N.C. program adds the missing link to the medical home

Collaborative care in a small town in North Carolina worked well years ago. When L. Allen Dobson Jr., MD, the family practitioner, had a concern about a medication, he would pick up the phone and speak with the local pharmacist. If a patient showed up at the pharmacy with a medication problem or appeared to be ill, the community pharmacist would reach out to Dobson.

“In our town of 1,200, my family practice and the local pharmacist were the healthcare system,” said Dobson, who is now president and CEO of Community Care of North Carolina (CCNC), an organization devoted to the patient-centered medical care model. “Even if I was seeing someone after hours, the pharmacist would be available and get the patient the medicine. The next healthcare facility was 20 miles away.”

Today’s healthcare delivery lacks that level of coordination, because the system isolates healthcare providers into professional silos. “The [community] pharmacist has become just a dispenser, and is a huge missing component of the healthcare system,” Dobson said.

To recapture that missing link and connect the pharmacist back to the medical community, Community Care of North Carolina (CCNC) and its affiliates announced in October that they are embarking on an ambitious three-year project to develop and test a community pharmacy network working with its 1,800 primary care practices, which represent 95% of primary care delivery in the state. CCNC serves approximately 1.3 million patients, including Medicaid beneficiaries, Medicaid/Medicare beneficiaries, privately insured employees, and the uninsured.

The purpose of this statewide initiative is to reconnect the clinical pharmacist with the primary care physician, so that the pharmacist can be an integral part of the multidisciplinary team of healthcare professionals. With the help of its partners, GlaxoSmithKline (GSK) and the Eshelman School of Pharmacy of the University of North Carolina (UNC), as well as a CMS Innovation grant, CCNC will test different ways the pharmacist can participate to help improve patient outcomes, quality of care, and cost.

“Our research shows that pharmacists have frequent, face-to-face contact with patients, far more than even physicians do,” Dobson said. “This alliance will help show that close patient-pharmacist relationships, coordinated with the patient’s physician, are indeed valuable to our healthcare system and can help improve quality and lower costs.”

A network of 150 pharmacies

CCNC will be working with a network of 150 pharmacies - independent community pharmacies, chain pharmacies, federally qualified health-center pharmacies, and hospital outpatient pharmacies.

“This is a system for any willing provider who can do the service and is willing to be measured,” said Troy Trygstad, PharmD, PhD, CCNC’s chief pharmacist and administrator of this project. He is vice president of CCNC’s Pharmacy Programs.

“This is not meant to be a narrow network. It is meant to be a high-performing network, which is a big difference. Anybody who can be a high performer is absolutely welcome,” Trygstad said.

Throughout the course of this initiative, CCNC plans to build a community pharmacy network and develop processes of care and relationships between the medical home teams, care teams, and community pharmacy. The first goal will be to test the processes and protocols of care in order to develop real interprofessional relationships, Trygstad said.

The second aim is to focus on the technology, so that CCNC can interact with the community pharmacies that will be responsible for a panel of patients, in a fashion similar to that employed in the medical home model. It will be important for the pharmacy and primary care physician to have access to a common pharmacy record, so that everyone is on the same page and the medication records can be saved.

Third, CCNC plans to compensate community pharmacies for their involvement, using a pay-for-performance approach. “With this, they would receive a certain level of payment. They would be paid for comprehensive medication reconciliations and medication reviews, which are additional services,” Trygstad said.

The role of the pharmacy school

In this endeavor, the UNC Eshelman School of Pharmacy is a critical partner with CCNC, working on the creation of new practice models that will enable all healthcare professionals to use the full range of their skills and training in a common cause.

“We want to make sure that patients receive the very best care at the most affordable prices, and do this within a framework that could be scalable across all different kinds of payer systems [public and private],” said Robert A. Blouin, PharmD, dean of the UNC Eshelman School of Pharmacy.

“There is a clear need to improve the effectiveness and safety of medication use if we are to significantly improve healthcare quality in the U.S. This collaboration will allow the school’s faculty and researchers to play an integral role in helping to define and evaluate best practices and train pharmacists to effectively implement new models of care,” he continued.

GSK’s role

GSK will continue to work with CCNC, using analytics on small pharmacy data sets to help predict outcomes for this project and determine which patients will need intervention. In 2012, GSK employees in North Carolina had the option of joining a primary care medical home that was similar to the one that CCNC pioneered in the public sector. This year, the medical home program for GSK employees included a comprehensive medication management initiative provided through the collaborative efforts of CCNC, GSK, and the school of pharmacy.

“We are excited to begin testing new ways to improve patient engagement and hands-on care management that could keep disease under control and patients out of the emergency room,” said Jack Bailey, senior vice president of Policy, Payers and Vaccines at GSK, in a prepared statement.

Care Triage: A powerful tool

The first phase of the new statewide initiative will involve the education of pharmacists within the network and the standardization of the best practices for pharmacies. “We want to take what is known that has a high probability of working, but has a high value for patients,” Blouin said.

Through the use of Care Triage, a health information technology tool, CCNC, GSK, and the school of pharmacy will use patient data from the pharmacies to identify patients at risk of hospitalization and drug therapy problems and to provide pharmacies with the resources to deliver comprehensive medication management services appropriately.

With Care Triage, CCNC can use this “logistics engine” to decide, on the basis of medication use, whether the patient can be managed by the pharmacist or needs to go to a care manager, a social worker, or a doctor.

“Pharmacists [using Care Triage] can identify in real time which patients have the highest probability of needing the most attention, and provide in a laserlike fashion the kind of pharmacy care that the patient needs to achieve the most desired outcome or to prevent certain events from occurring,” Blouin said.

Care Triage is a powerful tool when appropriately used by the pharmacist seeking to engage patients proactively. Through this software tool, pharmacists will receive a notification on a specific patient; for example, a patient who is about to be discharged from the hospital. The pharmacy will be expected to reach out to the patient within 72 hours to respond to the request for help from the medical home.

Key performance indicators

Some of the key performance indicators for the pharmacies include total cost of care, hospitalization rate, emergency department rate, adherence rate, and waste management rate - a problem with autorefills. In addition, the 72-hour response rate to care alerts will be another measure of pharmacy performance.

Patients will be encouraged to work through a consistent pharmacy provider, an approach similar to that of the medical home, whereby patients connect with their primary care physician. If patients don’t return to the pharmacy, it will be noted by their refill pattern.

“The network is tightly wound. It creates an even more robust type of relationship between the pharmacist and the primary care physician, where they truly are working as a team,” Blouin said.

Program kickoff

The three-year project is expected to be up and running January 2015. CCNC plans to report on the progress of the initiative on a quarterly basis and will share its insights at www.pharmacyhomeproject.com.

Although there are technical and pragmatic challenges, as with any endeavor, Trygstad is confident that a high-performing network of pharmacists will be able to deliver services and be measured for their performance. “If you can align incentives [for pharmacists], it is amazing what you can remove as far as barriers,” Trygstad said. “If you do that, there is a subset of pharmacies that will respond very well.”

Participating pharmacies that follow best practices will be able to use their current resources - staff - and meet the needs of CCNC. During a typical day, Trygstad said, about 15 to 20 patients need a level of reinforcement that takes up to 90 seconds. Another five to 10 patients will need about 90 seconds to 10 minutes of a pharmacist’s time. Approximately two to four patients per day will require a substantial amount of time.

“If the pharmacist can do it correctly, this initiative can be accomplished,” Trygstad said.