1. Transforming Care in Patient Centered Medical Home and Accountable Care Organization Hae Mi Choe, PharmD Director, Pharmacy Innovations & Partnerships University of Michigan Medical Group Associate Dean, Pharmacy Innovations & Partnerships College of Pharmacy, University of Michigan Director, Pharmacy Programs Physician Organization of Michigan (POM) ACO Building Organized Systems of Care

2. New care delivery model that replaces episodic with coordinated care Patients have a team that takes collective responsibility for meeting patient’s health care needs Ongoing relationship with primary care providers Definition of Patient Centered Medical Home (PCMH) Definition of Patient Centered Medical Home (PCMH)

3. Team-Based Care Care Management Self-Management Support Measure and Improve Performance Patient Tracking and Registry Functions Enhance Access and Communication Enhance Access and Communication Patient PCMH Joint Principles Test and Referral Tracking Advanced Electronic Communications

4. Physicians Pharmacists Nurses Medical Assistants Panel Managers Office Assistants Social Workers Nutritionists PCMH Team Members

5. 11 embedded pharmacists in all primary care clinics  5.2 clinical FTE  8 internal medicine and 6 family medicine sites Pharmacist’s time at PCMH sites varies depending on patient volume (range: 1 – 3 days/week) Provide disease management services (diabetes, hypertension, and hyperlipidemia) and comprehensive medication review services PCMH Pharmacist Practice Model

6. Evaluate and optimize therapeutic regimen Provide medication management to achieve treatment goals Assess and address barriers to medication adherence Provide education on chronic medical conditions and medications Assist in limited physical assessment (i.e. BP, foot exam) Order labs and medical equipment (i.e. glucometer) Facilitate referrals to other health care providers Set goals for self management using motivational interviewing Pharmacist’s Scope of Services Per Collaborative Practice Agreement Pharmacist’s Scope of Services Per Collaborative Practice Agreement

7. Patient Enrollment and Service Delivery Disease Management Services  Focus on diabetes, hypertension, and hyperlipidemia.  Proactively identify potential candidates through disease registry and/or provider clinic schedule.  Patients are scheduled for initial 30-minute clinic appointments or phone  Schedule patients for 15 – 30 minutes follow-up appointments to improve disease control and/or medication management.

8. Patient Enrollment and Service Delivery (cont’d) Comprehensive Medication Review (CMR) Services  Initial appointment: focus on patient’s medication concerns, confirm medication use, assess patient’s understanding of disease states and treatment plan, and identify potential barriers to treatment including drug cost.  Follow up appointment (2 weeks); discuss new treatment plans to improve efficacy, safety and lower drug costs.  Both initial and follow up appointments can be conducted over the phone or at the clinic for a total of 75 - 90 minutes of CMR experience.

9. Clinical Outcomes * Patients may belong to more than one category Average Decrease in A1c in Patients With Diabetes Co-Managed By Clinical Pharmacist Impact on Glycemic Control

10. Therapeutic Interventions by PCMH Pharmacists Therapeutic Interventions by PCMH Pharmacists Year 3: 2,674 interventions

11. Diabetes Registry QI Report

12. Medical Directors Satisfaction Survey Medical Directors’ Satisfaction Survey

13. Expansion of PCMH pharmacy care model to specialty clinics Building a medical neighborhood by developing collaborative care between PCMH and community pharmacies Creating telehealth partnership with home care services Implementation of employer-based comprehensive medication review program Collaboration with payers to improve HEDIS and Star Measures PCMH Practice Model: Building Blocks for Future Innovations in Ambulatory Care

14. Apply principles from PCMH and extend to specialty areas Integrate with inpatient care & transitions ACO Patient Centered Medical Homes (Primary Care) Specialty Areas Inpatient Care and Transitions of Care Accountable Care Organization (ACO)

15. Avoid unnecessary duplication of services and medical errors Link provider reimbursements to quality metrics and reduction in the total cost of care for the assigned population  When an ACO succeeds in saving health care dollars, CMS shares the savings ACO Goals

16. Physician Organization of Michigan (POM) ACO Partners University of Michigan Medical Group Integrated Health Associates (IHA) MidMichigan Health Oakland Southfield Physicians Olympia Medical Services United Physicians Huron Valley Physicians Asso. POWM Crawford Mercy PHO Wexford PHO Physician Organization of Michigan (POM) ACO Partners

17. POM ACO Pharmacists Program Develop infrastructure to embed pharmacists in the primary care clinics. 1 FTE pharmacist provides services across 2 – 3 practice sites. Initially focus on developing comprehensive medication review AND disease management services (diabetes/HTN).

18. Michigan Pharmacists Transforming Care and Quality (MPTCQ) Michigan Pharmacists Transforming Care and Quality (MPTCQ)

19. Identify and train one Pharmacist Transformation Champion per PO. Adopt and modify University of Michigan Health System’s integrated pharmacist practice model. Improve patient care and outcomes at participating POs through pharmacist integration. MPTCQ Goals/Objectives

20. Pharmacists are being recognized as an integral member of the new care delivery model. Need to develop a sustainable financial model for pharmacists. Demonstrate impact on patient care and health care costs. Provide leadership training for future pharmacists to build the new health care landscape. Creating New Opportunities for Future Pharmacists Creating New Opportunities for Future Pharmacists