Adherence Lessons from the Pharmacy Home Project

In my role as a director for Community Care of North Carolina (CCNC), I’ve had the opportunity to witness the positive impact care management programs can have on patients’ lives. CCNC’s Pharmacy Home Project was established in 2006 in response to a rapidly increasing need to provide medical home wraparound supports for Medicaid recipients and the aged, blind, and disabled populations of North Carolina. Over the past decade, this project has ultimately served millions of patients via many types of payers through a focus on team-based, multi-setting, multidisciplinary, whole-patient care delivery in which each patient’s drug use narrative and individualized plan is constructed and shared among care team members.

The evidence is in: CCNC medical home enrollees have been shown to have adherence rates that are 4% to 8% higher than nonenrollees on a case-mix adjusted basis, with better outcomes and lower rates of hospitalization and total cost of care.¹ Since 2013, over 300,000 drug therapy problems have been discovered among more than 50,000 patients. Here are a few of the patient adherence principles that have emerged:

Principle 1: Approach Each Patient as a “Snowflake”

Each patient’s experience with their medication(s) is unique, no matter how complex or simple the regimen. The patient experience has to be well understood to effectuate positive changes in drug use.

Principle 2: Adherence Counseling Without Clinical Review Is Nonsensical

Polypharmacy, undertreatment, interactions, identification of bad experiences with drugs, misunderstandings, and other “drug misadventures” need to be addressed before coaching so better adherence can ensue. In many instances, patient nonadherence can be safer and more advisable than adhering to the prescribed use of the medication, particularly in cases where the medication regimen is not optimized or maintains internal conflict between medications. Patients generally act rationally, and there is usually an understandable reason why the patient has altered their prescribed regimen.

Principle 3: Patient Nonadherence Is an Excellent Prognostic Indicator of Other Care Coordination Deficits

Conventional metrics of medication adherence can be a valuable ancillary data point for determining which patients need clinical reviews of their medication regimens. Discordant and sporadic patterns of medication use often uncover regimen conflicts and drug therapy problems not directly related to adherence but to a general lack of care coordination.

Principle 4: Interventions to Improve Patient Nonadherence Should be Longitudinal and Dynamic

A point-in-time intervention is practically useless for improving medication use. Patient nonadherence is what the patient does when they are not in front of a provider—and they spend a lot more time on their own than with care providers. Congruent, ongoing, individualized reinforcement is often necessary to ensure persistence to therapy.

Principle 5: Interventions That Improve Adherence Are Necessarily Multidisciplinary

The individualized drug use plan develops into a drug use narrative over time and needs to be shared with all provider touch points in a system of care. An adherence coaching plan that is not dynamic and upto- date may be counterproductive, or even dangerous.

Let us all commit to continued discovery, refinement, and investment in optimal interventions that lead to successful, patient-centered drug use.

Troy Trygstad, PharmD, PhD, MBA, is the director of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina (CCNC), a parent organization of 14 regional care management networks. These networks bring together medical practices, county health departments, hospital systems, and mental health providers to integrate care delivery for Medicaid, Medicare, private plans, employers, and the uninsured. CCNC and its networks are responsible for developing and evaluating accountable care systems in North Carolina. Under his direction at CCNC, the Network Pharmacist Program has grown to include pharmacists who are involved in a number of diverse activities including medication reconciliation, e-prescribing facilitation, and management of pharmacy benefits.He has also been involved in novel adherence implementations as well as the development of adherence technologies that use administrative claims data to predict, intervene, and triage adherence interventions and coaching opportunities. Dr. Trygstad received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina.He is co-editor-in-chief of the Pharmacy Times series Directions in Pharmacy^®.

References

• Cutler DM, Everett W. Thinking outside the pillbox—medication adherence as a priority for health care reform. N Engl J Med. 2010;362(17):1553-5. doi: 10.1056/NEJMp1002305.