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PolicyDECEMBER 15, 2015

Patient-Savvy Pharmacists Ready forMedical HomesData, technology among tools of the trade

By Lynne Peeples

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Chicago—The name might be deceivingat first. A “medical home” does not referto a tangible building, house or hospital,but rather an approach to providingcomprehensive, coordinated health care.It’s a concept well aligned with the U.S.health system’s evolving emphasis onboosting the quality and efficiency ofcare—a challenging goal thatpharmacists can help their organizationsachieve.

“We’re transitioning away from fee-for-service toward a focus on patientoutcomes,” Tim Lynch, PharmD, MS, the regional senior director and pharmacy officerat CHI Franciscan Health in Tacoma, Wash., told an audience during a session at theAmerican Society of Health-System Pharmacists (ASHP) Conference for PharmacyLeaders in October. In their workshop, Dr. Lynch and his colleague, Eric Wymore,PharmD, MBA, the regional clinical pharmacy manager at CHI Franciscan Health,discussed opportunities for pharmacists to use data, technology and their unique skillsets to contribute to the success of these new patient-centered medical home(PCMH) teams.

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Less than half of attendees, according to a preworkshop survey, knew what a PCMHwas and had implemented one in their organization. What’s more, 42% reported thatpharmacists were not included in their primary care clinic or medical home model.That gap indicates “there is a huge opportunity for pharmacists to get involved,” Dr.Wymore said.

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First Steps

A quick look at the history of health care funding provides some context for thepotential roles of medical homes, as well as for the pharmacists inside those homes.

“In the 1900s, there was no such thing as health care insurance as we think of ittoday,” Dr. Lynch explained. Patients back then simply paid for their medical servicesas they occurred, he noted. That evolved during the middle of the 20th century, whenearly plans had people pay a percentage of their salaries in advance of medical care.During World War II, when there was great competition for employees, employersenticed people to their companies by offering health care funding. Eventually, thefederal government became involved, and, by 1963, a majority of Americans werecovered by some form of health insurance.

Somehow, the model left taxpayers, providers and patients with a lot to be desired.Today, the health care system incurs billions annually, partly due to the costs ofavoidable adverse drug events. Chronic disease treatment consumes as much as 75cents of every health care dollar.

“Cuba pays far less for health care with equivalent life expectancy,” Dr. Lynch said.“Are we getting a positive return on investment in the United States?”

A key problem in the past, according to Dr. Lynch, was payors reimbursing physiciansfor providing care, regardless of quality. “In years past, there were fewer incentives todo it right the first time,” he said. “But that is changing.”

The system is moving from a focus on volume to value, with no reimbursement forpoor quality or injuries due to error. That’s where the medical home can help, he andDr. Wymore explained. Under the roof of a medical home, a team can work togetherto optimize population health—another concept emerging with health care reform,



reflecting an increased focus on the health outcomes of a group of individuals. Amedical home, for example, may cater to patients living in a specific region or thosebeing treated for a certain group of conditions.

“For patients with chronic conditions and complex medication regimens, there needsto be a strong patient–physician–pharmacist relationship that is ongoing and acontinuous one,” said Marie Smith, PharmD, FNAP, the Henry A. Palmer Professor inCommunity Pharmacy Practice and assistant dean for practice and public policypartnerships at the University of Connecticut School of Pharmacy, in Storrs, who didnot attend the ASHP conference. “The pharmacist meets with patients or familycaregivers, and is an integrated member of the practice’s primary care team.

Medical homes will look very different depending on the context, explained Dr. Smith,a thought leader on pharmacy’s role in medical homes and primary care practicetransformation. As a result, the roles of pharmacists may differ as well, according toa 2013 paper she co-authored (Health Aff [Millwood] 2013;32[11]:1963-1970).

Some of a pharmacist’s key contributions, according to another paper she authoredin 2010, may include reviewing prescribed and self-care medications, includingresolving any medication-related problems and optimizing complex regimens, as wellas designing adherence programs and recommending cost-effective therapies(Health Aff [Millwood] 2010;29[5]:906-913).

“Pharmacist integration in a patient-centered medical home can vary according to thesize of the practice and current medication-related workflows and processes,” sheadded. “Generally speaking, larger PCMH practices or PCMHs that are part of ACOs[accountable care organizations] may be more inclined to hire a clinical pharmacist,whereas a smaller practice may prefer to contract for clinical pharmacist servicesthat focus on a subset of patients with complex medication regimens.”

Often, the first necessary step is for pharmacists to simply get their feet in the door.That begins, explained Drs. Lynch and Wymore, with convincing the C-suite,physicians and other health care staff of their value.

“A lot of providers don’t know what you can do,” Dr. Lynch said. “You want to partnerwith providers familiar with what pharmacists are capable of.”

They both emphasized the importance of



(/aimages/2015/ppn1215_024a_13765_300.jpg)Hang Nguyen, PharmD, BCACP counsels apatient as part of CHI Franciscan Health’smedical home initiative.Photographer: ChrisWillard

They both emphasized the importance ofeducating providers and office staff ofpharmacists’ unique skills andknowledge, which extend well beyondwhat they might see in a community orretail setting. “Providers are your best orworst advocates,” Dr. Lynch said. “You’vegot to win over physicians. Once you gaintheir respect, they will tell others.”

The C-suite typically wants to see apharmacist’s value quantified, of course.So, the next step might be showing themthe “positive return on investment for theservices you provide,” Dr. Lynch added.“Look across your organization: Where are the gaps? Where are pharmacists uniquelypositioned to fill some of those gaps?”

Polypharmacy Initiative

Drs. Lynch and Wymore noted that one of the biggest factors in their success hasbeen earning this respect and acceptance within their organization. They highlightedsome of the progress they have achieved so far. In 2013, CHI Franciscan Healthlaunched a polypharmacy project, with the goal of creating a comprehensive processto optimize drug therapy. Based on an internal medication reconciliation project, theaverage patient arrived to the hospital taking 14 medications. This creates a lot ofopportunities for potential errors and bad outcomes, which was borne out by initial,preliminary results of the polypharmacy program (sidebar).

Around the same time, CHI Franciscan Health also implemented a PCMH model,focused on chronic disease management and care coordination for 715 patientsspread out among multiple clinics, Dr. Lynch noted. Just one pharmacist full-timeequivalent (FTE) was originally proposed. The team was able to identify and interveneon the highest-risk patients, such as those older than 65 years of age and with threeor more chronic diseases or eight or more medications.

By convincing providers of a pharmacist’s value, they succeeded in doubling theirallocation to two FTEs. Still, with such limited pharmacist resources, the team neededto prioritize their efforts.

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Doing More With Less

Drs. Lynch and Wymore and their team initially targeted clinics where there was ashortage of primary care providers, a larger number of providers, a strong physicianchampion, strong clinic leadership and providers who were more familiar with clinicalpharmacists. To cover multiple clinics with limited pharmacist resources, theyidentified clinics with high patient volume and a large proportion of high-risk patients.

After the first six months of the initiative, the pharmacists went from spending mostof their time processing refill requests and other administrative work to makingpatient phone calls and performing anticoagulation, diabetes care and direct patientcare transition visits.

“Say yes to everything at first to get your foot in the door, then of course correct,”advised Dr. Wymore.

As that trust builds, he said, providers will likely ask pharmacists to become involvedin more direct patient care and more complex cases.

Where To Start

Since most pharmacists are operating in the health-system setting, there is a need toprioritize and get involved in population health management, added Dr. Wymore. Thispresents another large opportunity for pharmacists to be involved as part of acoordinated effort to improve outcome measures for patients. The CHI FranciscanHealth team chose to focus on diabetes and hypertension measures.

“We have developed a 40/30/30 practice model in order to help other team membersunderstand where the pharmacists intend to focus their efforts: 40% of their day isspent on performing direct, face-to-face patient care visits; 30% of their day is spenton population health outreach; and the remaining 30% of the day is for on-the-fly orcurbside consults,” Dr. Wymore said.

Based on their own experience and those of participants, a few other strategiessurfaced during the workshop, such as having pharmacists rotate between clinicsusing set days or electronic schedules—which might enhance relationships withproviders—as well as identifying and utilizing various technologies.

“Traditional models of care, where you’re seeing the eyeballs of each and every



“Traditional models of care, where you’re seeing the eyeballs of each and everypatient, is just not always practical,” Dr. Wymore added.

Virtual Diabetes Project

In addition to phone calls, other forms of outreach such as Skype and email may alsohelp with continuing care. Through a collaborative virtual diabetes project with thecertified diabetes educator, CHI Franciscan Health provided iPads for a limitednumber of study patients to monitor their glycated hemoglobin A (HbA ). So far,they’ve seen a 2.2% improvement in HbA . That may not sound like much in absoluteterms, but according to data presented at the 72nd Scientific Sessions of theAmerican Diabetes Association, patients who reduced their HbA levels by nearlyone percentage point—from a mean of 7.8% to 7%—had a significant 45% decreasedrisk for cardiovascular death (hazard ratio, 0.55; 95% CI, 0.49-0.63; P<0.001).

“Tracking outcomes is also critical in establishing your value on the team,” Dr.Wymore said, who added that the virtual diabetes project “was run by our diabeteseducators; our pharmacists collaborated with the diabetes educators on thesepatients.”

Dr. Smith noted the integrated teamwork of a medical home “requires face-to-facepatient encounters to build a trusted relationship.” But “once an established patient ismaking good progress toward meeting their medication management goals, somefollow-up may be done with remote monitoring technology or virtual visits,” she said.However, she added that some payors may not recognize virtual visits.

Who’s Going To Pay?

Reimbursement roadblocks also can broadly hinder pharmacists’ ability to joinmedical home teams. “Even when physicians do want to add a pharmacist to thehealth care team in a primary care office or outpatient clinic, the main barrier is lackof a payment mechanism in a fee-for-service payment model,” Dr. Smith said.

“With the growth of ACOs and more value-based or risk-based payment models,” sheadded, “clinical and administrative leaders are recognizing that adding pharmaciststo the health care teams can have a positive impact on quality improvement and costsavings.”

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Drs. Lynch, Wymore and Smith reported no relevant financial relationships.

Outcomes Data Not Yet In, But Benefits Still ThereTracking clinical outcomes for any new initiative is difficult, and the medication reconciliation projectinitiated by CHI Franciscan Health in Tacoma, Wash., is a case in point. But that’s not to say there areclear indications of benefit, according to the program coordinators.

“The data that we had done from our medication reconciliation pilot showed that many of our patientswere arriving at the hospital on more than eight medications,” they noted in a followup email. “That wasrecognized as a risk factor for readmission, because taking multiple medications could indicate poorcontrol and lack of adherence. Increased readmissions were something that we were trying to reduce asone of our strategic initiatives. The polypharmacy program rolled in nicely under the PCMH that wastaking place in the clinics and the care redesign with care management. Since we were working onhaving a pharmacist review highrisk patients (e.g., over 65, on eight or more medications, recentlydischarged), incorporating them in the PCMH was a natural fit.

The polypharmacy program was a jumping off point for our PCMH— this was the intention of including itin our background. The program helped to propel our pharmacy services into the PCMH. There were notadditional outcomes beyond what was discussed.”

—L.P.

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