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Leveraging Pharmacists to Get to Better Blood Pressure Control

Learning Objectives
1. Explain how pharmacists add value and support better hypertension treatment
2. Identify resources pharmacists, expanded care team members, and public health professionals can use to support engaging pharmacists in hypertension management
3. Discuss the range of options to leverage pharmacist expertise in hypertension management
1 Credit CME

The Million Hearts Learning Lab is a bi-monthly learning series focused on cardiovascular disease prevention and management topics. The series is open to clinicians, quality improvement, and other interested staff across the country, but with a focus on community health centers. Clinicians may earn 1.0 CME credit per session through the American Medical Association's Ed Hub.

This project aims to utilize a mixed-method learning model to host bi-monthly “events”. Please watch the videos below, then select “Take Quiz” to earn CME.

Video 1
Leverage Pharmacists to Achieve Better Blood Pressure Control

The Million Hearts® Learning Lab focuses on cardiovascular disease prevention and management. In this video, experts will discuss how pharmacists can be integrated into the care of patients with uncontrolled hypertension.

Video 2
Leverage Pharmacists to Get to Better Blood Pressure Control

The Million Hearts® Learning Lab focuses on cardiovascular disease prevention and management. In this video, featured experts will provide an overview of resources that pharmacists, expanded care team members, and public health professionals can use to support engaging pharmacists in hypertension management.

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Video 1 Transcript

Adair Blyler, PharmD: (00:00) Hi, welcome to this brief Million Hearts Learning Lab webinar on leveraging pharmacists to achieve better blood pressure control. My name is Adair Blyler and I work at the Cedars-Sinai Smitt Heart Institute's Hypertension Center of Excellence.

(00:16) Joining me is Nicole Therian, who works at the Center for Disease Control and Prevention in the Division for Heart Disease and Stroke Prevention. Nicole and I are both trained pharmacists working in both clinical and research settings to improve cardiovascular outcomes. Over the next few minutes, we will discuss different strategies to integrate pharmacists into care for all people with uncontrolled hypertension or high blood pressure.

Nicole Therrien, PharmD, MPH: (00:43) Just a quick note that the findings and conclusion presented today are those of the presenters and do not necessarily represent the official position of the CDC.

Blyler: (00:56) It is perhaps useful to briefly review the evolution of pharmacy practice in the United States so that we can better understand where we have been and where we're going. Pharmacy's history in America can best be summarized as very slow but steady progress towards greater professional standing through changes in both pharmacy education and practice. Urick and Meggs describe it as having four distinct periods, the soda fountain era, the lick, stick, pour, and more era, the pharmaceutical care era, and the post-pharmaceutical care era, which we find ourselves in today. Prior to the 1920s, pharmacists were largely engaged in compounding activities.

(01:34) But by 1920, the pharmacy community experienced somewhat of an identity crisis when there was a shift towards pre-manufactured products being preferred over compounded products. While prescription dispensing remained an essential part of every pharmacy's identity, it became just one aspect of pharmacies businesses, as community pharmacies sought to increase front-end commercial interest through the expansion of soda fountains and offering of other goods for purchase.

(02:01) The period from 1950 to 1970s was a pivotal time for American pharmacy. A new version of professionalism arose with the introduction of PharmD programs, which provided the training needed to provide robust patient care services and introduced the notion that pharmacists had an obligation to their patients, which extended beyond simple dispensing of products.

(02:24) The pharmaceutical care era brought rapid change with new requirements for medication counseling in the 1990s. Pharmacist immunizers also emerged in the 1990s. And by the early 2000s, we had MTM or medication therapy management services. The post-pharmaceutical era brought full circle the transition from a focus on product to a focus on the patient. In this current era, pharmacists are pursuing residencies and additional clinical training with increasing frequency, readying them to provide patient care services not directly associated with medication dispensing.

Therrien: (03:00) So when we think about strategies to improve blood pressure control in the United States, why include pharmacists? Well, Adair described the evolution of pharmacy education and the introduction of postgraduate training has prepared pharmacists for a new role. Pharmacists are medication experts, accessible, and trusted.

(03:23) Since 2000, the Doctor of Pharmacy, or PharmD, has been the entry-level degree for US pharmacists. Core competencies of the PharmD program include biomedical and pharmaceutical sciences, cultural and structural humility, person-centered care, health services and public health, and interprofessional collaboration. Pharmacists are licensed health professionals through state licensing boards. Licensing requirements include those for maintaining competency through continuing education.

(03:54) In addition to the pharmacy curriculum and continuing education requirements of licensure, some pharmacists pursue additional postgraduate training such as residencies or fellowships and may attain board certification for specialized care. 88.9% of the US population lives within a five-mile driving distance of one of the over 61 000 community pharmacies in the US.

(04:20) We also know that patients, including Medicare beneficiaries and commercially insured people, visit a community pharmacy nearly twice as frequently as their primary care providers. Pharmacists are the third most highly trusted professionals behind nurses and medical doctors as measured by annual Gallup poll of Americans' ratings of honesty and ethics among professions. Surveys indicate that people are becoming increasingly comfortable with and interested in receiving health care services in community pharmacies and provided by pharmacists.

(04:59) There's strong evidence that leveraging pharmacists as part of the health care team can improve hypertension control and other cardiovascular disease-related health outcomes. There are several evidence-based strategies to engage pharmacists to improve blood pressure control and prevent and manage heart disease and stroke, including medication therapy management, tailored pharmacy-based interventions to improve medication adherence, and formally including pharmacists in team-based care models, including with collaborative drug therapy management and models in which the pharmacist makes therapeutic recommendations to the prescriber.

(05:38) There are a number of examples in the literature that cite the actions of pharmacists as having contributed to improved cardiovascular outcomes, many of which are included in evidence reviews like the two cited here from the Community Preventive Services Task Force and the CDC's Best Practices Guide for Heart Disease and Stroke Prevention.

(05:58) In the slides that follow, we will review a few of these strategies and specific examples of programs that engage pharmacists to improve blood pressure control in patients. Collaborative Drug Therapy Management, or CDTM, is the partnership between qualified pharmacists and prescribing clinicians to manage a patient's drug therapy as defined within the context of a collaborative practice agreement.

(06:22) This approach allows pharmacists to deliver services such as selecting, initiating, adjusting, and monitoring medications, ordering and interpreting laboratory tests, and administering drugs. Collaborative practice agreements create a formal practice relationship between a pharmacist and a prescriber, most often a physician, although a growing number of states are allowing CPAs between pharmacists and other health professionals, such as physician assistants and nurse practitioners.

(06:54) The agreement specifies what functions, in addition to the pharmacist's scope of practice can be delegated to the pharmacist by the collaborating prescriber. The terms used in the functions provided under a CPA vary from state to state based on the pharmacist and provider's scope of practice and the state's collaborative practice laws.

(07:16) The collaborative practice agreement can have many components, including the scope of the agreement covering patient inclusion criteria and authorized patient care functions, Legal components, which can include authority, liability insurance, informed consent, and the duration or review period for the agreement. And administrative components, such as training and education required, documentation and communication between the pharmacist and the collaborating prescriber.

(07:50) The variables in state laws and regulations that are related to collaborative practice agreement include authorized functions of the collaborating pharmacist or pharmacists. Participants in the collaborative practice agreement, including the number of pharmacists and prescribing clinicians, a pharmacist to prescriber ratio, number of patients, and the relationship between the prescriber and the patient, as well as requirements and restrictions including any education or qualifications required of the pharmacist, liability insurance, disease states or conditions under which the pharmacist may perform collaborative drug therapy management, specific medications, and documentation.

(08:40) More information about collaborative practice agreements can be found in Advancing Team-Based Care through Collaborative Practice Agreements Guide. The Division for Heart Disease and Stroke Prevention has completed a rigorous evaluation of the Michigan Medicine Hypertension Pharmacist Program. In this program, which is guided by the pharmacist patient care process, a framework that describes pharmacists' approach to patient care, patients with hypertension are referred to pharmacists who collect patient data, assess the patient's drug therapy for appropriateness, plan and implement an individualized medication and lifestyle plan, and monitor the effectiveness and adherence to the plan through collaborative drug therapy management facilitated by collaborative practice agreements.

(09:30) The health system also partnered with Meijer, a super center chain store with community pharmacies to extend pharmacy services in locations that were convenient for patients. Meijer pharmacists participating in the program provide hypertension management services, including making medication titration recommendations to the referring physician for their approval.

(09:58) Through interviews with program leaders, pharmacists and physicians, it was revealed that the program has increased availability of services to Michigan Medicine patients by extending care services at locations that are convenient for those patients. Additionally, including pharmacists as part of the care team allows patients to work directly with pharmacists on hypertension medication plans, which frees up primary care physician time so that they can accept new patients by transferring existing patients to be managed by a pharmacist.

(10:30) The program supported the achievement of quality measures and improved health outcomes. At six months, patients in the intervention group were more likely to have achieved blood pressure control than those in the comparison group. Similarly, on average, patients in the intervention group had significantly more days with their blood pressure at goal than those in the comparison group. We've shared the findings of this evaluation in this implementation guide.

Blyler: (11:01) The California Right Meds Collaborative, or CRMC, was launched in September 2019 by Dr Steven Chen at the USC School of Pharmacy. Its aim was to improve health outcomes in local communities while simultaneously decreasing health care costs and reducing unnecessary hospitalizations. The collaborative is a consortium of health plans, pharmacies, academic and professional organizations that serve over 3 million low income residents in the Southern California region.

(11:32) CRMC's participating pharmacies deliver high impact, comprehensive medication management services, or CMM, to health plan members through a sustainable value-based payment model. For those unfamiliar with the term CMM, it is the standard of care that ensures each patient's medications, whether they be prescription, non-prescription, vitamins or supplements, are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities the patient has, and is able to be taken by the patient as intended.

(12:07) In the CRMC model, Patients who have not achieved clinical goals of therapy are identified and recruited by the health plan and subsequently referred to participating pharmacies where pharmacists first understand the patient's personal medication experience, history, preferences, and beliefs, then identify actual use patterns of all medications, assess medications for appropriateness, effectiveness, and safety, identify any drug-related problems, and then finally develop a care plan with recommended steps needed to achieve optimal outcomes.

(13:05) Finally, the pharmacist ensures that both the patient and the provider agree and understand the care plan, which has been communicated. While CRMC initially focused on diabetes management and improvement of A1C targets, hypertension was quickly identified as an area of need with over 23% of LA residents being affected. The CDC recently highlighted CRMC's work in the hypertension space after an initial analysis done in May of 2022 revealed significant blood pressure reductions in their cohort of patients. The average systolic blood pressure decrease in patients with more than five visits with the pharmacist was five millimeters of mercury. While those with a baseline blood pressure of greater than 140 over 90 saw a more than five times larger decrease when managed by a pharmacist.

(13:31) These impressive outcomes combined with the sustainable payment model make CRMC a real trailblazer and role model for other pharmacist-led initiatives. The Los Angeles Barbershop Blood Pressure Study was a cluster randomized trial conducted by Dr Ron Victor at Cedars-Sinai Medical Center in Los Angeles, California. Its aim was to develop an effective and convenient intervention for Black men, which linked health promotion by barbers to drug therapy by pharmacists.

(13:59) In this study, black male barbershop patrons with uncontrolled hypertension were randomized by Barbershop to either an intervention group in which Barbers promoted follow-up with pharmacists or to a control group in which Barbers promoted follow-up with primary care providers and advocated for lifestyle modifications or usual care, if you will. In the intervention group, pharmacists met with patrons at least monthly in their own Barbershops where they checked blood pressure, prescribed medication under collaborative practice agreement, monitored electrolytes at the point of care and sent progress notes to the provider after each encounter.

(14:36) The figure on the right-hand side of the slide depicts the intervention model. Everything took place inside the barber shop, which is represented by the rectangles. The barbers promoted follow up with pharmacists and pharmacists met with participants by appointment to prescribe blood pressure medication. In essence, the patron or participant came to the barber shop to get both his hair and blood pressure cut. The novel part of this particular intervention is that it was pharmacist led.

(15:02) In many randomized controlled trials involving pharmacists, pharmacists often make treatment recommendations to the overseeing physician and the physician ultimately determines whether or not to move forward with those recommendations or write a prescription. In this case, the pharmacists were completely in the driver's seat. After the primary care provider signed the collaborative practice agreement, pharmacists had prescriptive authority and could write or call in prescriptions without having to go through the physician. The primary outcome of this study was the change in systolic blood pressure at 12 months.

(15:33) As you can see, the groups were well-matched at baseline with a baseline blood pressure in the low to mid 150 systolic. After 12 months, blood pressure fell by almost 29 millimeters of mercury in the intervention group compared to just seven millimeters of mercury in the control group. The large change in systolic blood pressure was accompanied by a similar fall in diastolic blood pressure, which favored the intervention group by almost 15 millimeters of mercury. And a goal blood pressure of less than 130 over 80 was attained by 68% of the intervention group compared to just 11% of the control group.

(16:05) This multifaceted intervention addressed multiple barriers to care, including disease state awareness, issues surrounding trust of the medical establishment, and of course, accessibility of care by making the barbershop a one-stop shop. The key takeaways here were that simple treatment algorithms and short follow-up intervals and persistence in ingesting therapy when blood pressure remains above goal are key to achieving goal blood pressure rates.

Therrien: (16:30) The BP HOP studies was a pilot project conducted by Brigham and Women's Hospital in Boston with the aim of developing an entirely remote hypertension management program that would leverage algorithmic pathways, home blood pressure monitoring, and patient coaching. A clinical algorithm, which I'll show in a minute, was developed by a multidisciplinary working group and designed to be automated and adapted for application by what they called patient navigators, essentially lay health care workers, who were trained by nurse practitioners and pharmacists to handle the daily aspects of hypertension management with patients.

(17:11) Patients with uncontrolled hypertension were identified through provider referrals and electronic health record screening aided by population health managers within the MGB health system. Patient navigators consented and enrolled patients by telephone and then mailed them a validated cellular or Bluetooth-enabled blood pressure device after educating them on home blood pressure monitoring and transmitting readings. Navigators were supervised by pharmacists and nurse practitioners while a physician oversaw the entire program as medical director. Home BP readings were monitored and analyzed as weekly reports. BPs that cross preset safety thresholds were shared via alerts with clinicians. Here's the full algorithm.

(18:03) The established algorithm determined not only medication intensification, the medications to start, but also the approach to routine lab monitoring. Upon review of necessary clinical data, the pharmacist under collaborative practice agreement makes changes via electronic prescribing. I'll note that the titration frequency was also noted in the algorithm. Finally, a progress note was routed to the patient's corresponding primary care provider or referring physician, and the algorithm also notes when referrals to other health care team members is warranted.

(18:42) Of the 130 total enrolled patients, control was reached in 81% of a defined as a blood pressure less than 135 over 85. 11 patients dropped out and in most instances because of insufficient engagement. Three had resistant hypertension and were referred to specialty care, but 116 remained in the program. Of those 116 who were engaged in the program and measured their BP at home, the number of participants achieving goal blood pressure actually increased to an impressive 91%.

(19:18) As you can see from the graph, systolic blood pressure fell from a baseline of 155 to 124 upon graduation from the program, and diastolic blood pressure fell similarly from a baseline of 92 to an average of 74. Of note, participants reached goal home blood pressure in an average of seven weeks. Like the barbershop study, this program enabled more frequent dose adjustments of medications than usual care. After each titration, patients waited one week for stabilization and then repeated a set of home blood pressure measurements for one week.

(19:53) Thus, the cycle of medication titrations occurred every two weeks. This rapid titration bypasses the inevitable therapeutic inertia that marks so much of traditional blood pressure care. It's also important to note that blood pressure control at the end of the study did not differ among most demographic subsets.

(20:12) And finally, control was reached without a large increase in pill burden. The average number of medications from baseline to control increased from 1.3 to 1.7. This implies that much of the benefit in blood pressure was achieved through improved adherence and maximizing drug choice and doses. So choosing drugs with fewer side effects, using combination therapy when possible, and providing consistent education on the purpose and importance of medication adherence.

Blyler: (20:49) As you can see, there are a number of ways that pharmacists can be engaged to help improve blood pressure control in patients with uncontrolled hypertension. We'd now like you to pause and reflect on ways in which your organization could include pharmacists in your existing workflows and care pathways. What barriers exist to this? What questions do you have about pharmacists and pharmacists' scope of practice? We look forward to a lively discussion during our Q&A portion on May 17th. Thanks so much for listening. Bye now.

Video 2 Transcript

Elizabeth Breitenbach: (00:00) Good afternoon and hello, everybody! Welcome to this edition of our Million Hearts Learning Lab: Leveraging Pharmacists to get Better Blood Pressure Controls, sponsored by the National Association of Kidney Health Centers. My name is Elizabeth Breitenbach. I'm a meeting and events specialist based in our Clinical Affairs Division here at NACHC and I'm pleased to bring this event along with my division colleagues.

Before we get started, I would like to review a few housekeeping announcements: First things first, this event is being recorded for playback at a later date. Automatically joining this event consents you to this recording. All attendee lines have been muted, or essentially been disabled, so you should not be able to unmute your line. If you're an attendee today, your videos also been disabled as well. The duration of this event is going to be approximately 45 minutes, including a very brief presentation and of course Q&A.

And let's get to the Q&A! Thank you to folks that have submitted questions in advance, we greatly appreciate that. But if you have questions throughout today's session, please use the Q&A box. It's either at the top of your Zoom screen, maybe at the bottom of your Zoom screen. Sometimes you need to take your cursor and hover to wake that up. Simply type your comments questions or concerns into this box at any time. We will answer as many questions in the time allotted with the additional resources. At this moment. I'd like to turn things over to Judy from the CDC who's going to be taking it from here. Judy, the floor is yours.

Judy Hannan, RN, MPH: (01:17) Thank you, Elizabeth, and welcome everybody to the May Learning Lab. Today's session will be about improving hypertension control with a specific role... key roles that they have in getting to the Million Hearts goal of improving 20% hypertension control, while addressing the needs of people with lower incomes and people from minority groups.

I am absolutely confident you will have a couple of takeaways from today's meeting that we hope you can deploy in your own area. ...Get your questions ready because we do have plenty of time for questions and answers. With that, let me turn it over to Meg.

Meg Meador, MPH, CPHI: (01:57) Thank you, Judy. I'm Meg Meador with the NACHC team and I just want to do a quick review of how our Million Hearts Learning Labs are structured. So, as Liz mentioned, the total time for the Learning Lab Live Session is 45 minutes, but the actual time for our whole package is 60 minutes. So the same as a traditional webinar, but... broken into three pieces.

The first is the pre-work video recording, and that's followed by a pre-work survey to gather your questions, and then today's live event. So our live event is 45 minutes, we'll be sharing at the end of this event how you can apply for CME credits. Next slide.

We have three learning objectives for today: The first is to specify examples of how pharmacists add value to hypertension treatment. We also want to share resources for pharmacists, expanded care team members, and public health professionals about how to engage pharmacists in hypertension treatment and management. And then the third objective is: to increase your understanding of the range of options to leverage pharmacist expertise. Very exciting content, very cutting edge.

We have two excellent speakers here today to answer your question—so excited to have them, thank you! We have Dr Adair Blyler and she's with the Smidt Heart Institute's Hypertension Center in Los Angeles, California. Joining her is Dr Nicole Therrien with the Division for Heart Disease and Stroke Prevention at the Centers for Disease Control and Prevention in Atlanta. Thank you so much to you both for being here. We're actually going to kick this off with a short presentation, as Liz said, that's going to be delivered by Nicole, thank you so much.

Nicole Therrien, PharmD, MPH: (03:41) Thank you, Meg, and just a reminder that the findings and conclusions in this presentation are those of the presenters and do not necessarily represent the official position of the CDC. Next slide, please.

Collaborative drug therapy management is the partnership between qualified pharmacists and prescribing clinicians to manage a patient's drug therapy as defined within the context of a collaborative practice agreement. This approach allows pharmacists to deliver services such as selecting, initiating, adjusting and monitoring medications, ordering and interpreting laboratory tests, and administering drugs. Next slide please.

Collaborative Practice agreements create a formal practice relationship between a pharmacist and a prescribing clinician. Most often a physician—though some states do allow CPAs—between pharmacists and other health professionals, such as physician assistants and nurse practitioners.

The agreement specifies what functions—in addition to the pharmacists scope of practice—can be delegated to the pharmacist by the collaborating clinician. The terms and functions provided under a CPA vary from state to state based on the pharmacist and the prescribing clinician scope of practice, and states the state's collaborative practice laws. Next slide please.

Currently, 49 states and DC have laws in effect that allow prescribing clinicians to delegate authority to pharmacists to manage patients drug therapy. Delaware is the only state that does not currently have such law. CPAs can have many components, which include the scope of the agreement covering things such as patient inclusion criteria authorized patient care functions, legal components—including authority and purpose—liability, informed consent, the duration of the agreement validity, and review process and administrative components such as training and education, documentation, communication, and quality assurance or quality measures. Next slide, please.

State laws and regulations vary widely. As I mentioned, most states have laws regarding collaborative practice agreements but there are variations. Some of these variables include authorized functions of the collaborating pharmacist or pharmacists, including which services—such as modifying initiating or discontinuing medications—may be performed.

They may also include variables such as the participants in the CPA, including the number of pharmacists and collaborating prescribing clinicians, pharmacist-to-clinician ratio, the number of patients, the types of prescribing clinicians, and the relationship between the clinician and the patient.

Finally, they may also include requirements or restrictions, including continuing education, qualifications of the pharmacist liability insurance, disease states or conditions to be managed by the pharmacist under the CPA, medications to be managed, involvement of the patient—this can mean that does the patient have to opt in or opt out, and how do they do this. Additionally, this can include documentation notification and communication between the pharmacist and the prescribing clinician. And finally, it can include duration of the agreement validity.

Before entering into a CPA, pharmacist and prescribing clinicians may benefit from reviewing their state's current laws and regulations pertaining to CPAs. State Boards of Pharmacy and Medicine and state pharmacy and medical associations can serve as point of contacts for the most up-to-date information on CPA authority in specific states. Next slide, please.

CPAs focused on caring for patients with chronic disease, including CBD, can empower pharmacists and collaborating prescribing clinicians. More information can be found in this resource, which I think we'll include the link to later that highlights much of the information I just mentioned, as well as additional information. Next slide, please.

Meador: (08:17) Thank you so much, Nicole, I mean, really powerful information. Yes, we will definitely include a link to that resource at the end. I wanted to say: we got a number of great questions that really helped us shape this session today, to tailor that to the things that you're most interested in hearing about. But we still want to hear from you today, so if you didn't have a chance to answer questions on the presurvey, you still can so feel free to add those in. We'll do our best to try to get to at least a few of those.

But I wanted to start with a theme that we had, we had a number of questions that came in on engaging pharmacists. The good news is that many of you are not only familiar with the concept of the pharmacist being part of the healthcare team, but really actually very excited about engaging one for hypertension care, which is great. You have lots of questions about how to engage pharmacists, particularly if they were not part of your organization. So we want you to feel like this webinar is for you even if you maybe don't have a pharmacist that's part of your care team. If you're just looking into the idea, the concept... how does that work? The first question I have is actually for both Nicole and Adair. Nicole, why don't we start with you and then we'll go to a Adair? What are some tips that you would share on how best to engage pharmacists?

Therrien: (09:39) Thank you, Meg, this is a great question. I would say an important early step is to convene a group of team members and decision makers—and this might include pharmacists, clinicians and leadership—to discuss priorities and jointly determined goals, objectives, activities, and expectations of each partner. Partnerships and engagement can look really different, so it's really important during these early conversations to figure out what is going to work best for this specific program or initiative, including having conversations early about communication—including the format and frequency—as well as evaluation or outcome reporting.

Meador: (10:24) Thank you, Nicole. Adair, same question to you. What are some tips you would share on how best to engage pharmacists?

Blyler: (10:31) I think what I would say first is... pharmacy career pathways are diverse—meaning pharmacists have varied interest, experiences, skill sets—and I say that because it's probably important to know that not every pharmacist that you may approach may have the desire to provide clinical services. As for how to best engage pharmacists, I'm not sure there's a right or a wrong way. As Nicole sort of alluded to there, I recommend you have sort of a very clear vision for how that pharmacist will complement your existing clinical practice, so that you could make that pitch to them.

I think, particularly if you're entering into a community or retail pharmacy environment where the demands on the pharmacist time are quite high, it's important to have a sort of well-defined ask of them so they can make an informed decision about whether or not it's something they could realistically take on.

But you know, I love that we're even talking about engaging pharmacists, because I think more often than not, pharmacists are continually having to make the case for why they should be included on healthcare teams, and how they can have a positive impact on patient outcomes. I just think it's really exciting that we're now moving into the space where healthcare leadership and clinicians really recognize the value of pharmacist and are interested in exploring partnerships.

Meador: (11:50) Adair, you said something that I think resonates with a lot of at least the health center audience on the call today. So, a lot of health centers don't have a pharmacist on their care team, they that's not a luxury that they have. But they often are in partnership with a community pharmacy or retail pharmacy, so they have maybe a contractual rate relationship, and you mentioned sort of that that can be a little tricky, because sometimes they're really busy and have to do a lot of other functions. But still, I think the question therein lies: how do you engage those pharmacists who are not embedded in your health system? I'm actually going to ask this of Nicole because you gave a great answer already Adair.

Therrien: (12:30) Oh, yes, this is this is a great question and that was really tied in very well. I would highlight, again, to bring together a group to jointly build the program or partnership. I'd also highlight that it's important to explore the landscape of community pharmacies in your specific community.

There are some variation in the type of community pharmacies, including those that are independently owned, are part of a small regional chain, or those that are part of larger chains, including those located in super stores or grocery stores, or a standalone pharmacy. Navigating the organizational structure and decision and engaging decision makers, as well as what services are offered may look different across these different types of pharmacies.

Consider exploring what types of pharmacies are most common in your community because this can have some really large variation regionally and also within cities. Consider exploring what pharmacies your patients are currently using to see where there may already be touchpoints or interactions.

I would say in terms of services that... pharmacists outside of your organization may be able to provide, there really is a range of services that pharmacists can provide in settings that aren't co-located. This can include everything from support for SMBP, or out-of-office blood pressure measurement, assessment and tailored services to support something specifically like medication adherence, medication therapy management, or collaborative drug therapy management.

There are sometimes challenges to implement collaborative drug therapy management outside of co-located collaboration, but it can happen in many states. Finally, I would really just highlight collaboratively building that program can ensure that the program fits the needs, priorities, and the resources of both organizations to ensure a successful program.

Meador: (14:56) Thank you, Nicole, and I actually want to pivot for just a moment We have a couple of questions that came in through the Q&A. A few of them are billing related, and we're going to touch on that topic a little bit later, but one of them I think, I think they call you can probably answer this: You were talking about which states have the ability for people to use a collaborative practice agreement. The question is: Do you have a recommendation on where to find a summary of the scope of practice for all 50 states? And maybe that's something we can share?

Therrien: (15:25) Yeah, that's a great question. I will say this is a sort of a constantly evolving landscape as new legislation is being introduced and implemented in states. We currently don't have a resource available for scope of practice for pharmacists. It's something we are exploring and there may be a resource in in either later this year or next year, but I would encourage looking at state-specific information because it can change across states during those legislative sessions or even as rulemaking and implementation of already enacted policy is occurring.

Meador: (16:20) Super, thank you. Adair, I'm going to ask this question to you and you may not have an answer for it, so feel free to say that you don't have an answer for this particular one. But the question is about a community pharmacist that has a collaborative practice agreement set up with a health care delivery organization, and then it says, "If that results in her prescription being filled at that pharmacy, is that sort of a strange kickback scenario?" I don't think it is. But I just want you to know, it's a question that's posed, and maybe we don't have a good answer for it.

Blyler: (16:53) I don't know that I have a great answer. I know what happens. I know that those sorts of relationships are being developed between individual practices and community pharmacies. I would assume that if the patients that are being managed are already having an existing relationship with that pharmacy, then it's an okay thing. At least, as I know, for some of these sort of larger MTM—like outcome MTMs and platforms that people used to do MTM—a lot of times, they're able to select patients out of that platform and manage them, and sometimes that comes with them becoming a new customer, and there's no conflict of interest with that. So, I think it's fair game, but don't quote me on that!

Meador: (17:41) As a non-pharmacist, I would have guessed the same thing, because a lot of organizations actually have an in-house pharmacy, and so it's sort of the same setup. But let's move on.

There's another question in the Q&A about buy-in, and we have some great questions that were posed in the pre-survey about that topic, so let's move on to engaging providers and clinicians and also talking about buy-in. This is a theme, as I said, that came up a lot and I want to ask you: How can pharmacists build relationships and trust to get that provider clinician buy-in so they can work effectively as a team member? And Nicole, maybe let's start with you, and then we'll move to Adair?

Therrien: (18:24) Yes, I think this is a really common question. I would say clearly defining goals, objectives, and activities, and then how those things will be evaluated can really support a successful and trusting relationship, I think for all involved, when there's as much transparency and clarity about expectations, and then how those expectations or how the program will be measured and how adaptations may happen is really important for both sides to make sure that they're happy with the program.

I'll say that many successful team-based care models involving pharmacist describe their guiding goal as a shared goal, a shared vision across all partners, to be providing the best possible care to patients. Especially in non-co-located or interventions that occur outside of more traditional clinical settings, part of that may be to provide increased convenience for the patients.

I would also say another key facilitator can be the agreement on preferred method and frequency of communication between the pharmacist and the cooperating clinician. There's really wide variation in individual preferences, and that may change throughout the life of the partnership. There may be a preference for more frequent communication really early on, as the partnership is new and that may change over time. So discussing these and being transparent is really important that to make sure that those are understood and agreed upon early on.

Meador: (20:12) Thanks, Nicole. Adair, to you!

Blyler: (20:15) I think this is tough. As I alluded to before, this is typically the situation that pharmacists find themselves in: they're having to demonstrate their abilities demonstrate, their worth. I think education is a big piece of this. I don't think society at large is really readily aware of what training is required for pharmacists. New PharmD programs require a minimum of four years, that's just like medical school, and many pharmacists now are going on to do one and two years of residency, depending on their interest in specializing.

That's anywhere from four to six years of laser-focused education on medications. In addition to that, there are a number of certificate training programs and board certifications that are now available to pharmacists. I think at sort of a base level, this is an easy way to not only communicate your skill set, but also allay any concerns that might still exist among clinicians about pharmacist readiness to provide clinical services.

As it relates to sort of building relationships, I think it's a little bit hard to speak in generalities, it really sort of depends on the environment the pharmacist finds themselves in. A pharmacist in a retail or community setting would have a very different challenge compared to someone who's already embedded in a clinic or is hospital based. What I've done personally is always try to clearly delineate for clinicians what my role is, and what my goals are, and also what they are not [laughs].

Unfortunately, we do sort of exist in this time where there's sort of turf wars [laughs] between different levels of providers, and I always feel inclined to state: "I'm not here to steal your patients. I'm here as an extension of you and your practice to help improve the care that you provide to patients."

Ideally, when you're first setting out to sort of create these relationships or partnerships, you want to target organizations or specific clinicians that have a history of working with pharmacists. Then, as Nicole said, you really want to make it a collaborative effort. I always ask lots of questions about "How can I be a help to you? I want to be a help not a hindrance." And then really make it a collaborative effort. When you work together to create care pathways that play to everyone's strength, there's sort of this automatic buy-in that happens, because everyone has a seat at the table and a say in how things go.

Meador: (22:41) I really appreciate that. It's true, Adair, it is new territory for a lot of clinicians. But I think it's interesting, in our Million Hearts project with NACHC, some of the health centers that are going down this road and exploring these collaborations have had their clinicians really experience how much pharmacists can... help give them more time with new patients, and give them more time with complex patients, and it actually expands their ability to see more patients. [Cross talk]

It's not about taking patients away from the clinicians, it actually increases their opportunities with those that need the clinician care most. I just wanted to share that bit that came out of our own project, really attesting to what you said.

I want to ask a follow up question that gets at buy-in, but from a different perspective. We talked about clinician buy-in in terms of pharmacists' engagement; what about patients? How are patients accepting pharmacist from your point of view? Have you experiencing challenges? Are there strategies that can help patients to see the pharmacist as a key player in their care team? Nicole, you want to start with this one? And then we'll move to Adair?

Therrien: (23:58) Yes, I can. I think that one of the most valuable things can be a warm handoff, and, again, transparency of the role. When a patient is going to be working with a pharmacist... for that to feel like an extension and part of the care team rather than a separate area. I'm going to go a little bit on one of the questions about identifying patients that I see in the Q&A.

I think that there have been some programs that have identified and at the time of identification, told the patient: "We're going to refer you using flags in electronic health records." For example, if a patient has an elevated blood pressure, they might be referred to the pharmacist for collaborative drug therapy management of hypertension. At the time when they're in front of a clinician or another health care team member, they're told: "We're going to have you work with a pharmacist who will do these things for this goal."

Meador: (25:26) Adair, to you. Patient engagement.

Blyler: (25:32) This is something that is still a challenge. It's great to hear the progress you've made at NACHC and now you've got providers and healthcare leadership coming around to the idea that pharmacists can have a really beneficial impact on the care team.

I still think that pharmacists providing patient care is a relatively new concept to many patients. I work with a lot of pharmacists and trying to implement research programs and something that they are always telling me that they hear is that patients say to them, "I just don't want you to do anything or change anything without you talking to my doctors first." I get that. It's still it's still sort of a relatively new concept, especially when it's a community pharmacist trying to implement some sort of change to a medication regimen, for example. As we just talked about clinician buy-in is essential. And as Nicole said, a warm handoff is really the best strategy, I think, that we have to get patients to engage with their pharmacist.

I'll use my own practice as an example: I work in a hypertension specialty practice that's part of the Division of Cardiology at Cedars-Sinai. I work closely with one cardiologist in particular, and I attend every new patient appointment with him. So when they meet him for the first time, they also meet me for the first time. It's wonderful, we've got like sort of a rhythm the two of us. When we walk in, he always says, "Hi, I'm Dr Rotter, this is Dr Bleiler, a pharmacist, and together we're going to tackle your hypertension."

I think that single line not only legitimizes my role in the eye of the patient, but it also makes clear to them that I'm going to be an active participant in their care going forward. After that first appointment, when they have questions about medication coverage, or side effects, or interactions, or how their blood pressure is maybe responding to the treatment we prescribed, and they send messages to us through our little provider portal, they're not caught off guard when I respond instead of Dr Rotter, because they know who I am and they know that I'm familiar with their case.

We also make clear from the get go that I'm going to be the one who's going to assist with med titration in between the in person clinic visits. Again, I'll respond to home blood pressure readings that gets sent in and make adjustments to medications or doses as I see fit. With this strategy, we virtually get no pushback from patients. A lot of the patients that I've had to call to communicate medication changes, now they have my phone number, they communicate directly with me.

I recognize that this is not a situation that all pharmacists find themselves in. Again, particularly when you're not clinic based, this can be a challenge. But the clinician can support engagement with the pharmacist by explaining why it's important, why... meeting with the pharmacist is important, and I think that endorsement is really what's key.

Meador: (28:24) I think this is... a testament to how powerful sort of the recommendation from the clinician is in all sorts of ways. I think whether it's a warm handoff, or whether you've endorsed, in real time, the pharmacists as part of your care team, that makes all the difference. The clinician buy-in seems to come first, and then having that clinician speak on behalf of the capabilities of the pharmacist as part of the care team.

I want to transition to another topic that surfaced as really important—and we can also see a lot of questions that have come in on this topic as well—around billing. Quite a few of you have these questions relating to billing or reimbursement for pharmacist services. I want to pass this one over to Adair, you probably would be the best one to talk to us a little bit about where we are with billing and where we're hopefully going.

Blyler: (29:27) First, I have to say, unequivocally, I am no billing expert. Also, we're limited on time here—I think this probably could be an hour-plus talk in and of itself. But I'll share some billing resources that specifically relate to hypertension management, since that's the focus of our talk today. I think we all are fairly familiar with this idea that pharmacists are not yet recognized as providers under Medicare, and so they can't directly bill for most of the clinical services that we're trained to provide.

However, through collaborations with other clinicians, state insurers, private insurers, health systems, we can start to implement some more sustainable clinical programs. I think it's worth mentioning that the COVID-19 pandemic has had a really positive impact on this whole pharmacist-provider discussion. When we were all obsessed with... how do we get medical resources like testing and treatment and vaccinations to more people, especially in medically underserved areas?

Pharmacies were sort of identified as ideal locations and pharmacist as ideal delivers of those care given our accessibility. My hope is really that this shift will help push through what has been a very long fight on the federal level.

The first set of slides that I'll go through here... I have to give full credit to Target:BP. If you're not familiar with Target:BP, it's a national initiative formed between the American Heart Association and the American Medical Association. They help health care organizations and care teams improve blood pressure control rates using an evidence-based quality improvement program.

Target:BP, I understand, was instrumental in pushing through some of these CPT codes for self-measured blood pressure, as Nicole alluded to. This is something that either clinic-embedded pharmacist or even a pharmacist who's outside your organization in the community space could help assist with. So these codes got pushed through, I think, right around the same time we were all transitioning to telemedicine during the pandemic, so it was really timely.

They allow healthcare providers to bill not only for training a patient on how to use a validated SMBP device, but also for collecting and formulating a treatment plan based on received SMBP data. Those codes are the first two that are listed there.

This is a slightly off topic, but I just want to quickly call out that the ValidateBP.org website that also appears on this slide. This website is a list of... validated home, office, and ambulatory blood pressure devices. I know, after the pre-work, there was at least one audience member who had submitted a question asking about whether we recommended a specific model or device. This is the resource for you to go to and find a device that you feel comfortable with. But these codes can really only be billed if a if a patient is using a device that's validated and on this list.

The next slide covers RPM, great! Remote physiologic monitoring services involve the transmission of patient-collected physiologic data to the health care team. Then these data are analyzed to determine what changes need to be made to the to the treatment regimen or treatment plan to improve patient outcomes.

Again, while pharmacists are may not be able to be recognized as billers through some payers, there are opportunities for pharmacists to collaborate with clinicians to enhance access to RPM services. I know, again, after the pre-work, there was at least one audience member who said they were getting ready to start an RPM program. I know of another pilot that was done at... RX Clinic Pharmacy—I think is what it's called—which is an independent community pharmacy located in Charlotte, North Carolina.

They published on a small pilot they did—this is, again, a community pharmacy that established a contractual agreement with local supervising community clinicians. In 2020, I think it was, they rolled out a program which was 100 patients from four collaborating clinics. They asked patients to use either a Bluetooth or cellular connected SMBP device to measure blood pressure.

The pharmacy team received all the readings on those monitors, and if the readings were outside of a defined range of "normal," the pharmacy technician prompted the pharmacist to reach out to the patient. The pharmacist could then reach out to the patients determine if there was an escalation in therapy needed. The escalation was clearly defined by the protocol or the collaborative practice agreement that existed between the community pharmacy and the supervising provider. Again, opportunity abound, for collaborating in this in this respect.

On the next slide, I want to call out that there are stipulations for how these codes can be used, so it's important to read the fine print here and understand the situations and timeframes when codes can and cannot be used. For example, you can't bill for receiving and responding to SMBP readings from the same month as a patient has an ambulatory blood pressure monitor, so it's important to know those distinctions so that you don't get caught out and you can bill for the services that you provide.

I'm not going to go over all this in the interest of time, and we don't expect you to be able to absorb everything on these slides right now. I think we'll provide the links to the resources at the end of the talk. I do want to move on to the next slide, just to talk about one of the primary means of performing billable services which is through "incident-to" billing.

That's where pharmacists can provide services "incident-to" or in support of a physician. This can be something like patient education, lifestyle management, or even something like CMM or MTM.

In order to bill "incident-to" the physician Medicare stipulates that nine requirements must be met. They're outlined here: I know this is a very busy slide, but the patient first has to be seen by the physician, the physician has to have that referral process where they've authorized this service. And the physician must continue to see the patient at a frequency that reflects that he or she is still actively participating in the treatment of the patient.

Some people have interpreted this as sort of like a rule of three so like every third visit must be with a physician, it can't be like the patient is only seeing the pharmacist in perpetuity and the physician is not checking in. There are stipulations about where these services can be provided, unlike stuff like RPM that can be done in different settings. This service is usually provided by the pharmacist in the provider's office or a clinic. It's got to be medically appropriate. Of course, it's got to be within the scope of practice as dictated by the given state's Pharmacy Practice Act, and you can see some of these other things.

I think the last point is really important that the pharmacist must be an employee leased or contracted to the physician who is the supervisor. The practice must have some legal control over the pharmacist and the services the pharmacists are providing. And it must, finally, represent an expense to that practice. Expenses can mean a lot of things: it can mean salary, it could mean non-salary support—such as providing the exam room or providing office supplies—or even staff support. So that's sort of loosely defined, it doesn't necessarily mean that they have to be a salaried employee of that organization.

If we go to the next slide, I want to highlight that there's a lot of misconceptions about "incident-to" billing. The 99211 code is really the code that we see most frequently used when pharmacists are trying to bill for services, but there are higher levels of billing for pharmacists, specifically 99213 and 99214 codes represent more intense services, and they can be billed at much higher rates. The current rates for 99211 is somewhere in the range of $20, whereas the higher levels can be in excess of $110, $120, $130 for each visit. The Pharmacy Times, not too long ago, did a break-even analysis. 99211 codes, a pharmacist would need to see 122 patients per week to break even which is just insane. But at the higher levels at 99213 and 99214, you'd only need to see 25, 26 patients per week, which feels like a much more manageable load.

Again, in the interest of time, I'm going to wrap up and just say a quick word on the next slide about the California Right Meds Collaborative, or CRMC, because I'm hoping that this is where we're headed as it relates to pharmacist reimbursement. CRMC was launched in 2019 by Dr Steven Chen at the USC School of Pharmacy, and its primary aim was to improve health outcomes and local communities while simultaneously decreasing health care costs and reducing unnecessary hospitalizations.

The collaboration itself is sort of a consortium of independently owned community pharmacies, health plans, and academic and professional organizations and they serve over 3 million low-income residents in the Southern California region. CRMC pharmacists and pharmacies deliver what's called "high-impact, comprehensive medication management," and they do so through a sustainable, value-based payment model.

I'm going to repeat that: it's a sustainable, value-based payment model. This particular group of pharmacies have sort of banded together and contracted directly with these two health plans, L.A. Care, which is a Medicaid provider in California, and also the Inland Empire Health Plan to provide a service and they're being directly compensated for it. It's really exciting.

In the CRMC model, patients who have not achieved clinical goals of therapy are identified by the health plan, and then they're referred to these participating pharmacies. Once they get there, the pharmacist is understanding what the patient's medication experience is, what their history is, what their preferences are, their beliefs around medication. They identify what the actual-use patterns of all medications are, they assess medications for appropriateness, efficacy, safety, interactions, all of that.

They ultimately develop a care plan that gets communicated back to not only the patient, but the patient's primary care providers. It pulls together all the approaches that we talked about: there's this warm handoff from the payer, who has notified the patient that you're not meeting goals, and we're going to connect you with a pharmacist who's going to help you achieve them. Then the pharmacist is helping develop a care plan that then gets communicated back to both the patient and the clinician. It's really sort of a full circle of communication and a true team effort.

Meador: (41:21) Thank you so much. It's so amazing to see what's possible, what's being explored out there, the ideal state for all of us...

In the interest of time, I think we're going to close out our Q&A session and just say, thank you so much, both to Adair and Nicole, I wanted to mention: we have a lot of really good questions still in the Q&A and I think what my team is going to do is gather those and do our best to answer those offline and send them out with the slides. We want to make sure that we're addressing the things that are of most interest to you.

If we can move on to the next slide, I wanted to quickly share with you: we do have a lot of resources for you. And you will have these slides very soon. We have some resources on best practices for heart disease and stroke prevention in general, we have resources on pharmacy prescribing and clinician collaborative practice agreements scenarios. Next slide.

We have a resource on using the pharmacist-patient-care process to manage high blood pressure. We have several resources here on billing for pharmacists services, I know that was of interest, and then we have several great examples of pharmacist-led hypertension management programs. I think these are really important because they help clinicians see that they can improve the care to their patients and their quality outcomes, including two big ones: the LA Barbershop Blood Pressure Study and the Michigan Medicine and Meijer Pharmacy Program, I highly encourage you to peek at those.

Then a total non-sequitur—not really total non sequitur, but it is related to cardiovascular health—we just wanted to put in a plug for a new campaign that CDC has called Hear Her. This is focused on preventing pregnancy-related deaths, which are usually related, often related, to hypertension, by sharing messages about urgent warning signs. With that, I'm going to turn it over to my colleague at the AMA, Rupi Hayer.

Rupi Hayer: (43:16) All right, great. Thank you, everyone. Hi, my name is Rupi Hayer, I manage the CME process for this learning lab. Here's a high-level summary of how to get access to your credit:

They will send the slides with you. But the activity page link is here. Once you click on that link, you'll be directed to either log into your ED Hub account, if you do not have one, you'll be directed to create one. Once you're in you'll be directed to hit the buttons the start button and complete the quiz. The after completing the quiz, you'll be asked to select the appropriate amount for CME to claim and, just a reminder, you have until June 28—that's about 45 days from now—to claim your credit. Next slide.

Here's a short set of instructions on how to access and download your certificate of participation. So again, once you've logged into your account, and you completed the quiz, you'll see on the top right hand corner, there's an opportunity to select transcript. And from there you can find your completed activity and select certificate to download. And next slide.

A friendly reminder that we do have our previous learning labs on demand on the Ed Hub site. So the treating patients with hypertension with the RX is up there the cholesterol one along with the motivational interviewing one on medication adherence, all three are up on the Ed Hub site on-demand in case you last one that we did, the bi-directional text messaging that will be up shortly. And then finally this is just a reminder about our next learning lab which is scheduled for July 9 In and that one will focus on improving blood pressure in African Americans and some common strategies to achieve health equity. So that's scheduled for July 19, from 3pm to 3:45pm Eastern time. Thank you again, all for attending. We appreciate you taking the time to join us today and hopefully, you will join us in our next session in July.

Meador: (45:25) Thanks, everyone.

Hayer: (45:28) Thank you


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