1. Pharmacists Transforming Care in Patient Centered Medical Home and Accountable Care Organization Hae Mi Choe, PharmD Director, Pharmacy Innovations & Clinical Practices University of Michigan Health System Clinical Associate Professor of Pharmacy University of Michigan College of Pharmacy Director, Pharmacy Programs Physician Organization of Michigan (POM) ACO, LLC Building Organized Systems of Care

2. Define patient-centered medical home in terms of characteristics and components of a medical home. Identify potential roles for pharmacists and possible barriers to the inclusion of pharmacists on the patient-centered medical home team. Outline strategies for demonstrating the value of pharmacist involvement on a patient-centered medical home team. Describe emerging opportunities for pharmacists in the Accountable Care Organizations. Learning Objectives

3. 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)

4. 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

5. Physicians Pharmacists Nurses Social Workers Dieticians Medical Assistants Panel Managers Office Assistants PCMH Team Members

6. 10 embedded pharmacists in all primary care clinics  4.9 clinical FTE  9 internal medicine and 6 family medicine sites Pharmacist’s time at PCMH sites varies depending on patient volume (range: 1 – 6 half-days/week) Provide disease management services (diabetes, hypertension, and hyperlipidemia) and comprehensive medication review services PCMH Pharmacist Practice Model

7. 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

8. 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.

9. 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.

10. Impact on Glycemic Control Patients with baseline A1c > 7.0% (n = 543) had a mean decrease in A1c by 0.85% (p<0.0001) Patients with baseline A1c > 8.0% (n = 373) had a mean decrease in A1c by 1.20% (p<0.0001) Patients with baseline A1c > 9.0% (n = 231) had a mean decrease in A1c by 1.75% (p<0.0001)

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

12. Diabetes Registry QI Report

13. Total N = 7145 A1c Tests LDLC Test LDLC < 100 On Statin Monitor for Nephropathy Eye Exam Foot Exam UMHS TARGET GOAL93%90%56%96%90%71%85% Non-PharmD Patients (N = 6329; 89%) No. of Patients Met Goal6057528736904528*557349764568 % of Patients Met Goal96%84%58%92%88%79%72% UMHS Goal Met?YesNoYesNo YesNo PharmD Patients (N = 816; 11%) No. of Patients Met Goal810736551628**770686660 % of Patients Met Goal 99%90%68%96%94%84%81% UMHS Goal Met?Yes No * Eligible patients: 4908** Eligible patients: 656 Diabetes Registry QI Report (cont’d) Reporting Period (07/01/2011 - 06/30/2012)

14. Medical Directors Satisfaction Survey The clinical pharmacist positively impacts the health status of my patients. The collaborative practice agreement is a valuable aspect of the clinical pharmacist/provider relationship. The clinical pharmacist provides useful communications to me regarding the health status of my patients. The clinical pharmacist makes appropriate clinical decisions for my patients. I am satisfied with the patient care provided by the clinical pharmacist. * All 14 medical directors completed the survey (June – July 2013).

15. 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

16. 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)

17. 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

18. Impact/Outcomes Align with P4P indicators and associate financial benefits Align with avoidance of penalties and financial impact Cost-savings to employers New revenue from direct billing opportunities Target Outcomes

19. Southeast Michigan UM Faculty Group Practice Integrated Health Associates Huron Valley Physicians Association MidMichigan Health Oakland Southfield Olympia Medical Services United Physicians West Michigan Advantage Health Lakeshore Health Network POWM Northern Michigan Crawford Mercy PHO Wexford PHO Physician Organization of Michigan (POM) ACO Partners

20. New POM ACO Pharmacists Program Develop infrastructure to embed pharmacists in the primary care clinics at 4 physician organizations/ health systems. 1 FTE pharmacist provides services across 2 – 3 practice sites. Initially focus on developing comprehensive medication review AND disease management services (diabetes/HTN).

21. Plant Trees Separately…

22. OR Create a Forest Together…

23. 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