Chronic Care Management: A Partnership Between a Primary Provider and Community Pharmacist

The Challenge

• People with chronic conditions often require care and support between physician visits. Gaps in care may occur when that support is lacking due to factors such as a person’s high-risk situation (i.e., uncontrolled blood glucose levels), follow-up challenges, or even lack of services. That gap places people at risk for complications, worsening symptoms and hospital visits.

• Primary care practices are moving from a fee-for-service payment structure to a new, quality payment structure for Medicare patients. Clinicians will be accountable for their patients’ chronic disease outcomes and clinical improvements.

The Idea

Chronic Care Management (CCM) supports patients with chronic conditions by providing them with monthly contact from a local pharmacist or clinician who is collaborating with other community providers. A clinician-created care plan guides the monthly appointments and the patient’s progress. The benefits include:

• Improvement in the effectiveness of medication therapy and adherence to a medication schedule. • More consistent guidance and support for patients. • Better patient preparation for provider appointments • Fewer emergency department visits • Improved, sustainable practice outcomes

Contents The CCM Implementation Guide features all the resources you need to get started. Each link features resources to help you implement this program in your community. Click on the “Step by Step Process” for detailed directions on how to get started. “Tips for Success” and the “Additional Resources” will support your efforts.

1. Step-by-Step Process 2. Tips for Success 3. Additional Resources 4. Data Collection Tools 5. Videos:

a. Part 1 – Ideas that Work: A Partnership in Chronic Care Management

b. Part 2 – Ideas that Work: A Partnership in Chronic Care Management

c. Part 3 – Ideas that Work: A Partnership in Chronic Care Management

Put New Ideas to Work in Your Community: “Chronic Care Management: A Partnership Between a Primary Provider and Community Pharmacist” is just one of several care transitions interventions highlighted in HQI’s Ideas That Work series. To explore other strategies for strengthening care coordination activities in your community, check out our YouTube Playlist.

Share your successes as you implement this Idea that Works! Contact HQI to ask your questions, share how your adapting CCM for your community and feedback on what we can do to improve this implementation guide: [email protected] Acknowledgements: American Pharmacists Association (APhA), A & B Pharmacy, Delmarva, Emporia Primary Care Practice, Portsmouth FQHC and People’s Pharmacy & Diabetic Clinic (for their support and initial CCM trials), the Virginia Department of Health (VDH) and the Community Pharmacy Enhanced Services Network (CPESN)

This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network-Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI|11SOW|20171214-164829