Pharmacy Training & Practice Report of Findings

Transcription

1 The Pharmacist's Rle in the Interdisciplinary Care f the Aging Ppulatin Pharmacy Training & Practice Reprt f Findings Reprt Authrs Dawn Bentn, MBA, CSHP Fundatin Steve Chen, PharmD, USC Schl f Pharmacy Elissa Maas, MPH, Prject Directr Jdy Sants, PharmD, USC Schl f Pharmacy Brad Williams, PharmD, USC Schl f Pharmacy December 2014

2 TABLE OF CONTENTS Page N THANK YOU S 2 EXECUTIVE SUMMARY 3 METHODOLOGY 5 KEY LEARNINGS Literature Review 6 Survey Research 11 Meta- Analyses Review 24 DISCUSSION 27 RECOMMENDATIONS 28 ENDNOTES 31 APPENDICES PROJECT SURVEYS (Available n Request) PRACTICING PHARMACISTS PHARMACY SCHOOLS PHARAMCY STUDENTS N prtin f this reprt may be reprduced, in whle r in part, withut the written cnsent f the CSHP Research & Educatin Fundatin. Requests fr reprints may be sent t fundatin@cshp.rg. When request apprved, the fllwing citatin will be used: Bentn D, Chen S, Maas E, Williams B. The Pharmacist Rle in the Interdisciplinary Care f the Aging Ppulatin (Prepared by the Califrnia Sciety f Health- System Pharmacists Research & Educatin Fundatin, Sacrament CA) January

3 Thank Yu The CSHP Research and Educatin Fundatin wishes t thank the Expert Panel members and Prject Spnsrs fr their supprt during Phase One f this prject. Expert Panel Members Michael Hchman, MD - AltaMed Larry Green - Amgen Daniel Kud, PharmD - Astra Zeneca Alisn Lum, PharmD - Blue Shield f CA Health Plan James Rse PharmD - Caremre Debra Brwn, PharmD CA Dept. f Public Health BJ Bartlesn, RN, MS Califrnia Hspital Assc. Jim Walsh, PharmD Dignity Health Lisa Ashtn, PharmD - HSAG April Canett, PharmD Health Net Jamie Spears, PharmD Health Net Nancy Wngvipat Kalev, MPH Health Net Chris Chan, PharmD - Inland Empire Health Plan Jamie Chan, PharmD - Kaiser Permanente Yana Paulsn, PharmD Janet Sjeung Ch Rebecca Cupp, RPh Krger, Ralphs Dana Garel Lilly USA Jnathan Medeirs, MBA - Pfizer Mark Snyder, PhD - Pfizer Liz Sampsel, PharmD San Francisc Health Plan Marsha Meyer, PharmD SCAN Health Plan Tiffany Harris, PharmD SCAN Health Plan Sergi Aguilar Gaxila, MD, PhD UC Davis Health System Timthy Cutler, PharmD UC Davis Medical Schl Mike Steinman, MD UCSF Schl f Medicine Laura Msqueda, MD USC Keck Schl f Medicine Steve Chen, PharmD USC Schl f Pharmacy Jdy Sants, PharmD USC Schl f Pharmacy Brad Williams, PharmD USC Schl f Pharmacy Haley Park, PharmD - Walgreens Sepi Sleimanpur, RPh - Walgreens Prject Spnsrs AMGEN BLUE SHIELD OF CA HEALTH NET INLAND EMPIRE HEALTH PLAN KAISER PERMANENTE KROGER/RALPHS LILLY USA PFIZER, INC. 2

4 EXECUTIVE SUMMARY The CSHP Fundatin initiated its prject, Pharmacist's Rle in the Interdisciplinary Care f the Aging Ppulatin, in July The aging fcus was selected t address a ptentially vulnerable ppulatin that wuld greatly benefit frm increased interactin with and care frm pharmacists, particularly when fcusing n ply- pharmacy issues and the prevalence f chrnic disease. The increasing diversity and lifespan f lder adults, and pprtunities t strengthen pharmacy practice resulting frm the passage f SB 493 in 2013 which designated pharmacists as healthcare prviders, pens the dr t the develpment f advanced practice pharmacy, which in turn increases pprtunity fr pharmacists in caring fr the aging ppulatin. The verall intent f the prject is t: 1) Maximize the rle pharmacists play n interdisciplinary care teams. 2) Imprve the health and healthcare f lder adults by strengthening the training and preparatin f pharmacists t wrk with lder adults. 3) Identify pprtunities where care fr lder adults can strengthen the implementatin f SB 493. Desired lnger- term utcmes f the prject include: Increased pharmacist invlvement n interdisciplinary care teams fcused n aging. Increased number f pharmacists in lead medicatin management rles fr lder adults. Expanded pharmacy schl curriculum fcused n aging that addresses the changes in the aging prcess and ppulatin. Increased number f pharmacy students chsing t wrk with lder adults. Increased number f rganizatins adpting payment refrms that include pharmacist reimbursement fr geriatric patient services. Phase One f the prject was structured t establish a baseline that wuld: Describe current appraches in pharmacy training and perfrmance that are embedded in tday s healthcare educatin and delivery system. Prvide recmmendatins t strengthen current pharmacy practice. Address identified gaps, with a particular emphasis n: Rles pharmacists currently fill in Califrnia t imprve healthcare fr lder adults. Gaps in senir healthcare that can be imprved thrugh pharmacy services. Hw the pharmacy wrkfrce is being prepared fr current and develping pprtunities. As we mve frward addressing the issues related t pharmacy and aging, there are a number f cnsideratins we shuld pnder. What fllws are seven factrs identified thrugh analyses f available literature. The challenge and task befre us is t identify the mst effective ways t supprt pharmacists as a prfessin able t care fr lder adults, btain recgnitin fr the quality f care prvided and be paid fr the care they deliver. 3

5 Factr One Cntinued Aging We are nt ging t get any yunger as a sciety. Peple will be living lnger with higher quality f life in later years. With this psitive lngevity, the lder adult ppulatin will still need medicatins the mst t help them manage their chrnic diseases. Factr Tw Aging & Diversity The aging ppulatin is grwing mre racially and ethnically diverse in ur ld age. This will require new parameters fr hw care is prvided and hw t mst effectively navigate medicatin and chrnic disease management. Factr Three Pharmacy Pipeline Frntline healthcare and clinical staff des nt, and in the next decade, will nt lk like the majrity f lder patients they serve. This will necessitate lking creatively abut hw t increase the diversity f the pharmacist pipeline. Factr Fur Interdisciplinary Care Teams Interdisciplinary Care Teams can wrk. Examining the geriatric ppulatin t be served and the needs they ll present, wh shuld be n the team and hw shuld each member s rle be shaped? Factr Five The Business f Pharmacy Practice The business f pharmacy is changing. Medicatin dispensing will nt fully ffset the csts f care r prpel pharmacists int a new mde f payment fr practice. What will that new business mdel embrace? Factr Six Pharmacy Schl Training Leadership Rle Tw f the key utcmes f SB 493 are the designatin f Advanced Practice Pharmacy (APP) and the pprtunity fr pharmacists t be paid fr services prvided. What leadership rles can pharmacy schls play t structure training in geriatric care t fulfill APP requirements? And, hw can schls best equip their students t graduate understanding the business f pharmacy practice? Factr Seven Physician Champins Physicians will cntinue t be ne f the key decisin- makers regarding payment fr pharmacy practice. Hw d we identify and strengthen the relatinship between pharmacists and physician champins wh supprt pharmacists as healthcare prviders and payment fr quality pharmacy care prvided? As yu read this reprt, cnsider these factrs and the next steps prpsed. Yur thughts n hw t maximize the rle f pharmacists as healthcare prviders caring fr lder adults are invaluable. 4

6 METHODOLOGY Three cmpnents were brught tgether t establish the prject s baseline assessment: Literature Review, Survey Research and Meta- Analyses Review. LITERATURE REVIEW A number f articles were reviewed t prvide the framewrk fr what is knwn abut the: 1) aging ppulatin, 2) aging prcess and 3) pharmacy wrkfrce and training t addressing aging, helping t frame the data elements f the prject s surveys. The articles reviewed included: Diabetes Tied t a Third f Califrnia Hspital Stays, Driving Health Care Csts Higher, Califrnia Center fr Public Health Advcacy, May 2014 Diversity in Califrnia s Health Prfessins 2008: Pharmacy, Center fr Health Prfessins Califrnia s Pharmacists and Pharmacy Technicians, 2014, Califrnia Healthcare Fundatin Primary Care: Prpsed Slutins T The Physician Shrtage Withut Training Mre Physicians, Health Affairs, Nvember 2013 Retling fr an Aging America: Building the Health Care Wrkfrce, Institute f Medicine (IOM) Reprt, 2008 Pharmacists as Vital Members f Accuntable Care Organizatins, Academy f Managed Care Pharmacy, 2011 The Hispanic Patient- Pharmacist Relatinship: Untapped Ptential, May 2012 The Value f Drug Adherence, 2014 Facts and Fictins Abut an Aging America, Weingarten Fundatin Research Netwrk n An Aging Sciety, Fall 2009 SURVEY RESEARCH PROCESS Three surveys were develped in partnership with the USC Schl f Pharmacy and disseminated by the CSHP Fundatin t each pharmacy schl in Califrnia, pharmacy students frm each schl and practicing pharmacists thrughut the care cntinuum, frm September thrugh mid December The CSHP Fundatin disseminated the surveys t its members. CSHP als reached ut t ther rganizatins t distribute the surveys t their members, including the Califrnia Pharmacists Assciatin (CPhA), Califrnia Hspital Assciatin Medicatin Safety Review Cmmittee and the Califrnia Assciatin f Physician Grups (CAPG) Pharmaceutical Care Cmmittee. The prject s expert panel was als apprached fr assistance in disseminating the surveys t their members. These appraches resulted in larger reach amng pharmacists in different practice settings. One shrtcming f the survey results, hwever, was mre limited participatin amng cmmunity pharmacists and pharmacists wrking in lng- term care settings. META- ANALYSES REVIEW Once results frm these surveys, particularly the survey addressing pharmacy practice were tabulated, the utcmes were cmpared t US Pharmacists Effect as Team Members n Patient Care Systematic Review and Meta- Analyses, the meta- analyses cmpiled by the Department f Pharmacy Practice and Science at the University f Arizna Cllege f Pharmacy. Cmparisn f survey results with the Meta- Analyses i helped t identify best practices and prpsed next steps fr the prject. Cmpletin f the literature review and extensive review f the meta- analyses prvided a strng fundatin used t shape the fcus and cntent f each f the three surveys develped and disseminated fr the prject. 5

7 LITERATURE REVIEW KEY LEARNINGS The key pints f the literature review highlighted areas where pharmacists culd play strnger rles t imprve the health and healthcare f lder adults. It als sharpened understanding f the dynamics shaping the aging ppulatin and aging prcess, and hw these will likely impact health pririties and healthcare practice, including pharmacy practice. THE AGING POPULATION The Baby Bmers are leading the way tward an aging sciety. We will cntinue t have an lder age ppulatin shape ur sciety past the impact f the Baby Bmers, due in part t increased life expectancy and reduced birth rates. ii The majrity f Medicare beneficiaries suffer frm a significant percentage f chrnic diseases, with 82% having at least ne chrnic disease. iii Older adults will cntinue t be mre likely t have multiple chrnic cnditins, with the treatment chice ften medicatin therapy. THE AGING PROCESS Active lifespan is increasing faster than ttal lifespan. This is because the health and functinal capacity f lder adults has been imprving since the 1980s due in large part t imprvements in healthcare and bimedical technlgy. Decreases in functinal capacity are als being driven by factrs utside f aging, including race, ethnicity, sciecnmics and educatin. iv Variatins in disease patterns amng lder adults are als seen by gender and race/ethnicity. v Gender Differences Men experience higher rates f heart disease, cancer, diabetes and emphysema, with mre inpatient stays. Wmen experience higher rates f steprsis, arthritis, asthma, chrnic brnchitis, and hypertensin and are mre likely t reprt episdes f depressin. Differences by Race/Ethnicity & Culture Asian Americans experience the lwest rates f disabilities, lngest life expectancy and fewest years in pr health. African Americans have the shrtest life expectancy, lngest number f years lived with chrnic disease and the highest prevalence f strke, diabetes and hypertensin. Accrding t the CDC s Natinal Center fr Health Statistics (NCHS), African Americans tend t use nursing hmes at a higher rate than white lder adults and accrding t the Agency fr Healthcare Research and Quality (AHRQ), were mre likely t experience preventable adverse events r cmplicatins f care frm hspitalizatin. Whites were mre likely t reprt cases f cancer and chrnic lung disease. Thse ver 65 will utnumber thse under 15 fr the first time by (United Natins) Older adults are becming mre diverse. By 2050, 40% f thse 60+ will be Latin. (Pew Research) It is estimated that 21% f Americans 45 t 64 years f age have at least tw chrnic cnditins and ver tw- thirds f thse 65 years and lder have tw r mre chrnic cnditins. (CDC) Medicare beneficiaries with limited English prficiency were less likely t have access t a cnsistent surce f care and less likely t receive imprtant preventive care than Medicare beneficiaries wh speak English fluently. 6

8 Hispanic and nn- Hispanic black lder adults experience greater limitatin r disability than nn- Hispanic whites and tend t use healthcare services less frequently. The grwing racial and ethnic diversity f ur aging ppulatin will require a greater understanding f hw race/ethnicity and culture effect health decisin making amng lder adults and their family members. The ability fr lder adults t understand and participate in their health decisin- making will be greatly increased with a pharmacy wrkfrce that better reflects their backgrund and understanding. Pharmacy Wrkfrce PHARMACY WORKFORCE, TRAINING & PATIENT ENGAGEMENT Nt unlike ther health prfessins, the race and ethnicity f pharmacists des nt match Califrnia s ppulatin. Accrding t the Califrnia Healthcare Fundatin s Califrnia Health Care Quick Reference Guide fr 2014 vi a significant gap exists between the race and ethnicity f Califrnia s ppulatin and its pharmacy graduates. Race/Ethnicity & Culture Table 1: Pharmacy & Pharmacy Tech 2012 Califrnia Graduates RACE/ETHNICITY PHARMACY PHARMACY TECH TOTAL CA GRADUATES GRADUATES POPULATION Asian 61% 13% 13% Latin 4% 44% 38% White 20% 19% 39% Native American <1% 1% <1% African American 2% 10% 6% Other/Unknwn 12% 13% 3% With the grwing racial and ethnic diversity f Califrnia s lder adults, it will be critical fr pharmacists t cnsider appraches t better cnnect a mre diverse aging ppulatin with a wrkfrce that mre clsely reflects their racial and ethnic diversity. This is an issue experienced by all general healthcare membership rganizatins. It is recmmended that CSHP and its Fundatin reach ut t rganizatins such as the: Califrnia Medical Assciatin (CMA), Califrnia Academy f Family Physicians (CAFP), Califrnia Academy f Physician Assistants (CAPA), and the Califrnia Assciatin f Nurse Leaders (CANL), t discuss the steps these rganizatins have taken t strengthen their relatinship with bth individual prviders frm different race/ethnicities and ethnic prvider rganizatins. Fr example, the CMA Fundatin tk steps a number f years ag t help rganize and supprt the Netwrk f Ethnic Physician Organizatins, (NEPO). NEPO is cmprised f ethnic physician rganizatins and ethnic medical student leaders and prvides input t bth the CMA Fundatin and CMA n healthcare plicy, patient engagement, public health, and healthcare quality. Similar rganizatins appear t exist in pharmacy, including the: Table 2: Ethnic Pharmacists Organizatins Assciatin f Black Health System Pharmacists, based in Flrida Hispanic Assciatin f Pharmacists Hustn, TX Indian Physicians Assciatin f Califrnia Vietnamese Pharmacists Assciatin f the USA and Suthern Califrnia 7

9 All pharmacy schls als have chapters representing the larger racial and ethnic pharmacist rganizatins n their campuses that can be reached ut t as well. HEALTHCARE WORKFORCE PIPELINE Pipeline Supprt There are a number f prgrams that prvide funding t increase the diversity f Califrnia s healthcare wrkfrce thrugh bth state and federal funding. These prgrams nly prvide supprt t grups that are designated as healthcare prviders, with the bulk f this funding ging t physicians and physician rganizatins. Prir t passage f SB493, when pharmacists were nt cnsidered healthcare prviders, their prfessin wuld likely nt have been eligible fr this supprt. Mving frward, the pharmacy prfessin and its leadership shuld reach ut t these rganizatins as well as ther health prfessins and learn what supprt might be available and the pipeline appraches used by ther healthcare prfessinals. Pharmacy Technicians Pharmacy leaders shuld als cnsider ways t utilize pharmacy technicians in mre patient centric care as a means f better aligning their wrkfrce better with the race and ethnicity f the lder patients they will be serving. This apprach has been cnducted in medicine with medical assistants (MAs) and has been met with success, including MAs having functined as members f care teams in medical practice. vii Data Capture Anther issue identified in the Institute f Medicine (IOM) Retling reprt was the fact that it is difficult, if nt smetimes impssible t capture data n the wrk pharmacists are ding with and fr lder adults. In the mre traditinal rle f cnsultant pharmacists wh prvide supprt t skilled nursing facilities and their staffs, data is mre readily available describing the wrk and relatinship these pharmacists have with patients and ther healthcare prviders. What is ften als nt tabulated, resulting in a lack f awareness abut pharmacy practice, is the wrk dne by pharmacists n care teams in medical grups, ACOs and health systems as well as much f the wrk taking place in cmmunity pharmacies, including independent pharmacies, unless this is part f a pilt r demnstratin prject specifically intended t capture that data. T substantiate the rle f pharmacists as healthcare prviders, it will be critical fr the pharmacy cmmunity t capture this data and its impact, making sure t gather the data that addresses the pharmacist s rle as a member f a multidisciplinary care team as well as direct patient interactins that might happen mre at the pint f care. PHARMACY TRAINING & THE BUSINESS OF HEALTHCARE Pharmacy Training Mre pharmacists and pharmacy technicians will need t have training in geriatrics. As we lked at current training f pharmacists and pharmacy technicians, a series f questins came t mind: 1) With the changes taking place in ur aging ppulatin, what new rles r new appraches t care might be necessary t deliver effective, efficient, high- quality care t lder adults? 2) Hw shuld the healthcare wrkfrce be educated and trained t deliver high- value care t lder adults? 3) What will strengthen the recruitment and retentin f the needed wrkfrce. 8

10 Medicatin Management T effectively respnd t the changes in the aging ppulatin, having a pharmacy wrkfrce that is seen as the leaders in medicatin management, with appraches that lead t greater medicatin adherence is essential. Amng healthcare prviders, pharmacists have the level f understanding and expertise in medicatin management. With their recent designatin as a healthcare prvider, it is paramunt fr pharmacists t be viewed as the leader in this area, and fr pharmacists, in a clear and cmpelling way, t cmmunicate the value they bring t rganizatins prviding care t lder adults. This is the area that pharmacists need t wn, especially thse wrking with lder adults. Care Cntinuum Pharmacy students wh plan t fcus n care fr lder adults shuld learn what is invlved in their care cntinuum. Fr lder adults, this can span frm preventin t palliative care. It is critical fr pharmacy students t be acquainted with the varius settings where care may be given, and intersects between care settings as the lder adult mves thrugh this cntinuum. This hand ff, when nt dne crrectly, ften results in hspital readmissins r medicatin errrs and adverse events fr lder adults. This type f training will als acquaint the pharmacy student with the ther types f healthcare prviders wh will be part f the patient s team in the varius settings. Given the greater number f lcatins fr patients t be seen, it wuld be advantageus fr students t have training pprtunities in additin t the hspital setting. New Mdels f Care & the Business f Healthcare The mdels f patient care being develped, including fr lder adults, are all based n the premise f Interdisciplinary Team Based Care. This phrase implies an interactin and interdependence amng healthcare prviders, each with a different area f expertise wrking tgether t care fr a single patient. viii Geriatric care played a lead rle in develping team based training methds in healthcare with the Veteran s Affairs (VA) develping its Interdisciplinary Team Training in Geriatrics Prgram in the 1970s and the Health Resurces and Services Administratin (HRSA) prviding financial supprt fr Geriatric Educatin Centers (GECs) respnsible t teach cllabratin and teamwrk in geriatric care. ix In the late 1990 s, the Jhn A. Hartfrd Fundatin funded eight natinal prgrams t develp geriatric interdisciplinary team training (GITT) prgrams fr students in nursing, scial wrk and medicine. x Pharmacy, hwever, was nt a fcal pint fr that wrk. Passage f SB 493 elevates the status f pharmacists in patient care and healthcare delivery, prviding them the designatin f healthcare prvider. With the grwing fcus n new mdels f patient care, whether they be a patient centered medical hme (PCMH) r accuntable care rganizatin (ACO), anther key area f learning fr pharmacy students, including thse in geriatric training, is learning the business f pharmacy and healthcare practice. As part f the ACO healthcare team, pharmacists will play an essential rle in helping their rganizatin achieve Centers fr Medicare and Medicaid Services (CMS) required quality benchmarks. xi They have the pprtunity t play a leadership rle by bth imprving healthcare fr lder adults and playing a necessary rle in lwering an rganizatin s ttal cst f care thrugh effective medicatin management and reductin f adverse events related t medicatin use. Pharmacists, well trained in pharmactherapeutics are uniquely psitined t help ptimize apprpriate medicatin use, reduce medicatin related prblems and imprve health utcmes. Even with this expertise, pharmacists are ften underutilized, with ther less cstly health care prviders playing the lead rle in maximizing safe medicatin use. xii Serving in these critical rles 9

11 n the patient s team will prvide the sunding bard fr the pharmacist s value prpsitin shwcasing their benefit t the rganizatin. Unfrtunately, mst healthcare prviders are still trained separately in their specific discipline, which sets up an implied hierarchy and respnsibility fr decisin- making and adds little understanding r appreciatin fr the expertise f ther team members. Team based training can break thrugh these barriers allwing fr healthcare prviders f varied backgrunds t have a deeper appreciatin f what each prvider brings t the team. Cultural Diversity With the grwing diversity f lder adults, there needs t be a greater fcus n hw race/ethnicity and culture influence health decisin- making xiii. Training shuld encmpass: Table 3: Recmmended Pharmacy Student Cultural Diversity Training Cmpnents An understanding f diverse cultural health beliefs and practice systems f the patient s culture. Histric ccurrences that lder adults may have experienced that will influence their health decisin- making and trust in their healthcare prviders Awareness f the impact f health literacy n health decisin making amng lder adults, particularly thse frm diverse cultural backgrunds Cmprehensin f the rle f bth palliative and hspice care by healthcare prviders, patients and their family members Culturally apprpriate respect fr lder adults Opprtunities t bserve & perfrm culturally apprpriate patient assessments Effective engagement with lder adults as they explain their health cnditins Learning hw best t wrk with family members Understanding the value and ability t identify health navigatrs r guides The Direct Patient Wrkfrce PATIENT ENGAGEMENT The Direct Patient Wrkfrce has been described as thse healthcare practitiners wh interact directly with the patient r patient s family and prvide direct patient care. xiv As reprted by the IOM in their Retling Reprt, direct care wrkers fr lder adults were identified as: Nurse assistants, wh prvided 70% t 80% f care hurs in lng- term care settings. Scial wrkers wh played leadership and cllabrative rles in lng- term care settings, particularly skilled nursing and hspice care. The IOM stated that lder adults accunt fr abut ne- third f the patient visits t Physician Assistants (PA), wh as a grup have less than 1% f their members specializing in geriatric care. The Retling reprt als indicated that less than 1% f pharmacists and registered nurses were certified in geriatrics. 10

12 As mentined previusly, it is still very difficult t capture data, even with strnger electrnic systems, that describe and quantify the wrk pharmacists, ther than cnsultant pharmacists wrking in lng- term care, prvide t lder adults. As pharmacy training and practice expands, it will be critical fr pharmacists and pharmacist rganizatins t develp standardized appraches t gather and reprt this data. When best practices in this area are identified, they shuld be widely shwcased by pharmacist rganizatins. Pharmacy Technicians as Care Navigatrs and Guides As reprted earlier, pharmacy technicians in Califrnia mst clsely mirrr the race and ethnicity f Califrnia s ppulatin, including the grwing cultural diversity f the aging ppulatin. This grup f pharmacy staff culd therefre play a brader rle as health navigatr and guide fr lder adults and their families nt familiar with the healthcare system, and thse with limited English prficiency. This type f wrk is being dne n a much brader basis in rganized medicine where medical assistants, wh als mre clsely reflect a physician s ethnic patient mix, are serving as health navigatrs and sme are als being trained t serve as health caches within primary care health hmes. xv Sme hspitals have already started dwn this path with the creatin f Hspital Navigatr Pharmacy Technicians. These technicians serve as a liaisn frm within the utpatient pharmacy and engage mre in face- t- face patient cmmunicatin. They are als expected t cllabrate with patients and their families, nursing staff, physicians and case managers t enrll patients in ppulatin health prgrams. Mving frward, it wuld be wrthwhile t determine if Califrnia hspitals have these navigatr prgrams in place. If these are nt fund in Califrnia, it wuld be advantageus t determine which f these prgrams are fund in ther states. SURVEY RESEARCH Results f the three surveys develped in partnership with the USC Schl f Pharmacy are summarized n the fllwing pages, prviding the highlights and key findings fr each survey. PRACTICING PHARMACIST SURVEY FINDINGS In the area f Pharmacy Practice, the survey addressed a number f factrs, with pririty given t the fllwing areas: Practice setting and the presence f interdisciplinary care teams. Referrals t pharmacists fr patient care. Imprvements in patient care and health utcmes. Appraches t wrk with diverse patients, their family and caregivers. Hw pharmacists cmmunicate their value in strengthening health, healthcare and reducing cst f care. Hw payment is factred int pharmacy practice. 221 practicing pharmacists initiated the survey with 105 cmpleting it fr a 48% respnse rate. Many f thse wh did nt cmplete the survey clsed it because little f their time was spent caring fr lder adults. 11

13 RESPONDENT BREAKDOWN The respndent breakdwn belw utlines the respnse pattern by type f pharmacy practice. The fllwing is the breakdwn f survey respndents by practice setting: Table 4: Breakdwn f Practicing Pharmacist Survey Participants Respndent Categry Percent Respndents Hspital r Inpatient 24% Overlap In & Outpatient 21% Outpatient Setting 17% Lng- term Care 16% Cmmunity Pharmacy 11% Health Plan 5% Telehealth 4% Other 2% This breakdwn f pharmacy practice settings appears t be under- represented in terms f cmmunity r retail pharmacy settings and the data prvides additinal lcatins capturing pharmacist wrk in bth utpatient and lng- term care settings when cmpared t the Califrnia Healthcare Fundatin s (CHCF) Healthcare Almanac Quick Reference Guide frm xvi This respnse pattern is likely the result f the fact that the prject s practicing pharmacy survey was targeted t pharmacists wh wrk with lder adults and this may nt be the primary target ppulatin f cmmunity pharmacists. The 2014 Reference Guide shws the fllwing distributin f Califrnia pharmacists fr 2010: Figure 1: Pharmacy Practice By Wrk Setting When cmparing the tw charts, the prject survey respnse pattern has a smaller percentage f participants frm Retail r Cmmunity pharmacies and appears t be n par related t hspitals. While the CHCF Reference Guide fr pharmacy practice des nt identify a specific categry related t utpatient care, as is identified in the Prject survey distributin, its Gvernment categry may include pharmacists frm that categry. The prject s respnse pattern is ver represented in the area f lng- term care and hme health cmpared t the CHCF Quick Guide. Overall, these differences can be explained by tw factrs: the prject target audience was pharmacists wh care fr lder adults which wuld lead t a greater cmpletin rate fr this grup, and in the last several years, the increasing amunt f activity f pharmacy practice in utpatient care settings necessitated surveying this grup f pharmacists. 12

14 INTERDISCIPLINARY CARE TEAM DISTRIBUTION Respndents were asked if interdisciplinary care teams were functining at their practice setting. Overall, 77% f respndents indicated that interdisciplinary care teams functined at their rganizatin. When digging deeper hwever, what emerged was the fllwing pattern: Table 5: Interdisciplinary Care Team Respnse Pattern Respndent Categry Percent Respndents Overlap In & Outpatient 100% Hspital r Inpatient 88% Lng- term Care 80% Outpatient Setting 76% Health Plan 71% Other 67% Telehealth 63% Cmmunity Pharmacy 46% Hspital and similar settings were mst likely t have functining interdisciplinary care teams. These were als seen quite extensively at lng- term care facilities as well as utpatient settings. Pharmacists wrking in cmmunity pharmacies were least likely t be part f an interdisciplinary care team. This may result frm the fact that many independent pharmacies are nt tied int rganizatins r systems prviding care t lder adults. What happens at the cmmunity pharmacy is the mst visible aspect f pharmacy practice and clse t what might be cnsidered the pint- f- care. Ging frward, it will be essential t determine hw t increase the cnnectivity between cmmunity pharmacies and ther rganizatins engaged in care fr lder adults. PHYSICIAN/PHARMACIST INTERACTION WHY CHAMPIONS ARE NEEDED A very imprtant set f survey questins shed light n the interactin between pharmacists and physicians, and why, especially with the recent designatin f pharmacists as healthcare prviders, it is critical t identify and wrk with physician champins frm arund the state wh supprt pharmacists in their rle as healthcare prviders. Physicians are key players n the interdisciplinary care team. They are the mst likely resurce fr patient referrals, and will play a critical rle in mving pharmacist payment t an accepted practice. What fllws is a breakdwn f survey results that address these issues. Interdisciplinary Care Team Based n the fact that interdisciplinary care teams have been tested and shwn t be a best practice bringing abut psitive change fr patient health in rganizatins, it was critical t supprt the spread f the teams thrughut the care cntinuum fr lder adults. xvii In every practice setting, except cmmunity pharmacy, the majrity f respndents reprted the presence f care teams. Only 46% f the cmmunity pharmacist respndents reprted being part f an interdisciplinary care team. This cmpared t 76% fr medical grups, 100% fr the VA, 80% fr skilled nursing and 88% fr hspitals. The cmpsitin f the care team was als reviewed t determine which healthcare prviders were mst likely t be n the teams. Pharmacists and physicians were mst likely t be mentined in all practice settings as being n a care team, fllwed by registered nurses (RN) and scial wrkers. There was sme variatin in participatin based n whether the rganizatin was hspital based, lng- term care r mre utpatient in its fcus. The respndents frm hspitals and lng- term care were mre likely t have dieticians and scial wrkers as members f their team as well. 13

15 Referral Prcess By far, physicians were the mst likely surce f referrals t pharmacist survey respndents. Fr all f the practice settings, physicians were the healthcare prvider verwhelmingly respnsible fr a referral t a pharmacist. This pattern was the same fr inpatient, utpatient, lng- term care and cmmunity pharmacy. A patient was mre likely t self- refer t Cmmunity pharmacists than in ther settings. Scpe f Practice Survey respndents were asked whether they had the authrity t initiate drug therapy changes r whether they were required t make recmmendatins t physicians, and with physician apprval, initiate the change. Fr all practice settings except cmmunity pharmacy, respndents were split n this questin. In inpatient, utpatient and lng- term care settings, pharmacists were as likely t be able t make mdificatins as they were t need physician apprval. Fr cmmunity pharmacists, the verwhelming respnse was that they culd nly make drug therapy recmmendatins t physicians and culd nt initiate changes withut physician apprval. Mving frward, this may be an area t explre mre fully as t the ratinale fr these practices. Types f Services Prvided Respndents were asked t identify the types f pharmacy services they prvide. The fllwing figure represents pririty services prvided. Figure 2: Types f Services Prvided 14

16 When we break this dwn further within practice settings, we see the fllwing pattern: Assisted living des little in the way f medicatin therapy management. Pharmacists invlved in all majr practice settings engage in cmprehensive medicatin review and reslutin f medicatin related prblems. Hspitals and IPAs are mre likely t prvide pharmacy cnsultatins fr team members, fllwed by hspital based clinics, the VA, health plans, staff mdel medical grups, skilled nursing facilities and cmmunity pharmacy. Cmmunity pharmacy is mre likely t prvide preventive services than the ther settings. Hspitals, the VA, medical grups, bth staff mdel and independent practice assciatins (IPA), engage mre in mdificatin f medicatin therapy care plans. Lab tests are mre likely t be rdered by pharmacists at hspitals, the VA, and IPA medical grups. Patient educatin is mre likely t be prvided by pharmacists at the VA, hspitals, and medical grups. Fllw- up care is mre likely t be prvided by the VA, in hspital clinics and IPAs, but nt by hspitals n the inpatient side. Payment fr Services Respnses t the questin abut payment fr pharmacy services shw sme mvement in the area f pharmacist payment beynd a salaried psitin. Salaried pharmacists were mre likely t be fund in large institutins. Cmmunity pharmacists are beginning t experience reimbursement as part f demnstratin prjects with health plans and ther payrs, including sme ACOs, where payment is based n imprvements made and benchmarks attained. A number f respndents chse the Other categry t describe their reimbursement. When reviewing their descriptin f Other, it meant that they were nt being reimbursed at this time and prviding additinal pharmacy services at n cst t the larger institutin requesting the services. This is a critical area t watch. Since SB 493 des nt require payment fr pharmacy services, pharmacists will need t demnstrate and dcument that their invlvement in patient care, including medicatin and disease state management, has lead t definite imprvements in patient health, making the link between payment and imprvement. COMMUNICATING THE VALUE PROPOSITION FOR PHARMACY PRACTICE When asked, pharmacist survey respndents had a difficult time clearly and cncisely describing the benefit they brught t their rganizatin in strengthening patient care, health utcmes and reducing cst f care. If this cannt be clearly articulated, it will be difficult t mve the bar fr pharmacists in terms f prvider status, recgnitin and payment fr pharmacy services. It is recmmended that as the prject mves frward, training and tls be develped t assist pharmacists in this effrt. 15

17 IMPROVEMENTS IN HEALTH OUTCOMES Respndents were asked t designate areas where they had been able t identify and dcument imprvements in care fr lder adult patients. Belw is a chart that summarizes thse changes. Figure 3: Dcumented Imprvement in Health Outcmes The tp three identified imprvements at ver 50% were seen in increased patient safety, imprvement in apprpriate medicatin prescribing and patient satisfactin. These three imprvement areas were fllwed clsely by increased medicatin adherence and increased satisfactin amng the members f the care team. When asked t identify the factrs that were felt t lead t these imprvements, the fllwing factrs were highlighted: The unifrm invlvement f the interdisciplinary care team members teamwrk! Supprt fr care crdinatin, allwing team members t supprt the patient. Putting plans tgether by the team t address imprvement pprtunities. Regular cmmunicatin with the patient s physician s he r she is in the lp n the imprvement plan and prgress. Accept that right nw, payrs aren t paying fr patient educatin. It needs t be dne, s we have accepted the lack f payment and still prvide this critical service. Paying attentin t medicatin management issues. Supprt frm ur rganizatin s leadership. As the prject mves frward, it wuld be wrthwhile t identify successful interdisciplinary care teams and engage them in a discussin abut their successful imprvement prcesses. 16

18 WORKING WITH DIVERSE COMMUNITIES As the aging ppulatin cntinues t becme mre ethnically diverse, it will be essential t identify prvider rganizatins and practitiners that have demnstrated success in wrking with diverse cmmunities. Respndents were asked t identify what methds their rganizatin had emplyed t help them vercme cultural barriers. The tactics chsen by the rganizatins fell int the fllwing categries: Language assistance when necessary. Diversify the rganizatin s wrkfrce. Cnduct nging staff training. Leadership attentive t this need and prviding supprt. Individual practitiners shared mre persnalized strategies t strengthen their relatinship with patients and family members frm mre diverse ppulatins: Build rapprt and trust with the patient, family members and caregivers. Use interpreter services when needed. Be respectful f the patient s beliefs, values, naming f the illness, etc. Find cmmn grund. Be aware f my wn biases. Be aware f health disparities and discriminatin affecting minrity ppulatins. Knw abut and understand different cultures and their health beliefs and practices. Mving ahead, it wuld be wrth explring hw t engage individuals and rganizatins wh have had success in wrking with diverse cmmunities f lder adults t learn mre abut their appraches and develp pprtunities t share their learning s and resurces. PHARMACY SCHOOL SURVEY FINDINGS All f Califrnia s eight Schls f Pharmacy were surveyed with all schls participating in the survey. What fllws is a summary and highlights f their survey respnses. In the area f Pharmacy Schl curriculum regarding geriatric training and expsure t cultural diversity, the survey addressed the fllwing issues, including the availability f Geriatric Didactic Cursewrk Cursewrk related t Cultural Diversity and Health Literacy Intrductry & Advanced Practice Pharmacy Experiences (IPPE & APPE) in Geriatrics Extra Curricular Activities in Geriatrics Inter- Prfessinal Teaching & Learning Opprtunities Qualified & Trained Geriatric Faculty GERIATRIC DIDACTIC COURSEWORK All schls ffer Geriatric Pharmactherapy cursewrk. Mre schls are inclined t integrate this cntent int ther therapeutic curses rather than make this a stand- alne ffering. When respndents were asked the ratinale fr incrprating geriatric materials int ther therapeutics curses, several respnses were prvided: 17

19 The fllwing tpics were mst likely t be included in the Geriatric Didactic Cursewrk: Medicare Part D Diversity f the Aging Ppulatin and Culturally Respnsive Pharmacy Care Specific Diseases in Geriatrics Geriatric Pharmactherapy Geriatric Syndrmes Physilgy f Aging Scilgy f Aging Psychlgy f Aging Other Tpics included elder abuse, aging netwrks, family issues, geriatric health plicy and demgraphics. What was nt included in the tpics and cntent f the cursewrk were aspects f interdisciplinary team based care, health preventin and health prmtin fr lder adults and the business f pharmacy practice with lder adults. CULTURAL DIVERSITY & HEALTH LITERACY COURSEWORK The majrity f respndents, 77%, indicated that they did nt ffer stand- alne cursewrk addressing cultural diversity r health literacy. These cncepts were integrated int ther curses. The ratinale fr this apprach was driven by bth practical and philsphical cnsideratins. Table 6: Ratinale fr Structure f Geriatric Curse Wrk Available time and space in the curriculum. This can be especially prblematic since didactic curses have t be cmpleted in the first tw years. Availability f faculty with training t teach the cursewrk. This cncern was viced several times. Tw- thirds f respndents indicated that their geriatric cursewrk was required, with the thers stating geriatric cursewrk was an elective. 56% f respndents stated that 1 t 2 credit hurs were dedicated t their geriatric didactic cursewrk. Respndents als had a preference t cmpartmentalize therapeutics curses by rgan systems r disease states. Several respndents indicated that it was difficult t find space in an already tight curriculum as well as finding qualified faculty t teach the curses. Others stated that they felt that it was better t incrprate these cncepts int ther curses s students wuld have many pprtunities t be expsed t the cncepts, seeing hw cultural diversity and health literacy were linked t ther imprtant health and healthcare issues. The Cultural Diversity and Health Literacy curses available are bth required and elective, depending n the pharmacy schl. Table 7: Cultural Diversity & Health Literacy Curse Cntent Cultural Diversity Backgrund n varius cultures in the US Wh the health decisin maker is in the family Health beliefs f the varius cultures in the US Beliefs f the varius cultures in the US regarding medicines and ther types f herbal and traditinal remedies Health Literacy Assuring that tls/resurces are easy t use Becming aware f biases/assumptins Accessing infrmatin apprpriate fr level f understanding Speaking clearly and listening carefully Educatin, individually r in a grup, in partnership with educatrs wh understand the patient and family s culture and hw this influences their health decisin making 18

20 Cursewrk als addressed vercming cultural barriers. Cntent addressing this subject area included: Explring and becming respectful f patient beliefs, values, meaning f illness, preferences and needs. Building rapprt and trust. Finding cmmn grund. Becming aware f wn biases and assumptins. Becming knwledgeable abut different cultures. Becming aware f health disparities and discriminatin affecting minrities. Using interpreter services when needed. Understanding the rle f a pharmacist. IPPE & APPE GERIATRIC ROTATIONS Intrductry and Advanced Pharmacy Practice Experience rtatins are ffered at all the Schls f Pharmacy. Hwever, several f the schls d nt have a specific geriatric APPE rtatin r require an IPPE rtatin. Fr thse schls withut a required IPPE rtatin, students may request an IPPE geriatric rtatin. Hwever, respndents indicated that the sites might nt always be available when a request is made. Respndents als indicated that while geriatric APPE rtatins are nt always available, there is a substantial geriatric ppulatin at the AAPE Rtatin sites. The purpse f these rtatins is t ffer mre hands n learning experience t pharmacy students. Rtatins are set at participating healthcare rganizatins. Organizatins listed as participating fr bth IPPE and APPE rtatins included: Table 8: IPPE & APPE Geriatric Rtatin Sites Hspitals Ambulatry Care Clinics Skilled Nursing Facilities Bard & Care Hmes Assisted Living Facilities PACE Clinics Cmmunity Pharmacies and Senir Husing Cmmunities What has been cvered n these rtatins in the past has included: Hw t perfrm a cmprehensive medicatin review. Identificatin and reslutin f medicatin related prblems. MTM fr Part D Patients and nn Part D Patients. Preventative Health Services such as immunizatins and health screenings. Drug infrmatin cnsultatins fr healthcare team members. Fllw- up care fr patients as needed. Educatin and cunseling t patients abut self- care t imprve their health cnditin. GERIATRIC EXTRA CURRICULAR PHARMACY ACTIVITIES Rughly tw- thirds f the respndents indicated that extra curricular pharmacy activities specializing in geriatrics were available at their schl. Settings used fr extra curricular activities include: Table 9: Geriatric Extra Curricular Settings Cntinuing Care Retirement Cmmunity (CCRC) Senir Wellness Centers Assisted Living Hme Care Student Run Free Clinics Sites selected fr these activities are mre likely t reflect mre infirmed, less active lder adults. 19 Skilled Nursing Facility Adult Day Health Centers PACE Clinics Health Fairs Bard & Care Hmes

21 Extra Curricular Pharmacy Practice activities address a number f health and geriatric issues: Figure 4: Primary Health Care Issues Addressed In Extra Curricular Pharmacy Practice Activities Additinal health and aging issues addressed include Urinary Incntinence, Musculskeletal Disrders, Cancers, Urinary Tract Infectins, Parkinsn s Disease, Anxiety Disrders, Oral and Dental Health, Pneumnia and Visin. What was nt included in the Extra Curricular activities was expsure t elements f multicultural healthcare. Several f the respndents shared cncerns abut their IPPE and APPE rtatins and extra curricular pharmacy activities, stating that mre sites were needed t meet student training needs fr these as well as the multidisciplinary teaching and learning pprtunities. INTER- PROFESSIONAL LEARNING OPPORTUNITIES Respndents reprted their schls ffer students participatin in Inter- Prfessinal activities that are made available all fur years with mre participatin in the student s first and third year. Available settings fr this fcused n the mre infirmed lder adult, leaving ut settings such as medical grups, ACOs r clinics where students wuld see lder adults as part f a brader healthcare practice and cmmunity. Als missing frm this training was a cmpnent addressing care transitins, which is critical fr this ppulatin. Figure 5: Healthcare Prfessinals that Cmprise Inter- Prfessinal Teams 20

22 Participatin n an Inter- Prfessinal Team allws the pharmacy student t experience first hand multidisciplinary team based care fr lder adults during their training, prviding the pprtunity fr this experience t be fundatinal fr the student and his r her belief in the value that healthcare is based n shared respnsibility. QUALIFICATIONS/TRAINING OF GERIATRIC FACULTY & ADDITIONAL GERATRIC TRAINING 70% f respndents stated their institutin ffers a Certificate r cncentratin in geriatrics with 20% ffering a Pst Graduate Year (PGY) 1 Residency in geriatrics. And, 92% f faculty wh teach geriatrics has geriatric experience, which strengthens what is taught. HOW DOES CURRICULUM MEASURE UP TO SB493 & THE BUSINESS OF PHARMACY At the cnclusin f the Pharmacy Schl survey, respndents were asked if they felt adding r enhancing what was ffered t students at their schl regarding geriatric educatin wuld be sufficient t meet what is t becme Advanced Practice Pharmacy, as was designated in SB493. Respndents stated that they felt geriatric training wuld fit well with Advanced Practice Pharmacy and that having this training wuld be very helpful fr upcming students. Hwever, at n time did the cncept f the business f pharmacy, r the cncept f linking quality imprvement with payment r incrprating utpatient services, r effective management f care transitins in geriatric training cme up. As has been learned the hard way in rganized medicine, simply learning hw t practice medicine withut knwing hw t practice the business f medicine can sink the ship. As schls cnsider ways t strengthen geriatric care, let s encurage them t include the business f geriatric pharmacy practice as part f that enhancement. PHARMACY STUDENTS SURVEY FINDINGS Students frm all Schls f Pharmacy participated in the survey. What fllws highlights the student s respnses t the survey questins. 154 students initiated the survey, with 71 surveys cmpleted, fr a 46% cmpletin rate. 40% f respndents were 1 st year, 20% were 2 nd year, 22% were 3 rd year and 18% were 4 th year students. The Pharmacy Student survey addressed student - Perceptins f and interest in wrking with lder adults. Perceived value f Geriatric Cursewrk Training. Opprtunity fr students t engage in real life experience wrking with lder adults in multidisciplinary care teams, identifying the span f these pprtunities. PERCEPTIONS OF OLDER ADULTS Students were asked t share their perceptins abut lder adults n a brad array f factrs. The fllwing charts shwcase thse results. Results are reprted using the number f student respnses fr each questin, nt the percent f respnses. 21

23 Figure 6: Pharmacy Students Perceptin f Older Adults (1 f 3) Medical care fr ld peple uses up t much human and material resurces. It is sciety's respnsibility t prvide care fr its elderly persns. If I have the chice, I wuld rather see yunger pa_ents than elderly nes The federal gvernment shuld reallcate mney frm Medicare t research n AIDS r pediatric diseases. Strngly Agree Agree Neither Disagree Strngly Disagree Mst ld peple are pleasant t be with Overall, these students, wh have a strng interest in geriatric pharmacy care and aging, have psitive perceptins f lder adults and express a strng cmmitment that gvernment resurces shuld be dedicated t prvide care and supprt t this ppulatin. Figure 7: Pharmacy Students Perceptin f Older Adults (2 f 3) Old peple in general d nt cntribute much t sciety I tend t pay mre aden_n and have mre sympathy twards my elderly pa_ents than my yunger pa_ents Taking a medical histry frm elderly pa_ents is frequently an rdeal Elderly pa_ents tend t be mre apprecia_ve f the medical care I prvide than are yunger pa_ents As peple grw lder, they becme less rganized and mre cnfused Strngly Agree Agree Neither Disagree Strngly Disagree

24 Students feel lder adults cntinue t be cntributing members t sciety as they age, but d believe that they becme less rganized and mve cnfused as aging cntinues. While memry disrders are mre prevalent in lder adults, it is cautinary that students seem t feel s strngly abut this. Figure 8: Pharmacy Students Perceptin f Older Adults (3 f 3) It is interes_ng listening t ld peple's accunts f their past experiences In general, ld peple act t slw fr mdern sciety. Old persns dn't cntribute their fair share twards paying fr their health care Strngly Agree Agree Neither Disagree Strngly Disagree Treatment f chrnically ill ld pa_ents is hpeless In these final factrs, students had a very psitive utlk n the capacity f lder adults t get alng in sciety and cntinue t cntribute t the greater gd. GERIATRIC COURSEWORK VALUE 15% f student respndents reprt having taken a stand- alne didactic geriatric curse at their schl. In this grup, nly 58% felt the curse ffered sufficient backgrund in geriatrics. T prvide a mre cmplete backgrund in geriatrics, respndents felt the curse shuld: Place mre emphasis n geriatric diseases and treatments. Prvide mre instructin regarding acute management f geriatric cnditins, such as hspice care and pain management. Incrprate a rtatin in geriatrics in the curse. Incrprate Beer s criteria in lectures. What students felt was f greatest value abut the curse was: Learning abut treatments and what can be used and nt used. Learning abut the treatment apprach with the geriatric ppulatin and hw it varies frm the yunger ppulatin. Knwing what medicatins t avid and why these shuld nt be used. Learning hw t treat geriatric patients relative t the nrmal adult ppulatin. Understanding the scial needs the elderly face as well as their physilgical respnse t medicatins. Medicare Part D Physilgical changes assciated with aging that can alter therapy. 23

25 Learning hw t interact with and care fr the elderly ppulatin. What this ppulatin is facing in their life; what they struggle with in ld age and hw imprtant the pharmacist s rle is in helping them. EXPERIENTIAL LEARNING OPPORTUNITIES 78% f student survey respndents reprt having participated in a number f hands n training and educatin pprtunities in geriatric care. These included extra curricular activities and rtatins. All f these students believe participating in these activities will imprve the delivery and quality f care. These fferings were structured as Inter- Prfessinal Activities where students had the pprtunity t wrk with ther healthcare prfessinals in the care fr lder adults. The settings fr these activities were primarily skilled nursing facilities, CCRCs, assisted living types f facilities and cmmunity based senir care prgrams. Healthcare prfessinals students wrked with included ther Pharmacists, Physicians, PAs, Occupatinal and Physical Therapists, Scial Wrkers, Nurses and Dieticians. A small grup als wrked with Mental Health Practitiners. While the students were ffered the pprtunity fr hands n, cmmunity based experiences, what seems t be missing frm the apprach at the Schls f Pharmacy is fcusing n the ttal care cntinuum fr lder adults. The sites, nce again, fcused n the mre infirmed lder adults. Our ppulatin is living lnger and staying healthier fr a lnger time frame. The geriatric training at the Schls f Pharmacy seems t miss that key aspect f the aging prcess, as well as the critical imprtance f care transitins fr lder adults and the rle pharmacists can play, and d play in helping lder adults stay ut f the hspital, keep well, and as well as play a rle in patient and cnsumer educatin, preventin and health prmtin. Offering students the pprtunity t participate in thse types f activities in cmmunity pharmacies, medical grups, clinics and ther utpatient settings alng with expsure t multicultural health settings, wuld prvide a mre cmplete expsure fr students in geriatric care. META- ANALYSES REVIEW At the cmpletin f the analysis f the prject surveys, it was clear that a brader rle fr pharmacists in patient care was f great value, in terms f: Patient benefit. Substantiatin f the healthcare prvider designatin resulting frm SB493. Prviding the anchr and justificatin fr payment fr patient care. Setting the parameters fr the training needed t supprt this wrk. Staff and cnsultants reviewed the meta- analyses cmpiled by the University f Arizna Cllege f Pharmacy xviii fcusing n the effect f pharmacists as team members when delivering patient care. The intent f the review was t identify best practices in pharmacy care that std the test f evaluatin. The meta- analyses were selected fr review given the depth and breadth f their analysis. RESULTS SUMMARY The meta- analyses included 298 studies, the majrity f which were cnducted in utpatient settings. The review f these studies fcused n team based direct patient care that included pharmacist participatin beynd dispensing f medicatin, including bth medicatin and disease management. The verall bjective f the f the meta- analyses was t cnduct a cmprehensive review f evidence examining the effects f pharmacists direct patient care interventins and services n: Therapeutic Safety, and Humanistic Health utcmes in the US 24

26 The mst frequently reprted pharmacist direct patient care interventins and services included: Making r recmmending medicatin adjustments. Patient Educatin addressing medicatin understanding. Patient educatin addressing disease understanding. Prspective r retrspective drug utilizatin review. Chrnic disease management. The intent f the meta- analyses was t identify what it wuld take t mve beynd what the IOM characterizes as usual care t best practice in patient care that invlved pharmacist practice and interventin with the gals f achieving desired therapeutic utcmes and reducing adverse health events. xix Over 90% f the studies included adults age 18 t 65 years f age and adults lder than 65 years f age. Of the disease states reviewed in the studies, thse mst frequently reprted were: hypertensin, dyslipidemia, diabetes, anticagulatin, asthma/chrnic bstructive pulmnary disease, infectin and psychiatric cnditins. Therapeutic Outcmes Analysis Of the studies reprting therapeutic utcmes, favrable results were fund, meaning that significant imprvement ccurred as a result f the pharmacist s direct patient care interventin when cmpared t mre traditinal r cnventinal frms f patient care. The fllwing disease states were selected t underg a meta- analyses where it was fund that pharmacists interventin and services significantly imprved utcmes xx : Hemglbin A1c Lw Density Lipprtein (LDL) Chlesterl Bld Pressure Results f this meta- analyses prvides substantiatin that pharmacist invlvement in team- based care and direct patient care can lead t significant imprvement and health utcmes. Safety Outcmes Analysis Favrable results were fund in the majrity f studies reprting adverse drug reactins and medicatin errrs where pharmacists were members f the care team cmpared t studies where the pharmacist did nt play a rle n this care team. This analysis fcused n issues such as: Adverse Drug Events Adverse Drug Reactins Medicatin Errrs Apprpriate Medicatin Dsing Once again, the meta- analyses shwed that pharmacist invlvement in medicatin therapy management where pharmacists are part f a care team is a demnstrated best practice. Humanistic Outcmes Analysis Humanistic Outcmes is the term used in the meta- analyses t refer t mre patient centric behavirs, such as: Patient Adherence Patient Knwledge (abut disease state and medicatin use) Patient Satisfactin Quality f Life 25

27 These are the indicatrs with the mst difficulty in seeing significant change. Six humanistic utcmes were selected fr meta- analyses evaluatin: medicatin adherence, patient satisfactin, patient knwledge, general health, physical functining and mental health. Medicatin adherence, patient knwledge and general health shwed statistically significant changes with pharmacist interventin, while the ther factrs did nt, indicating that pharmacist invlvement in Humanistic Outcme areas culd lead t significant psitive change. While medicatin dispensing is likely the mst well knwn rle f a pharmacist and remains a key aspect f pharmacist functinality, the results f these meta- analyses demnstrate the psitive effects f pharmacist- prvided direct patient care n a number f health utcmes that extend beynd medicatin distributin. Pharmacist- prvided care can be a cst- effective alternative t traditinal care appraches. xxi Based n the results f the meta- analyses, it wuld be advantageus t establish a prcess t identify best practice examples f this type f wrk invlving pharmacist practice in Califrnia and in the US. 26

28 DISCUSSION The US ppulatin will cntinue t age, requiring a healthcare system that can effectively address the needs f this ppulatin as they age and mve frm preventive services and health prmtin t palliative care. Pharmacists have the knwledge and skills t play a critical rle in helping lder adults manage their health and help rganizatins lwer their verall cst f care fr their aging patients. Life span is grwing and s is the functinal capacity f a large segment f lder adults. Successful partnership in preserving health and quality f life will require the healthcare cmmunity t see lder adults in their full breadth and, nt simply as shrinking, tttering, frgetful individuals with little left t ffer. This ppulatin will als cntinue t grw in its racial and ethnic diversity, requiring the healthcare cmmunity t have a strnger understanding f hw t wrk in partnership with these patients and their families. Pharmacy schls have the pprtunity t strengthen this aspect f their training, by wrking in cncert with multicultural rganizatins and identifying pprtunities fr their students t bserve and experience successful patient educatin and develpment f trusting relatinships. The pharmacy prfessinal shuld als take the pprtunity t identify shrt and lng- term appraches t braden its wrkfrce diversity t better match that f ur aging ppulatin. With the passage f SB493, fr the first time, pharmacists have a real pprtunity t receive payment fr their services after finally being acknwledged as healthcare prviders in Califrnia. Payment appraches have changed ver the years with the care f lder adults nw anchred in the era f managed care and health care cst cntainment. It will be even mre critical fr pharmacists t wrk in partnership with ther healthcare prfessinals, especially physicians t ensure payment ccurs fr quality pharmacy care prvided t lder adults. Pharmacists have nt always tld their stry well, including the Depth and breadth f their training. Impact they make in patient and cmmunity health. Leadership pharmacists prvide in medicatin management and safety, especially imprtant in the aging ppulatin with its increased prevalence f chrnic disease. Healthcare and medicatin access pharmacists and pharmacies prvide, particularly in rural areas. Rle in primary care many pharmacists play. Brad array f rles pharmacists play in ur healthcare system. Value pharmacists can bring t the healthcare system in imprving health, strengthening healthcare and reducing the ttal cst f care fr lder adults. With the pprtunity prvided thrugh the passage f SB493 t address pharmacy payment, the interactin between pharmacists and physicians is even mre critical. Physicians are the key players n the interdisciplinary care team. They are the mst likely resurce fr patient referrals t pharmacists and will play a critical rle in mving pharmacist payment t an accepted practice. It is therefre essential t identify and wrk with physician champins frm arund the state wh supprt pharmacists in their rle as healthcare prviders. 27

29 RECOMMENDATIONS FOR ACTION What fllws are a set f recmmended next steps fr the prject. These actin items are structured t run the gamut f 2015, funding and supprt permitting. Aging & Multicultural Health Decisin making Target Audiences Pharmacists Pharmacy Staff Interdisciplinary Care Team Members Multicultural Webinar Series 1) Wrking in partnership with Pharmacy Schl s Multicultural Aging Prgram faculty, state and natinal experts and Prject Expert Panel members, design a curriculum fr practicing pharmacists, pharmacy staff and members f Interdisciplinary Care Teams addressing: cmmunicatin appraches, health decisin making, health beliefs amng varius cultures, cultural beliefs abut medicines and ther types f remedies, successful appraches in building trust, the influence f culture in health decisin making and hw pharmacists are viewed in different cultures. 2) Address hw effrts t strengthen multicultural patient cmmunicatin can impact patient wrkflw and hw this can be addressed, identifying best practices where pssible. 3) Identify partner rganizatins t share their materials and experiences n this issue. 4) Cnduct a webinar series that includes pharmacist faculty wh have had success in their wrkplaces with a diverse grup f aging patients and their families. 5) Present bth a summary f pssible appraches and examples f hw pharmacists and their teams have addressed multicultural cmmunicatin and health literacy with diverse lder adults. Resurce Materials 1) Wrk with partner rganizatins t cmpile an Aging Multicultural Cmmunicatin Resurce Guide fr pharmacists and pharmacy staff. 2) Invlve Schls f Pharmacy, pharmacy students and culturally diverse patient/cmmunity- based rganizatins in the develpment f this resurce. Interdisciplinary Care Team Best Practices Target Audiences Pharmacists Pharmacy Staff Interdisciplinary Care Team Members Plicy Makers Payrs Best Practices Inventry 1) Building n the University f Arizna Meta- Analyses, identify rganizatins in Califrnia and natinally that have demnstrated success thrugh their Pharmacy Practice Interdisciplinary Care Team in breaking dwn practice sils and bringing abut psitive change in health utcmes fr lder patients with a primary fcus n utpatient care. 2) Develp a mngraph shwcasing the best practices and partnership between team members and patients. 3) Identify ther prvider rganizatins t pssibly cspnsr the mngraph. Prfessinal Educatin Prgramming 4) Implement prfessinal educatin prgramming highlighting the challenges and successful appraches f these rganizatins. a. Identify prvider rganizatins where this wrkshp culd be presented. b. Cnduct the wrkshp at the CSHP Seminar 2015 Cnference. 28

30 Physician Champins Target Audiences Pharmacists Pharmacy Staff Physicians Interdisciplinary Care Team Members Plicy Makers Physician Champin Inventry 1) Build an ethnically diverse grup f champins in Califrnia wh see value in their relatinship with pharmacists in strengthening healthcare fr lder adults. 2) Identify pharmacists acrss the care cntinuum and mdes f practice wh have psitive wrking relatinships with physicians in the care fr their patients. 3) Slidify a grup f physicians and pharmacists willing t be interviewed t share their stries abut the pwer f partnership in strengthening the health and healthcare fr lder adults. Media Methds t Tell This Stry 1) Develp a mngraph shwcasing the best practices and partnership between team members and patients. 2) Identify ther prvider rganizatins t pssibly cspnsr the mngraph. 3) Set up a prcess t distribute the mngraph and shwcase the stries included in the dcument with key audiences. 4) Explre the pssibility f develping a YuTube vide highlighting ne f these partnerships in rder t bring the stry t life. a. Include the vice f the patient in the vide. Payment Refrm Target Audiences Pharmacists Pharmacist Organizatins Healthcare Organizatins Plicy Makers Gvernment Organizatins Payrs Payment Refrm Inventry, Including Aging Fcus 1) Identify healthcare rganizatins in Califrnia that have started dwn the path t pay pharmacists fr the quality f care prvided. 2) Select a representative grup and Interview rganizatinal leadership t determine hw their payment is structured, paying particular attentin t thse rganizatins addressing aging and geriatric care. 3) Learn hw the rganizatins use data t evaluate impact f pharmacist practice n healthcare delivery, health utcmes and healthcare csts fr lder adults. 4) Discuss the mtivatin and challenges in their prcess. 5) With rganizatinal leadership, identify the key plicy issues that need t be addressed in rder fr there t be mvement in the area f pharmacy payment fr practice, with a primary fcus n payment fr care f lder adults. 6) Identify the recmmendatins these rganizatins wuld give t pharmacists and pharmacist rganizatins abut the value they bring t strengthening patient care and cntaining cst. a. Develp this int Value Prpsitin Talking Pints fr pharmacists. 7) Bring tgether leadership f the pharmacist rganizatins in Califrnia invlved in aging and geriatric care and their key partner rganizatins t develp a plicy brief addressing the issue f payment fr pharmacy practice fr lder adults that leads t imprved healthcare delivery, imprved health and cntained cst. 29