INTEGRATING PHARMACISTS INTO THE PATIENT CENTERED MEDICAL HOME
Recently Intermountain Healthcare (IH) reported on effort to integrate pharmacists in their patient centered medical home (PCMH). IH is an integrated delivery system of 22 hospitals, a medical group with more than 185 ambulatory physician clinics and approximately 1100 primary and secondary care physicians and an affiliated health plan.
Under the auspices of the Collaborative Pharmacist Support Services (CPSS) program, IH embedded clinical pharmacists in primary care medical home practices. These pharmacists were tasked with multiple patient care responsibilities including the co-management of diabetes (DM) and hypertension (HBP). These two responsibilities consumed an estimated 50% of the pharmacists’ time. Patients with DM and/or HBP were identified for referral to the clinical pharmacist. Pharmacist provided disease management services either face-to-face, telephonic or through secured messaging. Services were provided in accordance with a collaborative therapy management protocol.
A retrospective, observational evaluation (click here for full text) was conducted to determine the impact of the CPSS program. Impact was evaluated for pharmacist activity among adults with DM and/or HBP from 2012–2015. Patients who engaged with the CPSS program were considered the intervention cohort. The intervention cohort was matched with a control group of patients who did not engage with the CPSS. The evaluation identified 17,684 DM and/or HBP patients. Of these 359 engaged with the CPSS program. The control group consisted of 999 matched patients.
CPSS patients were 93% more likely to achieve the blood pressure goal (less than 140/90 mmHg), 57% more likely to achieve HbA1c values (less than 8%), and 87% more likely to achieve both disease management goals compared with the control group.
From a clinical perspective it would appear that embedded pharmacists are capable of impacting relevant care quality metrics.
The authors note, as pharmacists are not considered providers, they were not able to bill for their service. Consequently, from a fee-for-service perspective (and apart from clinical impact) it was difficult to assess the return on investment from embedded pharmacists. They also note that, as provider reimbursement is becoming more and more value based (dependent on quality metrics) this type of service would be effective in enhancing value based reimbursement.
It was interesting to note that of the 17,684 eligible DM/HBP patients only 359 (~2%) were engaged in the CPSS program. The authors noted operational and patient engagement issues.
The design of cost-effective pharmacist based programs must extend beyond clinical impact to consider clinician productivity, scalability and engagement strategies. For example, how could the 17,684 eligible patients be stratified such that engaging them first would provide the most significant clinical (and in turn cost impact). While the article did not speak specifically to the use of face-to-face versus telephonic intervention, stratification might provided some insight as to patients who might require a more labor intensive and difficult to coordinate face-to-face approach and those who could be effectively serviced by a centralized pharmacist call center. Moreover, stratification might inform a conversation regarding pharmacist case load and daily productivity requirements.
As always I am happy to discuss your medication therapy management program. CSS supports health plans, ACOs, integrated care delivery systems, pharmacists and physician groups in the design, implementation and management of medication management programs. Feel free to reach out by phone or e-mail.