Time to step up

Pharmacists across the country have found ways to make the concept of team-based care a reality - and it's yielding promising outcomes for patient care and healthcare costs.

As the healthcare industry moves away from fee-for-service and toward value-based reimbursement, the movement toward team-based care and improved coordination has gained increasing momentum.

By the end of 2018, the U.S. Department of Health and Human Services plans to have 50% of its Medicare payments tied to value-based alternative payment models, and private insurers are expected to follow suit.

While experts agree that the movement toward value-based arrangements and team-based care is on the horizon and quickly approaching, the structure of those teams is not yet set, and pharmacists are ready to demonstrate the value they can provide in team-based care arrangements.

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Seize the moment

Steven Chen"You need to think about how to do this now," said Steven Chen, PharmD, FASHP, FCSHP, FNAP, the lead author of a white paper highlighting the success of six comprehensive medication management (CMM) programs in California that include pharmacists.

The report, "Comprehensive Medication Management Programs: Description, Impacts, and Status in Southern California, 2015," was funded by a grant from the Centers for Disease Control and Prevention and published by the California Department of Public Health.

These programs, and other successful team-based collaborations across the country, pave the way for pharmacists and can serve as a roadmap of the challenges, victories, and strategies that yield the best results, as pharmacists become more integral members of the patient care team.

"These programs that we highlighted in a variety of different settings have been able to produce very high impact, very successful and sustainable comprehensive medication management services run by pharmacists," Chen said. "I think that's a powerful message that the quality and value is there, and now we need to replicate it."

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 Two approaches

While team-based care has been a term used in clinical settings for years, many states still haven't formally defined its meaning.

In a clinical sense, a pharmacist who participates in team-based care is a member of the healthcare team and works collaboratively with other providers without necessarily being governed by any formal rules or polices.

With a collaborative practice agreement, on the other hand, a formal agreement is in place that spells out what a pharmacist can or can't do in terms of independently prescribing, practicing, or changing medications.

Having a formal agreement in place can be an advantage for the pharmacist, said Carmen Catizone, MS, RPh, DPh, executive director of the National Association of Boards of Pharmacy.

"The protocols and the responsibilities that are spelled out there are usually in writing and many times even filed with the board of pharmacy or the board of medicine, so there's a very clear delineation and a very clear responsibility assigned to the pharmacist or the doctor," he said.

Catizone said another advantage of the collaborative practice agreement is that it may offer the pharmacist more latitude to exercise independent judgment based on the established agreement with the overseeing physician.

There can also be less friction between the physician and pharmacist when roles are clearly spelled out, easing the concerns of physicians who may be worried about a pharmacist encroaching on their turf.

Implementation

There’s more than one way a team-based initiative can get its start. It can be the result of a grant. It can be a new program created by administrators to address a specific need within a facility. Or it can be a patient management strategy created to meet quality standards outlined in an alternative practice agreement, such as that of an accountable care organization (ACO).

Regardless of the impetus behind a program, say those with experience, how a program is implemented can help pave the way for future success.

For instance, the initial messaging is often key to establishing a collaborative environment.

Kristi MarchKristi March, PharmD, BCPS, CDE, manager of ambulatory care clinical pharmacy for MemorialCare Medical Foundation, offered this example. When the Greater Newport Physician's Ambulatory Care Clinics approached physicians in its independent practice association (IPA), it emphasized how pharmacists could help them do their jobs, not take away part of the work upon which their livelihood depended.

The Greater Newport Physician's Ambulatory Care Clinics is part of the MemorialCare Medical Foundation. It operates three different clinics: a post-discharge clinic, an anticoagulation center, and its ACTIVE diabetes program. Pharmacists are involved in all three clinics.

In the post-discharge clinic, clinical pharmacists work on a team with a hospitalist, case manager, and social worker to meet the needs of high-risk patients who have recently been discharged from the hospital. 

The anticoagulation center, managed by a pharmacist, is a valuable resource for specialists and primary care physicians, who can refer patients for their anticoagulant therapy.

The ACTIVE diabetes program is led by pharmacists and includes a social worker and a dietician who work to help patients achieve greater control of their A1c levels.

Physician buy-in

When her facility was getting the diabetes program started, March said, one of the biggest challenges was winning physicians' support. They decided to change attitudes by degrees, starting small with a pilot project that would show other physicians the benefit of the program.

"We decided to start slow and develop the program in a way that would gain their trust and confidence. We asked one of the physician groups if they'd be willing to pilot us on monitoring their patients; that way we could get some patients in, get a chance to formulate how we were going to be able to do this in a way that was helpful, and yet not be seen as a threat," March said.

Tracking data

Another important step during the implementation process is to identify ways to track patient data from the beginning, so that outcomes from the program can ultimately be used to secure funding for the initiatives, increase physician participation, and demonstrate tangible benefits of team-based efforts.

"When you share your measures, especially your clinical measures, you want to make sure that you share measures that are not just of greatest importance but are aligned with standard metrics - whether you are talking nationally or locally - that everyone is benchmarked against," said Chen, who also serves as associate professor and chair of the Titus Family Department of Clinical Pharmacy and holds the William A. Heeres and Josephine A. Heeres Endowed Chair in Community Pharmacy at the University of Southern California (USC).

Over a three-year period, USC’s CMM program enrolled more than 6,000 high-risk or high-cost patients, who received services at AltaMed Health Services, the largest private Medicaid provider in the nation, with more than 40 clinics in Los Angeles and Orange County.

Target populations

Before implementing team-based care efforts, health systems first need to consider the unique characteristics of their patient population and identify the patients who represent the highest risks and costs.

On the basis of their health systems’ needs, the six California CMM programs highlighted in the recent white paper each targeted different patient groups, such as patients with diabetes, patients with heart failure, seniors, or patients with comorbid conditions.

"You're starting to focus in on the high-risk populations that drive value to the partner organization," Chen said.

Transitions of care

The Mission Health Partners ACO in North Carolina tries to help its patients during transitions of care. The ACO has a network of hospitals and about 800 physicians and other healthcare providers who are working together to improve healthcare quality, performance, and efficiency.

Each of the ACO's practices has a dyad that includes a pharmacy technician and nurse care manager. Focusing primarily on transitions of care, the pharmacy technician reinforces discharge plans, assesses a patient's understanding and support system, and determines whether the patient has access to needed medications. The nurse care manager assists with longer-term care coordination, education, and coaching to help patients address their medical needs and identify any social determinants that may be affecting their health.

Lori brown"We want good quality medical care, but it's often the social factors that get in the way of the patients' ability to access and afford their meds, and their ability to have reliable transportation to their appointments," said Lori Brown, the pharmacy director of clinical operations for the ACO. "So the work that we designed really assesses those components of care for the individual patients we're working with in an intentional way."

The ACO also regularly partners with community agencies, including community pharmacies that deliver medications or offer medication assistance programs, to help navigate patient access issues. She said the ACO looks for community partnerships that can help meet their patients’ needs effectively.

Healthcare quality and safety measures

Outcomes data on healthcare quality and safety measures can be a valuable tool to assess whether a program is able to meet its goals and demonstrate the health improvements or cost savings that help justify the program's existence.

Many of the established CMM programs in California are successful.

The pharmacist-led anticoagulation center connected with the Greater Newport Physicians Ambulatory Care Clinics produced results that demonstrated 53% fewer inpatient admissions and 41% fewer emergency room visits. In addition, within 180 days, the average patient in the ACTIVE Diabetes Program was able to meet his or her treatment goals.

Andrea DeCoroAndrea DeCoro, PharmD, executive director of clinical pharmacy services and performance at MemorialCare Medical Foundation, said that when they compared patients enrolled in the diabetes program with those who were not enrolled but had comparable baseline A1c levels, they found that those who weren't enrolled in the program had, on average, $1,200 more in medical resource utilization than did those in the program.

DeCoro said that return on investment diminishes when the cost of the program is factored in, but overall, she said, it remains a positive return on investment.

"You don't expect to make money on these programs; you do it because you are doing the right thing for patient care," she said.

Family medicine

At University of California San Diego Health Systems, several clinics have a pharmacist team member, including a family medicine clinic, a transplant clinic, a diabetes clinic, and a palliative care clinic.

Sarah McBane, PharmD, associate clinical professor, health sciences, in the Skaggs School of Pharmacy and Pharmaceutical Sciences at U.C. San Diego, is part of the family medicine clinic.

McBane, who is often paired with a physician for clinic sessions, will meet with patients in a session of her own for about half an hour, to conduct a comprehensive medication reconciliation with patients and address any medication concerns they may have. After the meeting, she'll meet briefly with the physician to go over her findings before the physician speaks with the patient and concludes the visit.

She didn't have access to specific figures but said that overall, the clinic has been well received by patients and has produced significant patient benefits.

"In general, the last time that we looked at the data we showed a significant improvement in hemoglobin A1c, both systolic and diastolic blood pressure, and triglycerides," she said.

The Transitions of Care program at the health system, which was run by another pharmacist, also reported annual cost avoidance of $503,278 as a result of its small pilot program.

Sustainability and impact

Evidence has shown again and again that team-based care that includes the expertise of a pharmacist improves patient outcomes and lowers healthcare costs. Nonetheless, Chen said, pharmacists aren’t making any easy sales.

"The problem, so to speak, with comprehensive medication management provided by a pharmacist is that it is not reimbursable, really, in any circle," he said.

Despite that, Chen believes, such programs are sustainable because the move toward value-based payment is inevitable, he said. To achieve success, pharmacists should align CMMs with the organizational priorities of lower costs and align with pay-for-performance measures, so that when the system shifts, the programs are already established and show value.

"If you drive your program toward those high-risk populations, you don't necessarily need to wait for payment systems to change," he said.

Team-based care approaches are not being embraced only by clinical pharmacists or health-system pharmacists either. Chen said that a recent national conference he helped organize also highlighted the work of independent pharmacies and chain pharmacy-based CMM programs that specifically targeted readmission rates for high-risk patients.

"That's dollars to the hospital," he said. "That's a way to sustain that sort of program."

Universal success

While each organization may choose to embrace team-based care in its own way within its own framework, the programs universally speak to the success that can be achieved when pharmacists are part of the team.

"The most enlightening thing is that it's really a reproducible service and that there are so many patients that can be impacted in all these different health systems," said Ashley Butler, a PharmD/MPH candidate at Touro University and lead student author of the white paper.

Jill Sederstrom is a freelance writer based in Kansas City.