Pharmacists provide medication guidance
Program also helps primary care providers
To help chronically ill members adhere to their medication regimens, Capital District Physicians' Health Plan (CDPHP) provides personalized support from pharmacists for members taking multiple medications in patient-centered medical homes and at community pharmacies.
"We started our medication therapy management program in 2007 to meet the Centers for Medicare & Medicaid Services (CMS) requirements for Medicare Part D. Initially, it was difficult to see the value of our efforts, but we quickly realized that our members and our primary care network could benefit from expanding the program. Our vision is to add the value of the pharmacists' expertise to the healthcare delivery system as a service beyond medication dispensing," says Eileen F. Wood, RPH, MBA, vice president for pharmacy and health quality programs with the Albany, NY-based health plan.
The health plan uses two approaches to providing medication therapy management to members. As part of the its Enhanced Primary Care initiative - a patient-centered medical home model - CDPHP has embedded pharmacists in large primary care practices to be a resource for physicians and meet with patients to discuss their medications and educate them on the proper way to take them. In addition, CDPHP has contracted with community pharmacists who provide face-to-face support to patients in retail settings.
Originally, to meet Medicare Part D requirements, CDPHP provided telephone counseling for patients. "We determined that community pharmacists were willing to collaborate with the health plan and primary care physicians, and redesigned the program, giving patients the opportunity to meet with pharmacists face-to-face," Woods says.
The health plan started its enhanced medication therapy management program as a pilot and has expanded it beyond the CMS requirements. It now offers the program to any patient with complex medication regimens and chronic diseases, as well as anyone referred by a case manager, a physician, a pharmacist, or who refers him- or herself, she says.
The pharmacists in both settings review the patient's record to identify gaps in evidence-based care, safety risks from drug-drug or drug-disease interactions, medications that can be dangerous for the elderly, and opportunities to simplify medication regimens or save members money by recommending generic medications in lieu of more expensive name-brand drugs.
The pharmacists conduct a comprehensive review of prescribed medications before they meet with patients. During the meeting, they find out what over-the-counter medications and supplements patients are taking and give them a comprehensive list of medications they can take with them to all healthcare encounters. They verify that patients are taking their medications as prescribed, explain why they are taking the medication, discuss side effects and other problems they may be experiencing, and answer questions. They may provide patients with pill boxes to help them organize their medication, and provide one-on-one instruction on how to use an inhaler or self-administer injections.
The embedded pharmacists work closely with physicians at the primary care practices and sometimes round with them. They collaborate with the practice case managers and have the option of bringing in a behavioral health case manager when needed.
The pharmacists are a resource to the physicians if they have a difficult or complex case. In addition, they review the charts of patients coming in the next day, perform comprehensive medication reviews, and offer suggestions for physicians based on nationally recognized guidelines, evidence-based standards, and the health plan's formulary.
By taking advantage of the pharmacists' expertise, primary care physicians can continue to provide timely care for complex patients, eliminating or delaying the need for more intensive or specialist care, Wood points out. For instance, teenagers with acne typically have to wait eight to 10 weeks to see a dermatologist. When they have mild to moderate acne, the pharmacist can provide comprehensive information about therapy choices, relative costs, and up-to-date medication protocols.
In the case of patients with newly diagnosed diabetes, the pharmacists provide support to primary care practitioners in initiating and adjusting insulin dosages, reserving endocrinology referrals for complex and difficult cases.
"This means that primary care practitioners can continue to take care of their patients, reserving referrals to specialists only when necessary. This provides patients and families with timely access to the care they need in the primary care setting that is familiar to them," she says.
When CDPHP set up its community-based medication therapy management program, it invited pharmacists from supermarkets, drugstore chains, and independent pharmacists to participate in the program. Participating community-based pharmacists go through a full day of orientation to learn about how the health plan operates and how to interact with members and their physicians. "We want the pharmacists who work in retail to learn about the health plan's care management programs and the importance of supporting primary care," Wood says.
The pharmacists work in conjunction with patients' primary care physicians and other CDPHP programs.
"Aside from the medication therapy management program, we have medical case management and behavioral case managers for our members who need those services. If pharmacists in the community identify social, behavioral, medical or other health challenges, they can contact the case managers, who will intervene," Wood says.
When members are referred to the pharmacy program, they receive a welcome letter explaining the program and telling them to expect a call from a pharmacist. When the health plan identifies patients who need medication therapy management and who already are working with a CDPHP case manager, the case managers can contact a pharmacist for assistance.
The community pharmacists receive referrals from the CDPHP pharmacy department and contact the patients by telephone to set up a time for a meeting. "The ideal engagement is face to face so members can bring in all their medications for the pharmacist to review. If patients prefer to talk on the telephone, the pharmacist can accommodate them," she says.
Pharmacists provide each patient's physician with a comprehensive medication list, including medications prescribed by other providers along with observations and recommendations. If there are urgent patient safety concerns, such as dangerous drug combinations, the pharmacists call the physicians directly.
Pharmacists follow up each quarter and review each member's records to identify new medications and call the patients to make sure they are following their medication regimen.