Increased technician job satisfaction

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Activities of Pharmacy #FSHP2019 Emerging Technician Roles and #FSHP2019 Technicians Responsibilities • Medication reconciliation • Prescription clarification Restock ADC or floor stock 99.7 • Medication therapy Cart fill (if utilized) 95.7 management • Quality assurance and quality Purchasing 95.1 improvement initiatives Packaging 92.4 • Immunization Non-chemo CSP 86.1 • Indigent care prescription • ACA Marketplace Certified Billing 74.8 programs Application Counselors Chemo CSP (if applicable) 74.8 QA activities / unit inspections 72.6 • Sterile & non‐sterile • CMS‐CMMI Grant Projects Controlled Substance mgmt 54.2 compounding (Innovations Center) IT system management 44.9 • Clinical technicians (e.g., • Community outreach Tech supervision 29.8 , appt. scheduling, Medication histories programs 26.3 medication adherence, Tech-check-tech 17.9 • DUE/ADR monitoring Medication Assistance Program 13.8 smoking cessation, Facilitating Transitions of Care 12.6 measurements, data • Informatics management, etc.) 0 20 40 60 80 100 120 • Medication safety initiatives % Hospitals • Prior authorization Source: 2018 ASHP National Survey of Hospitals • • Tech‐check‐tech

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#FSHP2019 Pharmacy Technician Shortage #FSHP2019 Ultimate Goal • Technician workforce demand commonly exceeds supply • A well-qualified and trained workforce • Shortage must be addressed so we can achieve our aspirations to improve care of patients • Improved patient safety • Possible solutions • Improve work environment -> decrease turnover • Standard knowledge base in technician workforce • Enhance compensation • Increase education/training capacity • Trained technician workforce that can assume more • Health system - technical school/community college pharmacy-based technical and business tasks partnerships • Health system (employer-based) program • Less turnover in pharmacy technician positions

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#FSHP2019 #FSHP2019

pharmacy.duke.ed u/duhs-pharmacy- technology- training-program

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#FSHP2019 #FSHP2019 Questions?

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