Implementing a Layered Learning Model into Introductory Pharmacy Practice Experience and Advanced Pharmacy Practice Experiences to Minimize Impact on Preceptor Workload

AUTHORs, DR. Elaine Law & Dr. Yvonne Mai REPORT NO CONFLICTS OF INTEREST TO DISCLOSE.
REVIEWERS, DR. Sharya V. Bourdet, DR. Diane wong, Dr. Lovelle Yano, DR. TINA DENETCLAW, & Dr. Jade M. Vitug REPORT NO CONFLICTS OF INTEREST TO DISCLOSE.

 

Learning objectives:

After the completion of reading the article, the reader will be able to:

  1. Describe the return on investment of the enhanced layered learning model, including Introductory Pharmacy Practice Experience (IPPE) and Advanced Pharmacy Practice Experience (APPE) student  integration.
  2. Identify opportunities for integrative learning at your institution.
  3. Apply the layered learning practice model into various areas of pharmacy practice.

 

CE Article (PDF) Post-Exam

 

Type of activity: knowledge

Target audience: pharmacists including pharmacy residents

Location: NCCCP eNewsletter and NCCCP website https://ncccp.net/ce/

Date and schedule: April 1, 2019

ACPE – pharmacist accreditation credit hours: 0.25

The ACPE Universal Activity Number: 0217-9999-19-084-H04-P

For the successful completion, readers should pass a post-test with a score of 70% or higher.
Go to: https://www.surveymonkey.com/r/LayeredLearning to take the post-exam. Pharmacists who pass the post-test with a score of 70% or higher by May 31, 2019 must have a valid NABP e-Profile ID and date of birth on file with ACCP and ACCP will submit credit to NABP. ACCP membership is not required; a free ACCP account can be created at https://www.accp.com/signin/register.aspx

Fee: Members – Free; Non-members – Free

This is a free CE activity with no financial support from an individual or an organization.

 

 The American College of Clinical Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

 

This activity is a knowledge-based activity and will provide 0.25 contact hour of continuing  pharmacy education. Pharmacists who pass the post-test with a score of 70% or higher by May 31, 2019 must have a valid NABP  e-Profile ID and date of birth on file with ACCP and ACCP will submit credit to NABP.

ACCP membership is not required; a free ACCP account can be created at https://www.accp.com/signin/register.aspx


About the Authors

 

 

Yvonne Mai, PharmD, MS, BCGP, BCACP

Yvonne Mai earned her doctor of pharmacy from University of the Pacific in 2013, where she also completed a fellowship in pharmacoeconomics, health care outcomes and clinical services. She joined the Pacific faculty in 2015 as Assistant Professor of Pharmacy Practice and Stockton Regional Coordinator.

She was originally drawn to pursue a career in healthcare with a focus on medication management because she wanted to empower and educate the underserved. Her research is focused on health outcomes of pharmacist provided services. She also evaluates innovative services or practice models to improve outcomes in the underserved and Medicare populations.

Elaine Law, PharmD, BCPS, FCSHP

Elaine Law earned her doctor of pharmacy from the University of California, San Francisco in 2008 and completed a PGY1 acute care residency at the University of California, San Francisco Medical Center. Elaine is currently an Assistant Professor of Pharmacy Practice at the University of the Pacific and Regional Coordinator of Experiential Education in the San Jose and Monterey Regions, a role she has worked in since joining UOP in 2015. Past experience includes being the lead clinical pharmacist specializing in Adult General Surgery, Surgical Oncology, and Bariatric Surgery at a the University of California-San Francisco Medical Center for 6 years before transitioning into her current academic position.

She is actively involved with CSHP and ASHP, serving on several committees to advance the practice of pharmacy, particularly focusing on professional development and mentoring students and new practitioner pharmacists. She is currently in her final year of a three-year elected term as a Board of Directors for the California Society of Health System Pharmacists and has previously helped shape policy development as a state Delegate to the American Society of Health System Pharmacists.

 

 

AB 1114

Medi-Cal: pharmacist services

 

 

About

California AB 1114 authorizes MediCal payments to pharmacists for providing immunizations, contraception, smoking cessation, and travel medication services authorized by SB 493.
Billing codes needed to implement AB 1114 were assigned as CPT codes 99201/99202 for new patients and 99211/99212 for returning patients to be used for pharmacist services. 

 

The assigned codes, however, are not adequate to address the specific requirements pharmacists must meet when providing immunizations, contraception, smoking cessation, and travel medication services. The assigned codes also do not reflect the CPT codes that are used by physicians to provide the same services. If pharmacist services are not coded correctly, pharmacists will not be compensated for the time required to deliver services to their patients and, in effect, these SB 493 services still cannot be implemented.

Learn more and join our letter writing campaign by reading Dr. Tina Denetclaw’s article Getting to our Destination.

Activities

This is a joint project of NCCCP, CSHP, and CPhA leadership. Our current focus is advocating adequate compensation for pharmacists providing services payable under AB 1114.

 

  • Letter writing session at UOP – March 26, 2019
  • Core Advocacy Group at UCSF meetings – April 14, 2019

 

Contact your Grassroots Committee representative or reach out to us to learn how to get involved in our letter writing campaign.

 

Join the Grassroots Advocacy Committee

 

Contact us

Advocacy Toolkit

  • Letter template (docx)
  • Getting to our Destination article, by Tina Denetclaw, PharmD, APh, BCPS (pdf) (docx)
  • AB 1114 handout, by Tina Denetclaw, PharmD, APh, BCPS (pdf ) (docx )
  • Text of the bill 

Getting to our destination through letters

Getting to Our Destination

By Tina Harrach Denetclaw, PharmD, APh, BCPS

 

Sometimes when my GPS announces, “You have arrived at your destination,” I look around and do not see my destination. Sometimes, it’s another block further, sometimes, it’s around the corner, or behind me. And, sometimes the GPS has taken me into the wrong neighborhood, altogether.

 

Something of this sort has happened with the 2016 California AB 1114, the first bill to authorize payment for pharmacists’ services as providers.

 

Passed in 2016, California AB 1114 authorizes Medi-Cal payments to pharmacists for providing immunizations, contraception, smoking cessation, naloxone, and travel medications services authorized by SB 493 and AB 1535. It states that the rate of reimbursement for pharmacist services shall be at 85 percent of the fee schedule for physician services under the Medi-Cal program and directs the California Department of Health Care Services (DHCS) to establish a fee schedule for the list of pharmacist services. Further, AB 1114 states pharmacists must be enrolled as ordering, referring, and prescribing (ORP) providers under the Medi-Cal program prior to rendering a pharmacist service that is submitted by a Medi-Cal pharmacy provider for reimbursement under AB 1114.

 

This winter (three and a half years later), the Department of Health Care Services (DHCS) assigned the billing codes needed to implement AB 1114 as Current Procedural Terminology (CPT) codes 99201 for new patients, and 99212 for returning patients, who receive these services when provided by a pharmacist. See Table 1.

 

The assigned codes, however, do not allow sufficient time for pharmacists to meet the legal requirements for providing immunizations, contraception, smoking cessation, naloxone, and travel meds services. The assigned codes also do not reflect the level of complex decision-making involved in providing these services, nor the CPT codes that are used by physicians, nurse practitioners, and physician assistants to provide the same services.

 

For example, I happen to be one of the first California pharmacists to obtain certification in Smoking Cessation Counseling, as I received my certificate from the Washington State association about 1998, prior to California offering its own certification process. Limiting face-to-face time to 10 minutes for smoking cessation counseling is contrary to my training. Specifically, 10 minutes is not adequate for a pharmacist to meet the statute requirements for “Providing Tobacco Cessation Counseling and Furnishing Nicotine Replacement Therapy” including under the item, “Review the patient’s current tobacco use and past quit attempts.”

 

Furthermore, the statutes addressed in AB 1114 consistently include requiring pharmacists to obtain complete information, ask the patient a list of questions, provide detailed training for the patient, and answer patients’ questions. As I look over the required elements, especially for furnishing self-administered contraceptives, nicotine replacement products, and naloxone, I do not see that these services can be provided in a manner that meets the statutes within the 10 minutes of time allowed by the CPT codes.

 

If pharmacist services are not coded correctly, pharmacists and their employers will not be compensated for the time required to deliver the required elements of service to their patients Conversely, if pharmacists conform to the time limits of the CPT codes assigned and submit claims correctly for time spent as ordering, referring, and prescribing providers of these services, they likely will be in violation of the specific provisions authorizing pharmacists to provide these services.

 

What can pharmacists do to advocate adequate coding for pharmacist prescribing provider services?

Write to the administrators who determine the codes for implementing AB 1114! Their names and addresses are listed in Table 2. Template letters developed by the NCCCP Grassroots Advocacy Committee Steering Group can be found in Figures 1 and 2. These letters communicate that the assigned billing codes do not reflect the complexity of decision-making needed for providing services covered by AB 1114, nor do they allow sufficient time to meet the statute requirements for pharmacists providing those services. Pharmacists and student pharmacists are welcome to make use of these template letters to write to the administrators at DHCS who determine the CPT codes for AB 1114. Table 3 lists the CPT codes that CPhA has requested DHCS to assign for AB 1114, and also outlines regulations pharmacists must meet when providing services covered by AB 1114.

 

Individuals may add to the template letters provided in Figures 1 and 2 to convey personal experience and more detailed rationale. Experts in grassroots lobbying recommend letters be specific, polite, and professional, and that they be kept to one page (you may need to change font size slightly). Please to add your letter-writing to our tally so we can communicate our numbers to DHCS.

 

The NCCCP Grassroots Committee asks that letter-writers focus on the mismatch between the intention of the 2016 California Assembly Bill (AB) 1114 and the billing codes assigned to implement AB 1114. Our effort will have the most impact, and therefore the best chance of success, if we provide congruent messaging en masse.

 

With enough collective voices, we can lead DHCS in the right direction and institute fair compensation for our profession.

 

Table 1. DOCUMENTATION REQUIREMENTS FOR NEW- AND ESTABLISHED-PATIENT OFFICE VISITS

New patient
Code History Exam Medical Decision-making Typical face-to-face Time (minutes)
99201 Problem-focused Problem-focused Straightforward 10
99202 Expanded problem-focused Expanded problem-focused Straightforward 20
99203 Detailed Detailed Low 30
99204 Comprehensive Comprehensive Moderate 45
99205 Comprehensive Comprehensive High 60
*All three key components must be met.
 
Established Patient
Code History Exam Medical Decision-making Typical face-to-face Time (minutes)
99211 Not required Not required Not required 5
99212 Problem-focused Problem-focused Straightforward 10
99213 Expanded problem-focused Expanded problem-focused Low 15
99214 Detailed Detailed Moderate 25
99215 Comprehensive Comprehensive High High 40
*Two of the three key components must be met.

 

Table 2. Administrators to address letters for advocating correct coding for AB 1114

DHCS DHCS
Harry Hendrix

Chief, Pharmacy Benefits Division

Department of Health Care Services

1500 Capitol Ave.

Sacramento, CA 95814

Mike Wofford, Pharm D.

Chief, Pharmacy Policy Branch, Pharmacy Benefits Division

Department of Health Care Services

1500 Capitol Ave.

Sacramento, CA 95814

 

Table 3. AB1114 covered statutes with CPT codes recommended by CPhA to DHCS

Patient Activity/Presenting Problem Patient Type CPT Code Medical Requirements of Pharmacist

per Statute and/or Regulation

Furnishing Travel Medications pursuant to CCR 1746.5 New

Established

99203

99214

Prior to furnishing travel medications, a pharmacist shall perform a good faith evaluation of the patient, including evaluation of the patient’s travel history using destination-specific travel criteria. The travel history must include all the information necessary for a risk assessment during pre-travel consultation, as identified in the CDC Yellow Book.
Furnishing Naloxone Hydrochloride pursuant to CCR 1746.3 New

Established

99203

99214

Screen the potential recipient. Provide the recipient training in opioid overdose prevention, recognition, response, and administration of the antidote naloxone. The pharmacist shall provide the recipient with appropriate counseling and information on the product furnished, including dosing, effectiveness, adverse effects, storage conditions, shelf—life, and safety. The pharmacist shall provide the recipient with any informational resources on hand and/or referrals to appropriate resources if the recipient indicates interest in addiction treatment, recovery services, or medication disposal resources. The pharmacist shall answer any questions the recipient may have regarding naloxone hydrochloride. A pharmacist shall advise the recipient on how to choose the route of administration based on the formulation available, how well it can likely be administered, the setting, and local context. A pharmacist shall label the naloxone hydrochloride consistent with law and regulations. The pharmacist shall provide the recipient a copy of the current naloxone fact sheet approved by the Board of Pharmacy. Each naloxone hydrochloride product furnished by a pharmacist pursuant to this protocol shall be documented in a medication record for the naloxone recipient, and securely stored within the originating pharmacy or health care facility for a period of at least three years from the date of dispense. 
Furnishing Self-administered Hormonal Contraception pursuant to 1746.1 New

Established

99203

99214

When a patient requests self-administered hormonal contraception, the pharmacist shall complete the following steps:

(A) Ask the patient to use and complete the self-screening tool;

(B) Review the self-screening answers and clarify responses if needed;

(C) Measure and record the patient’s seated blood pressure if combined hormonal contraceptives are requested or recommended;

(D) Before furnishing self-administered hormonal contraception, the pharmacist shall ensure that the patient is appropriately trained.

(E) When a self-administered hormonal contraceptive is furnished, the patient shall be provided with appropriate counseling and information on the product furnished, including:

1. Dosage;

2. Effectiveness;

3. Potential side effects;

4. Safety;

5. The importance of receiving recommended preventative health screenings;

6. That self-administered hormonal contraception does not protect against sexually transmitted infections (STIs).

The pharmacist shall provide the patient with a self-screening tool containing the list of questions specified in this protocol. The pharmacist should provide the patient with a copy of a current, consumer-friendly, comprehensive birth control guide such as that created by the Food and Drug Administration (FDA). The pharmacist shall provide the patient with the FDA-required patient product information leaflet included in all self-administered hormonal contraception products, as required by Business and Professions Code Section 4052.3(c). The pharmacist should provide the patient with a copy of an administration-specific factsheet. The pharmacist shall notify the patient’s primary care provider of any drug(s) or device(s) furnished to the patient, or enter the appropriate information in a patient record system shared with the primary care provider, as permitted by that primary care provider. The pharmacist, in consultation with the patient, may select any hormonal contraceptive listed in the current version of the USMEC for individuals identified as Category 1 or 2. Each self-administered hormonal contraceptive furnished by a pharmacist pursuant to this protocol shall be documented in a patient medication record and securely stored within the originating pharmacy or health care facility for a period of at least three years from the date of dispense.

 

Initiating & Administering Immunizations pursuant to CCR 1746.4 New

Established

99202

99213

A pharmacist shall notify each patient’s primary care provider of any vaccine administered to the patient, or enter the appropriate information in a patient record system shared with the primary care provider, as permitted by the primary care provider. A pharmacist shall report, in accordance with section 4052.8, subdivision (b)(3), of the Business and Professions Code, the information described in section 120440, subdivision (c), of the Health and Safety Code within 14 days of the administration of any vaccine. A pharmacist shall inform each patient or the

patient’s guardian of immunization record sharing preferences, detailed in section 120440, subdivision (e), of the Health and Safety Code. For each vaccine administered by a pharmacist, a patient vaccine administration record shall be maintained in an automated data processing or manual record mod e such that the information required under section 300aa-25 of Title 42 of the United States Code is readily retrievable during the pharmacy or facility’s normal operating hours. A pharmacist shall provide each patient with a Board of Pharmacy Order of Adoption 16 CCR§ 1746.4 vaccine administration record, which fully documents the vaccines administered by the pharmacist.

Providing Tobacco Cessation Counseling and Furnishing Nicotine Replacement Therapy pursuant to CCR 1746.2 New

Established

99203

99214

When a patient requests nicotine replacement therapy or other smoking cessation medication, or when a pharmacist in his or her professional judgment decides to initiate smoking cessation treatment and counseling, the pharmacist shall complete the

following steps:

Review the patient’s current tobacco use and past quit attempts.

Ask the patient the following screening questions:

(i) Are you pregnant or plan to become pregnant? (If yes, do not furnish and refer to an appropriate health care provider).

(ii) Have you had a heart attack within the last 2 weeks? (If yes, furnish with caution and refer to an appropriate health care provider).

(iii) Do you have any history of heart palpitations, irregular heartbeats, or have you been diagnosed with a serious arrhythmia? (If yes, furnish with caution and refer to an appropriate health care provider).

(iv) Do you currently experience frequent chest pain or have you been diagnosed with unstable angina? (If yes, furnish with caution and refer to an appropriate health care provider).

(v) Do you have any history of allergic rhinitis (e.g., nasal allergies)? (If yes, avoid nasal spray).

(vi) Have you been diagnosed with temporal mandibular joint (TMJ) dysfunction? (If yes, avoid nicotine gum).

The pharmacist shall review the instructions for use with every patient using a nicotine replacement product. Pharmacists should recommend the patient seek additional assistance for behavior change. The pharmacist shall answer any questions the patient may have regarding smoking cessation therapy and/or nicotine replacement products. The pharmacist, in consultation with the patient, may select any nicotine replacement product (alone or in combination) from the list of therapies specified in this protocol in the Table “Nicotine Replacement Therapy Medications for Smoking Cessation.” The pharmacist shall notify the patient’s primary care provider of any prescription drug(s) and/or device(s) furnished to the patient, or enter the appropriate information in a patient record system shared with the primary care provider, as permitted by that primary care provider. Each nicotine replacement product provided for smoking cessation and furnished by a pharmacist pursuant to this protocol shall be documented in a patient medication record and securely stored within the originating pharmacy or health care facility for a period of at least three years from the date of dispense. A patient medication record shall be maintained in an automated data processing or manual record mode such that the required information under title 16, sections 1717 and 1707.1 of the California Code of Regulations is readily retrievable during the pharmacy or facility’s normal operating hours.

 

S109

PHARMACY AND MEDICALLY UNDERSERVED AREAS ENHANCEMENT ACT

 

 

About

Notice: NCCCP’s efforts towards S109 have ended.

S109 will allow patients in medically underserved areas to receive state-sanctioned pharmacist services such as immunizations and medication therapy management. Pharmacists would be reimbursed by Medicare while taking this major step toward broader provider status.

Letter Writing Campaign

Send a letter using the CSHP Letterwriter Tool, then tally your support with NCCCP.

More Information