For health systems building a specialty pharmacy, the call center serves as the core of this service, receiving referrals from the specialty clinics, and then navigating and facilitating access to medications. The call center is integral to the specialty pharmacy practice model, which is described in a previous issue of PP&P (Stubbings JA. Top 10 Checklist for Launching a Specialty Pharmacy. March 2015), and virtually every specialty medication requires hours or days of effort to facilitate access. Activities span insurance benefit verification, prior authorizations, medication assistance, copay assistance, patient education and training, first medication coordination, delivery to the patient, and coordination of refills. Thus, the call center is a multidisciplinary practice, in that it performs financial, clinical, and administrative functions, and requires a staff with exceptional problem-solving skills.
At the University of Illinois Hospital and Health Sciences System (UI Health), the call center, or Patient Access Center, was established in 2012 and is part of our URAC-accredited specialty pharmacy. Using a closed-loop workflow (see FIGURE 1), the specialty pharmacy integrates the specialty clinics, patient access center, patient management program, and fulfillment, all within a single health system.
With a health-system based specialty pharmacy, direct access to the electronic medical health record eliminates the need for faxes and calls to doctors’ offices requesting information or clarification. This can shorten the time it takes for patients to begin taking their specialty medications, while simultaneously enhancing medication adherence, improving outcomes, and lowering costs. Because information is not faxed or transferred to entities outside the health system, communication is efficient, effective, and secure. In addition, the call center is an excellent source of data on the patient’s specialty medication experience, and as such, does not need to be limited to specialty pharmacy; rather, it can be positioned to perform all the medication coordination and management functions for the patients it serves.
Creating a Call Center Plan
Planning for the call center should be a preliminary step incorporated into the overall business plan for the specialty pharmacy to help avoid costly mistakes. An initial needs assessment should project the number of specialty clinics to be supported, number and complexity of prescriptions, projected revenue, and gross margin. Many health systems start with a call center that supports one clinic, such as hepatology or oncology.
At UI Health, our call center initially supported gastroenterology, rheumatology, neurology, pulmonary arterial hypertension, and hepatology, as those clinics had the greatest unmet need. We mined electronic prescribing data to get an estimate of the potential demand for specialty medications, and focused on the low-hanging fruit—medications our pharmacy could access and insurance plans we could accept. We have since expanded support to sickle cell disease, cardiology, transplant, and endocrinology clinics. (At UI Health, the oncology clinic is supported by a separate pharmacy and clinical staff.) At the outset, planning and implementation decisions must encompass staffing, location, and hours of operation; scope of activities; accreditation; case management systems; and workflow operations.
Staffing, Location, and Hours of Operation
A call center is typically staffed by pharmacists and pharmacy technicians, although additional staff may include nurses, social workers, pharmacy externs, or students. TABLE 1 details several staffing options. With option 1, all staff is located in the call center, whereas option 4 embeds the pharmacists and technicians in the specialty clinics.
UI Health employs options 2 and 4. The central call center is staffed by pharmacists, pharmacy technicians, and students (option 2), and the specialty clinics have fully embedded clinical pharmacists (option 4). The call center is staffed with seven FTE pharmacy technicians and students who perform benefit verification, prior authorization, copay assistance, patient and provider communication, refill surveys, and schedule deliveries. They manage 600 active patients in accordance with URAC accreditation guidelines. In addition, four FTE pharmacists perform clinical oversight, patient education and counseling, treatment initiations, clinical assessments, and ad hoc interventions. The pharmacists rotate so that only one pharmacist staffs the call center or is on call at any time. When they are not staffing the call center, they fulfill other specialty pharmacy responsibilities. One pharmacist is the clinical director for specialty pharmacy and staffs in the pulmonary arterial hypertension clinic. Another pharmacist is the medication safety officer for the outpatient pharmacies. The third pharmacist is the team leader for specialty pharmacy. The fourth is the operations pharmacist and performs all final verification for specialty prescriptions. In addition, these pharmacists perform research and teaching, and supervise students, technicians, and residents. The pharmacists conduct quality improvement projects and report their findings to the assistant director, who evaluates the overall specialty pharmacy program. Ten additional pharmacists are clinic-based, embedded in the rheumatology, hepatology, gastroenterology, neurology, transplant, sickle cell disease, pulmonary hypertension, cardiology, and neurology specialty clinics. The embedded clinical pharmacists have advanced training in their disease areas and manage most of the referrals to the call center. Integral to the call center, they are the main point of contact with the clinics for prior authorizations, treatment initiation, monitoring, safety, and all other patient issues.
Determining where to locate the call center will depend on projected staff size and available space. Call centers are commonly located in or near an outpatient pharmacy to take advantage of the proximity to dispensing once the prior authorization is approved. At UI Health, our call center is located in the same outpatient pharmacy as the specialty pharmacy. A potential disadvantage to this approach is space constraints. Few health system outpatient pharmacies have adequate space to allocate to a specialty pharmacy call center. At UI Health, we are moving our call center to a larger space outside the pharmacy due to the increasing demand for prior authorization support; however, we will maintain the pharmacy-based call center in the outpatient pharmacy.
Call centers must be open during normal business hours with 24/7 pharmacist availability. The UI Health call center operates from 7AM to 7PM Monday through Friday, and 9AM to 3PM on Saturday. When the call center is closed, a call center pharmacist is always available on call. The telephone messaging system sends a text and email alert to the on call pharmacist with a transcribed message. The pharmacist responds to all urgent requests within 30 minutes, both during and after call center hours.
Scope of Activities
The call center’s scope of activities can be quite broad, but it is important to carefully detail these activities, as well as determine the number of clinics to be supported, in order to help determine call center staffing requirements. At UI Health, the call center performs all activities listed in TABLE 2. For complex financial assistance issues, the call center coordinates with the UI Health Medication Assistance Program, which is located in the same pharmacy.
Consider the potential for specialty pharmacy accreditation before initiating a call center build. Even if there are no immediate plans to pursue accreditation, it is wise to plan for it, as accreditation standards provide a template for building and growth (see Kumor L, Stubbings JA. A How-To Guide for Specialty Pharmacy Accreditation. PP&P. November 2015). During the design process, planning for accreditation will impact decisions surrounding equipment, such as voice-over-Internet phones (VOIP). VOIP has the advantage of tracking metrics, such as speed of answer and call abandonment, which are necessary for accreditation and serve as a reliable tool for evaluating call center performance.
Case Management System
A specialty pharmacy call center cannot grow without an efficient case management system. Spreadsheets and calendars are not sufficient to accommodate the range of activities required to facilitate access to medications and manage monthly financial, administrative, and clinical tasks. Several specialty pharmacy case management systems are commercially available, and more are in development. Accordingly, the specialty pharmacy manager should decide whether the call center needs a system for case management, workflow management, and/or documentation. At UI Health, most clinical documentation occurs in the electronic health record (EHR), but a system for case management and call center workflow management was needed to serve as a bridge between the pharmacy dispensing system and the EHR.
We developed an in-house, custom case management system, E-Specialty Rx, that is based on a series of work queues, which are organized by function, level of expertise, and urgency (see TABLE 3). Each work queue is further organized by level of staff required to work on the queue (eg, pharmacist or technician). The queues facilitate an efficient workflow, eliminate activities falling through the cracks, and provide a platform for seamless communication among call center staff members rotating between shifts. E-Specialty Rx is open source software that is available to other health systems.
In addition to work queues, the case management system has a refill management calendar that is used to contact patients, conduct refill surveys, and schedule deliveries. The calendar is color-coded, with each color indicating a different step in the refill management process. The first step is triggered by a successfully processed prescription. The prescription is programmed to be processed according to a formula (days’ supply minus 5). If there are any problems processing the prescription, the other queues are activated, such as clinical queue or refill management/holds queue. Upon prescription processing, the patient’s name is color-coded on the date processed as an indication that the technician or pharmacy student may contact the patient by telephone and confirm the patient’s identity using two patient identifiers. The patient is asked a series of brief questions about medication tolerability, any new medications since the last refill, verification of correct dosing, missed doses, and satisfaction with medication therapy. Any of the patient responses can trigger an escalation to the pharmacist for intervention. If the patient requires a medication refill shortly, a delivery method and time are selected. Finally, the patient is asked if they have any questions for the pharmacist and the call is concluded. The completed survey is saved in the patient’s profile in the case management system.
The case management system is the cornerstone of our call center and allows us to manage 600 patients with a lean staff. In providing an electronic platform for a paperless operation, prior authorizations, refill surveys, delivery scheduling, medication lists, escalations, interventions, and clinical assessments are all part of the case management system. We can review the status of every patient enrolled in our program at a glance and any staff member can take over for another simply by reviewing the queues. In the future, the case management system, EHR, and dispensing system will be electronically integrated.
Call Center Workflow
As the first point of contact between the specialty clinics and the call center, referrals must be managed efficiently and effectively. UI Health only accepts referrals for prescriptions that can be filled by our pharmacy, as determined during benefit verification. Any provider can forward the clinical notes of a patient to our call center for benefit verification via the EHR. The technicians perform benefit verifications on the referrals within 24 hours and send a notification to the provider via the EHR using a standard template (see TABLE 4). If the prescription cannot be filled by our pharmacy, the referral is returned to the clinic for usual care or referred to an outside specialty pharmacy.
Four years ago, UI Health launched the specialty pharmacy with fewer than 100 patients; the same program now serves 600 patients in nine disease states. The call center works on a range of activities, including benefit verification, coordinating specialty and non-specialty medications, and arranging deliveries. By fully integrating the call center’s activities into the health system’s specialty clinics and fulfillment system, workflow problems are rare. In addition, the case management system supports efficient and flexible staffing, which translates into a call center with focused and organized staff members wherein each prescription is generating a positive return on investment.
Unquestionably, implementing a specialty pharmacy call center requires hard work, flexibility, and creativity. Nevertheless, the call center will serve as the operational core of any specialty pharmacy. While standardization drives efficiency, each specialty clinic has unique needs that must be addressed individually. As such, it is important to recognize that your customers are the health system’s providers and patients, and serve them accordingly.
JoAnn Stubbings, BS Pharm, MHCA, is assistant director of specialty pharmacy services in the ambulatory care pharmacy department at the University of Illinois Hospital and Health Sciences System, Chicago. She also serves as clinical associate professor in the department of pharmacy practice and the department of pharmacy systems, outcomes, and policy at the University of Illinois at Chicago College of Pharmacy.
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