This article is sponsored by Enclara Pharmacia. In this Voices interview, Hospice News sits down with Enclara Pharmacia Vice President of Clinical Services Raymond Capella, PharmD, MBA, to learn about the unique role that pharmacists play in hospice, why efficiency matters in hospice care and the three key challenges that the industry faces in efforts to bridge the racial access gap in hospice utilization.
Hospice News: You are vice president of clinical services with Enclara Pharmacia, but you’ve had a long career outside of that. What are your top career experiences that you most draw from in your current role?
Raymond Capella: I look at hospice as being a gift — an opportunity for patients to have a dignified death surrounded by loved ones. So, in terms of specific experiences that shaped my career, the one that always stays with me is the day I had the opportunity to shadow a hospice nurse as a pharmacy student.
Up until that time, I didn’t have any direct hospice experience, but I had the opportunity to travel with her and see how empathetic, caring and compassionate she was with each of her patients. The way that she consoled the families was a profound experience for me.
Enclara Pharmacia is a full-service pharmacy benefits manager for hospice and palliative care. Tell us about the company. How has it evolved to this point?
Capella: Enclara Pharmacia began in 2014 with the merger of two hospice pharmacy providers: Enclara Health and Hospice Pharmacia. It was a pretty exciting time, working with highly passionate, clinically attuned folks I learned from every day. We’ve accomplished a lot since then. We created a mobile medication management app and interfaces between the major EMR (electronic medical record) players in the hospice market. These provide efficiencies to nurses who are interfacing with us electronically as opposed to over the phone.
We created a best-in-class analytics suite, which includes our EnclarityTM pharmacy and technology dashboards. We built local pharmacy networks that complement our mail-order service. Finally, we assembled a library of clinical guidance and educational resources to support hospice clinicians.
These successes were possible because of the talented people within the Enclara organization as well as the strong partnerships we have with our hospice providers.
In 2019, hospice was already becoming a better known and better-accepted piece of the care continuum, as more families and care organizations saw its massive benefits. Then COVID hit. What did you see last year in terms of an evolution of hospice services across care settings?
Capella: First, we saw rapid adoption of technology. For Enclara specifically, we saw adoption of our E3 MobileTM app, as well as a large uptick in e-prescribing. Second, we saw hospice providers really valuing flexible medication access.
The third and final piece: We saw a greater demand for what I’ll term “informative analytics” versus just data. With hospices having so many unprecedented challenges to navigate, they needed a better understanding of what was happening. Operationally, we saw shifts from patients in long-term care settings to the home care setting, which impacted hospice staffing.
At Enclara, we were able to use a lot of our demographic and prescription claims data to inform clients about those shifts and how they would impact hospice’s costs and utilization patterns over time.
Pharmacists play a unique role in hospice. What makes them vital to the hospice process and how does that change in 2021?
Capella: Being a pharmacist by training, I’m a little biased. What I would say is that pharmacists are critical to value-based care models. The U.S. spends billions of dollars every year addressing adverse drug events, or ADEs, which cause hospitalizations, ER visits and so on. Pharmacists should be an integral part of the patient care team, collaborating closely with physicians and nurses. The good thing with hospice care is that pharmacists have been an integral part of that team for a pretty long time. Hospice is an excellent value-based care model whose goal is maximizing patient outcomes while minimizing the net cost of care.
The goal with hospice, different from other care settings, is pain and symptom management and that is strongly influenced by medication use. The piece that I really want to emphasize here is when we talk medication use, it’s important to note that it’s not just adding medications on, but also looking at what medications can be removed or substituted in order to lower the patient’s overall pill burden and lessen the risk of side effects.
Pharmacists are specially trained practitioners. We have a deep understanding of drug mechanism of action, and how combinations of medication impact a patient. So as I look at 2021 and beyond, I would say that as the U.S. health care system continues to move toward value-based care models and more seamless transitions of patients from setting to setting, I hope, and would expect, to see pharmacists as increasingly crucial to interdisciplinary teams. That involvement is a powerful way to positively influence care decisions in ways that align with patient goals.
Why specifically does efficiency matter in hospice care, and what does Enclara do to ensure it?
Capella: Hospice care is about providing the right care to the right patient at the right time. To accomplish that you have to be efficient. At Enclara, we focus on how we enable and empower our hospice partners to optimize their workflows.
We do that in a number of ways. First, there is utilization management. Each of our hospice partners is assigned a clinical manager who works strategically with clinical and operational leadership, providing guidance and education to find creative solutions and improve outcomes.
The other piece of what we do is technology. When you talk about efficiency, you have to think about technology. Hospice agencies that take advantage of Enclara’s digital tools reduce their administrative and manual work substantially. That allows them to focus on providing the best care to the patient.
Enclara was one of the first companies to develop a mobile medication app — E3 Mobile — that allows our hospice nurses to seamlessly access and e-prescribe medications through either our mail order or local dispensing. We have a local pharmacy network of over 65,000 pharmacies nationwide to help nurses access medication, and we have a subset of those pharmacies, just over 7,500, that we call our Neighborhood ConnectionsTM program. We work with those pharmacies to ensure they stock common hospice medications, understand the different regulations that pertain to terminally ill patients and meet certain service standards.
Tying all this together is on-demand clinical support. We want our hospice partners to have that support around the clock, seven days a week. A hospice-trained pharmacist is always a phone call away to help ensure patients receive appropriate symptom relief. We may not work with patients directly, but they are always front of mind.
Business analytics has everyone’s focus now. How are companies using hospice data to help improve quality and achieve better or best clinical outcomes?
Capella: There’s so much data out there today. We always say that it starts with how clean the data is and how proactive companies are in transforming all that data into actionable information.
Using Enclara as the example here, we built a real-time pharmacy dashboard that allows our hospice providers to see all their utilization metrics in a single view. It’s dynamic enough for them to drill down and analyze any of the KPIs (key performance indicators) that are impacting their business. It’s also full of clinical information so that clinical leadership can dive into specific therapy classes and match that up with their outcomes data.
Another good example here is that in October 2020, CMS implemented the hospice election statement addendum. Essentially what that did was reinforce conversations at the time of admission between hospice providers and patients in terms of what’s covered under the hospice benefit and what is not. We recognized that this would cause some challenges for hospices depending on their workflow, so in early 2020 we started using client data to proactively review each client’s historical medication coverage determinations and benchmark that against other organizations.
Despite the hospice benefit being such a wonderful care option for patients, why are there still disparities and inequality with hospice access?
Capella: There are three major challenges that we as an industry, as a country, need to overcome to reach a level playing field for hospice patients and for hospice access.
First is the lack of knowledge about hospice. Literally, how to sign up for it, how to access the benefit, what’s included, what’s not included. Medicare regulations require that a physician needs to certify patients as terminally ill to qualify them for the benefit, but there are many people in underserved communities who simply do not have those relationships with their doctors.
Many rely on ER, urgent care, minute clinics. If those patients even get to the point where hospice is presented, it’s often too late and they don’t receive the full benefit that they otherwise could have.
Second is the mistrust of the health care system. There is a lack of cultural diversity when it comes to hospice staff. There’s lots of well-documented research showing the mistrust that certain ethnic and racial minorities here in the U.S. have with the health care system.
Third is a lack of awareness of how different cultures approach the end of life. To address that, we need to work on improving communication with underserved communities, tailoring the messaging to be more culturally sensitive. I’m optimistic that we’ll continue to make strides, but there’s still a lot of work to do.
There was a lot of pain in 2020, but there is reason to be hopeful about the year ahead. What makes you hopeful for 2021 with regards to hospice care?
Capella: This is really the first opportunity I’ve had to sit back and think about and unbundle all that happened in 2020. It was dark. It was painful. But if we listened hard enough and observed, there were a lot of great stories that came out of this past year.
Think about the frontline workers like our hospice nurses, folks who literally put their lives on the line every day, or the volunteer groups early on that began making masks since supplies were short. There was pain, there was sadness, there was darkness, but there were also a lot of people who shined during that time.
What I’m most hopeful for in 2021 is that those hard conversations that we had this past year around race don’t end with words, but with actions. I hope that we continually work toward ensuring that all people receive equitable treatment, especially when it comes to health care. I’m also hopeful that technology that was developed this past year with the COVID vaccine is going to produce additional life-saving therapies that more patients can take advantage of in the future. Maybe that would even delay the need for hospice.
Finally, I am hopeful that a lot of the hard lessons that we learned this past year in 2020 — the physical, the mental, the spiritual — will prepare us for the next set of challenges that are inevitably going to come our way, whatever they may be.
Editor’s note: This interview has been edited for length and clarity.
Enclara Pharmacia serves nearly 100,000 patients daily, through partnerships with over 400 hospice providers across the country. To learn more about how Enclara can help your hospice, visit EnclaraPharmacia.com.
The Voices Series is a sponsored content program featuring leading executives discussing trends, topics and more shaping their industry in a question-and-answer format. For more information on Voices, please contact [email protected].