Collaborative Drug Therapy Management: Case Studies of Three Community-based Models of Care

Margie E. Snyder, PharmD, MPH; Tara R. Earl, PhD, MSW; Siobhan Gilchrist, JD, MPH; Michael Greenberg, JD, MPH; Holly Heisler, MPH, MBA; Michelle Revels, MA; Dyann Matson-Koffman, DrPH, MPH, CHES

Disclosures

Prev Chronic Dis. 2015;12(3) 

In This Article

Methods

Case Study Site Selection and Inclusion Criteria

We selected sites from states with scope of practice laws authorizing pharmacists to perform CDTM in any practice setting for a broad array of health conditions. We consulted with experts in MTM, CDTM, and collaborative models in pharmacy settings and reviewed the literature[14–17] to understand how CPAs might be implemented in different practice settings and to identify potential study sites. Three criteria emerged as the primary considerations for final site selection: duration, scope, and reach. Therefore, we sought a variety of sites, including some that were newly implemented (vs experienced), some that offered limited services (vs the full scope of CDTM services authorized by law), and some that reached a broad and diverse population (vs a more limited homogenous population).

We identified community pharmacies on the basis of expert recommendations and our literature review and contacted 10 sites. Each site received an email explaining the study and an invitation to participate. We excluded 5 sites for these reasons: CDTM services were not implemented because of the time and resources required, the contractual language of CPAs was considered prohibitive, or CDTM reimbursement mechanisms were lacking; 1 site declined; and another site did not respond. Ultimately, we used a combination of the criteria to select 3 sites that had CPAs in place: El Rio Community Health Center, Osterhaus Pharmacy, and Kerr Drug.

The research protocol was approved by the ICF International (ICF) institutional review board. CDC and Purdue University deferred to ICF.

Recruitment

We worked with each site's point of contact to identify potential key informants. Participants had to provide signed informed consent, be aged 18 years or older, and be comfortable speaking in English.

A purposive sample of potential informants at each site was recruited by email. To meet the study objectives, 9 key informants were recruited to share experiences on CDTM implementation. Three informants were recruited from each site: a pharmacist, a physician, and 1 other (eg, a pharmacy resident or administrator). Participants were not remunerated.

Data Collection

Case studies included key informant interviews and onsite observations. Before the site visits, interviewers completed a half-day training. Site visits took place during May through July 2012. Two study team members traveled to each site to conduct the interviews during a day-and-a-half visit. Because of the inability to schedule an in-person visit, we conducted telephone interviews for the Kerr Drug site. Interviews lasted about an hour and were audio recorded with consent.

A semistructured interview guide (available on request from the authors) was developed to focus on 6 topics: 1) CPA/CDTM policy implementation (eg, describe your CDTM policy and related guidelines for compliance with state law), 2) stakeholders, 3) effects of CPA/CDTMs on practice, 4) evaluation, 5) reimbursement, and 6) lessons learned and recommendations for implementing CPA/CDTM.

Description of Case Study Sites

El Rio Community Health Center (El Rio). El Rio, an FQHC, is the largest provider of medical and dental services to uninsured and Medicaid-covered populations in Pima County, Arizona. Of 76,190 patients seen in 2011, 76% had an income at or below the federal poverty line, 48% received Medicaid, 28% were uninsured, 13% had private insurance, and 8% were Medicare recipients. El Rio serves a large Hispanic and Native American patient population, many with diabetes. El Rio has extensive experience implementing CDTM; its on-site pharmacists began entering into CPAs with El Rio providers in 2000. In 2012, approximately 800 patients received CDTM services, mostly for diabetes. The CDTM protocols also cover hypertension, hyperlipidemia, asthma, and other conditions. CPAs authorize pharmacists to assess patients, review medication regimens, adjust medications in approved drug classes, and perform specified examinations (eg, foot examinations) as well as patient drug reviews for medications that require monitoring, such as anticoagulation therapy. El Rio bills for CDTM services through Medicare Part D and for diabetes CDTM services as an accredited site for diabetes self-management training.

Osterhaus Pharmacy. Osterhaus Pharmacy is an independent, community pharmacy in the largely white (95%) rural community of Maquoketa, Iowa. Osterhaus Pharmacy serves approximately 6,500 patients annually, offering various patient care services. Approximately 60% of patients have diabetes, hypertension, and/or hyperlipidemia. In 2012, about 13% of patients received Medicaid and 42% were Medicare beneficiaries. Since 2000, the pharmacy has implemented limited elements of CDTM with a family medicine and emergency medicine group practice: a medication substitution and an immunization protocol. Although Osterhaus Pharmacy has extensive CDTM experience, this model is less comprehensive than authorized by Iowa law. For example, the CPAs operate under limited conditions, such as medication substitution based on patient insurance or influenza vaccination criteria, or the CPAs limit the scope of their services (ie, preclude modification of drug dosages based on laboratory or physical findings). In addition, the pharmacy and medical practice collaborate informally by providing MTM and other services.

Kerr Drug. Kerr Drug, a regional pharmacy chain, operates several retail stores in North Carolina that serve a varied patient population. Since 2007, Kerr Drug has provided MTM services to Medicare Part D beneficiaries. Although state law allows clinical pharmacist practitioners (CPP) (a distinct pharmacist credential that designates pharmacists practicing under a CPA) to perform a broad array of CDTM services, Kerr Drug recently implemented limited elements of CDTM. The Chapel Hill location completed a pharmacogenetic feasibility study involving a CPP arrangement with the primary investigator for the pharmacist to order genetic tests from a laboratory. To perform any other CDTM services, the CPP would need to collaborate with each study participant's primary care provider. Kerr Drug's feasibility study was funded by the University of North Carolina and grants.

Analysis Approach

Data analysis involved audio recorded debriefs by interviewers within a week of each site visit and a review of the recordings by 2 site visitors. Excel software (Microsoft Corp) was used to select salient quotations. Thematic categories guided by the case study questions (ie, key features, barriers, facilitators, and lessons learned) were selected and discussed for and across each site. Results were synthesized and sent to at least 1 key informant from each site for feedback.

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