On Friday afternoon at one of Naval Hospital Pensacola’s Medical Home Ports, a physician stepped into the hallway to flag down the pharmacist. The physician thought the patient’s symptoms—diarrhea, headache, irregular heartbeat, and dizziness—might be drug-related. Upon hearing the patient’s symptoms and reviewing her medications, Lisa Fournier, PharmD, knew the problem was associated with her daily Reglan dose. The patient couldn’t remember why she was taking the Reglan, only that she had started a couple of years ago when she was seen in the emergency department (ED). Fournier recommended stopping the medication and four other medications she was taking to treat the symptoms.
“The doctor had no problem bringing a pharmacist into the appointment to help him work through this. I believe the providers truly love having that go-to person that they can say, ‘I need you to see this patient with me,’” said Fournier, who is the Clinical Pharmacy Manager of Naval Hospital Pensacola’s Medical Home Port Program.
Fournier was the first pharmacist embedded in one of the U.S. Navy’s first patient-centered medical homes (PCMH) in 2009, but collaborations like this one between a pharmacist and a physician still inspire her.
“This is everything we’ve fought for over the last 25 years. We are credentialed providers. And we are part of the team,” she said.
As part of a PCMH, Fournier is a member of a multidisciplinary health care team; as a pharmacist for the Navy, she is a level 2 provider (pharmacists, physician assistants, and nurse practitioners). Fournier sees patients and oversees pharmacists in the Naval Hospital Pensacola’s Medical Home Port Program—the Navy’s first network of patient-centered medical homes. Pensacola now has 10 naval PCMHs that provide all the primary care for the city’s naval health care system.
Above: Lisa Fournier, PharmD, Clinical Pharmacy Manager of Naval Hospital Pensacola’s Medical Home Port Program, shares her time between the pharmacy and helping patients in the Medical Home Port teams.
Above: Fournier fills a prescription for a patient.
What is a patient-centered medical home?
A patient-centered medical home is an innovative model of primary care delivery that employs a physician-led team of nonphysician health care providers who coordinate care in order to improve outcomes, improve access, and lower costs. Staff varies from one PCMH to the next, but a team may include nurse practitioners, physician assistants, social workers, dietitians, pharmacists, and behavioral health specialists.
The multidisciplinary team shares the patient panel to free up physicians to handle the more acute and complex complaints, which increases access to care for all. Referring patients to specialists onsite, such as behavioral health or a dietitian, during a primary care visit helps improve adherence.
Recently Fournier saw a patient for anticoagulation monitoring whose INRs (international normalized ratios) had suddenly become unstable. Discovering that the patient had recently lost his wife, become depressed, and quit eating right, Fournier referred the patient directly to the behavioral health specialist, who was able to see him that day.
“In the civilian world, trying to get in touch with a doctor, get a behavioral health referral, get the patient to see that behavioral health specialist, and then see him again in the Coumadin clinic could take months,” Fournier said. “Within 2 or 3 weeks we were back on track with that patient.”
When the PCMH model was designed in 2007, it wasn’t taken for granted that pharmacists would be a part of it. Even in 2010, after dozens of demonstration projects showing the value of the team-based PCMH had been executed, “Pharmacists [were] seldom mentioned in medical home discussions,” said an article in Health Affairs that year.
This was true of discussions of the new PCMH at Naval Hospital Pensacola as well.
“In 2009, when the implementation of the medical home port began, meetings were going on every week and pharmacy wasn’t included,” said Fournier, who was a clinical pharmacist in the Naval Hospital at the time.
The authors of the Health Affairs article stressed, however, “Pharmacists can play important roles in optimizing therapeutic outcomes and promoting safe, cost-effective medication use for patients in medical homes.” They called for pharmacists to “play key roles as team members in medical homes” and for “their potential to serve effectively in this role [to] be evaluated as part of […] demonstration projects.”
Fournier believed pharmacists had a role to play in the PCMH, too, and she took advantage of a chance meeting in an elevator to say so. Running into the hospital’s then–Executive Officer, now the Commanding Officer, CAPT Maureen O’Hara Padden, MD, USN, Fournier asked her what exactly a medical home was and whether pharmacy could be a part of it.
“It was like a lightbulb went off. Her eyes got really big, and she said, ‘Can you come to my office?’” Fournier recalled.
In their discussion, Fournier and Padden agreed, “All the goals of the medical home—to get patients who didn’t need to be in appointments with physicians out of those appointments, to improve access, to help improve the health and quality of life of patients suffering from chronic disease—were all goals pharmacists could help achieve,” Fournier said.
“And at a speed that you will never see the military move, within 3 months we had a pharmacist embedded in the medical home.”
While Fournier’s goals in the Navy’s new medical home port were clear, the plan of attack was less clear. With coworkers who didn’t know why she was working in the family medicine clinic, Fournier spent a great deal of those first days on the job explaining what she wasn’t there to do. “I had nurses, MAs [medical assistants], and corpsmen who thought that people got their prescriptions from me rather than from the outpatient pharmacy. When people said, ‘What do you do?’ I didn’t have an answer for them. So they didn’t know how to refer patients because they didn’t know what we could do,” she recalled.
Fournier took the challenge one patient at a time. When patients called to renew their prescriptions, Fournier called them back and performed a comprehensive medication review. From there, she identified the types of medication issues the patient population had and started making appointments with them.
Today the workflow is clear. Pharmacists manage most chronic diseases and see patients for minor conditions, such as allergy flare-ups, as well. They order labs, adjust medications, and exercise full prescribing authority. Pharmacists at the medical home see patients by appointment but also keep blocks of time open during the day so that other providers can pull them into a patient consultation as needed.
Above: Fournier assists a corpsman in the Internal Medicine Clinic, part of the hospital’s medical home program—the Navy’s version of patient-centered medical homes. Below: Fournier checks a patient’s international normalized ratio during an appointment. Fournier routinely interacts with patients.
Proof in the numbers
Using that first PCMH that opened in 2009 as a test model, the Navy now has 45 medical homes, including the 10 in Pensacola, though not all medical homes have a pharmacist. If Pensacola’s medical home outcomes are any indication, this model is here to stay.
From 2011 to 2013, the proportion of diabetic patients in the medical home port with an A1C (glycosylated hemoglobin) less than 9 rose from 75% to 85%. During that same time, diabetic patients with an LDL less than 100 rose from 47% to 63%. PCMH patients are more likely to be adherent to their treatment and within the goals for management of their particular condition than patients who receive care outside the PCMH. Medical home patients under a pharmacist’s care improve most.
In an informal experiment, health care teams in the medical home port measured 238 diabetic patients’ LDL improvement over the course of a year. At baseline, about 40% of patients on all teams had an LDL less than 100. A year later, the teams that did not include a pharmacist had 48% to 52% of patients at goal. The team that included a pharmacist, who spent the year seeing patients and adjusting their medications, now had 84% of patients at goal.
“Many MTFs [military treatment facilities] actually use that data from our very unscientific study to justify putting pharmacists in their medical homes,” Fournier said.
Naval Hospital Pensacola Medical Home Port is also keeping patients out of the ED. Before the model was launched in 2009, about 72% of patients went to the ED that year. In 2013, only 33% of patients went to the ED.
The program has achieved this by seeing most patients the same day they call and without adding physicians. The variety of providers, however, doesn’t mean that patients get bumped around. Before the medical home, patients saw the same provider about 40% of the time. Now it’s about 70% to 93% of the time. Perhaps patients themselves are happiest about this. Patient satisfaction in the PCMH is more than 90%.
While clinical pharmacists in the civilian world may struggle to get physicians to let them take care of patients, Fournier has faced the challenge that waits on the other side of that barrier.
“Clinical pharmacists once begged and pleaded with doctors. ‘Let us have a broom closet and we’ll take care of our patients, and we’ll only do what you tell us to do,’” she said. “And now when the doctors come out and say, ‘Okay. You can help us. Come on,’ now like any other provider, you never know what’s coming in the door next. It’s more than scary at first.”
After almost 5 years in this model, now Fournier expects to see a patient every day whose complaints will fall outside her area of expertise. The key, she says, is to know where her expertise ends and where her teammates’ begins.
“Sometimes we’re just an avenue to get them to the right person,” she said. “But it’s kind of nice too when somebody comes in for their Coumadin management, and we end up treating a rash or giving them some cold medicine so they don’t have to come back three times.”
Get in touch with Lisa Fournier at firstname.lastname@example.org.