Communication in Team-Based Care Can Have Effective Outcomes for Pharmacists

Darren Mensch, PharmD, BCPS, BCACP, clinical ambulatory care pharmacist of population health at Jefferson Health in Abington, describes the role pharmacists play in team-based care, population health management, and value-based care.

Q: To start, what is a team-based care model, and what role do pharmacists play in it?

The main definition is, according to the National Academy of Medicine, is the provision of health services to individuals and families and/or their communities by at least 2 health providers who are collaborative with patients and their caregivers, to the extent preferred by each patient to accomplish shared goals within and across settings to achieve coordinated high-quality care. Traditionally, the care team was always kind of viewed as the physician and then the office staff. Over the last few years and some movement towards more of the Patient Centered Medical Home, we've kind of pushed for care coordination, social work, behavioral health consultants, and now even more recently, kind of adding pharmacist into that, and really, pharmacists’ role in being the medication expert. Kind of the analogy is you go to your mechanic to fix your car and go to the cardiologist to fix your heart; you really should be going to your pharmacist to fix your medications. I think we're slowly getting there. It’s definitely been a process to get to that point. Being part of the team-based care and working hand in hand with physicians, the nurses and patients, I think we're really starting to kind of come to that value and bringing that expertise to the to the care team.

Q: What can pharmacists do to be successfully incorporated into this care model?

I think 1 thing that we definitely have to focus in on is, what are the pain points of the practice or the health system and what can we do to help? Not every office has an issue with prior authorizations, they might have a great process, and there's really nothing we can add to that. They might need some help with their quality measures like their diabetes panel and their metrics for those patients, and every practice, again, is very different. What you really need to do is build relations, relationships with the leadership team, the providers, staff patients to kind of see what what's going on and how can we help. And the clinical administrative champion, I can't emphasize that enough and it's not just who is the physician champion, we always talk about that a lot, but it's also you need somebody on the administrative side,that can really help push things forward within not just the C suite, but also the decision makers, if you will, of the organization.

When we first started our program, about 4 years ago, we were constantly kind of marketing our services at the beginning, and we've really gotten to a point wherw we're kind of looked at as that expert, did take a while, but we certainly got there. A lot of physicians and organizations might not be familiar with working with pharmacists, ao it did take some kind of education and reminders at the beginning. We've kind of gotten to that point, especially with our rapport with patients and staff and physicians, in fact, the other day, at a patient were unfortunate that providers leaving the organization, but they actually asked what other practices do I work with, so that they could stay on with me and follow up for their diabetes. So I think that demonstrates our kind of rapport with patients.

Another thing is always demonstrating your value. If you are seeing as a value add to the organization and the team and the patients, it kind of sets yourself up for success. You have to, again, tailor it to the audience, the outcomes and the patient stories, depending on if you're talking to the finance department, analytics department, clinical leadership, that messaging can be very different. Speaking of that messaging, you want to keep that messaging very consistent across the team. Make sure everybody's speaking the same language, and really, there's another part to that about you might not know the answer, it's okay to say that you don't, but the second part to that, I've heard a lot of people say that, but the second part is, if you don't know that answer, you still have to come back with the answer afterwards and follow up with those people that asked the question.

Q: What is a value-based delivery care model?

Value based care is really the shift from the traditional fee for service, which would be what you think of quantity. You're billing for lab tests, admissions at a hospital, and what we're trying to move towards is value-based care of really that quality aspect. So are you providing good quality care to your patients? And then that can, if you do meet those metrics, then your reimbursement will increase. A lot of that is if you are providing high quality care to your patients, your outcomes should improve, and really making sure that all the ducks are in a row to ensure that across the organization is very key.

A lot of those value based metrics are very specific to pharmacy, especially like the merit based incentive payment system, the MIPS program, about 20 to 25% of those are directly related to medications and probably even closer to 30% to 40%. If you look at some of the more indirect measures, and part of that value based care, it's not just the pharmacy team, you know, can't take on everything. Care coordination with that team based care to kind of come in and provide that value of the care coordination, they've got the establish relationships with local homecare, nursing homes, hospitals, they know the backline to that facility, they know how to get things done, and then certainly social work, same idea, they've got that familiarity with no local food banks, direct contacts at them to really help our patients. Then the pharmacists can come in and provide that comprehensive medication management and be able to focus in on that.

So having those additional resources if I have a patient in front of me that I can do everything I can with their medications, but they don't have access to sustainable food. There's really nothing much I can do. We can keep throwing and throwing medications at them. But they will also need those other social factors.

Q: What are some strategies for pharmacists to implement population health management into value-based delivery care models?

First, I definitely want to start off with kind of what population health management is. Population health management is really targeting a defined specific population to help slow that disease progression, improve health outcomes, and decrease the total cost of care. If you look at us literally targeting that population, you know, am I looking at patients with diabetes that have an A1c over 8%? What do I do for that group of patients? What project might I have for patients that were recently admitted for heart failure is really focusing in on that specific population? What services and what workflows you have around that group of patients?

The success of bringing a pharmacist on board for that population health management? Again, it gets back to where is your organization currently at? How are you doing with your metrics? How can pharmacist help what's already being done as well? There's a lot of duplication that goes on in health care, and I think pharmacists can find a way to either be indirectly or directly involved with that. Then the other one that I kind of naively, when I started the job didn't realize, was kind of when our decisions made recognizing the fiscal year, and also that a lot of contracts are multiple year contracts.

If you're trying to start a program in the middle of a contract, you're probably not going to go through. You have to set up kind of set the table for that when that contract negotiation is up. Then it talks a little bit about kind of the networking and trust with your organization, making sure you've got that physician champion. You really want to get within your organization to be if any medication related question comes up, you want to be the one that's first come to mind for those discussions.

Then working is not only just in your organization, it's also outside. So working with your state, pharmacy organization, national pharmacy organizations, I've utilized and worked with other pharmacists. The mantra of work harder, and work smarter, not harder, has really come through there and leaning on each other to build a professional.

Then trust within the organization, again, did take a little bit of time and some momentum building to get to that point, and certainly word of mouth spreads. I've had all the time where doctor recommended that I talk to you about this patient with diabetes because it was so helpful with 1 of my patients. Then once you have that trust, you can really start to implement some of those more high level, I guess you could say invasive, tests, tasks, like automatic refills or protocols.

You can kind of implement that because you've already built that trust, and they're in their mind thinking “Oh, this is from the pharmacy team, it must be important they'd helped me in the past.” So, kind of getting that to that point.

Then kind of lastly, on the population health management because it can be a very large group. For example, our team is only for pharmacists for about 300,000 patient lives. We do cover a huge, huge program. You do have to be able to delegate and automate your services. So, kind of the idea is you can be a part of the solution, but you don't have to be the solution. Designing a program for the nursing team for that protocol, or what the outreach should look like kind of a template and designing that with the pharmacists expertise in it, but the pharmacist isn't the one actually making that call, and also working with the EMR electronic medical record to make improvements there that again, doesn't require a physical touch by a pharmacist. It's utilizing that pharmacists’ kind of expertise to adjust that EMR to make it functional and more efficient.

Q: How should pharmacists and other health care providers utilize communication, in order to have the most effective outcomes?

I think with communication, certainly the number 1 thing, is keeping things kind of simple, complete, clear, brief and timely. Again, a lot of times there's hundreds of faxes coming in calls from patients, portal messages from patients, emails from administration. There's a lot of things that are coming to the provider’s staff. So really, you have to make it complete and clear and as easy to interpret as possible. Most health care organizations kind of use the SBAR, or the situation background assessment and recommendation. A lot of our communication is based on that. We have done some SBARS in the past, especially around some of the large recalls that occurred a couple years back there. So that was a quick message out to those providers.

Then the next thing with communication is you should really make sure that most the majority of what you're sending out is actionable and require something to be done and kind of limit those FYI notifications. A lot of providers have kind of that alert fatigue and burnout from getting all these messages, and there's not really a need to do something at the end, or we already did all this upfront. So you don't have to do that. Now just please do this part of it. We already did the kind of the digging into this as appropriate or not for you.

Q: Any closing thoughts?

I definitely would say that you should check out the great resources that the American Pharmacists Association has. Our Accountable Care Organization and medical home special interest group worked on a great resource called the successful integration of pharmacists and accountable care organizations and medical homes case studies. So it's about 8 or 9 case studies of some successful practices that are out there.

Also online, there's the learn the lingo, some value-based care terms that can kind of put a lot of things, that definitely didn't learn in pharmacy school, that are kind of those new terms that are coming out to help pharmacists kind of be a part of that conversation be at the table for these value-based care discussions.

Another great resource along those lines is the Get The Medications Right Institute as well. I've utilized some of their use cases to help us demonstrate our value and increase the likelihood of sustainability evaluation of our program.

Then another one that I definitely I've tried to do myself is advocating for the profession outside of pharmacy, and really trying to get the word out about how pharmacists can help within public health societies, medical societies, the American Diabetes Association, diabetes education as well. So certainly trying to kind of spread out our messaging.