Population Health Management In A Value-Based Market: Using Pharmacy Analytics To Increase Consumer Engagement & Improve Outcomes Sponsored By Care Management Technologies February 11, 2016 www.cmthealthcare.com
POPULATION HEALTH MANAGEMENT AND PHARMACY ANALYTICS Susan Wilson Missouri Primary Care Association February 11, 2016 Clearwater, FL
Missouri Primary Care Association Advocacy and member services for 29 Federally Qualified Health Centers in Missouri 31% Uninsured, 42% Medicaid, 9% Medicare, 18% Private Center for Health Care Quality Training and Technical Assistance Role-Based Learning Networks Missouri Quality Improvement Network Data Reporting and Visualization System (DRVS) Chronic Disease Collaborative Pharmacist Integration Initiative MO HealthNet Primary Care Health Home (ACA Section 2703) Chronic Pain ECHO partnered with University of Missouri-Columbia
MO HealthNet Primary Care Health Home ACA Section 2703 State Plan Amendment Six health home services, PMPMPS payment Patient Centered Medical Home Recognition required Diabetes, cardiovascular, asthma, obesity, developmental disability Required staffing at Primary Care Health Homes: Health Home Director, Nurse Care Manager, Care Coordinator, Behavioral Health Consultant DRVS to report 14 clinical quality measures on behalf of FQHC and non- FQHC Primary Care Health Homes CMT ProAct for Medication Adherence monitoring Preparation for Population Health Management and Value-Based Purchasing of Health Care Services
Chronic Disease Collaborative Partnership with MO Department of Health and Senior Services and Centers for Disease Control Chronic Disease Collaborative (training and technical assistance and measures reporting from DRVS) Diabetes, Hypertension/Cardiovascular, Tobacco Use/Cessation, Obesity, Asthma Pharmacy Integration Initiative (finishing 3 rd year) Diabetes, Hypertension Formally integrate pharmacist into Patient Centered Medical Home care team DRVS, CyberAccess, ProAct
Population Health Management and Chronic Pain Bio-Psychosocial Model: Primary Care, Pain Specialist, Behavioral Health Consultant, plus Patient Centered Medical Home Three-Year Project funded by Missouri Foundation for Health ECHO Partnership for knowledge sharing and specialist support for primary care Intense structured team training Data system patchwork: DRVS, ProAct, other? ACA Section 2703 Medicaid State Plan Amendment for Chronic Pain
Pharmacist Integration into Healthcare Teams The Evolution of Clinical Practice George L. Oestreich, PharmD., MPA Data and Analytics Jennifer Kemp-Cornelius, PharmD. February 11, 2016 www.cmthealthcare.com
The Evolution of Clinical Practice George L. Oestreich, PharmD., MPA Pharmacy Integration Analysis and Outcomes Jennifer Kemp-Cornelius, PharmD. # 8
History of Pharmacists and Clinical Practice Pharmacists were recognized as unique practitioners as far back as the recognition of physicians. Cosmos and Damion in 287 AD In Greek Mythology Hygeia as the daughter of Asclepius In the 1940 s the recognition of discreet medications with targeted outcomes changed pharmacy from compounded potions to discrete therapeutic choices. Sulfanilamide Penicillin # 9
Pharmacist Training and Specialties The profession began as an apprentice training paradigm. State registries were formed to identify competency and regulate by license. Formal education yielding a 4-year BS in pharmacy, late 1940s. Transition to a five-year BS in pharmacy in the 1960 s. Doctor of Pharmacy degrees were begun in the late sixties and became pervasive in the 1970s. The current six year Doctor of Pharmacy degree became the required degree for all pharmacist licensure in 2000. Specialization and/or certification is becoming more prevalent. Frequent add on degrees, MBA, JD, MPA, HIT Post graduate residencies # 10 Specialty certification
Pharmacists and Clinical Pharmacy Practice The evolution of clinical pharmacy has paralleled to complexity of drug regimens. Medications have increased in their complexity and unique characteristics as well as their ability to interact Patient response is varied and could product untoward effects The number of unique agents. A traditional pharmacy contains over 4000 unique agents A traditional prescriber will be well versed and use one percent (40) of those agents Pharmacists have specific knowledge and training to understand and research all therapeutic agents and their impact, drug experts. # 11
Goals of Pharmacist s Practice Right patient, right drug, right dose. # 12 Drug(s) choice Drug dose Drug combinations Genetic impact on drug choice Monitoring Impact of patient age and health status Medication adherence and reconciliation. Coordination of care in health care transitions. Population based analytics.
Medication Therapy Management, MTM (JCPP Approved) Patient-specific and individualized services or sets of services provided directly by a pharmacist to the patient. Face-to-face interaction between the patient or their caregiver using the pharmacist as the preferred method of delivery. Opportunities for pharmacists and other qualified health care providers to identify patients who should receive medication therapy management services. Direct payment for MTM consistent with contemporary provider payment rates and not aggregated to product delivery services. Delivered to improve continuity of care, outcomes, and outcome measures throughout the transition of care. # 13 Adapted from the Joint Committee on Pharmacy Practice definition.
Pharmacists MTM, MTS and Others Pharmacist practice has traditionally been recognized as occurring only in pharmacies. Pharmacists not recognized universally as healthcare practitioners Billing is traditionally product based Team practice and multidisciplinary practice although long integrated often still siloed (as is behavioral and general physical practice) # 14
Pharmacists often Practice by Protocol While MTM is part of pharmacists traditional scope of practice, protocol driven practice is an expansion and may be a physician extender. Over 45 states allow some level of collaborative or protocol driven pharmacist practice. States vary: Level of independence Record keeping and reporting Ability to diagnose in addition to initiate and modify therapy # 15
Pharmacists and Behavioral Health Practice The complexity of BH therapeutics has spawned one of the pharmacist specialties Neuropsychiatric Pharmacists Specialty recognition and certification (not required to practice in the BH area) BCPP (Board Certified Psychiatric Pharmacists) Their organization, College of Psychiatric and Neurologic Pharmacists (CPNP) Traditional pharmacy practice vs. MTM vs. MTS (acronyms are variable by state pharmacy boards) # 16
Coordinating Behavioral and Physical Health The battle for equality of behavioral to physical care. Equality in insurance coverage Equality in recognition of BH issues as diseases or chronic disease The recognition of BH practitioners among themselves as well as among physical health practitioners The dilemma now is the integration and more importantly in the coordination of care. Separate issues with EHRs and data integration The recognition of differential diagnostic coding and terms The more subjective evaluation of treatment outcomes # 17
The Goals of the Pharmacist in Multi-disciplinary Practice Support team members with expert drug information Indications, contraindications Dosages, best practice regimens Drug interactions Impact of patient genetic differences Direct patient interaction Medication history Prescribed medications Over-the-counter, herbal, food based issues Identify adverse drug issues and iatrogenic illness Support understanding and patient centered/directed care Maximizing therapeutic outcomes and supporting adherence # 18
The Whole is Greater than the Sum of the Parts Physician...Pharmacist...Nurse...BH practitioner # 19 Together we are better, and so are the patient outcomes!
# 20 Pharmacy Integration Project: Analysis and Outcomes Jennifer Kemp-Cornelius, PharmD
Pharmacy Integration Initiative: Goals Increase by 5% the proportion of patients with hypertension who are in adherence with medication regimen monitored by a pharmacist. Using NQF 18 as the measure, increase the proportion of patients with hypertension who have their blood pressure under control to 65%. Increase by 5% the proportion of patients with hypertension who have a self-management plan documented (and monitored by the pharmacist). # 21
Pharmacy Integration Initiative: Goals Increase by 5% the proportion of patients with diabetes who are in adherence with medication regimens monitored by a pharmacist. Using NQF 59 as the measure, decrease the proportion of patients with diabetes who have A1C>9 to 14%. Increase by 5% the proportion of patients with diabetes who have a self-management plan documented (and monitored by the pharmacist). # 22
Pharmacy Integration Initiative: Approach Start with Medicaid patients because there is an integrated data set. Identify electronic/analytic tools available to help manage patients and collect outcomes data. Health Center E.M.R. Paid claim database Population-based analytical tool (ProAct) # 23
Pharmacy Integration Initiative: Approach Identify pilot health centers and their pharmacy partners. Establish data baseline. Identify patients who fit program criteria. Choose small patient sample and use PDSA model to manage. Collect and report outcomes data. # 24
Pharmacy Integration Initiative: Teams Team A Urban In-house pharmacy (5 pharmacists) Team J Urban Community pharmacy in-house (1-2 pharmacists) Team M Urban In-house pharmacy (5 pharmacists) Team S Rural Community pharmacy external (1-2 pharmacists) # 25
Pharmacy Integration Initiative: Teams Team O Rural In-house pharmacy (1 pharmacist) Dropped out of initiative after Year 2 Team N Suburban and Rural Community pharmacy external (1 pharmacist) Dropped out of initiative after Year 2. May join again Year 4. Team Y Rural 1 clinical pharmacist in-house Joined initiative in Year 3 # 26
# 27 Pharmacy Integration Initiative: PDSA
Pharmacy Integration Initiative: Year 2 Adherence Diab. 5000 Total Number of Diabetic Patients All Health Centers 100% Total Percentage of Diabetic Patients in Adherence with Medication Regimen All Health Centers (+ 2.56% from baseline) 4500 90% 4000 80% 3500 70% 3000 2500 60% 50% % Adherent (Aggregate %) 2000 Total Patients w/diabetes (Aggregate Count) 40% 1500 Adherent Patients (Aggregate Count) 30% 1000 20% 500 10% 0 201405 201408 201411 201502 201505 0% 201405 201408 201411 201502 201505 # 28
Pharmacy Integration Initiative: Year 2 Adherence Diab. Percent of Diabetic Patients in Adherence All Centers 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% J M S O N A 0% 201405 201408 201411 201502 201505 # 29
Pharmacy Integration Initiative: Year 2 Adherence HTN 8000 Total Number of BP Patients All Health Centers 100.00% Total Percentage of BP Patients in Adherence with Medication Regimen All Health Centers (+1.08%) 7000 6000 95.00% % Adherent (Aggregate %) 5000 90.00% 4000 3000 85.00% 2000 Total Patients w/bp (Aggregate Count) 80.00% 1000 Adherent Patients (Aggregate Count) 0 201405 201408 201411 201502 201505 75.00% 201405 201408 201411 201502 201505 # 30
Pharmacy Integration Initiative: Year 2 Adherence HTN 100% 90% 80% Percent of Adherent BP Patients All Centers 70% 60% 50% 40% 30% 20% 10% J M S O N GH 0% 201405 201408 201411 201502 201505 # 31
Pharmacy Integration Initiative: Year 2 A1C/BP May 2014 May 2015 Measure Target Actual NQF 18 HTN BP in Control HTN Self- Management NQF 59 Diabetes A1C >9 Diabetes Self- Management 65% or higher 50% 30% or higher 32% 14% or lower 37% 30% or higher 39% # 32
Pharmacy Integration Initiative: Year 2 Lessons Learned Increase Health Center participation by using pharmacist integration to help achieve PCMH Recognition. Each Health Center had a different approach to defining the pharmacist s role and incorporating into workflow. Maintaining the pharmacy partnership has challenges. # 33
Pharmacy Integration Initiative: Year 2 Lessons Learned To be successful, Health Center staff include Quality Improvement, Risk Management, HIT, Practice Coaches, etc. To be successful, pharmacies should increase pharmacy technician duties (within proper scope) and increase ability for pharmacist to step away from dispensing activities. Establish communication method if pharmacist will be seeing patients they don t normally dispense to. # 34
Pharmacy Integration Initiative: Year 2 Lessons Learned Must ensure that clinical data is available to the pharmacist. Determine whether the pharmacist needs to document notes in the Health Center E.M.R. Must ensure that clinical data can be collected in a uniform way for outcome reporting. Desire to establish a working model that can be replicated for other diseases. # 35
Pharmacy Integration Initiative: Year 3 Adherence Diab. 3500 Total Number of Diabetic Patients All Health Centers 100% Total Percentage of Diabetic Patients in Adherence with Medication Regimen All Health Centers (+ 2.74% from baseline) 3000 90% 80% 2500 70% 2000 60% 50% % Adherent (Aggregate %) 1500 Total Patients w/diabetes (Aggregate Count) 40% 1000 Adherent Patients (Aggregate Count) 30% 500 20% 10% 0 201508 201511 0% 201508 201511 # 36
Pharmacy Integration Initiative: Year 3 Adherence Diab. Percent of Diabetic Patients in Adherence All Centers 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% J S Y M A 0% 201508 201511 # 37
Pharmacy Integration Initiative: Year 3 Adherence HTN Total Number of BP Patients All Health Centers Total Percentage of BP Patients in Adherence with Medication Regimen All Centers ( 0.38%) 6000 100.00% 5000 95.00% 4000 % Adherent (Aggregate %) 90.00% 3000 2000 85.00% Total Patients w/bp (Aggregate Count) 1000 80.00% Adherent Patients (Aggregate Count) 0 201508 201511 75.00% 201508 201511 # 38
Pharmacy Integration Initiative: Year 3 Adherence HTN Percent of Adherent BP Patients All Centers 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% J S Y M A 0% 201508 201511 # 39
Pharmacy Integration Initiative: Year 3 A1C/BP June 2015 Dec 2015 Measure Target Actual (to baseline) NQF 18 HTN BP in Control 65% or higher 57% (+7%) HTN Self-Management 30% or higher 25% (-7%) NQF 59 Diabetes A1C >9 Diabetes Self- Management 14% or lower 35% (-2%) 30% or higher 29% (-10%) # 40
Pharmacy Integration Initiative: Year 3 progress All teams to increase number of patients from the initial 5-20 PDSA patients in order to encompass entire Medicaid DM/HTN population. Focus on how to connect patient to pharmacist. How to schedule, timing with primary care visit, transportation Pharmacists are finding that it is difficult to keep the patient visit contained to a reasonable time frame (i.e. 15 30 min). Pharmacists must utilize others in care team for non-pharmacy issues. # 41
Pharmacy Integration Initiative: Year 3 progress Team A: Document noncompliance with medication therapy in the EMR Incorporate care coordination into the pharmacist consultation (addition of patient navigator to schedule appointment, referral issues, assist with insurance information) Focus on removing barriers to care such as medication affordability # 42
# 43 Pharmacy Integration Initiative: Year 3 progress Team J Collaborating with School of Pharmacy Hired pharmacy school faculty member who will provide care and incorporate pharmacy students Integrate pharmacy faculty member into the primary care team; available to all providers but focused on one team group 100 patients had pharmacist interventions Aug Dec 2015 Continue partnership with local community pharmacy/pharmacist
Team M Pharmacy Integration Initiative: Year 3 progress Pull list of all DM patients with A1C>9. Call to schedule follow-up appointment with the pharmacy at one site for Saturday clinic 10am-2pm to see if this increases patient commitment. Will followup call or send letter with reminder for Saturday appointment with pharmacist. Transportation is a barrier. Team S Expanding patient list to include patients that are not currently customers of the pharmacy partner. Exploring ways to alleviate patient confusion. Considering additional pharmacy partner in order to increase number of patients included in initiative. # 44
Pharmacy Integration Initiative: Year 3 progress Team Y Focus on getting patient scheduled with pharmacist when they see primary care provider. Requires change in workflow for front desk and nursing staff and ability to flag patients. Warm hand-off from Primary Care Provider to Pharmacist for DM with A1c > 9. 110 patients with pharmacist interactions Aug Dec 2015 (pharmacist works in clinic part time) # 45
# 46 Data and Analytics: Tools Beyond the EHR Carol D. Clayton, PhD, CEO
CMT s Technology for Population Health Management Supporting Payer and Provider Evolution to Value Based Service Delivery and Payment Transforming healthcare takes more than just dashboards and data. It takes an entirely new approach combining best practices, analytics, and adoption of the improvement program throughout the entire organization. Paul Hortsmeier, SVP, Health Catalyst A system that pays for value will require greater coordination, greater efficiency, a system in which all healthcare professionals can work at the highest level of their training, continued innovation, and the increasingly important use of technology. George Barrett, CEO, Cardinal Health # 47
CMT s Population Management Technology Beyond the E HR Patient Registry Risk Stratification Population Identification Population Profiling Evidenced Based Patient Summary Claims Data Intervention Opioid Prescribing Analytics Psychotropic Prescribing Analytics Adherence Analytics Schizophrenia Analytics Cardiovascular Analytics IDD Analytics Diabetes Analytics ADHD Analytics Substance Use Analytics Quality Analytics Outcomes Analytics Predictive Analytics Emergency Analytics Readmission Analytics Housing Analytics Assessment Analytics Employment Analytics Provider Analytics # 48 Payer Analytics
Value of Pharmacy Data Set Pharmacy data identifies undiagnosed BH conditions 10% increase. Pharmacy data is low cost, reliable data set for identification of future ER and hospital presentations/readmissions. Pharmacy data is foundational for bridging communication differences between medical and behavioral. # 49
Leveraging Pharmacy Data/Pharmacists to Meet New Expectations CCBHC and SAMHSA Health Home Prospective Rate Payment Addressing Readmission, ER and ACS Adherence to Antipsychotics and Antidepressants Disease Management Prevention and Treatment NCQA Coordination of Care across all Settings Addressing Care Fragmentation Identifying Need for Appropriate Care Evidence-based Care Medicare ACO Requirements Identifying Need for Appropriate Care Appropriate Use of Pain Medications Use of Drugs Safely Identification of Needs for Specialty Care # 50
CMT Customer Base Powered by CMT s ProAct Analytics solution, the firstin nation Behavioral Health Home for Missouri Medicaid Beneficiaries: Reduced costs by $31M over 2 years Reduced hospitalizations by 9.1% in the first year Lowered cholesterol by 28% over 2 years Lowered blood pressure by 30% over 2 years Lowered blood sugar by 39% over 2 years Using Opioid Prescription Intervention Analytics, MoHealthNet, achieved: 36.8% reduction in hospital admissions 14.8% - 19.1% reduction in the average adult monthly dose of opioids dispensed # 51
Know More. Care Wisely. Carol D. Clayton, PhD Chief Executive Officer Care Management Technologies Tel: 919-674-2547 Mobile: 919-491-0819 Email: cclayton@cmthealthcare.com www.cmthealthcare.com