Improving adherence in appointment-based model

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The appointment-based model can realign workflow to allow pharmacists to provide patient care services and help drive better health and wellness for patients

Looking for a way to improve medication adherence and build efficiencies in pharmacy operations? The appointment-based model (ABM) is a patient care model in which prescriptions are synchronized to a monthly pick-up date—a minor modification to pharmacy workflow that creates time for pharmacy staff to provide a monthly call before the visit and patient care services such as medication therapy management (MTM) at the appointment. First put into practice in 1995 by visionary pharmacist John Sykora, BSPharm, MBA, owner of Abrams & Clark Pharmacy in Long Beach, CA, the ABM increasingly is being adopted nationwide.

Sykora was among the 16 national stakeholders gathered by the APhA Foundation on January 9–10, 2013, to discuss experiences with successful ABMs and prescription synchronization programs. Meeting in Washington, DC, the consortium participants represented 11 community pharmacies or pharmacy networks, 3 national organizations, and 2 government agencies. On September 24, the Foundation released a white paper detailing the participants’ recommendations for ABM implementation, business modeling, and marketing, as well as a toolkit to help pharmacy practices implement the ABM. The implementation guide, white paper, and more are available at www.aphafoundation.org/appointment-based-model.

“The ABM is a game changer for community pharmacy in that it is a proven model that can realign your workflow so you can provide pharmacists’ patient care services such as MTM and improve medication adherence,” said APhA Foundation Executive Director Mindy D. Smith, BSPharm. “Our white paper and implementation guide are designed to show how simple the model is to integrate, and how transformational the benefit to patient health and pharmacy operations could be to health care.”

In the beginning

Flashing back to the mid-1990s, when managed care was evolving, Sykora’s pharmacy was doing a lot of business with that industry. His patients would call the pharmacy in the 11th hour and be out of their diabetes test strips or ostomy pouches, causing pharmacy staff to go through the procedure of getting refills approved, which could take anywhere from 1 week to 10 days. “We were on the bad end of everybody’s opinion. Patients were upset with us. Managed care was upset with us,” Sykora recalled in an interview with Pharmacy Today

So Sykora decided to put his patients into a tickler file and start calling them 7 days ahead of time to make sure they were still in the program and still using the supplies and then to get the authorization process moving. “It worked so well we just folded prescription drugs into it. That became the bigger part of it all,” he continued. “It turned out to be a fantastic business model that we fell into. It made us far more efficient and put us in control of our workflow.” His pharmacy became proactive, rather than reactive. “It kind of evolved. It was not created to be an adherence model. It worked out to be that way,” Sykora said. “We knew when our patients weren’t ordering things, so we could keep them on their meds.” 

Calling the dominant paradigm of waiting for patients to come in with an order “an outdated business model [that] is what we have been doing for 100 years,” Sykora said that “we have to change our business model to where we know what the patient is going to be needing and when they are going to be needing it, and when they have been in the hospital or when they have seen their doctor.” 

Early adopter

Bartell Drugs, a regional chain based in the Seattle area, adopted the ABM from Sykora’s pharmacy. Bartell’s was trying to improve adherence for patients with numerous chronic medications being refilled at multiple time intervals. The company wondered if it could “drive patient outcomes by helping patients put all their [medication refills] onto one date” and piloted the ABM in a handful of stores, said Billy Chow, BSc(Pharm), MSc(Pharm), Director of Pharmacy Operations and Clinical Services there. 

“Pharmacists always love to do things that are going to help drive patient outcomes,” Chow told Today. Immunizations are “another example where pharmacists who are truly passionate will find a way to incorporate it into their normal workflow,” he said. But for pharmacists uncomfortable with change, “think of all the time-saving elements you are going to gain,” namely fewer upset customers on the phone or coming to the counter. Instead, the pharmacy staff makes one monthly phone call to the patient that proactively identifies that patient’s needs. Then, when the patient comes in for the monthly appointment on the agreed-upon date, the pharmacist has all the medications ready to pick up. 

The ABM gives the pharmacist and pharmacy staff opportunities to talk to the patient. During the phone call, “check in with them to find out how their medications are working; ask if they had any recent hospitalizations; ask if they had any new medications added,” Chow explained. “You also get another opportunity [to provide patient care services], if it’s seasonal wellness prevention—for instance, flu shots.” While the positive gain in business is a nice coincidence, he said, the “most important thing is you’re demonstrating to the patients, and to any insurers or payers, what you’re doing to take steps to help drive patient outcomes.” 

Bridge to patient care services

Improved adherence resulting from the ABM can increase pharmacy revenue while also creating efficiencies in workflow. This combination presents a unique opportunity for pharmacies to increase the clinical pharmacy services they provide.

Getting a prescription filled and getting it into the patient’s hand doesn’t mean all of the medication-related problems are solved, Chow argued. “What that patient does with the pill and the bottle at the end of the day will be a completely different conversation.” The ABM improves more than adherence and presents pharmacists with expanded patient care opportunities; Chow added that the model carries “big implications for driving better health and wellness for patients overall.”

Once the ABM is fully integrated into care, pharmacists are empowered to review the entire patient profile at once and have more time to have conversations with patients about how to take their medications and optimize their outcomes, according to Lindsay Watson, PharmD, APhA Foundation Director of Applied Innovation. These conversations grow the patient–pharmacist relationship, which can solidify the pharmacist’s role as a trusted member of that patient’s health care team.

Easy to implement

“The ABM is intuitive and requires almost no financial investment to be successfully implemented,” Watson said. “The Foundation’s implementation guide helps pharmacy staff navigate through the initial setup process and provides resources to track the patients’ synchronized medications and grow the service. After that, all that is needed is a file folder to stay organized and a phone to begin making preappointment calls.”

When Watson talked to pharmacists on the ground about how it’s done in real life, the theory of synchronizing everything to the most expensive medication is ideal to minimize the out-of-pocket cost. When patients are mostly on generics, however, there is no “most expensive” medication. In that case, pharmacists have synchronized to the date around which most prescriptions are due “to reduce the out-of-pocket cost of the initial synchronization,” she said.

According to the Foundation’s white paper, the other organizations currently operating or exploring the ABM that were represented at the consortium in January included Fred’s Pharmacy in Memphis, TN; Rite Aid; Publix Supermarkets; and Thrifty White in Minnesota, which expects to fill more than 1 million prescriptions this year in its refill synchronization program. Across the country, hundreds of independently owned community pharmacies have also experienced success with the ABM through the support of the National Community Pharmacists Association.

With the ABM innovation, Sykora was able to change his pharmacy’s work hours to 9:30 am to 6:00 pm, Monday through Friday. The pharmacy doesn’t have to be open on weekends, holidays, and evenings. “We know when everyone is going to run out. They are all on maintenance drugs. We can have them in there or ship them to them before they run out,” he said. “The stress level has reduced dramatically, and you have a more fun and meaningful relationship with your patient.” 


The appointment-based model in 10 steps

  1. The patient brings new or refill prescriptions to the pharmacy.
  2. The pharmacy staff explains the appointment-based model (ABM) and how it can decrease visits to the pharmacy.
  3. The patient decides to enroll in the ABM and talks with the pharmacy staff about establishing a synchronized appointment date to pick up prescriptions each month.
  4. The pharmacy staff reviews the patient’s profile to formulate a plan to synchronize all chronic medications so they can be picked up on the same date.
  5. To synchronize prescriptions to the determined appointment dates, the pharmacy staff will perform “short fills” (less than a typical supply) or “long fills” (more than a typical supply) depending on refill timing and the cost of the medication.
  6. Each month, a member of the pharmacy staff will call the patient approximately a week before the appointment date to confirm that the prescriptions should be filled, to identify any changes in therapy, and to facilitate any care coordination that should take place before the medications are dispensed.
  7. After reviewing potential changes to the patient’s medication regimen, the pharmacy staff prepares each prescription and creates one package for easy pick-up on the patient’s appointment date.
  8. Each month, the pharmacist reviews the comprehensive prescription order, evaluates the medication profile, and uses information gathered on the monthly call to identify potential compliance issues and topics to discuss with the patient.
  9. On the selected appointment day, the patient visits the pharmacy to pick up the prescriptions that have been prepared.
  10. The pharmacist may engage in medication therapy management services, which can include performing a comprehensive medication review, counseling the patient about the prescriptions, asking questions that arose during the medication profile and monthly call review, and identifying ways to optimize medication use.

Source: APhA Foundation. Pharmacy’s appointment based model: a prescription synchronization program that improves adherence. www.aphafoundation.org/appointment-based-model. Accessed October 24, 2013.

 

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