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Pharmacists Add Real Value to UMHS Patient-Centered Medical Home

Hae Mi Choe, Pharm.D.

WHEN HAE MI CHOE, Pharm.D., joined the University of Michigan Health System (UMHS) 16 years ago, one of her goals was to develop a clinical practice model in which pharmacists and physicians interacted closely to improve patient care within the system’s extensive network of outpatient clinics.

The forward-looking UMHS had already adopted the patient-centered medical home (PCMH) model, but nationally, it was still a time when the notion of pharmacists providing direct patient care faced stiff headwinds.

“The services that clinical pharmacists provided then, and which they provide now, are not fundamentally new or different,” said Dr. Choe, director of pharmacy innovations & clinical practices and clinical associate professor of pharmacy. “What’s changed is how we integrate them into a team-based care model that is scalable and reproducible across an organization.

“Whichever primary care clinic a patient visits in our system, he or she will get the same level of high-quality care. When necessary, a pharmacist will be part of their care team.”

An Integrated Ambulatory Care Model

In 2009, Dr. Choe’s vision began to crystallize when she and her colleagues in the College of Pharmacy and the Department of Pharmacy partnered with the Faculty Group Practice to create an integrated pharmacist model in primary care.

This PCMH has been extremely successful, earning Dr. Choe and her team ASHP’s Best Practices Award in 2011 and a profile as one of the five best practices in the nation by The Advisory Board Company. The program is built on the rationale that PCMH pharmacists help manage patients with chronic conditions by augmenting physician care (thereby improving quality measures) and also increasing revenue by billing for their services.

This program is truly the realization of the patient-physician-pharmacist triad that we learned about in school.

A collaborative practice agreement, reviewed and signed by all clinic physicians, details pharmacists’ scope of practice. Pharmacists work closely with primary care providers to generate a single medication list, progress notes, and medication plan, among other activities. Salaries are paid jointly by the three partners and supported by incentives from BlueCross BlueShield of Michigan, which devised codes for reimbursing pharmacists for face-to-face visits and telephone consultations.

When the program rolled out, it supported 2.5 full-time equivalent (FTE) staff pharmacists practicing at nine ambulatory care sites. Today, five FTE pharmacists are deployed at 15 primary care clinics.

Expansion of Patient Services

Since the program’s start, the scope of practice has expanded from medication management for diabetes, hypertension, hyperlipidemia, and polypharmacy assessment to specialty clinical services for cardiology, psychiatry, and kidney disease. In addition, new services are being developed and implemented in various specialty clinics, and UMHS will continue to foster collaborations with community pharmacies as well as test new care delivery models such as telehealth.

Patients are identified through pharmacist screenings of disease registries and physician referrals, which have steadily increased as the pharmacy team’s reputation has grown and the awareness of their contributions has spread throughout the institution.

The Importance of Relationships

Dr. Choe knew that enlisting the support of medical leadership/administrators and gaining the trust of physicians would be the key for moving the program forward. So she pursued opportunities that raised the profile of pharmacy’s role in patient care, such as working on committees that had system-wide impact. “Working with visionary leaders and providers within our health system allowed me to successfully integrate pharmacists into our care model,” she said.

Pamela G. Rockwell, D.O. (left) and Heidi Diez, Pharm.D., (right) counsel a patient about his medication regimen.

Progress was gradual at first. During the first six months working in the clinic system, the number of referrals for pharmacist care was, not surprisingly, small. Team members like Heidi Diez, Pharm.D., a clinical pharmacist and clinical assistant professor at the University of Michigan College of Pharmacy, made use of the time to foster a rapport with the physicians and nurses she worked with, some of whom were a bit leery of a pharmacist stepping into a clinical role.

“The patients are the physician’s patients, so I had to earn the physicians’ trust before they were comfortable allowing me to prescribe medications to our patients,” Dr. Diez said.

Dr. Diez visited the staff room frequently to talk with doctors about their patients. “When I had a success story, I made a point to tell them about it so that it stuck in their minds. I might say, ‘Look at that, we got Mr. Smith’s A1c level down from 10.7 to 7.4. I am confident we can now get him to goal with some fine-tuning of his lifestyle.’

“I found even quick statements like that can go a long way,” she said.

A Win-Win-Win for Patients, Physicians, Pharmacists

Today, Dr. Diez says she feels like a valued member of the team. “This program is truly the realization of the patient-physician-pharmacist triad that we learned about in school. I think the clinics become very attached to their pharmacists.”

A pharmacist’s presence has been helpful for both patients and physicians because patients have access to more individual attention, guidance, and advice, and physicians can consult a medication expert rather than refer a patient to another physician, noted Pamela G. Rockwell, D.O., assistant professor, department of family medicine, University of Michigan Medical School and medical director of Domino’s Farms Family Medicine, a UMHS healthcare center.

“In the past, I often had to refer a patient with diabetes to specialty services outside our office for more intensive diabetes management,” she noted. The addition of a dedicated pharmacist who is highly knowledgeable in dealing with diabetes means that that same patient can get the care they need in the office without the inconvenience and added time of going to another location.

“For me, having pharmacists as regular care team members solidifies the PCMH model of a physician-led collaborative approach to treating patients, all in one place,” said Dr. Rockwell. “It’s been a win-win for everyone involved.”

–By Steve Frandzel