Improving Quality Care: The Appointment-Based Model

The appointment-based model provides an opportunity for pharmacy to solve medication-related problems.

In health care, doing more with less—improving quality while reducing costs—is the order of the day. Today’s transaction-based payments will soon be a thing of the past. Preparation for the transition to a value-based—or outcome-based—payment system requires immediate action on the part of pharmacies to ensure they are positioned for success. Well-defined strategies and effective tactical execution are essential to transform community pharmacy practice in such a way that the prescription fulfillment process continues while defined quality outcomes for patient care become the standard. The appointment-based model (ABM) allows a pharmacy to effectively do both and is the foundation of this transformation.

The ABM

The ABM is a model for patient-centered, outcome-focused care. It is a departure from the traditional reactive, transactional, on-demand prescription fulfillment approach that relies upon the patient to request refills, offering a proactive, scheduled, synchronous chronic medication fulfillment process that relieves patients of the refill management burden. While synchronous chronic medication fulfillment is the first step to an effective ABM, pharmacy team preparation in advance of the patient’s visit to the pharmacy is also vital. This requires the pharmacy team to review the patient’s entire profile and proactively communicate with the patient to provide the necessary interventions at the appropriate times to improve individual outcomes. Specific appointment times are not a mandate of the ABM. Pharmacies may choose to stipulate a specific date or window of time during a day, rather than a specific time for the patient’s visit to the pharmacy.

The basic tenets of an ABM are: (1) holistic care of the patient; (2) regularly scheduled visits to the pharmacy by the patient; (3) communication with the patient in advance of the scheduled visit to proactively assess needs related to medications and health conditions; and (4) pharmacist-patient engagement on a regular basis to address these needs.

The term ABM is often used synonymously with medication synchronization, the process of coordinating the filling of a patient’s chronic medications on a regular schedule. While medication synchronization is the starting point, the ABM enables pharmacy migration to patient-centered care management and provides the infrastructure and time for pharmacies to incorporate a variety of other services including medication therapy management, immunizations, health screenings, and the like.

Medication Synchronization—An Essential Component of the ABM

In the practice of medication synchronization, the pharmacy reviews the patient’s prescriptions for chronic conditions and selects an appropriate “sync date” with the patient. In advance of the anticipated prescription fill date, the pharmacy has the opportunity to conduct a review of all of the patient’s medications and contact the patient to determine whether there have been any changes in the medication regimen due to potential prescriber visits or hospitalizations that may require reconciliation. If not, the pharmacy confirms the patient’s readiness to fill their prescriptions. If the patient is not ready to fill a medication, the pharmacy has a perfect opportunity to identify and resolve nonadherence.

Medication synchronization, if implemented properly, provides a holistic view of the patient and ensures ongoing communication between the patient and the pharmacy to address and resolve medication-related problems and to drive adherence. Pharmacies that proactively intervene with patients have demonstrated the ability to increase adherence rates above 80%, as measured by proportion of days covered. It should be noted that medication synchronization is a clinical program, not to be confused with auto refill programs, which do not deliver the same results.

What Are the Advantages to the Patient?

Of patients who are offered enrollment in medication synchronization, 70% opt in.¹ Patients receive a host of health care benefits, in addition to convenience, from synchronized refills and routine pharmacist engagement within an ABM. Furthermore, the level of patient satisfaction is high, as the number of patients who choose to discontinue the program is negligible. Potential benefits include:

• Better care. Patients enrolled in medication synchronization receive holistic care and scheduled, highly productive time with a pharmacist due to advance preparation. For Medicare Part D beneficiaries, medication synchronization presents a great opportunity for a comprehensive medication review (CMR).
• Better outcomes. Patients benefit from improved medication adherence, prompt identification and resolution of medication-related problems, and administration of needed vaccines, all of which improve health outcomes.
• Convenience. Patients are relieved of the burden of managing their prescription refills due to proactive outreach by the pharmacy.
• Better quality of life. For patients with comorbidities and complex medication regimens, the improved care and better outcomes afforded by medication synchronization and the ABM translate to a significant positive impact on quality of life.

Why Should Pharmacies Consider Moving to the ABM of Patient Care?

The ABM may be the single greatest opportunity over the past 30 years for community pharmacy to become the solution to the systemic problems related to medication use that plague health care today. Pharmacies that have adopted the ABM are able to provide higher quality care, improved outcomes, and greater convenience to their patients, engendering a new level of patient loyalty. The pharmacies realize benefits that drive access to high-performance networks and new revenue channels.

To begin the transition, pharmacies can use simple manual processes to initiate medication synchronization or move to a patient management system that guides the pharmacy through each step of the synchronization process and longitudinal patient care management, ensuring active engagement with the patient. The move to an ABM brings additional benefits for a pharmacy:

• Better quality performance. Improved patient outcomes mean inclusion in high-performance pharmacy networks and greater impact on health plan quality measure performance (eg, improved proportion of days covered scores).
• Incremental fills. By eliminating late refills, pharmacies experience as many as 3 incremental fills per enrolled medication per year. With an average of 5 enrolled medications per patient, medication synchronization would yield 15 incremental fills per patient per year.
• Lower costs. ABM pre-visit preparation allows the pharmacy to anticipate when medications are needed, thus lowering inventory costs and producing higher inventory turns. Synchronous filling also means reduced shipping and medication delivery costs for the pharmacy.
• Scheduled patient visits. These appointments allow the pharmacy time to prepare in advance for any needed service delivery, and ensure that all medications are in stock and all prescriptions are ready.
• Patient loyalty. ABM patient satisfaction increases pharmacy loyalty. Patients using multiple pharmacies tend to transfer prescriptions from pharmacies that do not offer medication synchronization to those that do offer the service.
• Improved pharmacy efficiency. By enrolling the pharmacy’s most medically complex patients in medication synchronization, a disproportionate amount of time is saved. Additionally, the ABM affords efficiency by facilitating load-balancing, giving the pharmacy staff more control over their work flow. The pharmacy team has time it needs to prepare for each visit and is able to reserve time for scheduled visits that work well for both pharmacy and patient.
• Opportunity to offer additional services. The time savings afforded by consolidating a pharmacy’s most medically complex patients from multiple visits to 1 visit per month yields available time for additional pharmacy services, such as CMRs and vaccinations, to be delivered.

Aligning the ABM with Payer Initiatives

Adopting a proactive model of patient care management and having greater control over work flow and more time to provide much needed interventions allows pharmacies to deliver on outcomes for which they should be paid. While payers may have little interest in paying pharmacies for specific services, they are very interested in paying for outcomes. Pay-for-performance (P4P) models are very attractive to payers because they align pharmacy performance with the payers’ own quality measure outcome requirements and help them achieve higher star ratings and quality bonus payments.

Adoption of the ABM prepares pharmacies to take advantage of these P4P opportunities and for the major transition by federal and commercial plans further down the path of value-based payment. As part of the pharmacy’s strategy for preparing for the era of value-based payments, they must identify relationships/partnerships to best position them for:

• Inclusion in pharmacy groups or networks to provide adequate coverage to support payer needs. The payer may be a health plan, hospital/health system, or employer.
• Maintaining standardized processes for data collection and data analytics capabilities for outcome measurement and reporting.
• Population health capabilities, through which the pharmacy must be able to identify affected patients and provide the necessary interventions to these patients at the appropriate time.

Conclusion

Many innovative community pharmacy—based projects and programs involving pharmacists as patient care managers have demonstrated positive health outcomes and a highly favorable return on investment. Needs related to medication use are vast and contribute significantly to preventable costs related to health care. With the accessibility and current underutilization of pharmacists’ expertise, community pharmacy has a tremendous opportunity to be the solution to many of the problems facing health care today. The ABM eliminates the barriers to scalability and paves the way for patient-centered, outcomes-focused care and value-based remuneration to become mainstream in community pharmacy practice.

Click here to the related article, "The Two Fundamental Changes to Pharmacy Work Flow We've Been Awaiting," by Troy Trygstad.

Rebecca W. Chater, RPh, MPH, FAPhA, has been a career-long pioneer in innovative community-based clinical pharmacy practice. Chater is the executive health care strategist for Ateb, Inc, a leading provider of appointment-based model solutions for pharmacy. Throughout her career, Chater has championed the pharmacist as a medication expert, integral to the health care team in solving the systemic problems of medication use that compromise quality and place enormous economic burden on our nation’s health care system.Chater’s career in pharmacy spans many settings: community practice, medical practice, academia, long-term care, and specialty pharmacy. In the late 1990s, she led North Carolina’s Kerr Drug to national prominence for innovation by spearheading Kerr’s foray into community pharmacy—based clinical services utilizing an appointment-based model, including the Asheville Project.Chater is a past trustee and fellow of the American Pharmacists Association and has received numerous state and national awards for professional leadership and innovation.

References

• Ateb, Inc data on file.