Pharmacy Practice Initiatives

The Iowa Pharmacy Foundation supports practice-based research and fosters innovative pharmacy practice activities. Over the years, grants provided by the Foundation have fostered activity in the areas of immunization administration by pharmacists, pharmaceutical care in community pharmacy practice, pharmaceutical care education in acute care practice settings, community-based residency programs, and demonstration of overall health care savings with the addition of pharmacist services. Three (3) major initiatives are detailed here:

1. The Iowa Center for Pharmaceutical Care
2. A demonstration project to examine the impact of pharmaceutical care delivery in the community pharmacy setting in patients with asthma, hypertension, diabetes, or ischemic heart disease
3. Iowa Medicaid Pharmaceutical Case Management

Iowa Center for Pharmaceutical Care

The Iowa Center for Pharmaceutical Care (ICPC) is a unique, innovative three way partnership between IPA and the Drake and Iowa Colleges of Pharmacy. This collaborative approach was designed to allow community pharmacists to implement more patient care services, while enabling the colleges and IPA to achieve their educational and service missions more effectively. ICPC’s mission, history, and current educational program are detailed below.

Mission
The mission of the Iowa Center for Pharmaceutical Care (ICPC) is to serve pharmacists in Iowa as a resource center dedicated to the adoption, evaluation, and promotion of the tenets of pharmaceutical care as the basis and central focus of the practice of pharmacy. This mission is accomplished by a series of action steps:

• Provide site-specific advice, counsel, and guidance to aid in converting practices to pharmaceutical care
• Provide education and training on all aspects of pharmaceutical care practice
• Evaluate and disseminate information on pharmaceutical care practice
• Coordinate or conduct educational initiatives to pharmacists, payers, patients, health-care providers, and others to create a demand for pharmaceutical care practices
• Coordinate or conduct research or analysis on issues relating to pharmaceutical care
• Identify and evaluate innovative pharmaceutical care compensation methodologies
• Support the development, evaluation, and implementation of professional guidelines and standards for pharmaceutical care

History
In April 1994, a group of progressive Iowa pharmacists met with representatives of the Iowa Pharmacy Association (IPA), and the University of Iowa and Drake University Colleges of Pharmacy. Their objective was to obtain the assistance of the colleges and IPA to transform their practices to a pharmaceutical care model. Each college dedicated two faculty members to the effort and the Iowa Pharmacy Foundation, the research and education arm of IPA, agreed to underwrite the expenses, including professional and administrative staff support. Subsequently, the Iowa Center for Pharmaceutical Care (ICPC) was founded.

Beginning in 1994, ICPC developed and implemented a process in the state of Iowa to transform pharmacy practice to a more patient care focused approach known as pharmaceutical care. The medication use process, medication outcomes, and the understanding and adherence to medication regimens have been improved in the state of Iowa, as is documented by the Wellmark Demonstration Project and the Iowa Medicaid Pharmaceutical Case Management Initiative. ICPC, as a project, was developed to meet a specific need in Iowa. ICPC has expanded over the years to include many facets of education and re-engineering, while continuing to focus on one goal; expanding the practice of pharmaceutical care in Iowa.

ICPC’s primary task in the beginning was to teach pharmacists how to collect patient specific data, evaluate such data to identify drug therapy problems, devise a care plan to correct or prevent such problems, document their care, and monitor patients appropriately. ICPC has also developed methods for pharmacists to create the time and physical space to provide this care as well as tools for them to market their practices and receive reimbursement.

To gain interest from Iowa pharmacists in the training and education program and to facilitate the rapid development of an education and training program, pharmacists from 14 pilot pharmacies in Iowa participated in a joint training program conducted by the ICPC faculty and staff from the Peters’ Institute for Pharmaceutical Care at the University of Minnesota. The ICPC training program was developed from this experience as well as from an earlier pilot study on pharmaceutical care implementation conducted in Iowa (Currie JD, Chrischilles EA, Kuehl AK, Buser RA, "Effect of a Training Program on Community Pharmacists' Detection of and Intervention in Drug-Related Problems", Journal of the American Pharmaceutical Association, 1997; 37: 182-91). These 14 pharmacies were provided a forgivable loan by the Iowa Pharmacy Foundation in order to demonstrate the profession’s interest in facilitating the transition to pharmaceutical care.

The ICPC pharmaceutical care philosophy focused on equipping pharmacists to interact professionally with their patients in order to identify problems related to drug therapy, propose solutions to such problems to patients and other care providers, implement and monitor those solutions, and finally, document this activity.

In February 1995, "Implementing Pharmaceutical Care: A Consensus Conference", was held to build consensus among the pharmacists of Iowa in re-engineering pharmacy practice through the implementation of pharmaceutical care. Representatives of national pharmacy organizations described their efforts that were underway at the time to help facilitate the movement to pharmaceutical care-based practices. Additionally, the ICPC presented aspects of its training and implementation program. Several pharmacists in Iowa who had made the conversion to pharmaceutical care-based practices also provided comments on significant barriers they overcame to make the process successful.

On November 2-3, 1995, a conference was held on the "Implementation of Pharmaceutical Care and Payment Systems." This conference stemmed from the pharmaceutical care initiatives occurring in the state, and involved invited attendees from state associations and colleges of pharmacy. The activities of ICPC were presented at this conference in an effort to generate support for the pharmaceutical care movement throughout the country.

In the summer of 1995, several ICPC trained independent pharmacies located in eastern Iowa formed a unique service alliance. The group, the Certified Pharmaceutical Care Network (CPCN), met initially to offer support, feedback, and advice. The mission of CPCN evolved to "enhance and promote the ability of member pharmacists to improve the health related quality of life of their patients and community by the provision of pharmaceutical care". By developing quality assurance measures and adhering to high standards of practice, the CPCN pharmacists were able to partner with health professionals at a diabetes education center and a local hospital. Many of the pharmacies formed relationships with physicians and receive referrals for their clinical services. Several pharmaceutical companies also partnered with the CPCN pharmacists to look at the impact of medication management on patients’ quality of life, the effects of disease state management on at-risk populations, and the ability of community pharmacists to identify at-risk populations.

On April 13, 1997, ICPC hosted the "Compensation for Pharmaceutical Care: Exploring the Options" conference for nearly 100 pharmacists in the state of Iowa. This conference addressed the increasing opportunity for payment for pharmaceutical care services by discussing documentation and billing processes, pricing methodologies, research results from payment for pharmaceutical care services, as well as success stories on receiving payment for pharmaceutical care services.

In 1997, the Iowa Pharmacy Foundation approved a grant for the "Development and Evaluation of a Pharmaceutical Care Implementation Model for Hospital Pharmacies" (Hagel H, Bjornson D, Currie J, Fassett W, McDonough R, Rovers J, Sobotka J). By modifying the ICPC methodology for practice re-engineering and pharmacist training, a comparative pilot project to implement pharmaceutical care in two similar hospital settings was conducted in order to 1) evaluate the effectiveness of pharmaceutical care skill development offered with and without departmental re-engineering; 2) create a pharmaceutical care implementation model applicable to a wide array of hospital settings; and 3) quantify potential budgetary requirements for implementing pharmaceutical care in the hospital setting. Project results suggested that 1) pharmacist education and training without addressing organizational processes is less likely to increase pharmacist patient care behaviors; 2) the implementation of an integrated health-system approach to providing pharmaceutical care is evolutionary and requires continuous assessment; 3) data tracking capability can assist with implementation and quality improvement efforts; and 4) a substantial financial investment is necessary to initiate a pharmaceutical care practice model. Pharmaceutical care education and training was incorporated into the original ICPC model in order to facilitate the conversion to pharmaceutical care practice in the institutional setting.

In 1997, the University of Iowa, in conjunction with two pharmacies in eastern Iowa and the IPF, developed a community pharmaceutical care residency program. The residency program was developed in order to increase awareness about pharmaceutical care and further train pharmacists in the provision and marketing of patient care activities. The goals of the residency include; 1) providing high quality pharmaceutical care in the community pharmacy setting; 2) developing personal and professional leadership and communication skills to advance the practice at individual sites and lead the profession in its movement toward pharmaceutical care; and 3) implementing and demonstrating quality improvement in a specific therapeutic area of pharmaceutical care practice in the community pharmacy.

Following a successful year with its initial resident shared between two practice sites, the University of Iowa program expanded to four residents for the 1998-1999 residency year, and has since been a multi-site program. The program was the first multi-site community residency program and the second program overall accredited under the American Society of Health-System Pharmacy/American Pharmaceutical Association residency standard for pharmacy practice with an emphasis in community care. Entering its 7th year in July, 2003, the program graduated eighteen residents in its first six years. While the core practices have remained a part of the program, seven different practices have been used as training sites over the years. Drake University College of Pharmacy also implemented community pharmaceutical care residencies in 1999, and currently offers two (2) opportunities in conjunction with Medicap Pharmacies and Osco Drug.

In 1998, members of the University of Iowa College of Pharmacy faculty and Iowa Pharmacy Association staff were awarded an American Pharmaceutical Association Foundation Quality Center grant. Their project, "Quality Assessment for Documentation of Pharmaceutical Care," put forth recommendations to the profession and to quality assurance organizations regarding minimum standards of documentation for pharmaceutical care. Consensus for these standards was developed over a period of months by both pharmacists from diverse practice settings and health professionals outside of pharmacy. The final guidelines are presented in a CE program, Identification of Essential Elements in the Documentation of Pharmacist-Provided Care, offered by the American Pharmacists Association.

In May 1998, IPA held an employee benefit manager’s conference for the health care decision makers in Iowa entitled, "Challenges and Opportunities in Pharmacy Benefit Management: Current Costs and Future Value". The audience included benefit managers, human resource managers, employer groups, and business leaders throughout the state of Iowa. The purpose of the conference was to increase the understanding of pharmaceutical care services, and how they can impact patients’ overall health by discussing a product developed in Iowa through the Iowa Pharmacy Association and PCA Iowa, a provider owned pharmacy network committed to the design and delivery of pharmaceutical care services in Iowa. The product was designed to overcome the high cost of poor treatment outcomes in today’s health care system, and is intended to bring the pharmacist into a central role in the management of the quality and cost of health care services as it relates to drug therapy expertise.

IPF also awarded a grant to De Sloover Y, Doucette WR in 1998 to conduct "An Exploratory Study of Pharmacy Services and Community Pharmacy Change in Iowa". The objectives of the study were to 1) examine changes Iowa community pharmacies made to develop a capacity to provide pharmacy services, and 2) identify factors affecting a pharmacy’s ability to make those changes. A variety of factors appeared to influence a pharmacy’s ability to create a capacity to provide new pharmacy services. Environmental variables, organizational factors, owner characteristics, strategy-making features, and attributes of the pharmacy changes all helped discriminate between pharmacies that made a change and those that did not. From this study, De Sloover and Doucette encouraged pharmacists interested in fostering pharmacy change to consider a broad range of activities to assist in creating a capacity for providing pharmacy services.

Through the Iowa Pharmacy Association and the University of Iowa College of Pharmacy, an invitational “Midwest Consensus Conference on Community Pharmaceutical Care Residency Programs” was held in December 1998. The conference goals were to assess the value of community pharmaceutical care residency programs and to address the role of the colleges, state pharmacy organizations, and the pharmacy community in working collaboratively to further develop as well as to expand the number of pharmaceutical care residencies. College of pharmacy representatives, state pharmacy organization representatives, pharmacists, and residents were invited from Illinois, Indiana, Iowa, Michigan, Minnesota, and Wisconsin, in addition to representatives from the American Pharmaceutical Association and the American Society of Health-System Pharmacists, to address the future of community pharmaceutical care residency programs.

Once pharmacists were provided with the education and training needed to advance their general patient care skills, they continued to specialize their skills in more specific disease state areas. To facilitate this, certificate programs were developed in cooperation with the ICPC initiative. Certificate programs were offered for over 400 pharmacists in areas such as osteoporosis, immunization administration, women’s health, smoking cessation, dyslipidemia, and diabetes. Pharmaceutical Care Practice and Patient Care Review Programs were also held in the areas of asthma, diabetes, ischemic heart disease, hypertension, marketing and reimbursement. These programs assisted nearly 400 pharmacists to use the pharmaceutical care process in evaluating a patient case for management of drug therapy problems. In addition, studies and articles were published discussing pharmacist involvement in immunization administration in the state of Iowa.

After pharmaceutical care training, pharmacists also needed a mechanism for marketing their services not only to patients, but also to other health care professionals who may provide them with referrals. To facilitate this, marketing consultants developed a program which assisted pharmacists in educating their patients and selling their services.

Between 1996 and 1999, the Iowa Pharmacy Association administered and directed a demonstration project through Wellmark Blue Cross Blue Shield, utilizing the PCA Iowa Network and ICPC trained pharmacists. The study objective was to measure the impact of pharmaceutical care interventions on the cost of overall health claims in order to ascertain the value of pharmaceutical care.

Through IPA’s lobbying efforts, language supporting reimbursement for pharmaceutical care services was passed in the 2000 legislative session. State funds were appropriated to pay the professional fees to pharmacists, while the Iowa Pharmacy Foundation pledged to fund research to evaluate the impact of the services. The Iowa Medicaid Pharmaceutical Case Management (PCM) Program, designed in 2000 by an advisory committee of physicians and pharmacists, sought to improve the quality of medication use in Medicaid eligible patients at high risk for experiencing adverse effects from their medications. The University of Iowa’s Colleges of Public Health, Pharmacy and Medicine, investigated the potential quality and cost benefits associated with the PCM program and presented this report to the legislature.

Faculty involvement in ICPC led to numerous changes in available courses, course content, and clerkship rotation experiences at the University of Iowa and Drake University Colleges of Pharmacy, in conjunction with the Doctor of Pharmacy degree program. In addition, the Iowa Center for Pharmaceutical Care continues to offer a certificate program (link) to educate pharmacists on the tenants of pharmaceutical care and assist in implementation of a work-flow strategy to accommodate a more patient-focused, collaborative medication management practice.