Geisinger at Home - cdn.ymaws.com€¦ · 1 Geisinger at Home: A multidisciplinary primary care...

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Geisinger at Home: A multidisciplinary primary care effort to care for

patients with high healthcare utilization

Margaret Bigart Pharm.D

Sarah Krahe Dombrowski Pharm.D, BCACP

Michael R. Gionfriddo Pharm.D, Ph.D

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Disclosures

• MRG is/has been a co-I on several grants funded by

pharmaceutical companies: AstraZeneca, Merck, Takeda, and

Regeneron.

• MRG has acted on behalf of Geisinger as a consultant on

shared decision making (SDM) and medication adherence for

Pfizer and the PhRMA Foundation, respectively.

• MRG has had honorarium paid to Geisinger to speak on SDM

to Hillcrest Medical Center (Tulsa, OK)

• MRG is a co-I on a grant sponsored by the PA DoH studying

prior authorization and a PI on a grant studying transitions of

care funded by NACDSF.

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Acknowledgement

• We would like to thank the Geisinger at Home teams

• We would like to thank Geisinger Health Plan which

funded this work through the Quality Pilot Fund

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Objectives

1) Define Comprehensive Medication Management and

list pharmacists’ essential functions

2) Identify the role of the pharmacist on home-based

primary care teams

3) Discuss the barriers and facilitators to integrating a

pharmacist into a home-based primary care team

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Problem

• 5% of patients account for 50% of costs

• Complex

• Polypharmacy

• Multimorbidity

• Psychosocial

• Traditional models of care fail to meet needs

Timely access

Better coordination of care

Address social determinants

Home based care for medically

complex and terminal conditions

Triple

Aim

× Fragmented & episodic care

× Climbing acute-care utilization

× Excessive post-acute care

× Poorly managed specialty drug

costs

Home Based Care

(team travels) Traditional Care

(patient travels)

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• Geisinger at Home (G@H) is a portfolio of services

designed to provide integrated clinical care that

manages patients with multi-morbid medical conditions

primarily within their homes by delivering:

• Home Based Medical Care

• Comprehensive medical care

• Community Based Palliative Care

• Palliative end of life care

• Mobile Integrated Health

• Acute care by mobile paramedics

Overall Strategy of Geisinger at Home

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G@H Target Populations

• Home-bound

• Advanced age

• Multiple chronic conditions with increasing complexity

• Advanced illness with limited life span

• Significant social gaps

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Geisinger at Home Team Regional

Medical Director

Advanced Practitioner

(AP)

Registered Nurses

(NCM)

Direct Care (3)

Acute Care (1)

Advanced Practitioner

Registered Nurses

Direct Care (3)

Acute Care (1)

Advanced Practitioner

Registered nurses

Direct Care (3)

Acute Care (1)

Advanced Practitioner

Registered Nurse

Direct Care (3)

Acute Care (1)

Social Worker Dietitian Pharmacist Behavioral Health Palliative Care Paramedic

Community Health Assistant (CHA)

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General G@H Workflow

• Patient identified by G@H or PCP referral

• Enrollment visit with AP/NCM

• Frequency of follow up visits are dependent on patient’s

current medical status and goals of care

• Generally, stable patients every 1-3 months

• Other team members follow with patient as needed via

phone or home visits

• Weekly team meetings

• Constant communication with team through TigerText,

Skype, electronic health record

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Comprehensive Medication

Management (CMM)

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Comprehensive Medication Management

Clinical pharmacist develops an individualized medication therapy care plan in collaboration with the patient and the health care team that achieves the intended goals of therapy with appropriate follow-up to ensure optimal medication use and outcomes.

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Comprehensive Medication Management

• Ensures each patient’s medications (prescription, nonprescription,

alternative, traditional, vitamins, or nutritional supplements) are

individually assessed

• Purpose

• Optimize medication use

• Appropriate indication

• Effective

• Safe

• Able to be adhered to

• Improve patient health outcomes

• Patient-centered

• Patient is an active participant

• Collaborative

• Pharmacists worked closely with healthcare team

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CMM Framework – Core Components of Care

• A Shared Philosophy of Practice

• Establishes the values and beliefs that guide the clinical pharmacist’s action and

behaviors as a member of an interdisciplinary, patient-centered care team and

serves to foster relationships built on trust

• The Patient Care Process

• Establishes the nature of work that occurs when a clinical pharmacist, working in

collaboration with the patient and the healthcare team, provides care to an

individual patient with the goal of optimizing medication use and improving the

quality of their health care.

• Essential to understand the ways in which various members of the team

contribute to the patient care process for optimizing medication use

• Practice Management

• Includes the structural and system level supports within a

practice related to practice management and operations

• Enables the efficiency, effectiveness, and sustainability

of CMM services

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CMM Essential Functions

Collect and Analyze Information

Assess the Information and Formulate a Medication Therapy Problem List

Develop the Care Plan

Implement the Care Plan

Follow up and Monitor

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Collect and Analyze Information

• Assure the collection of the necessary subjective and

objective information about the patient

• Conduct a review of the medical record to gather relevant

information

• Conduct a comprehensive review of medications and

associated health and social history with the patient.

• Analyze collected information in order to understand

the relevant medical/medication history and clinical

status of the patient.

• Analyze information in preparation for formulating an

assessment of medication therapy problems

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Collect and Analyze Information - Activities

Inquire as to whether the patient has any questions or

concerns for the visit.

Review social history (e.g., alcohol, tobacco, caffeine,

other substance use).

Review social determinants of health relevant to

medication use

Review past medication history, including allergies and medication adverse

effects.

Obtain and reconcile a complete medication list that

includes all current prescription and

nonprescription medications, and complementary and

alternative medicine

Review the indication for each medication.

Review the effectiveness of each medication.

Review the safety of each medication.

Review the patient’s adherence to his/her

medications using available resources

Review the patient’s medication experience

Determine the patient’s personal goals of therapy.

Review how the patient manages his/her medications

at home

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Assess the Information and Formulate a Medication

Therapy Problem List

• Assess and prioritize the patient’s active medical

conditions taking into account clinical and patient goals

of therapy.

• Assess the indication of each medication the patient is taking

• Assess the effectiveness of each medication the patient is

taking

• Assess the safety of each medication the patient is taking

• Assess adherence of each medication the patient is taking

• Formulate a medication therapy problem list

• Prioritize the patient’s medication therapy problems.

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Medication Therapy Problem Categories

Indication

Unnecessary medication

therapy

Needs additional medication

therapy

Safety

Adverse medication

event

Dosage too high

Needs additional monitoring

Effectiveness

Ineffective medication

Dosage too Low

Needs additional monitoring

Adherence

Nonadherence

Cost

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Prioritize Medication Therapy Problems

Chief Complaint

• Why is the patient being referred to pharmacist?

• What is going to kill/harm patient first?

What else is patient interested in?

What can wait?

1 2 3

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Develop the Care Plan

• Develop a care plan in collaboration with the patient and the

patient’s health care providers to address the identified medication

therapy problems.

• Identify the monitoring parameters important to routinely assess

indication, effectiveness, safety, and adherence.

• Review all medication lists to arrive at an accurate and updated

medication list.

• Determine and coordinate who will implement components of the care

plan

• Determine the type of follow-up needed, appropriate timeframe

patient follow-up, and appropriate mode for follow-up (e.g., in

person, electronically, by phone).

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Implement the Care Plan

• Discuss the care plan with the patient.

• Ensure patient understanding and agreement with the plan and goals of

therapy.

• Provide personalized education to the patient on his/her medications

and lifestyle modifications.

• Provide the patient with an updated, accurate medication list.

• Implement those recommendations that you as the clinical

pharmacist have the ability to implement.

• Communicate the care plan to the rest of the care team.

• Document the encounter in the electronic health record

• Communicate instructions for follow-up with the patient

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Follow up and Monitor

• Provide targeted follow-up and monitoring where needed, to monitor

response to therapy and/or refine the care plan to achieve patient

and clinical goals of therapy.

• Could be in person, electronically, or via phone

• To assess general status of care, monitor blood sugar or blood

pressure, adjust insulin, check INRs, provide education, etc

• Repeat a comprehensive medication management visit at least

annually, whereby all steps of the Patient Care Process are

repeated to ensure continuity of care and ongoing medication

optimization

• If the patient is no longer a candidate for CMM, ensure that a plan is

in place for continuity of care with other care team members

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CMM Essential Functions

Collect and Analyze Information

Assess the Information and Formulate a Medication Therapy Problem List

Develop the Care Plan

Implement the Care Plan

Follow up and Monitor

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CMM in Telehealth

• Clinical pharmacists participating in telehealth can remotely obtain

a complete medication history from the patient or caregiver by

identifying the patient’s current medications, medication-taking

behaviors, adherence, allergies, attitudes, and medication

experience.

• Advantages to telehealth

• Incorporates patient care services into geographically limited settings

• Increases efficient use of health care professionals’ time, resources, and

expertise.

• Promotes cost savings by decreasing hospitalizations, assisting in transitions

of care, or reducing transportation costs

• Additional considerations

• Technology capabilities, mode of transmission, level of security, need for

sharing of the patient’s information, limitations of telehealth encounters, after

hours/on-call expectations, and expected turn-around time for follow-up

communications

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Pharmacist’s Role

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Why are pharmacists a vital member of home

based care team?

Population with:

• Multiple complex disease states

• Multiple medications

Can result in:

• Medication therapy problems

• Increased hospitalizations and ER visits

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Pharmacist’s Role

Comprehensive Medication Management

Disease Management

Drug Information Questions

Acute Management

Clinician and Patient Education

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Application of CMM in G@H

• Identification of patients

• Pharmacist review

• Provider or Case Manager referral

• Add to pharmacist schedule

• Complete essential functions

• Communication with patient through phone call

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CMM Essential Functions- Workflow

Collect and Analyze Information

•Chart review, Patient interview

Assess the Information and Formulate a Medication Therapy Problem List

• Indication, Effectiveness, Safety, Adherence

Develop the Care Plan

•Prioritized list based on goals of care

•Dose/frequency adjustment, Discontinue/Add med, Mail order, Referral, Lab monitoring

Implement the Care Plan

•Collaboration with Geisinger at Home team

Follow up and Monitor

•Collaboration with Geisinger at Home team

•Home visits, phone call, lab review

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Disease Management

Chronic Kidney Disease

Coronary Artery Disease

Peripheral Artery Disease

Chronic Obstructive Pulmonary

Disease

Diabetes Hypertension

• Focus on high 6 disease states

• Closure of care gaps

• Lab monitoring

• Disease education

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Drug Information Questions

Medication safety

• Renal Dosing

• Hepatic Dosing

• Drug/Disease interactions

Dose adjustments

Deprescribing

Treatment Recommendations

Cost

• Formulary alternatives

• Medication assistance programs

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Acute Management

• COPD exacerbations

• Hyper/Hypoglycemia

• Antibiotic recommendations

• HF exacerbations

• Medication Acquisition

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Clinician Education

• Present at weekly team huddles

• Clinical Pearls

• Examples:

• Diuretic titration plans

• COPD guidelines

• Steroid induced hyperglycemia

• Medication use in the elderly

• Influenza treatment

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Future

• Telehealth

• Ipad video visits

• Medications reconciliation

• Disease management

• Assess device technique

• Utilization of dashboard

• Target specific populations

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Facilitating Implementation

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Assembling the Study Team

• Leadership Support

• Physician Director

• Pharmacy Director

• Implementation expertise

• Research expertise

• Representatives from practice

• CMM pharmacists

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Making it happen

• We are taking several steps to facilitate the

integration of pharmacists with Geisinger at Home

• Standardized training/credentialing process

• Standardized documentation

• Quarterly chart reviews

• Quarterly workshops for pharmacists

• Standardized roles/responsibilities

• Standardized workflows

• Population monitoring dashboards

• Understanding and Improving Readiness

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Standardized Training

• 6-8 week training in chronic disease management

• Anti-Coag

• Diabetes

• Asthma/COPD

• Heart Failure

• Hypercholesterolemia

• Hypertension

• CMM Webinar

• Readings on CMM

• Shadowing pharmacists and providers

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Standardized Documentation

• Developed standardized note templates with our EHR

vendor

• Templated format/language

• Automatically pulls in certain data

• Labs

• Medications

• Problem list

• Smart data elements

• “.dot phrases”

• Facilitates data collection and consistency of

documentation

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Chart Reviews

• Quarterly chart reviews by peers

• Standardized rubric

• Needs Improvement

• Acceptable

• Exceptional

• Teachable moment

• Open-ended comments

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Rubric

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Self-Assessments

• Quarterly self-assessments

• Extent to which following best-practice for CMM

• Please reflect on the last 10 CMM visits (emphasis is

placed on the comprehensive nature of the visit) that you

have conducted. For what percent of CMM visits did you

complete the following steps?

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Workshops

• Quarterly

• Geisinger at Home Pharmacists

• Pharmacist Regional Supervisors

• Research Team Members

• Agenda

• Administrative Updates

• Group discussions

• Case Studies

• Educational presentations

• Communicating with patients

• Telephonic communication

• Deprescribing

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Workflows and Roles/Responsibilities

• Mapping out current and future state

workflows/responsibilities

• Ensure a standardized process to care delivery

• Highlight gaps or opportunities to improve workflow

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Dashboards

• Redesigning population health dashboard

• Track overall enrollment

• Tabulate pharmacist workload (# of interventions)

• Monitor individual pharmacist patient panel

• Present relevant individual patient data

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Understanding and Improving Readiness

• Goal

• Improve the integration and sustainability of CMM into G@H

• Process

• Identify implementation team

• CMM Pharmacist and 3-5 G@H team members

• Take Readiness Assessment

• Identify Opportunities

• Develop and Execute QI Plan

• PDSA

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Readiness Assessment Example

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Preliminary Impact

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Next Steps

• Refine population health dashboard

• Support ongoing readiness work

• Develop predictive analytics

• Evaluate success of program

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Questions?

Michael R. Gionfriddo Pharm.D, Ph.D

Geisinger Health System

Center for Pharmacy Innovation and Outcomes

Forty Fort, PA 18708

mgionfriddo@geisinger.edu