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MODULE 18: BUILDING AND LEADING HIGH-PERFORMING SPECIALTY PHARMACY TEAMS
Section 1: Building Cross-Functional Clinical/Operational Teams
Designing the Integrated Architecture for Flawless Patient Care.
SECTION 18.1
Building Cross-Functional Clinical/Operational Teams
Design team structures that effectively integrate pharmacists, specialized technicians, patient care coordinators, and data support staff to manage the complex specialty patient lifecycle.
18.1.1 The “Why”: The Failure of Silos and the Rise of the “Pod”
In traditional community pharmacy, the workflow is largely linear and contained. A prescription arrives, it is entered, filled, verified by the pharmacist, and sold. While you collaborate with technicians, the core responsibility is clear and the handoffs are simple. In hospital pharmacy, you are part of a larger clinical team, but your primary function is often distinct from that of the nurse, the physician, or the phlebotomist. You are a consultant, a verifier, and a dispenser.
Specialty pharmacy breaks these models. It is not a linear process; it is a complex, cyclical, and deeply interconnected ecosystem of tasks. A specialty patient’s journey from referral to adherence is a gauntlet of administrative, financial, and clinical hurdles. The prescription is not the end of the process; it is the start of a long-term relationship.
The cardinal sin of a poorly run specialty pharmacy is the creation of functional silos. This is what happens when you structure your pharmacy like a factory assembly line:
- The Intake Team‘s job is to get referrals in. Once the referral is entered, they are “done.”
- The PA Team‘s job is to get the prior authorization. Once the PA is approved, they are “done.”
- The Billing Team‘s job is to adjudicate the claim. Once it pays, they are “done.”
- The Pharmacist‘s job is to verify the script. Once verified, they are “done.”
- The Adherence Team‘s job is to make refill calls.
What is the result of this model? Catastrophic failure. The PA team gets the approval, but the pharmacist doesn’t know. The billing team adjudicates the claim, but the patient has a $3,000 copay they can’t afford, and no one from the financial assistance team was ever looped in. The pharmacist verifies the script, but the adherence team doesn’t make the outbound call for two weeks, and the patient misses their first dose. The adherence team calls for a refill, but the patient stopped the drug three weeks ago due to side effects, and the clinical pharmacist was never notified.
The Silo Pitfall: The “Perfectly Executed” Failure
In a siloed model, every single department can meet 100% of its internal goals, and the patient can still fail therapy.
- Intake’s Time-to-Enter: Met.
- PA Team’s Approval Rate: Met.
- Pharmacist’s Verification Time: Met.
- Dispensing Accuracy: Met.
- Patient’s 6-Month Adherence (PDC): Failed (0.3).
The entire pharmacy failed. The “Why” of cross-functional teams is to destroy this mentality. The new metric is not “Was my task done?” The new metric is “Did the patient get their drug, can they afford it, do they know how to take it, and are they still taking it?” This is a shared-accountability model. The PA technician is just as responsible for the patient’s adherence as the clinical pharmacist, because their work is a critical link in the same chain.
This module is your guide to designing a team structure that reflects this new reality. We will deconstruct the patient lifecycle and then build team models—known as “Pods”—that integrate all the necessary roles (clinical, technical, administrative) into a single, cohesive unit. This is how you translate your leadership skills from managing a pharmacy to conducting an orchestra.
18.1.2 Pharmacist Analogy: The Sterile Compounding Workflow
A Deep Dive into the Analogy
As a pharmacist, you understand the unforgiving precision of sterile compounding. A final sterile product—be it a complex TPN, a chemotherapy agent, or a sensitive biologic—is the result of a perfectly executed, multi-step, multi-person workflow. The final product is not “mostly sterile” or “close enough.” It is either sterile and safe, or it is contaminated and lethal. There is no middle ground.
Leading a specialty pharmacy team is exactly like being the Pharmacist-in-Charge (PIC) of this cleanroom. The “patient outcome” is your final, sterile compound.
Consider the workflow to make one TPN bag:
- The Order (Referral): An incomplete or ambiguous TPN order is received. The Intake Specialist doesn’t just enter it; they must recognize the ambiguity (e.g., missing electrolyte value) and flag it. If they fail, the process stops.
- The Calculation (BI / PA / Clinical Review): A pharmacist and a specialized technician perform complex calculations—checking osmolarity, calcium/phos compatibility, and dosing. This is the PA Specialist ensuring the “formula” (the PA) is “compatible” (clinically approved) and the Pharmacist ensuring the “ingredients” (the clinicals) are correct. If they fail, the product is unsafe or rejected.
- The Compounding (Financial Assistance / Coordination): A technician in full garb—the Care Coordinator—must meticulously draw up and inject dozens of ingredients in the correct order. Simultaneously, the Financial Assistance Tech is ensuring the “label” (the billing) is correct so the product can be dispensed. If they fail, the product is unstable or unaffordable.
- The Final Check (Dispensing & Logistics): The PIC—the Clinical Pharmacist—performs the final verification. They check the label against the order, the ingredients against the label, and the bag for particulates. The Shipping Team then packages it in a validated cold-chain shipper. If they fail, the wrong drug or a compromised drug reaches the patient.
The Leadership Insight: In this analogy, the pharmacist, the PA tech, and the care coordinator are not in different departments. They are part of one team with one goal: to produce one safe and effective TPN. They work in concert, communicating constantly. The PIC doesn’t just sit in the office; they are actively managing the workflow, solving problems, and ensuring every handoff is perfect. They have built a cross-functional team where success is shared, and a single error is a failure for everyone.
This is the mindset you must adopt as a specialty pharmacy leader. You are the PIC of a complex compounding process where the “ingredients” are data, clinicals, and authorizations, and the “final product” is a healthy, adherent patient.
18.1.3 Deconstructing the Lifecycle: The 7-Stage Framework for Team Design
Before you can design a team, you must have an intimate understanding of the “product” you are building. In specialty, that product is the patient journey. This lifecycle is the central organizing principle for your entire pharmacy. Every role, every task, and every handoff must align with moving the patient successfully through these seven stages.
A failure at any stage resets the entire process, creating rework, provider abrasion, and patient harm. Your team structure must be designed to create seamless, frictionless handoffs between each stage. Below is a deep-dive analysis of each stage, its primary goal, the key roles involved, and the most common failure points you must design your team to prevent.
STAGE 1
Referral & Intake Management
Primary Goal: To capture all necessary referral data (demographic, insurance, and clinical) in a “clean” and timely manner, creating the foundational record for the entire patient journey.
Key Roles: Intake Specialist, Data Entry Technician.
Deep Dive: This is far more than data entry. This is the pharmacy’s “triage” unit. A high-performing intake specialist is an investigator. They don’t just type what they see; they must recognize what is missing. The quality of their work dictates the success of every subsequent step. A “clean” referral with all data present allows the PA team to submit immediately. A “dirty” referral (missing diagnosis code, no insurance card, no recent labs) stops the entire process before it starts. The intake team’s primary metric is not just “referrals entered,” but “clean referral rate” and “time to clean referral.” This requires them to have the authority and training to make outbound calls to the prescriber’s office to chase down the missing data.
Common Failure Point: The “Garbage In, Garbage Out” Referral
A low-skill intake team that simply transcribes an incomplete fax and “saves it for later” creates a black hole. The PA team can’t start, the pharmacist can’t review, and the patient is in limbo. The prescriber’s office, thinking they’ve sent the referral, gets angry when the patient isn’t on therapy a week later. This single failure point is the #1 cause of provider abrasion.
Leadership Tutorial: The “Perfect Intake” Checklist
Train your intake team to be a quality assurance checkpoint. They should not be able to “complete” an intake task until this checklist is 100% complete:
- Patient Demographics: Full Name (spelled correctly), DOB, Address, Phone Number.
- Prescriber Information: Name, NPI, DEA, Address, Phone/Fax, and
Key Office Contact (e.g., the MA or nurse’s name). - Insurance Information: Front/Back of all cards (Medical AND PBM). This is critical.
- The Prescription: Drug, Strength, Sig, Quantity, Refills. (Is it a
starter dose ormaintenance ?). - The Clinicals (The “Golden” Data):
- ICD-10 Diagnosis Code: No PA can be submitted without this.
- Chart Notes / Recent Labs: (e.g., LFTs, HCV genotype, RA factor).
- Prior Failed Therapies: (e.g., “Patient failed methotrexate and Enbrel”). This is required for 99% of PAs.
STAGE 2
Benefits Investigation (BI) & Prior Authorization (PA)
Primary Goal: To secure payer approval for the prescribed therapy by proving medical necessity according to the plan’s specific clinical criteria.
Key Roles: Prior Authorization Specialist, Billing Technician, Payer Navigator.
Deep Dive: This is the specialty pharmacy’s “legal team.” Your PA specialists are not data-entry clerks; they are advocates and strategists. They must first be investigators, running test claims to identify the correct payer (is it medical or pharmacy benefit?), and then logging into the correct portal (e.g., CoverMyMeds, Surescripts, a payer-specific portal) to determine the *exact* clinical criteria. They then become “case builders,” pulling the chart notes and labs from the “clean” intake file to build a “bulletproof” submission. A great PA specialist knows that a submission with “Patient has RA, please approve” will be auto-denied. A submission that says “Patient (DOB 1/1/1970) has severe seropositive RA (RF+ 120), documented failure of 6 months of methotrexate (Jan-Jun 2024), and subsequent failure of Enbrel (Jun-Sep 2024) per attached chart notes. Requesting Humira per plan guidelines” will be auto-approved. This team is your single greatest asset in reducing time-to-fill.
Common Failure Point: The “Submit and Wait” Mentality
A passive PA team that submits a weak application and then “waits for the fax” is a liability. They create a 5-day delay, only to get a denial, which starts another 5-day appeal process. This infuriates providers and delays care. A high-performing team is proactive. They build a strong case on the first submission and are on the phone with the payer 48 hours later if an answer hasn’t been received. They are masters of
Leadership Tutorial: Masterclass on PA Submission Types
You must train your team to differentiate their approach. Not all submissions are equal:
- Standard Submission: The most common. Submitted via ePA portal (e.g., CoverMyMeds). The goal is first-pass approval. This relies 100% on the quality of the intake data.
- Stat/Expedited Submission: For urgent therapies (e.g., oncology, transplant). This requires a direct phone call to the payer’s pharmacy department to initiate a verbal, expedited review. The specialist must have the case ready to present orally.
- The Appeal (First Level): A written letter, often following a “peer-to-peer” review, arguing *why* the denial was incorrect. This requires a deep dive into the patient’s chart and the plan’s own coverage policy. A good appeal letter quotes the plan’s own criteria back to them.
- The Formulary Exception: A request for a non-formulary drug. This is the hardest submission. It requires not only proving medical necessity but also proving failure/intolerance to all formulary alternatives.
STAGE 3
Financial Assistance (FA) & Reimbursement
Primary Goal: To eliminate the patient’s cost-share barrier by securing funding from all available sources (manufacturer, foundation, or government).
Key Roles: Financial Assistance Specialist, Patient Care Coordinator, Billing Specialist.
Deep Dive: This stage runs concurrently with Stage 2. The moment the PA team identifies a high-copay plan, the FA team must be activated. This is not a passive role. This team must be masters of a constantly shifting landscape. They must know which manufacturers offer copay cards (for commercial patients) and which foundations (like the PAN Foundation, GoodDays, or HealthWell) have open funds for specific diseases (for Medicare patients). They must also be experts in screening for Medicare’s Low-Income Subsidy (LIS). A high-performing FA team has a database of these programs, knows when funds “open up” (often the first of the month/year), and has a triage process to enroll patients *before* the first dispense. This team’s success is measured by “dollars saved” and “abandonment rate reduction.”
Common Failure Point: The “Copay Surprise”
The worst patient experience in all of specialty pharmacy. This happens when the PA is approved, the pharmacist counsels, the drug is shipped… and the patient receives a bill for $2,500. This is a catastrophic process failure. It results in an angry patient, a non-adherent patient, a lost prescription, and an angry prescriber. The FA/Copay investigation must be completed and communicated to the patient before the clinical pharmacist ever conducts their onboarding call.
STAGE 4
Clinical Review & Patient Onboarding
Primary Goal: To clinically verify the appropriateness and safety of the therapy, and to onboard the patient with a comprehensive counseling session that sets expectations and drives initial adherence.
Key Roles: Clinical Pharmacist, Patient Care Coordinator.
Deep Dive: This is the first of two critical “pharmacist-only” control points (the other being ongoing management). Once the “administrative shell” is built (Intake, PA, FA are complete), the case lands in the pharmacist’s queue. This is not just a retail-style DUR. This is a Clinical Appropriateness Review. The pharmacist must review the intake labs, the diagnosis, and the PA to answer: “Is this the right dose? Are there contraindications? Are baseline safety labs (e.g., TB test, LFTs) complete?”
After this review, the pharmacist (or a highly-trained Care Coordinator under their supervision) makes the Onboarding Call. This is the most important 15-minute call in the patient’s entire journey. It is not a “hi, your drug is ready” call. It is a structured, empathetic, and clinical conversation that covers:
- Confirmation of therapy, dose, and prescriber.
- A “Teach-Back” segment on why they are taking the drug.
- A deep dive on common side effects and (most importantly) how to manage them (e.g., “It’s common to have injection site reactions. A hydrocortisone cream and a cool compress work wonders.”).
- A clear explanation of the injection device or oral dosing schedule.
- Confirmation of the first ship date, delivery logistics (cold chain, signature required), and ancillary supplies.
- A “warm-line” introduction: “I am your pharmacist, this is my direct number. You call me *before* you call your doctor if you have a drug-related question.”
Common Failure Point: The “Robotic” or “Missed” Onboarding
A pharmacist who is too busy, or a system that allows a drug to be shipped without this clinical call, is setting the patient up for failure. The patient receives a $10,000 cold-chain box with a complex auto-injector, no one to call, and a pamphlet. They will be terrified, store it improperly, use it incorrectly, or simply not use it at all. This “first-fill adherence” failure is a critical metric for manufacturers and payers.
STAGE 5
Dispensing & Logistics
Primary Goal: To accurately dispense and package the medication with all necessary supplies, ensuring 100% integrity via validated shipping processes (especially cold chain).
Key Roles: Operations/Dispensing Technician, Shipping Coordinator, Staff Pharmacist.
Deep Dive: This is the operational core of the pharmacy, and it is a zero-error environment. While the pharmacist performs the final product verification (as in retail), the process is far more complex. The dispensing tech must follow a pick-list that includes not just the drug, but all ancillary supplies (needles, syringes, alcohol swabs, sharps container, patient education). The shipping coordinator is a highly-skilled role, responsible for cold chain management. They must select the correct validated shipper (e.g., a 24-hour vs. 48-hour cooler) based on the destination, weather, and courier. They are responsible for ensuring the temperature-monitoring device (if used) is included and that the package is sent via the correct courier (e.g., FedEx Priority Overnight) to arrive when the patient expects it. This is a high-stakes logistics operation where a single mistake (e.g., shipping a biologic via 2-day ground) can cost the pharmacy $20,000.
Common Failure Point: The “Broken Cold Chain” or “Missing Supplies”
A patient with Crohn’s receives their Humira. It arrives in a non-insulated box, and the drug is warm and denatured. It is now useless. Or, a patient receives their vial of Cimzia but no syringes to draw it up with. In both cases, the pharmacy has failed, the patient misses a dose, and the provider is furious. This is an accreditation and patient-safety nightmare.
STAGE 6
Ongoing Clinical Management & Adherence
Primary Goal: To ensure the patient remains safe, adherent, and clinically stable on therapy through proactive, scheduled clinical interventions and relationship management.
Key Roles: Clinical Pharmacist & Patient Care Coordinator (PCC).
Deep Dive: This is the “specialty” in specialty pharmacy. This is not a passive, auto-refill program. This is a high-touch, clinical monitoring service. This stage is a continuous loop of proactive outreach, driven by the Care Coordinator and escalated to the Pharmacist.
The Care Coordinator’s Role: The PCC is the patient’s “best friend” at the pharmacy. They make the proactive adherence call 7-10 days before the next fill is due. This is not a “refill call.” It’s a clinical assessment disguised as a service call. They use structured scripts based on Motivational Interviewing to ask:
- “Hi [Patient], this is [PCC] from your specialty pharmacy. Just calling to check in on your [Drug]. How have you been feeling on the medication?”
- “Have you experienced any side effects we discussed, like [Side Effect 1] or [Side Effect 2]?”
- “How many doses have you missed in the last 30 days? (Asking non-judgmentally) Life gets busy, just want to see how we can help.”
- “Do you have enough supplies (needles, swabs) to last you?”
The Pharmacist’s Role: The PCC triages. If the patient says “I’m great,” the PCC schedules the refill. If the patient says, “Actually, I’ve been really nauseous and I stopped it last week,” the PCC does not schedule the refill. They perform a warm transfer directly to the Clinical Pharmacist. The pharmacist then takes over, performs a side-effect management intervention, and contacts the provider with a recommendation (e.g., “Patient non-adherent due to nausea. Recommend adding pre-medication with ondansetron.”). This pharmacist-led intervention is what defines specialty care.
Common Failure Point: The “Robotic Refill” Trap
The single biggest difference between a “specialty pharmacy” and a “mail-order pharmacy” is this step. A mail-order pharmacy’s system asks “Do you want a refill?” and ships the drug. A specialty pharmacy asks “How are you doing on your drug?” and *then* determines if a refill is appropriate. Shipping a refill to a non-adherent patient just wastes money and creates a false adherence record (e.g., their PDC is 1.0, but their adherence is 0).
STAGE 7
Data & Outcomes Reporting
Primary Goal: To aggregate and analyze patient data to prove value, satisfy accreditation/contract requirements, and identify gaps in care.
Key Roles: Data Analyst, Clinical Pharmacist, Leadership.
Deep Dive: This stage is the “umbrella” that covers all other stages. Every action taken by your team must be documented in the specialty pharmacy software (e.g., Therigy, Asembia1). Why? Because this data is your pharmacy’s currency.
- For Accreditation (URAC/ACHC): You must report on your performance, including time-to-fill, call center metrics, and adherence rates.
- For Payer Contracts: Payers will only keep you in-network if you can prove you are managing patients effectively.
- For LDD Contracts: Pharmaceutical manufacturers will only give you access to their limited distribution drugs (LDDs) if you can provide them with detailed, de-identified data on their patients (e.g., “What was the #1 reason for discontinuation in Q3?”).
Your data support staff are not just “report runners.” They are storytellers. They must work with the clinical pharmacist to *analyze* the data. For example, if “Time to PA Approval” jumps from 2.4 to 5.1 days for a specific payer, the data analyst’s job is to flag that, and the pharmacist’s job is to find out why (e.g., “Oh, that payer just added a new step-edit requirement”). You then re-train the PA team, and the metric improves. This is the continuous quality improvement (CQI) loop that high-performing teams are built on.
18.1.4 Designing the Team: Three Models for Cross-Functional Integration
Now that you have mastered the patient lifecycle, you can design a team structure to manage it. There is no single “perfect” model; the right structure depends on your pharmacy’s volume, disease state focus, and business goals. As a leader, your job is to be an architect. Here are the three most common models, their pros and cons, and a visual guide to how they work.
Model 1: The “Disease-State Pod” (The Gold Standard)
This is the most patient-centric and clinically-integrated model. In this structure, you create a series of small, self-contained “mini-pharmacies” within your pharmacy, each dedicated to one or two disease states.
Structure:
- “Inflammatory Pod”: Manages all RA, Crohn’s, and Psoriasis patients.
- Team: 2 Clinical Pharmacists, 3 PA Specialists, 3 Care Coordinators, 1 Financial Specialist.
- “Oncology Pod”: Manages all oral oncology patients.
- Team: 3 Clinical Pharmacists (specialized), 2 PA Specialists, 4 Care Coordinators, 2 Financial Specialists.
- “HCV / ID Pod”: Manages all Hepatitis C and HIV patients.
- Team: 1 Clinical Pharmacist, 2 PA Specialists, 2 Care Coordinators.
In this model, when a referral for Humira arrives, it is routed *directly* to the Inflammatory Pod. That single team handles the patient’s entire lifecycle from Stage 1 (Intake) to Stage 6 (Adherence). The patient has one phone number, one clinical pharmacist, and one team that knows them by name.
Visual: The “Disease-State Pod” Model
Inflammatory Pod (RA/Crohn’s)
1 RPh
2 PA Techs
2 PCCs
Oncology Pod
2 RPh
2 PA Techs
3 PCCs
HCV / ID Pod
1 RPh
1 PA Tech
2 PCCs
All referrals are routed directly to the correct Pod, which manages the entire patient lifecycle.
Pros & Cons: The “Pod” Model
| Pros | Cons |
|---|---|
|
|
Model 2: The “Functional” or “Assembly Line” Model
This is the most traditional model, common in very high-volume mail-order or PBM-owned pharmacies. It organizes all staff by their specific job function.
Structure:
- Intake Department: (10 Techs) Manages all new referrals for all disease states.
- PA Department: (15 Techs) Manages all PAs.
- Financial Assistance Dept: (5 Techs) Manages all FA cases.
- Clinical Department: (10 RPh) Manages all clinical reviews and onboarding calls.
- Adherence Department: (20 PCCs) Manages all refill/adherence calls.
In this model, a Humira referral is passed like a baton in a relay race: from Intake, to PA, to FA, to Clinical, to Adherence. Each team performs its one function and pushes the case to the next queue.
Visual: The “Functional / Assembly Line” Model
Intake Team
PA Team
FA Team
Clinical Team
Adherence Team
All referrals flow through the same functional departments. The patient is passed from queue to queue.
Pros & Cons: The “Functional” Model
| Pros | Cons |
|---|---|
|
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Model 3: The “Hybrid” Model (The Practical Compromise)
This model combines the efficiency of the Functional model with the patient-centricity of the Pod model. It is the most common and practical structure for many growing specialty pharmacies.
Structure:
- “Front-End” Functional Team: A large, centralized Intake and BI/PA team that handles all new referrals (Stages 1-3) for all disease states. Their job is to get every new patient *through* the administrative hurdles efficiently.
- “Back-End” Pod Teams: A set of disease-state pods (e.g., Onco, Inflammatory, ID) that are focused only on patient management (Stages 4-7).
In this model, a new Humira referral goes to the “Front-End” team. They get the intake, PA, and financial assistance. Once the patient is 100% “cleared” for their first fill, the case is permanently transferred to the “Inflammatory Pod.” That pod then takes over, with their dedicated pharmacist making the onboarding call and their dedicated PCCs managing all subsequent adherence calls for the life of the patient.
Visual: The “Hybrid” Model
All New Referrals
Processed by:
Central “Front-End” Team
(Intake + PA + FA Specialists)
“Approved” patient is handed off to:
Inflammatory Pod (Mgmt)
(RPh + PCCs)
Oncology Pod (Mgmt)
(RPh + PCCs)
HCV / ID Pod (Mgmt)
(RPh + PCCs)
Pros & Cons: The “Hybrid” Model
| Pros | Cons |
|---|---|
|
|
18.1.5 Masterclass on Roles: Defining Your Specialized Team
A cross-functional team is only as good as the people in the roles. As a leader, you must hire, train, and coach for a set of competencies that are fundamentally different from traditional pharmacy. This section is a deep dive into the job description, key competencies, and common pitfalls for each critical member of your team. This is your playbook for building talent.
The Clinical Pharmacist (The Clinical Anchor)
Translating Your Skills: This is the evolution of your role as the most-trusted healthcare professional. You are moving from a product verifier (retail) to a long-term disease state manager. All your clinical knowledge, your empathy, and your communication skills are now your primary tools.
Masterclass Table: Pharmacist Role Definition
| Component | Details |
|---|---|
| Primary Goal | To ensure all therapy is clinically appropriate, safe, and effective, and to serve as the team’s and patient’s expert clinical resource. |
| Key Responsibilities |
|
| Essential Competencies |
|
| Common Pitfalls |
|
The Prior Authorization Specialist (The Payer Navigator)
Translating Your Skills: This is not a typical technician role. You are hiring for persistence, attention to detail, and investigative skills. A great PA specialist is a “puzzle-solver” who enjoys navigating complex systems and “winning” the approval for the patient. This is one of the most valuable and high-leverage roles in your pharmacy.
Masterclass Table: PA Specialist Role Definition
| Component | Details |
|---|---|
| Primary Goal | To minimize time-to-fill by efficiently navigating payer portals and building clinically-sound PA submissions that result in first-pass approvals. |
| Key Responsibilities |
|
| Essential Competencies |
|
| Common Pitfalls |
|
The Patient Care Coordinator (The Patient’s Lifeline)
Translating Your Skills: This is the “customer service” and “relationship” hub of your pharmacy. You are hiring for empathy, organization, and communication. A great PCC is a “service-recovery” expert and a “trusted friend” to the patient. They are the “glue” that holds the pod together and ensures the patient never feels lost.
Masterclass Table: PCC Role Definition
| Component | Details |
|---|---|
| Primary Goal | To manage the non-clinical aspects of the patient relationship, focusing on proactive adherence checks, refill coordination, and logistical support. |
| Key Responsibilities |
|
| Essential Competencies |
|
| Common Pitfalls |
|
The Data Analyst / Support Staff (The Storyteller)
Translating Your Skills: This is your quality assurance and business intelligence unit. You are hiring for analytical, technical, and reporting skills. This person (or team) translates all the “clicks” your team makes into the “story” you tell to payers, manufacturers, and accreditors. They are the navigators, telling you if you are on course or veering into danger.
Masterclass Table: Data Analyst Role Definition
| Component | Details |
|---|---|
| Primary Goal | To manage the pharmacy’s data infrastructure, track key performance indicators (KPIs), and generate all necessary reports for accreditation, payer, and LDD contracts. |
| Key Responsibilities |
|
| Essential Competencies |
|
| Common Pitfalls |
|
Leadership Tutorial: Understanding Your Adherence Metrics (MPR vs. PDC)
Your data analyst will live and die by these two metrics. You must know the difference.
Medication Possession Ratio (MPR): A simple, older metric.
Formula: (Sum of days’ supply for all fills in a period) / (Number of days in the period)
Flaw: It can be > 100%. If a patient refills a 30-day supply on day 25, and does this 12 times, their MPR will be (30*12) / 365 = 98.6%. But if they refill on day 25 *and* on day 28 (e.g., going on vacation), their numerator becomes larger, and their MPR can be 110%. It’s imprecise.
Proportion of Days Covered (PDC): The industry gold standard (used by PQA and CMS).
Formula: (Number of unique days in the period the patient *had* the drug) / (Number of days in the period)
Strength: It cannot be > 100%. It only counts the days the patient was “covered.” If a patient has a 30-day supply, they are “covered” for 30 days. If they refill on day 25, their “covered” days just extend; they don’t double-count. This is a much more accurate measure of true adherence.
Your Goal: Your team must be designed to drive your disease-state PDC above 0.80 (the standard for “adherent”).
18.1.6 Building the Infrastructure: Huddles, Workflows, and Technology
A brilliant team design will fail without the infrastructure to support it. Once you have your “pods” or “hybrid” teams, you must give them the tools and forums to communicate. Silos will re-form instantly if you don’t actively fight them with process.
The Daily Cross-Functional Huddle (The “Synapse”)
This is the single most important 15 minutes of your day. This is not a status meeting. It is a high-speed, standing-room-only, problem-solving meeting. It is the synapse that connects the different parts of the team “brain.”
Leadership Tutorial: The 15-Minute Daily Huddle Agenda
Who: The lead RPh, lead PA Tech, and lead PCC from each pod.
When: Same time every day (e.g., 9:00 AM).
Rules: No sitting. No “status updates.” Only roadblocks.
The Agenda (run by the lead RPh):
- Stuck Patients (PA/FA): (Lead PA Tech) “We have 3 patients stuck in PA > 72 hours. Mr. Smith with Aetna (needs peer-to-peer), Mrs. Jones with Cigna (need new labs).”
- Action: RPh assigns peer-to-peer to themselves. PCC calls provider for new labs.
- Clinical/Adherence Issues: (Lead PCC) “We had two non-adherence triages yesterday. Mr. Brown (nausea) is already with RPh. Mrs. Davis needs an onboarding call today, but her financial assistance is still pending.”
- Action: FA Specialist (who is in the huddle) confirms they will have FA resolved by 2 PM so RPh can onboard.
- New High-Priority Starts: (Lead RPh) “We have a new stat oncology start and a new transplant start. They are all-hands-on-deck. Intake is clean, PA team, this is your #1 priority.”
- Action: PA team lead confirms they will initiate the stat PA immediately.
- Payer/Drug Issues (1 min): “FYI: Aetna is now requiring step-therapy for Otezla.”
This 15-minute meeting just solved 5 problems that would have taken 20 emails and 3 days to fix. This is the engine of a cross-functional team.
The Technology Stack (The “Single Source of Truth”)
Your team cannot function if they are working out of three different systems. You must invest in and enforce a “single source of truth.”
- The Specialty Patient Management (SPM) System: This is your central hub (e.g., Asembia1, Therigy, other proprietary software). This is not your dispensing system (like QS/1 or RX30). This is a Clinical Relationship Manager (CRM). It must be where everything is documented: every patient call, every PA status, every clinical intervention. If it’s not in the SPM, it didn’t happen.
- ePA Portals: Your PA team will live in these (CMM, Surescripts). The status from these portals must be manually or automatically updated in your SPM.
- Internal Communication Tools: A secure, HIPAA-compliant chat (like Microsoft Teams) is essential for rapid, cross-functional communication. The PCC must be able to “chat” the RPh: “Patient on line 1 with side effect question” without having to put the patient on hold and walk down the hall.
Workflow Mapping (The “Swim Lane” Diagram)
As a leader, you must *visually* map the patient lifecycle and assign ownership. The “Swim Lane” diagram is the best tool for this. It shows the process flow and the handoffs between roles.
Imagine a diagram with 4 horizontal “swim lanes”: Intake Tech, PA Tech, PCC, and Pharmacist. The process (a box) starts in the “Intake” lane (“Receive Referral”). An arrow moves to the “PA Tech” lane (“Submit PA”). When a problem occurs (e.g., “Denial”), an arrow moves to the “Pharmacist” lane (“Peer-to-Peer Review”).
By mapping this visually, you force your team to confront the handoffs. Who is responsible for moving the “box” from the PA lane to the RPh lane? What is the trigger? This map becomes your Standard Operating Procedure (SOP) and your training guide. It ensures no patient is ever “dropped” between the lanes.
18.1.7 Conclusion: You Are the Architect
Building a cross-functional team is the foundational act of specialty pharmacy leadership. Your success or failure is not determined by your personal clinical skill, but by your ability to design a system—a team of specialists—that can collectively manage a complex process without error. Your old role was the pharmacist. Your new role is the architect.
You must deconstruct the patient journey into its core components. You must define the specialized roles needed to execute each step. You must then choose a model—Pod, Functional, or Hybrid—that integrates these roles, forcing them to communicate and share ownership. Finally, you must build the infrastructure of huddles and technology that serves as the “synapse” for your team. By rejecting silos and embracing the “one-team, one-outcome” philosophy, you build a structure that is not only efficient and profitable, but also the only way to truly provide the safe, high-touch, and life-changing care that specialty patients deserve.
