American Pharmacists Association

Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

2020 Editor: Sara Wettergreen, PharmD, BCACP University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences

Medical Home-ACO SIG Case Selection Committee: Sara Wettergreen, PharmD, BCACP, Chair Cara Acklin, PharmD, BCACP John Boyle, RPh Courtney Doyle-Campbell, PharmD, BCACP, AHSCP-CHC Hannah Fudin, PharmD, BCACP Chidiya Ohiagu, PharmD, BCPS Natasha Petry, PharmD, BCACP

Medical Home-ACO SIG Case Review Committee: Sara Wettergreen, PharmD, BCACP, Chair Cara Acklin, PharmD, BCACP Courtney Doyle-Campbell, PharmD, BCACP, AHSCP-CHC

Acknowledgement: APhA staff members Anne Burns, RPh, and Isha John, PharmD, MBA, for their contributions.

Suggested citation: American Pharmacists Association. Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies. March 2020.

Disclaimer: The information in this document is provided for general informational purposes and does not constitute business, clinical, or legal advice. The American Pharmacists Association and document contributors assume no responsibility for the accuracy or timeliness of any information provided herein. The reader should not under any circumstances solely rely on, or act on the basis of, the information in this document. This information is not a substitute for obtaining business or legal advice in the appropriate jurisdiction or state. The document does not represent a standard of care or standard business practices. The information contained in this document may not be appropriate for all pharmacists or pharmacies. Billing practices should follow all state and federal laws and private Copyright © 2020 by policies. Nothing contained in this document shall be construed as an express the American or implicit invitation to engage in any illegal or anticompetitive activity. Nothing Pharmacists Association. contained in this document shall, or should be, construed as an endorsement of All rights reserved. any particular method of treatment, billing, or pharmacy practice in general. Table of Contents

Introduction...... 4

n Advocate Medical Group...... 7 Author: Christie Schumacher, PharmD, BCPS, BCACP, BCCP, BC-ADM, CDCES, FCCP

n Family Health Services of Darke County...... 12 Author: Rachel Barhorst, RPh, PharmD, BCACP

n Geisinger Ambulatory Clinical Pharmacy Program...... 17 Authors: Gerard Greskovic, BSPharm and Sarah Krahe Dombrowski, PharmD, BCACP

n Jefferson Health Population Health Pharmacy Team...... 24 Author: Darren Mensch, PharmD, BCPS, BCACP

n Michigan Medicine...... 28 Authors: Amy N. Thompson, PharmD, BCACP; Carol Becker, MHSA; and Hae Mi Choe, PharmD

n The Ohio State University General Internal Medicine Clinics...... 32 Authors: Kelli Barnes, PharmD, BCACP and Stuart Beatty, PharmD, BCACP, FAPhA

n Park Nicollet Health Services...... 37 Author: Molly Ekstrand, BPharm, BCACP, AE-C

n Providence St. Joseph Heritage Healthcare...... 42 Author: Jelena Lewis, PharmD, BCACP

n Think Whole Person Healthcare...... 47 Authors: Sara Woods, PharmD, BCACP; Shannon Peter, PharmD; and Nabil Laham, PharmD

n University of Washington Medicine...... 51 Author: Rena Gosser, PharmD, BCPS

Glossary...... 56

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 3 Introduction

Emerging value-based payment (VBP) increases each year.2 New models of care and models are changing the way healthcare is payment that reward providers based on the delivered and paid for in the United States value of services—both quality of care and (U.S.). Increasingly, healthcare providers are management of costs—are needed to ensure compensated for interventions that optimize wise use of healthcare dollars. clinical outcomes. As a result, opportunities Currently, our healthcare system is transitioning for pharmacists to practice at the top of their from the FFS model to VBP models. In VBP, license and training by delivering patient care providers receive financial incentives to services are emerging and expanding. consider both the healthcare needs of an This resource highlights case examples of individual patient and the importance of that pharmacists who are successfully providing care at a population level through a holistic services through VBP models in various practice approach that focuses on quality and cost. settings, both well-established and newly Many experts think that evolving VBP models developing. Detailed information is provided will improve care and decrease cost in the U.S. from 10 case examples to inform pharmacists, healthcare system. student pharmacists, and other stakeholders VBP is expected to be the future of U.S. about strategies that have proven to be healthcare payment, and pharmacists should successful for pharmacist integration in VBP engage in VBP models and invest in changing models with the goal of supporting expansion of their practices to optimize their participation. pharmacist inclusion in these models. These models use population health management to identify high-risk patients Value-Based Payment Model Overview who may need more intensive coordinated Payment for healthcare in the U.S. has care, promote evidence-based guidelines, and historically been based on the fee-for- monitor and track quality and cost metrics. The service (FFS) model, in which providers are capability to conduct data analytics is a key compensated based on the delivery of services feature, regardless of the type of model. (i.e., the volume of services). The U.S. spends more on healthcare per capita than many Examples of Value-Based Models: other industrialized countries yet ranks last in Patient-Centered Medical Homes and the overall quality of care.1 Furthermore, the Accountable Care Organizations percentage of the nation’s gross domestic Two common value-based models are product that is spent on healthcare in the U.S. patient-centered medical homes (PCMH)

______

1. Tikkanen R, Abrams MK. U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? The Commonwealth Fund, Jan. 30, 2020. Available at: https://www. commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global- perspective-2019. Accessed February 18, 2020. 2. National Center for Health Statistics. Health, United States, 2018. Hyattsville, MD. 2019.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 4 and accountable care organizations (ACO). and providing medication management and/ The PCMH is a care delivery model in which or chronic disease management services and patients’ primary care physicians coordinate prevention/wellness activities in collaboration their necessary care when and where they with the patient’s healthcare team. Pharmacists need it and in a manner they can understand. engaged in VBP models can be salaried Provider practices with PCMH status granted employees or contracted staff.3 by an accreditation organization may receive additional reimbursement from payers using About this Resource various payment models that can include a Developed by the American Pharmacists monthly care coordination payment, FFS, and Association Academy of Pharmacy Practice a quality performance component. and Management (APhA–APPM) Medical The ACO is a VBP model in which a group of Home/ACO Special Interest Group (SIG), physicians, hospitals, and other healthcare this resource highlights 10 examples providers deliver coordinated high-quality care in which pharmacists are successfully to a specified population of patients and is integrated into PCMHs and/or ACOs in accountable for overall care and costs for these various practice settings. patients across all care settings. To support Practices were identified for inclusion in quality care and control costs, ACOs have this resource via a call for submissions that incentives based on a defined set of quality was conducted from November 21, 2018 to measures and sharing savings opportunities January 7, 2019. Applicants completed a with the payer. Providers in ACOs may be survey that collected information about their reimbursed using FFS with incentives, salaried practice sites, roles of pharmacists in the compensation, or contractual arrangements. PCMH or ACO, models for sustainability, and other innovative features. A case selection Pharmacists in VBP Models committee comprised of SIG members PMCH and ACO models offer numerous evaluated the submissions and selected 10 opportunities for pharmacist involvement, programs as successful practices to be profiled and pharmacists across the country have in this resource. Representatives from selected developed unique and innovative practices programs were then asked to submit a 1500- within these settings. Pharmacists often work word description that included details about in population health management, direct the services delivered, sustainability through patient care services, or both. Population direct and indirect return on investment health management pharmacists identify strategies, future plans and innovation, and and address gaps in care, promote evidence- key lessons learned. These descriptions were based prescribing, and help track and meet reviewed by a committee for completeness and quality metrics. Pharmacists in direct patient to identify any additional information needed care roles focus on improving care transitions to enhance the description.

______

3. American Pharmacists Association. ACO Engagement of Pharmacists. 2014. www.pharmacist. com/article/apha-accountable-care-organization-aco-briefs. Accessed February 18, 2020.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 5 The case descriptions in this resource aim to n Funding model for pharmacists provide information useful to pharmacists, n Delivery mode for patient visits student pharmacists, and other stakeholders about how pharmacists are successfully n Average duration of pharmacist visit engaging in value-based models. For each n Use of collaborative practice agreements description, the following information is included, when available or applicable: n Billing codes used for services

n Type of practice site Each case also provides key lessons learned n Type of VBP model from integrating pharmacists into the value-

n Number of pharmacist FTEs (full time based model. The case examples in this equivalents) resource demonstrate that pharmacists are maximizing their roles within PMCHs and ACOs n Number of clinics/patients covered in many settings and contributing to improved by pharmacists access to care and health outcomes for the n Services provided by pharmacists patients they serve.

Detailed information is provided from 10 case examples to inform pharmacists, student pharmacists, and other stakeholders about strategies that have proven to be successful for pharmacist integration in VBP models with the goal of supporting expansion of pharmacist inclusion in these models.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 6 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Advocate Medical Group CHICAGO, IL

Author: Christie Schumacher, PharmD, BCPS, BCACP, BCCP, BC-ADM, CDCES, FCCP Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Health-system

Value-based model type PCMH; ACO

Number of pharmacists Three clinical pharmacists at the Advocate Medical Group Southeast Center (AMG-SE) (2.8 FTE), with a total of 13 clinical pharmacists (11.2 FTE) performing chronic disease management at six different Advocate Medical Group (AMG) sites. Number of clinics/patients At each of the six clinics, each clinical pharmacist covers a panel of covered by pharmacists approximately 200 to 300 unique patients Funding model of Five pharmacists are co-funded by a college of pharmacy and pharmacists AMG (50% each for 80% clinical time) One pharmacist is fully funded by a college of pharmacy (100% funded for 20% clinical time) Seven pharmacists are fully funded by AMG Delivery mode for patient Primarily face-to-face visits Telephonic follow-up as needed Average duration of Initial visits, post-hospital discharge visits, and complex patients: pharmacist visit 60 minutes Established care visits: 30 minutes Collaborative practice Yes—Pharmacists can initiate, discontinue and adjust medications, agreement in place? as well as order laboratory and diagnostic tests Billing codes used 99211: for pharmacist visits 95249, 95250, 95251: for professional and personal-use continuous glucose monitor placement and interpretation

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 7 Advocate Medical Group CHICAGO, IL

Background The Model: How it Works Advocate Healthcare is the largest health- Initially, the pharmacist provided system in Illinois and one of the largest ACOs comprehensive medication management in the country. The Centers for Medicare & (CMM) services that included: Medicaid Services (CMS) recently announced n Initiating and titrating guideline-directed that the savings generated by Advocate medical therapy Healthcare in 2016 ($60.6 million) ranked second out of 432 ACOs participating in the n Assessing patients’ reported symptoms and Medicare Shared Savings Program (MSSP). clinical status During 2016, Advocate provided care to the n Adjusting diuretic therapy largest group of Medicare beneficiaries and was among the highest in quality of the n Identifying and discontinuing medications MSSP ACOs. that exacerbate HF

The Advocate Medical Group Southeast n Ordering and monitoring laboratory values, Center (AMG-SE), part of the medical group echocardiograms, and electrocardiograms subsidiary of the Advocate Health System, n Educating patients on self-management is located in a lower-income neighborhood and monitoring techniques (e.g., daily in Chicago, Illinois. In 2008, a pharmacist weights, sodium and fluid restriction, home was appointed to the clinical operations blood pressure monitoring). and analytics teams of the patient-centered medical home (PCMH) pilot to develop the The pharmacist regularly monitored patients pharmacist’s role within the PCMH at AMG- for adherence barriers, such as cost of care and SE. The pharmacist attended PCMH planning patient understanding of therapy importance. meetings to ensure the team’s understanding All visits were conducted in person, and 60 of an ambulatory care pharmacist’s role and minutes were allocated for initial visits and 30 to facilitate the development of collaborative minutes were allocated for follow-up visits. practice agreements. The initial priority of the pharmacist was to reduce hospitalizations and The pharmacist’s impact on HF patients was 30-day readmission rates for patients with assessed by the rates of HF hospitalizations heart failure (HF). The long-term goal was to and readmissions. Additional goals of the expand the pharmacist’s role to all chronic program were to meet the requirements of disease states managed by internal medicine. federal and commercial VBP contracts— Healthcare Effectiveness Data and Information The AMG-SE PCMH was initially an Set (HEDIS) and CMS Star Measure metrics. interdisciplinary team including six primary care physicians, an advanced practice nurse, During the HF patient visits, the pharmacist the pharmacist, a dietician, a nurse, three identified a need for improvement in the patient care managers and a physician management of comorbid conditions (e.g., assistant responsible for acute care diabetes mellitus, dyslipidemia, hypertension, appointments. In the implementation stages, thyroid disorders, gout, COPD and asthma), the pharmacist worked with the AMG-SE resulting in an opportunity to expand the cardiologist to demonstrate competence and scope of collaborative practice. Due to the high gain the cardiologist’s trust and support for HF prevalence of patients with diabetes at AMG- medication management. SE and the lack of an endocrinologist within the multidisciplinary care team, the pharmacist’s expanded role began with patients with

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 8 Advocate Medical Group CHICAGO, IL

diabetes. Outcomes data in patients with to outcomes. It is also designed to identify diabetes improved following implementation areas of inefficiency to demonstrate need for of diabetes management by the pharmacist. support staff. While the pharmacists do not Because other provider services remaining have designated clinical support staff, such as unchanged, this improvement was deemed medical assistants, they do receive support to be attributable to the pharmacist. The from the clinic operational staff for the check- pharmacist was subsequently charged in/check-out process, scheduling patients, and with further defining and expanding the other administrative responsibilities. Since the role of the pharmacist in the PCMH and the pharmacists have a broad scope of practice, development of resources. This included writing designated clinical support staff may allow and implementing best practice protocol them to increase appointment capacity and guidelines for HF, asthma, COPD, hypertension, patient panel size in order to further improve hyperlipidemia and diabetes. clinical outcomes at the center. Initially, patients were identified for the pharmacist’s interventions based on HF Sustainability and Outcomes diagnosis codes and the daily hospitalization Midwestern University provides 50% of the list; however, once the pharmacist’s role funding for 80% of the original pharmacist’s expanded, new referral processes were created. clinical time. Seventy percent of patients at the The pharmacist receives referrals via four site are under a full-risk global payment model different avenues: 1. the provider can refer a through Medicare Advantage or commercial patient during their visit (curbside consult); payers. The pharmacists’ salary is financially 2. the electronic medical record (EMR) justified through their role in assisting the communication system portal, which enables medical group meet performance measures PCMH team members to send messages and decrease costs as part of the pay-for- regarding patient referrals or patient questions; performance incentives within the capitated 3. referral via phone or fax; 4. a daily list reimbursement model. of AMG-SE patients discharged with a HF In the first 10 months of the PCMH pilot, diagnosis. For referrals based on a hospital the pharmacist conducted disease state discharge, the pharmacist is responsible for management visits for 111 chronic HF patients. contacting the patient within the first 2 days A pre-/post-analysis of the 111 patients in the of discharge to address any initial barriers to 10 months prior to and after the pharmacist adherence or gaps in therapy and to set up an integration, showed a 50% reduction in appointment within 7 days of discharge. hospitalizations, from 63 in the 10 months Currently, the pharmacists do not receive prior to 30 in the 10 months after pharmacist assistance from clinical support staff during integration. This translated into a cost independent pharmacist visits. However, avoidance of $280,000 based on the average student pharmacists and residents are involved HF hospitalization cost at Advocate Trinity in conducting portions of the patient visit Hospital of $8,500. This result was used to to increase the capacity of the pharmacist’s demonstrate the benefit of the pharmacist on patient panel. This layered learning model has the PCMH team. Outcomes improved further promoted the sustainability of the pharmacist’s with greater pharmacist integration and role as the demand for clinical pharmacy rapport with the medical team. In an 18-month services has increased. Research is currently analysis, only three of the 153 HF patients being conducted at the site to evaluate the managed by the pharmacist had a 30-day workload of the pharmacist and how it relates readmission for a HF exacerbation.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 9 Advocate Medical Group CHICAGO, IL

Expansion of the pharmacist’s role to Innovations/Future Plans diabetes resulted in the recognition of AMG- The most innovative and critical aspect of the SE as one of the top five sites for diabetes practice is the broad collaborative practice management in 2012, out of approximately agreement, which allows the pharmacist to 250 Chicago metropolitan area AMG sites. initiate, titrate and discontinue medications This recognition was based on improved for all chronic internal medicine disease AMG diabetes quality metrics, including states, except controlled substances. This the percentage of patients receiving an model facilitates holistic management annual eye exam, annual foot exam, annual of chronic conditions such as HF, where nephropathy screening, and hemoglobin A1C poor management of diabetes, respiratory performed, and the percentage patients with conditions, gout or anemia may precipitate a hemoglobin A1C < 8%, and those reaching an exacerbation. CMM was key to improving guideline recommended blood pressure and outcomes in patients with HF. cholesterol targets. Pharmacists’ discussions with physicians facilitated further improvement In the ACO model, a broad collaborative in disease state management amongst all practice agreement improves population health providers at the center as it subsequently metrics as the pharmacist can make timely improved their knowledge of chronic disease interventions and improved holistic patient management. Additional quality metrics outcomes, compared with similar practices improved after the pharmacist integration, focused only on a specific disease state. including rates of generic medication use, Another key to the program’s success was full number of patients on an angiotensin- access to the EMR. The pharmacist had access converting enzyme inhibitor (ACEI) or to all medications, labs, provider notes, and angiotensin receptor blocker (ARB), and beta- was able to send electronic prescriptions to the blocker for HF management. patient’s pharmacy and place laboratory orders under the provider’s name. Physicians and The results of the PCMH pilot program other team members can place referrals and led to hiring more pharmacists at AMG- send patient messages through the EMR for SE and other AMG ambulatory care sites. more timely communication and follow-up. Two additional clinical pharmacists were hired at AMG-SE based on the increased demand for clinical pharmacist services Key Lessons Learned and are fully funded by AMG. Currently the n Strong leadership and support were key to AMG South Region employs a total of 13 the successful integration of the pharmacist clinical pharmacists at six different AMG on the PCMH team. sites. Seven pharmacists are fully funded n Initially focusing on the management of by AMG, five are co-funded by AMG and one disease state and gathering positive Midwestern University, and one is fully funded outcomes data allowed the pharmacist to by Midwestern University Chicago College build trust with physicians and expand the of Pharmacy. All clinical pharmacists provide service to the management of additional chronic disease management under the same chronic disease states. collaborative practice agreement developed by the original PCMH clinical pharmacist.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 10 Advocate Medical Group CHICAGO, IL

n Clinical outcome improvements, such as n The pharmacist’s strong knowledge base decreased hospitalizations and emergency and ability to support recommendations department visits, in costly disease states with the current primary literature and (e.g., COPD and HF) can demonstrate guidelines was cited by physicians as the the cost-savings value of a pharmacist most important factor when granting and and support expansion of the clinical expanding pharmacist prescribing. pharmacy services to other disease states. n Strategies to identify patients for clinical n Physician trust can be earned through pharmacy services include reviewing both demonstrating improved patient population health and hospitalization reports, outcomes and knowledge of chronic reviewing provider schedules for patients disease management. that could benefit, and asking physicians if they would like assistance with disease state management during patient visits.

The pharmacist regularly monitored patients for adherence barriers, such as cost of care and patient understanding of therapy importance. All visits were conducted in person, and 60 minutes were allocated for initial visits and 30 minutes were allocated for follow-up visits.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 11 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Family Health Services of Darke County GREENVILLE, OH

Author: Rachel Barhorst, RPh, PharmD, BCACP Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Federally Qualified Health Center (FQHC)

Value-based model type PCMH

Number of pharmacists 1.25 clinical pharmacy FTE, 1 pharmacy resident, 3 staffing FTEs

Number of clinics/patients 4 clinics encompassing 26,767 patients covered by pharmacists Funding model of Salaried employees of the FQHC pharmacists (salaried, contracted, leased, other) Delivery mode for patient Face-to-face and telephonic visits Average duration of 30-60 minutes pharmacist visit Collaborative practice Yes—diabetes and smoking cessation currently and expanding; agreement in place pharmacists can initiate, discontinue and adjust medications, as well as order laboratory and diagnostic tests; protocols are used for immunization and naltrexone injectable administration Billing codes used 99211 for medication therapy management in which the provider does not see the patient 99213, 99214 for Shared visit model in which both pharmacist and provider see the patient

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 12 Family Health Services of Darke County GREENVILLE, OH

Background each department in the facility, including a Family Health Services (FHS) of Darke County pharmacist and two patient representatives. is a FQHC located in rural Darke County, The team meets monthly to discuss ways Ohio. FHS builds healthy lives through the to enhance communication, patient care, provision of quality, comprehensive services. population health, and measure performance Seamlessly integrated with the community, in terms of quality markers and services FHS is recognized for win-win-win (patient- offered from both an employee and patient employer-provider) relationships that reach perspective. The fundamental purpose more people and provide better care at lower remains the same: to work together to cost. FHS practices motivate patients to seek provide comprehensive care to patients. care and information proactively. Above all, FHS became PCMH-accredited by the FHS supports a culture of nurturing leadership Accreditation Association for Ambulatory that preserves the “family” in Family Health. Healthcare (AAAHC) in 2013. FHS was founded in 1964 with volunteers providing seasonal sanitation and primary The Model: How it Works care services to local migrant workers and At FHS, pharmacists are present within the has grown to serve 26,616 patients. FHS has 340b dispensing pharmacy and integrated one main location with four satellite sites within the clinic. Within the dispensing in rural neighboring communities. Services pharmacy, pharmacists counsel patients offered include family practice, OB/GYN, on all new medications and medication pediatrics, medication-assisted treatment, changes and conduct medication therapy dental, radiology, vision, in-house laboratory, management visits. Within the clinic, behavioral health, medical nutrition counseling, pharmacists operate as drug information and an in-house 340b pharmacy. “I believe that experts for the approximately 40 providers, over the years Family Health has taken many conduct shared visits with the providers steps, to help turn a sick-care system into a for chronic diseases, package medication healthcare system” states Jean Young, the boxes, and facilitate transitions of care Executive Director. for patients post-hospital discharge. Being one of the only primary care providers Pharmacists also administer vaccines to in the county, FHS has a diverse patient patients. The pharmacists play a critical population and currently operates as a role in the medication-assisted treatment Patient Centered Medical Home (PCMH). program and harm reduction efforts by The PCMH was established as an extension providing naloxone nasal spray counseling of FHS’s integrative health model which at the needle exchange program and during originated in the 1990’s. “We had a strong patient appointments, administering Vivitrol belief then and today that if we provide injections as needed, developing a Vivitrol exceptional, comprehensive care and the drug repository program, working with the mechanisms to support our patients in United Way to help pay for medication- achieving good health for themselves and assisted treatment medications, and their families, we are achieving our core creating harm reduction kits to give to high- mission “to build healthy lives together” risk patients. The pharmacists also have said Dr. Laurie White who directs PCMH active roles on the diabetes, hypertension, development. The model was transformed medication-assisted treatment, PCMH, in 2012 when a PCMH core team was quality, care coordination, rapid response created. It is comprised of members from team, and transitions of care committees.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 13 Family Health Services of Darke County GREENVILLE, OH

Family Health Services utilizes a variety of hyperlipidemia, COPD, and smoking cessation. support staff to enhance services offered. Within this agreement, the pharmacist can Two pharmacists share a nurse and rotate start, stop, or modify therapy and can also throughout the 4 clinic sites. The nurse’s order labs. However, CPAs are not currently main roles are to room the patient, prep the used to their full potential because of the patient’s chart prior to the appointment, shared visit practice model. FHS is currently take vitals, ensure the medication list is implementing a pharmacist-driven smoking accurate, update the medical history, and cessation program that will utilize a CPA for complete screenings such as the PHQ2. The smoking cessation medication management. nurse completes any needed testing that Patients are identified for pharmacist can be done in office such as tests for A1C intervention by providers and nurses primarily and albuminuria. The nurse also assists with for medication cost concerns, nonadherence population health data collection, patient with medical treatment and medications, education on glucometers, and scheduling of elevated A1C, and high morphine milligram shared visits. equivalents (MME). When a patient is identified There are also several additional care or referred through the EMR, the patient is coordinators including a Screening Brief scheduled for a shared visit between the Intervention and Referral to Treatment pharmacist and the provider. (SBIRT) coordinator, psychosocial care Population health reports are used to coordinator, dietitian, and chronic care identify gaps in care such as uncontrolled manager. One of the strengths of our PCMH diabetes, defined as an A1C >9%, and initiate model is that all employees throughout the an automatic referral for clinical pharmacy organization from front office to provider are services. Population health is used to identify invested in the program and are therefore a number of other gaps regarding quality key stakeholders. From a patient perspective, measures, including patients who are in need of a variety of needs can be addressed at one Medicare Annual Wellness visits, statin therapy, time. For example, a patient with diabetes evaluation of high-risk medications, and may come in for a diabetic check where it is preventative screenings and immunizations. discovered they are uncontrolled due to food When a patient is identified on a population insecurities. They can then be referred to our health report, the pharmacist performs a chart psychosocial care coordinator for assistance review, seeks out an opportunity for patient and our dietitian for medical nutrition education, and makes recommendations when education. If they are nonadherent to appropriate. Pharmacists use population health medications, they can have their medications reports to assist in impacting high MMEs and packaged and/or delivered, consult with naloxone prescribing, obesity diagnosis and one of our pharmacists, have costs lowered screening for prediabetes, diabetes and annual through patient assistance programs or the eye exams. Pharmacists also identify persons sliding fee discount, and receive one-on-one with diabetes with an A1C >9% and ensure they care from our chronic care manager. If they have pharmacy consults. Discharge summaries have not seen a dentist, a dentist will speak are also sent to pharmacists for care transitions to them about the importance of dental care services by providers in the local hospital and through a warm hand-off. other hospitals, and these patients receive Pharmacists have a collaborative practice a phone call from the pharmacist upon agreement (CPA) for hypertension, diabetes, discharge.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 14 Family Health Services of Darke County GREENVILLE, OH

Key technology used at FHS includes the ACEI/ARB, have had an A1C in the previous 3 electronic medical record (EMR) and pharmacy months, blood pressure in range as defined by software system. One of the most valuable the American College of Cardiology/American assets is that the whole organization uses Heart Association Hypertension Guideline, have the same EMR. This allows for seamless care, been tested for albuminuria, completed a yearly and all visits from vision to dental to clinical foot exam, completed a yearly eye exam, and pharmacy to lab can be viewed in the EMR. have received the appropriate pneumococcal The EMR also allows for telehealth services, pneumonia vaccines.1 We also review A1C kiosks, and a portal where patients can send reductions in patients who have been seen messages. The pharmacy software is utilized to by clinical pharmacy and plot them on a line run reports on patient adherence, proportion graph. Additionally, tertiary markers including of days covered, high risk medications, and improvement in quality markers, decreased ensuring patients are on proper therapy for hospitalizations, and improved patient care and their disease states. Pharmacists also utilize satisfaction are tracked. Interventions tracked CliniSync for patient information from other by the pharmacists justified the creation of an healthcare systems. OutcomesMTM and Mirixa additional position for the next year. are the platforms utilized for medication Another benefit has been that patients therapy management. The organization also frequently request to transfer their uses social media and televisions in the waiting prescriptions to our in-house 340b pharmacy room to provide patient education. because of their trust in the pharmacists. Our prescription volume has increased with the Sustainability and Outcomes increase in pharmacy services. The pharmacists’ positions have been justified using multiple billing opportunities Innovations/Future Plans as well as FHS’s 340b funding. Billing for insurance-triggered medication therapy Future planned endeavors include broadening management takes place. Billing has also the shared visit model to include COPD. The started for pharmacists’ services such as COPD services will include assessing inhaler medication adherence packaging, chronic technique, adherence with medications, pain consults, and medication reviews decreasing hospitalizations for COPD incident-to a provider using Evaluation exacerbations, improving inhaler affordability and Management code 99211. Pharmacists and utilizing the CPA for smoking cessation. embedded in the clinic conduct shared visits In addition, the pharmacist and dietician are with the providers resulting in providers joining forces to begin a diabetes prevention being able to increase their patient volume. class offered one night per week for a year. This class will provide education, support, The majority of our ROI is indirect ROI, which motivational interviewing, and monitoring of can be difficult to track. We receive value- weight loss. based reimbursements through the clinic and the 340b pharmacy. We have created a clinical Through a grant, FHS is going to begin using pharmacy dashboard for diabetes and clinical a platform to identify social determinants pharmacy services. This is presented monthly of health and connect patients with local at our clinic’s quality meeting. Measures include resources such food banks, SBIRT coordinator, percentage of patients being seen by clinical and other community resources. FHS is also in pharmacy with an A1C >9%, and the number the infancy of using the Single Item Literacy of patients who are on a statin, on an Screener for health literacy screening.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 15 Family Health Services of Darke County GREENVILLE, OH

Key Lessons Learned References

n It is vital to have an implementation plan 1. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ for any new service being offered and to ASH/ASPC/NMA/PCNA Guideline for the communicate the plan in a formal manner, Prevention, Detection, Evaluation, and such as through regular meetings with staff Management of High Blood Pressure in and providers. Adults: A Report of the American College of Cardiology/American Heart Association n Perform continuous quality improvement Task Force on Clinical Practice Guidelines. using Plan-Do-Study-Act cycles. J Am Coll Cardiol 2018;71:e127-e248. n Thorough and consistent documentation improves care coordination with other providers.

n Developing trusting, collaborative relationships takes time as other providers learn about the services the pharmacist offers and the value they provide.

Developing trusting, collaborative relationships takes time as other providers learn about the services the pharmacist offers and the value they provide.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 16 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Geisinger Ambulatory Clinical Pharmacy Program DANVILLE, PA

Authors: Gerard Greskovic, BSPharm and Sarah Krahe Dombrowski, PharmD, BCACP Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Various, including FQHC, rural, primary care, specialty care, pharmacy tele-management Value-based model type ACO, PCMH

Number of pharmacists Total: 97 FTE (73 in disease management and 24 in pharmacy tele-management) Number of clinics/ Family practice: based on clinic’s risk adjusted patient panel: patients covered by 4000 (existing clinic)—6000 (new clinic)/1.0 FTE pharmacists Specialty: based off active patient roster with pre-specified condition: 750-1000 patients/1.0 FTE Funding model of All are employees funded by Geisinger clinical enterprise pharmacists (salaried, contracted, leased, other) Delivery mode for patient Mixed model of face-to-face (preferred) and telephone management visits Average duration of See Figure 3 and Figure 4: current is 15-30-45 minute OR 10-30-40 pharmacist visit minute visit model; Proposed change for FY21 will be 10-40 minute model Collaborative practice Yes. Monitor therapy and labs, titrate dosage, modify, and discontinue agreement in place medication; manage specific conditions, order labs/imaging, authorize medication refills/renewals (note that pharmacists do not have the authority to initiate therapy under CPAs in Pennsylvania) Billing codes used n Annual Wellness Visits: G0438/G0439

n Anticoagulation 93793

n Chronic disease hospital-based clinics: facility fee

n Chronic disease physician office-based clinics: 99211

n Continuous Glucose Monitoring placement: 95249

n Insulin pumps and nursing homes: direct contracting

n Smoking cessation: 99406/99407

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 17 Geisinger Ambulatory Clinical Pharmacy Program DANVILLE, PA

Background Figure 1: Medication Management Targets for Geisinger’s ambulatory clinical pharmacy Primary Care Pharmacists program started in 1995 with a single Anticoagulation anticoagulation clinic and, after several years of amassing clinical outcomes data and garnering Asthma physician support, began expanding into other therapeutic areas to target clinically relevant Behavioral health gaps in care.1 Initially, in collaboration with the Geisinger Health Plan, the program expanded COPD into the management of anemia of chronic kidney disease, a small yet costly patient Diabetes population in need of treatment optimization. Heart failure In the early 2000’s, the pharmacy program set its sights on chronic disease management in Hyperlipidemia primary care, and beginning in 2012, ventured aggressively into the specialty practice arena. Hypertension

Now, 24 years later, the program has more Osteoporosis than 90 ambulatory clinical pharmacists managing patients’ medication therapy for Pain over 20 medical conditions. Pharmacists are incorporated into both Geisinger-owned Smoking cessation Patient-centered Medical Home (PCMH) and Accountable Care Organization (ACO) sites within four practice models: primary care related patient outcomes and assist primary disease management, specialty medicine care providers in decreasing healthcare costs disease management, home-based primary and meeting quality benchmarks. Under care, and pharmacy tele-management (or collaborative practice agreements (CPAs) non-traditional “telepharmacy”). On average, with providers, pharmacists can modify and the primary care and specialty disease discontinue medication therapy and order management programs receive over 2,200 laboratory work and imaging. Pharmacists new referrals and complete 34,000 patient perform comprehensive medication reviews encounters every month. Additionally, the and medication reconciliation, identify and telepharmacy pharmacists average over resolve medication-related problems, manage 74,000 patient encounters monthly. chronic disease states through evaluation of the safety and effectiveness of medication The Model: How it Works regimens (including titration and monitoring towards targeted patient outcomes), design There are 52 primary care pharmacists patient-centered, cost-effective medication embedded within family practice and internal regimens, and provide education to patients medicine sites across the health-system. The and providers.1,2 pharmacists practice in a model of care based on comprehensive and high-value office-based The 21 specialty disease management visits. They are responsible for the ongoing pharmacists are centrally housed within management and co-ownership of chronic their applicable departments and operate disease patients at primary care sites (Figure 1). under CPAs. The specialty practice These pharmacists help to improve medication- model is primarily telemedicine-based, is

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 18 Geisinger Ambulatory Clinical Pharmacy Program DANVILLE, PA

customizable to the needs of the specialty, place and primarily practice telephonically and tends to be more population-health and through telemedicine. They provide focused. Specialty pharmacists help lead comprehensive medication management, drug the system’s clinical treatment pathway information, assistance with drug procurement, development process within their specialties acute disease co-management, antibiotic and work closely with pharmacists from stewardship, disease state monitoring, and the Geisinger Health Plan and Geisinger medication management. Specialty Pharmacy (Retail) to coordinate and optimize care for the patients (Figure 2). In response to a request from Geisinger’s executive leadership to have pharmacy own all incoming medication-related messages, Figure 2: Examples of Medication Management the telepharmacy program at Geisinger has Targets for Specialty Pharmacists been in a period of rapid development and Addiction implementation over the last 16 months. What started out as a pharmacy call center Anemia manned by 4 pharmacists and 12 pharmacy Antiplatelet monitoring pre-post technicians is now a highly productive intracranial stenting pharmacy tele-management site with 24 Brain-impairing medications Geriatrics pharmacists and 32 pharmacy technicians. The pharmacists, equipped with CPAs, Heart failure manage all medication-related electronic Hepatitis C communications and refill requests entering the system, saving physicians and their Irritable bowel disorder support staff hours of work every week. In addition, the pharmacists in the telepharmacy Multiple sclerosis program have recently begun to collaborate Medically-complex children with the embedded disease management pharmacists to implement a series of clinical Neuroimmune disorders programs including tele-management of anticoagulation patients and referral of Oral chemotherapy patients identified as having poorly controlled diabetes to the primary care pharmacists.

One of Geisinger’s newest initiatives, Geisinger The Geisinger ambulatory clinical pharmacy at Home, is an interprofessional home-based program has a highly developed organizational primary care model designed to increase structure (Figure 3). In addition to their access and decrease high-cost utilization for program oversight roles, the System Director the system’s neediest patients. Four clinical and Assistant Directors sit on system-level pharmacists work in collaboration with steering committees and have leadership registered nurse case managers, advanced roles on several of the system’s ProvenCare practitioners, community health assistants, and pathway teams.2 (ProvenCare is a care delivery regional medical directors. The pharmacists model centered around evidence-based typically begin to provide care for the patient best practices, clinical outcomes attainment, at enrollment in the program and/or during workflow optimization, patient engagement, a transition of care from an acute facility and a reduction in care variability across the to home. The pharmacists have a CPA in system). In addition, the pharmacy leadership

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 19 Geisinger Ambulatory Clinical Pharmacy Program DANVILLE, PA

Figure 3: Geisinger Ambulatory Care Organizational Structure The Geisinger Figure 3: Geisinger Ambulatory Care Organizational Structure ambulatory clinical pharmacy program has a highly developed System Director Ambulatory organizational structure (Figure Disease Management Programs 3). In addition to their program oversight roles, the System Director and Assistant Directors Administrative assistant sit on system-level steering committees and have leadership Northeastern Western Region Central Region Telepharmacy roles on several of the system’s Region Assistant Assistant Director Assistant Director Assistant Director ProvenCare pathway teams.2 Director (ProvenCare is a care delivery model centered around Regional Manager Regional Manager Regional Manager evidence-based best practices, clinical outcomes attainment, workflow optimization, patient Clinical Clinical Clinical Clinical engagement, and a reduction in Coordinator Coordinator Coordinator Coordinator care variability across the system). In addition, the Clinical Clinical Clinical Clinical pharmacy leadership team Pharmacists Pharmacists Pharmacists Pharmacists maintains highly productive relationships with leaders from their care team partners (e.g., Clinic Assistants Clinic Assistants Clinic Assistants Pharmacy Techs nursing, health management, clinical nutrition, physicians, advanced practitioners), the system’s Population Health and Quality pillars, and Medicine and System Operations. team maintains highly productive relationships stratification criteria and predictive analytics with leaders from their care team partners which direct patients to the appropriate (e.g., nursing, health management, clinical resource. The logic for this process runs behind Patients are referred to the program via one of two pathways: provider-initiated or an nutrition, physicians, advanced practitioners), the scenes and as patients are identified, automated process utilizingthe population system’s healthPopulation level Health data and and analytics. Quality The mosta referralcommon is referraltriggered in the EHR, pended, pathway is provider-initiated,pillars, whereby and Medicine clinicians and identify System a patient, Operations. order a referraland andpopulated when able,in the physician’s in-basket perform a warm hand-off to the pharmacist on-site. Alternatively, an increasingly important pathway is Patients are referred to the program via to sign. This approach has been especially the auto-enrollment of high-risk patients based upon customizable identification and risk stratification one of two pathways: provider-initiated or useful in Geisinger’s pharmacy chronic pain criteria and predictive analyticsan automated which direct process patients utilizing to the population appropriate resource.management The logic for program this where patients are process runs behind the scehealthnes and level as datapatients and are analytics. identified, The amost referral is triggeredproactively in the EHR,identified pended, and referred if they have and populated in the physician’scommon in-basket referral to pathway sign. This is approachprovider-initiated, has been especiallymorphine useful milligram in equivalents above CDC Geisinger’s pharmacy chronicwhereby pain management clinicians identify program a patient, where order patients a are proactivrecommendations,ely identified have and had a recent ED/ referred if they have morphinereferral milligram and when equivalents able, perform above a CDC warm recommendations, hand- hospital have visit, had or a arerecent on high-risk medication ED/hospital visit, or are on offhigh to- riskthe medicationpharmacist combinations.on-site. Alternatively, Pharmacists currentlycombinations. use a 15 -Pharmacists30-45 currently use a 15- minute OR 10-30-40 minutean visit increasingly model (Figure important 4). Starting pathway in FY21is the, a 10-40 minute30-45 visit minute model OR will 10-30-40 be minute visit model implemented (Figure 5). auto-enrollment of high-risk patients based (Figure 4). Starting in FY21, a 10-40 minute upon customizable identification and risk visit model will be implemented (Figure 5). Sustainability and Outcomes SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 20 Financially, the ambulatory clinical pharmacy program is supported through a mixed model of revenue generation and return on investment (ROI). Revenue is generated through annual wellness visits, “incident to” billing, anticoagulation and smoking cessation counseling codes, continuous glucose monitoring codes, insulin pump contracting, and private insurance reimbursement tied to quality Geisinger Ambulatory Clinical Pharmacy Program DANVILLE, PA

Figure 4: Primary Care Pharmacist Patient Visit Model for Fiscal Year 2020

10/30/40 Model 15/30/45 Model OR • 10 min POC INR • 15 min POC INR • 30 min Chronic Disease follow up • 30 min Chronic Disease follow up • 40 min Chronic Disease new patient • 45 min Chronic Disease new patient • 40 min AWV (+ address care gaps) • 45 min AWV (+ address care gaps)

• No POC INR ‘double books’ • POC INR ‘double books’ if needed • 90 minutes per day of schedule blocks • 60 minutes per day of schedule blocks • Option available for 20 min POC INR if (Additional cushion built into longer appt New or Pre-op visit slots) • Option available for 40 min Chronic • Option available for 45 min Chronic Disease f/u x 1 if complicated Disease f/u x 1 if complicated

90 minute schedule block options 60 minute schedule block options Decision point A (choose ONE option from below) Lunch Break □ 60 min: 12pm-1pm (lunch) □ 30 min: 12pm-12:30pm OR □ 60 min split: 930am-10am (AM) and 12pm-1230pm (lunch) AND AND Decision point B (Acute Slot*) Decision point A (Acute Slot*) (choose ONE option from below) (choose ONE option from below)

□ 30 min: 2pm-2:30pm (mid-afternoon) □ 30 min: 2pm-2:30pm (mid-afternoon) OR OR □ 30 min: 4pm-4:30pm (end of day) □ 30 min: 4pm-4:30pm (end of day) * slots reserved for acute or same day appointments * * slots reserved for acute or same day appointments *

Sustainability and Outcomes entities and/or system medication distribution channels, through cost savings in the form of Financially, the ambulatory clinical pharmacy compliance with evidence-based, cost-effective program is supported through a mixed treatment pathways, and by increasing patient model of revenue generation and return access for both clinicians and ancillary clinic on investment (ROI). Revenue is generated staff (e.g., nurses, phlebotomists). Each of through annual wellness visits, “incident to” these measures are subsequently linked to billing, anticoagulation and smoking cessation either revenue production for the system counseling codes, continuous glucose or a reduction in total cost of care, which is monitoring codes, insulin pump contracting, particularly important with participation in the and private insurance reimbursement tied to ACO partnerships and Geisinger Health Plan.2 quality outcomes and metrics. From a ROI perspective, Geisinger has been able to utilize Examples of measure improvement its data capabilities to track and demonstrate demonstrated at Geisinger include a 28% value via improvement in quality metrics reduction in annual ED visits among multiple and outcomes, the optimization of resource sclerosis patients managed by clinical utilization, as a conduit to 340b contracted pharmacists and 18% lower ED visits, 18%

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 21 Geisinger Ambulatory Clinical Pharmacy Program DANVILLE, PA

Figure 5: Planned Primary Care Pharmacist into a Tableau Dashboard in real time. The Patient Visit Model for Fiscal Year 2021 outcomes are reported out quarterly at a Community Medicine leadership meeting which is attended by medicine leadership and over 100 of the system’s medical and ALL CLINICS operations directors. One example, our diabetes dashboard, will track improvement 10/40 Model in A1C control, as well as scores on quality • INR metrics directly tied to that condition (e.g., • ll o sese I blood pressure control, statin use, ACEI/ • I ARB, nephropathy screening). This same dashboard also tracks the identical metrics • No POC INR ‘double books’ for the family practice physicians we • ues e d o sedule bloks work with thus allowing for comparison. • o lble o INR Ne The next iteration of the dashboard will o eo s incorporate diabetes-related ED visits and hospitalizations. Another example 60 minute schedule block options is our pharmacist-run pain management u ek clinic dashboard, which tracks close to 10 □ AND different outcomes for patients managed eso o ue lo by this service, such as morphine milligram oose ONE oo o belo equivalents (MME), number of patients on □ deoo opioids, patients on opioid/benzodiazepine OR combinations, naloxone usage, ED visits, □ ed o d slos eseed o ue o se d oes toxicity screens, medication use agreements, and others.

lower hospitalizations, and 23% lower total Innovations/Future Plans cost of care for warfarin patients managed by “The clinical pharmacy department is headed clinical pharmacists.1 Diabetes management by very talented, knowledgeable and caring by clinical pharmacists at Geisinger has leaders. With a well-established service model resulted in a 1.2% to 2.3% improvement in already in place, the proper allocation of hemoglobin A1C (depending on baseline resources will permit the patient to see the A1C and treatment goals), higher scores pharmacist in their area of expertise,” notes Dr. in metabolic disease quality metrics (e.g., Jon Han, Director, Interventional Pain. statin utilization, blood pressure control) and Over the next 3 years, Geisinger’s ambulatory reduction of primary care physician office pharmacy program strategic plan includes visits by anywhere from 17 to 35%. the addition of clinical pharmacists in new Geisinger has defined several condition- practice sites (e.g., Federally Qualified specific outcome metrics that we routinely Health Centers, senior-focused care sites, monitor and report back to both staff and rheumatology, infectious disease, ACO leadership. The data and outcomes are partner sites, and pharmacogenomics), the pulled directly from our data warehouse, incorporation of machine learning–based the EHR, and from available medical and referrals and interventions into the workflow, pharmacy benefit claims data and fed implementation of two PGY1 pharmacy

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 22 Geisinger Ambulatory Clinical Pharmacy Program DANVILLE, PA

residency programs, and the expansion of n Clearly define a program vision and target current pharmacy services in both cardiology population based on the optimization of and pulmonology. The four PGY1 residents will value at each patient touchpoint. Without practice across the continuum of ambulatory this framework, it is very easy to get pharmacy care including primary and derailed by ”non-value added” asks which specialty care, telepharmacy, transitions of will not contribute to the outcomes of the care, community pharmacy and home-based program nor support future growth. primary care. The telepharmacy team will n Implement a comprehensive training continue to expand its clinical service around and credentialing program, as well as a anticoagulation management, partner with system of ongoing quality assurance/ community medicine for an uncomplicated UTI improvement to ensure the program assessment program, and further develop its will be staffed by highly functioning and population health-based outreach. Finally, the clinically skilled pharmacists positioned to primary care disease management program produce optimal outcomes. is set to undergo a large-scale expansion in response to a looming physician shortage in n Pharmacy leadership must be involved primary care and a subsequent need to create across the continuum of care and across more appointment access for our community the health-system, having touchpoints in medicine partners. medicine, population health, and quality.

Key Lessons Learned References

n When establishing programs, bring clinical 1. Jones LK, Greskovic G, Grassi DM, et al. and operational partners to the discussion Medication therapy disease management: early and often to gain their input, support, Geisinger’s approach to population health collaboration, and buy-in. management. Am J Health-Syst Pharm. 2017;74:1422–35. n Leverage data and analytics to support the value of the program and identify areas 2. Knoer S, Swarthout M, Sokn E, et al. of opportunity. It is much easier to build a The Cleveland Clinic Pharmacy Population program based on proven success rather Health Management Summit. Am J than anecdotal reports. Health-Syst Pharm. 2018;75:1421–9.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 23 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Jefferson Health Population Health Pharmacy Team PHILADELPHIA, PA

Author: Darren Mensch, PharmD, BCPS, BCACP Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Value-based model type Formerly PCMH, now Comprehensive Primary Care Plus (CPC+) and Delaware Valley ACO Number of pharmacists Four (4.0 FTE) for three health-system campuses (two at Abington Jefferson, one at Jefferson Northeast, one at Jefferson Center City) Number of clinics/patients n Abington Jefferson (suburban, teaching hospital) covered by pharmacists* • 30 practices (~140,000 patients)

n Jefferson Northeast (urban, teaching hospital) • 16 practices (~47,000 patients)

n Jefferson Center City (urban, academic medical center) • 10 practices (~67,000 patients) Funding model of Clinic-funded through Comprehensive Primary Care Plus (CPC+) pharmacists (salaried, funds contracted, leased, other) Delivery mode for patient n Comprehensive Medication Management (CMM) encounters: visits 58% telephonic, 12% face-to-face, 15% chart review, 15% unable to reach

n Targeted Medication Reviews (TMR): 59% telephonic, 9% face-to-face, 26% chart review, 6% unable to reach Average duration of CMM (Face-to-face = 64 minutes, Telephonic = 31 minutes) pharmacist visit** TMR (Face-to-face = 50 minutes, Telephonic = 25 minutes) Collaborative practice No, working to implement agreement in place Billing codes used Not billing at this time

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 24 Jefferson Health Population Health Pharmacy Team PHILADELPHIA, PA

Background and reporting interventions without double Jefferson Health is an enterprise health-system documentation. In this workflow, pharmacists in the Greater Philadelphia region with three receive referrals from providers and the campuses in Pennsylvania and one in New nurse care coordinators. If it is determined Jersey. The system consists of 14 hospitals, 7 that a patient requires outreach, they are urgent care centers, 19 outpatient centers, and seen by the pharmacist at the patient’s next 60 Comprehensive Primary Care Plus (CPC+) provider visit or are scheduled for a separate practice sites. At the CPC+ practice sites in pharmacist visit. Patients may also be enrolled Pennsylvania, approximately 300 providers in longitudinal management when deemed care for over 250,000 patients. necessary (e.g., for diabetes, opioid tapering). The ambulatory care—population health To streamline and standardize documentation, pharmacy team was started through the we based interventions on the Pharmacy CPC+ and Innovation Committee at Jefferson Quality Alliance’s Medication Therapy Problem Health to improve the “joy of medicine” by Categories Framework, which focuses on enhancing workflow efficiencies and quality indication, effectiveness, safety, and adherence. of care in primary care offices. Under the Over a 6-month timeframe, two pharmacists Center for Medicare and Medicaid Innovation provided 931 education, 767 adherence, 711 CPC+ framework, Track 2 (reduced FFS indication, 401 safety, and 345 effectiveness payment plus bundled payments to increase interventions based on this framework. As comprehensiveness of care) practices for prior authorizations, we have focused on must provide comprehensive medication educating providers and office staff on how to management (CMM) at all practice sites avoid prior authorization requirements (e.g., by performed by pharmacists or other providers. following online formularies, step therapy) and Abington-Jefferson Health and Jefferson streamlining the office’s workflow inefficiencies. Northeast chose to utilize CPC+ funding to Providers and office staff are encouraged hire embedded ambulatory care pharmacists to get us involved with denials when no to perform CMMs as well as population health alternatives exist or if the prior authorization management, including chronic disease care. requires robust clinical information (e.g., for The program has hired four pharmacists specialty medications, opioids). (4.0 FTEs) since April 2018. Because clinical pharmacy was a new concept in the outpatient setting, we introduced The Model: How it Works the program at physician leadership, office The program started with three pharmacists manager, care coordination, and office for nearly 60 practices sites. Given such a high meetings. We also worked with Abington- volume of patients, the administration team Jefferson and Jefferson-Northeast marketing allowed time upfront to build an effective, teams to create a referral card based on the efficient foundation with help from pharmacists Integrating Family Medicine and Pharmacy at other national best practices sites, such as to Advance Primary Care Team (IMPACT) the University of Michigan College of Pharmacy program. Throughout the process, we have and Fairview Pharmacy Services. We spent a learned a lot about perceptions of pharmacy majority of our time developing the referral, within physician’s offices and how to best workflow, and documentation processes, as the explain how pharmacists (including clinical, team and key stakeholders felt these were key hospital, and community pharmacists) can to reaching the highest risk patients, ensuring collaborate with other providers to support a everyone understood each other’s role, team-based approach to patient-centered care.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 25 Jefferson Health Population Health Pharmacy Team PHILADELPHIA, PA

As for program support, the key stakeholders burnout. Many of the providers have spoken include the Ambulatory Pharmacist Program to the leadership team about the profound Medical Director, Associate CMO of Jefferson impact pharmacists have had on their patients Medical Group, and clinicians. The support and their workload. In fact, a provider saw a staff includes office staff/managers, care patient following a face-to-face CMM where coordinators, the Delaware Valley ACO numerous medication-related problems were (DVACO), and business analytics team. The addressed and the doctor said, “[the patient team does not currently have any collaborative was] the best he’s seen him all year!” practice agreements (CPA) signed, but the From a direct cost standpoint, we have tried legal department is currently reviewing a to help justify our positions by cost-savings draft of a CPA. Since embedded pharmacists to the DVACO by promoting high-value, are completely new to most providers in the low cost medications when appropriate. network, and this CPA would cover three The organization is also investigating direct health-system campuses and approximately billing with third-party payers for MTM 300 providers, we wanted to first develop codes; however, we focused on setting a strong relationships before managing disease sustainable foundation to be able to take the states under a CPA. program’s data to payers. We work to close Each pharmacist is provided with a mobile gaps in care and to improve performance work phone and laptop with direct access on various quality metrics. We also are to both outpatient (eClinicalWorks and tracking savings for patients that result from Touchworks) and inpatient (Sunrise) electronic reducing polypharmacy and copayments. medical record platforms (EMRs). In the EMR, From a quality perspective, we are going to we have access to practice-level HEDIS-based compare A1C control, statin utilization, and electronic clinical quality metrics (eCQMs) to healthcare utilization (ED and admissions identify patients with certain needs, such as from HealthShare Exchange) in patients with not on statins, with uncontrolled diabetes, etc. diabetes between usual care and pharmacist- Outside of the EMR, we track interventions integrated care. through ad-hoc reporting from a SQL database, which mines the data from the EMR Innovations/Future Plans for export to a Microsoft Excel spreadsheet. In early 2019, Jefferson Health hired an This has increased patient need visibility by additional pharmacist for the practices in identifying fragile, sub-populations who will Center City, Philadelphia. In the future, the benefit from pharmacy services. program hopes to add more pharmacist positions, a PGY-2 Ambulatory Care Sustainability and Outcomes Residency Program, pharmacy students, and For the current fiscal year, the goals for pharmacy navigators. Based on feedback justification are the number of CMM encounters from numerous providers, care coordinators, and targeted medication reviews (TMRs) office staff, and administrators, the team completed, academic detailing provided, hopes to expand while continuing to develop increased generic drug utilization, and relationships with the physician offices increased statin use. Since a lot of time was as well as the patients. The ambulatory spent developing the program, we focused pharmacy program’s medical director, Steven the initial goals around building a program Spencer, MD, MPH, FACP, internist and where we can provide the best possible care to Director of Population Health at Jefferson patients while also trying to decrease provider Medical Group-North, who splits his time

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 26 Jefferson Health Population Health Pharmacy Team PHILADELPHIA, PA

between being a front-line clinician and hoping to start offering practice experiences administrator, stated, “I look forward to the for students from local colleges of pharmacy continued collaboration with my ambulatory in order to extended outreach opportunities pharmacist. He continues to push the and to provide a unique learning opportunity practice of medicine forward. He is making for students. We are also hoping to add the care of my patients more efficient, timely, a pharmacy navigator program to help safe, and effective. He is a resource that has streamline financial assistance applications added immense value to my care team, and I and prior authorizations in order to free up cannot imagine practicing medicine without time for the pharmacists to focus on clinical his assistance.” issues and practice at the top of their license. The organization is hoping to collaborate with local pharmacies who provide advanced Key Lessons Learned services such as medication synchronization, n A program is only as strong as its adherence packaging, and delivery in order to foundation and leadership. Support from expand the program’s reach and address the leadership is invaluable for gaining buy-in needs of more patients. from other providers.

The most unique aspect of the program is n When starting a new program, take time that the physician network, not the pharmacy to plan service operations (e.g., workflow, department nor any large academic medical documentation) before beginning to see center affiliation, directly funds the pharmacist patients. positions. It is rare to find physician offices who pay pharmacist salaries without a university n Identify the needs of the providers and financially supplementing the cost. This shows health-system and then determine how the organization’s belief in developing the pharmacists can collaborate to address relationship and respect between physicians those needs.

and pharmacists. n Collaboration with and defining roles The perception of pharmacy is dynamically of team members from all areas of the changing within the organization and other health-system has been crucial to the healthcare providers are coming to realize success of our practice. From business the true value of a pharmacist. The greatest analysts to care coordinators, the support challenge has been scaling the operation: and teamwork across the organization has established models have one pharmacist been instrumental to providing patient- for one or two sites, whereas we have 15+ centered care.

practices and about 70,000 patient lives per n Take advantage of opportunities to present pharmacist. Another lesson is the importance at practices, meetings, community events, of an integrative model to be able to provide a etc. to increase awareness of the value of consistent message across disciplines. pharmacists in primary care.

From a growth standpoint, we hope to n Work smarter, not harder. Utilize resources expand our program by continuing to (e.g., experts in your field, pharmacy improve A1C control, provider/patient organizations) to see if something has satisfaction, statin use in patients with already been done before, then adapt to diabetes, readmission rates, and other areas your practice or gain insight. where we feel we can play a role in improving patient outcomes. In the near future, we are

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 27 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Michigan Medicine ANN ARBOR, MI

Authors: Amy N. Thompson, PharmD, BCACP; Carol Becker, MHSA; and Hae Mi Choe, PharmD Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Primary care health centers, community pharmacy

Value-based model PCMH

Number of pharmacists 13 pharmacists (5.6 FTE total)

Number of clinics/patients 14 PCMH sites, pharmacist care for 3,441 unique patients in the past covered by pharmacists 12 months Funding model of Pharmacist funding for their effort within clinic is paid by the clinics pharmacists (salaried, themselves. Each pharmacist is a salaried employee. contracted, leased, other) Delivery mode for patient Face-to-face, telephonic, and telehealth visits Average duration of Clinic visits: 30 minutes pharmacist visit CMR visits: 60 minutes Telephonic visits: 15 minutes Collaborative practice Yes. Duties delegated include the following:

agreement in place n Medication management (initiate, modify, or discontinue)

n Ordering of labs on behalf of MD (A1C, albuminuria, lipid profile, basic metabolic panel/comprehensive metabolic panel)

n Ordering DME

n Referrals for diabetes education classes, eye exam, nutrition counseling Billing codes used G9002- face-to-face encounters 98966-98968- telephonic services

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 28 Michigan Medicine ANN ARBOR, MI

Background diabetes, hypertension, and hyperlipidemia. Michigan Medicine, formerly the University They also offer comprehensive medication of Michigan Health system, is the academic management for patients with medication- medical center of the University of Michigan related problems to determine the most in Ann Arbor, Michigan. There are 14 patient- effective, safe, and affordable regimen. centered medical home (PCMH) primary care This work is made possible by collaborative health centers in Michigan Medicine with practice agreements (CPAs) between PCMH 13 PCMH clinical pharmacists (5.6 Full Time clinical pharmacists and physicians from Equivalent[FTE]) and three post-graduate the Michigan Medicine primary care clinics year 2 (PGY2) pharmacy residents embedded that allow pharmacists to initiate, modify, in primary care clinics. and discontinue medication therapies, order labs, order supplies, and refer to diabetes When the program began in 1999, it was education, diabetes eye exam, and nutrition funded by the University of Michigan College counseling. The current CPA protocols are for of Pharmacy. In 2009, Blue Cross Blue Shield, type 2 diabetes, hypertension, hyperlipidemia, the largest payer in the state of Michigan, and/or polypharmacy. As part of the CPA provided some funding to Michigan Medicine between the clinical pharmacist and providers, to support the development of team-based the clinical pharmacist must shadow providers patient care. This funding was used to build for a total of eight half-days and participate the PCMH-based clinical pharmacist model in ongoing case reviews with the clinic and implement it in all 14 Michigan Medicine medical director. Every 8 months, the clinical primary care clinics. At that time, the University pharmacist and medical director meet to of Michigan College of Pharmacy and the review 10 patient cases. There are plans to University of Michigan Medical Group provided expand the CPAs to include smoking cessation primary care clinics a subsidy that covered and COPD in the future. 50% of the clinical pharmacists’ clinic time. The remainder of clinical pharmacist time was Patients are referred to the clinical pharmacist covered by the clinics. Each year until 2017, the by their PCP or another member of the amount of the subsidy from the University of patient’s care team, such as a nurse care Michigan School of Pharmacy decreased and navigator or social worker, for chronic disease the amount covered by the clinics increased; state management. Referrals are typically then in 2017 the clinics took over 100% of placed for patients with uncontrolled diabetes the cost of the clinical pharmacists. Clinic or hypertension, and those with complicated leadership indicated that patient visits with medication regimens in need of further pharmacists are reimbursable by a number of education. Once patients are referred to the insurance plans. The clinics are able to support clinical pharmacist by the provider or team the remaining costs of clinical pharmacists member, patients are seen within 2 to 4 weeks through per member per month (PMPM) for a face-to-face in-clinic visit that lasts 30 fees and billing under the physician or other to 60 minutes. Subsequent visits can be face- provider in Medicare, Medicaid, and private to-face or telephonic for 15 to 30 minutes, payer programs. depending on the follow-up need. Our team follows the 80/20 rule in each half-day session. The Model: How it Works For each 4-hour clinic session, 80% (3 hours, The Michigan Medicine PCMH-based 15 minutes) is available for direct patient care clinical pharmacists provide chronic disease and 20% (45 minutes) is built-in administrative management services for patients with time. This system was important to establish

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 29 Michigan Medicine ANN ARBOR, MI

from the beginning as many of our pharmacists with diabetes. Data is tracked for each clinic practice at multiple sites and this allows them for quality metrics (e.g., A1C, blood pressure time to perform these administrative duties. (BP), immunization rates), and this data is readily available at each site and updated Patients are typically followed by the monthly. The data is available at the patient- pharmacist until they reach their goal set by specific level, allowing clinics to target patients the provider, pharmacist or patient (depending not at goal (i.e., patients with A1C >9% not on on reason for referral). Within the face- insulin). Additionally, pharmacists have helped to-face visit model, support staff are used improve other quality metrics such as asthma for scheduling, checking patients in, and action plans, urine drug screening, and foot rescheduling visits. Medical assistants also exams through working with the clinics on support the visit by rooming patients. implementing new workflows through Plan, Do, Study, Act (PDSA) cycles. Currently, six of our Sustainability and Outcomes 14 primary care PCMH clinics pay for a half-day The sustainability of pharmacists within of clinical pharmacist time to lead the effort our PCMH clinics is possible through the within the quality space. impact we have been able to demonstrate in the clinic through chronic disease state Innovations/Future Plans management, impact on quality performance Pharmacy practice within our PCMH clinics has measures, and through revenue generation led to the development of many innovative from billing. Pharmacists within the PCMH practices, including a partnership with three clinics at Michigan Medicine bill for their community pharmacies to help provide BP services through a unique payment model monitoring. When a patient has an elevated BP, utilizing care management codes. This based on Healthcare Effectiveness Data and allows for the pharmacists to generate some Information Set (HEDIS) guidelines, recorded revenue for the clinics. Currently, pharmacists’ in the electronic medical record (EMR), a “best services are billed under the physician using practice alert” to take a second BP reading is care management codes or “G-codes” that issued 5 minutes later. If the second reading are utilized by all care managers within is also elevated, the physician is provided an primary care at Michigan Medicine including order to sign if they would like the patient dieticians, nurse care navigators, and social to see a pharmacist for follow-up. Patients workers. Clinics are reimbursed for 30-minute are offered the opportunity to see a PCMH- face-to-face visits and for 5- to 30-minute based clinical pharmacist at the clinic or to telephonic encounters. see a pharmacist at one of the community pharmacies, depending on preference. The PCMH-based clinical pharmacists at Michigan community pharmacies have purchased the Medicine also play a big role in quality BpTRU monitor to ensure the most accurate initiatives to impact pay for performance BP reading possible. metrics, particularly those that are medication- related. Pharmacists have shown improvement Five pharmacists from three different in clinical outcomes with chronic disease community pharmacy sites have been trained state management, particularly reduction in by our PCMH pharmacy team and provide hemoglobin A1C, for patients. Additionally, this service to our patients. Additionally, pharmacists can perform targeted patient the community pharmacists have access to outreach and education to help clinics meet our EMR to allow for easy documentation quality metrics, such as statin use in patients and communication with the provider. The

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 30 Michigan Medicine ANN ARBOR, MI

community pharmacists are able to make Key Lessons Learned dosing and monitoring recommendations n Standardization of workflow is important for through their documentation and pending scaling clinical pharmacy programs. orders for provider review. Thus far, this program has been successful with n Build administrative time into pharmacists’ approximately 1,000 unique patients seen with schedules for documentation and necessary over 2,000 visits, and a 92% acceptance rate of follow-up with providers, pharmacies, and therapeutic recommendations by the provider. other care team members.

Another innovative practice utilizes an n Aligning pharmacists’ services with interactive voice response (IVR) system or institutional priorities helps foster leadership text messaging service to help with home BP engagement and support. monitoring. Pharmacists enroll patients into the IVR or text messaging system which can References be set to call/text the patient on specific days 1. Choe HM, Farris K, Stevenson J, et al. and times, based on patient preference. During Patient centered medical home: developing, these call/texts, patients are asked to enter expanding and sustaining roles for in their most recent BP values and are asked pharmacists. Am J Health-Syst Pharm. about adherence with their antihypertensive 2012;69:1063–71. regimen. When a patient enters their BP values, they are populated within the EMR and trigger 2. Ashjian EJ, Yoo A, Piette J, et al. an alert if the readings are too high or low, as Implementation and barriers to uptake previously set by the clinical pharmacy team. of interactive voice response technology This alert is sent directly to the pharmacist’s aimed to improve blood pressure control in-basket within the EMR, which prompts the at a large academic medical center. J Am pharmacist to reach out to the patient. Full Pharm Assoc. 2019;59:S104–9. analysis of this practice is being completed but a sampling of the data showed that of 936 calls made to patients, there was a 52% call completion rate for patients. The addition of text messaging is a new process that will help patient engagement in this practice.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 31 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

The Ohio State University General Internal Medicine Clinics COLUMBUS, OH

Authors: Kelli Barnes, PharmD, BCACP and Stuart Beatty, PharmD, BCACP, FAPhA Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Health-system general internal medicine clinics

Value-based model type Network of 6 PCMHs within an ACO

Number of pharmacists 6.5 FTE

Number of clinics/patients 6 clinics with more than 75,000 patient lives covered by pharmacists Funding model of Salaried employees of the practices (5.3 FTE) pharmacists (salaried, Shared-faculty pharmacists (1.2 FTE) contracted, leased, other) Delivery mode for patient Face-to-face, telephone, secure patient portal, and video visits visits Average duration of 5-60 minutes pharmacist visit Collaborative practice Yes; CPAs for diabetes, hypertension and smoking cessation agreement in place currently. Have ability to order/change medications, order labs, place referrals, etc. Billing codes used n Incident-to (99211) for comprehensive medication reviews or disease management visits

n Transitional Care Management codes (99495, 99496) billed by provider, and includes pharmacist and other healthcare professional involvement

n MTM codes (99605-607) for several private insurers

n OutcomesMTM claims

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 32 The Ohio State University General Internal Medicine Clinics COLUMBUS, OH

Background patients. Pharmacists provide a hybrid of The Ohio State University General Internal scheduled and on-demand patient care. Medicine Clinics (OSUGIM) are a network of Additionally, each pharmacist provides six National Committee for Quality Assurance population health management using patient tier-3 patient-centered medical homes (PCMH) registries and EMR-reporting capabilities. Each affiliated with a large academic medical center clinic has a pharmacist schedule template that and a part of a CMS shared savings program is used to schedule patients to see a pharmacist accountable care organization (ACO). A total for an office visit. In between scheduled patient of 59 attending physicians, more than 100 visits, OSUGIM pharmacists also see patients medical residents, nine pharmacists (comprising on demand, at the request of another provider 6.5 FTE), two pharmacy residents, 20 nurse during that provider’s office visit, and contact practitioners, 27 nurses, nine social workers, and patients via telephone or secure patient medical assistants collaborate to provide care portal to provide additional care. Within this for more than 75,000 patients. model, medical assistants are used to support scheduling and rooming patients. There are The pharmacist practice model was created in plans to hire a pharmacy technician for support. 2006, when one shared-faculty member started providing patient care services and education to OSUGIM pharmacists are providing chronic medical residents two half days per week in one disease state management, transitional care clinic. Over time, the clinics started to embed management, population health management, additional shared-faculty members leading and polypharmacy care with a focus on to the implementation of innovative practice deprescribing. Patients needing pharmacist- models for chronic disease state management, provided care are identified through referral population health management, and transitional from another provider, pharmacist-initiated care management. Due to the demonstrated contact, and EMR-generated reports/data value of the embedded pharmacists, the PCMH analytics. Regarding pharmacist-initiated network began hiring pharmacists fully in 2015. contact, pharmacists screen the daily clinic schedule to identify patients who could benefit As reimbursement shifted toward value-based from pharmacist management based on their payment models, a group of practice leaders, hemoglobin A1C, blood pressure, estimated which included clinic administration, clinic lead glomerular filtration rate, and medication lists. physicians, and the network’s lead pharmacist, started to examine which healthcare providers Chronic Disease Management and personnel were necessary to build OSUGIM pharmacists provide chronic disease efficient, successful primary care teams. When management through use of collaborative thinking about allocation of resources, the practice agreements (CPAs) in accordance group commonly referred to a publication with state laws and institutional regulations. by Patel, et al which summarized successful These CPAs allow OSUGIM pharmacists to PCMH administrators’ recommendations for initiate, titrate and discontinue medications and PCMH staffing infrastructure.1 This led OSUGIM order and interpret lab tests for medication to invest in a care delivery model with one monitoring. Currently at OSUGIM, diabetes, pharmacist per five clinical full time equivalents hypertension, and smoking cessation CPAs are of primary care physicians. utilized. Patients are referred for management by a pharmacist through use of warm hand- The Model: How it Works offs by another provider in clinic and through Currently, OSUGIM pharmacists provide a use of EMR-generated reports used to identify variety of primary care services for complex patients with poorly controlled disease states.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 33 The Ohio State University General Internal Medicine Clinics COLUMBUS, OH

Care is provided through a combination of outreach effectiveness compared the rate of office visits, telephone contact and secure hospital readmission and ED visits within 30 patient portal messaging. Outcomes are tracked days in patients contacted by a pharmacist for individual patients and contribute to quality for TCM compared to patients that did not metric tracking for value-based contracts. receive TCM. This analysis showed 20% fewer readmissions and 53% fewer ED visits within Transitional Care Management 30 days of initial admission for the highest risk OSUGIM pharmacists started providing patient group. This data is used to support the transitional care management (TCM) in January necessity of a high performing pharmacy team. of 2013 when the Centers for Medicare and Medicaid Services (CMS) released the TCM- Population Health Management specific billing codes. These current procedural OSUGIM pharmacists started providing terminology (CPT) codes require a patient be population health management in 2010 by contacted by a licensed clinical staff member using systematic, targeted interventions to within 2 business days of discharge from an improve outcomes associated with chronic acute care setting and to have a face-to-face disease management, preventive health, and visit with a physician within 7 to 14 days. After high-risk medications.3-6 To provide population the face-to-face visit, the physician can bill the health management, OSUGIM pharmacists TCM codes, which reimburse at a higher rate follow the workflow shown in Figure 1. than a typical level 4 or 5 physician office visit.2 Initially, TCM occurred as a result of the Figure 1. OSUGIM Pharmacist Population patient’s primary care provider (PCP) Health Management Workflow requesting a pharmacist contact the patient for TCM because the PCP felt the patient was Identify Care Gap at high risk for readmission. As the OSUGIM pharmacy team grew and payment shifted to a value-based model, OSUGIM clinics refined Measure and Track Define and Identify the TCM workflow to reach a larger number Outcomes Population of patients during this high-risk period. To do this, EMR-generated reports were created to

identify all patients discharged from an OSU Consider Risk Engage Patients medical center or emergency department Stratification (ED). An EMR-generated readmission risk score was included on the reports and used to Implement risk-stratify patients for pharmacist or nurse Intervention outreach. Currently, pharmacists contact patients at highest risk for readmission and nurse care coordinators reach out to patients at moderate risk for readmission. Care gaps are identified by providers or OSUGIM pharmacists and nurses complete 700 pharmacists during routine patient care or to 800 TCM outreaches per month on average, through use of data analytics identifying areas with ~25% completed by a pharmacist and where disease state or healthcare utilization 75% completed by a nurse care coordinator. outcomes could be improved. The patient TCM call times vary, commonly taking 5 to population is then defined, typically by a 20 minutes per call. Initial analysis of TCM specific demographic, disease state or

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 34 The Ohio State University General Internal Medicine Clinics COLUMBUS, OH

high-risk medication. Patients in the population low levels of fee for service reimbursement by are identified through use of EMR reporting showing time savings and improved accessibility capabilities. A data analytics staff is shared for other providers and improving clinical between the entire division of General Internal outcomes and medication safety. In January Medicine, who provides support for identifying of 2013, CMS released the TCM billing codes these patient populations. described above and OSUGIM pharmacists sought the opportunity to take responsibility for Once patients are identified, risk stratification TCM to further justify the pharmacist-provided may be completed to identify the portion of care. Because these TCM codes result in higher the population that would benefit most from an payment than a typical level 4 or 5 physician intervention and ensure that the intervention office visit, the supplemental amount, meant to can be completed with available resources. support the TCM happening between hospital Once the patients are identified and risk discharge and hospital follow-up visit, can stratification is considered, proactive, targeted, be attributed to the work of the pharmacist evidence-based interventions are implemented completing that work. to improve outcomes. Interventions are most successful when pharmacists engage patients Currently, each of the OSUGIM clinics is in informed decision-making regarding changes enrolled in the CMS alternative payment model, to medication therapy or recommended Comprehensive Primary Care Plus (CPC+), medical care. Finally, outcomes are measured Ohio Medicaid’s Comprehensive Primary and tracked within the EMR and the process is Care (CPC) program, the CMS Million Hearts analyzed for quality improvement. Initiative, and several other shared-cost savings payment models with private payers.7-9 OSUGIM Polypharmacy and De-prescribing pharmacists provide care that contributes to OSUGIM pharmacists play a key role in achievement of quality metrics resulting in polypharmacy management through performance-based incentive payments and comprehensive medication reviews. Medication care management fees. Impact on quality reviews occur through scheduled pharmacist metrics is tracked so the value of the pharmacist visits, scheduled team-based visits with a can be assessed and communicated. To do provider and pharmacist, and also on demand this, OSUGIM pharmacists have transitioned to during other provider visits. Comprehensive documenting in EMR documentation formats medication reviews can be requested by that contribute to tracking quality metrics and another provider or initiated by the pharmacist can be integrated into reports for quick analysis reviewing clinic patient schedules and of outreach volume. identifying patients who could benefit from OSUGIM pharmacists work to track the service. Pharmacists also use medication improvement in mean A1C, percentage of therapy management platforms to provide and patients with A1C >9% and percentage of bill comprehensive medication reviews. patients with BP <140/90. Additionally, pharmacists track the percentage of Sustainability and Outcomes TCM outreaches completed per patients Since inception, OSUGIM pharmacists have discharged from an OSU facility and track the worked to financially justify the pharmacist- improvement in ASCVD risk scores for high provided care in a fee for service system risk primary prevention cardiovascular patients through use of incident-to and OutcomesMTM enrolled in the Million Hearts Cardiovascular billing. Additionally, pharmacists supplement Disease Risk Reduction Model.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 35 The Ohio State University General Internal Medicine Clinics COLUMBUS, OH

Innovations/Future Plans 2. Centers for Medicare and Medicaid Future plans focus on expanding chronic Services. MLN Fact Sheet: Transitional disease management through collaborative care management services. January practice. We are working to identify models 2019. Available at: https://www.cms.gov/ of care that allow pharmacists to function outreach-and-education/medicare-learning- as the chronic disease care provider and network-mln/mlnproducts/downloads/ increase access to our physician providers for transitional-care-management-services-fact- higher acuity care while also achieving better sheet-icn908628.pdf. Accessed June 7, 2019. health outcomes for our patients. We are also 3. Otsuka SH, Tayal NH, Porter K, et al. exploring the creation of collaborative practice Improving herpes zoster vaccination rates agreements for management of depression through use of a clinical pharmacist and a and anxiety. personal health record. Am J Med. 2013;126: 832 e 1–6. Key Lessons Learned 4. Barnes KD, Tayal NH, Lehman AM, Beatty n Pharmacist accessibility and visibility in the SJ. Pharmacist-driven renal medication clinic is imperative. Shared working spaces dosing intervention in primary care patient- facilitate collaboration. centered medical home. Pharmcotherapy. 2014;34:1330–5. n Working closely with other members of the healthcare team results in mutual trust. 5. Matthews DE, Beatty SJ, Grever GM, et al. Comparison of 2 population health n Use of clear, concise, and timely communication with the healthcare team management approaches to increase vitamin maximizes the efficiency and impact of B12 monitoring in patients taking metformin. patient care that can be provided by a Ann Pharmacother. 2016;50:840–6. pharmacist. 6. Coffey CP, Barnette DJ, Wenzke JT, et

n Understanding and sharing in the practice’s al. Implementing a systematic approach care goals helps to establish and expand to deprescribing proton pump inhibitor pharmacy practice in a PCMH or ACO. therapy in older adults. Sr Care Pharm. By working toward shared goals, the 2019;34:47–55. pharmacist becomes an indispensable part 7. Centers for Medicare and Medicaid Services. of the healthcare team. Comprehensive Primary Care Plus. Available

n Creating a sustainable practice model allows at: https://innovation.cms.gov/initiatives/ for expansion of the pharmacy team and comprehensive-primary-care-plus/. pharmacist scope of practice. Accessed June 7, 2019.

n Flexibility and adaptability are crucial for 8. Ohio Department of Medicaid. optimizing opportunities for pharmacist- Comprehensive Primary Care Program. provided care in an ever-changing Available at: https://www.medicaid.ohio.gov/ healthcare environment. Provider/PaymentInnovation/CPC. Accessed June 7, 2019. References 9. Centers for Medicare and Medicaid. 1. Patel MS, Arron MJ, Sinsky TA, et al. Million Hearts Cardiovascular Disease Risk Estimating the staffing infrastructure for a Reduction Model. https://innovation.cms. patient-centered medical home. Am J Manag gov/initiatives/Million-Hearts-CVDRRM/. Care. 2013;19:509–16. Accessed June 7, 2019.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 36 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Park Nicollet Health Services MINNEAPOLIS, MN

Author: Molly Ekstrand, BPharm, BCACP, AE-C Contact: [email protected]

Organizational Contact: Dan Rehrauer, PharmD Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Integrated Delivery Network

Value-based model type ACO and PCMH

Number of pharmacists 10 (9.1 FTE)

Number of clinics/patients 15 clinics; 13 primary care, 1 chronic pain management, 1 infectious covered by pharmacists disease. Funding model of Pharmacists are salaried through the health-system. pharmacists Delivery mode for patient face-to-face (67%), and telephonic (33%) visits Average duration of New visits 60 minutes, Follow-up visits 30 minutes pharmacist visit Collaborative practice Yes—allows for the pharmacist to stop, start, and modify agreement in place medication therapy and order labs for 13 conditions Billing codes used 99605, 99606, and 99607 only

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 37 Park Nicollet Health Services MINNEAPOLIS, MN

Background coordinator, certified medical assistants, panel Park Nicollet is an integrated care system, managers, front desk staff and RN triage. based in Minneapolis, Minnesota and the The primary focus of the MTM pharmacists surrounding suburbs. It is part of the is direct patient care through the delivery HealthPartners family of care and includes of comprehensive medication management Park Nicollet Methodist Hospital, Park Nicollet (CMM) services. This patient-centered service Primary Care and Specialty Clinics. Park ensures that an individual patient’s medications Nicollet Health Services has participated in are indicated, effective, safe and convenient. value-based contracting with most Minnesota In this context, pharmacists provide disease Commercial Payers since 2011 and began management services while practicing under participating in the Center for Medicare and a broad collaborative practice agreement Medicaid Service Pioneer Accountable Care (CPA) that is approved system-wide through Organization (ACO) Program in 2011, which primary care and several specialty lines. evolved to the Next Generation ACO program The CPA includes disease-specific clinical in 2016. Concurrent with its ACO development, frameworks for the management of asthma, Park Nicollet began adopting the patient- benzodiazepine taper, COPD, diabetes, HIV and centered medical home (PCMH) model in HIV pre-exposure prophylaxis, hypertension, its primary care practices. Park Nicollet hypothyroidism, lipid management, naloxone, Health Services employs many pharmacists opioid taper, therapeutic interchange, and throughout the health-system in a variety of tobacco cessation. Pharmacists also participate both traditional and innovative roles. in population healthcare conferences, quality improvement projects, clinic initiatives, In 2011, as part of that PCMH transition, or health-system workgroups to improve pharmacy leadership conceptualized a medication utilization and related healthcare program that would integrate pharmacists quality goals. into primary care practices as medication specialists. The medication management “Having the MTM pharmacist in the clinic with (MTM) department began in 2011, starting personal relationships to patients and clinicians with two primary care sites and three (2.2 makes their input much more valuable than a FTE) pharmacists, growing steadily over the letter from a health plan. A strong [internal] years. In 2019, Park Nicollet employed 10 MTM MTM program has the ability to take over some pharmacists (9.1 FTE), one PGY1 pharmacist of the potentially duplicative or costly work resident (1.0 FTE), one non-pharmacist patient done by health plans in a more integrated, outreach coordinator (1.0 FTE), and one clinically relevant way. I can no longer imagine pharmacist leader (1.0 FTE). MTM pharmacists practicing without our healthcare home teams, are embedded in the care teams at 13 primary and our medication management pharmacist is care sites (65%) and 2 specialty sites: Pain a crucial member,” remarked Bernt Helgaas, MD, Management and Infectious Disease/HIV. Med/Peds Maple Grove Clinic Medical Director. The MTM department is able to utilize The Model: How it Works primary care department support staff and MTM pharmacists practice alongside their system resources. The front desk teams PCMH care team members. These teams check-in arriving patients or schedule CMM typically include physicians, advance practice follow-up visits, and the central call center clinicians, an MTM pharmacist, registered schedules appointments for CMM. Certified nurse care coordinators, a social worker care medical assistants are available to administer

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 38 Park Nicollet Health Services MINNEAPOLIS, MN

immunizations if needed. In addition to the CMS ACO are referred for CMM services. scheduling appointments from the internal The MTM department may also have separate referral queue, the medication management CMM patient engagement goals specific to patient outreach coordinator is dedicated payer-identified patients. In 2019, the MTM to special populations and proactive ACO department was working with four different engagement strategies. payers.

MTM leadership works closely with the ACO/ The MTM department has been able to access Population Health department to review the health-system’s informatics and technology stratified patients and develop a strategy resources. Generally, measures and metrics for MTM pharmacists to contribute to for the MTM department are intentionally patient clinical and financial outcomes. MTM aligned with the Triple Aim. Pharmacists have leadership collaborates with the Clinical full access to the electronic medical record Quality Improvement department to optimize (EMR). An EMR security template was created quality goals that are impacted by medication for MTM pharmacists to differentiate scope utilization. of practice and authorize certain activities Patients engage with medication management apart from other PCMH team members. MTM services in several ways. The MTM department pharmacists maintain a unique schedule in receives an average of 385 internal referrals the EMR. Pharmacist utilization and patient each month. Patients may be specifically access to pharmacist care is measured referred by their Park Nicollet primary care or through slot utilization reports. Patient visits specialty clinicians. Often these referrals are for are correlated to the pharmacist and their a comprehensive medication review or disease National Provider Identifier (NPI) number. management services. Additionally, patients MTM CPT Codes (99605, 99606, 99607) are may be identified through clinic specific the only codes utilized by the pharmacists to initiatives. Park Nicollet also has partnerships allow for capture of the unique patient care with several externally owned Skilled Nursing service provided only by pharmacists. Patient Facilities (SNFs). When patients transition back level data and metrics from pharmacist visits to independent living after a transitional care are captured through Epic using SmartData unit stay, these SNFs will refer Park Nicollet- elements, SmartForms, unique pharmacist attributed patients for a care transitions departments, and visit types. An annual patient CMM consultation. Community and hospital satisfaction survey is deployed through the pharmacist colleagues may also refer patients organization’s research institute each year for they identify into medication management each pharmacist. services. “Every aspect of the Park Nicollet care delivery In some cases, patients are proactively system, from hospitalist services, to specialty identified for CMM services. These patients services, to primary care services, is benefiting are then invited to participate by the MTM from medication optimization through department outreach coordinator. With ACO Medication Management Pharmacy Services. and population health initiatives, internal Especially, this is a tremendous service to colleagues may risk-stratify populations our patients, who benefit very directly from using a number of different data points and addressing barriers to medication adherence,” identify patients appropriate for CMM and observed Thomas Martens, MD, Internal other interventions. For example, all patients Medicine Brooklyn Park Clinic and Primary in the End Stage Renal Disease sub-group of Care Diabetes Quality Medical Director.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 39 Park Nicollet Health Services MINNEAPOLIS, MN

Sustainability and Outcomes 4. Hyperlipidemia (885) 6% MTM pharmacists receive a salary through the 5. Antithrombics (766) 5% pharmacy department and are credentialed in 6. Tobacco Use (399) + Asthma (340) + the health-system and enrolled as providers COPD (281) 7% with eligible payers. When possible, CMM visits are billed using MTM CPT codes; however, only Work with five priority patient populations in approximately 20% of CMM visits qualify for 2018 with shared goals with health plans: fee-for-service reimbursement. Leadership understands that the MTM department n Total patients provided proactive CMM operates “in the red” each year based on outreach: 1,601

direct reimbursement and recognizes the CMM n Priority population CMM engagement rates: service as a core component to our bundled 31% to 89% services that contribute to success in improving healthcare quality and reducing total cost of n Achievement of Pay for Performance care in value-based contracts. When considering Contracts for CMM engagement rates the numerous alternative contracting (e.g., CMR Completion Rate) methods with payers, all of which transcend Park Nicollet Health Services has long fee-for-service reimbursement, medication demonstrated financial success in quality-based management services, unless contractually pay for performance contracts. Park Nicollet specified, are considered a covered benefit for Health Services is consistently a top performer patients in the Park Nicollet system. in Minnesota Healthcare Quality as measured in The MTM department strives to demonstrate the state mandated reporting Minnesota Health optimal utilization of the pharmacists and Scores. Park Nicollet Health Services is also alignment of services to system quality and nationally recognized as succeeding in ACO/ financial goals. Average performance on Value & Risk based contracting. In both the monthly system utilization measures include: CMS Next Generation ACO Model site and in Becker’s Hospital Review, 2019 ACOs to Know, n 385 internal referrals Park Nicollet is recognized for innovation and n 93% average patient care slot utilization, financial success. demonstrating full pharmacist schedules In the team-based PCMH care model at n 827 Comprehensive Medication Park Nicollet, there is pride in knowing that Management encounters everyone is contributing to the financial

n 498 unique patients success of the organization. While it is directly difficult to link any of the financial n 1,260 Medication Therapy Problems success specifically to the contributions of identified and 76% considered resolved the MTM pharmacists, there is a belief that implementing risk stratification strategies to Pharmacist work aligned with quality goals: determine which patients will most benefit n Medication Therapy Problems identified for from pharmacists’ services is a successful conditions aligned with quality goals: (total) strategy. One unpublished internal analysis % of total MTPs of medication management services has 1. Hypertension (2,914) 18% suggested a Total Cost of Care reduction of up to 27% in high-risk populations, mainly 2. Diabetes (2,375) 15% through reduction of inpatient stays and 3. Pain Control (2,157) 14% utilization of high-cost medical care.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 40 Park Nicollet Health Services MINNEAPOLIS, MN

Innovations/Future Plans Key Lessons Learned

Park Nicollet has been conservative in n Pharmacists must define and differentiate recent years with respect to growth of the their service so that it is complementary in MTM department. While pharmacists have the PCMH team and maintain consistency experienced success with PCMH teams, quality across the program. measures, and ACO models, there are other n Invest in informatics that efficiently capture forces contributing to a volatile healthcare necessary data elements without external environment. Mergers, acquisitions, and platforms and double documenting. moving payment models inhibit investment in resources without a direct reimbursement n Identify areas where CMM can truly be model. Opportunity exists to continue to effective in preventing future risk and risk refine risk stratification models and proactively stratify patients to identify those most likely identify and engage high-risk populations to benefit from services. appropriate for CMM services. Demand is n While the program should align with exceeding supply of CMM services at Park broader system goals, each practice should Nicollet. There is opportunity to expand in be flexible and encourage innovation to both primary care and specialty services lines. address its unique needs. In July 2019, the Park Nicollet MTM program became more formally aligned with the HealthPartners health plan.

Pharmacists must define and differentiate their service so that it is complementary in the PCMH team and maintain consistency across the program.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 41 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Providence St. Joseph Heritage Healthcare FULLERTON, CA

Author: Jelena Lewis, PharmD, BCACP Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Medical group

Value-based model type ACO/PCMH

Number of pharmacists 12 pharmacists; 2 are 0.2 FTE, 4 are 0.8 FTE, and 6 are 1.0 FTE

Number of clinics/patients 22 clinics with Medical Group plus Affiliated Physicians (we do not covered by pharmacists have the exact number for this) Funding model of Salaried, contracted, co-funded pharmacists (salaried, contracted, leased, other) Delivery mode for patient Face-to-face, telephonic, telehealth visits Average duration of 60 minutes initial visit, 30 minutes follow-up visit, 20 minutes pharmacist visit telephonic visits Collaborative practice Yes. Duties delegated: agreement in place n Order, initiate, modify, discontinue medications

n Provide refills

n Order and interpret labs

n Refer to other providers Billing codes used Not currently used

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 42 Providence St. Joseph Heritage Healthcare FULLERTON, CA

Background for the management of comprehensive type Founded in 1994, St. Joseph Heritage 2 diabetes (excluding gestational diabetes Healthcare (which recently became a part of mellitus), hypertension, and dyslipidemia. Providence health-system) is an Accountable The physician could refer a patient with any Care Organization (ACO) with over 900 of these three disease states; however, a medical group providers and approximately comprehensive diabetes referral automatically 175 clinics. St. Jude Heritage Medical Group included management of dyslipidemia and/ (SJHMG) located in Fullerton, CA is part of or hypertension if the pharmacist felt it was Providence St. Joseph Heritage Healthcare clinically appropriate. Under the CPA, the and one of the eight medical groups in pharmacist is able to autonomously prescribe California. In 2017, SJHMG began piloting a medications (i.e., initiate, modify, discontinue), team-based care model that consisted of six order and interpret labs, provide refills, refer primary care physicians (PCPs), one nurse to other providers, and perform foot exams practitioner, one registered nurse, and one in addition to providing education about the case manager. Because most team-based care patient’s chronic condition for patients referred programs include pharmacy services1, the initial to the program. lack of a pharmacist on the team created a Initially, there was no formal referral system good opportunity for a partnership between built into the EMR. The physician lead referred Chapman University School of Pharmacy and many of his patients to the clinical pharmacist Providence St. Joseph Heritage Healthcare. This via task messages, but other physicians did partnership provided one clinical pharmacist not refer many patients at the beginning of faculty member from Chapman University the program. To help generate referrals, the School of Pharmacy to be on site at the clinic pharmacist attended huddles (5 to 10-minute two days each week. The pharmacist’s goal meetings with all providers at the site) during was to develop a pharmacist-run, collaborative which the pharmacist reminded the physicians practice agreement (CPA) facilitated, disease about the DSM program and answered any state management (DSM) program within the questions they had about the program. physician office practice at SJHMG. Additionally, the clinical pharmacist was provided with reports which included patients After meeting with the administration, the with hemoglobin A1C values clinical pharmacist met with the physician lead ≥7% and would for team-based care at SJHMG to discuss the reach out to those patients’ provider for a focus and the purpose of the DSM program. referral. This helped increase the number of Additionally, the pharmacist also met with all referrals as the providers were generally willing the healthcare providers at the site to present to refer their patients to the DSM program. information about the clinical pharmacy Patients who were referred to DSM were services to be provided at the site, why there seen in-office for a 60-minute initial visit and is a need for the services, how to refer patients 30-minute follow-up visits. The pharmacist also to the pharmacist, and relevant laws governing delivered services to some patients via phone clinical pharmacy practice in California. or via a patient portal built within the EMR. During the first 6-months of the program, The Model: How it Works the pharmacist received 73 new referrals. The primary focus of the initial DSM program Interventions were documented manually in was to help PCPs at the practice site with an Excel sheet. With the help of Providence outcome measures such as hemoglobin A1C St. Joseph’s ACO partner, Blue Shield, the and blood pressure levels. The CPA was written cost savings component was attributed to

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 43 Providence St. Joseph Heritage Healthcare FULLERTON, CA

each intervention. Cost savings produced and can educate other parties about the role of by interventions were estimated based on a pharmacists and pharmacy services within the study of the clinical and economic outcomes organization. associated with pharmacist recommendations Other changes that resulted from the that was performed at a VA Medical Center.2 expansion of the pharmacist’s role are the The data from the first 6 months of the creation of a formal referral system in the program made a compelling case for the value EMR which the PCPs can utilize to refer of the pharmacist, and the administration patients to the pharmacist, the addition supported streamlining the referral process. of a dedicated pharmacy technician who The clinical pharmacist was onboarded in the helps with scheduling for the pharmacy EMR as a mid-level provider and had their department, and the creation of an own schedule. The pharmacist also obtained interventions tracker within the pharmacy a California Advanced Practice Pharmacist encounter template in the EMR. Currently, license. Onboarding a pharmacist as a mid-level at each patient encounter, pharmacists provider for the first time within a healthcare document the type of visit (e.g., face-to-face, system redesigns workflow for many phone), the primary reason for the visit, time parties. Thus, a great deal of communication spent with the patient, and our interventions. was needed so that the IT department, Some of the interventions built into the EMR administration, and other providers understood for the pharmacists’ use include: the role of the clinical pharmacist within the n Medication Reconciliation organization. Challenges that needed to be addressed included educating office staff n Increase dose of medication regarding how to schedule patients for the n Decrease dose of medication pharmacist, building the referral system into the EMR, and a lack of support staff to room n Start new medication patients for the pharmacist. n Discontinue medication

In mid-2018, additional partnerships formed n Therapeutic interchange between Chapman University School of Pharmacy and Providence St. Joseph Heritage n Referral to other service

Healthcare to bring additional clinical faculty to n Prevent/manage ADE other sites within the healthcare organization. Furthermore, with the help of a grant provided n Lab/test needed for medication by Providence St. Joseph’s ACO partner, Blue n Lab/test needed for disease Shield, pharmacists have also been hired by n Drug-Drug/Drug-Disease Interaction Providence St. Joseph Heritage Healthcare. A formal pharmacy department has been n Disease State Education Completed formed by the Associate Vice President of Care n Medication Education Completed Management who hired a pharmacy supervisor and created a CARE Rx (Clinical Advocacy n Schedule Appointment with PCP and Reducing Expenses with Pharmacy) n Schedule Appointment with Other Ambulatory Clinical Pharmacy team, which includes the Chapman University faculty. This Pharmacists autonomously manage patients has helped resolve many of the issues we had under the CPA, (e.g., initiate medications, order in the beginning as the pharmacy supervisor labs) and route their note from the visit to the has presence throughout the health-system referring physician within 24 hours.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 44 Providence St. Joseph Heritage Healthcare FULLERTON, CA

Sustainability and Outcomes Associate Vice President, Joyce Komori, The pharmacy department does not bill for RN, MSN, states “the evolution of the CARE services. The pharmacists are funded through Rx program and rebuilding the support three models: 1. Chapman School of Pharmacy infrastructure with EMR enhancements has faculty who practice 2 days per week and already shown an improvement in patient care are fully funded by the University, 2. clinical and clinical outcomes. The CARE Rx team faculty from Chapman School of Pharmacy is foundational to the disease management who practice 4 days per week and are co- strategies we are deploying at our organization funded by St. Joseph Heritage through a Blue and we are proud of the partnership we have Shield grant for the first 2 years and also by with Chapman University faculty who bring the University, and 3. clinical pharmacists who current, evidence-based clinical discipline to practice 5 days a week who are funded by our patient care.” Providence St. Joseph Heritage through a Blue Shield and SCAN grant for the first 2 years. We Innovations/Future Plans currently also have one pharmacy technician We aim to continue to expand awareness coordinator funded by Blue Shield and SCAN throughout the organization about the money; we are hoping to hire 2 more. After the pharmacy services and their value to develop 2-year grant, the program will continue to be support for service expansion. Our goal is to supported by Providence St. Joseph Heritage. expand our disease management programs Because some of the pharmacist program to include heart failure, COPD, asthma, and is funded by Blue Shield and SCAN grant perhaps build residency programs. monies, there is a focus on population health We will be hiring a post discharge pharmacist management for full-risk ACO patients. to help us with medication reconciliation for Interventions are performed by clinical our patients. We are starting to use telehealth pharmacists who see patients in clinic and in some of our clinics and hope to expand the have telephonic visits for disease management. use of this service. Additionally, we have a total Additionally, through the grant monies, we of 11 primary care sites in Northern California have also been able to hire one refill center that we will start to support. pharmacist to oversee our refill center department as well as one managed care Key Lessons Learned pharmacist. As our focus is on improvement of quality metrics and containing medication n Collaboration is key. costs, we do not bill for our services in the n Administration support and physician current state but aim to do so in the future. buy-in to pharmacy services are extremely Hemoglobin A1C outcomes, adherence, important both during implementation and therapeutic interchange, cost assistance, throughout ongoing operations. medication reconciliation and education are some of the key areas we are targeting n Healthcare providers at each site that has currently. Specific metrics that are evaluated pharmacy presence need to be educated on include statin adherence, A1C values, blood the pharmacist’s role and scope of practice. pressure, ensuring a yearly albuminuria and Regular team meetings or “huddles” are eye exam for patients with diabetes, and helpful for providing and reinforcing this ensuring that patients with albuminuria receive information. treatment with an ACEI or ARB.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 45 Providence St. Joseph Heritage Healthcare FULLERTON, CA

References

n Support staff and administrative personnel 1. Schottenfeld L, Petersen D, Peikes D, et who are dedicated to supporting the al. Creating Patient-Centered Team-Based pharmacist are important to support a Primary Care. AHRQ Pub. No. 16-0002- growing and successful practice. EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2016. n Pharmacists who demonstrate improvements on quality metrics can use 2. Lee AJ, Boro MS, Knapp KK, et al. Clinical this information to demonstrate their value and economical outcomes of pharmacist and encourage decision makers to embed recommendations in a Veterans Affairs them in clinical practice sites. medical center. Am J Health-Syst Pharm. 2002;59:2070–7.

Healthcare providers at each site that has pharmacy presence need to be educated on the pharmacist’s role and scope of practice. Regular team meetings or “huddles” are helpful for providing and reinforcing this information.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 46 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

Think Whole Person Healthcare OMAHA, NEBRASKA

Authors: Sara Woods, PharmD, BCACP; Shannon Peter, PharmD; and Nabil Laham, PharmD Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Primary care center, community pharmacy

Value-based model type ACO

Number of pharmacists 9 community, 9 clinical (18 FTEs)

Number of clinics/patients Approximately 40,000 patients in this single clinic covered by pharmacists Funding model of Pharmacists are salaried pharmacists (salaried, contracted, leased, other) Delivery mode for patient Face-to-face; telephone visits Average duration of 15 minutes for anticoagulation visits pharmacist visit 30 minutes for transitions of care visits 15-60 minutes for other pharmacy visits pending reason Collaborative practice Yes—allows for pharmacists to initiate, modify, and discontinue agreement in place therapy, authorize refills, and order PT/INR for point-of-care testing Billing codes used 99211—used for anticoagulation visits with INR out of range MTM billing through Outcomes MTM and Mirixa Billing through Medwise (Tabula Rasa) for the Enhanced MTM program Physician billed, with pharmacist collaboration for Transitional Care Management: 99495/99496, 1111F for medication-reconciliation post-discharge, chronic care management codes

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 47 Think Whole Person Healthcare OMAHA, NEBRASKA

Background The Model: How it Works Think Whole Person Healthcare (Think) is a Think offers a robust amount of both large, independent, primary care center in dispensing and clinical pharmacy services Omaha, Nebraska, that opened in July 2015 and with pharmacists, interns, and technicians serves over 40,000 patients in the Metro area. working together. There are nine clinical Think is an Accountable Care Organization pharmacists and ten technicians assigned to (ACO) with multiple payers since 2016, and support primary care provider teams. These with a Medicare Advantage Plan since 2019. pharmacists manage panels of patients Think is also a Track 2 site for Comprehensive with their providers and work to optimize Primary Care Plus (CPC+) since January of medications. When first meeting with patients, 2018. Think opened as a partnership with the pharmacists identify necessary changes several primary care provider investors along and work on a plan to synchronize chronic with backing from BCBSNE. medications to be dispensed together and to coordinate compliance packaging when Think uses a team approach, including requested. Clinical pharmacy technicians are coordination of care with physicians, paired with each clinical pharmacist to assist pharmacists, care coordinators, nurses, with refill calls, prior authorization requests, and various specialist services. These in- synchronizing, and delivery services. They house services include dentistry, mental contact patients via phone, a secure texting health, optometry, physical therapy, diabetes platform, or an integrated patient portal per education, and podiatry along with onsite patient request. labs, x-ray, CT, mammography, ultrasound, and DEXA scans. Think also has an onsite urgent Working alongside providers within a CPA, care and pharmacy with extended hours for the clinical pharmacists can initiate, modify, patients. Think physicians and clinicians see change, or discontinue therapies, focusing over 2,500 patients weekly, with a mission to on chronic disease management, transitions provide better outcomes for patients, give of care, and population health strategies. them an enhanced health experience and to Patients can be referred for pharmacists’ lower the cost of care by treating the whole services in several ways, including provider to person. Think utilizes Allscripts EHR as an pharmacist, pharmacist to provider, pharmacist electronic health record and QS1 for the on-site to patient, or patient to pharmacist. Generally, community pharmacy. pharmacists target patients with five or more chronic medications or patients who have Upon opening in 2015, Think committed the chronic disease states. Common appointment initial investment to support the integration types that patients are seen for include but are of pharmacy services in the clinic. Clinical not limited to: pathways were developed with interdisciplinary teams in order to facilitate collaborative n Anticoagulation monitoring services practice agreements (CPAs) and the impact n Transition of care visits that pharmacists have in the clinic. As time has elapsed since opening, our pharmacy n Device teaching services continue to grow and develop based n Comprehensive medication reviews on the needs of the clinic population and administration. n Chronic disease follow-ups (e.g., hypertension, diabetes, pain management)

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 48 Think Whole Person Healthcare OMAHA, NEBRASKA

The pharmacy department implements several n Increased dispensing volumes of population health initiatives annually to prescriptions through Think Pharmacy. The improve outcomes for the patients and achieve onsite dispensing pharmacy is now the organizational goals. Some projects include highest-volume independent pharmacy in increasing statin use in patients with diabetes, the Midwest. chronic kidney disease identification and n MTM claims through platforms such as dose adjustments, and pharmacovigilance for OutcomesMTM and Mirixa for direct revenue duplications of therapy. The department uses and to improve pharmacy Star Ratings and several methods of communication, including reduce DIR fees. a new healthcare texting platform, for patients to communicate with their pharmacists and n Incident-to physician billing for caregivers in a more efficient and personalized anticoagulation monitoring appointments manner for refill reminders, immunization using code 99211. reminders, and chronic disease follow-up. Think n Contributing to tracked time spent is different from many other PCMH and ACO managing patients enrolled in our chronic practices as the on-site community pharmacy care management (CCM) program with allows for easy adherence monitoring and cost CCM codes comparisons. n Medication reconciliation claims identified In the on-site community pharmacy, there by an insurer for patients transitioning care are nine pharmacists who are supported by with 1111F and transition of care codes. technicians to dispense prescriptions and offer patients delivery and adherence packaging The second prong, which we are poised to services free of charge. The community rely on for long term viability, is the value our pharmacists have access to the electronic pharmacy team brings to the clinic in gain- health record to support involvement in the sharing dollars through our ACO contracts. care team. Vaccinations that are covered The practice has seen that when patients through pharmacy benefits are provided in the work with a clinical pharmacist through Think pharmacy and vaccinations covered through and use the onsite pharmacy, adherence medical benefits are coordinated with the on- improves, the price per prescription dispensed site urgent care clinic. The pharmacy partners is reduced, generic utilization rates increase, with several local businesses to coordinate and overall healthcare costs as reported to delivery-to-work services for large companies us by claims data from multiple insurers are in the surrounding area. In addition to all the reduced. As we look to the future, our clinical dispensing services, Think’s pharmacy also initiatives are largely targeting improving the hosts the largest drug takeback initiative in the cost and quality of care for our high-cost, state of Nebraska. high-risk patients identified through our ACOs. The clinical pharmacist team also focuses on Sustainability and Outcomes helping to reduce gaps in care (e.g., statin use in patients with diabetes) for the entire Sustainability for the pharmacy program has population. Other metrics of focus include a two-pronged approach. The first prong statin use in cardiovascular disease, adherence is through fee-for-service methods, which measures for hypertension, hyperlipidemia, includes the following strategies: and diabetes, medication reconciliation post discharge, A1C control, and more.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 49 Think Whole Person Healthcare OMAHA, NEBRASKA

Think has a robust analytical team that pulls incorporating patient care and pharmacy data from insurance claims, electronic health services continuing as the company grows records, dispensing platforms, and other and develops. Think is continuing to grow sources. The pharmacy management team relationships with providers and specialists works with the analytical team to design in the Omaha area with hopes to expand our and refine reporting measures to determine impact for patients. The pharmacy team is the impact the team is making across our also continually working to improve tracking various initiatives as well as in our day-to-day and reporting of more clinical outcomes, to work. This has been used to plot refill data, both guide future initiatives and to report on adherence claims for patients, and clinical changes in biometric markers, increases in outcomes. adherence, and cost savings that result from pharmacy services. Innovation/Future Plans Since opening, the pharmacy department Key Lessons Learned has spearheaded several initiatives, working n Remaining abreast of healthcare system alongside clinic providers and leadership to changes allows pharmacists to recognize identify and execute projects to optimize emerging opportunities to provide clinical patient outcomes. One example initiative services. developed through this process was the n Be flexible and willing to adapt to changing decision by Think to have a pharmacist do a market conditions. face-to-face medication review at the start of every transition of care appointment scheduled n Building personal relationships with primary for a patient on 5 or more medications. care and specialist provider colleagues is crucial for providing effective patient care. Think Whole Person Healthcare will continue to put the patient at the center of healthcare n Recommendations that are direct, specific, and strive to improve primary care services and thorough are more likely to be accepted and coordination of care, with support for by other providers.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 50 Successful Integration of Pharmacists in Accountable Care Organizations and Medical Home Models: Case Studies

University of Washington Medicine SEATTLE, WA

Author: Rena Gosser, PharmD, BCPS Contact: [email protected]

Practice Site Details

DETAIL SITE INFORMATION Practice setting type Health-system

Value-based model type ACO, PCMH

Number of pharmacists 22 (18.4 FTE)

Number of clinics covered 14 by pharmacists Funding model of Salaried pharmacists (salaried, contracted, leased, other) Delivery mode for patient Face-to-face, telephonic. visits Currently exploring telehealth options in our UWNC. Average duration of 30 minutes pharmacist visit Collaborative practice Yes; Pharmacists can initiate, modify, and discontinue therapy and agreement in place order laboratory tests and vaccines Billing codes used Pharmacist professional billing (complexity/time) Hospital-Based & Neighborhood Clinic Billing:

n E/M 99201-99205 n E/M 99211-99215 Facility billing (Hospital based clinics for Medicare) “Incident to” (UWNC-physician based clinics for Medicare)

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 51 University of Washington Medicine SEATTLE, WA

Background organizations to share best practices and The University of Washington (UW) Medicine collaborate to achieve medication-related is a comprehensive, integrated health-system annual goals, and promote the value of in the Pacific Northwest that provides high clinical pharmacy services to realize success quality, ambulatory care for patients at on medication-related quality measures. The Harborview Medical Center (HMC), Northwest UW Medicine ACN pharmacy committee Hospital (NWH), UW Medical Center (UWMC), is chaired by the UW Medicine population UW Neighborhood Clinics (UWNC), and Valley health pharmacist who develops and Medical Center (VMC). Clinical ambulatory coordinates action plans across UW Medicine pharmacists are well established in hospital- ACN organizations to optimize medication based primary care and specialty clinics prescribing. The UW Medicine population at HMC, UWMC, and VMC. The University health pharmacist also coordinates medication of Washington is recognized as a Practice prescribing improvement initiatives, tracks Transformation Network by the Centers for and reports pharmacoeconomic trends, and Medicare and Medicaid Services. Additionally, develops and implements drug-use policies the UW Neighborhood Clinics have received under the guidance of the assistant director recognition from the National Committee of pharmacy clinical services, who oversees for Quality Assurance as a Level 3 Patient ambulatory pharmacy practice across UW Centered Medical Home. Medicine.

To address the changing healthcare The Model: How it Works environment from fee-for-service to value- based care, the UW Medicine Accountable The UW Medicine population health pharmacist Care Network (UW ACN) was established in is responsible for the identification of target 2014 to lead care transformation in the region. populations that may benefit from medication The UW ACN delivers a patient-centered management. Target populations primarily approach to healthcare that prioritizes the focus on those identified in medication related patient experience, improves the health Healthcare Effectiveness Data and Information of the population, and lowers the cost of Set (HEDIS) and Pharmacy Quality Alliance care. It is composed of 9 health-systems, 20 (PQA) measures. Various analytics platforms hospitals, 1,400+ clinics, 1,000+ primary care are used to leverage data, which are both providers, 5,000+ specialists, and more than internally generated by the UW Medicine 60 independent group practices and care Population Health Analytics (UWPA) team providers throughout the Puget Sound region. and externally generated by payers. Reports UW Medicine provides centralized leadership created by the UW Medicine population health and administrative support for the ACN, pharmacist and UWPA are then shared with including funding of a centralized population the Assistant Director of Pharmacy Clinical health pharmacist, with member organizations Services and the appropriate pharmacy participating in committees focused on manager to operationalize interventions at strategic initiatives.1 the respective ambulatory clinic. Ambulatory clinical pharmacists then collaborate with The UW Medicine ACN Pharmacy Committee support staff, care managers, nurses, and was created in 2015 to identify, prioritize, providers at individual clinic sites to confirm and implement high value prescribing appropriateness of patient contact and opportunities, provide a forum for pharmacy coordinate to meet the care needs of patients leadership from UW Medicine ACN identified in reports.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 52 University of Washington Medicine SEATTLE, WA

In Washington state, collaborative practice David C. Dugdale, MD, FACP, Medical Director, agreements are called collaborative drug Hypertension Population Health and Medical therapy agreements (CDTAs). CDTAs Director, Accountable Care. are established with clinic leadership to Patient outcomes for diabetes management provide pharmacists the authority to act also showed positive results. The UWNC autonomously to manage medication therapy pharmacist co-managed 15 patients with a for most chronic disease states. Under 3- to 6-month hemoglobin A1C follow up, CDTAs, pharmacists can initiate, modify, and demonstrating an average A1C reduction of discontinue therapy as well as order laboratory 1.0% to date. tests and vaccines. Providers may refer patients to clinic pharmacists identified during In response to the opioid epidemic and clinic visits or via population health reports for regulatory changes, UW Medicine sought to focused medication management that meets pilot a pharmacist intervention on population individual patient care needs. Targeted system- opioid use, promoting opioid stewardship wide initiatives may establish agreed-upon and education on opioid taper strategies. A referral criteria to further promote pharmacist key measure was to determine the change co-management for select disease states. in average morphine milligram equivalent Outreach to patients for face-to-face visits (MME) dose at baseline and after provider- with the pharmacist is accomplished by use led implementation of pain pharmacist of e-Care messages in the electronic health recommended opioid tapering plans for record, marketing flyers describing the role of patients with chronic, non-cancer pain. Change the clinic pharmacist, and formal biographies in patient pain, function, and satisfaction available on clinic websites. Patient outcomes were also evaluated. After implementation of are tracked via internal quality measure opioid taper plans across a 6-month period, dashboards, with the ability to filter to assess average MED decreased from 258 to 225 performance by clinic and pharmacist. morphine milligram equivalents across the UWNC pilot sites. Patient pain, function and UW Medicine is currently conducting a satisfaction did not differ by a significant level pharmacist-driven hypertension (HTN) between patients who underwent the tapering management initiative in a pilot UWNC site. plan versus those who did not. This pilot The UWNC pharmacist co-manages patients provided a preliminary look at the outcomes with uncontrolled HTN and medication of pain pharmacist expertise on opioid taper management needs as identified centrally by recommendations. However, further exploration the UW Medicine population health pharmacist utilizing direct pain pharmacist engagement in using pre-specified criteria. The purpose of chronic pain follow-up appointments in a team- this grant funded HTN management initiative based, opioid tapering program is warranted. is to evaluate and justify the value of clinical pharmacy services in helping patients achieve goal blood pressure (BP) and meet quality Sustainability and Outcomes measure targets. At 6 months, 73% of patients Published studies, national guidelines, and who completed at least one visit with the internal evaluations are collated and presented UWNC pharmacist were able to achieve and to UW Medicine leadership to demonstrate sustain target BP goals. ” “It has been very the value of integration of clinical pharmacists satisfying to collaborate with our clinical on the care team upon exploration of pharmacists on innovations to improve blood system-wide medication management pressure control for our patients,” remarked initiatives.2-13 Projected revenue generation

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 53 University of Washington Medicine SEATTLE, WA

and professional billing estimates may be developed include pharmacist-led interventions calculated to demonstrate coverage of a on comprehensive diabetes care management, significant portion of the pharmacist salary and optimization of billing via pharmacist support staff assistance. In Washington State, involvement in chronic care management, pharmacists are now recognized as providers and active pharmacist engagement in a in commercial health insurance provider team-based opioid taper process across UW networks. Pharmacists may bill evaluation Medicine. and management (E/M) visits for commercial insurance with a provider’s order or referral on Key Lessons Learned file. The referral must indicate drug therapy modifications that can be completed per the n Establish positive relationships with established CDTA. Medicare patients may be physician leadership.

billed using incident to/facility only billing. Data n Ensure medical and pharmacy leadership on patient outcomes pre- and post-pharmacist share and convey common goals. intervention, in comparison to standard care, are used to justify the role of the pharmacist n Leverage internal pharmacist performance and may provide further potential savings or to use as proof of concept to expand cost avoidance. Additionally, grant funds are pharmacist services.

utilized when available to support the work of n Ensure data is translated into a format ambulatory clinical pharmacists. that identifies key patient populations for Pharmacist professional billing was targeted initiatives. implemented in March 2019. In the first 6 months, approximately 50% of the UW References Neighborhood Clinic pharmacist was 1. UW Medicine Accountable Care Network. supported by reimbursement from billed visits. Available at: https://www.uwmedicine.org/ Professional billing was also implemented in aco. Accessed May 10, 2019. our hospital-based clinics as well. However, given payer mix and billing rules, we anticipate 2. Fabel PH, Wagner T, Ziegler B, et al. that less than 50% of the pharmacist’s salary A sustainable business model for will be covered by revenue generated from comprehensive medication management billing. in a patient-centered medical home. J Am Pharm Assoc. 2019;59:285–90. Innovations/Future Plans 3. Boren LL, Locke AM, Friedman AS, et al. Future enhancements to these initiatives Team-based medicine: Incorporating a include pharmacist-led HTN management clinical pharmacist into pain and opioid expansion to hospital based clinics at HMC practice management. PM R. 2019;11:1170–7. and UWMC, telehealth HTN visits for patient outreach and intervention, deployment of 4. Thielemier B, Tu A. Pharmacists’ impact ambulatory BP devices with telemonitoring on quality measures and opportunities for capability for assessment of non-office visit pharmacy enhanced services. America’s BP readings, and a benzodiazepine tapering Pharmacist. May 2017. Available at: http:// process for patients prescribed concurrent, www.ncpa.co/issues/APMAY17-CE.pdf. chronic opioids. Additional initiatives being Accessed January 28, 2020.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 54 University of Washington Medicine SEATTLE, WA

5. Devine EB, Hoang S, Fisk AW, et al. 11. Woolf R, Locke A, Potts C. Pharmacist Strategies to optimize medication use in prescribing within an integrated health- the physician group practice: The Role of system in Washington. Am J Health Syst the Clinical Pharmacist. J Am Pharm Assoc. Pharm. 2016;73:1416–624. 2009;49:181–91. 12. Centers for Disease Control and Prevention. 6. Margolis KL, Asche SE, Bergdall AR, Methods and Resources for Engaging et al. Effect of Home Blood Pressure Pharmacy Partners. Atlanta, GA: Centers Telemonitoring and Pharmacist for Disease Control and Prevention, U.S. Management of Blood Pressure Control: The Department of Health and Human Services; Hyperlink Cluster Randomized Trial. JAMA. 2016. Available at: https://www.cdc.gov/ 2013;310:46–56. dhdsp/pubs/docs/engaging-pharmacy- partners-guide.pdf. Accessed January 28, 7. Cowart K, Olson K. Impact of pharmacist 2020. provision in value-based care settings: How are we measuring value added services? J 13. Centers for Disease Control and Prevention. Am Pharm Assoc. 2019;59:125–8. A Program Guide for Public Health: Partnering with Pharmacists in the 8. Planas LG, Crosby KM, Mitchell KD, et al. Prevention and Control of Chronic Diseases. Evaluation of a hypertension medication Atlanta, GA: Centers for Disease Control and therapy management program in patients Prevention, U.S. Department of Health and with diabetes. J Am Pharm Assoc. Human Services; 2012. Available at: https:// 2009;49:164–70. www.cdc.gov/dhdsp/programs/spha/docs/ 9. Moore JM, Shartle D, Faudskar L, et al. pharmacist_guide.pdf. Accessed January Impact of a patient-centered pharmacy 28, 2020. program and intervention in a high risk group. J Man Care Pharm. 2013;19:228–36. 10. Gatwood JD, Chisholm-Burns M, Davis R, et al. Impact of pharmacy services on initial clinical outcomes and medication among veterans with uncontrolled diabetes. BMC Health Serv Res. 2018;18:855.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 55 Glossary

340B Chronic Care Management (CCM) The federal drug discount program authorized A covered service in Medicare, Chronic Care under section 340B of the Public Health Management (CCM) applies to a non-face to Service Act and established by Congress under face care coordination with “patients with the Veterans Healthcare Act of 1992. “The two or more chronic health conditions that 340B programs requires drug manufacturers to are expected to last at least 12 months or until enter into pharmaceutical pricing agreements the death of the patient. A comprehensive with the Health and Human Services Secretary, care plan must be established, implemented, where manufacturers agree not to sell above revised, or monitored. CCM services include the the 340B ceiling price to covered entities.”1 following five core activities: using a certified electronic health record (EHR) for specified Accountable Care Organization (ACO) purposes, maintain an electronic care plan, ensure beneficiary 24-hour-a-day, 7-day-a- A voluntary group of doctors, hospitals, and week access to care, facilitate transitions of other healthcare providers, who convene to care, and coordinate care.”7 Care must be provide coordinated high-quality care to the provided for a minimum of 20 minutes (CCM) Medicare patients they serve. Patients benefit or 60 minutes (complex CCM) of non–face-to- through this “coordinated effort to get the face care management services per month.7 right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.”2,3 Comprehensive Medication Management (CMM) Advanced Alternative Payment Comprehensive medication management Models (APMs) is defined as “the standard of care that ensures each patient’s medications (whether One of two avenues in the CMS Quality they are prescription, nonprescription, Payment Program. “A payment approach that alternative, traditional, vitamins, or nutritional gives added incentive payments to provide supplements) are individually assessed to high-quality and cost-efficient care. APMs can determine that each medication is appropriate apply to a specific clinical condition, a care for the patient, effective for the medical episode, or a population.”4 condition, safe given the comorbidities and other medications being taken, and able to be Capitation taken by the patient as intended.”8 A specified amount of payment over a defined time period that is paid to a health plan or doctor. The capitation may be full where the plan is providing services solely through capitation or partial capitation where the “plan is paid for providing services through a combination of both capitation and fee for service reimbursements.”5,6

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 56 CMS Star Measures Federally Qualified Health Center The Centers for Medicare & Medicaid Services (FQHC) (CMS) creates plan ratings to measure the “A community-based healthcare provider that experience that Medicare beneficiaries have receive funds from the Health Resources and with the health plan and healthcare system. Services Administration (HRSA) Health Center The star rating program indicates the quality Program to provide primary care services of Medicare plans on a scale of 1 to 5 stars with in underserved areas. An FQHC must meet 5 stars being the highest rating. The overall a stringent set of requirements, including star rating is determined through numerous providing care on a sliding fee scale based on performance measures across several domains ability to pay and operating under a governing of performance and is published information.9 board that includes patients.”13

Collaborative Practice Agreement MACRA—Medicare Access and CHIP (CPA) Reauthorization Act of 2015 An agreement that details functions that The MACRA law was passed in April 2015, can be delegated by a prescriber or group to transform the basis of healthcare clinician of prescribers to a pharmacist or group of payment from volume to value. MACRA pharmacists based on a formal practice created the Quality Payment Program (QPP) relationship (as authorized by state laws and that repealed the sustainable growth rate regulations). CPAs expand a pharmacist’s formula used to determine physician and scope of practice. CPA authority varies other clinician fee-for-service (FFS) payment among states, and common functions rates in Medicare and created the Merit- include initiating, modifying, or discontinuing based Incentive Payment System (MIPS) and medication therapy and ordering laboratory Advanced Alternative Payment Programs tests.10 Various terms are used for CPAs among (APMs).14 the states (e.g. collaborative drug therapy agreement, drug therapy management, Merit-based Incentive Payment (MIPS) protocol). One of two avenues in the CMS Quality Payment Program (QPP), eligible clinicians Healthcare Effectiveness Data and receive fee-for-service (FFS) payment Information Measure (HEDIS) adjustment for services provided for Medicare A performance measure that is administered Part B patients based on performance in four by the National Committee for Quality categories including quality, cost, improvement Assurance (NCQA). The HEDIS measure activities, and promoting interoperability. applies to 190 million people that are Performance in these categories results in enrolled in health plans and is a widely used a MIPs payment adjustment to the FFS rate performance improvement tool that includes 2 years after performance measurement more than 90 measures. There are 6 domains period. Payment adjustments can be positive of care that include effectiveness of care, or negative depending on the clinician’s access/availability of care, experience of care, performance score.15 utilization and risk adjusted utilization, health plan descriptive information, and measures collected using electronic clinical data systems. NCQA uses the HEDIS measures for ranking of health plans each year.11,12

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 57 Medicare Shared Savings Program to the Quadruple Aim has been proposed to (MSSP) improve the work life of healthcare providers. The Medicare Shared Saving Program (MSSP) Pharmacists can also play a role in quality- offers providers and suppliers (e.g., physicians, focused initiatives to support the system and hospitals, and others involved in patient care) providers’ efforts to improving the quality of 19 an opportunity to create an Accountable care provided. Care Organization (ACO). An ACO agrees to be held accountable for the quality, Quality Measures cost, and experience of care of an assigned Quality measures, which can also be referred Medicare fee-for-service (FFS) beneficiary to as Clinical Quality Measures (CQMs) and population. The Shared Savings Program has electronic Clinical Quality Measures (eCQMs), different tracks that allow ACOs to select an “are tools that help measure or quantify arrangement that varies in risk and makes the healthcare processes, outcomes, patient most sense for their organization.16 perceptions, and organizational structure and/or systems that are associated with the Patient Centered Medical Home ability to provide high-quality healthcare and/ (PCMH) or that relate to one or more quality goals for 20 The Patient-Centered Medical Home is a team- healthcare.” based approach to comprehensive primary care coordinated by a primary care provider. Transitional Care Management The medical home is a model or philosophy A covered service in Medicare and by other of primary care that is patient-centered, payers, Transitional Care Management (TCM) comprehensive, team-based, coordinated, in Medicare applies to a patient following accessible, and focused on quality and safety.17 a discharge from a hospital, skilled nursing facility, or community mental health center Population Health stay, outpatient observation, or partial Population health refers to the outcomes of a hospitalization. TCM includes a bundled group of individuals with similar characteristics, payment that covers that covers the transitional including the distribution of such outcomes services of a care team during the first 30 days within the group and the role of health after a patient is discharged from the hospital. determinants. These health determinants Assessing and supporting treatment regimen can include medical care, public health, adherence and medication management are social environment, genetics, and individual required components of TCM and an ideal behavior.18 opportunity for pharmacist integration as clinical staff on the care team.”21, 22, 23 Quadruple Aim Value-Based Payment The quadruple aim is an expansion of The Triple Aim which includes enhancing patient “Value Based Payment (VBP) is a concept by experience, improving population health, which purchasers of healthcare (government, and reducing costs. This expansion includes employers, and consumers) and payers an additional goal of improving the work (public and private) hold the healthcare life of healthcare providers. The Institute for delivery system at large (physicians and other Healthcare Improvement terms this new aim providers, hospitals, etc.) accountable for both 24 Joy in Work. The expansion of the Triple Aim quality and cost of care.”

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 58 References

1. 340B Health. Key Terms. Available at: 8. American College of Clinical Pharmacy. https://www.340bhealth.org/mem- Comprehensive Medication Management in bers/340b-program/key-terms/. Accessed Team-Based Care. Available at: https://www. February 10, 2020. accp.com/docs/positions/misc/CMM%20 Brief.pdf. Accessed February 10, 2020. 2. Centers for Medicare and Medicaid Ser- vices. Accountable Care Organizations 9. Pharmacy Quality Alliance. PQA Measure (ACOs): General Information. Available Use in CMS’ Part D Quality Programs. at: https://innovation.cms.gov/initiatives/ Medicare Part D Star Ratings. Available ACO/. Accessed February 10, 2020. at: https://www.pqaalliance.org/medi- care-part-d. Accessed February 10, 2020. 3. Primary Care Collaborative. Accountable Care Organizations (ACOs). Available at: 10. Centers for Disease Control and Preven- https://www.pcpcc.org/topic/account- tion. Advancing Team-Based are Through able-care. Accessed February 10, 2020. Collaborative Practice Agreements. A Re- source and Implementation Guide for Add- 4. Centers for Medicare and Medicaid ing Pharmacists to the Care Team. Avail- Services. AMPs Overview. Available at: able at: https://www.cdc.gov/dhdsp/pubs/ https://qpp.cms.gov/apms/overview. docs/CPA-Team-Based-Care.pdf. Accessed Accessed February 10, 2020. February 10, 2020. 5. American College of Physicians. Under- 11. National Committee for Quality Assurance. standing Capitation. Available at: https:// HEDIS and Performance Measurement. www.acponline.org/about-acp/about-inter- Available at: https://www.ncqa.org/hedis/. nal-medicine/career-paths/residency-ca- Accessed February 10, 2020. reer-counseling/guidance/understand- ing-capitation. Accessed February 12. Becker’s Hospital Review. 5 Things to 10, 2020. Know about HEDIS. Available at: https:// www.beckershospitalreview.com/payer-is- 6. Centers for Medicare and Medicaid Ser- sues/5-things-to-know-about-hedis.html. vices. Glossary. Available at: https://www. Accessed February 10, 2020. cms.gov/apps/glossary/search.asp?Term=- capitation&Language=English&Submit- 13. Health Resources and Services Adminis- TermSrch=Search. Accessed February tration. Federally Qualified Health Centers. 10, 2020. Available at: https://www.hrsa.gov/opa/ eligibility-and-registration/health-centers/ 7. American Pharmacists Association. APhA’s fqhc/index.html. Accessed February Billing Primer. A Pharmacist’s Guide to 10, 2020. Outpatient Fee-for-Service Billing. Avail- able at: http://elearning.pharmacist.com/ 14. Centers for Medicare and Medicaid Ser- products/5185/billing-primer?sectionId=7 vices. What’s MACRA? Available at: https:// 7d77567-bb94-4784-9750-074f9877d0be. www.cms.gov/Medicare/Quality-Initia- Accessed February 10, 2020. tives-Patient-Assessment-Instruments/ Value-Based-Programs/MACRA-MIPS-and- APMs/MACRA-MIPS-and-APMs/. Accessed February 10, 2020.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 59 15. Centers for Medicare and Medicaid Ser- 22. Centers for Medicare and Medicaid vices. Quality Payment Program. MIPS Services. Frequently Asked Questions Overview. Available at: https://qpp.cms. about Billing the Medicare Physician Fee gov/mips/overview. Accessed February 10, Schedule for Transitional Care Management 2020. Services. March 17, 2016. Available at: https://www.cms.gov/Medicare/ 16. Centers for Medicare and Medicaid Ser- Medicare-Fee-for-Service-Payment/ vices. Shared Savings Program. Available PhysicianFeeSched/Downloads/FAQ- at: https://www.cms.gov/Medicare/Medi- TCMS.pdf. Accessed February 10, 2020. care-Fee-for-Service-Payment/sharedsav- ingsprogram/about. Accessed February 10, 23. American Pharmacists Association. 2020. APhA’s Billing Primer. A Pharmacist’s Guide to Outpatient Fee-for-Service 17. Patient-Centered Primary Care Collabora- Billing. Available at: http://elearning. tive. Defining the Medical Home. Available pharmacist.com/products/5185/billing- at: https://www.pcpcc.org/about/medi- primer?sectionId=77d77567-bb94-4784- cal-home. Accessed February 10, 2020. 9750-074f9877d0be. Accessed February 18. Kindig D, Stoddart G. What is population 10, 2020. health? Am J Public Health. 2003; 24. American Academy of Family Physicians. 93:380–3. Value-Based Payment. Available at: https:// 19. Bodenheimer T, Sinsky C. From triple to www.aafp.org/about/policies/all/value- quadruple aim: care of the patient requires based-payment.html. Accessed February care of the provider. Ann Fam Med. 2014; 10, 2020. 12:573–6. Available at: https://www.ncbi. nlm.nih.gov/pmc/articles/PMC4226781/. Accessed February 10, 2020. 20. Centers for Medicare and Medicaid Services. Quality Measures. Available at: https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/ QualityMeasures. Accessed February 10, 2020. 21. Centers for Medicare and Medicaid Services. Transitional Care Management Services. ICN 908628, January 2019. Available at: https://www.cms.gov/ Outreach-and-Education/Medicare- Learning-Network-MLN/mlnproducts/ downloads/transitional-care-management- services-fact-sheet-icn908628.pdf. Accessed February 10, 2020.

SUCCESSFUL INTEGRATION OF PHARMACISTS IN ACCOUNTABLE CARE ORGANIZATIONS AND MEDICAL HOME MODELS: CASE STUDIES • © AMERICAN PHARMACISTS ASSOCIATION • 60