Single day for all prescriptions: Sykora invents ABM, sees chains scale nationwide
John Sykora, BSPharm, MBA, owner of Abrams & Clark Pharmacy in Long Beach, CA, thinks that the traditional pharmacy setting can tend to be reactive. “Patients hand over a prescription and pharmacists fill it. Mail [service] is even less collaborative,” he told Pharmacy Today.
Twenty years ago, Sykora decided to take a proactive approach. In the mid-1990s, when managed care was becoming a big part of pharmacy, his practice felt reactive and off kilter. “We thought we would change that by being more proactive,” said Sykora.
Under managed care, patients had to reorder supplies every month, and the pharmacy was in charge of obtaining authorization. Patients would call the pharmacy at the last minute, but it would take 7 days to get the order approved—and by that time, patients would be out of supplies. Sykora decided his staff would call the patients instead of waiting for them to call the pharmacy.
“By being proactive, we had the product ready before the patient ran out,” said Sykora. Because the system worked so well, they folded in prescription medications.
Sykora’s proactive approach from 20 years ago led to what has today become known as the appointment-based model (ABM), in which a patient’s prescriptions are synchronized to a single, convenient day each month for pick-up. It also creates an opportunity for pharmacists to provide a monthly check-in call before the patient comes in and to provide medication therapy management (MTM) during the appointment.
“MTM must include personal drug adherence management through an ABM collaboration between patient, physicians, and pharmacist,” said Sykora. “The cost would be far less than the cost of failed therapeutic outcomes.”
According to the APhA Foundation, more than 23 pharmacy chains in the United States have implemented ABM, totaling more than 20,000 community pharmacies, along with roughly 2,000 independent pharmacies. Thirteen states have passed legislation to remove barriers to help streamline the process for patients, too, and CMS now requires plan sponsors for Medicare Part D–covered drugs to offer prorated copayments to Medicare beneficiaries who have their medication synchronized for a single pick-up day each month.
How ABM works
Patients who come into Abrams & Clark Pharmacy are mainly seniors, but many are mental health patients. The pharmacy manages about 350 patients on a regular basis using ABM. But Sykora said they could easily handle two to three times that amount without any issues.
Sykora reviews with a patient the medication changes resulting from a recent hospitalization.
Since most people prefer convenience, getting patients enrolled in the program is not a difficult proposition. Sykora and his staff identify patients, or family members, who are on many drugs and ask if they would like to have all their prescriptions ready for pick-up on 1 day a month. “That simple concept they grasp quickly, and usually jump on board right away,” said Sykora.
When a patient is enrolled, the pick-up day is established in the computer system first. Sykora said they also review the patient’s drugs for adverse effects and costs. Once everything is synchronized to the pick-up day, a pharmacy technician calls the patient 5 to 7 days before the pick-up date to start the process of refilling or obtaining prior authorizations, if necessary.
Sykora said the first month typically requires the most maneuvering to synchronize the patient’s medications, but any changes or new medications introduced become automatic and streamlined afterward.
“But during that month, if they bring in a new order, you’ve got to synchronize it immediately to the fill date. You can’t give them a 30- or 90-day supply in the middle of the month,” said Sykora.
Sykora and his staff fill the prescriptions the day before the patient’s scheduled pick-up because it gives the pharmacist or technician an opportunity to look for gaps in therapy. For instance, if there’s not an order for the patient’s regular medication, the pharmacy technician speaks with the patient. Sykora said it’s typically a cost issue that leads the patient to stop taking a medication—he sees it all the time. But they try to find alternatives with the patient’s physician.
“No one typically looks for gaps in therapy, but this system allows you to,” said Sykora. He said it’s also a chance to ask the patient if he or she has been to the hospital, where new orders are typical. But communication often lags.
“Oftentimes the patient doesn’t even know they have new orders,” said Sykora.
When Sykora and his team encounter this scenario, they can insist on seeing the orders. Sykora said they almost always find changes.
“We take a proactive approach in trying to find those orders to keep [patients] from going back into the hospital. We’re trying to get everything done before the patient needs it, to process problems that may have occurred during that month,” said Sykora. This translates into finding out what every new order might be replacing, too, especially with senior and mental health patients.
Technology certainly plays a role in the process. The pharmacy system QS1 manages the process of synchronizing, filling, and billing. Sykora said they need Microsoft Word and Excel to communicate with patients and physicians, too.
According to Sykora, his ABM patients have high satisfaction rates. They appreciate not only the convenience and the amount of time it saves, but also the ongoing communication with the technician or pharmacists whom they get to know well.
He said there are even a couple of patients using ABM who are on just one drug. These patients are typically calling the pharmacy at the last minute for a medication.
“We don’t want patients to run out of their medications,” said Sykora.
Thrifty White: Early adopter
ABM has been recognized and adopted by other community pharmacies over the years. Thrifty White Pharmacy, a chain of employee-owned community pharmacies located in several rural Midwestern states, was one of the first pharmacy chains to scale the model. The average Thrifty White patient is older than 65 years, a woman, and enrolled in a commercial insurance plan.
Thrifty White patients learn about the program verbally or from printouts stapled to prescription bags. They go through a formal enrollment process that includes an agreement form. Once patients are enrolled, Thrifty White pharmacists work with them to synchronize their medications to a single, convenient day each month. Most Thrifty White pharmacies use an automated call service to schedule a monthly call with patients in order to review medications and identify any changes. Finally, patients pick up the medication or have it delivered to them on a scheduled appointment date.
“On this date, the medication can simply be dispensed like all medications, or it can be accompanied by medication therapy management, disease management, or other more intensive pharmacist-delivered services,” said David Holdford, BSPharm, MS, PhD, FAPhA, Professor and Vice Chair of Graduate Education at Virginia Commonwealth University School of Pharmacy. “Getting patients to engage in MTM is still a difficult task, but [ABM] allows pharmacists more time to work on recruiting patients and helping them.”
Holdford led a study, published in JAPhA in 2013, which was the first to assess the impact of ABM on medication adherence. The study was conducted from June 2011 through October 2012 on patients served at Thrifty White pharmacies. The study found that patients enrolled in ABM had three to six times greater odds of adhering to their medications over a 1-year period compared with patients who were not enrolled.
Holdford said that ABM also saved technicians’ and pharmacists’ time and money.
“Based upon my discussion with individuals at Thrifty White, revenue increased because people filled their medications more, but other sales did not suffer much,” said Holdford.
Publix: Nation’s largest program
Publix Super Markets, a grocery store chain in the southeastern United States, implemented ABM in all of its 959 pharmacies in January 2014. According to Maria Brous, Director of Media and Community Relations for Publix, the chain has the largest ABM program in the country in terms of the number of patients enrolled. Similar to other pharmacies using the ABM, patients decide on a convenient day each month to pick up their prescriptions, and pharmacy staff synchronize the patient’s medications to that day.
Sykora and Montesa discuss an annual comprehensive drug review for a Medicare Part D patient.
“Having technology is extremely important for a chain as large as Publix, and good training for pharmacy staff from the beginning is key, too,” said Brous.
Publix uses a software system to help pharmacy staff identify potential candidates for the program. The software program also assists pharmacy staff with the initial synchronization, queues the medications for refill each month, and makes automated phone calls to the patient each month to determine if changes have occurred to the medication regimen. According to Brous, if changes have occurred, the software program triggers a manual phone call from the pharmacy staff to discuss changes with the patient. Also, patients are contacted about 8 days before the pick-up date to verify that refills are still needed. Patients also receive an automated call or text 1 day before their pick-up date.
After just 1 year, Brous said medication adherence has improved with ABM patients. “We are seeing similar increases in ‘proportion of days covered’ scores, as has been reported by other pharmacies,” she said.
They are noticing enhanced relationships between patients and Publix pharmacists as well.
“By knowing when the customer will be coming in for their appointment, the pharmacist can prepare for patient engagement—prepare to give the patient an immunization, medication consult, or discuss medication adherence,” said Brous.
Some patients encounter barriers with their insurance plans—for instance, having to pay full copays for partial refills—that discourage them from enrolling. Sykora said it’s important to educate payers, providers, and others on the ABM concept—and on what pharmacists are capable of doing.
Despite the challenges, the benefits of ABM give Sykora confidence that the model will spread. “Overall, we’ve cut down on phone calls, deliveries. We’ve increased inventory turnover, and we’ve improved patient and employee satisfaction,” said Sykora.
Patient care staff (L–R): Fonda Ramirez, MA,
DME specialist; Lucila Hernandez, CPhT; Eddie Flores, delivery; Johanna Martinez, insurance specialist; Bellamay Montesa, 2015 PharmD candidate; Carol Sykora, manager; John Sykora, BSPharm, MBA, pharmacist.
By being able to manage workflow, Sykora’s staff can fill up slow times with filling orders and performing MTM. Financially, they don’t need to order expensive drugs until they are filling an order, which has caused their inventory turnovers to go up, leading to significant savings.
Sykora said that implementing ABM not only can make a pharmacy profitable, but also allows pharmacists to better serve their patients.
“If we’re going to move from a traditional way of reacting to our patients to a proactive way to serve our patients,” Sykora said, “then it’s going to allow pharmacy to become more clinical in its approach to delivering drugs and pharmaceutical services.”
Align My Refills campaign: APhA Foundation increases public awareness
APhA Foundation kicked off a national campaign last fall to create awareness for consumers around medication synchronization, or the appointment-based model (ABM), as momentum continues to build around its effectiveness.
“Data have confirmed that medication synchronization is an effective strategy for improving medication adherence,” said Mindy Smith, BSPharm, APhA Foundation Executive Director.
The APhA Foundation believes it’s an opportunity for pharmacists to provide patient care services. In addition to pharmacists syncing a patient’s medication to a single, convenient pick-up day each month, the model creates an opportunity for pharmacists to provide a monthly check-in call before a patient comes in, as well as medication therapy management during the appointment.
“Our goal through this campaign is to make patients aware that pharmacies are providing this service and promote how valuable developing a relationship with their pharmacist is to their health,” said Smith.
The campaign kicked off in October 2014 during American Pharmacists Month, with a national media tour and engagement with stakeholder groups focused on caregiving, patient safety, and chronic disease prevention.
The APhA Foundation has an implementation guide (www.aphafoundation.org/appointment-based-model) on its resources page for pharmacies interested in medication synchronization and a map (www.aphafoundation.org/map) for patients who want to find a nearby pharmacy offering medication synchronization.