Quality Initiative Demonstrates the Benefits of Integrated Pharmacy Care Model

Jennifer Donovan, PharmD

Pharmacists and pharmacy technicians can more efficiently and proactively incorporate their expertise into patient care, reduce the administrative burden on nursing staff, and help patients overcome financial obstacles and other hurdles to accessing medications.

Like others who rely on specialty medications, patients with cystic fibrosis (CF) benefit from the patient-centered, high-touch care they receive at health systems with integrated specialty pharmacy capabilities. For patients with CF, this model of care includes medication therapy management and helps address complexities surrounding pulmonary exacerbations, nutrition support, mental health, and other clinical issues.

For providers, embedded specialty pharmacy staff members can ease the burden of prior authorization and other administrative requirements. They also help patients access financial resources and untangle insurance issues.

A health system that exemplifies this care model for patients with CF is Billings Clinic, a member of the Excelera Network and Montana’s largest health system, serving a largely rural population over the vast geographic region of Montana, Wyoming and the Dakotas. To further improve quality and patient care, the health system’s CF Center has utilized a 3-year grant from the Cystic Fibrosis Foundation to embed pharmacy services staff and ramp up quality improvement (QI) practices.

While the COVID-19 pandemic has presented challenges, especially in conducting outreach clinics, the team has succeeded in using the grant to expand and enhance pharmacy care for CF patients. During Cystic Fibrosis Awareness Month this May, Shields Health Solutions (SHS) highlighted health systems with demonstrated high-performing specialty pharmacy capabilities for CF.

Therapeutic advances over the past several decades have resulted in people with CF living longer and with greater quality of life. According to CF Foundation Patient Registry data, the life expectancy of patients born 2015–2019 is 46 years, up from 32 years for those born 1995–1999. As one would expect, healthier CF patients live longer. However, reliance on complex medication regimens is lifelong, and as those patients age, they can develop complications. Certain antibiotics, for example, should be taken only for a limited time after a positive culture, but this limitation sometimes is overlooked.

Billings Clinic Specialty Pharmacy (BCSP) is among 130 CF centers nationwide accredited by the CF Foundation that care for the estimated 35,000 people living with CF in the United States, including adult and pediatric patients. Collectively, 24 of the accredited CF centers are working with Shields and have integrated specialty pharmacy capabilities.

At Billings Clinic, which is the only CF center in Montana and Wyoming, the CF Foundation grant allowed pharmacist Chris Larson to take on the adult CF pharmacist role, spending one-fourth of his time onsite in the adult CF clinic and three-fourths in his existing role in the specialty pharmacy. Additionally, pharmacy technician Laura Kirschenmann was embedded in the Pediatric Specialty Clinic, at 0.45 FTE, with desk space near the pediatric pulmonary team. She also worked with adult CF patients, as part of CF Foundation grant activities.

During the period studied, from December 13, 2019, to December 1, 2020, Larson and/or Kirschenmann were in the CF clinic 1- to 2-days per week. Larson attended 54 patient visits in clinic and 26 patient visits via telemedicine. He reviewed patient profiles, identified interventions and worked with the interdisciplinary CF care team to meet patients’ needs and advance their quality of care. He also answered patient and provider questions during CF outreach days and completed chart reviews of patients who were not seen due to COVID-related issues.

Interventions and recommendations were made in a range of categories, including:

  • acquisition medication barriers
  • adverse drug reaction
  • does not understand instructions
  • dosage too high
  • dosage too low
  • drug-drug interaction
  • duration of therapy too long
  • education needed
  • immunization needed
  • medication access
  • medication follow up
  • needs additional monitoring
  • needs additional therapy
  • new start
  • poor adherence
  • unnecessary drug therapy

Kirschenmann worked in the adult clinic for 26 days and in the pediatric clinic for 43 days during the study period. In addition to interacting with patients, she took on work from the nursing staff to complete prior authorizations (PAs), assist with medication access and acquisition (operationally and by helping patients enroll in medication assistance programs), and complete patient refill histories.

In doing so, she identified several patients who were not filling hypertonic saline, vitamins, and other drugs due to insurance exclusions and costs, but who had not reported this to the team in clinic. As a result, BCSP was able to write letters of medical necessity and pursue the PA and appeal process to get these essential medications covered through the patients’ insurance. The good news? These patients have since been able to fill and take these critically important medications.

After the 3-year grant ends, the evidence gathered during the initiative is expected to demonstrate therapeutic benefits for patients and financial sustainability for the health system.

“The grant gives you a boost for the initial 3 years and allows you to prove your impacts and hopefully continue after the three years,” Larson said.

From a specialty pharmacy perspective, the results have been excellent. BCSP now fills for 25 total adult CF patients, up from 11 prior to the addition of the adult CF pharmacist and CF technician roles, which represents 83.3% of adult CF patients who are eligible to use it (i.e., not mandated to receive specialty pharmacy medications outside of the integrated health system). This allows the CF team to monitor these patients more closely and collaboratively between their clinic visits.

In the United States, more than 30,000 people live with CF, according to the CF Foundation’s Patient Registry, and each year, approximately 1000 new cases are diagnosed. An integrated pharmacy care model helps these pediatric and adult patients manage complications of this disease better and live their lives to the fullest.

About the Author

Jennifer Donovan, PharmD, is vice president of Clinical Services, Compliance/Accreditation at Shields Health Solutions.

Excelera the company behind the Excelera Network, is a subsidiary of Shields Health Solutions, the premier specialty pharmacy accelerator health system leaders trust to elevate clinical, operational and financial performance.