Purpose The objectives and strategies used by an ambulatory care pharmacy team operating within a large health system’s pharmacy incident command structure during the initial response to the coronavirus disease 2019 (COVID-19) pandemic are discussed. Summary In a time of crisis, a pharmacy “ambulatory action team” was formed to provide ambulatory clinical pharmacy expertise and meet an immediate and ongoing need to limit nonemergent care during the COVID-19 pandemic. By building a strong communication infrastructure and partnership with ambulatory care providers, clinic medical and operational leaderships, clinical laboratory staff, and infusion centers, the team was able to swiftly execute solutions and respond to new issues and requests. Ambulatory care pharmacy practice continued to advance through provision of services to vulnerable patient populations with chronic conditions that were anticipated to experience gaps in care management during the COVID-19 pandemic. These efforts resulted in expansion of pharmacists’ involvement in collaborative drug therapy management, support of patients’ transition from in-clinic injection to home self-administration, provision of medication assistance support, and management of 1,300 patients via protocol-based warfarin management. Additionally, ambulatory pharmacy services in 15 primary care, anticoagulation, and specialty clinic sites were transitioned to telehealth. The ambulatory action team also implemented several strategies to manage medication therapy associated with COVID-19–related shortages and implemented electronic decision support to guide prescribing of hydroxychloroquine and azithromycin. Conclusion Building a strong communication infrastructure and a pharmacy ambulatory action team were essential to respond to a crisis and continue ambulatory clinical pharmacy services expansion.
Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To expand health-system specialty pharmacy (HSSP) clinical continuity by implementing a specialty integrated model for clinical services in target sites. Summary After evaluation of baseline clinical continuity and institutional goals, select clinics were identified as target sites to which to expand this integrated approach of a medication management clinic (MMC). In this MMC model, the key steps included engaging stakeholders, workflow training, optimization of the electronic health record, service evaluation, compliance with regulatory standards, and development of marketing strategies. The initial focus was development of innovative collaborative practice agreements (CPAs) to expand the scope of ambulatory care pharmacists’ practice. Analysis of existing specialty and ambulatory workflows and technology was completed before development of the integrated workflow. Existing credentialing policies were updated to support expanded practices, and marketing collaterals were developed to support growth of pharmacy referrals. Meetings with stakeholders took place to ensure smooth transitions into integrated areas. Primary endpoints included clinical continuity, as determined by prescription orders placed within the health system sent to the HSSP, and number of signed referrals to MMC. Secondary endpoints included disease state–specific clinical outcomes as well as overall outcomes such as medication adherence, laboratory test adherence, immunization rates, and patient and clinician satisfaction. An MMC model was successfully implemented in 5 target specialty practices. Specialty clinic CPAs were developed for rheumatology and digestive health (including viral hepatitis). Since implementation, clinical continuity increased 23% and referrals exceeded the target at 165%. Data on secondary endpoints are currently being collected to evaluate quality of pharmacy services. Pharmacy services have enhanced patient care and received positive feedback from clinicians. Conclusion Expansion of integrated decentralized pharmacists into target practices has increased clinical continuity and the number of pharmacist referrals. Clinicians have regarded pharmacists as vital members of the team. Creation of additional specialty CPAs will be needed to support further growth in other clinics.
108 Background: Recent focus has shown that oral chemotherapy is high risk for medical error. Our QOPI certification process identified that oral oncologic processes were marked by: lack of documentation in the EMR, patients receiving refills from third party pharmacies after prescription discontinuation, incorrect self-administration of medications due to lack of education, delivery delays, high copays, and underuse of available patient assistance programs. Methods: A multidisciplinary task force developed a program to expedite drug access, standardize consent, and ensure clinical support including education, adherence and toxicity monitoring. We expanded an existing health-system pharmacy to provide specialty services. Treatment protocols were created for every oral oncologic drug, which are routed to a clinical oncology pharmacist and the specialty pharmacy. Nursing and pharmacist verify all orders. Medication Assistance Program for copay support. Day 1, 5 and 21 pharmacist to patient calls. Multidisciplinary flow sheet documentation. Results: Today, 80% of our patients receive medication within 72 hours. Specialty pharmacists monitor toxicity even for patients whose prescriptions are filled by other pharmacies. Pharmacists have prevented more than 400 prescription errors. Today, monthly revenue before cost for the oral chemotherapy program is nearly than $4 million. The total revenue since initiation in February 2015 is over $44 million, yielding an approximately $9 million margin after costs. Funding through the medication assistance program exceeded $1 million thus far in 2016, with an average of 140 patients receiving assistance each month. Conclusions: A patient-centered multidisciplinary model integrating clinical, operational, financial, and IT resources optimized care for patients receiving oral oncologic therapy. This project transferred revenue from for-profit third party pharmacies to our non-profit health system, and revenue is used to provide enhanced education, monitoring, and patient assistance. Our collaborative improvement model can be adapted to many practice settings.
Introduction: Therapeutic low molecular weight heparin (LMWH) regimens were developed empirically based on patient weight and renal function without the need for laboratory monitoring. The role of anti-Xa monitoring for patients receiving LMWH has yet to be fully established and is routinely performed only in high risk patients. At our institution, guidelines for monitoring LMWH recommend drawing anti-Xa levels for patients with chronic kidney disease or those with obesity requiring long-term therapy. The purpose of this analysis was to evaluate compliance with institutional guidelines for monitoring anti-Xa levels for patients receiving LMWH, including indication for anti-Xa monitoring, timing of anti-Xa level in relation to drug administration, and follow up actions of providers in response to abnormal anti-Xa levels. Methods: We conducted a retrospective chart review of adult patients who received therapeutic LMWH (enoxaparin or dalteparin) and were ordered for an anti-Xa level between September 1, 2014 and July 1, 2015. Patients were excluded if they were ordered for an anti-Xa level while on a prophylactic dose of LMWH or while on a non-LMWH factor Xa inhibitor. Data collected included patient demographics, LMWH dose and indication, ordering service, presence of a Hematology consult, reason for anti-Xa monitoring, timing of the level after the previous LMWH dose, and provider response to the level. Results: One hundred patients met inclusion criteria, 99 of whom received enoxaparin. Venous thromboembolism was the most common reason for LMWH therapy (85%) followed by atrial fibrillation (11%). The most frequent doses of enoxaparin administered were 1 mg/kg every 12 hours (52%), 1 mg/kg every 24 hours (22%) and 1.5 mg/kg every 24 hours (21%). The most frequently specified indications for anti-Xa monitoring were renal dysfunction and acute kidney injury (30%), followed by abnormal body mass index (13%); no indication was specified by the prescriber or pharmacist in 36% of cases. Of the 100 anti-Xa levels in the study, 65 were drawn at the correct time (3-5 hours after the previous dose of enoxaparin); of the 35 drawn at an incorrect time, 33 had levels measured more than 5 hours after the previous enoxaparin dose. Fifty-four of the initial anti-Xa levels were not within the therapeutic range for the dosing interval of LMWH; of these, follow up action was taken for only 21 patients (39%), most frequently resulting in a dose increase or decrease. Conclusions: In clinical practice, the use of anti-Xa monitoring is inconsistent and commonly done without a documented need. The majority of anti-Xa levels at our institution are drawn at the appropriate time after the previous dose of LMWH, but action is generally not taken in response to non-therapeutic levels. Additional guidance on the use of LMWH monitoring is needed. Disclosures No relevant conflicts of interest to declare.
PURPOSE Nonadherence is a significant issue in cancer care, especially as more oral therapies become available. Measuring and optimizing adherence to such therapies is challenging. In this study, we tested a novel technology that records real-time medication-taking behavior from a smart prescription bottle and can communicate with patients via text message to intervene in cases of nonadherence. METHODS We conducted a 28-patient pilot study to assess the feasibility of this technology in measuring and improving adherence in patients taking capecitabine, an oral chemotherapy agent with a complex, cyclical regimen. The study had a preintervention stage, during which patients were monitored, and an intervention stage, during which the text messaging intervention was enabled. RESULTS During preintervention, patients had an average self-adherence of 89%, and during post intervention, they had an average adherence of 90%. We defined three categories of patients by change in adherence: category 1 (> 8%), category 2 (−8% to 8%), and category 3 (< −8%). Patients in category 1 tended to live in regions with lower average household income (mean = $58,937 in US dollars [USD]) than those in category 2 (mean = $77,482 USD) and category 3 (mean = $90,972 USD). Of poststudy survey respondents, most indicated that they would want to continue using this technology and that they would recommend it to others. CONCLUSION This novel technology is able to monitor, measure, and intervene for patients taking capecitabine in real time. Adherence overall was high, and some patients appeared to benefit more from text-message interventions. Future work should focus on patients deemed high risk for nonadherence.
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