AS HEALTH CARE REFORM EVOLVES and providers are held to higher standards of quality and improved patient outcomes, more physicians and health systems are turning to the patient-centered medical home (PCMH) to offer comprehensive, cost-effective care.
At Advocate Medical Group, a subsidiary of the Advocate Health System in Chicago, administrators recognized the value pharmacists can bring to the medical home. When they needed a pharmacist who had experience working with heart failure patients, they contacted the Midwestern University College of Pharmacy for a candidate.
Enter Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE, assistant professor of pharmacy practice at Midwestern University Chicago College of Pharmacy, whose work with Advocate meets ASHP’s Pharmacy Practice Model Initiative recommendations for pharmacist involvement in the medical home. She is part of a PCMH that includes six primary care physicians, a cardiologist, a nurse practitioner, a physician assistant, a nurse educator, and a dietician.
Schumacher has a broad and well-integrated role in the PCMH. Through collaborative practice agreements, she initiates, discontinues, and titrates medications and provides medication reconciliation and education to improve patient adherence. She also orders and interprets laboratory values, arranges medical referrals, and provides disease-state and lifestyle education. Schumacher is also available for medication recommendations and physician consults.
A Key Member of the Health Care Team
Schumacher works closely with the team’s nurse practitioner, Monique Colbert, APN. The primary care physicians and cardiologist refer heart failure patients to Schumacher and Colbert through a “task” message in the patients’ electronic medical records.
Although physicians can select the team member whom they would like a patient to see, Schumacher and Colbert often review the medical history and make the determination themselves.
Patients who need more help with their medications see Schumacher, whereas those who need lifestyle management counseling see Colbert. Yet the two share the goals of improving patient outcomes and lessening the physicians’ load.
“We are extra help for the doctors. When patients need follow-up, the cardiologist and primary care physicians just can’t see them every two weeks. That’s where we step in and provide that in-depth care,” said Schumacher. Initial visits last about an hour, and follow-up visits last about 30 minutes.
Although Schumacher was initially tapped for her experience in treating heart failure, it soon became clear that patients needed assistance in managing coexisting conditions.
“We were seeing high A1Cs in people with diabetes, up around 10 or 11 percent, so we started making recommendations to the physicians about how to treat them. Then we did the same for patients with hypertension and dislipidemia,” said Schumacher. “The physicians asked us if we could handle treating this condition, and we went from there.”
Schumacher now uses pharmacist-created protocols and current guidelines to help her manage patients with diabetes, hypertension, dislipidemia, chronic obstructive pulmonary disease, and asthma. Plans are in the works to add chronic kidney disease to the mix.
Colbert said she has learned from Schumacher. “My background is heart failure, and Christie helped me come on board with diabetes. At first, I would see the patients with A1Cs of eight or lower, and Christie would see patients with more complex cases, but as I became more educated and more skilled, I began to take on complex patients as well.”
Proving the Case
The PCMH took six months to implement and, initially, there weren’t many patients to see: The primary care physicians and nurses were a bit wary of Schumacher conducting physical assessments. But support from the cardiologist, with whom she had worked before, helped, as did Schumacher’s own drive to show the value of pharmacist-provided care.
“I took the time to learn physical assessments. Many pharmacists aren’t comfortable with that, but it makes a difference. You need to show the physicians that you know what you are talking about,” she said. “At first, the physicians wanted us to run everything by them, but after two weeks of seeing what we could do, they told us to just go ahead [with our care].”
Although physicians still sign off on the care notes, both Schumacher and Colbert can now write prescriptions.
Goldbarg Moaddab, M.D., an internist on the team, finds the collaboration indispensible. “I can’t imagine practicing without the medical home anymore. The other professionals can be so much more thorough regarding patient history and medications, and they have more time to spend with patients than physicians do,” she said.
Advocate Medical Group is currently looking at outcome measures such as hospitalizations, readmissions, emergency room visits, blood pressure, LDL cholesterol, and A1Cs.
Regardless of how those measures come out, Moaddab said she has noticed a change among her patients.
“Before Christie was part of the medical home, it took much longer to get patients to their goals for A1Cs, blood pressure, and lipid control. Now that they are seen more frequently by other health care professionals on the team, they get there faster,” she said.
The patients appreciate the care, as well, said Schumacher, noting that for many patients, the in-depth follow-up is a new phenomenon.
“We have patients in their 60s who tell us that no one has ever sat down with them and discussed their medications,” she said. “We have a high turnout, and they like to come to their appointments. That’s going to go a long way toward increasing adherence and helping them to get better.”
–By Terri D’Arrigo