1. National Forum Podcast July 2014 Brian J. Isetts, RPh, PhD, BCPS, FAPhA Professor, University of Minnesota

2. Our Speaker Our Speaker: Brian J. Isetts, RPh, PhD, BCPS, FAPhA Professor, University of Minnesota College of Pharmacy Dr. Isetts is a practitioner, researcher and educator dedicated to building a medication use system we deserve. Brian recently returned from a three- year sabbatical serving as a Health Policy Fellow at the Centers for Medicare & Medicaid Services in the CMS Part D Program and at the CMS Innovation Center. 2

3. 1. Understand the comprehensive patient care process for achieving drug therapy treatment goals 2. Describe the evidence supporting team-based medication management 3. Build a true medication use system aligned with our 3-part aims

4. 1. Review the consequences of our dysfunctional medication use system 2. Describe efforts to build a medication use system based on the way patients take medications 3. Understand the outcomes of integrating pharmacists in new care delivery and financing models

5.  What would a rational medication use system look like from the patient’s perspective?  What are the responsibilities of pharmacists in a redesigned medication use system?

6. Power of the Patient’s Perspective in Improving Health Care “We would all be far better off if we professionals recalibrated our work with patients and families not as hosts in the care system, but as guests in their lives.” Don Berwick, M.D. (former CMS Administrator), Institute for HealthCare Improvement

7. This is Reality in Homes across America 7

8.  How can we accelerate progress toward a medication use system in which patients routinely achieve their drug therapy treatment goals with zero tolerance for preventable medication harms?  How can we engage patients and families in team- based medication management in a system of care built around the manner in which patients use medications in their homes?

9. Drug-related Morbidity/Mortality-a National Crisis  Spend ~$300 billion/year due to the ineffective and unfortunate consequences of medication use  Largest category of hospital acquired conditions  Most common cause for hospital readmissions  3 categories of drugs related to over 70% of costs (Anti-coagulants, Hypo-glycemics, Opioid analgesics)  Approximately 10 people die every HOUR from preventable medication consequences So why has it taken so long to do something about this national crisis?

10.  We haven’t applied a standard care process to the way patients take medications  We don’t have a good idea of a patient’s medication needs across care settings  In a traditional fee-for-service system there are few incentives ensuring medications are indicated, effective, safe and can be taken by the patient  THAT IS – Until Now!!

11. It is difficult to be an Accountable Care Organization (ACO) if you’re not accountable for what happens when patients take medications

12. Medication Therapy Management Official Health Reporting Nomenclature (CPT®) assigned by the American Medical Association A practice in which a pharmacist takes responsibility for all of a patient’s drug-related needs and is held accountable for this commitment Separate and distinct from dispensing Systematic patient care process (assessment, care plan and evaluation)

13. 13 T HE P ATIENT C ARE P ROCESS ESTABLISH A THERAPEUTIC RELATIONSHIP What are the patient’s needs & preferences? What am I going to do with the patient? How will we know if it is working? Continuous Follow-up ASSESSMENTCARE PLANEVALUATION

14. 14 Basis of a Therapeutic Relationship Accept responsibility to identify all of a patient’s drug-related needs, and commit to working with the patient to meet those needs

15. 15 P HARMACIST R ESPONSIBILITIES To ensure that all of a patient’s drug therapy is appropriately indicated, the most effective available, the safest possible, and the patient is able to take their medications. The identification, resolution, and prevention of drug therapy problems.

16. Drug Therapy Treatment Goals Are established for each indication managed with drug therapy Are used to evaluate effectiveness and safety of drug therapy Collaboratively set with patients and care-givers Observable, measurable, realistic with time frames Aligned with patient preferences & motivating events Are abundantly more achievable when the patient knows you’re non-judgmental and in it for the long run as their life champion It’s the journey as much as the destination

17. Within each medical condition for which patients are taking a medication (if 5 medications for 3 conditions = 3 goals of therapy) 1) Like to have both objective and subjective measures 2) Must be observable, measurable, and realistic 3) Have a desired value & specific time frame in which the goal is to be met. When we collaborate to achieve goals of therapy patients are empowered to take control of their medications, rather than medications controlling their lives

18. Drug therapy problems are undesirable events or risks that the patient experiences that inhibit or delay him/her from achieving the desired goals of therapy. They are identified during the assessment process, so they can be resolved through individualized changes in the patient’s drug therapy regimens.

19. The Pharmacy Dilemma: Proving we Save Money before being Paid to Provide Care ● 56,000+ studies of care by pharmacists ● Meta-analysis published in 2010 ● Clinical outcomes: % of goals of therapy achieved, improved care (A1c, BP, LDL, etc) ● Humanistic outcomes: Quality of life, patient satisfaction, reduced sick days ● Economic outcomes: Total cost of care ↓, fewer hospitalizations; R.O.I. = $4:1 to $12:1

20.  Shift from F-F-S to Value-based $  Pharmacists' Outcomes Studies  Lessons from Patient-centered Homes & Accountable Care Organizations  Transitions of care focus on helping patients manage their medications  Urgent national call to action – alignment with our 3-part national aims

21. Better Care for Individuals Better Health for the Populations Lower Cost Through Improvement A Three-Part Aim 21

22.  What would a rational medication use system look like from the patient’s perspective when we all work together?  What are the responsibilities of all care-givers in a redesigned medication use system?

23. This is What We Do Together First is a therapeutic alliance, because patients don’t care what you know until they know that you care Use a systematic patient care process to assess all of a patient’s drug related needs Clear care plan responsibilities so each of us are held accountable for work to achieve goals We follow-up to evaluate progress toward goals, and the resolution of drug therapy problems, because if you don’t follow-up – you don’t care We document care – because if you don’t document, it didn’t happen

24. Comprehensive Team-based Medication Management All team members help set patient-specific drug therapy goals for each medical conditio n: Assessment of intended use, effectiveness, safety, and adherence embedded across the care continuum When patient is not achieving goals of therapy there is more efficient and effective use of pharmacists Coordination of care as pharmacists conduct comprehensive assessments of drug-related needs Patients/care-givers help team define “high-risk” as core element of the patient-centered health home 24

25. Dear Health Care Experts : We request your guidance in establishing a medication use system focused on helping patients and families find the answers to three essential questions: 1) What is the intended medical use for each of my medications? 2) What are the realistic, patient-specific goals for the medications used to treat each of my conditions? 3) What are the unique safety concerns specific to my mix of conditions & medications? We look forward to your response, Sharon and Edward Jungbauer, Maplewood, MN (11/30/2012)

26. Key Characteristics  Every drug in use in America is assessed to ensure: it has an intended medical use, is effective and safe, and can be taken by the patient as intended  Patients, family members, and care givers contribute to establishing realistic, achievable goals of therapy  Clear care plan responsibilities for achieving goals Patients will Demand our Health System Help Them :  1) Describe the intended medical use of each medication  2) Set realistic, patient-specific goals of therapy  3) Understand safety for their co-morbidities & medications

27. Lessons Learned Along the Journey Value-based financing is good news for patients who take medications We have a second chance to make a first impression in designing a medication use system we deserve Can’t be an ACO if not accountable for medications Outcomes of medication management can facilitate progress toward our 3-part national aims Patient demand will accelerate progress All team members help set patient-specific goals 27

28. Key Aspects of the SPCC Innovation Pharmacists are functionally integrated into electronic medical records Pharmacists are paid through the MN-Medicaid Medication Therapy Management Care Law The Univ. of MN-College of Pharmacy & the MN Pharmacists Assn. will work with pharmacists to ensure service delivery expectations This will serve as a national exemplar of the medication use system our patients deserve consistent with our 3-part national aims!

29. Discussion.