ASHP InterSections ASHP InterSections

May 9, 2013

Pharmacist Involvement Integral to Medical Home at Advocate Health

From left, a patient reviews his test results with Golbarg Moaddab, M.D., and Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE.

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.

Christie Schumacher, Pharm.D., BCPS, BC-ADM, CDE

“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.

Golbarg Moaddab, M.D.

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



September 6, 2012

Innovations in Reimbursement

Betsy Bryant Shilliday, Pharm.D., CDE, CPP, right, speaks with a patient during the patient’s Annual Wellness Visit (AWV).

LAST APRIL, THE PHARMACY DIRECTOR of a large, multi-hospital health system in the Midwest phoned Gloria Sachdev, Pharm.D., clinical assistant professor of primary care at the Purdue University School of Pharmacy, West Lafayette, Ind.

Several administrators had bombarded the director with requests for additional clinical pharmacists. Faced with juggling the competing demands while securing adequate resources to support the costs—and with his organization in the midst of becoming an accountable care organization (ACO)—he turned to Dr. Sachdev, an authority on establishing sustainable clinical pharmacy models.

“No one had a firm idea of what services they needed, yet they all felt pressure to meet shifting quality-of-care measures,” said Dr. Sachdev. These included reducing 30-day readmission rates or boosting subpar performance measures which would be tied to how much money they could share from savings created by its ACO. And all of the petitioners knew that medication-related measures were intertwined with many of the health outcomes they wanted to influence.

“The question was wide open: Can pharmacists make an impact on some of these measures? The answer is yes,” said Dr. Sachdev.

Creating a Financially Sustainable Plan

After multiple meetings with the administrators and the pharmacy director, Dr. Sachdev helped the group identify what services each had in mind, which diseases and conditions needed the most attention, and the role pharmacists could play within the organization’s nascent accountable care model. Then, they hammered out a financially sustainable plan to expand pharmacist services.

Ultimately, two ambulatory care pharmacist positions were approved to focus on chronic disease management, transitions of care, and quality improvement. Both positions were designed to be billed “incident to” a physician’s care.

Gloria Sachdev, Pharm.D.

“Reimbursement for the pharmacists will cover a bit more than the cost of their services,” said to Dr. Sachdev. “It’s essentially a cost-neutral proposition.”  Getting the billing department involved and educating employees regarding billing opportunities for pharmacists early on was key to the group’s success.

When direct billing for pharmacist services isn’t available—which is usually the case in today’s health care environment—Dr. Sachdev noted that “in a pay-for-quality environment, if pharmacists can show that they can help a health system achieve quality measures of high priority, when the organization gets a large payment for attaining these measures, some of that money can be designated to pay the pharmacists’ salaries.”

“Pay-for-quality programs, such as ACOs, Patient-Centered Medical Homes (PCMHs), Medicare Part C (Medicare Advantage), etc., offer pharmacists new payment opportunities by implementing this indirect model of reimbursement,” she added.

Helping Patients Manage Their Medications

Elsewhere, pharmacists have put their own distinct imprint on direct patient care. The P3 (Patients, Pharmacists, Partnerships) program at the University of Maryland School of Pharmacy began as a diabetes management initiative, then broadened its scope considerably.

The P3 Program is a dynamic partnership that begins with the University of Maryland School of Pharmacy, and includes the Maryland Pharmacists Association, the American Pharmacists Association Foundation, the Maryland General Assembly, and the Maryland Department of Health and Mental Hygiene, Office of Chronic Disease Prevention.

The program contracts with six companies, including ASHP, to conduct medication management and preventive care for employees with chronic diseases such as diabetes, high blood pressure, and high cholesterol. Any employee covered under the employer’s health plan is eligible, and more than 400 are currently enrolled.

P3 pharmacists consult patients four to seven times annually. They assess each patient’s understanding of his or her illness and medication regime, emphasize the importance of medication adherence, and provide education about adverse effects and drug interactions. Pharmacists may also help patients set personal goals, coordinate referrals for lab tests and specialist visits, and administer pneumococcal and influenza vaccinations.

Consults occur at wellness clinics, at community pharmacies, or at an employer’s premises. All P3 pharmacists receive training in medication therapy management, chronic disease management, and self-management coaching and must have completed an Accredited Council for Pharmacy Education-level Diabetes Certficate program, be a certified diabetes educator, or be a Board-certified Pharmacotherapy Specialist.

“We bill the employer every month based on the number of visits and pay the pharmacists who saw the patient,” said Dawn Shojai, Pharm.D., assistant director of P3.

The results are telling: Since January 2009, P3 participants have experienced statistically significant improvements in outcomes for all clinical endpoints, including hemoglobin A1c levels, blood pressure, and LDL cholesterol levels.

The numbers also compare favorably to national and statewide indicators, according to Dr. Shojai. For example, 83 percent of P3 participants had HbA1c levels under 8 percent, compared with 62.3 percent and 64 percent of patients enrolled in national and Maryland commercial plans, respectively, according to data from the 2011 HEDIS (Healthcare Effectiveness Data and Information Set). On average, employers saved about $1,500 per employee annually.

Dr. Shojai continues to push hard for recognition of P3 by Maryland’s Medicaid program, which she expects to occur eventually. “Most of the battles have been to convince people that paying for pharmacists, while expensive, will save money and lives,” she said.

Annual Wellness Visits: A New Kind of Patient Care

Farther south, pharmacists in North Carolina are mining a section of the Affordable Care Act (ACA) and hauling out a steady new revenue source. The ACA established Medicare coverage for annual wellness visits (AWV), but Medicare doesn’t stipulate who must conduct the visit except to say that the clinician must be a licensed health professional.

“This is a completely new avenue for pharmacists to generate revenue by seeing Medicare patients and earning direct reimbursement at a higher service level,” said Betsy Bryant Shilliday, Pharm.D., CDE, CPP, associate clinical professor at the University of North Carolina at Chapel Hill School of Medicine and Eshelman School of Pharmacy.

“Across the board, this is a different type of visit than pharmacists are used to providing. It’s a big deal,” she said. Patients seem to think so, too. Appointment slots fill up weeks in advance. “It’s a service patients want, and that means I am generating income, too,” Dr. Shilliday added.

Reimbursement varies by region, but rates are uniformly higher than for nurse visits, and the service isn’t subject to the usual 20 percent copayment, said Dr. Shilliday, who details the visit requirements on the Section of Ambulatory Care Practitioners portion of the ASHP website.

The practice of pharmacists conducting AWVs is not yet widespread, but Dr. Shilliday predicts steady growth as health systems realize that this represents a practical and profitable way to mitigate the shortage of primary care providers. Ultimately, it is up to pharmacists to identify these kinds of opportunities, according to Dr. Shilliday. “We need to step outside our comfort zone of practice to embrace innovative opportunities, expand our scope of practice, and assume new responsibilities” she said.

Bearing the Burden of Proof 

Mary Ann Kliethermes, Pharm.D., vice chair of ambulatory and associate professor at the Chicago College of Pharmacy, Midwestern University, in Downers Grove, Ill., agrees that in the current health care landscape, pharmacists bear the burden to prove their worth. Her own experience is a case in point. Dr. Kliethermes works part-time in an internal medicine office of a large, multi-site physician group in the Chicago suburbs. Until recently, her main responsibility had been counseling patients who were on anticoagulation therapy. She and the one other pharmacist in the office, however, envisioned much more.

Mary Ann Kliethermes, Pharm.D.

Over six months, they assembled a detailed business plan to broaden medication management services and projected the potential clinical and financial gains. They supported their case with data that showed, among other things, how pharmacist-directed medication management greatly reduced drug-related hospital readmission rates. By fortunate coincidence, the physician group had decided to adopt a patient-centered medical home model, necessitating a closer look at clinical outcomes. The result: Two pharmacists were added to their staff and a third is under consideration.

Their approach embraced the reality of the newer models to which health organizations must hew, and which tie reimbursement to quality and cost reduction, said Dr. Kliethermes, who co-edited, Building a Successful Ambulatory Care Practice, recently published by ASHP.

“We offered a total business package, justified our skills, and showed how we could help the practice meet its goals,” she said. “It is up to the health organization to decide how to allocate its resources, but it is up to pharmacists to show how they can improve outcomes.”


December 26, 2010

Pharmacists Integral to Creating Medical Home Models

Stephen M. Setter, Pharm.D., CDE, CGP, FASCP, speaks with an elderly patient.

AS HEALTH CARE REFORM GETS UNDER WAY, hospitals and health systems across the country are looking into the viability of implementing the Primary Care Medical Home (PCMH) model. In PCMHs, provider-led teams of health care professionals provide coordinated, patient-centered care. The provider is often a physician, whose office acts as a kind of care hub, but much of the direct care is delivered by a multidisciplinary team.

Pharmacists’ Roles Changing

With more than 18 states currently participating in PCMH pilots, the model stands to make a deep impact on the way that care is provided and on the pharmacist’s role as an allied health professional.
Stephen M. Setter, Pharm.D., CDE, CGP, FASCP, associate professor of pharmacotherapy at Washington State University, Spokane, sees the PCMH model as a golden opportunity for pharmacists.
“Pharmacists will be able to use their training to the utmost in this model,” he said, adding that the challenge is simply getting a foot in the door with providers. “Pharmacists are often reactive in the way we provide care,” he said. “We find errors or interactions, but that is downstream. In the medical home model, we can be right at the point of care.”

L. David Harlow III, R.Ph.

Pharmacists need to be more proactive in communicating their expertise to providers, according to L. David Harlow III, R.Ph., director of pharmacy operations at the Carilion Clinic’s New River Valley Medical Center, Christiansburg, Va., and Tazewell Community Hospital, Tazewell, Va.

“Physicians are just not familiar with what pharmacists are qualified to do,” said Harlow, “and that’s just as much our fault, because we have not gotten
the word out.”

Evidence and Incentives

The evidence is there to support pharmacist involvement in multidisciplinary models like PCMH. Studies have shown that pharmacist-provided direct patient care improves patient outcomes across several disease states, and that patients cared for by a team that includes a pharmacist have fewer hospital readmissions.1

Troy Trygstad, Pharm.D., MBA, Ph.D.

Troy Trygstad, Pharm.D., MBA, Ph.D.

As the Centers for Medicare and Medicaid Services roll out “accountable care” projects, the financial incentive for including pharmacists in care teams will grow, as well. Accountable care makes providers responsible for ensuring that patients do not return with preventable complications, such as venous thromboembolisms after orthopedic surgery. If a patient returns with a condition noted under accountable care, the provider will not be reimbursed.

“That changes the equation completely,” said Troy Trygstad, Pharm.D., MBA, Ph.D., director of the Network Pharmacist Program at Community Care of North Carolina in Raleigh. “Now you have business reasons for a multidisciplinary team. Physicians need help in providing the deliverable, and they’re asking, ‘Who can you give me?’” Harlow notes how pharmacists are a natural choice for reining in health care costs.

“Twenty percent of the patient population uses 80 percent of the dollars in health care,” he said. “They are the patients with chronic diseases like diabetes and cardiovascular disease—the same things that account for the drug dollars. If you think about that in primary care, those patients take the most time, their medication regimens need the most tweaking, and they are most likely to relapse to the hospital if their medication issues are not corrected.”

Even in smaller medical practices, scheduling patients to come in and see a pharmacist can go a long way toward addressing those issues, he added.

Cushioning the Impact of Health Care Reform

The cost-effectiveness of involving pharmacists in the PCMH model is one reason ASHP worked so hard to obtain appropriate recognition for pharmacists in health care reform legislation, said Joseph M. Hill, ASHP’s director of federal legislative affairs.

Gretchen Tong, Pharm.D., discusses a patient’s medications with a University of North Carolina Family Medicine physician.

“Our initial accomplishment was the inclusion of pharmacists in the Affordable Care Act, which mentions pharmacists as part of the care team,” he said. “The Act sets out to develop and test delivery and payment models in health care, and [the PCMH model] could potentially be the first step.”

The PCMH model may prove to be a boon to patient care by driving health professionals together, even as it gives providers a cushion for absorbing the impact of health
care reform.

“It’s a holistic model,” said Setter of Washington State University. “From my perspective, that’s the way pharmacists should be practicing and the way medicine needs to move forward.”

Trygstad predicts that as physicians begin to lead multidisciplinary teams, they will see the value in such intense collaboration. The signs are already there, he said, reflecting on a conversation he recently had with a physician in a small town. “He was the sole doctor in the town” said Trygstad, adding that the doctor told him, “I’ve been practicing medicine for nearly 30 years, and it has taken me this long to realize how much I could have been learning from other professionals like pharmacists.’”

1. Chisholm-Burns MA, Graff Zivin JS, Lee JK, et al. US pharmacists’ effect as team members on patient care: Systematic review and meta-analyses. Medical Care. 2010;48:923–933

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