ASHP InterSections ASHP InterSections

April 3, 2015

Pharmacists Add Real Value to UMHS Patient-Centered Medical Home

Hae Mi Choe, Pharm.D.

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.

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

July 17, 2013

Novel Missouri MTM Program Benefits Patients, Pharmacists

DC Pro is a feature of the MO HealthNet Medicaid program.

DC Pro is a feature of the MO HealthNet Medicaid program.

A NEW FEATURE OF MISSOURI’S MEDICAID PROGRAM is drawing admiration from health care experts around the country for its ability to bring pharmacists and patients together.

The program in question—Direct Care Pro (DCPro)—provides pharmacists with a database of patients in their area who are eligible for medication therapy management (MTM) and other cognitive therapies.

Gloria Sachdev, Pharm.D., a clinical assistant professor, primary care, at Purdue University, West Lafayette, Ind., and director-at-large of ASHP’s Executive Committee for the Section of Ambulatory Care Practitioners, is one of the program’s admirers.

​“I would love Indiana to one day have the IT infrastructure in place to provide MTM like Missouri does,” she said, calling DCPro “an amazing example of how to operationalize MTM services in a streamlined manner.”

Gloria Sachdev, Pharm.D.

Gloria Sachdev, Pharm.D.

Pharmacists under the Missouri program receive direct reimbursement as health care providers, and a variety of conditions are covered, including asthma, chronic obstructive pulmonary disease, diabetes, gastroesophageal reflux disease, heart failure, hypertension, and hyperlipidemia.

“The number of covered conditions is constantly expanding,” according to Sandra Bollinger, Pharm.D., provider outreach coordinator with Xerox, which manages MO HealthNet. She added that only a handful of states allow pharmacists to bill directly to their Medicaid programs as health care providers.

Helping Patients During Care Transitions

The program is an excellent example of how pharmacists can help patients during transitions of care, according to Justine Coffey, JD, LLM, director of ASHP’s Section of Ambulatory Care Practitioners.

“It’s a great model because it ensures that patients receive the care they need once they leave the hospital and are back in the community setting,” Coffey said, noting that patients receive better care when pharmacists are involved in medication management decisions.

“This program provides both an opportunity for better patient care and new opportunities to advance ambulatory pharmacy practice.”

Opportunities for Intervention

Pharmacists who are registered with MO HealthNet can log into the DCPro system and view a list of all patients who are eligible for cognitive services. The information is based on gaps in Medicaid claims that would have been filed had the patient been keeping up with their care for a particular disease state.

Next, pharmacists select which patients they want to assist and then “reserve” an intervention (many patients are eligible for multiple interventions). They then contact patients and arrange face-to-face consultations. Interventions can take place in outpatient clinics, patients’ homes, or in areas of community pharmacies that are designated for patient care. Once reserved, an intervention must be completed within 30 days or the patient is released back into the database.

For example, consider an MO HealthNet patient who has diabetes, but has not had an A1C blood test for more than 90 days. The MO HealthNet system will detect that a claim for the test has not been filed.

Based on that care gap, the system automatically adds that patient’s name and flags the intervention for which the patient is overdue. A pharmacist seeing the information can provide the test as well as additional counseling.

During an intervention, DCPro guides the pharmacist through questions that must be answered before it allows users to move to the next topic. It also fills in progress notes and submits the billing automatically once an intervention is complete.

Reimbursement (which is based on the amount of time spent with the patient rather than the nature of the intervention) is calculated in 15-minute increments. Payment ranges from $10-$20 per 15-minute period with a one-hour maximum per intervention. There is no limit on the number of intervention hours a pharmacist can bill annually.

“Pharmacists who use the system don’t have to keep their own records regarding which patients are eligible. They can just log in to see a complete list of all eligible patients in their area,” said Dr. Bollinger. The system also handles all recordkeeping and billing.

Justin May, Pharm.D.

Justin May, Pharm.D.

Utilizing Program Results to Increase Pharmacist Reimbursement

Pharmacists at Red Cross Pharmacy’s 15 locations regularly check DCPro for any pending MTM and cognitive therapy claims, said Justin May, Pharm.D., director of pharmacy with the chain, based in Marshall, MO.

“Ideally, we use the system as part of our adherence program,” he explained. “A pharmacist takes a look at a patient’s medications five to seven days before the prescriptions are filled and identifies patients who require cognitive services. Then, they set up intervention times. When patients come in to pick up their prescriptions, we sit down with them to conduct the interventions for whatever health issues are indicated.”

Chuck Termini, B.S. Pharm., RPh, a hospital staff pharmacist and independent clinical pharmacist in Kansas City, MO, connects with many of his MO HealthNet patients through referrals from nursing homes and community pharmacies, who contract with him to provide cognitive services. But he also mines the database for additional interventions.

“I almost always find patients who need help,” Termini said, estimating that he interacts with about 60 MO HealthNet patients each month.

Although pharmacist enrollment in the system has been slow to catch on, Dr. Bollinger is optimistic that the numbers will grow as pharmacists learn of these new opportunities for patient intervention and care.

“My goal is to get every pharmacist in the state enrolled,” she said, adding that growing enrollment will help her make a case to state legislators to increase reimbursement rates. “It may take a little time, but I’m confident they will increase eventually.”

Dr. Bollinger also said that MO HealthNet has been able to demonstrate cost savings resulting from decreased emergency room visits and hospitalizations among patients who participated in the program.

“This is a huge opportunity for health-system pharmacists who can get past the idea that the business comes to them, because it doesn’t,” said Termini. “You have to be proactive in assisting patients.”

–By Steve Frandzel


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