Pharmacy and the Medicaid Accountable Care Organization
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1 RCCO Pilot Project
2 CDC Grant Increase engagement of non-physician team members (ie., pharmacists) in Hypertension (HTN) and Diabetes Mellitus (DM) management in health care systems; Increase the proportion of community pharmacists that promote medication-/self-management; Increase the proportion of adults with diabetes and high blood pressure in adherence to medication regimens; and Increase the proportion of adults who have achieved blood pressure and/or diabetes control.
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4 The Accountable Care Organization Centers for Medicare and Medicaid Services: Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the patients they serve.
5 The ACO System in Colorado Design: Primary care medical providers contract with Regional Care Collaborative Organizations (RCCOs) to help provide medical homes to Medicaid enrollees. Primary Care Medical Providers (PCMPs) serve as a Medical Home that: Is member/family centered Is whole person oriented Is coordinated Promotes client self-management Provides care in a culturally sensitive and linguistically sensitive manner Is accessible RCCOs achieve financial and health outcomes and ensuring comprehensive care coordination and a Medical Home level of care for every Member through: Network Development/Management Provider Support Medical Management and Care Coordination Accountability/Reporting
6 The ACO System in Colorado Design: Primary care medical providers contract with Regional Care Collaborative Organizations (RCCOs) to help provide medical homes to Medicaid enrollees. Primary Care Medical Providers (PCMPs) serve as a Medical Home that: Is member/family centered Is whole person oriented Is coordinated Promotes client self-management Provides care in a culturally sensitive and linguistically sensitive manner Is accessible RCCOs achieve financial and health outcomes and ensuring comprehensive care coordination and a Medical Home level of care for every Member through: Network Development/Management Provider Support Medical Management and Care Coordination Accountability/Reporting
7 The ACO System in Colorado, continued Currently: - Regional Care Collaborative Organizations (RCCOs) receive $9 per member, per month (PMPM) payment. In the future: - After a RCCO operates on a cost neutral basis, they are eligible to draw from a quarterly incentive payment pool. - To receive incentive payment, they must meet specific performance goals: - reduce ER visits - reduce hospital re-admissions - and address utilization of medical imaging.
8 The ACO System in Colorado, continued Was it not ideal for a RCCO to: consider being the intermediary for integrating pharmacy provide reimbursement using their PMPM to contract with community pharmacists and to focus on adherence toward the goal of increasing control of HTN and DM just like CDC had asked us to do?
9 Why Now? 1. Pharmacy engagement 2. Conversations with Health Care Policy and Financing (state Medicaid) 3. Provider shortage focus 4. Centers for Disease Control and Prevention focus and grant 5. Existing diabetes management clinics through University of Colorado (CU)
10 University of Colorado Disease State Management Clinics 12 diabetes disease management clinics in rural pharmacies across the state Purpose: To further develop and evaluate a diabetes disease state management (DSM) program that provided direct patient care responsibilities to advanced pharmacy practice experience (APPE) students as members of healthcare teams.
11 RCCO Pilot Elements 1. Strong relationships between RCCO clinics/providers and pharmacists/pharmacies 2. Utilization of claims data to identify clients who could benefit from adherence and disease management services, with specific attention to hypertension and/or diabetes 3. Enrollment of a distinct number of clients in a program 4. Use of multiple pharmacies 5. Specific program offered by pharmacy students 6. Fourth year pharmacy students provide services at no cost
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13 Region 4: Integrated Community Health Partners
14 Pilot Sites Buena Vista Drug Safeway Pharmacy Valley-Wide Pharmacy
15 Overall Project Design
16 Overall Project Design
17 Overall Project Design
18 Overall Project Design
19 Pharmacy Program Components Relative to Defined MTM Performing or obtaining necessary assessments of the patient s health status; Formulating a medication treatment plan; Selecting, initiating, modifying, or administering medication therapy; Monitoring and evaluating patient s response to therapy; Performing a comprehensive medication review; Documenting care delivered and communicating essential information to patient s PCPs; Providing verbal education/training to enhance patient use of his/her medications; Providing supports/resources to enhance patient adherence with therapeutic regimens; Integrating MTM services with patient s broader health care-management services
20 Diabetes management curriculum Current diabetes management program follows the nationally recognized Diabetes Self- Management Education (DSME) program Components include: What is diabetes? Cardiovascular risks of diabetes Exercise benefits with diabetes Hypoglycemia and diabetes Diabetes medications Long-term complications of diabetes Medication Nutrition Therapy with diabetes Insulin Injection technique/pen devices Pre-diabetes Sick day management Smoking cessation Weight loss Gestational diabetes Advanced nutrition Complementary/alt medicine and diabetes Glucose monitor training Travel and diabetes
21 Cardiovascular/HTN disease management curriculum Current CVD management program includes: What is high blood pressure? How to monitor your blood pressure OTC meds and blood pressure Prescription blood pressure medications Diet and nutrition and cardiovascular disease What is high cholesterol? Prescription cholesterol medications CV Complications- heart attacks and strokes OTC/herbal/CAM and CV disease Smoking cessation Exercise and activity and CV disease Patient resources
22 Data measurement design Clinical Outcomes/Descriptors: - How many clients accessed services; what kinds of insurance, demographics - What kinds of services were most accessed and most useful, consultation, self-management plans, lifestyle tools - Total Cholesterol, LDL-C, HDL-C, Triglycerides, Systolic BP, Diastolic BP, A1C, height, weight, Waist circumference - If obtained: Blood glucose, Highest SMBG read, Lowest SMBG read, Average SMBG glucose, Serum creatinine, Urine creatinine, BUN, Microalbumin Educational Outcomes/Descriptors: - How many students are in the field? - Student s knowledge gain of team-based care, readiness to work in care teams Systems Outcomes/Descriptors: - Facilitators and barriers of implementation of component
23 Pillars of Support
24 Pillars of Support: Clinical Transformation Overall Clinical Quality Improvement Clinical Quality Improvement to take practices through integration with pharmacy Medication Adherence Pharmacy Practice Toolkit Key Partners: Skaggs and Regis Schools of Pharmacy, Project Extension for Community Healthcare Outcomes (Project ECHO), State Clinical Quality Improvement team, Evidence Now (AHRQ grant)
25 Pillars of Support: Sustainability Replicable model of integration at RCCO level ROI, value statement for community pharmacy integration Key Partners: Skaggs and Regis Schools of Pharmacy, Integrated Community Health Partners, clients
26 Next Steps Diabetes self management reimbursement Connectivity Provider Status Other sites, other RCCOs, Other Programs
27 Thank you! RCCO Pilot Project
28 Questions? RCCO Pilot Project
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