integrated pharmacy models in primary care · integrated pharmacy models in primary care health...
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©2015 The Advisory Board Company • advisory.com
Integrated Pharmacy Models
in Primary Care
Health Care Industry Committee
Summary
The health care industry has selected one phrase to describe growing efforts to improve the long-term health outcomes of
populations while lowering long-term costs: population health. Despite the consistency in terminology, hospital population
health strategies are anything but uniform, especially when it comes to how they incorporate pharmaceutical management.
Pharmaceuticals are one of the most powerful methods of improving long-term health outcomes, but only if the right patient
takes the right prescriptions at the right time. Increasingly, hospitals are bringing pharmacists and medication therapy
management services to the forefront of population health initiatives. The population health leaders spearheading these
initiatives, as well as their nursing and pharmacy allies, need your support to make the right investments and get the most
value out of your products.
This research brief profiles several advanced population health programs integrating pharmacy services directly into the
primary care setting. While the brief was originally produced for hospital population health managers, we believe the insights
are important for the pharmaceutical industry as well. By understanding how progressive hospitals are structuring innovative
pharmacy programs that incorporate your products, we believe you can better position your expertise in medication
management and patient education to augment your partners’ efforts.
©2015 The Advisory Board Company • 29994 advisory.com 2
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Program Director
Contributing Consultants
Research and Insights
Design Consultant
Sara Sanchez
Rebecca Tyrrell, MS
Tracy Walsh, MPH
Meridith Weiss, MPH
Stefanie Kuchta
©2015 The Advisory Board Company • 29994 advisory.com 3
Table of Contents
Research in Brief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
A Checklist for Integrated Pharmacy Program Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1: Five Programs You Can Learn From . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Profile #1: University of Michigan Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Profile #2: University of Southern California-AltaMed CMMI Pilot . . . . . . . . . . . . . . . . . . . . . 9
Profile #3: Hennepin County Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Profile #4: University of North Carolina-MAHEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Profile #5: University Connecticut CMS Demonstration Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Section 2: Action Steps and Cross-Program Insights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Key Insights from Integrated Pharmacy Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Core Components Grid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
©2015 The Advisory Board Company • 29994 advisory.com 4
Research in Brief
Source: Advisory Board interviews and analysis.
The Research
Advisory Board researchers conducted a literature review of integrated pharmacy models in primary
care. Then we interviewed some of the best organizations with models demonstrating positive
clinical and financial outcomes to get actionable insights.
Here, we’ve profiled five organizations that represent a broad range of integrated pharmacy
models in terms of geographic location, patient population, and program scale. You’ll get an
overview of each program and its defining characteristics, as well as an in-depth look at each
organization’s approach to the six critical components of an integrated pharmacy program:
• Staffing and Deployment
• Patient Eligibility and Referral Processes
• Patient and Provider Engagement Strategies
• Care Coordination Processes
• Performance Metrics and Outcomes
• Financial Considerations
Finally, we recommend action steps to help your organization implement these best practice
models and advance an integrated pharmacy program.
The Challenge
Drug-related morbidity and mortality cost nearly $200 billion annually in the United States.
Integrating pharmacists into primary care can prevent avoidable spending by increasing patient
adherence, optimizing prescription regimens, and preventing medication-related complications. To
address these cost and quality opportunities, progressive health care systems are expanding the
role of the pharmacist as a central component of primary care transformation.
©2015 The Advisory Board Company • 29994 advisory.com 5
A Checklist for Integrated Pharmacy Program Development
Source: Advisory Board interviews and analysis.
Topics to Address Insights from Top Programs
Staffing and Deployment
Staffing ratios
Team composition
Pharmacist affiliation
Scheduling
Establish a pharmacy support role that performs
administrative, analytic, and patient outreach
functions
Patient Eligibility, Referral Processes
Physician referral protocols
Patient identification triggers
Referral conversion rates
Leverage comprehensive risk stratification criteria
to identify eligible patients
Patient and Provider Engagement Strategies Tactics for promoting provider acceptance
Tactics for increasing patient utilization
Institute mechanisms for interdisciplinary
collaboration between pharmacists and primary
care physicians
Care Coordination Processes
Pharmacist scope of practice
Templates and collaboration agreements
Range of pharmacy interventions offered
Graduation criteria
Use standardized intervention templates to
efficiently track and coordinate pharmacist
activities
Performance Metrics and Outcomes Operational metrics
Pharmacy program impact
Carefully select, monitor, and report clinical and
quality outcomes to facilitate buy-in and best
practice sharing
Financial Considerations
Funding source(s)
Financial impact
Sustainability planning
Measure program impact on total cost of care and
downstream utilization to demonstrate business
case
©2015 The Advisory Board Company • 29994 advisory.com 6
Five Programs You Can Learn From
See how five organizations have integrated pharmacists into their primary care
teams to improve patient outcomes and reduce avoidable health care spending
Section 1
©2015 The Advisory Board Company • 29994 advisory.com 7
Profiled Organizations Represent Varying Degrees of Program Scale
Source: Advisory Board interviews and analysis. 1) Medication Therapy Management.
Organization Background Program Overview
University
of Michigan
Health System
(UMHS)
990-bed academic medical center and
health system based in Ann Arbor,
Michigan, with an integrated pharmacist
model deployed at 15 primary care
clinics and four specialty clinics
• Partnership with department of pharmacy, college of pharmacy, and physician group practice
• Group practice model expanded from 3 to 15 primary care sites since 2009
• Pharmacy teams consist of pharmacist and pharmacy residents and students, with support from clinic
panel managers
• Supported by financial incentives from BlueCross BlueShield of Michigan and the creation of T codes to
reimburse non-physician providers for face-to-face and phone visits
University of
Southern California-
AltaMed Health
System CMMI Pilot
(USC-AltaMed)
Integrated pharmacy partnership
between the USC School of Pharmacy
and AltaMed Health System, a network
of 43 community clinics located in Los
Angeles and Orange counties,
California
• Engaged in a CMMI Challenge grant through July 2015 to assess the feasibility and impact of an
integrated pharmacist model across 10 primary care practice sites and 3 video telehealth locations
• Clinical pharmacy teams provide services directly to patients under a set of standardized, evidence-based
protocols
Hennepin County
Medical Center
(HCMC)
894-bed medical center based in
Minneapolis, Minnesota, offering
specialty and primary care MTM1
services at 16 ambulatory care sites
• Embeds 12 FTE pharmacists and two clinical pharmacy residents across 16 ambulatory clinic sites, the
Augustana skilled nursing facility, and the Harbor Light homeless shelter clinic
• Ambulatory MTM services have decreased average variable cost by approximately $2,000 per patient per
year
University of North
Carolina– Mountain
Area Health
Education Center
(MAHEC)
Family medicine residency training
program with seven family health
centers serving 16 counties in western
North Carolina
• Embeds 5.25 FTE pharmacists and two pharmacy residents across the system’s seven ambulatory sites
• Pharmacists work with UNC’s Department of Medicine to conduct Medicare Wellness visits, enabling
pharmacists to bill at a higher reimbursement rate
• Significant collaboration with community organizations, including a community pharmacy, medication
assistance program, and the regional aging council
University of
Connecticut CMS
Demonstration Pilot
CMS demonstration project to embed
pharmacists across five primary care
sites in Connecticut between July 2009
and May 2010
• Examines impact of the integrated pharmacy model for Medicaid polypharmacy patients
• Contracted with nine independent pharmacists at five primary care practices in Connecticut
• Program led by stakeholders from the University of Connecticut School of Pharmacy, the Connecticut
Pharmacists Association, and the Connecticut Department of Social Services
• Results included an estimated annual savings of $1,595 per patient
©2015 The Advisory Board Company • 29994 advisory.com 8
Profile #1: University of Michigan Health System
University of Michigan’s Close Partnerships Drive Credibility, Scaling Efforts
Source: University of Michigan Health System; Advisor Board interviews and analysis.
Case in Brief University of Michigan Health System
(UMHS)
• 990-bed system comprised of three hospitals,
40 outpatient locations with more than 120
clinics, and a medical group of 1,800
• In 2009, launched collaborative partnership
between College of Pharmacy, Department of
Pharmacy, and Faculty Group Practice to
create an integrated pharmacist model, now
deployed at 15 primary care clinics and 4
specialty clinics
• Through the BCBS of Michigan PCMH program,
UMHS developed new reimbursement process
for clinical pharmacy services, generating
revenue through use of T codes that allow non-
physicians to bill for services; currently,
pharmacists are participating in a multi-payer
demonstration project
UMHS Collaboration Across Groups to Support Pharmacy Model
Commercial Payer
• Provides initial funding for patient-centered medical home development (BCBS of Michigan)
• Offers financial incentives for quality performance
• Provides reimbursement for fee for service and enhanced E&M codes
College of Pharmacy
• Faculty make up the
core practitioner group
• Students support to enhance
patient care and outreach
Faculty Group Practice
• Provides infrastructure, funding
• Leverages existing relationships
to improve patient recruitment
Department of Pharmacy
• Standardizes processes;
promotes unity across sites
• Helps support cost of direct
patient care
• Partially funds pharmacist salaries
Staffing and
Deployment
Patient Eligibility,
Referral Processes
Patient and Provider
Engagement Strategies
Care Coordination
Processes
Performance Metrics
and Outcomes
Financial
Considerations
• Staffing ratio:
Variable based on
facility size, budget
allocation, and team-
based care readiness
• Team composition:
Pharmacist, pharmacy
residents and students;
outreach support from
clinic panel managers
• Patient caseload:
Avg. 6.5 patients/half-
day; goal of 5+/half-day
• Direct referral:
Variable based on
program maturity;
initially rely on registry
to drive volumes and
increasingly shift toward
provider referrals
• Clinical triggers:
Diabetes, hypertension,
polypharmacy, not on
evidence-based
medications
• Time to steady-state
referral volumes:
6 months
• Strategies: Building on
existing patient-provider
relationships,
positioning pharmacist
as an extension of the
PCP’s services and
network
• Collaboration
strategies: Single
medication list,
progress notes, and
medication plan shared
between pharmacists
and PCPs; pharmacist
conducts follow-up visit
after initial intake to
discuss medication
changes and action
steps for patient
• Clinical outcomes:
0.8% decrease in A1c
for patients with
baseline A1c>7% and
1.4% decrease for
those with baseline
A1c>9%
• Funding source: 70%
clinical pharmacy work
paid by health center,
30% subsidized;
increasingly shifting
more costs to clinic
• Other: Developed new
reimbursement process
for clinical pharmacy
• Financial outcomes:
Generated $154,831 in
revenue via T codes in
first year (2009)
©2015 The Advisory Board Company • 29994 advisory.com 9
Profile #2: University of Southern California-AltaMed CMMI Pilot
USC-AltaMed’s Pharmacy Care Managers Optimize Team Workflow
Source: University of Southern California, AltaMed Health System; Advisory Board interviews and analysis. 1) Based on 1 year pre- vs. 1 year post-enrollment; controlled evaluation anticipated by 2015.
Case in Brief University of Southern California-AltaMed CMMI
Pilot (USC-AltaMed)
• Integrated pharmacy partnership between the USC
School of Pharmacy and AltaMed Health System, a
network of 43 community clinics located in Los
Angeles and Orange counties, California
• Currently engaged in a CMMI Challenge grant
through July 2015 to assess the feasibility and
impact of an integrated pharmacist model across
10 primary care practice sites and three video
telehealth locations
• Clinical pharmacy teams provide services directly
to patients under a set of standardized, evidence-
based protocols
• Pharmacy Care Managers handle majority of
administrative work, enabling pharmacists to focus
more on patient care and leading to a 40%-50%
increase in visits per pharmacist per day
Staffing and
Deployment
Patient Eligibility,
Referral Processes
Patient and Provider
Engagement Strategies
Care Coordination
Processes
Performance Metrics
and Outcomes
Financial
Considerations
• Staffing ratio:
1 clinical pharmacy
team per 4 FTE PCPs
and 8,000 patients
• Team composition:
Pharmacist, pharmacy
resident, and clinical
pharmacy technician
• Patient caseload:
350-725 per team;
average 14-22 patients
per day
• Direct referral:
≈50% of patients,
usually by primary care
physician
• Clinical triggers: Of
remaining 50%,
patients identified using
patient registry (e.g.,
A1c>9%, BP>140/90
mm Hg) or identified
following hospital
discharge
• Time to steady-state
referral volumes:
4-6 months
• Strategies: Instituted
daily team huddles and
weekly interdisciplinary
team meetings; started
with practices that
already embrace team-
based care
• Collaboration
strategies: Developed
a set of collaborative
practice agreements
permitting pharmacists
to initiate, adjust, and
discontinue medications
for many chronic
conditions
• Process outcomes:
Between Oct 2012 and
Aug 2013, 19,696 Rx
problems identified
among 1,993 patients
• Clinical outcomes:
Inpatient admissions
decreased 13.1%, ED
visits by 37.8%, and
observation visits by
50% (n=1,171)1
• Funding source:
Pharmacist teams are
employed by USC, but
program costs are
covered by CMMI grant
through July 2015
• Cost outcomes:
Projected savings
are $31.7M over three
years
Clinical Pharmacy Teams
Primary care team conducts daily huddles and weekly
interdisciplinary team meetings with clinical pharmacy teams
Clinical Pharmacists
• Target most
complex patients
• Manage caseloads
of 350-725 patients
Primary Care
Team
Resident Pharmacists
• Recruited from across
the nation, enrolled in
USC School of
Pharmacy's accredited
residency program
Pharmacy Care Managers
• Review patient registries
for proactive identification
• Conduct patient outreach
• Perform first steps of
medication review
• Prepare medication pill
boxes and lists to help
improve adherence
©2015 The Advisory Board Company • 29994 advisory.com 10
Profile #3: Hennepin County Medical Center
Multiple Referral Channels Boost Patient Volumes and Facilitate Scheduling
Source: Hennepin County Medical Center; Advisory Board interviews and analysis.
Case in Brief Hennepin County Medical Center
(HCMC)
• 894-bed medical center based in
Minneapolis, Minnesota
• Embedded 12 FTE pharmacists and
2 pharmacy residents across 16
ambulatory clinic sites, the
Augustana skilled nursing facility,
and the Harbor Light homeless
shelter clinic
• Ambulatory MTM services have
decreased average variable cost by
≈$2,000 per patient per year
Staffing and
Deployment
Patient Eligibility,
Referral Processes
Patient and Provider
Engagement Strategies
Care Coordination
Processes
Performance Metrics
and Outcomes
Financial
Considerations
• Staffing: 12 FTE staff
pharmacists, two
pharmacy residents
across seven clinics
• Team composition:
Pharmacy Support
Analyst (0.8 FTE)
conducts departmental
administrative, analytic,
and billing functions
• Direct referral:
Combined with use of
disease registry;
Pharmacy Support
Analyst generates a
weekly list of patients
with an upcoming
appointment who meet
clinical criteria
• Clinical triggers:
Physician referral,10+
medications, or asthma
diagnosis
• Provider engagement:
Long-standing inpatient
clinic pharmacy team
creates receptive
system culture
• Patient engagement:
Multiple forms of patient
notification, including
brochures, warm
handoffs, and
telephonic reminders;
MyChart patient
portal access
• Standardization:
In-house EMR
templates, but most of
pharmacist actions are
left to their clinical
discretion
• Process outcomes:
Two drug problems
identified on average
per patient visit
• Clinical outcomes:
3.4% lower 30-day
readmission rate in
hospital clinic; 90% of
patients surveyed
would recommend
MTM services to a
family member or friend
• Funding source:
Approximately 10%
grant funded, 15%
reimbursed, 75% offset
by reductions in total
cost of care and
increased utilization of
community pharmacy
• Other considerations:
Increased in-network
utilization of HCMC
pharmacies by 15%
among patients who
see MTM pharmacists
Patient Identification Driven by Referrals, Reinforced by Data and Analytic Reports
Patient Outreach
Includes warm handoffs,
brochures on site, automated
reminders, and follow-up calls
for no-shows
Physician Referral
Primary care provider submits
referral order for pharmacist
consult through shared EMR
Data Registry Report
Pharmacy Support Analyst
generates weekly list of patients
with an upcoming appointment
who meet clinical criteria
Number of MTM visits
since January 2014 9,040
Avg. number of drug
therapy problems
identified per visit
2
Patient no-show rate;
comparable to other
ambulatory services
17%
Estimated cost
avoidance for HCMC
in 2013
>$2M
©2015 The Advisory Board Company • 29994 advisory.com 11
Profile #4: University of North Carolina–MAHEC
Shift from Grant Funding to Billable Services to Ensure Program Sustainability
Source: University of North Carolina; Mountain Area Health Education Center; Advisory Board interviews and analysis.
Case in Brief University of North Carolina-Mountain
Area Health Education Center (MAHEC)
• Family medicine residency training program
that is part of a statewide health education
center system; seven family health centers
serve 16 counties in western North Carolina
• MAHEC works closely with Mission
Hospital, an 800-bed tertiary care teaching
health system
• Pharmacists and pharmacy residents
provide MTM services within
disease-specific clinics and conduct
Medicare Wellness Visits and employee
wellness visits
• Adding a PGY2 residency program in
July 2015
Staffing and
Deployment
Patient Eligibility,
Referral Processes
Patient and Provider
Engagement Strategies
Care Coordination
Processes
Performance Metrics
and Outcomes
Financial
Considerations
• Pharmacy team: 5.25
FTE pharmacists and 2
pharmacy residents
employed by MAHEC
and co-funded by UNC
• Patient caseload:
4-5 per pharmacist on
average per half day
• Duration of visits:
15 min. for
anticoagulation teams,
30 min. for others
• Direct referral:
≈80% of referrals are
from PCPs
• Clinical triggers:
Automatic referrals for
key conditions (e.g.,
abnormal DEXA results
or hypertension scores
exceeding thresholds),
Medicare Wellness
Visits, employee
wellness visits
• Time to steady-state
referral volumes:
Practice dependent
• Strategies:
Interprofessional
meetings monthly to
discuss shared
expectations and
quality indicators
• Standardization: EMR
templates for
documentation of
encounters, team
member
communication, and
quality indicators for
chronic illnesses
• Clinical outcomes:
Improved utilization of
ACE inhibitors, beta
blockers for CHF
patients, inhaled
corticosteroids for
persistent asthma,
DEXA screening rates
• Funding source:
“Incident to” billing and
transitions in care
codes allow billing at
higher levels if
physician sees patient
with a pharmacist
• Other considerations:
In several states,
pharmacists may bill for
Medicare Wellness
Visits
• “Incident to” billing codes allow
pharmacists to start bringing in
revenue
• New transitions in care codes yield
higher reimbursement rates than
incident to billing
• Pharmacists bill for Medicare
Wellness Visits (WMVs), most
profitable service for program
• Employee wellness visits negotiated
with self-insured employer bring
additional revenue
“Quilt Approach” Shifts Funding Sources Over Time to Support Program Growth
Months to transition away
from grant funding
12–18 Initial target for billable
reimbursement
50% Approximate annual billing per
pharmacist for MTM services
$70K
Initial Grant Funding Early Billable Services Increasing Self-Sufficiency
Billable Services Replace Initial Grant Funding
• University support enables
program launch
©2015 The Advisory Board Company • 29994 advisory.com 12
Profile #5: University Connecticut CMS Demonstration Pilot
Connecticut CMS Demonstration Yields Positive Clinical Impact, ROI
Source: Smith M, et al., “In Connecticut: Improving Patient Medication Management in Primary
Care,” Health Affairs, 30(4):646-654; Advisory Board interviews and analysis.
1) n=917 reported drug problems.
Case in Brief University of Connecticut CMS
Demonstration Pilot
• CMS demonstration project examining
the impact of the integrated pharmacy
model on Medicaid patients with
polypharmacy needs receiving care
at five primary care practices in
Connecticut between July 2009
and May 2010
• Program led by stakeholders from the
University of Connecticut School of
Pharmacy, the Connecticut Pharmacists
Association, and the Connecticut
Department of Social Services
• Results included an estimated annual
savings of $1,595 per patient
Staffing and
Deployment
Patient Eligibility,
Referral Processes
Patient and Provider
Engagement Strategies
Care Coordination
Processes
Performance Metrics
and Outcomes
Financial
Considerations
• Staffing:
Independent
pharmacists contracted
under a Shared Service
Model with the
Connecticut Pharmacist
Association’s network
• Patient volumes:
88 patients across 9
pharmacists (≈10
patients per pharmacist
• Direct referral:
None; relied on
proactive outreach with
patient registry
• Eligibility criteria:
Medicaid beneficiary;
receipt of primary care
services at one of the
selected sites; at least
one chronic condition;
3+ medications for
chronic conditions
• Strategy: Participating
PCPs were already
familiar with integrated
pharmacy model
• Application of
pharmacist
recommendation:
82% of prescribers
made at least one
change in patients’
therapies based on the
recommendation of the
pharmacist
• Encounters: 401
across 88 patients (avg.
of 4.6 per patient)
• Duration of visits:
Initial appointment of
60-75 minutes with a
pharmacist and up to 5
follow-up appts. at
monthly intervals, each
lasting 20-40 minutes
• Process metrics:
Pharmacists identified
917 drug therapy
problems and 3,248 Rx
discrepancies
• Clinical outcomes:
Nearly 80% of the 917
identified problems
were resolved within
four sessions; patients
achieved 91% of their
treatment goals by their
final visit
• Funding source: CMS
grant, although cost
savings exceeded
contracting costs for
pharmacists
• Cost of pharmacist:
Contracted on a fixed-
fee basis, amounting to
$2-$3 per minute on
average for MTM
• Sustainability
planning: Estimated
ROI of 2.5x
Program Results
Problems classified as preventable
medication errors that required a pharmacist
to intervene1
76%
Drug therapy problems resolved after four
patient-pharmacist encounters1
Program Design
Shared Service Model
The Connecticut Pharmacists
Association, a network of independent
pharmacists available to work on a
contractual basis
Co-located Pharmacists
Nine pharmacists embedded part-time
within four FQHCs and one primary care
practice between July 2009 and May 2010
Complex Patient Management
Pilot offered up to five MTM visits with the
co-located pharmacist for 88 Medicaid
patients with polypharmacy needs
Estimated annual total cost savings
per patient $1,595
Total return on investment (ROI) 2.5x
Process Metrics
Clinical Outcomes
Cost Implications
80%
©2015 The Advisory Board Company • 29994 advisory.com 13
Action Steps and Cross-Program Insights
Understand key action steps and components for implementing an effective
integrated model
Section 2
©2015 The Advisory Board Company • 29994 advisory.com 14
Key Insights from Integrated Pharmacy Programs
Source: Advisory Board interviews and analysis.
Competency Area Insight Rationale Action Steps
Staffing and Deployment
Establish a pharmacy
support role that performs
administrative, analytic, and
patient outreach functions
• Increases pharmacist capacity for patient
visits, medication therapy management,
and other top-of-license tasks
• Calculate efficiencies gained through use of pharmacy
support to build business case for additional staff
• Clearly define responsibilities per role to prevent
redundancies and facilitate collaboration
Patient Eligibility, Referral
Processes
Leverage comprehensive
risk stratification criteria to
identify eligible patients
• Enhances efficiency in managing
patients with multiple comorbidities
• Creates scalable model for expanding
across multiple practices
• Determine data sources for mining patient information
• Identify relevant clinical, demographic, and psychosocial risk
factors such as use of 10+ medications, frequent ED use,
behavioral health diagnosis, etc.
Patient and Provider
Engagement Strategies
Institute mechanisms for
interdisciplinary
collaboration between
pharmacists and primary
care physicians
• Builds trust between providers through
regular communication and empowers
top-of-license care
• Documents formal expectations for
coordination between pharmacists and
primary care providers
• Assess state regulations pertaining to pharmacist scope-of-
practice and the role of collaborative practice agreements
(CPAs); enlist pharmacist and physician champions to guide
creation of a template CPA
• Dedicate time for huddles, team meetings, or other
interdisciplinary forums
Care Coordination Processes
Use standardized
intervention templates to
efficiently track and
coordinate pharmacist
activities
• Identifies unmet patient needs and
potential areas for improvement
• Ensures standardized data capture to
assess program performance and build
physician buy-in
• Consult with pharmacists to build intervention checklist that
compiles information on daily activity (e.g., medication
problems identified, pharmacist recommendations, physician
response)
• Incorporate tool into organization’s EMR to enhance ease of
use
Performance Metrics and
Outcomes
Carefully select, monitor,
and report clinical and
quality outcomes to facilitate
buy-in and best practice
sharing
• Illustrates cost and quality improvement
benefits of the integrated model
• Facilitates learning across sites and
allows for effectiveness comparisons
• Clarify relevant process and outcome measures, as well as
desired program targets
• Utilize tracking systems to regularly report on program
performance
Financial Considerations
Measure program impact on
total cost of care and
downstream utilization to
demonstrate business case
• Supports financial sustainability planning
and program expansion beyond grant-
funded pilot
• Builds case to present to commercial
payers
• Identify program costs, including staffing, IT investments,
and training
• Estimate cost avoidance attributable to integrated model and
compare to overall program costs
©2015 The Advisory Board Company • 29994 advisory.com 15
Core Components Grid: Staffing and Deployment
Pharmacists Augment Team-Based Primary Care Models
Source: Advisory Board interviews and analysis.
Staffing Ratio Team Composition Pharmacist Affiliation Scheduling
University of
Michigan
Health System
(UMHS)
Variable based on facility size,
budget allocation, and practice
readiness for team-based care
Pharmacy team consists of
pharmacist, pharmacy residents and
students; clinic panel managers
support with patient recruitment and
outreach
Pharmacy teams are jointly
salaried by the department of
pharmacy services, college of
pharmacy, and faculty group
practice
1-6 half-day clinics per week
(varies by center); pharmacists
provide care to an average of 6.5
patients per half-day (5 is min.
target)
University of
Southern California-
AltaMed CMMI Pilot
(USC-AltaMed)
Approximately one clinical
pharmacy team per four FTE
primary care providers and
8,000 adult patients; caseload of
500 patients per team
Team includes a clinical pharmacist, a
pharmacy resident, and a pharmacy
technician serving as the pharmacy
care manager (e.g., reviews patient
registries, conducts patient outreach)
Clinical pharmacy team members
are employed by USC and
embedded within AltaMed clinics
Clinical pharmacy teams work 40
hours per week; each team sees
an average of 14-22 patients per
day (target is 20 patients per day)
Hennepin County
Medical Center
(HCMC)
12 FTE staff pharmacists
embedded across 16 clinic sites
in the ambulatory setting
0.8 FTE Pharmacy Support Analyst
covers administrative, analytic, and
billing functions for the department;
two pharmacy residents provide
additional weekend support
Pharmacists are employed by
HCMC and embedded within the
system’s ambulatory clinics
At least one pharmacist staffs
each clinic at any given time
during traditional clinic hours (8-5,
Mon-Fri), with overlap at the
positive care clinic1 and internal
medicine clinic
UNC-Mountain Area
Health Education
Center (MAHEC)
Expanded from 3 pharmacists
and 2 pharmacy residents to
5.25 FTE pharmacists and 2
pharmacy residents since 2011
Varies by practice site Faculty employed by MAHEC and
co-funded by UNC provide
pharmacy services 50%-60% of
the week while embedded within
the clinics
Faculty provide clinic services
50%-60% of the week;
pharmacists see 4-5 patients per
half day (10-11 per half day for
anticoagulation visits)
University of
Connecticut CMS
Demonstration Pilot
Approximately 10 patients per
pharmacist
Contracted with independent
pharmacists under a Shared Service
Model with the Connecticut
Pharmacists Association network
Pharmacists contracted on a
fixed-fee basis, with fees
amounting to $2-$3 per minute on
average for MTM
Between July 2009 and May
2010, pharmacists reported 401
encounters across 88 patients;
pharmacists conducted an
average of 4.6 visits per patient
©2015 The Advisory Board Company • 29994 advisory.com 16
Core Components Grid: Patient Eligibility, Referral Processes
Identify Patients through Combination of PCP-Referral and Data Analysis
Source: Advisory Board interviews and analysis.
Physician Referral Protocols Patient Identification Triggers Referral Conversion Rates
University of
Michigan
Health System
(UMHS)
Pharmacist screens disease registries to
proactively identify eligible patients for
outreach and minimize physician burden;
traditional physician referrals
Diabetes (A1c >8%), hypertension (>140/90 mm Hg),
polypharmacy (8+ medications), patients not on
evidence-based medications (e.g., statin use in
diabetes)
72% referral conversion when pharmacy team
performed outbound calls to promote
comprehensive medication reviews for retiree
population
University of
Southern California-
AltaMed CMMI Pilot
(USC-AltaMed)
Balance of direct referrals from care team
members (usually primary care
physicians) and patient identification
using clinical triggers from the patient
registry
More than 48 clinical triggers deployed (e.g.,
BP>140/90 mm Hg, acute care utilization for asthma
and no controller medication issued, A1c>9%, heart
failure on diuretics, frequent ED use, frequent
hospitalization, recent discharge)
Minimal referral challenges reported (i.e., few
patients decline pharmacy services)
Hennepin County
Medical Center
(HCMC)
Predominantly provider referrals
supplemented by weekly lists of patients
with upcoming appointments who would
benefit from a pharmacy session,
generated by support analyst
In addition to physician referrals based on clinic-
specific criteria, pharmacy screens for patients on 10+
medications or with a diagnosis of asthma
17% no-show rate for pharmacy appointments,
which is comparable to primary care clinic rate
UNC-Mountain Area
Health Education
Center (MAHEC)
Referrals from any team member, with
approximately 80% coming from PCPs;
patients were able to self-refer to drive
referral volumes at program outset
Automatic referrals for key conditions (e.g.,
osteoporosis patients referred by lab tech when DEXA
results are abnormal); diabetic and hypertensive
patients identified through disease registry; patients
most commonly referred for complex medication
regimens, diabetes management, medication
assistance, Medicare Wellness Visits, employee
wellness, osteoporosis, and pain
85%-90% referral conversion rate, with no-
show rate comparable to primary care clinic
rate
University of
Connecticut CMS
Demonstration Pilot
Proactive outreach using patient registry Medicaid beneficiary who previously received primary
care services at one of the selected sites; must have
at least one chronic condition and take three or more
prescription medications for chronic conditions
88 patients across four FQHCs and one private
practice met eligibility criteria
©2015 The Advisory Board Company • 29994 advisory.com 17
Core Components Grid: Patient and Provider Engagement Strategies
Anticipate Up to Six-Month Period Before Provider Referrals Reach Steady State
Source: Advisory Board interviews and analysis.
Tactics for Promoting Provider Acceptance Tactics for Increasing Patient Utilization
University of
Michigan
Health System
(UMHS)
• Train pharmacists to frame partnership discussions around how the
physician will benefit
• Emphasize pharmacist support as an opportunity to free up physician
time to focus on non-medication-related issues
• Frame pharmacy as an extension of PCP’s services and network
• Conduct all initial visits in person to build relationships before
transitioning to phone follow-up based on patient needs and
preferences
University of
Southern California-
AltaMed CMMI Pilot
(USC-AltaMed)
• Invest in program marketing and communication from the outset
• Conduct daily huddles and weekly interdisciplinary team meetings with
provider, case manager, and clinical pharmacist to support ongoing
communication for all patients
• Share results, data, and high-impact patient stories
• Use warm hand-offs from PCP and emphasize continuity
of care
• Staff bilingual clinical pharmacy technicians to promote culturally
competent care
• Incorporate awareness of psychosocial factors (e.g., housing stability,
social support) into all encounters, given safety net status
Hennepin County
Medical Center
(HCMC)
• Host presentations upon program launch to encourage pharmacists to
introduce themselves and the program
• Establish interdisciplinary staff meetings to introduce teams to
pharmacist role
• Encourage face-to-face meetings
• Enable patient communication through MyChart patient portal
UNC-Mountain Area
Health Education
Center (MAHEC)
• Identify a physician champion who supports PCMH concept, pharmacy
integration
• Conduct monthly interdisciplinary meetings with physicians,
pharmacists, nursing staff, and behavioral health to discuss shared
expectations and quality indicators
• Hold monthly pharmacy group meetings to discuss practice-related
issues
• Encourage patient self-referral at outset
• Personalize transitions using warm hand-offs
University of
Connecticut CMS
Demonstration Pilot
• Select primary care team with prior experience with integrated practice
models and an understanding of how to effectively utilize pharmacists
• Promote face-to-face meetings
• When possible, resolve medication problems without requiring patient
to make a separate appointment
©2015 The Advisory Board Company • 29994 advisory.com 18
Core Components Grid: Care Coordination Processes
Determine Criteria for Patient Graduation Early in Program Development
Source: Advisory Board interviews and analysis. 1) The positive care clinic is an interdisciplinary clinic for patients living with HIV/AIDS.
Pharmacist Scope of Practice Templates and Collaboration
Agreements
Range of Pharmacy
Interventions Offered Graduation Criteria
University of
Michigan
Health System
(UMHS)
In 2010, all PCMH pharmacists had
their scope of practice approved by
the UMHS credentialing committee to
include diabetes, hypertension,
hyperlipidemia management, and
polypharmacy management
Intervention checklists highlight evidence-
based guidelines per disease state and
track activities performed during visit;
pharmacists and PCPs share patient
medication lists, progress notes, and
medication plans; pharmacist-led follow-
up visits include discussion of medication
changes and action steps for patient
Providing leadership in chronic
care quality improvement
initiatives; evaluating and
optimizing treatment regimens
for diabetes, hypertension,
hyperlipidemia, and
polypharmacy
Patients are encouraged to
return to their PCP once
the pharmacist feels there
are no additional active
pharmacy interventions to
impact clinical outcomes
University of
Southern California-
AltaMed CMMI Pilot
(USC-AltaMed)
CPAs in place to provide physician
reassurance and give pharmacists
sufficient liberty to make impactful
changes for patients; starting January
1, 2014, SB493 expanded pharmacist
scope of practice, enabling the use of
CPAs under the televisit model across
three primary care clinics
Collaborative practice agreements permit
pharmacists to initiate, adjust, and
discontinue medications for many chronic
conditions
Changing dose or drug interval
(38%), conducting patient
education (38%), adding or
discontinuing medication (19%),
substituting medication (5%)
Clinical pharmacy teams
check in every two months
with patients who have
graduated to confirm that
chronic disease targets are
still being met
Hennepin County
Medical Center
(HCMC)
Every pharmacist on the MTM team
holds a specialty certification or board
certification; specialty pharmacists
have received training in oncology,
solid organ transplant, infectious
disease, asthma education, and/or
diabetes education
Co-location of pharmacists with the rest of
the care team facilitates routine
interaction; shared EMR streamlines
referrals and provider communication, and
contains intervention checklist templates
Conducting general medication
therapy management (e.g.,
reviewing medication therapy
regimens, performing disease
management coaching/support)
Pharmacists use clinical
judgment to determine
when patients should
graduate from the program
and discontinue pharmacy
services
UNC-Mountain Area
Health Education
Center (MAHEC)
All pharmacists are recognized as
clinical pharmacist practitioners by the
state board of pharmacy and practice
collaboratively with PCPs. The
expectation is that pharmacists will
become board certified within 1-2
years; MAHEC pays for review
courses and exams
Shared EMR templates standardize team
member communication, documentation,
and quality indicators; embedding
pharmacists at clinics more than one day
per week facilitates relationship building
and consistency; pharmacists ensure
access to community resources and assist
with transitions in care
General MTM, ensuring access
to community resources,
providing interprofessional
education, assisting patients with
care transitions, participating in
quality improvement initiatives,
conducting employee wellness
visits for chronic diseases
Patients are seen until drug
therapy issues are
resolved, with complex
patients often returning for
annual or biannual
checkups; anticoagulation
patients followed
indefinitely
University of
Connecticut CMS
Demonstration Pilot
Not available Standardized medication action plan and
summary report, including evidence-
based recommendations from the
pharmacist, used to guide pharmacist
interventions
Screening for inappropriate
medication choice, omission or
duplication, dosage issues, drug
interactions, adverse reactions,
adherence issues, and health
literacy or cost issues
Patients see the
pharmacist for maximum of
five visits
©2015 The Advisory Board Company • 29994 advisory.com 19
Operational Metrics Pharmacy Program Impact
University of
Michigan
Health System
(UMHS)
• Average number of patients per half-day clinic
ranges from 4.5-8.3
• 80% direct patient care, 20% clinical administration
• Average duration of appointment is 30 minutes
(reduced from initial 45 min)
• Glycemic control and diabetes-related care improved
• Increased goal attainment of many pay-for-performance process measures for the pharmacy-
managed population
University of
Southern California-
AltaMed CMMI Pilot
(USC-AltaMed)
• 15,540 patient visits for 3,001 patients over 12
months
• Daily visits of 14-22 patients per team
• Team patient panel size of 350-725
• Average appointment duration is 30-45 minutes
• Over 2 years, inpatient visits decreased 13.1% for participating patients
• ED visits decreased 37.8%
• Observation visits decreased 50%
• Average patient satisfaction score of 9.6/10 for surveyed patients
• 9.9 problems identified per patient on average, of which 43% were related to effectiveness,
27% to non-adherence, and 18% to safety issues
Hennepin County
Medical Center
(HCMC)
• Patient visit numbers tracked per FTE per clinic to
establish daily targets for pharmacists
• 17% no-show rate, on par with the rest of the
organization
• Pharmacists identified more than 3,500 adverse drug events; two drug problems identified on
average per patient visit
• 30-day readmission rate reduced by 3.4% in hospital clinic
• 90% of patients surveyed would recommend MTM services to a family member or friend
• Outpatient utilization increased by 40% and inpatient utilization decreased by 12%
UNC-Mountain Area
Health Education
Center (MAHEC)
• 4-5 patients per pharmacist per half day
• 10-11 anticoagulation patients per pharmacist per
half day
• 80% of referrals from PCPs
• 85%-90% of referred patients receive services
• Average appointment time is 15 min. for
anticoagulation teams, 30 min. for others
• Program tracks disease-specific clinical outcomes such as ACE inhibitor use for CHF patients
and inhaled corticosteroids for persistent asthma
• Appropriate use of calcium and vitamin D use increased from 30% to 99%
• DEXA screening for women increased from 25% to 80% and INRs in range improved
• Transitions in care program reduced 30 day readmission rate from 15.5% to 5.3%
• Reductions in A1c scores from 9.4 to 7.7 among pharmacy clinic patients since March 2014
• Pharmacists increase primary care physician capacity by conducting Medicare Wellness Visits
University of
Connecticut CMS
Demonstration Pilot
• Nine pharmacists worked with 88 Medicaid patients
• 401 total patient encounters
• Average of 4.6 encounters per patient
• Initial appointments 60-75 minutes, follow-up
appointments 20-40 minutes
• 82% of prescribers made at least one change to patients’ therapies based on pharmacist
recommendations
• Nearly 80% of drug therapy problems were resolved within four patient-pharmacist encounters
• 91% of patients achieved their treatment goals by the final visit (63% within first visit)
• Pharmacists identified 917 drug therapy problems and 3,248 medication discrepancies
Core Components Grid: Performance Metrics and Outcomes
Leverage Performance Outcomes to Increase Provider And Payer Buy-in
Source: Advisory Board interviews and analysis.
©2015 The Advisory Board Company • 29994 advisory.com 20
Core Components Grid: Financial Considerations
Most Programs Initially Rely on Grant Funding, Then Push for Reimbursement
Source: Advisory Board interviews and analysis.
Funding Source(s) Financial Impact Sustainability Planning
University of
Michigan
Health System
(UMHS)
• Majority of costs absorbed by UMHS
practice sites with support from Dept. of
Pharmacy and College of Pharmacy
• Commercial payer reimbursement
available, but varies by practice payer mix
• Currently, five payers contribute to
Pharmacy Services through capitated
payment and fee-for-service
• The PCMH model enabled use of T code billing
with BCBS of Michigan
• In its first year, the program generated
$154,831 in T code revenue
As model evolves, program costs are
increasingly shifted to practices; cost
breakdowns are practice dependent, but on
average, the practice covers 70% of program
cost and 30% is subsidized by the Dept. of
Pharmacy and College of Pharmacy
University of
Southern California-
AltaMed CMMI Pilot
(USC-AltaMed)
• Recipients of three-year, $12M CMMI
grant through July 2015
• AltaMed provides clinic infrastructure while
USC provides salaries for pharmacy teams
• Projected savings are $31.7M over three years
• Increase in drug spending (≈$400 per patient
per year) expected to be offset by reductions in
medical care spending
Sustainability plans range from expanding
patient panels, increasing billable activity
among pharmacists, and/or piloting the model
within risk-based or capitated payment
structures
Hennepin County
Medical Center
(HCMC)
• Approximately 15% of program costs are
covered by insurance reimbursements,
10% by grant funding, and 75% absorbed
by the system due to demonstrated
reductions in total cost of care and
increased utilization of community
pharmacy services, resulting in an overall
positive ROI
• For patients receiving pharmacy services,
HCMC has been able to decrease patient
total cost of care by over $2,000 per patient per
year
Exploring risk-based contracts under their
Hennepin Health Insurance Group, a county
plan that provides assistance for individuals
below the poverty level who are ineligible for
Medicaid; increasing payer contracting activity
to support MTM services
UNC-Mountain Area
Health Education
Center (MAHEC)
• “Quilt approach” consisting of combination
of grant funding and use of “incident to”
billing codes, transitions in care codes,
employee wellness visits negotiated with
self-insured employer, and Medicare
Wellness Visits
• Initial target for billable reimbursement to
cover 50% of program costs
• The transition away from grant funding took
≈12-18 months
• Each pharmacist bills approximately $70,000
annually for MTM services
• Billable reimbursement target is 50% of
program costs
Continuing to explore creative ways of billing for
services to shift away from grant funding;
recently procured 2-year grant to evaluate
financial sustainability of the integrated
pharmacy model in rural areas
University of
Connecticut CMS
Demonstration Pilot
• Part of a $5M grant from CMS to
Connecticut Medicaid
• Additional grant program elements
included e-prescribing and health
information exchange development
• Estimated annual savings of $1,595 per patient
• Savings exceeded program costs with
estimated ROI of 2.5x; calculations include the
cost of contracted pharmacists and
administrative inputs
The principal investigator of this demonstration
project subsequently joined the CMS Innovation
Center to guide pharmacy intervention
development for Comprehensive Primary Care
(CPC) initiative
©2015 The Advisory Board Company • 29994 advisory.com 21