Program Description

Location:

  • Located within the Eskenazi Health – Pedigo Health Center
  • Connected to Horizon House – a facility that provides aid to the homeless population with resources, relationships, and life skills
  • Clinic Hours
    • Tuesday & Friday: 8:00 am – 5:00 pm
  • Clinic is already established with exam rooms, medication rooms, work space, and computers.

Staffing Requirements:

  • Half of an FTE — ambulatory care pharmacist working 8 am – 5 pm
    • Requirements include 1) PharmD, 2) PGY1, and 3) PGY2 in Ambulatory Care/Primary Care/Pharmacotherapy -or- currently completing an Eskenazi Health PGY2 Ambulatory Care Pharmacy Residency.
  • Clerical staff already in place with existing clinic
    • Will aid in scheduling patients and reminder calls

Referral Process:

  • Self-referred, or referred through the Horizon House

Barriers specific to Pedigo Clinic:

  • Storage
    • Pharmacist will have to understand that storage for medications is difficult with this population and determine a way to keep refrigerated medications, like insulin, efficacious, especially during the winter months.
    • Pharmacist will have to work on the medication room to make the process more efficient and less prone to regulatory issues.
  • Adherence
    • Pharmacist will have to educate patient on importance of adherence and try to decrease barriers that lead to decreased adherence, such as:
      • Physical cost to travel to the off-site pharmacy
    • Pharmacist will have to organize medication regimens to 1 or 2 weeks of days supply.
  • Health Literacy
    • Pharmacist will have to understand what resources are available to this specific population and what resources are most important for this population.
  • Administration
    • Pharmacist will have to educate patient on administration of medications in clinic, such as insulin.
  • Housing, Meals, Etc.
    • Pharmacist will have to work with Horizon House staff and the social worker on site to help patient find the resources they need.
  • Vaccinations
    • Pharmacist will have to make sure patients are up to date with their vaccinations with their disease states.
    • Pharmacist will have to recommend vaccinations to patients, if needed be and then administer them.
  • Hepatitis C Management

Billing Processes:

  • Fixed rate for reimbursement for patients with Medicaid regardless of level of service provided
    • Level 3 or 4 for Medicaid = $304
  • Medicaid – primary insurance used at clinic (FQHC)
  • Level 5 with shared
  • Level 3/4 with only physician
  • No billing for independent visits

Patient Visits:

  • Shared visits vs. independent pharmacist visits:
  • 1/2 a day with shared visits
    • 10 patients with physicians vs. 5 patients on own
  • 1.5 days with independent model
    • 15 patients altogether

Pharmacist – Patient Interaction:

  • CVRR management
    • Management of diabetes, hypertension, dyslipidemia, and tobacco cessation per CDTM.
  • Asthma and COPD management
    • Initial and follow up visits may include any of the following:
      • Patient will meet with the pharmacist within the clinic.
      • Pharmacist will explain the purpose of the visit.
      • Pharmacist will do a medication reconciliation with each of the medications patient is on.
        • Any changes in adverse effects, any concerns from the patient regarding their disease states, missed doses, storage issues, etc.
      • Pharmacist reviews patient’s disease states and medications prescribed looking to optimize therapy by reducing duplicate therapy and preventing adverse effects.
      • Pharmacist will alter medication regimen using lab values and goals based on guidelines that are established in the CDTM.
      • Pharmacist will educate on disease state, current medication side effects, storage, and additional monitoring.
      • Pharmacist will educate on lifestyle modifications and considerations.
      • Pharmacist to schedule follow-up appointment at the end of the initial visit.

Scope of practice and Pharmacologic Privileges:

  • Independent – no routine provider consultation required
    • Antidiabetic agents – oral and injectable
    • Antihypertensives and diuretics
    • Antilipidemic agents
    • Diabetic and blood pressure supplies 
    • Insulins (with the exception of Humulin R U-500 Insulin)
    • Nicotine replacement products and medications to aid in smoking cessation 
    • OTC medications
    • Vaccines 
    • Inhaled beta-2 agonists and combination products 
    • Inhaled corticosteroids and combination products
    • Inhaled anticholinergics and combination products
    • Inhaler/nebulizer supplies
    • Phosphodiesterase-4 Inhibitors 
  • Provider consultation required for initiating therapy – independent for renewing and adjusting
    • Antidepressants for neuropathy
    • Anticonvulsants for neuropathy
    • Humulin R U-500 Insulin
    • Oral corticosteroids
  • Independent (pursuant to treatment guidelines) for renewal only
    • Antiplatelets 

Visit Documentation:

  • Documentation of all visits will be done on Eskenazi’s electronic medical record (EPIC).
    • Recommendations for adjustment in therapy
    • Interventions for patient’s compliance
  • All providers will be able to stay informed on patient progression through EMR.
  • Notes on all patients seen that day will be updated and available for all providers to review at the end of each clinic day.

Data Measures:

  • Pilot Pedigo Clinic’s success will be measured utilizing retrospective data looking at cost avoidance specifically regarding:
    • Time to Next Available Appointment (TNA)
    • ED readmission rates
    • Clinical values
      • Smoking status
      • BP <130/80 mmHg
      • BMI
      • A1C < 8
      • Lipid levels
  • Documented in EMR for each visit
    • Change in clinical values related to specific disease state being managed
    • Patient reported ED visits and hospitalizations related to one of the five disease states listed under CDTM
    • Patient’s vaccination history
    • Pharmacist’s progress note, including all the recommendations made

Interventions:

  • Medication Reconciliation
  • Recommend and adjust medications based on current guidelines in the CDTM and physician recommendations 
  • Vaccination recommendations and reconciliations
  • Drug Interaction screenings
  • Education regarding HTN, DM, smoking, and dyslipidemia
  • Assistance in medication dosing, selection, titration, and ordering.
  • Assistance with PAs/facilitation with nursing PA coordinator or MDs unsure of rejections
  • Contact pharmacy to ensure delivery of medications to improve adherence.

Patient Discharge from CVRRC

May include, but are not limited to the following:

  • Achievement of all relevant clinical goals
  • Consistent failure to keep appointments
  • Threatening or abusive behavior
  • The patient decides to opt-out of CVRRC services
  • The patient’s provider opts-out of having his/her patient enrolled in CVRRC services

The pharmacist documents reason for discharge in the patient’s electronic medical record and notifies patient, as appropriate.

Established Collaborative Drug Therapy Management Protocol (CDTM):

  • The following guidelines should be used in the management of patient’s disease states:
Diabetes Mellitus American Diabetes Association (ADA)
Hypertension ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
Hyperlipidemia AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCN A guideline on the Management of Blood Cholesterol

AAC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease
Tobacco Cessation US Department of Health and Human Services, Treating Tobacco Use and Dependence
Asthma National Asthma Education and Prevention Program (NAEPP)
COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD)