In this episode, the team from the Henry Ford Health System to discuss their award winning submission to the ASHP Best Practices. They will share how the addition of a pharmacist to the multidisciplinary interstitial lung disease (ILD) team, along with the robust collaboration with a specialty pharmacy, improved the quality of patient care in ILD and generated significant revenue for their health system.
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This series focuses on discussions for all things related to research, including fundamentals, best practices, and practical advice for all of those interested in contributing to the advancement of knowledge. My name is Vicki Bassalega, and in today's episode, we'll be chatting with the team at Henry Ford Health about their ASHP best practice award-winning program called improved access and outcomes for patients with interstitial lung disease and a pharmacist-led medication management program. For those of you unfamiliar with the ASHP best practices, this award recognizes outstanding practitioners in pharmacy who have successfully implemented innovative systems that demonstrate best practices. This year, ASHP's best practices were sponsored by Power Pharmaceuticals True Delivery. Welcome and thanks for joining us today, everyone. So let's start with a brief introduction. Can you tell me a little bit about yourself, your team, and your practice location? Sure, my name is Krishnal Gavarajah. I'm one of the pulmonologists at Henry Ford Hospital, and I run our interstitial lung disease program. So we are located in Detroit, and we draw patient population from the Detroit area and then surrounding suburbs. So we have the main hospital and three satellite hospitals that are about 30, 40 minutes from our main hub. In terms of what we do on a day-to-day basis in the interstitial lung disease program is take care of patients who have either inflammation and/or scarring in the lungs. This is often progressive. The most serious form is universally progressive, and patients are treated with, depending on their underlying disease, steroids-sparing agents, anti-fibrotics, and some won't ultimately go on to lung transplant. And so our program started in 2009, and we've grown from seeing about 50 patients a year to close to 800 active patients in 2023. So we've grown from a very small to medium and bordering on larger program now. And so about, let's say 20% of patients are on drug therapy. I'll jump in next. My name is Amber Lynn A. Marjorosev, and I am the clinical pharmacy specialist in the ambulatory care pulmonary clinic at Henry Ford Health, and I work very closely with Dr. Sabarajah for these patients that she just described, and I will let my other co-pharmacist introduce a little bit about themselves as well. My name is Hannah Ferrari. I am a clinical assistant professor at Wayne State University with a practice site at Henry Ford Hospital in the cardiology clinic. I was a previous resident of the ambulatory care pharmacy PGY2 at Henry Ford Hospital, so I am experienced in working with our providers in the pulmonary clinic and with patients who have interstitial lung disease. Hi, my name is Amanda Soya. I'm the manager of clinical services at pharmacy advantage that's Henry Ford's specialty and mail order pharmacy. So I oversee the specialty team and all of the medications, and we partner closely with our specialty clinics within all of the health system. Okay, so you talked a little bit about how this clinic started in 2009. Can you tell me a little bit about why you started it, and what you hope to see by adding an ambulatory care pharmacist to the interstitial lung disease team, and this has been a program around for a while. So how do you define success? So I'll go ahead and start. So when we started the program, the goal was to take better care of these patients. There were some already in the system. We're hoping to help the surrounding areas, and that's just the program overview to provide a certain level of standardized care, opportunities for education for fellows, residents, for multiple disciplines, and then also provide research. Whether that's pharmaceutical trials for patients, given that there's no care for these disease, this group of diseases, or if it's implementation research, as we're talking about today. In terms of what we would hope when we're adding the pharmacy team, before the pandemic, we had a very different program. We seem to have exploded. Just as the pandemic hit, we had closed, physically closed the clinics for three months, given the inability to control some of the infectious risks for patients. And when we reopened the clinic, we found that many of our patients had delayed contacting us to let us know that things were going worse, because they were so afraid about having to come in or talk with someone. And so we found that we were needing to treat many more patients with either steroids-bearing agents or anti-fibrotic agents, and both of those required quite a bit of monitoring and touch points with the patients. So Amber and I had worked together on our COPD and asthma program in the program's initiatives within the system, and wanted to work together in terms of improving access for patients and monitoring, because the concern we had going into this was that we really weren't able to keep up with one nurse coordinator, two physicians at the time and one APP with a very busy clinical practice. And so the pharmacist really stepped in to help keep this endeavor safe for our patients, and I'll let Amber fill in the gaps there. So I think Dr. Thavraja did a fantastic job of explaining kind of the background, and I'll just talk a little bit about some of the details that from a pharmacist's perspective we came into. So we came back to this clinic looking at where the gaps in care were, and if you think about the drugs that are used, there is a lot of monitoring that needs to be done that unfortunately just wasn't able to be conducted because of the pandemic, but also because of just the sheer volume. So the pharmacy team really worked with the providers to develop a clear clinical workflow of once a patient starts drug, what should the pharmacist actually be responsible for, and how can we ensure that our patients are not only getting access to their drug quicker, but they are also being appropriately managed on that, and then taking some of that workload off the providers so that the providers then have opening in their access so that the patients can be followed up with for more acute reasons. We did a really great job, I think as a team of really delineating what those roles are, and who was responsible for what as a way to reduce redundancy and duplication. We also did a really good job of standardizing things to ensure that whether it was me as the lead pharmacist or my pharmacy residents taking over the patients were getting a consistent message, and our team was getting a consistent message to ensure that there was success within our program. And then I think we're going to probably get to this a little bit later, but then there became opportunities as we were evaluating what success looked like to then create further partnerships with our specialty pharmacy to ensure that we would improve overall access, but also funding for these patients with some of these higher cost drugs. And I think it's a really great definition for success for us to be able to say that one, we are looking at that patient and really putting the patient as our focus, but then two, then looking at some of those objective outcomes such as financial cost, actual patient access to our providers, to the pharmacy team, and then really the impact on those patients in terms of disease state control, that lab monitoring, and so forth. So I think overall, those are kind of the things that we used as we were creating the program to truly define what success would look like in this program. So can you tell me a little bit more about the role of the pharmacist within the team? Just a little bit maybe about what they did on a daily basis. I truly feel that people, when they get their pharmacist, they're so excited and they realize how much we can do, and they just keep adding more and more. They just really love us because we're great, of course. So can you tell me about how the position evolved once pharmacist introduced to the clinic? Yeah, so I'll start and then I'm probably going to bounce off to my other pharmacist colleagues on the call, but essentially what we did as a team first was we actually created a standing multidisciplinary team meeting, and I actually think that this is something that's so critical because it ensures that our team has dedicated time to talk about patients and not only the patients, but what is going well and what isn't going well in our program so that we can make those quality improvements along the way. On a day-to-day basis, we kind of have what I like to refer to affectionately as three buckets. So our first bucket is our enrollment bucket. So what this is is the providers actually tell us, hey, we're going to start a patient on drug therapy. Please evaluate this therapy and the patient to make sure that it's appropriate, and then as long as everything is above board, all the testing has been done, call the patient, and see if they are ready to start their therapy. Once the patient is agreeable to start therapy, they then move to what we call our second bucket, which is now the initial phase of treatment. And in that phase, we're following up with the patient a little bit more closely to ensure that they're not having side effects to the drug, that they're actually getting their drug from the pharmacy, they're not being delayed because of prior authorizations or costs, and then after we've ensured that they're stable on the drug for about four to six weeks, we then move them to our third bucket, which is now our monitoring bucket. And this is where we have a clear standardized process for following up with patients at a cadence that's appropriate for the drug they're on. So some patients will get labs monthly for the first six months. They're on therapy, other patients will only get labs for the first three months, and we kind of have set that based on what the literature suggests and what we as a team has decided is really best practice for our patients. And that's kind of our day to day workflow. And then obviously, there's always going to be a patient who something has changed. And so we have to get involved with those. While we were creating that day to day workflow, though, that's where we identified this opportunity for a second partnership. And that was with our specialty pharmacy. So what ultimately ended up happening pre the pharmacist team being involved is that there was information that was given to our former nurse coordinator by drug reps that basically said, here's the prescription form, fill this out, facts it to our company, and we will take care of the rest. And so that's what our providers were doing, because that's what they thought was kind of a best practice. What we actually found was that that wasn't a best practice, and it resulted in significant delays to patients getting therapy, or not even getting therapy at all. Because we had the specialty pharmacy, I reached out to our leadership and said, hey, is there an opportunity to partner here to do this? And I'm going to now turn it over to Amanda, so she can kind of describe some of the things that we were able to achieve with them. Yeah, so I think our focus for the specialty pharmacy involvement was to really eliminate kind of the natural disconnect that happens when patients are started on therapy and the prescription is written. But maybe that patient isn't being served by a health system pharmacy, and there becomes a disconnect between what happens for that patient in the end. So our specialty pharmacists collaborated with the pharmacists in the clinic, the providers in the clinic, and really just tried to utilize all those resources that Amber's speaking to that we had available to us within the health system. So the responsibilities of the specialty pharmacists and the technicians are to really complete that benefits investigation, financial assistance, prioritizations, clinical counseling assessments, and make sure that all that can be shared back within the health system's medical record. So it's really accessible to all of the team members, and that communication is transparent. And we found that that was really helpful for the clinic tab, that transparency and for the patient to know that their providers were all communicating with each other. And I'll just add that one of the best things I think that Amanda and I were able to achieve with her team is an ability for us to have kind of an instantaneous communication back and forth, instead of relying on notes being put in a chart, or how we have to operate with other specialty pharmacies where we're waiting on faxes, because they don't want to communicate about certain issues over the phone. And so that instant back and forth communication allows us to resolve patient issues quite quickly, so that these patients aren't hanging in limbo for quite a long time. In addition to that specialty collaboration, I think the other evolving that we were able to do, and I didn't really mention this at the top, but I am also split faculty between Wayne State University and Henry Ford. And so what that means is I'm actually only in clinic 50% of the time, but our patients need care as often as we can possibly get it. And as Dr. Thavraja mentioned, our team continues to grow and our patient load continues to grow. So the other thing that we did is we identified roles for trainees to be able to step in and do some of that low hanging fruit options for patients that a pharmacy student, a pharmacy resident could easily do that ensures that patients are getting care five days a week, even though the lead pharmacist is only in clinic two and a half days a week. And so some of what Hannah did during her residency was to ensure that continuity of care, but also to improve some of the standardized templates that we were using so that it was easy for a pharmacy student to call patients and do wellness checks. It was easy for a pharmacy student to follow up on labs and know which labs need to be triaged back to the providers so that the pharmacist could continue patient care without any disruptions. Hannah, I don't know if there's anything else you would add to that from a trainee perspective on that front. I think just as you said given the fact that you are split faculty in a world where we don't have these trainees available, there's only coverage two and a half days. So really the trainees serve as the space of pharmacy and as a pharmacy representative five days out of the week, which then allows for a layered learning approach when we have residents, PGI1s, PGI2s, and then when we have student learners as well, so that you can kind of triage the responsibility. Maybe the residents are able to take some of those curbside consults from Dr. Thavaraja and her colleagues and as you mentioned, the students who may not be familiar with these medications really at all because they don't have time to learn about them in school since they're such rare diseases, they have the opportunity to learn about these new medications, become used to the counseling and the lab monitoring formats and then can take that experience and independently be able to assess labs, follow up with patients, and work together with the rest of the team to help make judgment calls on what needs to be addressed as you said with just the pharmacy team and what needs to be brought to the group as a whole. So really the learners have the opportunity to have a lot of independence in this clinic. I like that you guys are talking about how you kind of had to adapt and overcome once the program was established and it seems pretty successful now, you know service five days a week is fantastic. Given the success you've had this practice model, do you guys have any plans to expand this program into other disease states? That is a really great question and something I get asked all the time Dr. Thavaraja is chuckling right now because she knows that there are other providers who maybe throw tantrums about the fact that they don't have the pharmacist on their team, but so in a pulmonary realm we've had some discussions about potentially is there a role for a pharmacist in sarcoidosis and then Amanda and I have really grand aspirations to leverage some of the relationships that Dr. Thavaraja actually has with rheumatology because we think rheumatology is a very untapped area where we could have a very similar if not bigger impact simply because their drug portfolio is a thousand times bigger than what we have for pulmonary fibrosis or interstitial lung disease. So yes we have plans, I'm only one person so one of the negotiation parts that Dr. Thavaraja and I are working on from a pulmonary side but then also Amanda and I are working on from a pharmacist side is where can we get financial support for those FTEs to be able to move into those frontiers because we genuinely believe that the model that we've created for interstitial lung disease would be very successful in some of these areas like rheumatology potentially sarcoidosis and then another area that we've talked about is neurology. I don't know if Dr. Thavaraja or Amanda have anything they want to add to that. I think that every time I tell another sub-specialist or specialist about what we've done people get very jealous and I tell them I'm very spoiled. It really has enhanced the care for our patients and so I think yes expanding to areas where there's already some knowledge first in terms of rheumatology because we are a little different than some of the other IOT programs out there. We actually take on some of the treatment of the autoimmune diseases if that's what's driving their interstitial lung disease. So I think in terms of when you're comparing to maybe other pharmacy programs that are embedded in IOT programs I don't know that they necessarily have that same level of experience. So I think leveraging that and moving that over to something like rheumatology would be a next natural step. Yeah I'll add that our pharmacy department is very eager and confident that this program and workflow could be replicated and successful in all of our different specialties. And to Amber's point I think we're really just trying to make sure that if we were to expand we make sure that they're fully supported and properly supported so that we you know it's expanding to a service a new service line that gets that full support and full workflow. On the prescription portion of it we've started to expand some of that connectivity between the clinics and the pharmacy. So we're really looking to just kind of comprehensively provide that support similar to this program and in the other specialties. Yeah I like that you guys are marrying like especially the specialty piece of it. I would imagine that many rheumatology drugs also have to go that specialty pharmacy route. So it's very it seems like a very natural progression. So with the lessons that you've learned a long way like reaching out to specialty pharmacy what else have you learned a long way? What was the easiest thing to implement? The hardest and what really surprised you? I'll go first. Definitely the easiest thing for me was working with the team that we have. I mean I think from from the pharmacy students to residents to of course amber and then our team where we have fellows rotating with us are now four physicians and APP and coordinator and hopefully social work again soon. To me that it really I feel like I learned so much during these meetings every week and so for me I really enjoyed that process and there are things that I don't think I would have ever thought of and same for you know another discipline and so I think that that for me is is by far been the easiest and most rewarding part of this. I think in terms of the things that are are tough you know we all sometimes have very different opinions on how to get how to do the best thing for the patient and I think working through how to standardize things for so many different folks who are sharing the same group of patients. So for our end we're again a little bit different from some of the other programs we share all of our patients and so we will have multiple meetings a week to walk through that. So I think that's definitely a challenge but something that can be absolutely be worked through in terms of some of that standardization. In terms of the lessons learned and the surprise I think those for me are the same. I think I've been so surprised with how much a patient is sometimes willing to tell a pharmacist over what they tell the provider that there's we I think as a provider I think of myself as not very intimidating and how I give recommendations I'll try to be very straight with people about hey I really think you need this because and folks will agree and then the pharmacy team will call them the next week and things that maybe didn't come up during that clinic visit or they just weren't comfortable saying for for any of our writers comes up. I think the other thing that that comes out of that is that sometimes the patients are embarrassed to tell us about some of the financial or social constraints they have that completely interfere with their ability to either care for themselves or be adherent with medications. So those I think are things that I've learned along the way and in terms of maybe translating that to other people trying to do this I think for me the openness and the willingness to learn from other people are the things that I think that make make our program successful from from all ends. I kind of want to just say ditto to everything that Dr. Thavaraja just said. I agree that for me the easiest thing is the team and you know you really in order to have a successful program you have to have a good team and does that mean that our team always agrees absolutely not like there can be some heated discussions and we can draw some lines in the sand but at the end of the day I think our team each of us respects the role that we have and I feel like I'm the luckiest pharmacist in the world because I have providers that want me to work at the top of my license. They trust my judgment and sure there are times we don't agree and that's fine but they give me the opportunity to truly do the job of a pharmacist at the best level that I possibly can so that makes this program the easiest thing I've ever done. The hardest thing is just building a clinic post-pandemic while also on maternity leave and I have to give a special nod to this is like my second or third baby along the way but I think it was hard also because we were trying to figure out how to integrate other people into the program and so really I think that hard part is truly finding out what are those roles where should people be doing the things that they need to be so that there's not duplication but then also being willing to say hey specialty pharmacy I know we've never done something like this before but can we try to do this and oh by the way pharmacy students I know you're terrified about these diseases and these drugs but you can do it and let me tell you how I can standardize this to make it easier for you in the long run those steps along the way really were quite difficult but we navigated through it and I think that's what's made our program you know successful honestly the surprise for me while I knew in my core that we were doing really good work I have to go back to what our actual data showed my mentor told me that you would never be wrong if you put the patient first and our data proves that by putting the patient first we've actually made a huge impact on them in terms of getting their drug at a cost that is affordable to them giving them better dz state control minimizing the amount of side effects that they're having we've actually done what I think a pharmacist should do we put the patient first and we've given them good outcomes and so to me to have that validated with actual data was the biggest surprise of all and that's kind of my summary I'll turn it over to the rest of the group yeah I have to say I fully agree with Amber and Dr. Tovraja I think not repeat exactly what they say I would say my my lesson learned would be just consistently think beyond our existing workflow whether it's you know big or small I think we can always work to improve a patient experience and sometimes you just have to take that leap and do some really great project planning get the right people involved and kind of see where it takes you and I think you'll be pleasantly surprised and with Amber's point really just put the patient first and kind of see where it goes I think for me just to echo what everyone else has said obviously the collaboration and teamwork has really been the easiest and one of the greatest rewards of this program as Amber Linna alluded to I think being a learner in this type of clinic one of the hardest things was you know walking into residency being thrown this new disease state and having to precept so many learners well you're also trying to understand the workflow and understand what's going on in such a specialized clinic but truly is rewarding to see those patients calling in asking for you by name and establishing those long-term relationships I really think it is really something special that we've done here. So what advice do you guys have for hospitals and health systems who would seek to replicate this practice model for patients? So I'm going to start I'm going to take the lead on this one I my entire career has been about asking why when people tell me no and I genuinely think if things don't make sense they're not lining up you think that there could be an improvement don't hesitate to ask those questions because in asking questions you may find avenues where you can truly start to get creative and and change the the way you're providing care and then I'll just restate what I just said which is put the patient first every time you put the patient first you can't go wrong. To Amber's point how do we help the patient best and for me it's always been trying to draw on the strengths around me there are things that I'm you know going to love doing and probably have more of a role in in the clinic room is where I'm probably the happiest the second happiest place would be in this team working in this team but I think that drawing on on the strengths of the folks around you and I think with the level of emotional investment that we put into these patients sometimes we lose sight that there are folks that are around us that are interested in the same things that we are in terms of helping these patients and how do we build a team to to do that and so I would say I think just being aware that those resources are often closer than you think would be that would be my advice for folks in this in this position. I would say to really create connections with your peers whether it's in your department or outside of your department start reaching out to other departments seeing what are they doing that they love what do they wish that they had more support in and just start really thinking about where you can make those connections and relationships and and that's really the starting point to where these initiatives or you know new programs new clinical programs can be developed. Great well that's all the time we have today. I want to thank the team at Henry Ford Health again for joining us today to discuss their ASHP's best practice award. If you haven't before I encourage you all to check out ASHP and the ASHP Foundations research resources you can find member exclusive offerings such as the preceptor toolkit the research resource center and exchange ideas with your peers on the ASHP education connect community. 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