Lana Gerzenshtein, PharmD, BCPS, CSP

Defined as “the conditions in which people are born, grow, live, work and age,”

 the impact of social determinants of health (SDoH) on individual and population health risks and outcomes is widely recognized. Categories of social determinants include:

In the quest for improved population health and lower total cost of care, providers, payers, and public health agencies are developing ways to address SDoH. Small steps can result in noticeable improvements.

Health insurer Humana reported that by screening a group of members for food insecurity and offering Supplemental Nutrition Assistance Program (SNAP) benefits and an emergency food box to those who qualified, they were able to cut the members’ number of unhealthy days in half. Separately, Humana has found that food insecurity results in significantly higher rates of diabetes and heart failure as well as a somewhat higher rate of hypertension.

Among providers, integrated health systems are ideally positioned to address SDoH. With broad and deep connections to their communities, health systems have the reach and the data to allow them to take specific steps for their populations, often in partnership with local health plans and public health agencies.

Ideally, these initiatives not only help manage chronic illnesses successfully and cost effectively, but in the long run actually reduce their incidence by changing health behaviors heavily affected by SDoH. Value-based care contracts add a sense of urgency, but long-term thinking is required.

Specialty pharmacy and social determinants 

Specialty pharmacies are attuned to obstacles to initiating therapy and maintaining adherence, given the high cost of many specialty drugs and the potentially catastrophic consequences of non-compliance or non-adherence for their complex patients. In addition to the out-of-pocket cost—which can be prohibitive for many patients, not only those defined as low income&mdash;social determinants that can create obstacles include:

Transportation access for critical follow-up appointments.

Substandard housing or homelessness that makes correct storage of medications impossible.

Food instability or healthy food access, making it difficult to take medications correctly with food or to adhere to a modified diet.

Poor literacy, making it difficult to follow written instructions.

Language barriers, impeding communication with the care team.

Instability due to neighborhood safety or domestic violence.

Stress related to day-to-day concerns, such as lack of childcare.

Any major social disruption will make certain social determinants of health more pronounced. The impact of the coronavirus disease 2019 outbreak will likely include growth in the uninsured, underinsured, and Medicaid-covered population, due to job losses, and exacerbation of chronic and complex conditions in individuals who delay care or cannot access care during the crisis.

Steps that health system specialty pharmacies are taking

Integrating specialty pharmacy staff into oncology, neurology, rheumatology, and other specialty clinics within their health systems is a growing trend with a range of beneficial outcomes. By providing assistance with prior authorization; financial assistance; direct patient care, such as medication counseling and disease state education; and care coordination, clinic liaisons ease the way for initiating and maintaining therapy for complex patients. They may also be able to refer patients to other resources within the health system, such as social workers.

Health system social workers can address multiple barriers to care, whether directly or by linking patients to social service organizations. For example, offering access to ride-share services helps patients get to appointments. Simply making the offer, even if it is refused, emphasizes the importance of the appointment.

Fairview Health Services, a founding member of Excelera, a nationwide network of health systems, provides comprehensive therapy management for Fairview Specialty Pharmacy patients. Some are referred to a health coach who can address complex patient needs and SDoH.

An evaluation of the program found that patients perceived that health coaching had a positive impact on their physical and mental health. Patient depression scores improved and 44% were referred to other resources, ranging from disease-state support groups to smoking cessation programs to end-of-life support.

Integrated health systems put the patient at the center of care. Risk stratification for targeted interventions is a tool for lowering total cost of care. It also is a powerful tool for making a difference for individual patients and reducing disparities caused by SDoH.

For those health systems that are members of the Excelera Network, the proprietary Complex Patient Data Platform captures a wide—and increasing&mdash;range of longitudinal medical, pharmacy, and patient journey data for complex patients. The platform informs decisions around clinical best practices and it holds potential as a tool for insights into SDoH.

Health system specialty pharmacies, as integral providers of complex and chronic patient care, are key to developing innovative ways to address social determinants of health as a means to positively affect outcomes, population health, and total cost of care.

 is the Director of Pharmaceutical Accounts for ExceleraRx Corp.

 is Manager of Network Clinical Programs for ExceleraRx Corp.

 is the Vice President of Pharma Strategy & Relations for Fairview Pharmacy Services.

World Health Organization website. Accessed April 30, 2020. 

https://www.who.int/social_determinants/sdh_definition/en/

Artiga, Samantha, and Hinton, Elizabeth. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation. Published May 10, 2018. 

https://www.kff.org/disparities-policy/issue-brief/beyond-health-care

Sullivan, Tom. Social Determinants of Health and the $1.7 Trillion Opportunity to Slash Spending. Healthcare IT News. Published October 9, 2017. 

https://www.healthcareitnews.com/news/social-determinants-health-and-17-trillion-opportunity-slash-spending

Simonson, Dana & Wittenborg, Marj & Snyder, Mallory & Wiest, Holly & McNamara, Ann. (2019). Evaluation of a specialty pharmacy health coaching program. Journal of Drug Assessment. 8. 36-36. 10.1080/21556660.2019.1658316.

Articles

Integrating specialty pharmacy staff into oncology, neurology, rheumatology, and other specialty clinics within their health systems is a growing trend with a range of beneficial outcomes.

Health-System Specialty Pharmacies Address Social Determinants of Health

The American Society of Health-System Pharmacists (ASHP) launched a Section of Specialty Pharmacy Practitioners (SSPP) last year to represent the needs of providers in large areas of practice, such as specialty pharmacy. As of May, the SSPP had approximately 4400 members, which further underscores the industry trend of health system-based specialty pharmacies and the desire for additional representation in this practice area.

At the ASHP Summer Meetings and Exhibition 2019, held June 8-12 in Boston, MA, thought-provoking sessions included reporting on clinical outcome measures, the importance of accreditation, and the need to build and maintain relationships. Notable advice for health systems building out new specialty pharmacy services included aligning your program with the mission and vision of your overall health system strategy, to incorporate yourself into the clinics, and become part of the multidisciplinary care team. The conference also featured 5-minute sessions called “Specialty Pharmacy Pearls,” which provided quick descriptions of specialty pharmacy programs covering a wide range of topics.

Two "pearls" of note are highlighted below:

Zach Russell, PharmD CSP/ExceleraRx Corp, provided recommendations around the development of key performance measures for specialty pharmacies to show their value to stakeholders. He also highlighted how standardization around key performance metrics (KPMs) can improve internal operational goals and fulfill accreditation, payer, and pharma requirements. Examples such as turnaround time, prescription abandonment and patient or provider satisfaction are important to assess regularly, as these allow for benchmarking opportunities, quality improvement and reporting to key external stakeholders.

Julie Kidd, PharmD, MPH, BCPS, CPP/Novant Health Specialty Pharmacy, presented on "Pharmacist-led Strategy for Monitoring Infusible Disease Modifying Therapies for the Treatment of [multiple sclerosis (MS)]

which described services that extended beyond oral and self-injectable medication to pharmacist-led monitoring for infusible treatments in MS. This scenario allows the pharmacist to be integrated into the clinic in a practitioner role with privileges to order labs and medications and send referrals with oversight from a physician partner. The pharmacist can also take charge of risk evaluation and management strategies (REMS) requirements as needed for patient follow-up. This model allows for more timely assessment of labs and follow-up as well as improving adherence to REMS monitoring.

“Our clinical pharmacist practitioner (CPP)—led service at Novant Health Center for Multiple Sclerosis leverages the pharmacist in a practitioner role,” Kidd explained. “This has become important to ensure required safety labs are completed by patients on infusible disease modifying therapy (DMT) and care plans are promptly created. Patients are receiving high-touch care from the CPP either face-to-face in clinic or by phone between office visits. We have eliminated gaps in patient care plans by engaging the CPP into the MS center to ensure timely and appropriate treatment with infusible DMT.”

In general, other conference topics tied to the overarching themes of health system specialty pharmacy operations, clinical outcomes and business development. Many of these tied to initiatives already underway in many health systems and discussed at other recent conferences.

The summer meeting stressed the importance of including clinical outcome measurements as HSSPs develop their program capabilities. Adherence measures such as proportion of days covered (PDC), hepatitis C virus cure treatment completion and cure rate, and time to progression with certain cancer therapies are some examples. It is also important for HSSPs to review pharma studies and set up programs that mimic these studies so that results and outcomes can be compared. Additionally, it is also important to use patient stories to link HSSP performance with adherence, defined end-of-treatment outcomes, and financial impacts. In addition, ongoing analytics can provide insight into prescription capture opportunities.

The pearl session titled “The Health System SP: Clinical Pharmacist or Sales Specialist?” (Aimee M. Banks, PharmD BCPS, MSCS/Vanderbilt UMC) provided strategies to align the clinical and business aspects of the specialty pharmacist’s role to provide excellent patient care while growing the specialty pharmacy business opportunity management and conversion rates. Although optimal patient care is the priority, learning how to engage patients surrounding the types of services they could be getting at the HSSP is vital as well. Successful opportunity management includes providing patients with an understanding of the service and the goals of their care as part of a collaborative multidisciplinary team to build trust, establishing specialty pharmacy staff goals for conversion, tying results to patient satisfaction surveys, and using routine meetings to provide feedback.

Overall, the development of a specialty pharmacy track at the ASHP Summer Meeting signifies the growing importance of HSSPs as a critical component of pharmacy practice moving forward. I fully expect it will be an ongoing focus at ASHP as more health systems incorporate specialty pharmacy services and existing HSSPs find more ways to optimize outcomes and streamline their operations.

Lana Gerzenshtein PharmD, BCPS, CSP, is manager of Network Clinical Programs at ExceleraRx.

American Society of Health-System Pharmacists summer meeting included topics tied to the overarching themes of health system specialty pharmacy operations, clinical outcomes, and business development