Evolution of Pharmacy Teams Role in Population Health Management 15 - - PowerPoint PPT Presentation

Evolution of Pharmacy Team’s Role in Population Health Management

15 May 2019

Leandra Battisti, PharmD Kanan Shah, PharmD Sonia Alva, PharmD, BCACP

Objectives

• 1. Describe the skill set of each role within a pharmacy team to support population health initiatives.
• 2. Illustrate integrated workflows within a pharmacy department to support complex patient needs

across the continuum of care.

• 3. Explain how intradepartmental engagement can result in positive outcomes for disease specific

programs.

• 4. Describe initiatives aimed at improving patient care and reducing total medical expenditures on

targeted patients.

Patient care is evolving and we are changing our standard approach to healthcare

What is “Population Health”?

• Defined as “the health outcomes of a

group of individuals, including the distribution of such outcomes within the group."

1. Kindig D, Stoddart G . "What is population health?" American Journal of Public Health. 93 (3): 380–3, March 2003. 2. Centers for Disease Control and Prevention, Office of Public Health Scientific Services, Center for Surveillance, Epidemiology, and Laboratory Services, Division of Scientific Education and Professional Development

Components of Population Health

• Interdisciplinary, customizable approach that

allows health departments to connect practice to policy for change to happen locally

• Utilizes non-traditional partnerships among

different sectors of the community

• An opportunity for health care systems,

agencies and organizations to work together in order to improve the health outcomes of the communities they serve

Data Integration Patient Stratification & Intake Care Coordination Patient Engagement Performance Measurement

There are three key components to population health management that are the basis of our integrated pharmacy programs

Identify

• Know your patient

population

• Patient identification in the

Electronic Health Record (EHR)

• Data analytics and

warehouse

• Quality and regulatory

reporting

Engage

• Member engagement
• Care management
• Home care
• Pharmacy services
• Triage of health related

social needs (HRSN)

Manage

• Care management

software

• Clinical research
• Performance improvement
• Predictive modeling
• Registries and scorecards

BMC’s culture and core values reflect our mission of exceptional care without exception

Source: https://www.bmc.org/about-us/mission-vision-values

The patients we serve are disproportionately minority and low income

More than 50% of our patients have an annual household income below the federal poverty line. More than 30% of our patients speak a primary language other than English. More than 70% of our patients identify as minority. More than 50% identify as African American More than 20% identify as Hispanic

• r Latino.

Our patients face an extraordinary number of social, cultural, linguistic, and economic barriers to care when compared to patients at other area hospitals.

BMC has the highest public payor mix in Massachusetts

Source: 2018, CHIA Acute Hospital Utilization Hospital Site databook

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Medicaid HSN Medicare Other Commercial

Massachusetts large hospitals discharges payor mix FY 2017 data, non-340B hospitals excluded

BMC Pharmacy Services are truly a health-system pharmacy department spanning across many different areas of focus

BMC Health System Pharmacy Department

Inpatient Retail and Outpatient Specialty and Ambulatory Health Plan External Partnerships

• Centralized and

decentralized model

• Residency program
• Transitions-of-care

program

• Medical reconciliation

technicians

• Investigational

Pharmacy Services

• Clinic-based

ambulatory care pharmacists

• Specialty Pharmacy
• Patient liaison

technicians

• Prior authorization

center

• Chemotherapy

Pharmacy

• Three retail

pharmacies

• Off-site mail order

pharmacy

• Medication refill

center for primary care

• Telephonic MTM
• Adherence

packaging

• Medicaid MCO plans

for MA and NH

• Clinical and service

support with pharmacists

• Formulary

management

• Commercial and dual

eligible programs

• External consultancy

relationships

• Specialty pharmacy

integrator

Timeline of pharmacy department evolution at BMC

2014 HIV Pharmacy Program HCV Pharmacy Program Readmission Risk Assessment (RRA) Program

Specialty Pharmacy Program BMCHP Accountable Care Organization (ACO)

2016 2017 2019 2018 2015 Pharmacy Care and Quality Programs Complex Care Management (CCM)

Transition of Care Services

Our specialty model utilizes the key components of population health to provide comprehensive pharmacy support

In-Clinic Support BMC Specialty Care Management

Management

• Clinical RPh consult

and visits

• Phone call support
• Adherence monitoring

and feedback to MD Engagement

• Rapid prior

authorizations

• Fast Rx fulfillment and

delivery to clinics

• Mail delivery and

blister pack offering Identification

• Identify patients
• Letters to patients from

MD

• Outbound calls to

patients

• In clinic contact

The specialty pharmacy team is positioned to provide collaborative support from clinic to pharmacy

Clinic Embedded Centralized Pharmacy Embedded Specialty Clinics Primary Care Clinics On Site Pharmacies Offsite Specialty Rx Medication Access Refill Request Mgmt

• 21 liaisons and 9 pharmacists embedded in 11 specialty clinics including:

Heme/Onc, Derm, Neuro, Rheum, GI, ID, Renal/Transplant, Pedi Specialties

• 10 liaisons and 4 pharmacists embedded in primary care clinics across 2

sites

• 9 liaisons and 3 pharmacists embedded in 4 pharmacies on BMC campus
• 12 liaisons and 5 pharmacists located at offsite specialty pharmacy
• 5 liaisons centralized providing PA processing and med access support for 17

clinics

• 4 pharmacists centralized managing ~10,000 refill requests monthly for 2

primary care clinics

Dedicated focus in process and performance excellence drive superior clinical outcomes for patients enrolled in our programs

Process and performance excellence by our specialty team …

2 vs. 212

Prior authorization turnaround time (days)

$3M+

Patient assistance dollars secured

95% vs. 60%1

Medication adherence (PDC)

… drives superior treatment

• utcomes for specialty providers

80% vs 33%3

HIV viral load suppression

76% vs 50%3

CML molecular response rate in oncology

98%2

SVR12 of Hep C treated patients

1. BMC pharmacy and partner medication adherence measured vs. community averages as exhibited by BMCHP health plan 2. Prior auth time and SVR12 measured via HealthCloud platform; 99% represents those who completed tx outside of lost to follow up. 3. Reflect independent studies done for BMC patients receiving therapy from internal specialty pharmacy vs outside, 2017

Specialty pharmacy’s multidisciplinary staffing model for HCV treatment is a key driver in improving clinical outcomes

Public Health Social Worker

• Completes bio-psycho-social intake and addresses barriers to appointment

and med adherence prior to and during HCV treatment

• Collaborates with patient, provider and pharmacy team for coordination of care
• Provides clinical support regarding treatment guidelines, regimen selection,

drug interactions, and side effects

• Sees patients for clinical support visits at treatment initiation and throughout

treatment course in collaboration with provider

• Processes prior authorization request and coordinates with pharmacy for

prescription processing

• Provides adherence outreach and refill coordination while on HCV treatment

Pharmacy Patient Liaison Clinical Pharmacist

Strong clinical outcomes are maintained in the HCV program despite a psychosocially complex patient population

HCV patients in GIM clinic

Homeless Distribution

28%

Past 6 mo. illicit substance usage

32%

Past 6 mo. heavy ETOH

19%

Treatment completed

99%

Negative SVR at 12 weeks post tx completion

98%* Measured patient barriers (Health Cloud) Treatment results

• Includes 325 patients from 9/2015 to

12/2018

• 4 patients did not complete treatment

‒ 2 due to ADRs, one due to incarceration, 1 lost to follow up after 1 month ‒ 1 patient who d/c’ed at 8 weeks still achieved SVR

• *Negative SVR of those tested; 4% lost

to follow up ‒ ITT SVR = 94%

Implementing new workflows does not come without its challenges…

Challenges Solutions

Employee recruitment and training

• HR/ hiring support
• Development of training protocols and policy /

procedures Determination of patient panel and recruitment / enrollment process

• IT integration
• Real time analytics on patients, prescriptions,

reporting

• Customer relationship management software

Integration within specialty and primary care clinics

• Clinic leadership and staff support and buy in
• Centralization of non-patient facing staff to

provide space for those to engage patients in clinic

Timeline of pharmacy department evolution at BMC

2014 HIV Pharmacy Program HCV Pharmacy Program Readmission Risk Assessment (RRA) Program

Specialty Pharmacy Program BMCHP Accountable Care Organization (ACO)

2016 2017 2019 2018 2015 Pharmacy Care and Quality Programs Complex Care Management (CCM)

Transition of Care Services

BMC Pharmacy has designed transitions of care services to support a growing complexity in the care continuum

Traditional Current

Subacute ICU Observation Assisted Living OR/PACU Med/Surg Nursing Home Home Patient Discharged

BMC launched a readmissions risk assessment (RRA) tool to identify at- risk patients and implement targeted interventions

• Initially required for DSTI* Medicaid measure,

ultimately applied to “all payors”

• Hospital-wide multidisciplinary effort
• Internally developed scoring tool to predict

readmission risk

• Score calculates upon admission

Patients are scored on based on assessment Number of readmissions and ED visits Disease states (e.g., CHF, COPD, dialysis) Medications (e.g., opioids, anticoagulation) Nutritional status Social determinants of health Activities of daily living

*DSTI: Delivery System Transformation Initiative

Inpatient medical teams and ancillary services are notified of at-risk patients through electronic medical record

RRA score calculated for admitted patients

Very High Risk 5%; RR: 63% Pharmacy driven interventions RR: Re-admission Rate High Risk 15%; RR: 54% Moderate Risk 30%; RR: 17% Low Risk 50%; RR: 7%

The unique skillset of pharmacists and technicians supports effective medication management throughout the continuum of care

Technicians Description Value Added Medication Reconciliation (MRT)

• Completes comprehensive medication history
• Call pharmacies
• Interviews patients and care provider
• Documents notes in medical chart

 Prevents medication errors  Supports pharmacists in reaching more patients for accurate medication reconciliation Pharmacy Patient Liaison

• Submits prior authorization to 3rd party payors
• Enrolls patients in co-pay assistance programs
• Enrolls in specialty care program to improve

adherence  Prevents medication access barriers prior to discharge  Supports on going medication access needs to improve medication adherence Medication to Bedside

• Processes and delivers medications to bedside

prior to discharge  Resolves medication barriers facing patients  Patient mobility, long pharmacy wait times, limited pharmacy hours

The unique skillset of pharmacists and technicians supports effective medication management throughout the continuum of care

Pharmacists Description Value Added Inpatient Clinical Specialist

• Reviews and co-signs MRT note and reconciles

medications with provider

• Recommends pharmacotherapy changes
• Proactively identifies medication barriers prior to

discharge  Prevents medication errors  Prevents unnecessary medication- related readmissions Ambulatory Care Specialist

• Completes 48-hour post-discharge call
• Offers clinic visit to patients needing advanced

pharmacy support  Supports post-discharge prescription questions  Manages chronic diseases through scope of practice Medication to Bedside Pharmacist

• Counsels patients on medications
• Enrolls patient in services provided through mail-
• rder pharmacy and pill packaging

 Supports medication comprehension

TOC interventions are provided at each phase of the continuum to prevent medication-related readmissions

Admission During Hospital Discharge Post-Discharge

• Targets based on

RRA score

• Documents

medication history in chart

• Reconciles

medications and note is cosigned

• Evaluates for

medication access barriers

• Requests PA for

new prescriptions

• Completes 48 hour

discharge phone call

• Manages chronic

disease in clinic

• Completes

discharge med rec/TOC note

• Provides med

counseling

• Processes Rxs and

delivers to bedside

• Manages future

refills to improve adherence

• Processes PA to

prevent prescription pick up barriers Certified pharmacy technician Registered Pharmacist

Identification Management Engagement

Initial results demonstrated that re-visit rate improved significantly when all three pharmacy interventions were completed

Interventions Revisit Rate* Number of Patients No intervention 42.4% 59 Post-discharge phone call 42.6% 61 Admission and discharge med rec 39.4% 669 Admission, discharge med rec and phone call 34.9% 707

*High-risk discharges 9/2016-11/2017

The decrease in readmission rates after inpatient admissions has been sustained since program launch

17.8% 17.8% 18.0% 16.8% 18.0% 17.0% 17.9% 16.8% 15.4% 5.8% 5.4% 5.3% 5.2% 4.4% 4.8% 4.8% 4.6% 4.7%

14.0% 16.0% 18.0% 20.0% 22.0% 24.0% 26.0% 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1

Readmit as IP Return as OBS

30d revisit rate from IP admissions Percentage, all payors

Reinforced RRA efforts

Data Source: BMC ICOC data. 1/2016-3/2018.

Pharmacy Department is continuing to improve workflows and is expanding TOC to other service areas

• Workflow: Standardized notes and

common database to share daily task

• Leadership: Communication and

feedback

• Workflow: Competing pharmacy

priorities

• Staffing: No evenings or weekends
• Learners: Required a culture

change within pharmacy

• Staffing: Coverage 7 days/week
• Learners: Utilizing students and

residents

• Workflow: Integrated TOC services
• Service: Expanded medication

delivery to bedside and TOC to ambulatory care

• Workflow: Notification of

discharges

• Service: Expanding TOC to surgery

line

Initial Current Successes Challenges

Timeline of pharmacy department evolution at BMC

2014 HIV Pharmacy Program HCV Pharmacy Program Readmission Risk Assessment (RRA) Program

Specialty Pharmacy Program BMCHP Accountable Care Organization (ACO)

2016 2017 2019 2018 2015 Pharmacy Care and Quality Programs Complex Care Management (CCM)

Transition of Care Services

What is an Accountable Care Organization (ACO)?

• Defined as “groups of doctors, hospitals, and other health care providers, who come together

voluntarily to give coordinated high-quality care to their patients.”

• Accountable to patients and to third-party payers to provide quality, appropriate, efficient and safe

services  ACO reimbursement model drives value-based care

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/, https://development.bmc.org/our-impact/stories/bmc-accountable-care/, Accessed 4/27/2019

Avoid duplication of services Better manage medications

Patients

Reduce preventable and avoidable hospital utilization Address Social Determinants

• f Health (SDOH)

Total Medical Expenditure Quality of care

BMC pharmacy is leading initiatives aimed at reducing cost and increasing quality for our ACO

Program Target Population Intervention Setting Team Members

Complex Care Management

• Highest risk

(1-2% risk percentile)

• Care coordination and adherence support
• Comprehensive medication management
• Transitions of care services

Ambulatory Home/ Community Liaisons Clinical Pharmacists Pharmacy Care Program

• High risk

(3-10% risk percentile)

• Care coordination and adherence support
• Medication adherence, ambulatory engagement

and social needs

• Comprehensive MTM

Ambulatory Liaisons Clinical Pharmacists Diabetes

• A1c > 9.0%
• Pharmacotherapy and disease management

Ambulatory Clinical Pharmacists Asthma

• Asthma medication

ratio (AMR) < 0.5

• Medication adherence support and monitoring

Ambulatory Liaison My Medicine Health

• Poor performance in

DM and AMR quality measures

• Medication adherence support and monitoring
• Prescription fulfillment support

Retail Retail Pharmacists Technicians

BMC pharmacy teams are providing patient-centered care management and medication support services to at-risk ACO patients

Risk Stratification

• Identifies patients

with highest risk

• f negative
• utcomes or high

cost of care

• Enables targeted

interventions (e.g., care management, TOC)

Source: https://www.healthcatalyst.com/healthcare-total-cost-care-analysis-vital-tool, Accessed 4/27/2019

Complex Care Management Pharmacy Care Program

Strategy Pharmacy Interventions

Care Coordination

• PCP and specialty appointment navigation
• Referrals for medical and behavioral needs

Care Management

• Care planning with multidisciplinary teams
• Self-management education, support

Cost Avoidance

• Comprehensive MTM (e.g., deprescribing)
• TOC medication management

Cost Savings

• Copay assistance
• Recommendations for cost-effective

alternatives High Cost & Need (Top 5%) Rising Risk (5-20%) Low risk (all others)

Medication adherence support programs and pharmacotherapy services are key interventions in driving performance for ACO quality measures

Quality Performance

(Asthma, Diabetes)

Retail Pharmacy Services Formulary Navigation Medication Adherence Monitoring Pharmacotherapy Management

Service Pharmacy Intervention

Retail pharmacy services

• Mail order
• Medication packaging

Formulary navigation

• Benefits investigation
• Prior authorization support

Medication adherence monitoring

• Refill reminders
• Prescription fulfillment

Pharmacotherapy management

• Optimization of regimen
• Lab monitoring
• Disease education
• Follow-up

Elevating the scope and skillset of pharmacy teams requires focused tools and continued coaching Skills Tools

Care coordination

• Community resource mapping
• Referral submission and tracking

Patient engagement and behavior change

• Focused trainings: motivational interviewing, social

determinants of health, harm reduction Team-based care

• Defined workflows for integrated, team-based tasks
• Care-planning tools and schedules

Ambulatory clinic integration

• Orientation to clinic teams and resources
• Clinic leadership support and buy-in

Panel management

• IT platforms
• Data support

Summary

• Intradepartmental sharing of best practices is integral to the success of launching new programs
• Identification, engagement and management of patients is the foundation of any population

health-focused initiative and should drive program design

• Pharmacy staff engaged in population health initiatives will require elevation of their scope and

skillset and dedicated pharmacy leadership support

• Intradepartmental pharmacy teams need to coordinate their efforts in order to provide high-quality

care that is targeted, efficient and impactful