Pharmacist services in ACOs improve outcomes that matter
Advocate Medical Group in Chicago; Coastal Medical ACO in Rhode Island
Health care is often focused on outcomes—reductions in readmissions, reductions in cost, increases in care quality, or improved medication adherence. Every health system’s journey toward better outcomes starts with a first step, many times with pharmacists leading the way.
Largest ACO in the country
Pharmacists from two health systems talked about their efforts to improve outcomes during a session at the 2015 American Society of Health-System Pharmacists Summer Meetings.
“I was charged with setting up pharmacist services in a patient-centered medical home,” said presenter Christie Schumacher, PharmD, BCPS, BC‐ADM, CDE, a clinical pharmacist at Advocate Medical Group, the largest accountable care organization (ACO) in the country. The ACO has more than 250 clinical locations in the Chicago area.
“[The clinic where I work] is on the southeast side [of Chicago], and we have a low-income African American population,” she added. The service was implemented because the clinic had the worst outcomes for heart failure, diabetes, and stroke in all of the Chicago area, she noted.
In addition to Schumacher, the staff at Advocate’s southeast clinic includes six primary care physicians, one cardiologist who floats between six different sites, a nurse, a physician assistant, a dietitian, an advanced practice nurse, and three care managers.
Schumacher initially created pharmacist services for the clinic’s heart failure patients. “Our goal was to decrease hospitalizations and improve medication adherence for our patients,” she said.
Once Schumacher started managing heart failure patients, she began to notice that patients needed pharmacy services in other disease areas. “Chronic disease management in general was a huge problem,” she said. “I started making recommendations to the physicians about diabetes care, hypertension, cholesterol management, asthma, and chronic obstructive pulmonary disorder (COPD).”
The physicians noticed the improvement in patients’ health and asked if they could start referring patients with those diseases to Schumacher directly. “Now our clinic has expanded to cover a wide variety of disease state management in addition to doing medication reconciliation and posthospital [discharge] follow-up,” she said.
Schumacher sees about 8 to 14 patients a day. The initial patient visit lasts about 60 minutes, and follow-up visits are usually 30 minutes in length. “Because we have a high demand and see a lot of patients, I use students and residents to help me,” said Schumacher. Often the students will start the visit and assess adherence. “I rotate back and forth between rooms so I see multiple patients at the same time,” she added.
Schumacher communicates with the medical team through an electronic medical record (EMR) system. “We have a task system where we can write messages back and forth about the patient and ask questions,” she said. Right now, because of high demand (about 5 to 15 new patient referrals every week), the waiting list to receive pharmacist services is about 6 weeks, Schumacher noted.
Patients enter into Schumacher’s service in three ways. “The physician calls me on my cell phone [or I] get a text that says come to [the exam] room,” Schumacher explained. She then goes to the physician’s room, meets the patient, establishes contact, and makes a follow-up appointment with the patient. “I have found that is the best way—to meet the patient during the physician visit,” said Schumacher.
Another way Schumacher receives patients is through the hospital discharge process. Every patient with heart failure or diabetes who is discharged from collaborating hospitals receives a call from a pharmacist within 7 days of discharge.
The third way patients connect with Schumacher is through the EMR. “A physician can send me a text letting me know information about the patient and what they need,” said Schumacher. “A pharmacist calls the patient and schedules a one‐on‐one appointment or makes an appoint with the patient on the same day as their next primary care physician visit.”
Improving patient care
Under Schumacher’s leadership, pharmacy services are designed to solve problems and improve patient care. The team accomplished this by developing and implementing an individualized patient care plan; titrating medications; providing medication reconciliation and education to improve adherence; and ordering and interpreting laboratory values.
The pharmacy team also arranges appropriate medical referrals; monitors safety and efficacy of medications; identifies barriers to adherence; and educates patients, medical staff, students, and residents.
In 2008, 313 patients were readmitted within 30 days for heart failure exacerbation, which Advocate estimated is a $2.4 million risk cost, noted Schumacher. Thirty percent of these patients then were readmitted within 1 year for heart failure, she added.
When Schumacher started working at Advocate in 2009, she identified high-risk heart failure patients. “I reached out to 150 of them,” she said. Between May 2010 and November 2011, only three of those patients were hospitalized within 30 days of discharge.
“We had a significant decrease in hospital readmissions just by adding ACE inhibitors, beta-blockers, and titrating the target doses,” said Schumacher. “The readmission rate for Advocate Medical Group went down to 8% in 2013, and the national average was 18% to 25%.”
According to Schumacher, “we went from being the worst clinic in the Chicagoland area to one of the best clinics now at Advocate Medical Group.” The clinic in southeast Chicago was named one of the top Advocate sites for diabetes management in 2012.
Coastal Medical ACO
Sarah Thompson, PharmD, CDOE, Director of Clinical Pharmacy Services at Coastal Medical, located in Providence, RI, shared her successful journey toward improved patient outcomes.
Coastal Medical was founded 20 years ago by a small group of physicians. It has grown into an organization that provides cutting-edge clinical services to around 120,000 patients (about 10% of Rhode Island’s population) at 20 sites across the state. Coastal Medical is a primary care–driven ACO with 84 physicians, 27 advanced practitioners, 21 nurse case managers, 10 pharmacists, and five pharmacy technicians.
According to Thompson, the medical team focuses on the triple aims of health care as part of its strategic vision: improve the patient’s experience of care, improve the health of a population, and reduce the per capita cost of health care. “We think really hard about how we brand ourselves as a team, as a service—not only to our patients, but to our providers,” said Thompson.
Thompson was hired by Coastal Medical in 2009 to provide clinical services in as many offices as she could visit. “Clearly I couldn’t get to 20 offices, so I started with 3,” said Thompson. “I started a virtual anticoagulation clinical for one practice. I managed 130 Coumadin patients and took care of everything, [including] calling the patient, tracking down labs, setting up the next order, and ordering any new medications that they needed. That kept me pretty busy for a couple of years.”
After that, the group’s leadership changed and there was a shift in what pharmacy services looked like. Today, we have pharmacists in three kinds of roles in the organization, noted Thompson.
Population health pharmacists run many of the central clinical initiatives. Within population health, “we have a diabetes management program, [consisting of] an interdisciplinary team of two pharmacists, a nurse, and a medical assistant who segment the population into high, rising, and low risk,” said Thompson. “Our pharmacists take care of the high-risk patients and are responsible for all the insulin initiation and titration.”
The pain management service is also under population health. “Rhode Island has one of the [highest] overdose death [rates] in the country, so we started to look at narcotic prescribing in our system,” explained Thompson. The pharmacy team worked with the physicians to put all of Coastal Medical’s patients on controlled substance agreements, she noted. “We monitor our patients and help our physicians through the complex medication regimens,” said Thompson.
Centralized role and office-based services
Pharmacists at Coastal Medical also have a centralized role. Pharmacists in this area work on refills and prior authorizations. “We developed a medication reconciliation program for our medical assistants, [which] enables physicians to know that when they walk into [a patient’s] room, the medication list is correct,” said Thompson.
The third category of pharmacy roles is office-based services. This includes medication therapy management consults, collaborative disease state management, cardiac risk reduction, and medication conversion.
Elements for success
Both Schumacher and Thompson improved patient outcomes by implementing pharmacist services. Schumacher told meeting attendees that it is important to have a good working relationship with your physicians and nurse practitioners.
Strong communication skills are needed to work with difficult populations, according to Schumacher. “We don’t work with the most compliant people, so motivating people to want to take care of themselves is really important” as is choosing the right person for the correct setting, she added.