An interview with Nicole Green, BSP, RPh, ACPR, DPLA, Director of the Ambulatory Pharmacy Services Program at ThedaCare, a healthcare organization based in northeastern and central Wisconsin serving both rural and urban areas.
By: Aanchal Gupta, Program Coordinator, NaRCAD
Tags: Program Management, Detailing Visits, Opioid Safety
Aanchal: Hi Nicole, thank you so much for talking about your program with us today! You’re a pharmacy director at ThedaCare—tell us more about the academic detailing component of your programming.
Nicole: During the past four years working at ThedaCare, I’ve been studying ways in which pharmacists could serve as academic detailers to support opioid stewardship initiatives in order to positively influence prescribing. I was able to collaborate with other physician leaders as well as executive leadership who supported the program, gather data on opioid prescribing, and work on a proposal for academic detailing.
We created our first formalized detailing project, called the Ambulatory Pharmacy Services Program, in January 2021. We had four detailers kick off our program and we’ve now doubled our team with a total of eight detailers that have all been trained by NaRCAD. Our detailers are ambulatory pharmacists who are embedded in ThedaCare’s family medicine and internal medicine clinics, serving as both medication experts and pharmacy consultants for patients and providers.
Aanchal: It’s incredible how quickly your program grew! Can you tell us more about the areas you’ve been focusing on for academic detailing?
Nicole: Opioid stewardship is our main focus area for our detailing initiative. Our detailers identify patients who are candidates for Naloxone and work with clinicians to provide education to patients and their family members. The detailers also assess patients who have been on opioids for a long time and determine if they still need to be on them or if tapering should be considered.
The second focus area is comprehensive medication management services for our self-insured population. This includes having our detailers identify chronic disease management gaps and partner with our state employees to optimize care for patients to reduce cost and readmissions.
Our last focus area is to support our new heart failure clinic. Patients are referred to this clinic if they’ve been discharged from the hospital with heart failure or if they’ve been referred by a cardiologist. On initial visits, patients see a cardiology provider followed by an ambulatory pharmacist. Our role is to review the patient’s chart and provide recommendations to the team, as well as education to the patients. Our goals are to decrease readmissions and improve guideline-directed medical therapy.
Aanchal: Wow - your team’s impact is tremendous. You previously mentioned that you were able to double your detailing team in less than a year. What characteristics do you believe are needed to have a strong detailing team?
Nicole: Having in-depth knowledge about the clinical topic is extremely important. Detailing is also about building trust and strengthening the relationship with confidence. Detailers need to be confident, especially when they’re first starting out and are meeting with providers that they have yet to build a relationship with.
Detailers also need to be prepared to respond confidently and in a way that will still engage the providers in an open conversation. Providers typically don't understand that ambulatory pharmacists’ jobs are to assist patients to meet medication-related goals. There have been assumptions about why we’re delivering this service or why we’re meeting with clinicians. Clinicians ask questions such as, “Is it because I’m being targeted?” or “Is it because of my prescribing practices?”
Aanchal: Agreed; at NaRCAD, we know that having both clinical expertise and confidence communicating is essential to detail successfully. We know what makes a successful detailer – now let’s talk about what qualities you believe make you successful as a leader.
Nicole: The first quality that comes to mind is passion. I lead with energy and show my team how exciting this work can be. I think that's important because previously we didn’t have pharmacists embedded in primary care and patients didn’t have an option to book an appointment with a pharmacist for consultation. Our pharmacists are delivering a service that was not there before. They need to promote themselves and make others aware of how they can help.
Also, I like to be a strong advocate for my team. I constantly raise my hand saying that we can help with different initiatives or that certain projects are right up our alley.
Finally, I encourage my team to be persistent. We can't take the first “no” from a clinician as rejection. It might mean, “not now,” “I don't understand,” or “I haven't been exposed to this.” It doesn’t mean that they never want to have a visit with an academic detailer or will never change their prescribing behavior.
Aanchal: These are all core elements in building a strong team. Some situations can feel defeating and having a strong leader that has your back is so important. Lastly, what advice do you have for someone who is new to managing a team of detailers?
Nicole: Prepare your detailers for the field with the most up-to-date clinical content so that they can interact with clinicians confidently.
Also, provide your detailers with training opportunities and use resources like NaRCAD. If you have the capacity, take it one step further by adding practice role play sessions among peers and allow new detailers to observe other detailers in the field. When training, help the detailers step out of their comfort zone within a group of people that they know before they step out of their comfort zone with a stranger.
Aanchal: Yes, having support and receiving feedback from peers is an important element of building a strong team. Thank you so much for sharing your perspectives with us, Nicole! We look forward to continuing to see your team grow and feature your work at our upcoming conference!
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BIOGRAPHY: Nicole Green completed her pharmacy education at the University of Saskatchewan, Canada followed by a hospital residency. She practiced for over a decade as a Clinical Coordinator primarily in the area of cardiology. She has completed year-long learnings through the AIMM (Alliance for Integrate Medication Management) collaborative as well as the ASHP PLA (Pharmacy Leadership Academy). She is the Director of Ambulatory Pharmacy with ThedaCare. She leads the comprehensive strategic plan to embed pharmacists within family and internal medicine clinics as providers and vital members of the primary care clinical team. She has served as an Executive panelist with GTMRx (Get the Medications Right) and the Institute for Advancing Health Value.
Her program utilizes Academic Detailing as a means of building professional relationships, establishing credibility and influencing prescribing improvements. Much of her team’s work is related to Quality improvement initiatives in medication stewardship and safety as well as maximal performance in Pharmacy related ACO measures.
Nicole has worked with the ThedaCare cardiology team to build a collaborative Heart Failure Clinic where patients see both a cardiology provider and am ambulatory pharmacist.
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