An Interview with Paula Walker, Clinical Pharmacist
Baylor, Scott & White Health | Dallas, Texas
Tell us a bit about yourself. How did you get into care redesign and transitional care? I grew up in the area of Inman Square Pharmacy in Cambridge, Massachusetts. After graduating from Northeastern University in 1990, I began my career in community pharmacy. Soon after I entered the pharmaceutical industry, I spent many years representing the biological division of Rhone-Poulenc. I continued to keep connected with public health by practicing in the community part time; I’ve also been serving in a family practice clinic for over 8 years now. Three years ago, upon recommendation from our clinic director, I joined The Institute of Chronic Disease and Care Redesign at Baylor Scott and White Health in Dallas.
Tell us about the institute. What does your team focus on with regards to providing transitional care? What approach do you take?
Our multidisciplinary team focuses on improving outcomes among chronically ill older adults. Our innovative approach includes using advanced technology to identify patients at most risk for readmission. With a focus on heart failure, COPD, and pneumonia, patients are identified and supported as they transition from one level of care to the next. Our transitional care team encourages each specialty to work at the very top of their license to assist patients whose recovery is complicated by cognitive impairment, frailty, and social issues. Our team shares offices together so each discipline is available to all team members at all times. A strong team and constant communication is the key to our success.
What does a typical day or week look like for you in this field? How do you incorporate academic detailing techniques into your work?
My role is to perform the medication reconciliation on all of my patients and communicate any concerns with the appropriate providers. I attend weekly rounding with my team and need to be able to make and support any medication recommendations. In terms of using academic detailing techniques, our team practices evidence-based medicine in the care and treatment of our population with chronic disease. It’s also key for a pharmacist in this role to be able to communicate to providers quickly and effectively regarding drug selection, dosage, and titration. Learning and practicing the skills required to communicate effectively in this environment is essential. In a typical day I will consult with a geriatric specialist, cardiology, nephrology, APRN, social worker, and corporate administration. That is a lot of communicating!
You attended our Academic Detailing Techniques Training a few years back. What parts of the program worked well for you, and what are the most useful resources or information that you’re still using today? I found the skills learned during the NaRCAD training to be useful and confidence building. There is an art to being able to research information then applying it to support a recommendation in a short amount of time. NaRCAD brings together professionals from different disciplines that are focused on improving the communication of science-based information in their practice or facility. It is useful to connect with others that require these skills in their work. The small class size made it very easy to meet all the participants and learn from their experiences. I believe you can never be too experienced, and I constantly learn from the experience of others.
What are some future successes you’re looking forward to in your work and in the field in general? As we prepare to expand the Transitional Care Model at Baylor Scott and White Health under the population health infrastructure, I look forward to the pharmacist’s role to expand as well. Our goal of disease management, well above the national standard, will require evidence based medicine and the sharing of clinical information to all members of the care team. I look forward to continuing my relationship with NaRCAD—together we can help each other transform care, resulting in an improvement in the quality of life for our patients. And I’m looking forward to NaRCAD’s 3rd International Conference on Academic Detailing this November in Boston!
Biography: Paula Walker, Clinical Pharmacist, joined the Baylor Scott & White Health Transitional Care Team in 2012. Paula is the team pharmacist and oversees all medication reconciliation for their older adult population with heart failure, COPD, and pneumonia. Prior to joining BSW, Paula has worked in community pharmacy, clinic pharmacy (still active), and the pharmaceutical industry. Paula holds BS in Pharmacy from Northeastern University.
by Joy Leotsakos, PharmD
Who We Are. The Academic Detailing Service (ADS) of the Atrius Health Clinical Pharmacy Program provides clinically appropriate, evidence-based, cost-effective medication management in a multidisciplinary team setting. Our Clinical Pharmacy Program includes 15 clinical pharmacists (CPs) serving nineteen Internal Medicine and Family Medicine (IM/FM) ambulatory care practice locations. In the past four years, our program has evolved and transformed through evaluating our impact, absorbing and implementing internal feedback, and collaborating with others in the field, including NaRCAD.
Our Start. As the program manager of our ADS, I’ve seen our service grow and change. When we began our program in 2011, it was as an administrative mandate to meet with all IM/FM prescribers once per fiscal quarter to deliver messages about cost-effective prescribing and clinical quality. We started by formulating a menu of topics to cover in our ADS work each quarter, including individual clinician prescribing reports reflecting performance on prescribing initiatives from the Pharmacy & Therapeutics Committee, specific questions to survey clinicians on a clinical topic, targeted education for low performers on prescribing initiatives, and various other ‘hot topic’ clinical issues. CPs detailed individual clinicians via formal 1:1 scheduled appointments, and also did so less formally (such as by catching them in the hallways) or in larger groups during department meetings.
Is it Working? We documented our ADS activities by checking off the individual clinicians we detailed each quarter. At that time, there was no formal training for our CPs on how to conduct a detailing meeting. Unfortunately, this method of creating content for visits soon resulted in a large menu of topics so varied that each quarter’s detailing became unwieldy and too broadly focused. And our documentation, while it gave us a general sense of the number of clinicians detailed, did not tell us anything about the quality of this detailing.
Room for Improvement. Our group is fortunate in that our ADS activities have always been accepted and even expected by our IM/FM clinicians. We experienced almost no clinician resistance to our educational meetings. But in 2013, when attending one of NaRCAD’s 2-day Academic Detailing Training sessions, I learned that we could make changes to improve our services, as well as my own skills as a detailer. As a result, we altered the format of our ADS program, choosing to detail clinicians in a 1-1 or small group format of less than 4. We also selected a goal of 90% of clinicians receiving detailing at least once every quarter.
Evaluating Impact. We began evaluating the impact of the changes we’d made to our ADS, specifically choosing to look at its impact on a discretely measurable topic: reducing the unnecessary ordering of an ALT test (alanine transaminase) in patients on the ’statin’ cholesterol-lowering medications. We were able to demonstrate that our detailing of all IM/FM clinicians led to significant reductions in ALT ordering and meaningful cost avoidance for our organization.
Asking for Feedback. With NaRCAD’s support, we further refined our program in 2014 based upon feedback from an internal focus group. By soliciting honest feedback from the CPs about their detailing experiences, I discovered considerable variation in how they approached the menu of topics provided each quarter and came to understand that the continuous process of visiting with each clinician at their sites often felt stale and repetitive.
New Approach, New Results. We revised our ADS workflow to tie each round of clinician appointments directly to a specific and single P&T prescribing initiative. Furthermore, we developed a method to tag low performing clinicians for an ‘intense’ ADS visit and higher performers for a ‘touch’ ADS visit. We began this new workflow with an initiative to improve the use of evidence-based beta-blockers in patients with heart failure, a quality measure for the Medicare Pioneer Accountable Care Organization (ACO) project. Using this new approach, clinical pharmacists were able to deliver a fresh and meaningful message to the right prescribers, resulting in a change from 73.6% to 97.8%prescribing of evidence-based beta-blockers in this patient population.
Partnering with NaRCAD for Ongoing Learning. In March 2015, we coordinated with NaRCAD again, and they provided our group of clinical pharmacists with a 2.5 hour workshop to enhance our AD skills. I’d encourage anyone who does this type of educational outreach to make use of this invaluable resource. Of course, our Atrius Health Academic Detailing Service will continue to grow and change as we find additional ways to improve our workflows and messages. I look forward to continued collaboration with NaRCAD and with others in the field, so that we can all keep learning from each other and improve health outcomes through effective academic detailing.
Bio: Joy Leotsakos is a senior clinical pharmacist and the program manager for the Academic Detailing Service (ADS) of the Atrius Health Clinical Pharmacy Program. Joy joined Atrius Health in 2007 and became the program manager for the ADS program in 2012. Prior to joining Atrius Health, Joy worked as an assistant professor at Massachusetts College of Pharmacy and Health Sciences University in Boston, MA and provided ambulatory care pharmacy services to the South End Community Health Center also in Boston. Joy graduated with a Doctor of Pharmacy degree from Virginia Commonwealth University School of Pharmacy and then completed her residency in Ambulatory Care and Community Pharmacy at the University of Florida College of Pharmacy. Joy is the mother of one son, and enjoys salsa dancing, cycling and running in the summer and skiing in the winter. You can reach Joy by email at firstname.lastname@example.org.
Highlighting Best Practices
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