Med Management and the Medical Home
The medical home model can provide a foundation for an ACO. In this model, pharmacists, working as members of the interdisciplinary care team, concentrate on medication management as a way of not only improving patient care but also curtailing costs.
For example, Baylor Health Care System in Dallas is creating an ACO in which chronic disease management is a core competency. Pharmacists will be involved in several key areas: medication compliance, polypharmacy management, and reduction of unnecessary medication. Baylor is integrating hospital electronic health records with outpatient electronic health records to facilitate medication reconciliation, as well.
Baylor also operates a medication assistance program for indigent patients at high risk for hospital readmission. Pharmacists help patients in the program apply for free medications from pharmaceutical manufacturers.
“We started that many years ago, and originally focused on the transplant patient population to help them get medications to prevent organ rejection, but the program has been so successful in realizing savings that we plan to use it heavily in our ACO,” said Michael D. Sanborn, vice president, cardiovascular services. “If we are able to get high-risk patients free or reduced medications, we can reduce hospital admissions and reduce overall cost.”
At four clinics, Fairview Health Services, an eight-hospital health system in Minnesota, is also incorporating the medical home model into its ACO. Fairview is establishing medical homes in which the goals are to reduce costs, increase patient satisfaction, place 50 percent more patients under a clinic physician’s care, and improve quality-of-care measures.
Efficient work flow is a cornerstone of Fairview’s efforts, said Scott Knoer, Pharm.D., M.S., director of pharmacy at the University of Minnesota Medical Center. “We want to have the right people doing the right thing. Anything with medication should involve the pharmacy, either pharmacists or pharmacy technicians, as appropriate.”
For example, pharmacy technicians interview patients and enter patient histories into the electronic health record. Standardizing medical histories enhances medication reconciliation and can help smooth the transition from inpatient to ambulatory care. Meanwhile, pharmacists have more time for direct patient care and education, such as helping patients manage their blood pressure and control their diabetes. These efforts will combine to improve patient care and rein in costs, Knoer said.
Waiting for Guidelines
The Department of Health and Human Services hasn’t yet laid out guidelines or rules governing ACOs. But there are several things to keep in mind as health systems forge ahead to provide higher quality while lowering costs, said former ASHP President Kevin J. Colgan, M.A., FASHP, corporate director of pharmacy at Rush University Medical Center in Chicago.
“It’s important to set parameters to determine risk for readmission or problems with adherence and incorporate pharmacy services as appropriate,” Colgan said, pointing to a study of 58 readmitted patients at the medical center that revealed each patient was taking, on average, 11 different medications.
“It’s obvious what the role of the pharmacist is there,” Colgan said. “Pharmacists should be providing medication education and assistance with managing therapy so that you get good outcomes.”
Health systems in the process of creating ACOs will also have to determine which patients should be enrolled, he added, noting that the opportunity to reduce overall cost shrinks for those at low risk who require fewer services.
Finally, ACOs will need to determine where to concentrate resources to provide the best care. “Theoretically, the idea would be to transition patients to prevent unnecessary hospital readmissions and lower costs that way,” said Colgan. “It may mean that you move some resources to an ambulatory setting to help patients avoid hospitalization.”
He added that overall, there is room for variation in ACO development. “There will be different forms and structures, with room to shape what the pharmacist’s role will be,” he said.