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Trinity Pioneer ACO MTM Program Results

Trinity Pioneer ACO MTM Program Results. MTM Referral Process – Trinity ACO. High Risk Chronic Care Patients. High Risk Transition of Care Patients.

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Trinity Pioneer ACO MTM Program Results

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  1. Trinity Pioneer ACO MTM Program Results

  2. MTM Referral Process – Trinity ACO High Risk Chronic Care Patients High Risk Transition of Care Patients Population Management Pharmacist High risk patients identified by review of claims data (high risk medications, multiple prescribers, not achieving quality measures; nonadherence). Trinity Pharmacists Identify patients on high-risk medications or fit criteria for needing post-discharge follow-up. Primary Activities • Create linkages with case management & analytics • Identify and triage high risk MTM patients • Solve medication issues telephonically, if able • Send referrals to MTM-Trained community pharmacists via OutcomesMTM platform Iowa Health ACO Pharmacists (Triage High-risk Patients) Referral Primary Activities Communication • Complete MTM activities for all referred patients • Assist with medication reconciliation • Assist with monitoring for pts started on high risk med (ex: insulin, steroids, antiplatelets, warfarin) • Assist with improving medication adherence • Document activities in OutcomesMTMplatform • Communicate with providers as needed OutcomesMTM MTM-Trained Community Pharmacist Providers

  3. Unique Patients Served per Month (including referrals) • 10.01.2013-06.30.2014 3

  4. Unique Patients Served per Month 80/267 = 30.0% 269/543 = 49.5% • 10.01.2013-06.30.2014 4

  5. MTM Claims per Month (including referrals) • 10.01.2013-06.30.2014 5

  6. MTM Claims per Month • 10.01.2013-06.30.2014 6

  7. MTM Claims Summary Average 2.4 MTM claims per patient • 10.01.2013-06.30.2014 7

  8. Top Reasons for MTM Services • 10.01.2013-06.30.2014 8

  9. Top Results for MTM Services • 10.01.2013-06.30.2014 9

  10. Top Pharmacy Performers 10

  11. DISCUSSION • Feedback or topics from pharmacists • Prioritizing patients in cue • Discharge patients vs. others • Communication from leadership team • 1-on-1 visits • Live group meetings • Expected project timeline

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