Innovations and Challenges for Pharmacist dealing with Asthma. Dimmy Sokhal, PharmD Clinical Pharmacist Hayat Pharmacy, Milwaukee WI

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1 Innovations and Challenges for Pharmacist dealing with Asthma Dimmy Sokhal, PharmD Clinical Pharmacist Hayat Pharmacy, Milwaukee WI

2 Objectives Outline methods of identifying community pharmacy/clinic patients that would benefit from pharmacist interventions to improve asthma care. Describe interventions that can be implemented by pharmacists in the community pharmacy and ambulatory clinic setting to improve care of patients with asthma Suggest measures to assess outcomes of pharmacist asthma care interventions List challenges that need to be addressed to facilitate pharmacist care of patients with asthma

3 Introduction Locally owned pharmacy in Milwaukee Dedicated to providing quality care to our patients Free delivery for our patients to their doorstep based on their convenience Simplify my meds program Medication Therapy Management (MTM) program or medication check-up with pharmacist

4 Role of pharmacists Identifying patient Non-adherent Multiple Emergency room visits Declining quality of life

5 Role of Prescribers Identifying patients Results from spirometry Requesting refill for rescue inhalers only Making referrals Describing the referral Involving the patient

6 Interventions by Pharmacists Medication Therapy Management (MTM) Comprehensive Medication Review & Assessment Intent is to work collaboratively with physicians Enhance therapeutic outcomes Aligning with evidence-based guidelines No therapeutic changes are made without healthcare prescriber approval

7 MTM services at Hayat Home MTMs Pharmacists visit patient at their home Educate on importance of adherence Assist with tools for improving adherence Lifestyle education Training on appropriate administration of devices 8-10 Home MTMs/day

8 Referrals for MTM services at Hayat Prescribers refer patients for MTM services at Hayat Local MA plan Staffing pharmacists Self-referral where patients or caregivers request MTM services

9 MTM services at Hayat Clinic MTMs Collaboration with clinics Work in collaboration with prescribers Assist with medication reconciliation Device training Evaluate issues with adherence Help set up goals for patients

10 MTM services at Hayat MTMs post Hospital Discharge Provide transition care in collaboration with home health services Patient education on any medication related changes Assisting with follow-up with PCP post discharge Assisting with adherence

11 MTM Services Payers Wisconsin Medicaid (Forward Health) covers MTM services for patients who meet eligibility criteria Billing for MTM services for Medicaid patients is done through Forward Health Portal

12 Assessing outcomes for pharmacist s intervention Decrease use of rescue inhaler Better quality of life Improved adherence to controller inhaler Decreased emergency room visits

13 Assessing outcomes for pharmacist s intervention Correct inhaler technique is recommended by guidelines for optimum asthma care Study performed on predictors for appropriate administration Education with health care professional (nurse/pharmacist)

14 Challenges faced by pharmacists Lack of communication from prescribers Pharmacists underutilized for their clinical skills Pharmacists often are not aware of an Asthma Action Plan

15 Future Directions Involving pharmacist in care for patients with Asthma Increase in communication amongst different members on patient s health care team

16 Questions?

17 CURRICULUM VITAE Dimmy Sokhal DIMMY SOKHAL, PharmD WI Pharmacist License Number: Address: W234N7960 Mallard Ct Sussex, WI Cell: EDUCATION Degree Year University PharmD 2013 School of Pharmacy, UW Madison M.S. (Pharmacy) 2007 National Institute of Pharmaceutical Education and Research, Mohali, INDIA Bachelors in Pharmacy 2005 DIPSAR, Delhi University, New Delhi, INDIA PROFESSIONAL EXPERIENCE July 2014-Present Clinical Pharmacist Hayat Pharmacy, 5434 W Capitol Drive, Milwaukee July 2013-June 2014 University of Wisconsin-School of Pharmacy PGY-1 Community Pharmacy Residency Program at Access Community Health Center Pharmacy Scaling up medication therapy management (MTM) services provided by pharmacists Establishing pharmacy resident s role in inter-professional health care team in medical home Implementing Wisconsin Pharmacy Quality Collaborative (WPQC) measures in to the workflow of the pharmacy Providing, documenting and billing for level 1 and 2 services Performing continuous quality improvement by setting goals and preparing monthly reports for clinic administration Working with behavioral health team on quality improvement project to ensure appropriate lab monitoring recommended for patient on psychotropic medications Participating in United Way events to perform medication reviews for older adults in the community Teaching in pharmacotherapy labs at UW School of Pharmacy Serving as a clinical instructor for Advanced Pharmacy Practice Experience for UW School of Pharmacy students

18 Dimmy Sokhal July 2007 January 2008 Research Associate in the Department of Drug Regulatory Affairs at Ranbaxy Research Laboratories, INDIA Integrated the information from other scientific departments Preparing Drug master files (DMF) for filing of generic products with various regulatory agencies like FDA. Review DMFs in progress prior to final submission December 2003 January 2004 Training in manufacturing tablets and capsules at Asclepius Pharmaceutical Limited, New Delhi, INDIA RESEARCH EXPERIENCE July 2013 June 2014 Title: Psychotropic medication review to facilitate monitoring in complex psychiatric patients Performing chart reviews for patients who receive psychiatric consult Documenting lab monitoring/aims assessment for patients who are not up to date and routing to PCP Scheduling and performing AIMS assessment for patients Performing retrospective chart reviews to determine if pharmacists intervention contributed in quality improvement June June 2007 M. S. (PHARM.) DISSERTATION: Design and Synthesis of N,N- Di-substituted Biguanides as Potential Antidiabetic Agents Synthesizing various di-substituted biguanides by utilizing different synthetic schemes Studying compounds computationally on a software: GAUSSIAN98W Study relation between therapeutic activity and the conformation displayed biguanides Studying reaction mechanism for synthesis of metformin computationally PROFESSIONAL ASSOCIATIONS Member since September 2009 Wisconsin Society of Pharmacy Students (WSPS) American Pharmacist Association (APhA) Pharmacy Society of Wisconsin (PSW) American Society of Health System Pharmacists (ASHP) Meetings attended PSW Annual Meeting 2014 Great Lakes Pharmacy Residency Conference 2014 APhA Annual meeting, 2014 ASHP Midyear, December 2013 PSW annual meeting, September 2013 PEB Meeting, September 2013 PSW Geriatric Syndromes Preconference attendee, September 2012 PEB Meeting, August 2012 Wisconsin Pharmacy Examining Board Meeting attendee, July 2012

19 Dimmy Sokhal SPEAKING ENGAGEMENTS Pharmacy Society of Wisconsin- Education Conference 2017 National Community Pharmacist Association Annual Conference 2016 Pharmacy Society of Wisconsin- Educational Conference 2016 American Diabetes Association Conference- March 5 th, 2016 Wisconsin Center for Nursing Conference- June 2015 Pharmacy Society of Wisconsin-Education Conference April 2015 Poster Presentation at APhA Annual meeting-2014 Great Lakes Pharmacy Residency Conference-2014 CERTIFICATIONS Basic Life support (CPR and AED) by American Heart Association 9/13/2016-9/30/2018 Immunization Delivery by UW-Madison, School of Pharmacy 5/2012 ADVANCED PHARMACY PRACTICE EXPERIENCE (DPH-4) Walgreens, Middleton (March May 2013) Administered immunizations Promoted immunizations offered at the pharmacy UW Hospitals, General Medicine Unit (January 2013 March 2013) Rounding with Gen Med team Completing discharge summary Performing medication reconciliation Performing chart reviews CVS Pharmacy, Middleton, WI (October 2012-December 2013) Learned how to deliver best care with limited health related information about patient Developed relation with senior living center VA Epilepsy Clinic, Madison WI (August 2012 October 2012) Assessing adverse effects of antiepileptic medications Staffing patients progress with attending Completing documentation UW Health, West Towne, Madison, WI (August October 2012) Practiced utilizing resources like Epic Performing dose checks, pre-verification and verification of prescriptions Administering flu shots and encouraging patients to get immunized Access Community Health Center Pharmacy, Madison, WI (July-August 2012)

20 Communicating with patients having financial issues Handling prescriptions as per priority Dimmy Sokhal Oakwood Village Pharmacy, Madison, WI (May-July 2012) Communication with older adults Organized talk on diabetes Prepared med boxes for patient Performed chart review for nursing home patients PROJECT INVOLVEMENT Projects at Hayat Assisting with Medication Therapy management for patients Improving adherence Working with Medicare Advantage plan to help reduce hospital readmissions Partnering with City of Milwaukee to help families with Asthma Partnering with Milwaukee Fire Department in the Home Outreach Initiative Preceptor for student pharmacist from University of Wisconsin, Concordia University and Rosalind Franklin University. QI Project for improving quality of care for patients on psychotropic medications July (Referred above under research experience) Pharmacy Workflow Improvement July Teaching and training pharmacy staff Pertaining to filling medications that are profiled Educating on calculation of days supply for medications like insulin, inhalers, etc. Educating on identifying patients in workflow who qualify for WPQC CMR/As Scaling up WPQC CMRA s delivered by pharmacists July Working with PCPs Getting warm hand offs for performing medication reviews especially for complex patients Identifying, scheduling, documenting, billing and performing follow-ups for patients Comprehensive Medication Review project at Oakwood Village, Madison, WI October 2011-December 2012 Completed data entry for project Conducted follow up interview Analysis of data collected

21 Dimmy Sokhal PUBLICATIONS Gallimore, Casey E.; Sokhal, Dimmy; Zeidler Schreiter, Elizabeth; Margolis, Amanda R. Pharmacist medication reviews to improve safety monitoring in primary care patients. Families, Systems, & Health, Mar 17, Sokhal D, Kraus C. Insulin sensitizers for treatment of menstrual irregularities associated with PCOS. Am Fam Physician. September Sokhal D, Kraus C. Will insulin sensitizers treat menstrual irregularities associated with PCOS? Evidence-Based Practice Lukazewski A, Martin B, Sokhal D, Hornemann, Schwartzwald A. Adverse drug event (ADE) screening in older adults: detecting ADE risk, prevalence of self-reported ADE and impact of interventions. The Consultant Pharmacist. October 2014 Safety of NSAIDs vs Opioids in Older Adults, in WPQC United Way July 2012 Newsletter. VOLUTEERING EXPERIENCE Volunteer at Senior Centers in Milwaukee to perform blood pressure, blood glucose checks and educate on health topics. Volunteered for Comprehensive Medication Review project at Oakwood Village: Worked 10 hours per week for total of 250 hours (October 2011-May 2012) Ambassador Program ( ), School of Pharmacy UW Madison Volunteer for a community kitchen in Madison and Milwaukee once a month REFERENCES AVAILABLE ON REQUEST

22 GHC-SCW Asthma Risk Project Laya Esmaili-Rashid, RPH, Clinical Pharmacist Association of Asthma Educators Annual Meeting - July 2017

23 I have no financial or other conflicts of interest to disclose

24 Group Health Cooperative of South Central Wisconsin Non-profit, member-owned cooperative health plan and primary care delivery system that serves the greater Madison, WI area Approximately 70,000+ insured members 3/4 of those receive primary care services at 6 GHC-SCW owned clinics NCQA Health Plan Accredited since 1995 Best Performer in state for health care quality from Team-based primary care, urgent care, pharmacy, integrated behavioral health, health education and complementary medicine services

25 History of Asthma Risk Report Asthma Committee created report in 2004, based on NHLBI/NAEPP Asthma Guidelines Looked for a way to provide more seamless asthma care within our organization Pilot project from January to June 2016 to conduct outreach to members on the report Revamped report and workflows several times based on clinic staff feedback

26 What is the Asthma Risk Report? Report was designed to provide risk stratification of GHC members with asthma by assigning risk scores for: Inpatient visit for asthma in last 12 months (3 points) ER visit for asthma in last 12 months (2 points) Rescue medication in last 12 months greater than or equal to 4 fills (2 points) Urgent Care for asthma in last 12 months (1 point) Oral steroid count in last 12 months (1 point)

27 Rationale Risk stratification and outreach to members who have poorly controlled asthma Poorly controlled members with asthma more likely to have future Urgent Care, ER, and hospital visits Targeted workflows help to address member s individual needs Proactive care can improve health outcomes and save money for the member and organization

28 Asthma Mediation Ratio (AMR) AMR measures Controller Fills / (Controller Fills + short-acting beta-agonist SABA Fills) A Ratio 0.50 indicates use of a controller medication for 50% of their treatment period Measure endorsed by National Quality Forum (NQF) and HEDIS measure

29 Asthma Control Test (ACT) Report also includes whether or not the member has had an ACT conducted in the last 1 year (Y/N) For members who are on the risk report, approximately 25% had an ACT in the last year Consistent with organizational rate for all members with asthma but goal is at least 1x/year

30 Example Asthma Risk Report

31 Workflow Overview Clinical Pharmacist and Nursing staff review colorcoded Asthma Risk Reports each quarter Nursing staff focus outreach to members assigned to a provider with an AMR >.50 (& risk score of 3) Clinical Pharmacists focus on members assigned to a provider with AMR <.50 (& risk score of 3) Schedule appointments with PCP, Asthma Educator and/or Clinical Pharmacist as needed

32 Clinical Pharmacist Telephone Outreach

33 Visit with the Clinical Pharmacist If patient using rescue inhaler > 2x/week, it may be due to non-adherence CP schedules an appointment with patient Assess and address reason(s) for non-adherence: Incorrect technique/difficulties using devices provide referral to Asthma Educator Forgetfulness Side effects Misunderstanding/lack of instruction Complex medication schedule Cost Discuss goals of therapy Update ACT score Follow-up with patient as needed

34 Asthma Risk Follow Up Letters If multiple attempts have been made to reach the patient by phone and patient has not responded, Care Team members may send a Follow Up Letter Adult Asthma Risk Follow Up and Peds Asthma Risk Follow Up Letters available in Epic Asthma Risk Questionnaire will also be available to send via MyChart (patient portal)

35 MyChart Asthma Risk Questionnaire

36 Pilot Project - Outcomes N= 77 N= 94 N= 165 N= 186 N= 71 N= 78 N= 95 N= 89 Baseline timeframe: January 2015 December 2015 Post pilot timeframe: September 2015 August 2016

37 Measuring our Success Process Measures Track outreach conducted by various members of the Care Team Outcome and Cost Measures Total Percent of Premium PMPM Pharmacy Costs ER Visits/1000 members/year PMPM ER Costs

38 Laya Esmaili-Rashid, RPh 675 W. Washington Ave. Madison, WI P: (608) , ext or (608) F: (608) Education University of Wisconsin, Madison Baccalaureate in Pharmacy 1992 Employment Group Health Cooperative of South Central Wisconsin Clinical Pharmacist 2014 Present. Provide asthma outreach to target high-risk patients with poorly controlled asthma and encourage follow-up with clinical providers. Collaborate with the primary care provider, Asthma educator, and patient to develop an asthma treatment plan. Educate patients on asthma therapies, goals of treatment, and proper inhaler technique. Monitor medication use and response to therapy, including effectiveness, adverse effects, and adherence, and recommend adjustments to therapy as needed Group Health Cooperative of South Central Wisconsin Staff Pharmacist Wal-Mart Pharmacy Madison, Wisconsin Staff Pharmacist Licensure and Certifications Licensed Pharmacist Wisconsin WPQC Certified Professional Activities

39 Group Health Cooperative of South Central Wisconsin Asthma Pilot Project GHC Asthma Committee 2015 Present