The care manager who fills prescriptions
Which healthcare providers do patients interact with most?
Hint: It's probably not their primary care physician.
According to claims data from Community Care of North Carolina, the state's Medicaid care coordination network, complex patients see their local pharmacists an average of 35 times per year – 10 times more than they see their primary care provider.
That puts community pharmacists in a unique position to help patients understand their conditions and medications — and to stick to care plans. So, in 2014, Community Care of North Carolina (CCNC) won a $15 million grant from the Center for Medicare & Medicaid Innovation to demonstrate how community pharmacists might lower the cost of care for the state's 1.7 million Medicaid patients.
And four years later, the results are in. While 10 to 15 percent of healthcare spending is on prescriptions, that's not where community pharmacists have the most impact, according to CCNC. Instead, pharmacists can reduce the other 85 to 90 percent of healthcare spending through care management.
Connecting clinicians and pharmacists
In their initiative, CCNC sought to deepen the relationships between medical practices and local pharmacists. They began by identifying pharmacies that prioritized support for patients through enhanced services like medication synchronization, patient education, and home delivery. They then invited those pharmacists to partner with medical practices to prevent readmissions.
Many of those medical practices “never thought about sharing discharge instructions or care plans with community pharmacies," says Troy Trygstad, vice president of pharmacy programs at CCNC.
With new partnerships — or "care compacts"— in place, providers can message pharmacists, saying, for example, “Here's a prescription for metformin, 500 milligrams BID. Please make sure the patient comes back for her follow-up in three months. And we want you to follow up in three days to ensure that she's not getting stomach upset."
In functioning as care managers who also dispense medications, the pharmacists earn a care management fee as well as the cost of medications and related services. And medical practices in the CCNC network have been able to rely on community pharmacies as a force multiplier for their case management teams.
The power of relationships
The strength of the care compacts comes in large part from the visibility pharmacists have into the lives of patients —and their barriers to better health.
“It's great for you to diagnose a patient and put them on the best regimen," says Amina Abubakar of physicians, “but you may not know they just lost their house, couldn't afford their copays, or don't have a refrigerator to store their insulin." As owner of RxClinic Pharmacy in Charlotte, Abubakar ensures that her pharmacists ask about those things and share the insights with medical practices — as well as connecting patients with community resources to help.
Counseling patients in transitions of care is a particular focus of RxClinic Pharmacy and others participating in the CCNC network. “Within two days of discharge, we make sure patients have received all their medications and understand how to take them," says Abubakar, as well as preventing potentially life-threatening interactions between medications prescribed by multiple specialists.
Pharmacists in the CCNC network are also helping patients navigate prior authorizations by understanding the system and suggesting substitutions when necessary. At RxClinic, Abubakar says, approval times for prior authorizations have been cut by 75 percent.
Building a pharmacy network
Care management services are not an entirely new idea for pharmacies, but have generally lacked standard protocols. So, as part of the initial CMMI grant, Trygstad and his team at CCNC addressed that gap by building an enhanced service network of community pharmacies, trademarked as CPESN.
CPESN establishes common standards for data transmission, quality assurance requirements, and standard services. For an annual fee, member pharmacies receive access to the shared services of the network, including model contracts with health networks or payers, and analyses of patients' risk scores and their likely need for intensive medication management.
By tracking the cost of care across the network, CPESN revealed that while complex patients had double the health spend of other patients in the system, that rate of spend leveled off after pharmacists began coordinating care with medical practices. Patient outcomes also improved – patients who were customers of member pharmacies consistently scored 4 to 5 percent higher on medication adherence than those of other pharmacies.
CPESN is rapidly becoming a national network, with member pharmacies in 37 states, and expects to be within the delivery radius of 85 percent of the U.S. population by the end of 2018.
Speaking the same language
One high-impact benefit developed by CPESN pharmacists in North Carolina is the Pharmacist eCare Plan, a standardized electronic document shared between community pharmacists and clinical care teams detailing health goals and concerns, labs, medications, and outcomes for patients over time.
The document captures what community pharmacists were already finding out about patients — from behavioral issues to what the pharmacies' drivers observe on their delivery runs — but had no way to share. Pharmacist eCare codifies and delivers patient and quality information across members' platforms, supporting cohesive patient management.
By integrating community pharmacists with care management, says Shelly Spiro, executive director of the Pharmacy HIT Collaborative, a work group of the American Pharmacy Association, CCNC's patients "stay out of the hospital, better understand what's happening to them, and become more stable patients."
Like other successful population health initiatives, CCNC's work with pharmacists takes care out of the walls of the healthcare system and into neighborhoods — which are the "primary infrastructure for improving health," according to Prabhjot Singh, M.D., chair of Health System Design and Global Health at Mount Sinai in New York.
Lia Novotny is a frequent contributor to athenaInsight.