"We are looking for the most efficacious and safe therapy for the shortest duration that is clinically appropriate and financially feasible."
Lindsey Poppe, PharmD, MS, BCPS, has accomplished quite a bit since joining the University of North Carolina (UNC) Hospitals pharmacy team 15 months ago. As the clinical manager for the oncology service line and emergency department (ED) services, she facilitated the implementation of a new practice model to improve patient care through direct care services and launched a first-of-its kind stewardship program for blood factors used by patients with hemophilia. Poppe also revamped a program where specially trained pharmacy technicians talk to patients to obtain medication histories.
Poppe’s career path to UNC Hospitals was fairly direct. Originally from western Nebraska, she graduated from the University of Wyoming in 2009 with her PharmD and moved to Chapel Hill, NC, to complete a 2-year health-system pharmacy administration residency at UNC Hospitals in conjunction with a master’s degree in pharmacy administration at UNC Eshelman School of Pharmacy. She was offered a permanent position after completing her residency.
Today, Poppe manages 29 employees in the oncology service line, including central pharmacists, clinical pharmacists, and pharmacy technicians, as well as 5 technicians who are medication history specialists in the ED. “The best part of my job is working with all of the pharmacy aspects—distributional preparation and dispensation of medications, clinical review and progression of clinical pharmacy, advancement of technician roles, and business management through the financial components,” said Poppe.
As part of the bone marrow transplant layered learning model, Poppe reviews a chemotherapy order with Christian Conley, PharmD, PGY1 Pharmacy Administration Resident.
Poppe was instrumental in developing and launching a layered learning practice model within the oncology service line at UNC Hospitals. The program combines pharmacy practice with education to enhance pharmaceutical care delivery to patients. The model comprises multidisciplinary team members including an attending pharmacist, a pharmacy resident, a student pharmacist, and a clinical pharmacist generalist.
“This is a learning model where [participants] take an active role and really engage with patients one on one through discharge counseling and obtaining medication histories,” said Poppe. The education sessions with the learners promote active learning through topic discussions pertaining directly to patients’ disease states and medications, “rather than a general topic discussion that may not relate to a patient on the service,” she added.
Pharmacy technicians who are medication history specialists play an important role in this model. “There is a meeting once a day where the tech or a student pharmacist [relates] the patient’s medication history to the rest of the pharmacy team so that the pharmacist can reconcile all of the patients’ medications,” Poppe told Pharmacy Today. “Prior to discharge, the team reviews the history and any additional meds that were added during the patient’s stay. All of this information is reconciled with what the patient should go out on at discharge.” The pharmacy team updates the medication list in the electronic information system and uses the list to counsel patients.
The team also partners with the Medication Assistance Program to conduct benefits investigations, including prior authorizations, to ensure that patients have access to their outpatient medications upon discharge.
So far, the layered learning practice model has been implemented on three oncology services—hematology malignancy, bone marrow transplant, and solid tumor. Although this program is still in the beginning phases, the results are remarkable.
“Before this model, there was a 0% discharge counseling rate for patients in the heme malignancy service. Through this model, 78% of patients are now counseled prior to discharge,” said Poppe. On the bone marrow transplant service, the pharmacy team performs medication reconciliation on 100% of the patients, compared with 30% to 40% of patients before the program. “The solid tumor service for patients has a very high turnover for patients, but we were able to go from zero to 31% of patients being counseled prior to discharge,” explained Poppe. “This model truly enhances the direct patient care services provided by pharmacy.”
While completing her residency at UNC Hospitals, Poppe, in collaboration with Scott Savage, PharmD, MS, Assistant Director of Pharmacy, University of North Carolina Health Care, began working out the details for a stewardship program for blood factors. “I always joke that projects stay with you forever, and now this project that I started in my residency has come to fruition,” said Poppe.
During her residency, she noticed that there was not consistent pharmacy oversight of expensive factor medications for patients with hemophilia. “We see a lot of these patients, either those who have an active bleeding disorder or surgical patients who do not have hemophilia but need the bleeding to stop,” said Poppe.
UNC Hospitals is also a regional referral center for all patients with hemophilia. Through the factor stewardship program, a specially trained benign hematology pharmacist collaborates with the coagulation consultation team so there is a continuity of care. “This allows us to have consistent oversight and coordination of care for all hemophilia patients,” said Poppe. “It also provides the structure and education around factors used for nonhemophilia patients in the surgical areas.”
As part of the stewardship program, Poppe and her team switched patients with hemophilia from using intermittent infusions of factors to continuous infusions if the patient is scheduled for more than five doses. “We saved over $1 million by switching patients over to the continuous infusion,” said Poppe.
To her knowledge, this is the first factor stewardship program in existence. “We are looking for the most efficacious and safe therapy for the shortest duration that is clinically appropriate and financially feasible,” explained Poppe.
Poppe and pharmacy technician Ashley Pope, CPhT, use technology to ensure an accurate inventory of products.
Although pharmacy technicians routinely obtain medication histories for patients in the ED being admitted to the hospital, Poppe broadened this initiative so that technicians now take the medication histories of patients that are admitted to the hospital and are up on the floors.
“It’s an advanced role for the technician and brings them closer to the medical teams,” said Poppe. The technicians talk with patients all day long to obtain a comprehensive medication list that can be used by pharmacists to reconcile the medications the patient should be on. In addition, having technicians throughout the hospital has “facilitated the use of these histories, so that they’re tied with the medical service,” said Poppe.
Technicians spend about 8 hours per day talking with patients to obtain a comprehensive medication list. The process includes speaking with the patient or the caregiver, calling the patient’s pharmacy to ensure that the patient has been picking up and filling all the medications, and identifying the last fill date. Technicians may also reach out to the patient’s nursing home or long-term care facility to request a medication administration record to facilitate the list acquisition.
The technicians compile all of the medications into one list and present the list to the pharmacist. “The technicians will point out potential discrepancies that were noted, and the pharmacist can then act upon those discrepancies,” said Poppe.
Theresa Stroud, CPhT, pharmacy technician, talks with Poppe during the practical portion of a competency evaluation.
An important part of successfully expanding pharmacist and technician roles includes advanced training and competency. “How do you ensure that your employees are competent and are performing the functions required of them? I believe that having competencies is essential to practice,” Poppe said.
Poppe and her team developed different competencies for pharmacists and technicians at UNC. “Especially with the medication history specialists, we get questions from people outside of pharmacy who want to know whether the techs are competent to take a patient’s medication history,” she said.
The competency exam for medication history specialists includes multiple choice questions and fill-in-the-blank case study questions. There is also a practical component where pharmacists observe a technician as they take a patient’s medication history and then provide feedback to the technician on their technique.
The group is currently in its second year of requiring competencies for oncology pharmacists. Oncology technicians are required to complete a practical test each year. Competencies for medication history specialists started last year and Poppe is assessing how often these should be conducted. See the October issue of Today (page HSE 14) for more information about developing a competency program.