Practice Models within Patient Centered Medical Home

1. Practice Models within Patient Centered Medical Home

2. Objectives • 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

3. 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

4. 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 System Redesign: Patient Center Care 4

5. Renewed Emphasis on Skills of the Primary Care Team • 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

6. Future Weekly Schedule

8. 8 McGinnis 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.

10. 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

11. 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

12. Clinical Pharmacy SpecialistsIncrease the efficiency of physician-patient interactions & allow for greater patient access Improved Quality & Efficiency of Care TIER II TIER I

13. 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

14. CPS Scope of Practice Scope 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.

15. 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

16. 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)

17. 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

18. Patient Scheduling:with and without the use of CPS with PharmD without PharmD Courtesy of Dr. Rubin, D.O. Chief of Primary Care Service West Palm Beach VA Medical Center

19. Jesse Brown Chicago VA Medical Center

20. Jesse Brown VAMC Primary Care Home Model • Primary Care Team Staffing • Each 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

21. Jesse 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

22. Jesse Brown VAMC Home Model Four Primary Care Teams Data from 3/09 – 3/10; source – VSSC cube and VISTA

23. Jesse 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

24. 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

25. Jesse 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

26. Jesse Brown VAMC Home Model Pharmacy Clinic Outcomes – Diabetes Management Percentages given as a mean 2009

27. Jesse Brown VAMC Home Model Pharmacy Clinic Outcomes – Women’s Health Multidisciplinary clinic model Mean number of visits: 2.4 over 6 months Values given as a mean 2009

28. 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.

29. Questions ?