Transcript The Patient-Centered Medical Home

Building Organized Systems of Care
Transforming Care in Patient Centered
Medical Home and Accountable Care Organization
Hae Mi Choe, PharmD
Director, Pharmacy Innovations & Partnerships
University of Michigan Medical Group
Associate Dean, Pharmacy Innovations & Partnerships
College of Pharmacy, University of Michigan
Director, Pharmacy Programs
Physician Organization of Michigan (POM) ACO
Definition of Patient Centered
Medical Home (PCMH)
• New care delivery model that replaces episodic with
•
•
coordinated care
Patients have a team that takes collective
responsibility for meeting patient’s health care
needs
Ongoing relationship with primary care providers
PCMH Joint Principles
Team-Based Care
Enhance Access
and Communication
Advanced Electronic
Communications
Care Management
Patient
Test and Referral
Tracking
Self-Management
Support
Patient Tracking and
Registry Functions
Measure and Improve
Performance
PCMH Team Members
•
•
•
•
•
•
•
•
Physicians
Pharmacists
Nurses
Medical Assistants
Panel Managers
Office Assistants
Social Workers
Nutritionists
PCMH Pharmacist Practice Model
• 11 embedded pharmacists in all primary care
clinics


5.2 clinical FTE
8 internal medicine and 6 family medicine sites
• Pharmacist’s time at PCMH sites varies depending
•
on patient volume (range: 1 – 3 days/week)
Provide disease management services (diabetes,
hypertension, and hyperlipidemia) and
comprehensive medication review services
Pharmacist’s Scope of Services
Per Collaborative Practice Agreement
• Evaluate and optimize therapeutic regimen
• Provide medication management to achieve treatment goals
• Assess and address barriers to medication adherence
• Provide education on chronic medical conditions and
medications
• Assist in limited physical assessment (i.e. BP, foot exam)
• Order labs and medical equipment (i.e. glucometer)
• Facilitate referrals to other health care providers
• Set goals for self management using motivational interviewing
Patient Enrollment and Service Delivery
• Disease Management Services




Focus on diabetes, hypertension, and hyperlipidemia.
Proactively identify potential candidates through disease
registry and/or provider clinic schedule.
Patients are scheduled for initial 30-minute clinic
appointments or phone
Schedule patients for 15 – 30 minutes follow-up
appointments to improve disease control and/or
medication management.
Patient Enrollment and Service Delivery
(cont’d)
• Comprehensive Medication Review (CMR) Services



Initial appointment:
• focus on patient’s medication concerns, confirm
medication use, assess patient’s understanding of
disease states and treatment plan, and identify
potential barriers to treatment including drug cost.
Follow up appointment (2 weeks);
• discuss new treatment plans to improve efficacy,
safety and lower drug costs.
Both initial and follow up appointments can be
conducted over the phone or at the clinic for a total of
75 - 90 minutes of CMR experience.
on Glycemic Control
ClinicalImpact
Outcomes
Average Decrease in A1c in Patients With Diabetes
Co-Managed By Clinical Pharmacist
Average Reduction In A1c
0.00%
-0.20%
-0.40%
n=543
n=373
-0.60%
n=231
-0.80%
-1.00%
-0.90%
-1.20%
-1.20%
-1.40%
-1.60%
-1.80%
-2.00%
-1.80%
>7.0%
>8.0%
Baseline A1c
p<0.0001
*Patients
may belong to more than one category
>9.0%
Therapeutic Interventions by
PCMH Pharmacists
211
Year 3: 2,674 interventions
245
357
1338
523
increased dose
added medication
decreased dose
deleted medication
optimized regimen
Diabetes Registry QI Report
100%
95%
99%
96%
95%
95%
93%
90%
88%
87%
86%
85%
81%
80%
80%
81%
76%
75%
71%
69%
70%
65%
65%
60%
59%
55%
50%
A1c Tests
LDL-C Test
LDL < 100
On Statin
Non-PharmD Patients
Monitor for
Nephropathy
PharmD Patients
Eye Exam
Foot Exam
Flu Shot
MedicalDirectors
Directors’
Satisfaction
Survey
Medical
Satisfaction
Survey
PCMH Practice Model: Building Blocks for
Future Innovations in Ambulatory Care
• Expansion of PCMH pharmacy care model to specialty
•
•
•
•
clinics
Building a medical neighborhood by developing
collaborative care between PCMH and community
pharmacies
Creating telehealth partnership with home care services
Implementation of employer-based comprehensive
medication review program
Collaboration with payers to improve HEDIS and Star
Measures
Accountable Care Organization (ACO)
ACO
Patient Centered
Medical Homes
(Primary Care)
Specialty Areas
Inpatient Care and
Transitions of Care
•
•
Apply principles from PCMH and extend to specialty areas
Integrate with inpatient care & transitions
ACO Goals ACO Goals
• Avoid unnecessary duplication of services and
•
medical errors
Link provider reimbursements to quality metrics
and reduction in the total cost of care for the
assigned population
 When an ACO succeeds in saving health care
dollars, CMS shares the savings
Physician
of Michigan
Michigan(POM)
(POM)
Physician Organization
Organization of
ACO Partners ACO Partners
•
•
•
•
•
•
•
•
•
•
University of Michigan Medical Group
Integrated Health Associates (IHA)
MidMichigan Health
Oakland Southfield Physicians
Olympia Medical Services
United Physicians
Huron Valley Physicians Asso.
POWM
Crawford Mercy PHO
Wexford PHO
POM ACO Pharmacists Program
•
•
•
Develop infrastructure to embed pharmacists in the
primary care clinics.
1 FTE pharmacist provides services across 2 – 3
practice sites.
Initially focus on developing comprehensive
medication review AND disease management
services (diabetes/HTN).
Michigan Pharmacists Transforming
Care and Quality (MPTCQ)
MPTCQ Goals/Objectives
• Identify and train one Pharmacist Transformation
•
•
Champion per PO.
Adopt and modify University of Michigan Health
System’s integrated pharmacist practice model.
Improve patient care and outcomes at
participating POs through pharmacist integration.
Creating New Opportunities for
Future Pharmacists
• Pharmacists are being recognized as an integral
member of the new care delivery model.
• Need to develop a sustainable financial model for
pharmacists.
• Demonstrate impact on patient care and health care
costs.
• Provide leadership training for future pharmacists to
build the new health care landscape.