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North Carolina
Pharmacist
Vol. 94, Number 3 Advancing Pharmacy. Improving Health. Fall 2014
Annual Convention Preview
October 26-28, 2014
Raleigh Convention Center, Raleigh, NC
Host Hotel: Sheraton Raleigh Downtown, Raleigh, NC See http://www.ncpharmacists.org/
for more information and to register/book hotel room
Theme: "Pharmacy's Modern Role in 2014"
Highlights
Immunization Certificate Program
MTM Certificate Program
Pragmatic Issues for NOACs
Tales from the Crypt...Well Actually, The Cath Lab
Pursuit of Provider Status
MTM & Diversity: "One Size Doesn't Fit All”
"Pharmacy's Modern Role" Panel Discussion
Key Note Address
Residency Showcase and Student Sessions
Pharmacist Impact on Core Measures
Pain Management and the Forgotten Patient
Value-Based Purchasing
Point of Care Testing, A New Opportunity for Pharmacist Services
HIV and HCV Tx Update
Challenges in Antimicrobial Stewardship
Guidelines for Cholesterol Management
Pharmacy Law Update/BOP Inspections
Immunization Update
Health-System Manager’s Forum
Pharmacist Fatigue
Hypertension Management
and much more
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North Carolina Pharmacist, Fall 2014 2
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North Carolina Pharmacist, Fall 2014 3
Official Journal of the North Carolina
Association of Pharmacists
109 Church Street · Chapel Hill, NC 27516
Fax 919.968.9430
www.ncpharmacists.org
Like us on Facebook: https://www.facebook.com/pages/North-Carolina-Association-of-Pharmacists/
136657113055347?fref=ts
Follow us on Twitter:
NC Assoc of Pharm
ASSOCIATION STAFF
EXECUTIVE DIRECTOR
Daniel L. Barbara, Sr., M.Ed.
MEMBERSHIP DIRECTOR
Teressa Reavis
EVENTS DIRECTOR
Sandie Holley
ADMINISTRATIVE DIRECTOR
Linda Goswick
BOARD OF DIRECTORS
PRESIDENT
Michelle Ames, Pharm.D.
PRESIDENT-ELECT
Ashley Branham, Pharm.D.
PAST PRESIDENT
Mary Parker, Pharm.D.
TREASURER
Dennis Williams, Pharm.D.
BOARD MEMBERS
Randy Angel, Pharm.D.
Andy Bowman, Pharm.D.
Paige Brown, Pharm.D.
Thomas D’Andrea, R.Ph., M.B.A.
Stephen Dedrick, R.Ph., M.S.
Lisa Dinkins, Pharm.D.
Leigh Foushee, Pharm.D.
Ted Hancock, Pharm.D.
Jennie Hewitz, Pharm.D.
Debra Kemp, Pharm.D.
LeAnne Kennedy, Pharm.D.
Kim Nealy, Pharm.D.
Becky Szymanski, Pharm.D.
North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists. An electronic version is published quar-terly at 109 Church St., Chapel Hill, NC 27516. The journal is provided to NCAP members through alloca-tion of annual dues. Subscription rate to non-members is $40.00 annually. Opinions expressed in North Carolina Pharmacist are not necessarily official positions or policies of the Association and do not necessarily represent the views and opinions of NCAP or of NCAP board members. Publication of an adver-tisement does not represent an endorsement. Noth-ing in this publication may be reproduced in any man-ner, either in whole or in part, without the express writeen permission of the publisher.
North Carolina
Pharmacist Vol. 94, No. 3 Fall 2014
Inside
From the Executive Director………………………………………………..4
From the President…………………………..………………………………...5
H.R. 4190 From the Perspective of New Practitioners………….6
New Practitioner Network Member Spotlight……………..……...9
2014 Pharmacy Residency Conference Photo Essay…….…….10
What Can We Do Without Provider Status?……….……..……...13
Pharmacists as Critical Members of the Integrated Care
Team…………………………………………………………………………...16
The Second Victim: Caring for the Caregiver………………..…...18
NCAP Calendar for Fall 2014
September 18th at 12:00 PM —Board of Directors Meeting
September 18th at 3:30 PM—Provider Status Taskforce
September 20th—Student Leadership Conference
October 3rd—2014 NC Pharmacy Leaders Forum
October 26th-28th—NCAP Annual Convention
November 20th at 12:00 PM—Board of Directors Meeting
November 20th at 3:30 PM—Provider Status Taskforce
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North Carolina Pharmacist, Fall 2014 4
Fall 2014 promises to be an exciting time at NCAP.
At the start of a new school year, many of our members and
certainly our student pharmacists across the state are resuming
their roles as faculty, preceptors, and students. Our schools of
pharmacy are each in the process of implementing new pro-
grams, innovative ideas, and/or new curriculum. There is a
sense that pharmacy, not only in North Carolina, but national-
ly, is moving forward, endeavoring to keep pace with the ever-
changing landscape that is health care.
NCAP is certainly a part of the effort to ensure that
pharmacy remains at the cutting edge of health care and that
pharmacists, who have always been the trusted confidants of
and advocates for their patients, continue to be in a position to
provide the care that their patients need and deserve while
receiving appropriate recognition and compensation for doing
so. This is no small task, considering the extremely complex
environment of health care practice and reimbursement
(including the government and private sector health insurance
markets). Now, more than ever, it is essential that pharmacy
coalesce around and advocate for inclusion in the decision-
making process related to health policy and the development
and implementation of new practice models, services, and
reimbursement schema that advance quality healthcare,
streamline patient access to care, and ensure the solvency of
care providers.
To that end, and anticipating the need for the devel-
opment of solid public policy and position statements specifi-
cally tailored to the North Carolina practice environment,
NCAP has established a Provider Status Taskforce to study
the issue of state and federal level provider status efforts. By
collaborating with and learning from efforts underway at the
local, state, regional, and national level across the country and
across the associations representing various segments of phar-
macy practice, it is certain that we can work together to devel-
op and encourage the implementation of sound public policy
that is representative of both pharmacy interests and the inter-
ests of the patients pharmacy serves. The work and make-up
of this taskforce are representative of the diversity of pharma-
cy practice.
In addition to in-house efforts (as it were), NCAP is
once again actively participating in the development of the
program for the NC Board of Pharmacy-sponsored annual
Pharmacy Leaders Forum in early October. The purpose of
this forum is to provide pharmacy leaders from across the
state and across the various pharmacy disciplines an oppor-
tunity to discuss, find, and recommend solutions to issues and
challenges facing pharmacy now and in the near future. The
primary topic of the 2014 NC PLF is the “Role of Pharmacy
in NC.” Participants are tasked with considering the current
role of pharmacy in North Carolina and discussing the future
of pharmacy practice from a uniquely North Carolina per-
spective with the goal of developing clear, concise, and unify-
ing statements regarding the future of pharmacy practice that
will help guide advocacy efforts across the state in the coming
year.
Setting the stage for current and upcoming advocacy
efforts on behalf of our members and providing quality com-
prehensive information regarding both clinical and public
policy issues is the upcoming NCAP Annual Convention, a
preview of which was provided to you on the front cover of
this issue. The focus of this year’s convention is the
“Changing Role of Pharmacy,” and as you can well imagine
the diversity of subjects within that topic are nearly endless.
While providing the customary specific educational opportu-
nities related to pharmacy practice that are the hallmark of
our NCAP conventions, our speakers, presenters, and panel-
ists will attempt to help you, as participants and attendees gain
key insights into the many innovative practice models
statewide and nationally which are integral to discussing the
current and changing role of pharmacy and to gauging where
pharmacy will be in the future.
I look forward to continuing to work with you
throughout the fall season and to the exciting venues for col-
laborative discussion and learning NCAP offers. See you at
convention!
Most sincerely,
Daniel “Dan” Barbara, Sr., M.Ed.
Executive Director
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North Carolina Pharmacist, Fall 2014 5
Greetings NCAP members!
I find it amazing that I am addressing you with my third jour-
nal message and more than half of my term as President of
NCAP now behind me. The calendar for the remainder of
2014 holds an extensive list of wonderful programs and
events, promising to make the last half of my term pass equal-
ly as quickly.
Convention planning continues to drive onward with our Edu-
cation Committee Co-Chairs Jenn Wilson and Sonia Everhart
providing excellent direction for programming. The theme
“Pharmacy’s Modern Role in 2014” fits perfectly with the hot
topics of HR 4190 and defining provider status for pharma-
cists now on the legislative forefront. NCAP is thrilled to have
Mollie Scott serving as our keynote speaker offering her per-
spective on this important topic. The North Carolina Alliance
for Healthy Communities (NCAHC) offers programming in
conjunction with convention, a new partnership NCAP is very
excited to see blossom. Needless to say, the annual conven-
tion offers a wealth of information relevant across all practice
settings which you will not want to miss!
Development of October’s 2014 Pharmacy Leaders Forum is
also in full swing with NCAP Executive Director Daniel Bar-
bara and Dean Ronald Ragan co-chairing the planning com-
mittee. Significant attention to the current and future roles of
pharmacy in North Carolina lies within the topics for this
meeting. Attendees will be tasked with developing a position
statement articulating the role of pharmacists in health care in
NC. The committee is excited to have a broad range of lead-
ers in pharmacy representing nearly every practice setting con-
tributing to what is destined to be a lively debate.
The annual Residency Conference held in July produced an-
other year of success. Attendance was exceptional! NCAP is
extremely grateful to Jamie Brown for his efforts and dedica-
tion to planning a truly wonderful event.
NCAP continues to work with the student groups from all NC
schools of pharmacy in an effort to finalize the “Student Phar-
macist Network” (SPN). The group intends to be a collective
student organization of NCAP representing all schools of
pharmacy, serving as a voice for our future pharmacists. A
united group of students presented to the NCAP Board of
Directors in July, showcasing extensive efforts in creating by-
laws and formal organization. I speak confidently for the Ex-
ecutive Committee and Board in expressing our enthusiasm
over expanding student involvement and excitement at formal-
izing SPN.
Provider Status and HR 4190 persist as hot topics both locally
and nationally. On a local level, NCAP’s Provider Status
Committee continues to shape up nicely under Patrick
Brown’s leadership as Chair. While national headlines report
progress across the country on the expanding definition of the
pharmacist as provider, this committee is eager to see action
in North Carolina. On a national level, APhA reports grow-
ing encouragement of HR 4190 with 31 elected officials issu-
ing their support in July alone, with a total of 94 co-sponsors.
I encourage each of you to find a way to contribute to the suc-
cess of the provider status effort by writing letters to your Rep-
resentatives or participating on a committee. As Ghandi said
best, “You must be the change you wish to see in the world.”
I look forward to seeing each of you at many of the NCAP
events this fall!
Michelle Ames, Pharm.D.
President
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North Carolina Pharmacist, Fall 2014 6
by Amanda Kaye Peters, Pharm.D. and Autumn D. Carroll, Pharm.D.
H.R. 4190 was introduced in
the House of Representatives in
2014 and is more commonly known
as the Pharmacist Provider Status
Act. The bill is currently in the
Ways and Means Committee of the
House, and a companion bill is ex-
pected to be introduced in the Sen-
ate later this year. This bill repre-
sents a critically important advance-
ment in pharmacy practice, because
it seeks to increase access to clinical
pharmacy services throughout the
country. The proposed amendment
to Title XVIII of the Social Security
Act would recognize pharmacists as
health care providers, thereby allow-
ing for the expansion of clinical phar-
macy services for Medicare benefi-
ciaries residing in medically under-
served areas1. Rural and medically
underserved areas typically have a
shortage of primary care physicians,
and this disparity is expected to wors-
en with an overall projected 20,400
FTE shortage by 20202.
Healthcare systems are cur-
rently undergoing significant changes
while seeking to achieve the Triple
Aim, which includes improving care
for populations and individuals, low-
ering costs, and improving the pa-
tient experience3. The Patient Cen-
tered Medical Home (PCMH) mod-
el is a successful strategy for re-
organizing primary care that stresses
patient-centered care while allowing
each member of the healthcare team
to work at the top of his or her li-
cense. On average, a physician
spends 20.8 minutes in a face-to-face
encounter with a patient4.
During this
short amount of time, the physician
is expected to take an accurate histo-
ry, diagnose the problem, educate
the patient, and prescribe a medica-
tion. Managing chronic conditions
also requires frequent follow-up,
which may be delayed if access to
care is poor.
Pharmacists trained in am-
bulatory care are important mem-
bers of the health care team and
have the knowledge and skills neces-
sary to manage chronic conditions.
The role of pharmacists in the
PCMH has been defined by Marie
Smith to include medication therapy
management, optimization of pa-
tients’ regimens, assessing compli-
ance, and proposing cost-saving alter-
natives to current therapies5.
By uti-
lizing pharmacists in these roles, the
PCMH model allows physicians to
focus on diagnosis and treatment,
while ensuring appropriate follow-up
and long-term management by other
qualified healthcare professionals,
including pharmacists.
Although the role of phar-
macists in primary care has been
defined, there is a lack of pharmacy
presence in many primary care phy-
sician offices across the United
States. Inadequate reimbursement
has been the biggest barrier to the
inclusion of pharmacists in PCMHs.
Many pharmacists in physician offic-
es are co-funded by pharmacy
schools or grants and rely on cost-
saving analyses to show financial ben-
efit, which can take years to demon-
strate. Smaller offices in rural and
underserved areas not associated
with pharmacy schools simply cannot
afford the upfront investment of a
pharmacist salary, regardless of the
potential cost avoidance in the fu-
“Look at the world around you. It may seem like
an immovable, implacable place. It is not. With
the slightest push - in just the right place - it can
be tipped.”
― Malcolm Gladwell, The Tipping Point: How
Little Things Can Make a Big Difference
Page 7
North Carolina Pharmacist, Fall 2014 7
ture. Because pharmacists are not
recognized as providers under the
Social Security Act, they cannot bill
at the level of service provided. In-
stead, the pharmacist may bill
“incident to” a physician for a five-
minute nurse visit (99211), which
averages around nineteen dollars in
reimbursement6. The management
of a complex chronic condition such
as diabetes requires more time, criti-
cal thinking, and problem-solving
than a five-minute visit allows. Ap-
proval of H.R. 4190 would allow
pharmacists to bill Medicare at the
level of service provided with the
likelihood that Medicaid and private
insurance companies would follow
suit. This change would increase re-
imbursement by approximately fifty
dollars per visit, more easily justifying
the cost of adding a clinical pharma-
cist to the patient care team.
Despite the financial barriers
associated with embedding pharma-
cists into the PCMH, several practic-
es in Western North Carolina have
incorporated Clinical Pharmacist
Practitioners (CPPs) in primary care
clinics. These pharmacists are
providing patient education, stressing
primary prevention measures, man-
aging chronic disease states, reconcil-
ing medications and coordinating
transitions of care, and leading Medi-
care Annual Wellness visits. The
CPP is a unique credential from the
NC Boards of Medicine and Phar-
macy and allows the pharmacist to
initiate, modify, and monitor drug
therapy in collaboration with a super-
vising physician7. At Mountain Area
Health Education Center (MAHEC)
Family Health Center, CPPs are im-
portant team members providing
coordinated whole person care.
CPPs manage clinics for pharma-
cotherapy consults, anticoagulation,
Medicare Annual Wellness Visits
(AWV), transitions of care, and em-
ployee wellness. MAHEC is an edu-
cational hub for medical students
and physicians training in family
medicine, OB/GYN, geriatrics, and
sports medicine, as well as pharmacy
students and pharmacists training in
ambulatory care. As recent graduates
of MAHEC and Mission’s PGY-1
ambulatory care pharmacy residency
program, we had the fortuitous op-
portunity to work in this collabora-
tive environment and see firsthand
the impact pharmacists can have in
primary care.
We received many consulta-
tions for the chronic disease state
management during our year at MA-
HEC, many of which required
monthly, and sometimes weekly fol-
low-up visits. One patient in particu-
lar, a 31-year-old female with uncon-
trolled type 2 diabetes, was being
seen by one of the resident physi-
cians. This patient was extremely
high risk, with established coronary
artery disease, a current smoker with
COPD, and peripheral neuropathy.
Prior to her visit with a pharmacist,
her most recent A1c was 11.4% on
Lantus 90 units twice daily and Hu-
malog 42 units with every meal. Be-
cause this patient was on extremely
high doses of insulin, the resident
wanted to transition to insulin regular
U-500 but was hesitant to do this on
her own. During a joint visit, we were
able to transition the patient to U-
500, and provide essential education
on administration and dosing. We
also provided education for the pa-
tient about all of her medications
and lifestyle changes that she could
make to improve her health. Now
the patient’s blood sugars are much
better controlled with an A1c of
8.2%, and the patient is pleased with
the switch. In this situation, potential-
ly fatal errors in dosing and admin-
istration may have been avoided with
a high-risk medication, and better
glycemic control was achieved
through collaboration with a pharma-
cist available on site. Moreover, this
team approach improved elements
of the Triple Aim by improving the
patient’s health along with her pa-
tient experience.
As new practitioners
searching for employment, it is frus-
trating to appreciate the potential
impact of pharmacists in primary
care only to face a financial road-
block to finding employment in this
area. Many physicians in Western
North Carolina, especially those
trained at MAHEC, realize the im-
portance of H.R. 4190 to increasing
patient access to pharmacists. In the
words of Dr. Jeff Heck, CEO and
family physician at MAHEC and
Dean of the UNC School of Medi-
cine’s Asheville Campus, “Primary
care will thrive and our patients will
be healthier if every practice has a
clinical pharmacist.” Imagine the
impact we could make on patient
health outcomes if all physicians had
the opportunity to see the value of a
pharmacist at their practice site.
The world of healthcare can
feel like an immovable, implacable
place, especially to new practitioners.
H.R. 4190 carries the promise of
significantly impacting the delivery of
healthcare and changing pharmacy
practice, allowing pharmacists to
have a seat at the table that we have
never had before. We feel we are at
a tipping point, and H.R. 4190 is the
push in the right direction to advance
clinical pharmacy services by dupli-
Page 8
North Carolina Pharmacist, Fall 2014 8
cating the types of experiences we
had as pharmacy residents into rural,
underserved areas.
For more information about
H.R. 4190 and provider status for
pharmacists, go to www.ashp.org and
www.pharmacist.com. Links are
available on these websites with in-
formation regarding how you can
reach out to your own representa-
tives in Congress.
The authors would like to
thank Mollie Scott, Pharm.D.,
BCACP, CPP, for her review of our
manuscript.
References
1“To amend title XVIII of the
Social Security Act to provide
for coverage under the Medicare
program of pharmacist ser-
vices.” (H.R. 4190).
GovTrack.us. Retrieved May 30,
2014, from https://
www.govtrack.us/congress/
bills/113/hr4190
2“Projecting the Supply and De-
mand for Primary Care Practi-
tioners Through 2020 In Brief”.
US Department of Health and
Human Services. Retrieved May
30, 2014 from http://
bhpr.hrsa.gov/healthworkforce/
index.html.
3Institute for Healthcare Im-
provement. IHI Triple Aim
Initiative. http://www.ihi.org/
Engage/Initiatives/TripleAim/
Pages/MeasuresResults.aspx.
Accessed 8/12/2014.
4“15-Minute Visits Take A Toll
on the Doctor-Patient Relation-
ship”. Kaiser Health News. Re-
trieved July 17th, 2014 from
http://www.kaiserhealthnews.org/
stories/2014/april/21/15-minute-
doctor-visits.aspx.
5Smith M, Bates DW, Boden-
heimer T, et. al. Why Pharma-
cists Belong In The Medical
Home. HEALTH AFFAIRS.
2010;29(5): 906–913
6Centers for Medicare & Medi-
caid Services. Physician fee
schedule. http://www.cms.gov/
apps/physician-fee-schedule.
Accessed 8/13/14
7NCBOP: Clinical Pharmacist
Practitioners. http://
www.ncbop.org/
pharmacists_cpp.htm. Accessed
8/13/14.
8Gladwell, M. (2000). The tip-
ping point: How little things can
make a big difference. Boston:
Little, Brown.
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North Carolina Pharmacist, Fall 2014 9
New Practitioner Network Member Spotlight
Tasha Woodall, Pharm.D., CGP, CCP
Tasha Woodall received her Pharm.D. from Purdue University in West Lafayette,
Indiana. Upon graduation, she came to Asheville, North Carolina to complete her
PGY1 Pharmacy Practice Residency in Ambulatory Care with Mission/MAHEC.
She earned her Certification in Geriatric Pharmacy (CGP) in 2013. Dr. Woodall
currently serves as Assistant Professor of Clinical Education for the UNC Eshelman School of Pharmacy and As-
sociate Director of Pharmacotherapy in Geriatrics at Mountain Area Health Education Center (MAHEC) in Ashe-
ville. At MAHEC, her practice sites include two continuing care retirement communities, where she works with
residents in the ambulatory setting.
Dr. Woodall became involved in NCAP to form a closer network with other progressive-minded pharmacists. She
recognizes the value of grassroots support that can be fostered at the state level, especially for legislation such as
H.R. 4190, which “has the potential to so greatly advance the level of care pharmacists are able to provide.” She
feels that NCAP enables her to learn from others how to work alongside pharmacist leaders to leave a legacy of
excellence for future generations of pharmacists.
Her piece of advice to other new practitioners: “Patience is a virtue: just because you know the extent of your own
knowledge base doesn’t mean other health care providers are equally as familiar. It takes time to build a trusting
relationship that can serve as a solid foundation for flourishing team-based care.”
Page 10
North Carolina Pharmacist, Fall 2014 10
15th Annual Pharmacy Residency
Conference
Steve Kearney, Pharm.D., Co-Moderator, rep-
resenting Pfizer (co-sponsor of the 2014 Phar-
macy Residency Conference) introduces the
morning program.
Jamie Brown, Pharm.D., Co-Moderator and Chair of the NCAP
Residency Committee, introduces the afternoon program.
NCAP Executive Director Dan Barbara, M.Ed. encour-
ages residents to become and remain actively involved
in their state association and in the legislative process.
Rowell Daniels, Pharm.D., M.S.,
Director of Pharmacy, UNC
Medical Center and Executive As-
sociate Dean of UNC Eshelman
School Pharmacy, delivered the
Keynote Address entitled
“Punctilious Leadership.”
Page 11
North Carolina Pharmacist, Fall 2014 11
Steve Kearney, Pharm.D., Co-Moderator, rep-
resenting Pfizer (co-sponsor of the 2014 Phar-
macy Residency Conference) introduces the
morning program.
The Fifteenth Annual Pharmacy Residency Conference boasted record attendance and participation resulting from the efforts of
the NCAP Residency Committee, the participating preceptors, and the encouragement of all participating schools of pharmacy.
Program roundtables for residents (led by the NCAP
New Practitioner Network) focused on “Getting the
Most Out of the Residency Year.”
Preceptors discussed “Developing Successful Residents
and Programs.”
Mary H. Parker, Pharm.D.,
Past-President of NCAP
(representing the NCAP
Executive Committee),
discussed “Advancing
Pharmacy Practice: Where to
Begin?”
Page 12
North Carolina Pharmacist, Fall 2014 12
Page 13
North Carolina Pharmacist, Fall 2014 13
What Can We Do Without Provider Status?
by Courtenay Gilmore Wilson,
Pharm.D., BCPS, CDE, CPP
Provider status remains one of
the main obstacles to fully integrating
clinical pharmacy services into ambula-
tory healthcare settings. The 2011 Re-
port to the Surgeon General highlighted
pharmacists in physician practices as a
way to increase access to care, improve
patient outcomes, and reduce healthcare
costs1. To meet these goals, the Report
stresses the importance of recognizing
pharmacists as providers as well as re-
forming payment structures to allow for
reimbursement of pharmacists’ cognitive
services. In March 2014, legislation was
introduced in the US House of Repre-
sentatives that seeks to recognize phar-
macists working in Medically Under-
served Communities as providers, which
would greatly expand the role of the
clinical pharmacist on the healthcare
team. However, even in the absence of
provider status, there are several options
available for pharmacists to generate
revenue for a physician practice.
Currently, many pharmacists
practicing in physicians’ offices utilize
the “incident to” method. This allows
pharmacists and other non-physician
healthcare providers (i.e. nurses) to bill
for their services under the physician’s
name2. For pharmacists, this method of
billing is limited to a Level 1 or 99211
visit, which is reimbursed at a rate of
about $193. With such low reimburse-
ment potential, billing solely with the
Level 1 visit is not a financially viable
way to sustain clinical pharmacy services.
In 2011, the Medicare Annual
Wellness Visit (AWV), which focuses
heavily on preventive care services, was
introduced as part of the Affordable
Care Act (ACA). This visit may be con-
ducted by any healthcare provider work-
ing under the direct supervision of a
physician, including pharmacists4. Aver-
age reimbursement rates are $160 for
the initial AWV and $110 for subse-
quent AWVs, presenting a significant
opportunity for pharmacists to generate
revenue for a physician’s office3. War-
shany, et al. recently described the im-
plementation of a pharmacist-
administered AWV clinic that success-
fully billed for AWVs conducted by the
pharmacist5.
In January 2013, Medicare in-
troduced new Transitional Care Man-
agement (TCM) codes in efforts to im-
prove care coordination and reduce re-
admissions6. Two required components
for utilizing these codes are: 1) commu-
nication with the patient within two days
of hospital discharge; and 2) medication
reconciliation6. Pharmacists may com-
plete these required components, allow-
ing for the physician to employ the
TCM code for the office visit, which is
reimbursed at a level significantly higher
than the Level 4 or Level 5 office visit3.
Due to the aging population
and the expansion of health insurance
coverage under the ACA, the U.S. is
faced with an expected shortage of pri-
mary care physicians. Consequently,
team-based care models, including the
Patient Centered Medical Home
(PCMH) and Accountable Care Organi-
zation (ACO), are gaining momentum as
a way to better utilize non-physician ser-
vices. These models offer new opportu-
nities for pharmacists in the ambulatory
care setting. In these settings where pay-
ment is driven by performance, the
pharmacist is the team member respon-
sible for maximizing patient outcomes
with comprehensive medication manage-
ment6. The 2014 Ambulatory Care Sum-
mit hosted by the American Society of
Health-System Pharmacists (ASHP)
released several briefing documents,
including one regarding outcomes evalu-
ation. This report outlines 23 of the 33
ACO core measures that may be im-
pacted by a pharmacist7. Thus, pharma-
cists are important members of the team
who may help achieve and maintain
these designations.
Achieving provider status re-
mains a priority for many pharmacists.
Until this occurs, we must take ad-
vantage of existing revenue streams that
allow pharmacists to establish a presence
in physician practices. By doing so, we
will be well positioned to capitalize on
the opportunities that provider status
will offer.
1Giberson S, Yoder S, Lee MP. Improving
Patient and Health System Outcomes through
Advanced Pharmacy Practice. A Report to the
U.S. Surgeon General. Office of the Chief
Pharmacist. U.S. Public Health Service. Dec
2011.
2Scott MA, Hitch WJ, Wilson CG, Lugo AM.
Billing for pharmacists’ cognitive services in
physicians’ offices: Multiple methods of reim-
bursement. JAPhA 2012; 52:175-180.
3Physician fee schedule. www.cms.gov/apps/
physician-fee-schedule/search/search-
criteria.aspx. Accessed February 10, 2014.
4Centers for Medicare & Medicaid Services.
Quick reference information: The ABCs of
providing the Annual Wellness Visit. http://
www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/
MLNProducts/downloads/
AWV_chart_ICN905706.pdf. Accessed Febru-
ary 10, 2014.
5Warshany K, Sherrill CH, Cavanaugh J, et al.
Medicare annual wellness visits conducted by a
pharmacist in an internal medicine clinic.
AJHP 2014;71:44-49.
6Centers for Medicare & Medicaid Services.
Transitional Care Management Services. http://
www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/
MLNProducts/Downloads/Transitional-Care-
Management-Services-Fact-Sheet-
ICN908628.pdf. Accessed February 10, 2014
7Patient-Centered Primary Care Collaborative.
The Patient Centered Medical Home: Integrat-
ing Comprehensive Medication Management to
Optimize Patient Outcomes. June 2012. http://
www.pcpcc.org/sites/default/files/media/
medmanagement.pdf Accessed February 10,
2014
8Kliethermes MA. Outcomes evaluation: Striv-
ing for excellence in ambulatory care pharmacy
practices. ASHP Ambulatory Care Conference
and Summit. March 2014.
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North Carolina Pharmacist, Fall 2014 14
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North Carolina Pharmacist, Fall 2014 15
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North Carolina Pharmacist, Fall 2014 16
Pharmacists as Critical Members of the Integrated
Care Team by Samuel Stolpe, Pharm.D., Director,
Pharmacy Quality Alliance (PQA) & Maria
Scalatos, Pharm.D., Executive Fellow, PQA
The future of quality patient care
relies on learning from the success stories
and best practices of today in order to
shape the health care system of tomorrow.
Six Medicare plans were recently acknowl-
edged by the Pharmacy Quality Alliance
(PQA) for excellence in medication safety,
based on the Centers for Medicare & Medi-
caid Services’ (CMS) Star Ratings. The Chi-
nese Community Health Plan of California,
Humana’s Medicare plan in Illinois, and
four Kaiser Permanente regions (California,
Colorado, Hawaii and the Mid-Atlantic
region) were recognized for their achieve-
ment of a 5-star rating on the PQA
measures of medication safety and appro-
priate use that are included in the CMS Star
Rating Program for Medicare plans, as well
as achievement of at least a 4.5-star sum-
mary plan rating. The six awardees spoke to
the best practices that contribute to their
outstanding medication management, and
ultimately ensure optimal medication out-
comes.
With the advent of new quality
incentive structures put in place through
federal government programs, health plans
and PBMs are becoming increasingly fo-
cused on medication use quality. Pharma-
cists can contribute meaningfully to the
quality goals of these organizations as a
member of a virtual integrated care team.
Of the fifteen quality measures used by
CMS to evaluate Medicare Part D plans in
2014, five relate to medication safety and
adherence. These measures account for
nearly 50% of a given Part D sponsor’s star
rating, and represent a potential impact area
for pharmacist intervention. In fact, in a
systematic review of interventions to im-
prove adherence to medications for cardio-
vascular disease and diabetes, Cutrona, et
al. found that interventions in a pharmacy
conducted by a pharmacist improved medi-
cation adherence more than any other pro-
fessional in any other setting.
This represents a tremendous
opportunity for pharmacies. But to take
advantage of this opportunity, pharmacists
must transition their approach from a mind-
set of quality measurement resistance, to
quality measurement engagement. To facili-
tate this transition to becoming an engaged
partner, many community pharmacies are
using EQuIPP, the Electronic Quality Im-
provement Platform for Plans & Pharma-
cies. EQuIPP is a performance information
management platform that provides unbi-
ased, benchmarked data on the quality of
medication use to both health plans and
community pharmacies. It allows pharma-
cists at an individual store or corporate lev-
el, to see exactly how individual pharmacies
are performing on the medication use quali-
ty measures that matter to payors.
The unique position of pharma-
cists in the community setting grants en-
hanced patient access and excellent oppor-
tunities for medication management. Phar-
macists are increasingly viewed as a key
collaborative partner. Managing the quality
of medication use is now a recognized com-
ponent of ensuring optimal care. Collabo-
ration on shared quality targets and goals
connects pharmacies to other partners
along the care continuum.
Pharmacies are not exempt from
quality measurement. Health plans and
PBMs are already moving forward with
incentive and penalty programs for pharma-
cies based on quality performance. Phar-
macists are an integral part of the solutions
to meet payors’ quality needs. Being proac-
tive in this new quality environment is a
must. Moving forward, pharmacists should
look to initiate dialogue, establish and nur-
ture relationships, and seek opportunities to
deliver point-of-care interventions that drive
quality. Payors are not the only health care
organizations with quality goals. Other
health care organizations have performance
measures that they are accountable for that
can be directly influenced by pharmacists.
In addition to making contributions to
health plan quality goals, pharmacists can
reach out to local Accountable Care Organ-
izations (ACOs), and Patient Centered
Medical Homes (PCMHs) to look for col-
laboration points. Examples of areas that
pharmacists can impact include ACO
measures of medication reconciliation and
influenza immunization, or helping them
reach quality measure goals related to cho-
lesterol, A1Cs, and blood pressure through
appropriate medication management. Of
the 33 quality measures a federal Medicare
Shared Savings Program ACO has to meet,
at least 11 of them can be influenced by
community pharmacists. Focus should be
centralized on interventions that drive spe-
cific goals; communicating ways in which
pharmacists influence the safe and effective
use of medications and reach these goals
will lay the foundation for the pharmacist’s
role in integrated care teams.
1Pharmacy Quality Alliance. PQA Recognizes
Six Medicare Plans for Excellence in Medication
Use and Safety Based on CMS’ Star Ratings
[Press release]. http://pqaalliance.org/images/
uploads/files/Press%20Release%
202014_QualityAward.pdf. Accessed June 30,
2014.
2Cutrona S, Choudhry N, Shrank W, et al.
Modes of delivery for interventions to improve
cardiovascular medication adherence. The
American Journal Of Managed Care [serial
online]. 2010;16(12):929-942. Available from:
MEDLINE, Ipswich, MA. Accessed June 30,
2014.
3Center for Medicare and Medicaid Services.
ACO Quality Measures. http://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/
sharedsavingsprogram/Downloads/ACO-Shared-
Savings-Program-Quality-Measures.pdf. Ac-
cessed June 30, 2014.
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North Carolina Pharmacist, Fall 2014 17
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North Carolina Pharmacist, Fall 2014 18
The Second Victim: Caring for the Caregiver by Mariel Pereda, Pharm.D. Candidate,
Class of 2015, UNC Eshelman School of
Pharmacy
A medical error happens in
your organization. The first victim is the
patient and/or his/her family members.
Accordingly, many health care organiza-
tions have mechanisms in place to pro-
vide support to these first victims.
But what about the second victim?
Who is the second victim?
The second victim is the health
care provider involved in a medical er-
ror or patient event who has been trau-
matized by the event.1 The range of
effects on a provider can be from mild
and transient, to serious and persistent.
The degree to which a health care
worker is affected is not necessarily re-
lated to the severity or outcome of the
error. Many factors affect where an in-
dividual falls on the spectrum of reac-
tions, including individual characteris-
tics, cultural or environmental factors,
and the significance of the event itself.
In 2011, ISMP published the
story of a nurse who was involved in a
medication error that resulted in the
death of her critically ill patient. The
nurse was fired from the hospital where
she had worked for 27 years. Her state
licensing board issued a four-year pro-
bation period during which she was
required to be supervised during all
medication administration activities.
Despite her years of experience, she
was unable to find employment as a
nurse following the highly publicized
event. Seven months after the event,
she took her own life.2
Healthcare workers dedicate
their lives to helping others and can
become distressed when their mistake
results in harm. The case above high-
lights one extreme consequence. How-
ever, minor traumas can occur even
more frequently. These less extreme
responses are also harmful, since they
can affect an individual’s well-being and
professional performance.
After being involved in an er-
ror, second victims can experience both
emotional and physical distress.3 Com-
mon emotional and physical symptoms
are presented in Table 1.
It is not uncommon for second
victims have doubts about their compe-
tence and abilities following a medical
error. These doubts can lead to second-
guessing, difficulty making decisions,
requests to leave clinical care areas, or a
desire to leave their place of employ-
ment or profession entirely.
Many patient safety and quality
organizations recognize the second vic-
tim phenomenon, including the Agency
for Healthcare Research and Quality,
Institute for Healthcare Improvement,
National Quality Forum, National Pa-
tient Safety Foundation, The Joint
Commission, and The American Socie-
ty for Health Risk Management. Addi-
tionally, a number of medical and nurs-
ing organizations have published studies
and resources related to the topic, in-
cluding the American Medical Associa-
tion and the American Nurses Associa-
tion.
How do we care for second victims?
Just as there are “rights” of
medication safety, there are also rights
of the second victim. An easy acronym
to help you remember these is
“TRUST,” which stands for:1
T – Treatment that is just. The first step
in helping the second victim is acknowl-
edging that the second victim exists.
Second victims deserve not to be aban-
doned by their organization, managers,
and peers. Health care delivery occurs
in a complex system, and we cannot
assign full responsibility for a medical
error to one person.
R – Respect. Give second victims the
respect they deserve as human beings as
well as healthcare professionals. Sham-
ing remarks or actions are neither ap-
propriate nor constructive.
U – Understanding and compassion. Following a medical error, leadership
and peers should reach out to the indi-
vidual involved. Second victims often
need someone who understands their
situation, who is familiar with their
work, to empathize with them.
S – Supportive care. Second victims
should be encouraged to make use of
counseling services. Additionally, if the
situation calls for it, the individual
should be directed to legal services. It is
important to know how and where to
refer someone within and outside your
organization. Details on support pro-
grams for second victims follow in the
next section.
T – Transparency and the opportunity to contribute. An important part of
healing is the opportunity to participate
in the learning that takes place after the
event. Allow the second victim to pro-
vide insight into the event and potential
solutions moving forward.
Support Programs for Second Victims
Scott et al. identified a three-
tiered model for second victim support
systems.4
The first tier is the immediate
“emotional first aid.” This occurs at the
local or departmental level. The second
tier provides more aggressive support,
connecting individuals with patient safe-
ty or risk management experts. The
third tier involves referral to profession-
al counseling services. Some individuals
may only require the first tier of sup-
port while others may need a higher
level. Regardless, all levels should be
readily available.
The current body of literature
provides little guidance on what specific
elements to include in an effective sec-
ond victim support program. However,
some key elements to consider are:
Timing of Support
The initial period after the event is the
most crucial. A manager or supervisor
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North Carolina Pharmacist, Fall 2014 19
Table 1:
Emotional Symptoms3 Physical Symptoms
3
Frustration Extreme fatigue
Anger Sleep disturbances
Extreme sadness/depression Increased blood pressure
Self-doubt/loss of confidence Muscle tension
Anxiety about returning to work Rapid heart rate/breathing
Difficulty concentrating
Flashbacks
should provide support immediately. A
protocol should make clear regarding
who is formally responsible for reach-
ing out to the second victim.
Relief from Clinical Duties
What is the protocol in the event that
the second victim is unable to return to
work in the days following the event? A
plan should be in place to address relief
from clinical duties in the aftermath of
a medical error.
Legal Concerns
Legal consultation should be sought
when building a program to ensure the
protection of conversations. Managers
should familiarize themselves with these
legal requirements.
Varying Levels of Support
Programs should provide varying levels
of support, ranging from peer discus-
sion groups to formalized counseling
services. The three-tiered model is one
way to structure a support program, but
other ways may be more appropriate
for your organization.
A Hospital-wide Commitment
A strong support program can only be
achieved with the support of hospital
leadership. Provide training to manag-
ers and employees on how to support
second victims.
One example of a well-
developed second victim response pro-
gram is the University of Missouri
Health System’s for YOU team, made
up of health care clinicians trained to
assist second victims. A dedicated pager
line connects individuals in need with a
team member 24/7. When peer sup-
port is not enough, the program can
connect individuals with an employee
assistance program or a clinical psy-
chologist.5
The program also provides
brochures for staff and their families to
help them understand the second vic-
tim experience. Additionally, the pro-
gram’s website features a “Share Your
Story” portal through which users are
invited to anonymously share their ex-
periences with or as second victims.5
This story-telling tool is an important
way to learn valuable lessons about the
second victim experience.
How do I get started?
Developing or enhancing your sec-
ond victim support program will take
time. Here are a few important first
steps that you can get started on today.
Identify which resources already exist in
your organization.
Identify who should be involved in
building a second victim program.
Develop a policy on caring for second
victims.
Develop training materials to introduce
the topic to staff.
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North Carolina Pharmacist, Fall 2014 20
1Denham C. TRUST: The 5 Rights of
the Second Victim. Patient Saf. 2007;107-19
2ISMP Medication Safety Alert. July
2011.
3Scott SD, Hirschinger LE, et al. The
natural history of recovery for the
healthcare provider “second victim”
after adverse patient events. Quality & Safety in Health Care. 2009;325-30
4Scott SD, Hirschinger LE, et al. Caring
for Our Own: Deploying a Systemwide
Second Victim Rapid Response Team.
The Joint Commission Journal on Quality and Patient Safety. 2010;36:233
-40.
5University of Missouri Health System.
Understanding Second Victims . http://
www.muhealth.org/secondvictim
Ms. Pereda authored this paper during
her medication safety clerkship at Sec-
ondStory Health, LLC in Carrboro,
NC, June 2014. Correspondence can
be addressed to John Kessler, PharmD
at [email protected]
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