MODULE 9: Establishing a Network Pharmacist Program

In this module, we will discuss the need for pharmacy coordination as part of a care delivery improvement program. We will also explain the method we followed in creating our comprehensive medication management infrastructure and describe five medication management projects that we’ve developed.

The need for pharmacy coordination

In 2007, approximately 10 years after the Community Care program was first launched, North Carolina’s General Assembly charged Community Care with implementing a high-risk case management system for the aged, blind and disabled — a population that requires intense and complex medication management across multiple providers and settings. Spurred by this new need and concerned about cost-effective prescribing and drug use for all populations, we developed a pharmacist support initiative designed to benefit both networks and practices: the Network Pharmacist Program.

In the three years since we launched the program, we’ve learned that medication management is an integral part of health-care delivery improvement. Consider that chronic disease treatment accounts for 75 percent of all health care costs nationally and that medication is our primary mechanism of intervention for chronic disease. When treating the aged, blind and disabled, a population in which co-morbidities are common, the management of medication becomes even more critical.

Reducing total costs, improving total health

Our primary goal for the Network Pharmacist Program was to create a medication management infrastructure that improved care outcomes while reducing total health care costs, not just drug costs. Historically, pharmacist-led management programs have been concerned primarily with drug selection, especially when drug costs are managed or administered separate from non-drug medical costs. We wanted to avoid that trap, creating instead a program focused on improving overall health — a well-coordinated, goal-oriented, continually reinforced drug-use plan that would span settings and providers.

The Network Pharmacist Program was launched during a tumultuous time for pharmacists and prescribers. Just a year earlier in 2006, the introduction of Medicare Part D created wholesale change in pharmacy benefits and administration of preferred drug lists and prior authorizations, affecting millions of Americans and their health-care professionals. Seeing the confusion and frustration that resulted, we aimed to create a drug-management program that would encourage judicious, evidence-based, cost-effective prescribing while also ensuring that the patient, pharmacy and prescriber remained at the center of the effort, with autonomy and workflow preserved. The three central goals to any cost-effective prescribing initiative at Community Care are to:  (1) minimize to the greatest extent possible patient attrition (going without a needed medication); (2) minimize to the greatest extent possible prescriber disruption; and (3) minimize to the greatest extent possible pharmacy disruption.

Figure 1. Community Care Pharmacy Management Model

As with other Community Care initiatives, we implemented the Network Pharmacist Program in phases. First, each network recruited 14 Network Pharmacists — professionals who would be responsible for leading all pharmacy-related projects in their respective networks. Once the Network Pharmacist was placed (the pharmacy projects manager), we began recruiting Clinical Pharmacists, who would work directly with care managers and patients. Once patient, prescriber and case manager facing pharmacists were on board, we began launching clinical pharmacist pilot programs. The most successful pilot programs were then rolled out to the entire Community Care system, managed by Network Pharmacists.

The role of the pharmacist

Because each of the 14 networks enjoys a great deal of autonomy in hiring and project implementation, each network pharmacist is supervised and directed locally by the leadership within the network rather than by the central office. Because we are also a learning community, however, networks also enjoy strong centralized support and facilitation from Community Care by employing a Director (lead facilitator) that is responsible for creating, sharing and giving direction and vision as well as shared informatics services that provides meaningful pharmacy information.

Community Care’s network pharmacists come from a variety of backgrounds: managed care, retail pharmacy, hospital pharmacy, specialty pharmacy, mail-order pharmacy, HIV clinics, anti-coagulation clinics, diabetes clinics and academic residency teaching. This diversity is advantageous given the breadth and scope of pharmacy-related activities that touch every aspect of the health care system.

In our program, network pharmacists also serve as administrators; each network pharmacist is responsible for directing and managing projects in his or her network. They oversee clinical pharmacists, the professionals who deliver care by working directly with patients or as part of a multidisciplinary team. In smaller networks, the network pharmacist may also serve as the clinical pharmacist.

General responsibilities for the network pharmacist include:

• Coordinating pharmacy-related initiatives.
• Coordinating and managing education on Community Care and Medicaid pharmacy initiatives for community pharmacists.
• Coordinating pharmacy activities across the continuum of care, including hospitals and nursing homes, to assure appropriate and economical use of medications.
• Creating programs that address new drug policies implemented by the North Carolina Division of Medical Assistance (the state’s Medicaid management agency).
• Participating in local network meetings.
• Serving as a resource on general drug information and Medicaid drug policy issues.

General responsibilities for the clinical pharmacist include:

Clinical pharmacist placement models

As of 2009, all 14 networks have well-established network pharmacist positions. We are currently focused on recruiting clinical pharmacists, who will add an additional layer of expertise to the case management team and help practices build patient-centered medical homes.

Because pharmacists typically garner compensation that surpasses that of traditional surrogates and extenders of physicians such as advanced practice nurses and physician’s assistants, it is challenging to construct sustainable models that support embedding a clinical pharmacist in every setting, especially in the absence of an all-payor approach. (For us, the exceptions are a few practices with large Community Care-linked Medicaid populations; these practices can support a full-time embedded pharmacist based on a $2.50 or $5.00 per-member, per-month payment.)  As a result, Community Care uses a range of creative placement models for pharmacists.

Centralized (network) placement: In this model, clinical pharmacists are located in the central network office, working with each member of the network often via fax or email. This model ensures universal network coverage at a reasonable cost. The disadvantage, however, is that a centralized pharmacist is less integrated with and, therefore, less invested in individual practices and providers. This can hinder the development of meaningful and efficient work relationships between pharmacists and medical home providers.

Hospital-based placement: Employed either by the network directly or through network funding, the hospital-based clinical pharmacist is responsible for network- sponsored medication management activities and collaboration within the assigned hospital that expand medication management beyond the typical responsibilities of the hospital and into the community; he or she enjoys the same access as other pharmacists in the hospital without the burden of routine hospital responsibilities. Hospital-based pharmacists work mostly with Medication Reconciliation Plus (the Community Care program that works to identify medication discrepancies resulting from hospitalization with the “PLUS” constituting the responsibilities of patient follow up following discharge that go beyond traditional Medication Reconciliation and incorporate outpatient providers and address drug therapy problems associated with disparate, disorganized and ill-coordinated drug use plans). They also participate in other initiatives and handle medication management referrals from network providers and case managers. Hospital-based placement keeps pharmacists close to one of Community Care’s primary quality and cost-savings endpoints: hospitalizations and transitions of care. It is also advantageous for enacting Medication Reconciliation Plus, as it allows the pharmacist to oversee the entire prescribing process. The disadvantage, however, is the same barrier presented by centralized placement: distant working relationships between pharmacists and outpatient medical home providers, which may reduce response rates and collaboration.

Clinic-based placement: While in-house pharmacist placement is perhaps the most beneficial model for practices, it is also the most challenging, both economically and logistically. The advantages are many: the ability to schedule patients for face-to-face pharmacy appointments, immediate access to medication management expertise, improved trust and collaboration. Practices that embed clinical pharmacists report high satisfaction. None of the networks, however, has the funding to support full-time placement in every practice, though a multi-payor approach would alleviate much of the burden for Medicaid to wholly support the development of these positions. Thus the necessary disadvantage is a logistical challenge associated with sharing pharmacists across multiple clinics.

Hybrid hospital-practice placement: In this model, the clinical pharmacist spends part of the day at his or her hospital and part of the day at a designated practice. Hybrid placement creates a good balance of activities as the pharmacist can divide his or her working hours between discharges and clinical practice as the caseload demands. For Community Care, hybrid placements directed by the network pharmacists may ultimately become the preferred operating model in many areas of the state, especially where large multi-specialty practices provide the dominant supply of physicians admitting or referring to the hospital. Of course, this model is limited in so much as the number of scenarios where hospitals are linked closely to a large outpatient practice.

Support Models

In addition to placement, levels of support vary by setting and scenario.

Fully employed placement: Some networks have chosen to fully employ a clinical pharmacist. This option is beneficial when an economy of scale is present (for instance, a concentration or large number of Community Care-linked enrollees in a practice or hospital setting). When a network employs a pharmacist, it has close control over that pharmacist’s responsibilities, activities and time. The downside to this approach, however, is that practices and hospitals may feel less ownership in the pharmacist program as it necessarily restricts activities to a portion of the census or practice catchment that is linked to Medicaid, the primary source of support for the pharmacists’ employment. In the absence of a multi-payor supported model, it is difficult for hospitals and clinics to create workflows and carve out processes that match with particular payors; a necessary requirement when the pharmacist is wholly owned and operated by the network.

Partial-support placement: A more valued approach for a practice or set of practices is the partial-support model where the practice contracts with a clinical pharmacist for a predetermined number of hours or activities. Since clinical pharmacists can bill some medication management activities to other state and federal programs, Community Care often provides the last critical funding a practice may need for in-house pharmacist support. Under this model, a network with three large practices in three counties could embed three clinical pharmacists perhaps for the cost of a single full-time equivalent (FTE) split three ways. The model is advantageous because it allows for shared ownership of the pharmacist and because the network can divide its FTE among many practices. The model can be disadvantageous to the network if it desires to have a high level of control over the pharmacist.

Partner placement: There are also a number of circumstances that may lead to the creation of Community Care Clinical Pharmacist Partners. That is, where no fiduciary relationship or payment or direct support exists for the pharmacist, but it is simply a matter of combining what non-Community Care supported pharmacists are currently doing in the hospital or clinic together with existing Community Care activities. Two examples currently in place are the pharmacist-residency program model and the hospital-medication reconciliation model.

In the residency model, the clinical pharmacist already has a set of responsibilities as outlined by the residency director that is typically aligned with intensive medication management and in line with Community Care goals and initiatives. These residencies typically place pharmacists inside of a practice seeing patients and working on an interdisciplinary team, much like the PCMH model. If that resident is engaged with Community Care case managers or perhaps a centralized network pharmacist, it may enhance their existing program, benefiting both the residency and the networks.

A more concrete example might be the deployment of Community Care care managers for home visits post discharge. If there is already a pharmacist performing medication reconciliation at discharge and a care manager is being deployed to the home for a post-discharge visit, then it makes logistical and economical sense to use that pharmacist as the starting point and starter set of information to inform that home visit (rather than create another layer of pharmacist(s). Moreover, quite often the hospital may be engaging in medication reconciliation, but that reconciliation is not translated well to the outpatient provider. Community Care may facilitate that transmission to benefit both hospital and clinic.

Both of these examples of Community Care Clinical Pharmacist Partnerships cost little or no money to the practice or network and create a situation that is mutually beneficial to the partner and Network since it is only a matter of connecting the teams and working collaboratively. In many instances the networks are engaging in activities that augment hospital and/or practice activities and the hospitals and/or practices are engaging in activities that augment the networks. This type of coordination and facilitation, and not necessarily direct financial or human resource support, may ultimately be the primary driver of success for Accountable Care Organizations going forward; the goal being a smarter system of care, with roughly the same staffing being used in a more efficient, effective an coordinated way as payment systems begin to align and the ACO being the medium for coordination.

Getting to work

We strongly believe that any health care delivery improvement program will benefit from a pharmacy support component led, at least in part, by a pharmacist who is part of the program’s interdisciplinary management and development team. When we launched the Network Pharmacist Program, we began from scratch and development was slow at times. Now that we have the necessary infrastructure in place, pharmacy projects are improving in quality and growing in quantity at an accelerating pace.

To date, we’ve created and piloted a number of pharmacy programs; in the following sections, we’ll discuss five in detail, with the first three tracking the evolution of our clinical pharmacy programs and the last two an example of the diversity and breath in scope of pharmacy programs within the Community Care system. While these programs may not be the exact ones you’ll need in your community or state, we hope they’ll help you understand how you can develop initiatives that will suit your specific situation.

Chronic Care Initiative

Our first pharmacy-based pilot, the Chronic Care Initiative was developed to address the increasingly disproportional costs and co-morbidities associated with specific segments of the population. To begin, we focused on the aged, blind and disabled (ABD) — Medicaid patients who, as a whole, required a great deal of care and created a substantial cost burden. Because the ABD population requires health care coordination across numerous settings (including primary health care, specialty health care, mental health care and social services) and because medications are often prescribed in more than one setting for each patient, we wanted to offer pharmacist support to enhance the existing medication management.

For the Chronic Care Initiative, networks created comprehensive medication regimen review processes. These reviews considered patient adherence and polypharmacy and polyprovider traits (such as the use of eight or more medications in a month or visits to three or more unique providers in three months). This was a population-based approach with a targeting strategy that used claims data to determine recipients of a service. The intervention deployed intensive case management and adherence coaching as a follow up to a comprehensive medication regimen review performed by the Network Pharmacist. Much was learned in this first attempt at comprehensive medication management including the need to strengthen the medication management acumen of the case managers as well as the clinical acumen of the pharmacists. Most obvious was the need to reach out to different settings and providers, the most prominent of which were hospitals and specialists and the realization that we could not solve most of the drug related problems without a more meaningful and efficient relationship with our providers. This Initiative was a precursor to many Community Care pharmacy programs to come.

Pharmacy Home Project

On average, primary care providers have between six and 13 minutes of face time with a patient in a typical ambulatory encounter. For patients with multiple co-morbidities, it could easily take 13 minutes just to acquire a complete medication history. As a result, providers may not learn a patient’s history or adequately identify and resolve problems related to medication use in the time allotted.

Community Care’s Pharmacy Home Project seeks to enable the primary care team to efficiently identify, resolve and follow up on drug-therapy problems while resolving a greater number of the drug-use problems discovered by the extended Community Care care management team. In short, the program creates a “pharmacy home” — part of the medical home — that gathers drug use information from multiple sources to better inform prescribing patterns and identify opportunities in pharmacy management.

The Pharmacy Home Project enables comprehensive medication management through Community Care clinical pharmacists and care managers who follow a patient across care settings to help PCPs manage their most at-risk and challenging patients.

The emphasis on drug-use information is important and distinguishes the Pharmacy Home Project from other medication management projects and decision support tools. Providers and care managers need actionable information that is corroborated by multiple sources, not a simple listing of medications prescribed or taken. These sources can include the patient, his or her medical chart and his or her previous drug claims.

Figure 3. Drug Use Information from Multiple Sources

Figure 4 is an actual case study that occurred in the first week of deployment of the Pharmacy Home Project. This underscores the need for human and technological infrastructure as well as a multidisciplinary approach that uses each member of the team in an efficient and cost-effective manner. We have found that in almost all instances, drug therapy problems and their subsequent solutions require patient interaction along with a coordinated, goal-oriented, continually reinforced drug-use plan. In this example, uncovering a single actionable problem required a case manager (to bring the problem forward), a network pharmacist (to confirm use and assess the drug regimen), the pharmacy home portal which displays prescription fill history at the pharmacy (as one source of information), the patient chart and clinic personnel (as another source of information) and ultimately the primary care provider (to enact a solution).

Figure 4. Example of Drug Use Information Gathering (Ambulatory)

While a number of health care professionals (including doctors, nurses and pharmacists) are capable of participating in comprehensive medication management services, our current health care system does not provide monetary incentives for such work. In addition, the general lack of integrated pharmacy records across settings and providers makes such management cumbersome and expensive.

Figure 5. System of Silos and Inadequate Medication Management

The good news is that a program model like Community Care can both create incentives (through direct and indirect support) and guarantee the integration of robust and comprehensive medication management because it transcends settings and isn’t sustained or burdened by unit-based reimbursement.

Figure 6. Integrated and Aligned System of Medication Management

In short, the Pharmacy Home Project helps to:

Medication Reconciliation Plus

The Pharmacy Home Project created flexibility and a variety of exciting new ideas, projects and processes. One of the more popular and easily accepted, though challenging to implement offshoots of the Pharmacy Home Project was Medication Reconciliation Plus: a comprehensive medication review and reconciliation process that extends the reconciliation process beyond hospital discharge and into the community setting. This process involves multiple patient touch-points in many settings, including a requisite patient interview by either a pharmacist or nurse a few days following hospitalization with the goal of preparing the PCP for a productive post-hospitalization follow-up visit.

In essence, Medication Reconciliation Plus builds on the work of the Pharmacy Home Project, requiring more in-depth problem identification, including uncovering discrepancies resulting from a patient’s institutionalization. Medication regimen confusion is common in institutional environments as there may be formulary differences between a patient’s at-home medications and the hospital medications or because a dysfunctional drug-use plan that oftentimes may have ultimately caused the medical event that necessitated hospitalization. Figure 7 illustrates the way information is gathered following a hospitalization.

Figure 7. Convergence of Drug Use Information with Medication Reconciliation

Three months after Medication Reconciliation Plus was launched, we discovered an average of 5.1 discrepancies per patient following hospital discharge. While we initially believed that PCP follow-up would be required only in rare cases of therapeutic duplication, dose-duration incongruence, drug-drug or drug-disease, or other classic regimen-related problems. However, we ultimately found that 90 percent of patients had a medication discrepancy that required intervention by the PCP (or a specialist involved with a particular drug). This single statistic both reinforced the need and the challenge of more enhanced, multi-setting medication reconciliation activities.

As we analyzed the data more closely, it became clear that in many cases, there was no single provider — and more significantly, no community-based provider — in charge of the patient’s drug regimen. The net result of this was non-adherence becoming a predominant contributing factor to regimen confusion. Non-adherence, combined with a hospital event potentiated an ill-informed, ill-coordinated, never reinforced drug regimen that was without a plan to meet therapeutic goals – the photo negative of the goals of the Pharmacy Home Project. While adherence problems often existed prior to the medical event, we found that they were compounded by the hospitalization. A further complication was that patients were increasingly being admitted to hospitals without PCP oversight as fewer and fewer community-based providers admit to hospitals. The combination of these factors created for PCPs a very challenging patient encounter following a hospitalization.

In Figure 8, we attempt to illustrate the intended effect of Medication Reconciliation Plus. It is an attempt to contrast the type of conversation that is more advantageous in the first PCP visit post-hospitalization versus the traditional conversation that is currently taking place many thousands of times a day.

Figure 8. Breaking the Cycle: Transitional Care

Standard practices under most health-care models plus a lack of a common pharmacy record leave the PCP in an information vacuum, especially if there are no partners (such as case managers) who can research and collect drug-use histories and information. When evaluating a recently hospitalized patient with complex health issues, a PCP shouldn’t simply ask, “What did they tell you to take and how?”  Gathering critical information in this way from the patient will likely be time-consuming and riddled with inaccuracies, omissions and outright confusion. Patient recall of hospitalization and associated instructions is often poor; when combined with drug-related issues that existed prior to (or perhaps caused by) hospitalization, you have a perfect storm of drug therapy problems and lack of information.

Working with a care team that can schedule, prepare for and support a PCP follow-up visit ensures that the physician has a more informed starting point. Additionally, the case manager or clinical pharmacist can follow up on whatever is discussed and decided upon during that encounter.

To provide a real-life snapshot of how Medication Reconciliation Plus works, Figure 9 shows a dialogue that occurred in the first three months of the initiative. Note that a Community Care clinical pharmacist, a Community Care case manager, a hospitalist and ultimately the community-based prescriber collaborated on and were jointly responsible for post-hospitalization care. Significantly, there were multiple sources of drug-use information (i.e., discharge list, home visit brown bag, electronic medical chart and the involved physicians).

This dialogue illustrates the need for a whole-team approach to medication management. Even when the hospital has the benefit of complete information about a patient’s drug use prior to and during the hospitalization, the patient is often too confused or hurried for counseling or coordination — and in this case, two of the four discrepancies discovered may have occurred even with perfect discharge counseling. First, the metoprolol duplication could not (or likely would not) have been known at the time of discharge. Furthermore, despite the counseling at discharge to the contrary and resolution of the ramipril omission, the patient was still taking two ACE-inhibitors after hospitalization. In the final analysis, there were problems addressed at discharge, during the home visit and following the home visit, each in coordination and communication with the PCP responsible for post-acute care.

Figure 9. Example Medication Reconciliation Plus Dialogue

Prescription Advantage List

In addition to clinically oriented initiatives that help improve patient outcomes by lowering total health care costs, the Network Pharmacist Program also includes initiatives to encourage cost-effective prescribing. The Prescription Advantage List (PAL) was adopted by Community Care in coordination with the state’s Physician’s Advisory Group and North Carolina Medicaid’s Pharmacy and Therapeutics Committee. PAL is a voluntary preferred drug list managed and promoted by Community Care that includes a large number of drug classes and conditions. Community Care does not set or approve North Carolina Medicaid policies, and the PAL remains completely voluntary. On occasion (but with increasing frequency as the state budget continues to be strained), the PAL list has been augmented by North Carolina Medicaid with a number of prior authorizations in select classes. As such, Community Care works with Medicaid to make prior authorizations as patient-, prescriber- and pharmacy-friendly as possible.

One of the challenges associated with prior authorization (PA) is patient, prescriber and pharmacy disruption. This occurs when the pharmacy is unable to fill the prescription for the patient and must contact the prescriber, who in turn must contact a third party to document criteria for approval. Then, without notification to patient, prescriber or pharmacy, the third party accepts or denies the application for PA override.

In order to avoid these administrative hassles and delays in access to medication, Community Care worked with the Physician’s Advisory Group and the North Carolina Medicaid Pharmacy and Therapeutics Committee to create the Instant Approval (IA) program. IA allows the prescriber to document criteria on the prescription so that the pharmacist can override the PA to avoid delays and excess paperwork. First used for proton-pump inhibitor prescriptions, IAs are now widely employed; pharmacies and prescribers overwhelmingly prefer them to traditional PA processes.

Community Care created a second tool to make IAs available for refill prescription, as well. The MD-EZ program sent to providers pre-printed prescriptions for all the Community Care-linked patients. These prescriptions included the PA criteria and an option to either select a non-PA generic or use an IA. More than 30,000 proton-pump inhibitor prescriptions were sent to practices, where network pharmacists counseled physicians on how to use them. Pharmacists are also available for consultation by phone before, during and after North Carolina Medicaid implements a new PA.

eRx Initiative

To capitalize on technology that can create a more efficient and effective pharmacy home, Community Care launched, in collaboration with Blue Cross and Blue Shield of North Carolina and with support from the North Carolina Department of Health and Human Services and Blue Cross and Blue shield, an electronic prescribing effort focused on promotion, education and support at the local level. Seven e-prescribing expert facilitators (who were also clinical pharmacists) were added to the Network Pharmacist Program and existing medical management, clinical director and network coordinator meetings were used for additional promotion and education.

Thanks to our existing infrastructure, Community Care’s eRx Initiative was fully deployed in just four weeks and dramatic results were realized in only two months. From July 2008 to May 2009, the percentage of eligible prescriptions sent electronically rose from six percent to 17 percent statewide. Furthermore, because the community-based approach allowed facilitators and networks to bring all stakeholders to the table, adoption occurred among providers inside and outside the Community Care network. This benefitted all practices and settings since community-wide adoption is necessary for interoperability and to create a critical mass of users. Of the practices receiving e-prescribing support, education and troubleshooting, half are outside of the Community Care network.

Points to remember

• Medication management is critical to any health care delivery improvement program.
• Without a complete care team responsible for research and follow-up, physicians and hospitals will never have a complete understanding of a patient’s drug-use history (or the adherence problems that may have necessitated the hospitalization in the first place).
• It is valuable to employ two types of pharmacists: those who work directly with patients and providers and those who supervise your program’s pharmacy-related initiatives.
• Few practices can afford a full-time, embedded pharmacist. Consider alternative placement models to best provide coverage and support.
• Strive to make drug-use plans accessible to the entire health care team (including PCPs, nurses, social workers and pharmacists) so the plans are understood and supported by every provider at every step of the way.