Transcript The Patient-Centered Medical Home

Building Organized Systems of Care
Pharmacists Transforming Care in
Patient Centered Medical Home and
Accountable Care Organization
Hae Mi Choe, PharmD
Director, Pharmacy Innovations & Clinical Practices
University of Michigan Health System
Clinical Associate Professor of Pharmacy
University of Michigan College of Pharmacy
Director, Pharmacy Programs
Physician Organization of Michigan (POM) ACO, LLC
Learning Objectives
• Define patient-centered medical home in terms of
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characteristics and components of a medical home.
Identify potential roles for pharmacists and possible
barriers to the inclusion of pharmacists on the
patient-centered medical home team.
Outline strategies for demonstrating the value of
pharmacist involvement on a patient-centered
medical home team.
Describe emerging opportunities for pharmacists in
the Accountable Care Organizations.
Definition of Patient Centered
Medical Home (PCMH)
• New care delivery model that replaces episodic with
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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
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Physicians
Pharmacists
Nurses
Social Workers
Dieticians
Medical Assistants
Panel Managers
Office Assistants
PCMH Pharmacist Practice Model
• 10 embedded pharmacists in all primary care
clinics
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4.9 clinical FTE
9 internal medicine and 6 family medicine sites
• Pharmacist’s time at PCMH sites varies depending
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on patient volume (range: 1 – 6 half-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
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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
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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.
Impact on Glycemic Control
• Patients with baseline A1c > 7.0% (n = 543) had a
mean decrease in A1c by 0.85% (p<0.0001)
• Patients with baseline A1c > 8.0% (n = 373) had a
mean decrease in A1c by 1.20% (p<0.0001)
• Patients with baseline A1c > 9.0% (n = 231) had a
mean decrease in A1c by 1.75% (p<0.0001)
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
99%
100%
96%
96%
95%
91%
95%
92%
90%
88%
85%
85%
84%
81%
80%
79%
75%
72%
69%
70%
65%
60%
58%
55%
50%
A1c Tests
Non-PharmD Patients
LDLC
Test
PharmD Patients
LDLC <
100
On
Statin
UMHS Target Goal
Monitor
for
Nephropathy
Eye
Exam
Foot
Exam
Diabetes Registry QI Report (cont’d)
Total N = 7145
A1c
Tests
LDLC
Test
LDLC
< 100
On
Statin
Monitor
for
Nephropathy
Eye
Exam
Foot
Exam
UMHS TARGET GOAL
93%
90%
56%
96%
90%
71%
85%
Non-PharmD Patients (N = 6329; 89%)
No. of Patients Met Goal
6057
% of Patients Met Goal
96%
Yes
UMHS Goal Met?
5287
84%
No
3690
58%
Yes
4528*
92%
No
5573
88%
No
4976
79%
Yes
4568
72%
No
PharmD Patients (N = 816; 11%)
No. of Patients Met Goal
810
% of Patients Met Goal
99%
Yes
UMHS Goal Met?
736
90%
Yes
551
68%
Yes
628**
96%
Yes
770
94%
Yes
686
84%
Yes
660
81%
No
* Eligible patients: 4908
** Eligible patients: 656
Reporting Period (07/01/2011 - 06/30/2012)
Medical Directors Satisfaction Survey
The clinical pharmacist positively impacts the health
status of my patients.
The collaborative practice agreement is a valuable
aspect of the clinical pharmacist/provider relationship.
The clinical pharmacist provides useful communications
to me regarding the health status of my patients.
The clinical pharmacist makes appropriate clinical
decisions for my patients.
I am satisfied with the patient care provided by the
clinical pharmacist.
* All 14 medical directors completed the survey (June – July 2013).
PCMH Practice Model: Building Blocks for
Future Innovations in Ambulatory Care
• Expansion of PCMH pharmacy care model to specialty
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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
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Apply principles from PCMH and extend to specialty areas
Integrate with inpatient care & transitions
ACO Goals ACO Goals
• Avoid unnecessary duplication of services and
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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
Target Outcomes
Impact/Outcomes
• Align with P4P indicators and associate financial
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benefits
Align with avoidance of penalties and financial
impact
Cost-savings to employers
New revenue from direct billing opportunities
Physician Organization of Michigan (POM)
ACO Partners
Southeast Michigan
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UM Faculty Group Practice
Integrated Health Associates
Huron Valley Physicians
Association
MidMichigan Health
Oakland Southfield
Olympia Medical Services
United Physicians
West Michigan
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Advantage Health
Lakeshore Health Network
POWM
Northern Michigan
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Crawford Mercy PHO
Wexford PHO
New POM ACO Pharmacists Program
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Develop infrastructure to embed pharmacists in the
primary care clinics at 4 physician organizations/
health systems.
1 FTE pharmacist provides services across 2 – 3
practice sites.
Initially focus on developing comprehensive
medication review AND disease management
services (diabetes/HTN).
Plant Trees Separately…
OR Create a Forest Together…
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.