Practice Models within Patient Centered Medical

Home

Practice Models within Patient Centered Medical

Home

ObjectivesObjectives

• Describe Patient Centered Medical Home concepts

• Describe system redesign goals for providers and team members

• Explain how clinical pharmacy contributes in providing direct patient care

• Present examples of pharmacy outcomes data from Medical Home Models

Patient Centered Medical Home

Patient Centered Medical Home

Replaces episodic care based on illness and patient complaints with coordinated care and a long term

healing relationship    • The Primary Care Team

– Takes collective responsibility for patient care– Responsible for providing all the patient’s health care

needs– Arranges for appropriate care with other specialties as

needed • Enhanced Access• Enhanced communication between

– Patients– Providers– Staff

• Focused on the principle that all redesign is guided towards – Removing Waste– Enhancing Value

• Value is defined by the Veteran & Customer– The VETERAN first– The secondary

customers next– Never on the system

itself

• Value changes as Veteran and Health care expectations evolve– Veteran Centered

(each patient has their own)

– Evidence Based (right care, right place)

• Value is comprised of – Quality– Efficient/Costs (not solely

financial)– Effective– Access– Reliability– Equity– Satisfaction

4

System Redesign: Patient Center Care

• Leadership • Teamwork• Teaching• Clinical expertise in Veteran-specific

problems– Mental Health– Pain management– Military medicine

• Knowledge of facility, VISN, and community resources

• Systems Redesign• Clinical Microsystems• Change culture

Renewed Emphasis on Skills of the Primary Care Team

Renewed Emphasis on Skills of the Primary Care Team

Mon Tue Wed Thu Fri

8 PC team meeting

Virtual Inpt care

PC team meeting

Virtual Inpt care

PC team meeting

9 Phone Phone Panel Mgmt Phone Scheduled PC

10 Care mgmt Scheduled PC

Panel Mgmt Care mgmt Scheduled PC

11 Care mgmt Scheduled PC

Phone Care mgmt Phone

12 Virtual Journal club

Grand Rounds

1 Secure messaging

NP/PA oversight

Secure messaging

Scheduled PC

Virtual Inpt care

2 Urgent PC Urgent PC NP/PA oversight

Scheduled PC

Urgent PC

3 Urgent PC Urgent PC Urgent PC Scheduled PC

NP/PA oversight

4 Virtual Inpt care

Secure messaging

Urgent PC Secure messaging

Secure messaging

Future Weekly ScheduleFuture Weekly Schedule

8McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

Group Health Cooperative – Seattle

Group Health Cooperative – Seattle

• One-year study provides some of the nation's first empirical evidence of the benefits of this new type of care. It compared 9,200 patients at Group Health's medical home to a control group. At one year, patients at the medical home:– Had 29 percent fewer emergency room visits, 11 percent

fewer hospitalizations that primary care can prevent, and 6 percent fewer in-person visits.

– Used 94 percent more e-mail, 12 percent more phone, and more group visits and self-management support workshops.

– Patients received better health care, including needed screening tests, management of their chronic illnesses, and monitoring of their medications.

– Reported, in a random-sample survey, higher ratings on six scales of patient experience.

September 2009 American Journal of Managed Care

Key Principles of the Medical Home

Key Principles of the Medical Home

• Each member of the team works at their highest training level– Medication management goals can be delegated

to Clinical Pharmacy Specialists, who are key members of PCMH

• When possible care of the patient will be delivered by their team

• Same day appointments will be available to care for acutely ill panel members decreasing ED visits

• Improve provider throughput to improve time spent with direct patient care

Pharmacy

Workload

Provider

Burden

Clinical Pharmacy Specialists

Increase the efficiency of physician-patient interactions & allow for greater patient access

Clinical Pharmacy Specialists

Increase the efficiency of physician-patient interactions & allow for greater patient access

Improved

Quality &

Efficiency of Care

TIER

I

TIER

II

Clinical Pharmacy Specialist (CPS)

Clinical Pharmacy Specialist (CPS)

• Primary Care can utilize the Clinical Pharmacy Specialist in direct patient care roles. They are mid-level providers with a VA scope of practice and able to perform to the highest level of their profession.

* Managing patient’s drug therapy to goal for chronic disease states and other specialty

care

• These positions are highly respected provider members with advance professional skills

CPS Scope of PracticeCPS Scope of PracticeScope of Practice allows CPS to:• CPS’s are granted medication prescribing &

monitoring privileges based on a locally-defined scope of practice. – Prescribe medications includes: initiation, continuation,

discontinuation, monitoring and altering therapy without co-signature

• Work in concert with an attending physician• Evaluate medication therapy through direct

patient care involvement• Perform physical measurements necessary to

ensure appropriate patient clinical responses to drug therapy

• Order consults, as appropriate, to maximize positive drug therapy outcomes and disease state management.

Chronic Disease Medication Management

Chronic Disease Medication Management

• Chronic diseases have multiple drug therapy options to achieve therapeutic goals.

• VA’s National Formulary and PBM/MAP Criteria for Use documents provide patient specific criteria– CPS and Clinical Pharmacists are well versed with the

VA National Formulary and are VA experts on drug information, medication selection for specific diseases and medication safety (alerts and bulletins).

• CPS have the advance skills necessary to provide Medication Management Services in Primary Care and Specialty Care

• The Clinical Pharmacist plays a vital role in dual-care management, therapeutic interchange, and medication reconciliation

A Routine Day: Utilizing CPS Within the Home Model

A Routine Day: Utilizing CPS Within the Home Model

• Patient Clinic Visits (via appointment package)– Managing Pharmacotherapy– Patient Education– Clinical Reminders– Physical Assessment

• Medication Renewals• Precepting Pharm.D.

Residents/Students• TeleHealth Follow-Up & Interventions• Quality Assurance, education and

training – Medication Use Evaluations (MUEs)

Patients Not Meeting Goals

Referrals From Primary Care

Bi-Weekly Outliers From Vista Lab

Package

Decision Support Performance

Data

Clinical Pharmacy Specialists Can Address:

•Identification of absent therapies, sub-optimal doses, significant drug interactions

•Medication adherence assessment•Provision and monitoring of cost effective and safe regimens•Dietary/Lifestyle recommendations •Participation in quality improvement initiatives•Provider education•Patient education

Patient Scheduling: with and without the use of

CPS

Patient Scheduling: with and without the use of

CPS

Initial VisitPC Visit

LDL not at goal

6 Months PC Visit

12 Months PC Visit

18 Months PC Visit

4-6 weeks Pharm D

6 Month PC Visit

4-6 weeks Pharm D

12 months

4-6 weeks Pharm D Visit

18 months

Patients generally get to goal quicker with the use of Pharm D’s because there are more aggressive medication changes done in a shorter period of time.

with PharmD

without PharmD

Courtesy of Dr. Rubin, D.O.Chief of Primary Care ServiceWest Palm Beach VA Medical Center

Jesse Brown Chicago VA Medical Center

Jesse Brown Chicago VA Medical Center

Jesse Brown VAMC Primary Care Home Model

Jesse Brown VAMC Primary Care Home Model

Primary Care Team StaffingEach team:

• 3 Primary Care Physicians• 1 Nurse Case Manager• 1 LPN• 0.5 Health Tech• 1 Clinical Pharmacy Specialist

Chronic Disease Management Role of CPS• Anticoagulation

• Diabetes• COPD/Asthma• BPH

• Hypertension• Hyperlipidemia• Medication Management• Therapeutic Drug

Monitoring

Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model

Standard Pharmacy Clinic Structure• 4.5 clinic days per week• 20 minute appointments• 16-18 appointment slots per day

(except Thursdays: ½ day clinic)

Referral Process• providers schedule directly into CPS clinic• review of patients who do not meet

performance/therapeutic goals are scheduled• Referrals based on national formulary changes and

national medication efficiency programs

FTEE Unique patients

Encounters Unique patients per provider

Primary Care Physicians

10.6 13,134 40,468 1,239

Clinical Pharmacy Specialists

3.5 2,779 11,769 794

Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model

Data from 3/09 – 3/10; source – VSSC cube and VISTA

Four Primary Care Teams

Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model

Other Clinical Pharmacy Specialist Responsibilities

• Medication Use Evaluations – QA program• Non-Formulary Consult Review• Assist with Formulary Conversions and Annual Cost Savings Initiatives• Assist with facility performance measures/initiatives• Membership in various Local, VISN, and/or National Groups/Committees• Research• Precept 4th Year Pharmacy Students (min 5 students/year)• Precept PGY-1 Pharmacy Practice Residents

Jesse Brown VAMC Home Model

Jesse Brown VAMC Home Model

• CPS integrated in primary care at main station and four community based outpatient clinics (CBOC)

• CPS reports to pharmacy service• Success of this integrated role has led to

CPS expansion in specialty clinics throughout the medical center

• Pharmacy continues to receive requests from medical staff to expand CPS services

Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model

Specialty Clinical Pharmacy Clinics

• Intense Diabetes Management

• Emergency Department • Geriatrics• Gastroenterology• Home Based Primary Care• Home Infusion Program• Infectious Diseases• Co-Infection – Hepatitis C

• Mental Health

• Nephrology

• Pain

• Pulmonary

• Smoking Cessation

• Urology

• Women’s Health

Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model

N = 142 Baseline Follow Up (6 mos)

HgbA1c 11.1% 8.3%

HgbA1c < 9% 0% 63%

HgbA1c < 7% 0% 29%

LDL (<100 mg/dL) 55% 82%

Statin Use 71% 86%

BP (<130/80 mm Hg)

43% 71%

ACE Inhibitor Use 87% 90%

Anti-Platelet Therapy

78% 89%

Pharmacy Clinic Outcomes – Diabetes Management

Percentages given as a mean2009

Jesse Brown VAMC Home ModelJesse Brown VAMC Home Model

N = 48 Baseline Follow Up Mean Change

HgbA1c 10.3% 7.3% - 3.0%

LDL (mg/dL) 161.6 104.9 - 56.7

BP (mm Hg) 148/89 130/80 -18/9

Pharmacy Clinic Outcomes – Women’s Health

Multidisciplinary clinic modelMean number of visits: 2.4 over 6

months

Values given as a mean2009

VA is a nationally recognized leader in Clinical Pharmacy

Services.

The team based approach of the Patient Centered Medical Home provides the opportunity for this role and that of the other team

members to become the standard of care.

Questions ?Questions ?