A tale of two health systems: New care models showcase pharmacists’ skills across the continuum of care


Virginia’s Carilion Clinic and Florida’s Martin Health System

The hospital pharmacist’s role in transitions of care is one of the hottest topics in health-system pharmacy. It is an area in which clinical pharmacists are uniquely qualified to help patients at every point along the health care continuum, from hospital admission to discharge to follow-up care in the community or home setting. Two health systems on the east coast have developed innovative transitions of care programs that include hospital pharmacists, community pharmacists, and clinical pharmacists as part of the primary care health team. These models of coordinated acute and chronic community health care delivery models were highlighted during a session at the 2014 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting.


Acute care model


The Carilion Clinic is a seven-hospital health system located in southwest Virginia covering a population of 1.2 million lives in more than 28 counties. The health system includes more than 90 primary care practices and several specialty practices. In 2012, Carilion applied for and was awarded a CMS Center for Medicare & Medicaid Innovation grant to develop a mechanism for continual and coordinated care across the health care system, Gary R. Matzke, PharmD, BSPharm, FCP, FCCP, Professor and Director of Pharmacy Practice Transformation Initiatives at the Virginia Commonwealth University School of Pharmacy, explained to ASHP meeting attendees. 


The project, Improving Health of At-Risk Rural Patients (IHARP), brings together hospital pharmacists, community pharmacists, and primary care clinical pharmacists and physicians to improve medication therapy and chronic disease state management for at-risk patients who receive care within the Carilion Clinic health system during and after their hospital stay. (For more information, see page 48 of December’s Pharmacy Today.)


“A patient enters into the care process upon referral from a physician in one of the participating primary care practices or at time of hospitalization. When they are getting ready to be discharged, the hospital clinical pharmacist communicates directly to partner entities in the community to provide care proactively,” said Matzke in an interview with Today. 


Hospital pharmacists on the front line identify patients who meet the criteria for high-risk individuals, which includes those patients with multiple chronic disease states who are on multiple medications. “The hospital pharmacist then notifies the patient’s primary care clinical pharmacist that the patient is being discharged,” Matzke explained. 


Intervention touch points


Hospital pharmacists also contact the community pharmacy that the patient has identified as being his or her “home” pharmacy via fax and an electronic message that gives them access to the patient’s Carilion Clinic electronic health record, Matzke noted. “When the patient is discharged, it gives the community pharmacist an alert and provides a discharge note from the hospital physician and the hospital pharmacist so the community pharmacist knows what’s happened during the admission,” said Matzke.


A primary care clinical pharmacist follows up with the patient by phone 72 hours after discharge and assesses how he or she is transitioning back to the home setting. At that time, the pharmacist sets up a face-to-face appointment with the patient at the primary care practice in which the patient was seen prior to hospitalization. Through a collaborative effort, this model of care allows pharmacists to touch patients at each of the intervention points (hospital, physician offices, and community setting) to provide continuity of care.


Better care and outcomes


The program was initially rolled out using two pharmacists in eight clinics. “We now have seven pharmacists supported by the grant in 22 different clinics of the health system,” said Matzke. 


Currently, 2,606 patients are enrolled in the IHARP project. William Lee, DPh, MPA, FASCP, Pharmacy System Director at Carilion Medical Center and principal investigator on the grant project, along with Michael Czar, BSPharm, PhD, Pharmacy Director and Program Manager, and the IHARP team are beginning to see some dramatic improvements in clinical outcomes, quality measures, and economic factors related to reducing the utilization of health care services. 


Results have shown that in 1 year alone, the pharmacists were responsible for preventing nearly 250 admissions or readmissions and saving the system millions of dollars. “We’re getting strong feedback that the health system sees the value of pharmacist integration, and physicians are voicing their support of the value of pharmacists’ interactions with patients in the clinic,” Matzke said.


Martin Health System


Martin Health System, located in Stuart, FL, is focused on community health and engagement of patients in the self-management of their chronic conditions. L. David Harlow III, PharmD, is the Chief Pharmacy Officer at Martin Health System. He worked for several years at Carilion Clinic before his current position at Martin Health. Harlow also addressed ASHP attendees during the session.


“South Florida is retirement mecca, and by extension, it is also a chronic illness haven, so given all of the dynamics going on in the health care marketplace with changes in terms of value-based purchasing and Medicare’s movement away from fee-for-service, we wanted to create a health care model here at Martin that was effective,” said Harlow. “If we could pull off a health care model in such a high Medicare market like southern Florida, then we could pull it off anywhere in the country.”


There are three hospitals in the Martin Health System, along with eight physician-owned practices and other physician practices in the community. “Martin Health has been very active in carrying out community health needs assessments,” said Matzke. “They are building a broad array of community health partners to support coordination of programs to meet the community health needs.”


According to Matzke, Martin Health developed a partnership plan in which the health system works with local community partners such as the county health department, referral services for senior patients, home health agencies, and the Florida Department of Health to engage at a preventive health care level with individuals.


Team-based care


Harlow sees chronic disease management and the maintenance of complex chronic disease medications as something pharmacists can address systematically. “This is what we’re painting the picture of,” he said. “Our new model of care is very team-based on both the acute care side and the ambulatory care side.”


In traditional care models, physicians have “captained” the ship, but we now need to use different resources, such as pharmacists, to provide patients with the best care, noted Harlow. “It comes down to whether you have a good health care model in which pharmacists are partnering with the rest of the health care team in a meaningful way across the continuum of care in an integrated system,” said Harlow.


He also pointed out that it is critical to have involvement and support of the senior administration, CEO, Chief Financial Officer, and Chief Medical Officer in the C-suite. “You need to engage physicians who are willing to champion team-based causes,” said Harlow. “You need those physicians to realize how pharmacists can be a benefit to their practices and to their patients. Further, pharmacy leadership has to be willing and able to communicate this vision to their organization such that it makes clinical and financial sense.”


Protocol development


An important first step is to partner with physician champions to develop collaborative practice agreements and structured protocols for pharmacists to engage in the care of patients with diabetes, chronic heart failure, chronic obstructive pulmonary disease, and hypertension. “Once you have protocols and best practices created and vetted by physician champions, it allows pharmacists to do their part, and it becomes the corporate standard of care,” said Harlow.


“Once the physician gets comfortable with the level of care a pharmacist is providing as part of the team to their patients, it increases collaboration and teamwork,” said Harlow.


At Carilion Clinic, the primary care clinical pharmacists spend 1 to 2 days per week in each of their three to four primary care practices. “In the Martin Health model, the primary care clinical pharmacists have taken the lead, and they established new collaborative clinics with their physician colleagues focused on the management of chronic disease states,” Matzke explained. 


“As physicians get more comfortable with the pharmacists caring for patients under the institutional approved protocols, then they share more of the workload with pharmacists,” said Harlow.


Care commonalities


Although Carilion Clinic and Martin Health care delivery models are different, both health system models have actively engaged clinical pharmacists as the lead change agents to improve patient outcomes associated with transitions of care.


According to Matzke, the models are successful because senior leadership had the vision to embrace change and move institution-based pharmacists into community-based primary care practices. 


Another reason these health systems have been successful in developing new models of care is because both “embraced rigorous electronic health records systems,” said Matzke. “The electronic records systems have greatly enhanced communication and improved care coordination.”


A third contributor to success was the development of novel training programs to prepare pharmacists to practice in their new roles. “Pharmacists were specifically prepared to work in the primary care and emerging new community-based practice environments to help patients with chronic diseases,” Matzke added. 


“It’s becoming clearer that pharmacists can have a great impact on the 5% of the population that spends 50% of the health care dollars,” said Harlow. “Pharmacists have the opportunity to engage patients in comprehensive health management across the health care continuum, and I believe these types of health care models resonate well with patients, physicians, and pharmacists.” 


Harlow added that the challenge now is how to orient and train our pharmacists to meet the expanded direct patient care responsibilities, especially in light of the evolving reimbursement environment when pharmacists will be officially recognized as providers by Medicare.